Psychiatric Annals

CME Article 

Nature, Assessment, and Treatment of Generalized Anxiety Disorder in Children

Jennifer L. Hudson, PhD; Charise Deveney, BPsych (Hons); Lee Taylor, BA (Hons)

Abstract

Few empirical studies have examined children with generalized anxiety disorder (GAD) exclusively. Much of our knowledge of the disorder is derived from studies using a sample of children with a range of anxiety disorders. Knowledge of GAD also relies heavily on research conducted on over-anxious disorder, the likely diagnosis given to children with excessive worry using the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).1

Introduction of DSM's fourth edition (DSM-IV)2 evidenced a change in the classification of childhood anxiety-related disorders, and as such, over-anxious disorder was subsumed under GAD. A comparison of cases diagnosed independently revealed that the change in the nosology has not changed the characteristics of identified cases dramatically.3 The nature, assessment, and treatment of GAD in children are reviewed in this article.

Approximately 3% to 12% of children experience excessive and uncontrollable worry that is both chronic and disabling.4 Diagnosed as GAD, this worry is accompanied by at least one persistent physiological symptom such as stomach aches, disturbed sleep, irritability, restlessness, or concentration difficulties.5 The worry is not confined to a specific situation or event as in phobic disorders but pertains to a number of domains in the child's life and occurs for the majority of the child's day, more days than not.

Typically, children with GAD worry excessively about their own and their family's safety and health, their performance at school, unfamiliar situations, keeping schedules, getting things right, getting into trouble, family finances, their friendships, and local and world events (such as war and natural disasters). Parents often report that children with GAD catastrophize situations and worry about all things possible. This processing bias toward threat has been demonstrated by a number of experimental studies showing that children with GAD are more likely to have both attention and interpretation biases toward threat.6,7

Parents also report that children with GAD seek excessive reassurance before an event: “Is it going to be okay? What is going to happen?” As part of normative development, children frequently ask inquisitive questions, but for children with GAD, this questioning is repetitive and excessive in nature.

GAD rarely presents alone and is likely to be comorbid with other anxiety or mood disorders. This is a common feature of anxiety disorders in children, and GAD is no exception. Therefore, much research on GAD relies on data from children with a number of anxiety disorders, not just GAD, somewhat limiting our understanding of pure GAD.

Perhaps the most comprehensive study of comorbidity in a clinical sample of anxious children was conducted by Verduin and Kendall.8 In a sample of 199 children with anxiety disorders, 55% met criteria for a primary diagnosis of GAD. Of the entire sample, 83% met criteria for more than one disorder, indicating high levels of comorbidity. The most common diagnosis occurring with GAD was specific phobia (48.6%). Other comorbid diagnoses included social phobia (31%), separation anxiety disorder (24.8%), attention-deficit/hyperactivity disorder (18.3%), dysthymia (11%), oppositional defiant disorder (10%), and major depressive disorder (6.4%). These results show a strong pattern of comorbidity in children with GAD.

A study by Masi and colleagues9 showed even higher rates of comorbid mood disorders in children with GAD: in a clinical sample, 62% of children with GAD met criteria for a mood disorder. Masi et al.10 also showed that children with GAD who also have mood disorders were more impaired than children with GAD only. Clearly, these results show that children with GAD rarely present with only one diagnosis. Assessment of children with GAD requires screening for multiple anxiety, mood, and behavior disorders.

Theverage age of onset of childhood GAD is…

Few empirical studies have examined children with generalized anxiety disorder (GAD) exclusively. Much of our knowledge of the disorder is derived from studies using a sample of children with a range of anxiety disorders. Knowledge of GAD also relies heavily on research conducted on over-anxious disorder, the likely diagnosis given to children with excessive worry using the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).1

Introduction of DSM's fourth edition (DSM-IV)2 evidenced a change in the classification of childhood anxiety-related disorders, and as such, over-anxious disorder was subsumed under GAD. A comparison of cases diagnosed independently revealed that the change in the nosology has not changed the characteristics of identified cases dramatically.3 The nature, assessment, and treatment of GAD in children are reviewed in this article.

