Gail A. Bernstein

Anxiety Disorders in Children and Adolescents: A Review of the Past 10 Years

OBJECTIVE To critically review the research on anxiety disorders in children and adolescents, focusing on new developments in the past 10 years. METHOD This review includes recent articles which contribute to the conceptualization, assessment, and treatment of childhood anxiety disorders. RESULTS Information was organized into a developmental framework. Anxiety disorders research has shown steady progress. CONCLUSIONS More research is needed, particularly in the areas of neurobiological basis of anxiety disorders, longitudinal studies, and treatment.

Anxiety Disorders of Childhood and Adolescence: A Critical Review

The 1980s were a decade of advancement in the knowledge of anxiety disorders in children and adolescents; this sets the stage for research achievements in the 1990s. This review examines the anxiety disorders of childhood and adolescence (separation anxiety disorder, overanxious disorder, and avoidant disorder), including prevalence rates, demographic profiles, comparisons of clinical presentations in different developmental age groups, and comorbidity patterns. Fears and simple phobias, obsessive-compulsive disorder, post-traumatic stress disorder, and panic disorder in children and adolescents are also evaluated. The controversy of whether panic attacks occur in prepubertal children is addressed. A brief review of behavioral and pharmacological treatment studies is included. Future directions for research are suggested.

School Refusal in Children and Adolescents: A Review of the Past 10 Years

OBJECTIVE To critically review the past 10 years of research on school refusal in children and adolescents. METHOD Literature on school refusal published from 1990 onward was reviewed following a systematic search of PsycINFO. The review focuses on definitional issues, epidemiology and school refusal identification, diagnostic considerations, family functioning, assessment, treatment, and follow-up studies. RESULTS While definitional and conceptual issues are still evident, promising developments have occurred in relation to assessment and treatment practices and understanding of the family context of school refusal. CONCLUSIONS From a clinical viewpoint, school refusal cases require comprehensive assessment and treatment. Advances have been made in the treatment of school refusal. However, additional controlled studies evaluating interventions for school refusal are needed.

Imipramine Plus Cognitive-Behavioral Therapy in the Treatment of School Refusal

OBJECTIVE To investigate the efficacy of 8 weeks of imipramine versus placebo in combination with cognitive-behavioral therapy (CBT) for the treatment of school-refusing adolescents with comorbid anxiety and major depressive disorders. METHOD This was a randomized, double-blind trial with 63 subjects entering the study and 47 completing. Outcome measures were weekly school attendance rates based on percentage of hours attended and anxiety and depression rating scales. RESULTS Over the course of treatment, school attendance improved significantly for the imipramine group (z = 4.36, p < .001) but not for the placebo group (z = 1.26, not significant). School attendance of the imipramine group improved at a significantly faster rate than did that of the placebo group (z = 2.39, p = .017). Over the 8 weeks of treatment, there was a significant difference between groups on attendance after controlling for baseline attendance; mean attendance rate in the final week was 70.1% +/- 30.6% for the imipramine group and 27.6% +/- 36.1% for the placebo group (p < .001). Defining remission as 75% school attendance, 54.2% of the imipramine group met this criterion after treatment compared with only 16.7% from the placebo group (p = .007). Anxiety and depression rating scales decreased significantly across treatment for both groups, with depression on the Childrens Depression Rating Scale-Revised decreasing at a significantly faster rate in the imipramine group compared with the placebo group (z = 2.08, p = .037). CONCLUSIONS Imipramine plus CBT is significantly more efficacious than placebo plus CBT in improving school attendance and decreasing symptoms of depression in school-refusing adolescents with comorbid anxiety and depression.

School phobia: the overlap of affective and anxiety disorders

In a group of 26 early adolescent, chronic school refusers, 69% met DSM-III criteria for affective disorder (depression), 62% met criteria for anxiety disorder, and 50% had both depressive and anxiety disorders. Patients with both disorders were more severely symptomatic as indicated by higher scores on rating scales for anxiety and depression. While children and adolescents with depressive disorders frequently reported anxiety symptoms, in general those with anxiety disorders did not commonly describe depression. However, those patients with severe anxiety symptoms reported specific depressive symptomatology, indicating that severe anxiety disorders in children and adolescents may be clinically indistinguishable from depression.

