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R E V I E W

Anxiety disorders

Cornelia Mohr • Silvia Schneider

Published online: 12 December 2012

� Springer-Verlag Berlin Heidelberg 2012

Abstract With the adoption of a developmental psycho-

pathology perspective, the DSM-5 translates empirical

evidence on the continuity of childhood anxiety disorders

into diagnostic practice, thereby completing a process that

started with the exclusion of the former childhood anxiety

disorders overanxious disorder and avoidant disorder from

DSM-III to DSM-IV. This change in perspective, however,

leads to a low level of concordance between the DSM-5

and ICD-10. To reliably identify anxiety disorders at dif-

ferent points in development, and to take into account their

developmental pathways, assessment instruments need to

be sensitive to age-related manifestations and age-related

subtypes of a disorder. This may best be achieved by a

multi-informant, multi-method assessment approach. With

regard to treatment, only cognitive-behavioral therapy

(CBT) fulfills the criteria of an evidence-based treatment

approach in youth. Disorder-specific treatments can lead to

larger treatment effects and slightly higher remission rates

as compared to more general treatment programs for

childhood anxiety disorders (e.g., Coping Cat). Parental

involvement seems not to add to treatment success. In

conclusion, the evidence-based diagnostic approach of the

DSM-5 needs to be complemented by the development and

evaluation of child-friendly, developmentally sensitive

assessment tools and evidence-based treatments for anxiety

disorders in children. With regard to diagnostic concor-

dance, the gap between the DSM-5 and ICD-10 needs to be

bridged by more closely aligning the two nosological

systems.

Keywords DSM-IV � DSM-5 � ICD-10 � Separation anxiety disorder � Specific phobia � Social anxiety disorder � Generalized anxiety disorder � CBT � Childhood � Adolescence

A developmental lifespan perspective on anxiety

disorders

With lifetime prevalence estimates ranging from 15 % to

20 % and a median age of onset of 11 years [1], anxiety

disorders are among the most prevalent and earliest

forms of psychopathology [2] and are known to function

as a pacemaker for mental disorders later in life [3–5].

Yet, research on anxiety disorders in younger populations

lags behind studies on anxiety disorders in adults. The

adoption of a developmental psychopathology perspective

is one of the major changes from DSM-IV to DSM-5.

This change might gradually shift the focus of researchers

and clinicians toward a clinical psychology of the

lifespan.

Continuity in diagnostic criteria across age groups

With regard to defining the criteria for diagnosing anxiety

disorders in different age groups, empirical evidence sup-

ports continuity in criteria (as in DSM-IV-TR and DSM-5)

instead of applying different criteria to children/adoles-

cents and adults (as in ICD-10). Contracting an anxiety

disorder at any time during childhood or adolescence

increases the risk for developing either the same anxiety

disorder (strict homotypic continuity) or another anxiety

C. Mohr � S. Schneider (&) Clinical Child and Adolescent Psychology, Ruhr-Universität

Bochum, Universitätsstraße 150, 44780 Bochum, Germany

e-mail: [email protected]

123

Eur Child Adolesc Psychiatry (2013) 22 (Suppl 1):S17–S22

DOI 10.1007/s00787-012-0356-8

(broad homotypic continuity) or mental disorder (hetero-

typic continuity) later in life.

Changes in classification from DSM-IV to DSM-5

Overall changes

The revision of the anxiety disorder section has been

developed by the Anxiety, Obsessive–Compulsive Spec-

trum, Posttraumatic, and Dissociative Disorders Work

Group. Overall changes from DSM-IV to DSM-5 within

the anxiety disorder section concern the systematic appli-

cation of a developmental lifespan perspective and con-

sistent re-wording of criteria throughout the chapter. For

example, the combined term ‘‘fear or anxiety’’ is used

consistently in the DSM-5 (while the DSM-IV sometimes

uses ‘‘fear’’ and in other instances ‘‘anxiety’’). The devel-

opmental lifespan perspective of the DSM-5 also led to a

chronological reorganization of anxiety disorders accord-

ing to their age of first onset, beginning with separation

anxiety disorder and concluding with panic disorder

(Table 1).