Nature

Approximately 3% to 12% of children experience excessive and uncontrollable worry that is both chronic and disabling.4 Diagnosed as GAD, this worry is accompanied by at least one persistent physiological symptom such as stomach aches, disturbed sleep, irritability, restlessness, or concentration difficulties.5 The worry is not confined to a specific situation or event as in phobic disorders but pertains to a number of domains in the child's life and occurs for the majority of the child's day, more days than not.

Typically, children with GAD worry excessively about their own and their family's safety and health, their performance at school, unfamiliar situations, keeping schedules, getting things right, getting into trouble, family finances, their friendships, and local and world events (such as war and natural disasters). Parents often report that children with GAD catastrophize situations and worry about all things possible. This processing bias toward threat has been demonstrated by a number of experimental studies showing that children with GAD are more likely to have both attention and interpretation biases toward threat.6,7

Parents also report that children with GAD seek excessive reassurance before an event: “Is it going to be okay? What is going to happen?” As part of normative development, children frequently ask inquisitive questions, but for children with GAD, this questioning is repetitive and excessive in nature.

Comorbidity

GAD rarely presents alone and is likely to be comorbid with other anxiety or mood disorders. This is a common feature of anxiety disorders in children, and GAD is no exception. Therefore, much research on GAD relies on data from children with a number of anxiety disorders, not just GAD, somewhat limiting our understanding of pure GAD.

Perhaps the most comprehensive study of comorbidity in a clinical sample of anxious children was conducted by Verduin and Kendall.8 In a sample of 199 children with anxiety disorders, 55% met criteria for a primary diagnosis of GAD. Of the entire sample, 83% met criteria for more than one disorder, indicating high levels of comorbidity. The most common diagnosis occurring with GAD was specific phobia (48.6%). Other comorbid diagnoses included social phobia (31%), separation anxiety disorder (24.8%), attention-deficit/hyperactivity disorder (18.3%), dysthymia (11%), oppositional defiant disorder (10%), and major depressive disorder (6.4%). These results show a strong pattern of comorbidity in children with GAD.

A study by Masi and colleagues9 showed even higher rates of comorbid mood disorders in children with GAD: in a clinical sample, 62% of children with GAD met criteria for a mood disorder. Masi et al.10 also showed that children with GAD who also have mood disorders were more impaired than children with GAD only. Clearly, these results show that children with GAD rarely present with only one diagnosis. Assessment of children with GAD requires screening for multiple anxiety, mood, and behavior disorders.

Onset and Course

Theverage age of onset of childhood GAD is estimated to range from 8.8 to 10.11,12 Parents often find it difficult to pinpoint the age of onset, as they frequently report that their GAD child has always worried. In line with this, adults with GAD typically report a chronic course of GAD present since childhood. Evidence points to GAD as a chronic disorder that, without treatment, persists and places the child at risk for developing other disorders, such as depression.13

One factor associated with the onset of excessive worry is cognitive development.14 With cognitive development comes the ability to make predictions about a future event and the ability to anticipate multiple negative outcomes. The anticipation of multiple misfortunes is part of the worry process. With increased cognitive ability, the capacity to worry in a more complex fashion emerges. A recent study by Muris and colleagues15 showed that in a sample of 8- to 13-year-olds, age and cognitive development (as measured by performance on a series of Piagetian conservation tasks) predicted the child's ability to elaborate on possible negative outcomes which in turn predicted the emergence of worry. Further, Muris et al.16 showed that children who had demonstrated concrete operational abilities had higher rates of worry. These results stress the importance of cognitive development in understanding the emergence of GAD in children.

Assessment

Studies consistently have shown relatively low rates of agreement among parents, children, and teachers on anxiety symptoms.17 As a result, multi-informant assessment is important in the correct diagnosis and identification of children with GAD.18 Higher rates of agreement between parents and children are reported for the more observable symptoms,19 but children generally report fewer symptoms than parents and tend to be unreliable in reporting complex details, such as onset and duration of anxious symptomatology.17 As such, the preference is to collect information from a number of sources to obtain the most accurate and comprehensive picture. In addition to multiple informants, a multi-method assessment including diagnostic interviews, questionnaires, and behavioral observations is preferred. The following section details some of the most commonly used assessment measures of GAD in children and adolescents.