Comparative Studies of Pharmacotherapy for School Refusal

Two studies compared alprazolam and imipramine in the treatment of school refusal. In an open label study (N = 17), two-thirds of the subjects completing a trial in both the alprazolam and imipramine groups showed moderate to marked global improvement in symptoms of anxiety and depression. In the double-blind, placebo-controlled study (N = 24), posttreatment scores calculated as change from baseline on the Anxiety Rating for Children were significantly different (p = .03) among the three treatment groups, with the active medication groups showing the most improvement. Additionally, on all depression rating scales, similar trends were evident with the alprazolam and imipramine groups demonstrating greater improvement than the placebo group. However, analyses of covariance (with pretreatment scores as the covariates) showed no significant differences among the three treatment groups on change in anxiety and depression scales. Thus, additional research is needed to determine whether trends in this study are explained by drug effect or baseline differences on rating scales.

Comorbidity and severity of anxiety and depressive disorders in a clinic sample.

Ninety-six children and adolescents with school refusal were evaluated with clinician and self-report rating scales for anxiety and depression. Patients meeting DSM-III-R criteria for both anxiety and depressive disorders scored significantly higher than those in the other three diagnostic groups (anxiety disorder only, depressive disorder only, and no anxiety or depressive disorder) on all anxiety and depression rating scales. Patients with no anxiety or depressive disorders scored lowest on all scales. Patients with pure depression and pure anxiety disorders were psychometrically similar, with scores that were intermediate between the other two groups. Demographic profiles and types of comorbid anxiety diagnoses within the diagnostic groups are presented.

Practice Parameters for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders

This revised practice parameter reviews the evidence from research and clinical experience and highlights significant advancements in the assessment and treatment of anxiety disorders since the previous parameter was published. It highlights the importance of early assessment and intervention, gathering information from various sources, assessment of comorbid disorders, and evaluation of severity and impairment. It presents evidence to support treatment with psychotherapy, medications, and a combination of interventions in a multimodal approach.

Caffeine dependence in teenagers

This study identifies and characterizes symptoms of caffeine dependence in adolescents. Thirty-six adolescents who consumed caffeine daily and had some features of caffeine dependence on telephone screen were scheduled for outpatient evaluation. Evaluation included the Diagnostic Interview Schedule for Children-IV-Youth Version (DISC-IV) and modified DISC-IV questions that assessed caffeine dependence based on DSM-IV substance dependence criteria. Of 36 subjects, 41.7% (n=15) reported tolerance to caffeine, 77.8% (n=28) described withdrawal symptoms after cessation or reduction of caffeine intake, 38.9% (n=14) reported desire or unsuccessful attempts to control use, and 16.7% (n=6) endorsed use despite knowledge of physical or psychological problems associated with caffeine. There was no significant difference in the amount of caffeine consumed daily by caffeine dependent versus non-dependent teenagers. These findings are important due to the vast number of adolescents who drink caffeinated beverages.

Somatic symptoms in anxious-depressed school refusers

OBJECTIVE To identify the most common physical complaints in a sample of adolescent school refusers with comorbid anxiety and depressive disorders. Whether somatic symptoms are more likely to be associated with high levels of anxiety or high levels of depression was also explored. METHOD Forty-four adolescents in a treatment study were evaluated at baseline with structured psychiatric interviews and measures of anxiety, depression, and somatization. RESULTS The most common somatic complaints were in the autonomic and gastrointestinal categories. In simple regression analyses, anxiety level as measured with the Revised Childrens Manifest Anxiety Scale and depression level as measured with the Beck Depression Inventory each significantly predicted the severity of somatic symptoms. The correlation between percentage of days absent from school and severity of somatic symptoms approached significance (r = .27, p = .074). CONCLUSIONS Knowledge that somatic complaints are commonly an expression of underlying anxiety and depression may facilitate more rapid referral for psychiatric assessment and treatment and thereby help avoid unnecessary medical workups and sequelae from school refusal.