Major changes for separation anxiety disorder

In DSM-5, separation anxiety disorder has been moved

from the category ‘‘disorders usually first diagnosed in

infancy, childhood, or adolescence’’ (DSM-IV) to the

anxiety disorders category, and the age-of-onset require-

ment (‘‘before age 18 years’’) has been dropped. Accord-

ingly, terms are added (A-4: ‘‘work’’) or changed (A-5:

Table 1 Changes in diagnostic criteria for anxiety disorders in children and adolescents from DSM-IV to DSM-5 (American Psychiatric Association DSM-5 Development. Retrieved from http://www.dsm5.org on 09.09.2012)

Anxiety disorder DSM-IV DSM-5

Separation anxiety disorder

Category ‘‘Disorders usually first diagnosed

in infancy, childhood, or adolescence’’

Moved to the ‘‘anxiety disorders’’

category

Age delimiter Limited to childhood/adolescence

(‘‘before age 18 years’’)

All age groups

Duration 4 weeks 6 months or more for all age groups

Specifier Early onset (‘‘before age 6 years’’) –

Specific phobia

Terminology Fear is ‘‘excessive or unreasonable’’ Fear/anxiety is ‘‘out of proportion to the actual

danger posed’’

Duration 6 months or more for individuals under

18 years

6 months or more for all age groups

Insight May be absent in children –

Social anxiety disorder

Title Social phobia Social anxiety disorder

Terminology Individual fears humiliation and

embarrassment in social or

performance situations with

unfamiliar people

Individual fears negative evaluation

(e.g., being humiliated, embarrassed,

or rejected) by others (either unfamiliar

or familiar) in performance, interaction,

or observation situations

Duration 6 months or more for individuals under

18 years

6 months or more for all age groups

Insight May be absent in children –

Specifier ‘‘Generalized’’ ‘‘Performance Only’’

‘‘Selective Mutism’’

Generalized anxiety disorder

Specific criteria – Avoidance of activities/events with

possible negative outcomes

Difficulties in controlling worry –

Symptom count Anxiety/worry associated with three

or more (out of 6) symptoms

Anxiety/worry associated with one

or more (out of 2) symptoms

Duration 6 months or more 3 months or more

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123

‘‘major attachment figures’’ for ‘‘adults’’) to better suit all

age groups. Also, the early-onset specifier (‘‘before

6 years’’) has been dropped and duration is specified as

‘‘typically lasting six or more months’’ (instead of 4 weeks)

to minimize over-diagnosis of transient fears.

Major changes for specific phobia

Within the specific phobia category, revisions mainly aim

at clarifying the terminology and increasing the usability of

criteria. The term ‘‘excessive or unreasonable’’ is either

omitted or replaced by the term ‘‘out of proportion to the

danger posed’’, thereby relating the fear/anxiety to its

source. Furthermore, the sociocultural context needs to be

taken into account when judging the proportionality of an

individual’s fear/anxiety, because the danger posed by

certain objects or situations (e.g., the probability of

encountering a lethally toxic spider, becoming a victim of

war, or getting caught in a blizzard) varies among cultural

groups and geographic regions.

Major changes for social anxiety disorder

(formerly social phobia)

The most obvious change to the social anxiety disorder

category is its new title, which was chosen to emphasize

the broad range of social situations that are feared/avoided.

Based on factor-analytic approaches, three types of social

situations have been discerned and are now reflected in

criterion A: performance, interaction, observation (with the

latter two being new to the DSM-5). As a common

denominator of what is feared in such situations, the

broader term ‘‘negative evaluation’’ has been introduced to

represent the core fear in social anxiety disorder. The terms

‘‘humiliation’’ and ‘‘embarrassment’’ (DSM-IV) have been

subsumed under this term and are now listed as examples

or consequences of negative evaluation fear (criterion B).

In addition to the range of situations, also the range of

people with whom the child/adolescent may experience

fear/anxiety has been extended from DSM-IV to DSM-5.

The limitation ‘‘to unfamiliar people’’ has been removed

because social fear/anxiety may also arise in social-eval-

uative situations with familiar people.

Further, the prefix ‘‘actively’’ has been added to the

descriptor ‘‘avoided’’ to exclude relatively common age-

typical reactions to mild social fears as opposed to the

active avoidance of social situations due to age-inappro-

priate fears. Finally, the ‘‘Generalized’’ specifier has been

removed while ‘‘Performance Only’’ and ‘‘Selective Mut-

ism’’ have been added as specifiers. That is, the generalized

form of social anxiety disorder is now seen as the norm.

Since evidence indicates that fears can also take the form

of transient perturbations in adulthood [6], the duration

criterion of ‘‘6 months or more’’ has been unified across age

groups for separation anxiety disorder, social anxiety dis-

order, and specific phobia, and the age restriction of the

duration criterion (‘‘individuals under age 18 years’’) has

been removed. For both specific phobia and social anxiety

disorder, the criterion of having insight into the inappropri-

ateness of one’s fears has been dropped (new for adults). In

effect, the duration and self-recognition criteria have now

been matched for children, adolescents, and adults.