Structured Diagnostic Interviews

Given the high incidence of comorbidity in children with GAD, structured diagnostic interviews are recommended. These provide a more reliable assessment of the child's worry and more clearly identify the presence of other internalizing or externalizing disorders.20 The Anxiety Disorders Interview Schedule for DSM-IV: Child Version (ADIS-C/P)21 is a widely used, structured diagnostic interview designed for use with children and parents to diagnose anxiety disorders according to DSM-IV criteria in children ages 6 to 17. Psychometric studies of the ADIS-C/P show good to excellent reliability for GAD symptoms and diagnosis.22 Several other diagnostic interviews have been developed for children,23 including the Diagnostic Interview for Children and Adolescents,24 the Child and Adolescent Psychiatric Assessment,25 and the Kiddie-Schedule for Affective Disorders and Schizophrenia.26

Questionnaires

Questionnaires frequently are used to provide ancillary information to diagnostic interviews when assessing anxiety in children and adolescents. Two of the most commonly used self-report measures, the Revised Children's Manifest Anxiety Scale (RCMAS)27 and the State-Trait Anxiety Inventory for Children (STAIC),28 recently were criticized for their developmental insensitivity and inability to discriminate children with anxiety disorders from children with other internalizing and externalizing disorders.29

To address this limitation, measures such as the Multidimensional Anxiety Scale for Children (MASC),30 the Spence Children's Anxiety Scale (SCAS),31 and the Screen for Child Anxiety Related Emotional Disorders (SCARED)32 have been developed. The MASC has demonstrated excellent retest reliability and adequate convergent and divergent validity in children ages 8 to 19.33 The SCAS has shown adequate internal consistency and 6-month retest reliability, strong convergent validity and good discriminant validity for children ages 7 to 16.31 The SCARED has demonstrated good internal consistency, retest reliability, and discriminant validity for children ages 9 to 18.32 Both child and parent versions of these questionnaires are available.

The SCARED and the SCAS were designed to assess DSM-IV-defined anxiety disorders; therefore, both include a generalized anxiety factor. The MASC has a number of scales that assess GAD symptoms, including physical symptoms (eg, tense/restless and somatic/autonomic) and harm avoidance (eg, perfectionism and anxious coping). While these three measures have included scales designed to assess GAD, the ability of these scales to differentiate children with GAD from children with other non-GAD diagnosis so far has proved limited.33

Another questionnaire useful in the assessment of excessive and uncontrollable worry in children and adolescents is the Penn State Worry Questionnaire for Children (PSWQ-C).34 The PSWQ-C has been shown to have excellent retest reliability and good convergent and discriminate validity. Chorpita and colleagues34 found that the PSWQ-C was able to discriminate between children meeting DSM-IV criteria for GAD, those meeting criteria for any other DSM-IV anxiety disorder, and those not meeting criteria for any DSMIV anxiety or mood disorder. PSWQ-C scores also have been shown to be associated with GAD symptomatology.35

A number of other parent and teacher report questionnaires offer additional and important perspectives on the child's overall symptoms and behavior; however, they do not specifically measure symptoms of GAD. These measures include the Child Behavior Checklist,36 and the Strengths and Difficulties Questionnaire.37 Both of these scales have shown adequate psychometric properties and include both parent and teacher versions.

Behavioral Observations

Throughout the diagnostic interview, the clinician observes any behavior suggestive of anxiety, such as fidgeting, fingernail biting, eye contact avoidance, leg shaking, voice trembling, and task avoidance. Unstructured behavioral observation may also take place in other settings, such as the classroom or the child's home. More structured observation techniques are employed in behavioral avoidance tasks (BATs), where the child is exposed purposely to a feared object or situation (eg, unfamiliar situation, running late to school, forgetting a school book) while the trained clinician concurrently assesses the child's subjective level of anxiety, physiological reactions, and other behavioral responses.

