Separation Anxiety Disorder, Generalized Anxiety Disorder and Social Anxiety Disorder

The essential feature of separation anxiety disorder is excessive worry concerning separation from the home or from those to whom the person is attached. This worry is beyond what is expected for the individual’s developmental level. In clinical samples, the disorder is equally common in males and females; however, in epidemiological samples the disorder is more frequent in females.

Generalized Anxiety Disorderl (GAD) is character­ized by excessive worry about a variety of situations. In children and adolescents, the worries often concern the quality of performance at school or in sporting events, punctuality or catastrophic events. The diagnosis of overanxious disorder from DSM-III-R was eliminated in DSM-IV and the criteria for GAD modified for children. Therefore, there is some controversy about the link between overanxious disorder and generalized anxiety disorder in children. In a study by Kendall and Warman, a large group of children with overanxious disorder met criteria for generalized anxiety disorder. Therefore, the prevalence rates for the two closely approximate each other. As a result, many of the studies reviewed here tended to collapse the two groups into one category. In community epidemiological studies, the prevalence rates for overanxious disorder have ranged from 2.9% to 4.6%.

Social anxiety disorder (social phobia) has as its core feature excessive anxiety about social or performance situations in which the individual fears scrutiny or exposure to unfamiliar persons. Onset of social anxiety most commonly occurs in mid-adolescence. Adolescents with social anxiety disorder may have few friends, have difficulties with intimate relationships and/or develop substance abuse. Figures based on DSM-III-R criteria placed the prevalence rate at 1%. Kendall and Warman’s study found that 18% of their sample met DSM-III-R criteria for social phobia, yet 40% of the same sample met DSM-IV criteria. This may indicate an underestimation of the prevalence of social anxiety disorder.

The literature has relatively recently begun to evolve to include clinical trials of childhood anxiety disorders. Kendall performed the first randomized clinical trial investigating the efficacy of a cognitive-behavioral therapy intervention for children diagnosed with an anxiety disorder (these disorders did not include specific phobias or OCD). Forty-seven children aged 9—13 years old were randomly assigned to either cognitive-behavioral therapy (N=27) or a wait-list condition (N=20). Children in the CBT condition received 16 weekly sessions that included helping the child to: 1) recognize anxious feelings and somatic reactions to anxiety, 2) clarify cognition in anxiety-provoking situations, 3) develop a plan to help cope with the situation, and 4) evaluate performance and administer self-reinforcement as appropriate. The wait-list condition was for eight weeks, at the end of which time those children could receive the CBT intervention. The results revealed that the subjects treated with the CBT intervention made clinically significant gains as measured at the end of treatment and that these gains were maintained at a one-year follow-up. Kendall’s study has since been followed by a controlled trial by Barrett, Dadds, and Rapee in Queensland, Australia, and another study by Kendall et al. in 1997, again looking at treatment of anxiety disorders in children using a cognitive-behavioral approach.

There is emerging evidence that group CBT is efficacious in the treatment of childhood anxiety disorder (Abilify tabletes). Barrett conducted the first study exploring the efficacy of group CBT (GCBT). The three treatment conditions included GCBT, GCBT plus family management (GCBT + FAM) and wait-list. At the 12-month follow-up, there was no statistically significant difference between the GCBT and GCBT + FAM groups; however, both groups maintained significantly better outcomes than the waitlist condition. Thus, it appeared that GCBT was effective but that the parental involvement was equivocal.

In a study by Silverman and colleagues, the primary goal was to evaluate the efficacy of GCBT for treating anxiety in children. A secondary goal was to extend and complement the ratings instruments that had been used in previous studies to measure outcome. Two global ratings of clinical severity were used as well as three child self-report measures and three parent-report measures. In addition, frequency of follow-up intervals was increased to three-, six-and 12 months. Fifty-six children ages 6-16 years old were randomly assigned to GCBT or wait-list condition. The results showed that 64% of the children in the GCBT were recovered at posttreatment, compared to 13% of the children in the wait-list condition. Significant treatment gains were also maintained in the GCBT subjects at 12 months.