Major changes for generalized anxiety disorder

Consistent with the criteria for other anxiety disorders, an

avoidance criterion has been introduced for generalized

anxiety disorder (‘‘marked avoidance of activities or events

with possible negative outcomes’’) under criterion D which

specifies anxiety- and worry-associated behaviors such as

reassurance seeking, procrastination in behavior or decision

making, or time and effort spent on preparation to fend off

anticipated negative outcomes. Other changes concern the

duration criterion (reduced from 6 to 3 months), the

symptom count (reduced from 3 criteria to 1), and the cri-

terion of difficulties in worry control (omitted). These

changes are based on empirical evidence suggesting that the

two symptoms retained for DSM-5 (restlessness or feeling

keyed up; muscle tension) and the reduced threshold of

3 months are sensitive and specific enough to identify

clinically significant cases, while deleting the control cri-

terion has little effect on the number of identified cases [7].

Assessment and treatment of anxiety disorders

in children and adolescents

Applying a developmental lifespan perspective to anxiety

disorders and redefining diagnostic criteria accordingly

entail a need for developmentally sensitive assessments in

youth. The revised practice parameter of the American

Academy of Child and Adolescent Psychiatry (AACAP)

[8] and the results of meta-analyses on randomized con-

trolled trials with children with anxiety disorders [9, 10]

result in the following recommendation. According to the

AACAP’s guidelines, the assessment phase should contain

three steps. With prevalence rates being high for anxiety

disorders, screening questions for anxiety symptoms should

routinely be run during mental health examinations (Step

1) and, if positive, be followed up by a formal evaluation to

determine the presence, severity, and duration of symp-

toms, and the degree of impairment (Step 2). Furthermore,

due to high comorbidity, a broad assessment approach

above and beyond the anxiety disorders needs to be applied

for purposes of differential diagnostics (Step 3). As a

consequence of the developmental lifetime perspective of

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123

the DSM-5, risk estimation and prognosis should always

endorse the assessment of prior disorders because the

individual history of any anxiety disorder (e.g., SAD in

childhood) adds to the risk for other disorders inherent in

later age periods (e.g., social anxiety disorder in adoles-

cence or panic disorder in adulthood). Based on rigorous

empirical evidence obtained through randomized con-

trolled trials and meta-analyses, cognitive behavior treat-

ment should always be the first treatment choice for all

subtypes of anxiety disorders across all age groups. Phar-

macotherapy might be considered to be delivered in com-

bination or alone in cases of non-responders to CBT. While

the efficacy and safety of short-term SSRI use has empir-

ically been established in children and adolescents, the

risk–benefit ratio of long-term medication has not yet been

assessed, and no dosing guidelines have been established to

date.

From a developmental lifespan perspective, it follows

that assessment tools for children need to be sensitive to

both age-related manifestations and age-related subtypes of

a disorder [2]. Age-related subtypes identify developmen-

tally unique forms of a disorder (e.g., selective mutism in

social anxiety disorder), while age-related manifestations

relate to changes in how a particular symptom manifests

itself at distinct points in development [2]. Further, because

anxiety disorders can be understood as a child’s failure to

master age-typical fears or to overcome anxiety-provoking

repercussions of negative life events [11], assessment tools

need to reliably differentiate age-appropriate from age-in-

approriate fears (e.g., stranger anxiety vs. SAD). This dual

task of achieving both developmental sensitivity and

specificity may best be addressed by an assessment

approach that is multi-informant (child, parent, and tea-

cher) and multi-method (i.e., combining different, but

converging data gathering procedures). Self-report mea-

sures such as the Multidimensional Anxiety Scale for

Children (MASC [12]), the Screen for Child Anxiety

Related Emotional Disorders (SCARED [13]), or the

Spence Child Anxiety Scale (SCAS [14]) may be helpful to

assist with the initial screening and/or to supplement the

clinical interview during the formal evaluation. The

structured diagnostic interview, however, is absolutely

essential for the assessment of anxiety disorders in youth

and can be supplemented, yet not substituted, by self- and

other-report measures. Examples of DSM-based structured

interviews for children and adolescents are the ADIS-C

[15] or the Kinder-DIPS (Diagnostisches Interview bei

psychischen Störungen im Kindes- und Jugendalter [16]).