BATs are useful because they provide direct and objective information about situations that induce the most anxiety and how the child reacts to them. Nevertheless, several disadvantages exist for this method of data collection, the most notable of these being the time-consuming nature of the assessment and the lack of reliable and valid coding methods. Also, BATs are less practical for disorders such as GAD where threatening stimuli are difficult to create because they involve a complex set of cognitive cues.

Psychotherapeutic Treatments

Specific clinical trials for the treatment of childhood GAD are lacking. However, a growing body of empirical evidence supports the efficacy of cognitive-behavior therapy (CBT) in the treatment of childhood anxiety disorders. As such, CBT has emerged as the treatment of choice and has been labeled a “probably efficacious” treatment for childhood anxiety disorders.38

The first randomized controlled clinical trial evaluating child-focused CBT, Individual Cognitive Behavioral Therapy (ICBT), for the treatment of childhood anxiety disorders was conducted by Kendall in 1994.39 Subsequent to that, a number of studies have provided mounting support for the efficacy of CBT in the treatment of childhood anxiety disorders. Additionally, CBT intervention has received empirical support in a group format and with an active family treatment component. Many of the clinical trials of CBT for anxious youth have consisted of samples with a significant proportion of children with a diagnosis of GAD or overanxious disorder,39,40 giving practitioners confidence in the use of CBT for children with GAD. These studies will be reviewed briefly.

Child-focused CBT

In a randomized controlled trial, 47 children with anxiety disorders (60% diagnosed with overanxious disorder) were randomly assigned to either child-focused ICBT or a wait-list condition.39 For children in the ICBT group, treatment consisted of 16 sessions that covered affective recognition, development of coping self-talk, relaxation training, self-evaluation and reward, problem solving, and gradual exposure. When compared with children in the wait-list group, ICBT was associated with improvements in both parent- and child-reported coping and distress, as well as in observations of behavior.

Furthermore, 64% of the children treated with ICBT no longer met diagnostic criteria at post-treatment, compared with 5% (one child) in the wait-list group. Treatment gains reportedly were maintained at 1-, 2-, and 5-year follow-up41 and were replicated in a second randomized controlled trial.40 These results provide support for the efficacy of ICBT in the treatment of children with anxiety disorders.

Given that group treatment acts to minimize cost delivery, improve time effectiveness, and enhance positive modeling opportunities, research has examined whether CBT intervention presented in a group format is as effective as ICBT in the treatment of childhood anxiety disorders. Flannery-Schroeder and Kendall42 conducted a randomized controlled trial in which 37 children ages 8 to 14 who were clinically diagnosed as anxious — 57% of whom met diagnostic criteria for GAD — were assigned randomly to one of three conditions: ICBT, group CBT (GCBT), or wait-list. Across both treatment conditions, significantly more children did not meet diagnostic criteria at post-treatment (73% ICBT; 50% GCBT) when compared with participants in the wait-list condition (8%). The difference between the two treatment conditions was not statistically significant. Furthermore, 64% of the children in the ICBT and 50% of the children in the GCBT no longer met criteria for GAD, separation anxiety disorder, or social phobia at post-treatment, and gains were maintained at 3-month follow-up.

Family CBT

It is widely documented that parental factors play a role in the maintenance of childhood anxiety.43 For example, parental encouragement of avoidance and parental overinvolvement or overprotection are two family factors that have been associated with childhood anxiety disorders.44 As such, research has examined the efficacy of parental involvement in the treatment of children and adolescents with anxiety disorders. Although the exact nature of the content and structure of family involvement in treatment varies between studies, a mounting body of evidence suggests that parental involvement in the treatment of children and adolescents with anxiety disorders is associated with enhanced outcomes.

