Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children

Abstract

It is widely believed that anxiety is a common disorder of childhood and adolescence, but epidemiological studies have varied substantially in the prevalence rates that they report. In addition, less attention has been paid to the prevalence of anxiety in pre-adolescent children. For these reasons, a review of epidemiological studies reporting on the prevalence of anxiety disorders in this younger population is described.

A comprehensive literature search, encompassing electronic searches of databases and hand searches of journals, returned 11 studies that reported on the prevalence of DSM-III-R or DSM-IV anxiety, specifically in children aged below 12 years of age, which had employed certain minimum standards of epidemiological practice, and had some degree of generalisability to wider populations.

The rates of diagnosis of ‘any anxiety disorder’ varied widely between the studies. The minimum figure reported was 2.6%, and the maximum was 41.2%. Separation Anxiety Disorder appeared to be the most common individual anxiety diagnosis in this age group. Anxiety disorders appear to be more common than depressive disorders, and probably also more common than disorders of behaviour.

Anxiety disorders are, at the very least, fairly common in pre-adolescent children. This is concerning when the limited current treatment options for this age group are considered. Reasons for the varied prevalence rates reported by the studies, focussing on the differences in methods employed, are suggested. Implications for treatment are discussed.

Introduction

As described in the introduction to this special edition of Clinical Psychology Review, anxiety is thought to be a very common–perhaps the most common–psychological disorder of childhood and adolescence. Moreover, it is now thought that anxiety of childhood and adolescence is not always transitory, and in very many cases, leads to anxiety and other disorders that are persistent into later childhood and into adulthood. In response to these concerns, the past decade has seen an upsurge in research aimed at understanding, and, ultimately, at treating anxiety in young sufferers. However, in a recent review of psychological treatments for anxiety disorders in children and adolescents (Cartwright-Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004), the authors concluded that the only intervention for anxiety in this population for which there was substantial evidence of efficacy, was Cognitive Behaviour Therapy (CBT). The authors also concluded that, based on the studies included in the review, there were no treatments that had been shown to be efficacious for young children. The youngest child included in any of the treatment trials under scrutiny was 6 years of age, and in most cases, despite treating children of wide-ranging ages (6–18 years), the results of the trials were generally not broken down by age. Where separate analyses were conducted for older and younger participants, the studies did not appear to have adequate power to detect any actual differences that might be present. As a result, it was not possible to ascertain the effectiveness of CBT for anxiety for children in different age groups. Although the results of the CBT in the overwhelming majority of the trials in the review were positive, it remains possible that the effects were largely confined to the older children participating in the studies. Indeed, there is reason to believe that this is quite likely. Cognitive Behaviour Therapy, in its current form, generally requires the client to engage in rather complex cognitive skills, and it is possible that younger children may not yet have developed these abilities (Grave & Blissett, 2004). Moreover, there is direct evidence from meta-analytic studies, that when compared with older children, younger children may benefit less from traditional CBT approaches: Bennett and Gibbons (2000) conducted a meta-analysis of 30 studies where CBT techniques were used to treat children referred with behaviour difficulties. Similarly, Durlak, Fuhrman, and Lampman (1991) reviewed over 60 studies of CBT type approaches for a range of disorders (although the majority was for externalising problems, and not all were of clinical severity). Both studies concluded that the CBT was more effective for older children and adolescents than for younger children. Although there is precious little evidence to judge at exactly what age a child is ‘ready’ for CBT, there is a widely held assumption, that CBT in its current form is rather difficult with children under the age of about 10 or 11 years.

If, as is widely suspected, current CBT techniques are of circumscribed use with younger children, what treatment options are available to the clinician working with the younger anxious child? At present, it would seem that, in terms of well evaluated interventions at least, there are few.

If this is the case, should we be concerned? In answering this question, we first need to ascertain how many younger children experience clinical levels of anxiety? Although, there is evidence that, when childhood and adolescence are taken as a whole, anxiety is rather common (Kashani & Orvaschel, 1990), the aim of this review is to examine whether this widely held assumption is accurate when the data for young children only is examined.