Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children
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.
Section snippets
Search strategy
Relevant studies were identified using a number of strategies. First, electronic searches using the keywords [(CHILD⁎ or PRESCHOOL⁎) and (ANXIETY or PANIC or PHOBIA or (OBSESS⁎ and COMPULS⁎)) and (EPIDEMIOLOG⁎ or PREVALENCE or INCIDENCE or ONSET)] were undertaken. The following databases were searched: Cinahl (1980–2004); Embase (1982–2004); Medline (1980–2004); and PsycInfo (1980–2004). Second, the reference lists of articles produced by the electronic search were scrutinised for further
Results
The 11 studies that were retained will now be described. Two main types of information were extracted from the studies. First, the prevalence of anxiety disorders in any children aged 11 years or less was obtained. Second, the relative prevalence of anxiety, in comparison with any other disorders that were studied, is reported.
The prevalence of anxiety disorders in any groups under the age of 12 years was extracted. In some cases, authors had broken prevalence rates down into smaller age bands
Prevalence of anxiety disorders
The reported prevalence of ‘any anxiety disorder’ varied substantially between studies. The lowest rate that was reported was 2.6% in the American 11 year olds in the study by Costello et al. (2003), and the highest was 41.2% in the Japanese 7–9 year olds reported by Sugawara et al. (1999). Both of these rates may not be representative of their wider communities, for the reasons outlined above. However, it is interesting to note that, even when these two outlying studies are not considered, the
Acknowledgement
The authors are grateful to three anonymous reviewers for their comments on an earlier draft of this paper. Sam Cartwright-Hatton is grateful to the Medical Research Council for support during the preparation of this manuscript.
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