Using an Australian adaptation of Kendall's “Coping Cat” program, Barrett, Dadds, and Rapee45 evaluated the incorporation of structured family intervention in the treatment of childhood anxiety in a randomized controlled trial. Seventy-nine children with anxiety disorders ages 7 to 14 (45 boys, 34 girls; 38% with overanxious disorder) were randomly assigned to one of three conditions: ICBT, CBT plus family anxiety management training (CBT+FAM), or wait-list. In addition to children receiving ICBT intervention, as in the ICBT-only condition, children and parents in the CBT+FAM condition also attended family anxiety management therapy sessions. The family component of treatment covered three key areas: child management, including educating parents on how to reward courageous behavior and extinguish excessive anxiety; parent anxiety management; and communication and problem-solving skills. A total of 12 sessions were dedicated to family intervention.

Highly favorable results were forthcoming supporting strong treatment gains for both treatment groups. Results indicate that, at post-treatment and 12-month follow-up, treatment gains were significant across multiple assessment tools, for both the CBT and CBT+FAM interventions. At post-treatment, 70% of children in the treatment conditions no longer met criteria for a current anxiety disorder, compared with 26% for the wait-list group. A significantly greater number of children in the CBT+FAM group than the ICBT group no longer met diagnostic criteria for an anxiety disorder at post-treatment (84% in CBT+FAM versus 57.1% for ICBT). Treatment gains were maintained at 12-month follow-up, with 95.6% of the children in the CBT+FAM group and 70.3% of children in the ICBT group no longer meeting criteria for an anxiety disorder. Given the focus on GAD, of particular interest is the finding that 68.2% of the children in the study diagnosed with overanxious disorder were diagnosis-free at post-treatment, and that number rose to 75% at 12-month follow-up.

These findings must be interpreted in light of significant effects for age and gender. While girls responded significantly better to CBT+FAM than ICBT at post-treatment (83% CBT+FAM and 37% ICBT diagnosis-free), and 12-month follow-up (100% CBT+FAM and 57% ICBT diagnosis-free), boys showed no significant differences across treatment conditions at either timepoint (84% CBT+FAM and 65% ICBT diagnosis-free at post-treatment; 92% CBT+FAM and 75% ICBT diagnosis-free at 12-month follow-up). With regard to age, younger children (ages 7 to 10) responded better to CBT+FAM, but older children showed no difference between the two treatments. These results provide preliminary evidence that family involvement in treatment is most beneficial for younger children and for girls.

The treatment gains were not only maintained at 12-month follow-up but also at 6 years following treatment.46 Of particular importance is the finding that 81% of participants initially diagnosed with overanxious disorder were diagnosis-free at long-term follow-up. Thus, it can be concluded that CBT for childhood anxiety disorders has demonstrated long-term efficacy.

Other studies also have evaluated the efficacy of CBT group-based family intervention with favorable results.47–49 Silverman et al.49 conducted a randomized controlled trial comparing the therapeutic efficacy of group CBT with concurrent parental sessions with a wait-list condition in the treatment of 56 children with anxiety disorders, ages 6 to 16. Substantial improvement across main outcome measures was evident for children in the GCBT plus parent session treatment group. Sixty-four percent of participants in the GCBT group no longer met criteria for their primary diagnosis at post-treatment (versus 13% in the wait-list group), and 82% showed clinically significant improvement at post-treatment (versus 9% in the wait-list group). At 3-month follow-up, 77% of participants no longer met criteria for their primary diagnosis, and gains were maintained at 6- and 12-month follow-up.

Components of CBT

CBT manuals are available readily to practitioners for use in the treatment of childhood anxiety.50,51 Although the specific combination of techniques may vary slightly from clinician to clinician, somatic awareness, cognitive restructuring, problem solving, and behavioral exposure underpin the general application of CBT for childhood anxiety. In family-based programs,51 additional components such as contingency management and parent anxiety management often are included. Homework is emphasised as having a key role in the treatment of anxiety because it provides participants with an opportunity to practice the skills they have learned during the sessions.

