A DSM-IV–based diagnosis of separation anxiety disorder requires that the child exhibit at least three of the following symptoms for at least four weeks10:
• Clinically significant distress regarding the anticipated or actual separation from the home or from “major attachment figures” (ie, caregivers)
• Excessive fear of harm to caregivers
• Persistent worry about separating events, such as being kidnapped or getting lost
• Reluctance or refusal to leave home for any reason, including school
• Fear of being alone or without caregivers, at home or elsewhere
• Inability to sleep away from caregivers
• Frequent nightmares about separation
• Physical symptoms, such as headaches or nausea, prompted by anticipated or actual separation from caregivers.
Symptoms must be sufficiently severe to cause the child significant distress or interfere with school or other daily activities.10
Generalized Anxiety Disorder
“Overanxious disorder of childhood” is included in the DSM-IV description of generalized anxiety disorder (GAD), a condition of excessive, unfounded worry over numerous aspects of life.10 Among GAD-affected children are found several common characteristics, including self-consciousness, reassurance-seeking behavior,18 and preoccupation with punctuality, following rules, and maintaining a certain appearance; children are often overly mature for their age. Because of their perfectionist tendencies, these children may avoid challenging activities or public performances for fear of being judged incompetent or foolish.10,11 Identifying GAD in children may be difficult, as many adults view their meticulous, submissive behaviors as advantageous traits.19
Natural disasters, physical attack, upcoming school-related events, and scapegoating by peers are the most common worries to affect children between ages seven and 12 who experience GAD.11,20
For a diagnosis of GAD based on DSM-IV criteria, the patient must experience anxiety most days for at least six months, and the source of anxiety should be distinguishable from those associated with other anxiety disorders. The child must exhibit at least three of the following symptoms: restlessness, inclination to fatigue, difficulty concentrating, irritability, muscular tension, and sleep disturbances. Additionally, the child’s symptoms must be severe enough to disrupt daily activities or cause the patient significant psychological stress.10
Obsessive-Compulsive Disorder
Either obsessions or compulsions can satisfy a diagnosis of obsessive-compulsive disorder (OCD). Obsessions are recurring and irrepressible thoughts or impulses that may be illogical or unrelated to real-life problems but cause significant distress; compulsions are repetitive behaviors or mental acts performed to reduce anxiety or prevent a feared situation or event. Childhood OCD is more common among boys than girls.10
Children who have OCD are often affected by aggression obsessions (concerns about giving in to aggressive impulses, for example) and fear of catastrophic events.21,22 Counting, checking, ordering, and washing in an effort to gain or maintain control are the most common compulsions seen in children and adolescents, but hoarding and saving compulsions are also prevalent, particularly among girls.18,22
Children who meet the DSM-IV diagnostic criteria for OCD experience significant distress or impairment as a result of their
symptoms. Devoting an hour or more each day to managing an obsession or compulsion is an essential feature of OCD. Unlike adults, who usually come to realize that their obsessions or compulsions are not reasonable, children with OCD often are not aware that they need help; usually their caregivers recognize the problem.10
Diagnostic Tools
In the primary care setting, open-ended questions about a child’s academic performance, social activities, and home life are easily incorporated in the history taking and may yield important information that indicates the need for further evaluation. A number of simple screening tools have been shown effective in identifying various anxiety disorders in the pediatric population. (See Table 223-25 for information regarding availability of these tests and instructions for scoring and interpretation.)
The Screen for Child Anxiety Related Emotional Disorders (SCARED),23 a 41-item self-report questionnaire administered to both child and parent, has been shown effective in identifying pediatric anxiety disorders in both primary care and outpatient settings.23,26 Both child and parent versions of the SCARED are available online.
The Multidimensional Anxiety Scale for Children (MASC)24 is a 39-item instrument with both child and parent self-report components available for purchase. It has been successfully used in both clinical and community samples to screen for pediatric anxiety disorders.24,27
The Pediatric Anxiety Rating Scale (PARS)25 is a clinician-scored instrument that has been used to evaluate the severity of anxiety disorders in children.
Researchers conducting a comprehensive review of the most commonly cited and psychometrically valid anxiety scales used in children concluded that the PARS, combined with either the SCARED or the MASC, provided an appropriate assessment for pediatric anxiety disorders.28
Treatment
Early detection of anxiety increases the patient’s likelihood of receiving early, effective treatment—which has been associated with short- and long-term success.1,29