Evidence-based psychotherapy

Of all forms of psychotherapy, cognitive-behavioral ther-

apy (CBT) is the only empirically supported psychotherapy

of anxiety disorders in youth, with an average remission

rate of 56–68.9 % and mean pre-post treatment effect sizes

of 0.58 (intent-to-treat) to 0.86 for completers in meta-

analyses [9, 17, 18]. One of the most widely used catch-all

anxiety treatment programs, Coping Cat [19, 20], and

adaptations of this program [21], have demonstrated good

efficacy in treating a host of childhood anxiety disorders,

with between-group effect sizes of 0.87 across disorders on

general anxiety measures as compared to the waitlist [19].

The percentage of children no longer meeting diagnostic

criteria after Coping Cat treatment varies between 59 % in

intent-to-treat samples [21] and 64–70.6 % [19, 20], with

gains well maintained over time [22]. As suggested by the

TAFF treatment study (TAFF: Trennungsangstprogramm

für Familien [23]) and the meta-analysis on treatment

studies for social phobia [24], effects may even be larger

and remittance rates higher for disorder-specific treatments.

However, this promising research line has just been started

for children and adolescents and needs further replication.

The role of parents in CBT

While family therapy and education of the parents about

the anxiety disorder is recommended by the 2007 guide-

lines of the AACAP as part of a multimodal treatment

approach, empirical evidence has since been accumulated

indicating that supplementing the child’s CBT with a par-

ent training component adds no gain over child-only CBT

[25, 26].

Comment

With the change from a ‘top down’ approach to childhood

anxiety disorders in DSM-IV (application of adult diag-

nostic criteria to children and adolescents) to a develop-

mental lifespan perspective in DSM-5, hopes are high that

the focus of research into anxiety disorders, which still

is adult-centered, might shift toward a clinical psychology

of the lifespan. First steps have already been taken, for

example, by the development of age-appropriate, child-

friendly assessment instruments like the Picture Anxiety

Test for children 4–8 years of age [27] or the development

of disorder-specific treatments for children like the TAFF

program for separation anxiety disorder [23]. Thereby,

researchers respond to empirical findings that show anxiety

disorders to start early in childhood and to continue into

adulthood if left untreated, with remission rates as low as

10 % for specific phobia or 13 % for social phobia. By

comparison, remission rates after cognitive-behavioral

therapy (CBT) range between 56 and 68.9 % [9, 17]. In

conclusion, CBT can be considered a well-established

treatment for childhood anxiety disorders. Inclusion of the

S20 Eur Child Adolesc Psychiatry (2013) 22 (Suppl 1):S17–S22

123

parents, however, did not significantly improve treatment

success above and beyond that of child-only CBT treat-

ments [28]. In comparison to other treatments of childhood

anxiety disorders, only CBT fulfills the criteria of an evi-

dence-based treatment approach.

However, the changes from DSM-IV to DSM-5 might

have far less impact on clinical practice than on research.

Of the two major nosological systems, the ICD-10 is the

classification system used for diagnoses in psychiatric

clinics and private practice in Europe. Contrary to

empirical evidence, the ICD-10 diagnostic criteria are

grounded in the assumption of discontinuity of mental

disorders, maintaining separate divisions for adult (F4)

and childhood (F9) anxiety disorders. Between the ICD-

10 and DSM-IV-TR, a low level of concordance has been

found for anxiety disorders in youth. More specifically,

the DSM diagnoses more, but not necessarily the same,

children with an anxiety disorder than the ICD-10 [29].

Differences in diagnoses could be attributed to the two

systems using different definitions of common features,

e.g., the definitions of (specific and social) fear and

impairment, and to differing age delimiters and duration

criteria. As a consequence of these differences, knowledge

gained from research (using DSM) may not be readily

applicable to clinical practice (utilizing ICD), pointing to

the need to make the two nosological systems more

compatible. Hopefully, this compatibility will be fostered

with the upcoming ICD-11. With the adoption of a

developmental lifespan perspective in the DSM-5 and the

assumption of continuity of anxiety disorders, the gap

between the two systems has become even wider. Yet, as

the changes are empirically well founded, they can be

considered a necessary step toward an evidence-based

approach to the diagnostics, assessment, and treatment of

anxiety disorders in children.

Conflict of interest On behalf of all authors, the corresponding author states that there are no conflicts of interest. This article is part

of the supplement ‘‘The Future of Child and Adolescent Psychiatry

and Psychology: The Impact of DSM 5 and of Guidelines for

Assessment and Treatment’’. This supplement was not sponsored by

outside commercial interests.

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