Cognitive-behavioral therapy, both individual and group, has been shown to be efficacious when treating childhood anxiety disorders when compared to a wait-list condition. Several investigators have identified that and are seeking to understand how the parental component contributes to the improvement of these children. There is growing evidence that anxiety in children is significantly related to frequent negative feedback and parental restriction. Prior to a 1996 study by Barrett and associates, no study had yet examined the value of incorporating parent training in treatment outcome studies in childhood anxiety. One significance of this study is its design, which compared two methods of treatment with a control condition. Barrett and colleagues investigated the effectiveness of cognitive-behavioral and family management training procedures with childhood anxiety disorders. Seventy-nine children aged 7-14 years were randomly assigned to receive child-only CBT, child CBT plus family anxiety management training (CBT + FAM) or a wait-list condition. The family intervention involved three phases: 1) parenting skills for managing child distress and avoidance, 2) parenting skills to manage their own anxiety and 3) parental communication and problem-solving skills. The results of the study were very promising indeed. Both the CBT and CBT + FAM groups had significantly better outcomes than the wait-list group, and the CBT + FAM was found to be significantly more efficacious than the CBT group. Sixty-one percent of the children in the CBT group no longer met DSM-III-R criteria for any anxiety disorder (generic Duloxetine) as compared to 88% of the CBT + FAM group, which no longer met diagnostic criteria. At the 12-month follow-up, the difference between the CBT and the CBT + FAM groups remained significant. Fifty-two of the participants from the original study participated in a six-year follow-up to examine not only if the treatment gains were still present within the two groups but also whether the CBT + FAM group still had relative superiority to the CBT-only group. The results showed that 87% of the children no longer met diagnostic criteria for an anxiety disorder and that both treatments were equally effective.

Mendlowitz and colleagues also examined the role of parental involvement coupled with group cognitive-behavioral therapy in the treatment of childhood anxiety disorders. Sixty-two children were randomly assigned to one of three 12-week treatment conditions: 1) parent and child intervention, 2) child-only intervention and 3) parent-only intervention. All treatment groups experienced a reduction in both anxiety and depressive symptoms, suggesting that group CBT is efficacious in treating children with anxiety disorders. It was also noted that parental involvement uniquely contributed to improved coping strategies in the parent-child condition. In this study, there was no 12-month follow-up posttreatment.

Shortt and colleagues conducted the first randomized clinical trial evaluating the efficacy of the FRIENDS program, a family-based group cognitive-behavioral treatment (FGCBT) for anxious children. FRIENDS is an acronym for the strategies taught in the sessions (F—Feeling worried?; R—Relax and feel good; I—Inner thoughts; E—Explore plans; N— Nice work so reward yourself; D—Don’t forget to practice; and S—Stay calm, you know how to cope now). FRIENDS has a number of unique features, including two forms for children ages 6-11 years and ages 12-16 years. Also, it incorporates a family skills component involving cognitive restructuring for parents and assisting families in building social support. Seventy-one children ranging in age from 6-10 years who met diagnostic criteria for separation anxiety disorder (Wellbutrin SR 150 mg), generalized anxiety disorder or social anxiety disorder were randomly assigned to the FRIENDS group or a wait-list control. Children in the treatment group participated in 10 weekly sessions in addition to two booster sessions that occurred one- and three months following completion of treatment. The results indicated that children who completed the FRIENDS program showed greater improvement than the wait-list condition. Sixty-nine percent of children who completed the FGCBT were diagnosis-free, as compared to 6% of the children in the wait-list condition. At 12-month follow-up, 68% of the children in the treatment group were diagnosis-free.

Beidel and colleagues conducted a study evaluating the efficacy of Social Effectiveness Therapy for Children (SET-C) a structured behavioral therapy. The therapy consisted of 24 sessions with 12 group sessions and 12 individual exposure sessions. Sixty-seven children aged 8-12 years were randomly assigned to either the SET-C group or an active, nonspecific intervention (Testbusters). Testbusters is a program that includes study skills and test-taking strategies but does not specifically address social anxiety. Fifty children completed the study. Those in the SET-C group showed significant improvement in functioning and decrease in symptoms. Sixty-seven percent of the SET-C group no longer met diagnostic criteria for social phobia compared to 5% of the control group. Treatment gains were maintained at six-month follow-up.

Few controlled studies exist that examine the pharmacological treatment of childhood anxiety disorders. The Research Unit on Pediatric Psychophar-macology Anxiety Study Group conducted a randomized, double-blind trial of fluvoxamine and placebo in children with social phobia, separation anxiety disorder (Risperidone pills) or generalized anxiety disorder. The study included 128 children aged 6-17 years. All children received supportive psychotherapy during the eight-week study period. Significant differences between the treatment groups were detected as early as week three and increased through week six, at which time they plateaued. In a second study, Rynn and colleagues conducted the first randomized, double-blind, placebo-controlled trial of a selective serotonin reuptake inhibitor (SSRI)—sertraline—in children and adolescents with a primary diagnosis of generalized anxiety disorder. Twenty-two children and adolescents aged 5-17 years were assigned to either the Generic sertraline or placebo group for a nine-week study. Psychotherapy except for cognitive-behavioral therapy was allowed, provided the patients had been receiving the same therapy for the three months prior to the study and that the level of intensity remained unchanged throughout the study. The results of this study suggest that sertraline tabletes at a low dose of 50 mg daily is safe and efficacious in treating generalized anxiety disorder in children. There were no significant differences between the groups with respect to adverse events.