Question

21. Compare and contrast the way mood disorders are expressed in child/adolescents and elderly adults. How might these differences be explained from a biological perspective? From a social perspective?

Answer 1

Childhood and adolescence is the core risk phase for the development of symptoms and syndromes of anxiety that may range from transient mild symptoms to full-blown anxiety disorders.

Challenges from a research perspective include its reliable and clinically valid assessment to determine its prevalence and patterns of incidence, and the longitudinal characterization of its natural course to better understand what characteristics are solid predictors for more malignant courses as well as which are likely to be associated with benign patterns of course and outcome. This type of information is particularly needed from a clinical perspective to inform about improved early recognition and differential diagnosis as well as preventions and treatment in this age span.

Anxiety refers to the brain response to danger, stimuli that an organism will actively attempt to avoid. This brain response is a basic emotion already present in infancy and childhood, with expressions falling on a continuum from mild to severe. Anxiety is not typically pathological as it is adaptive in many scenarios when it facilitates avoidance of danger. Strong cross-species parallels—both in organisms’ responses to danger and in the underlying brain circuitry engaged by threats—likely reflect these adaptive aspects of anxiety.

One frequent and established conceptualization is that anxiety becomes maladaptive when it interferes with functioning, for example when associated with avoidance behavior, most likely to occur when anxiety becomes overly frequent, severe, and persistent.

Thus, pathological anxiety at any age can be characterized by persisting or extensive degrees of anxiety and avoidance associated with subjective distress or impairment. The differentiation between normal and pathological anxiety, however, can be particularly difficult in children because children manifest many fears and anxieties as part of typical development (Table 1). Although these phenomena might be acutely distressing, they occur in most children and are typically transient.

For example, separation anxiety normatively occurs at 12 to 18 months, fears of thunder or lightning at 2 to 4 years, and so forth. Thus, given that such anxiety occurs in most children and typically does not persist, distress, in and of itself, represents an inadequate criterion for distinguishing among normal and pathological anxiety states in children.

This problem creates unique challenges when trying to distinguish among normal, subclinical, and pathological anxiety states in children. Other challenges in the assessment of childhood fears and anxiety are that children at younger ages may have difficulties in communicating cognition, emotions, and avoidance, as well as the associated distress and impairments, to the diagnostician because they might lack the cognitive capabilities used to communicate information vital to the application of the diagnostic classification system. Thus, developmental differences (eg, cognition, language skills, emotional understanding) must be carefully considered when assessing anxiety in young people to make a diagnostic decision.6

Table 1

Normative anxiety and fears in childhood and adolescence

Anxiety disorders are described and classified in diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM, currently version IV-TR, American Psychiatric Association)2or the International Classification of Diseases (ICD, currently version 10, World Health Organization) (Table 2).

Across these systems, many anxiety disorders share common clinical features such as extensive anxiety, physiological anxiety symptoms, behavioral disturbances such as extreme avoidance of feared objects, and associated distress or impairment. Nonetheless, differences exist and it should be noted that narrowly categorized anxiety disorders such as panic disorder, agoraphobia, and subtypes of specific phobias also exhibit a substantial degree of phenotypical diversity or heterogeneity.

Table 2

Classification of anxiety disorders according to ICD-10 and DSM-IV

In the assessment of anxiety features in children one has to recognize that the core diagnostic criteria might present differently in the young, requiring special assessment strategies and the recognition of special features that are unique to or characteristic for this age group. DSM-IV acknowledges this by adding for some disorders, though not consistently, some of the features that might present differently in children and adolescents. With the exception of separation anxiety disorder, all of the anxiety disorders in DSM-IV are grouped together irrespective of the age at which the disorder manifests; separation anxiety disorder, in contrast, is defined as manifesting before adulthood. Thus for most of the anxiety disorders, differences between diagnostic criteria for children and adults, if any, are provided within the same criteria set. Examples include duration commentaries, differences in symptom type or count, or insights into the excessiveness/inadequacy of fear (Table 2).

More specifically, for example, the threshold in DSM-IV for diagnosing generalized anxiety disorder is lower in children than adults (1 instead of 3 out of 6 symptoms); in phobias, children are not required to judge their anxiety as excessive or unreasonable, yet duration must be at least 6 months among individuals under the age of 18 years. For ICD-10, in contrast to DSM-IV, children receive other diagnostic codings, separate from adults, for anxiety disorders that reflect exaggerations of normal developmental trends. The specific differences in diagnosis and diagnostic criteria between children and adults for DSM-IV and ICD-10 are listed in Table 2.

It should be noted that it remains unspecified as to what age range the “child-specific” diagnostic criteria refer. Given cognitive and language development, the increasing importance of peer relationships, and the seeking of autonomy from parents, it is crucial to specify similarities and differences in anxiety expressions for different ages (eg, childhood up to 12 years, adolescence 13 to 17 years). This important issue is rarely acknowledged in the current diagnostic criteria, and not even in the text portions of the DSM that generally contain important additional information for diagnosticians and clinicians (see Table 2).

There is also little guidance in the diagnostic systems on developmentally appropriate assessment of anxiety disorders to identify those in need of treatment. Although the development of explicit descriptive diagnostic criteria has facilitated the development of diagnostic instruments for the assessment of anxiety disorders, diagnosticians and clinicians should be aware of their limitations, particularly related to developmental issues in obtaining self-reports from children and adolescents.

Table 3 provides a selection of the most commonly used diagnostic tools for assessment of anxiety symptoms and anxiety disorders in children and adolescents. In children, applications of these tools to younger children might be more problematic than to older children, as reflected in poorer psychometric data. This problem undoubtedly at least partly reflects the difficulty young children face when trying to communicate information about internally experienced affective states.

Therefore, assessments in young children often require solicitation of information from multiple sources beyond the child to reliably and validly distinguish among normal anxiety, subclinical, and pathological anxiety syndromes and disorders. This assessment includes parent or teacher reports. In older children and adolescents, in contrast, diagnostic decisions can rely heavily on information provided directly by the patient, although even in this age group parallel informants can also be helpful.

Table 3

Assessment in children and adolescents

Beyond these problems, unclear rules for applying diagnostic thresholds and variations in the methods used to aggregate information from different sources may drastically influence prevalence estimates (see later discussion) and might also impact findings from basic and epidemiological research. Thus, anxiety disorders in children and adolescents cannot be easily assessed with standard questionnaires or interviews that have been derived from adult instruments. In fact, the use of structured and standardized interviews for children and adolescents has much improved the reliability and validity of anxiety diagnoses in children and adolescents in the last 2 decades. Such instruments also have an advantage over symptom scales in that they allow a better delineation of transient subclinical manifestations of anxiety from anxiety disorders that were shown to have predictive validity and even concrete implications for prevention early intervention, and treatment.

The next section highlights developmental issues in anxiety, with focus on anxiety disorders (1) by critically reviewing recent data on the prevalence, incidence, age of onset, natural course, and longitudinal outcome of anxiety disorders, including comorbidity and psychosocial impairments and disabilities, and (2) by addressing important correlates and potential risk factors. The review focuses on the following categorically defined anxiety disorders: separation anxiety disorder, specific phobias, social phobia, agoraphobia, panic disorder, and generalized anxiety disorder (GAD).

Obsessive-compulsive disorder and posttraumatic stress disorder are not covered in this article because of additional complicating issues involved with these diagnoses, for example, controversy in regard to their grouping with the other anxiety disorders.10 As an attempt is made to provide information on development, the authors focus on children (defined here as up to age 12), adolescence (defined here as ages 13 to 17), and young adults (defined here as ages 18 to 35 years).