It is unclear from current research which of these components serves as the active component of treatment. Consequently, further research using dismantling, parametric, and additive designs52 in treatment outcome research for children with GAD is needed. The following provides a brief description of the key areas and where involvement of the family is appropriate.51

Awareness of physical symptoms and somatic management. Under these guidelines, children are taught that when they become anxious, physiological changes occur in their body. Awareness of physical symptoms is emphasised as being helpful in the early detection of anxiety. Techniques such as deep, diaphragmatic breathing and muscle relaxation often are taught as a component in the somatic management of anxiety. Deep breathing is particularly useful as an easy and portable tool for children to use. Muscle relaxation may be taught by having the children tense and relax muscle groups sequentially. Relaxation scripts or tapes can be provided to children to practice the technique for homework. Children are encouraged to practice and use the somatic management techniques in anxiety provoking situations.

Cognitive restructuring. Cognitive restructuring involves understanding the relationship between thoughts and feelings, the effects of thinking errors on feelings and behavior, and the process of evaluating or challenging negative thoughts. Children learn to identify negative “self-talk” and understand that anxiety is associated with “expecting bad things to happen.” Children are instructed to become “thought detectives” and to treat their thoughts as mysteries to be tested and challenged. The detective thinking process includes identifying the event that is causing concern, identifying the thought behind the feeling, looking for realistic evidence, listing all the alternative things that might happen by asking, and identifying a realistic thought to replace the worried thought. Parents are taught to coach and encourage their children in thought challenging, rather than providing excessive reassurance in response to their child's anxious thoughts.

Problem solving. Problem solving is aimed at assisting children to generate alternate, more adaptive solutions to a given situation. The aim is to enable children to cope in anxiety-provoking situations without reverting to their usual maladaptive response of avoidance. For example, children are taught to identify a specific problem, generate possible responses to the problem, explore the costs and benefits associated with each possible response, and implement the most feasible response. Problem-solving skills are most effectively taught by working through a real life example with the child.

Contingency management. Children are taught that, although rewards can come from others, they also can reward themselves. The concept of positive self-talk as a reward is introduced. For example, children learn how to reward themselves by saying things such as, “I did a good job.” The rewarding of courageous behavior and effort are emphasized, not just rewarding the outcome. When children engage in exposure to feared stimuli or situations, rewards become important. The use of appropriate rewards is modeled throughout the session by the therapist to reward contribution in session and engagement with homework tasks. Parents also are educated about the principles underlying contingent rewarding and ways in which they can encourage courageous behavior rather then anxious behavior. Techniques include differential attention to anxious versus courageous behavior; the importance of clear, concrete, and specific praise; the use of proportional rewards; modeling appropriate behavior; and providing children with independence to “fight their own battles.”

Gradual exposure. Exposure is considered a key component in the treatment of anxiety disorders. The rationale behind exposure is that a child needs to face fear to fight fear. In exposure, fears are faced gradually, working from lesser fears to greater fears. A hierarchy of fears and worries is devised, containing a number of feared situations. The feared situations are placed in order of least fearful to most fearful. Each fear on the hierarchy is then broken down into steps on a “stepladder.”

For example, if a child is continually worried about forgetting her school books and checks multiple times before leaving for school, the stepladder might start with the child only checking her bag twice before school, and a more difficult step might include deliberately forgetting an important book for school. Children must face up to the fear successfully before progressing to the next rated fear on the hierarchy. In addition, the young person is encouraged to stay in the feared situation until he or she learns that nothing bad happened. Repetition of exposure to the feared situation or stimuli is essential.

Exposure can take many forms, such as imaginary (imagining the feared situation or stimuli), symbolic (using pictures or props), and in vivo (actually being in the feared situation or with the feared stimuli). Exposure is first attempted in the therapy setting and is continued by the child for homework between sessions.

Pharmacologic Treatments for Childhood GAD

It has been suggested that the clinical use and prescription of most psychotropic medications for psychological disorders in childhood far exceeds rigorous evidence supporting their effectiveness and safety.53 This is reflected in the paucity of empirical data regarding the use of pharmacotherapy for childhood GAD. To date, only a handful of studies have examined the effectiveness of psychotropic medications for the treatment of GAD in children. In 2001, Rynn, Siqueland, and Rickels54 conducted a placebo-controlled trial of a selective serotonin reuptake inhibitor (SSRI), sertraline, in the treatment of children with GAD. Fluvoxamine, another SSRI, has also shown therapeutic potential in an 8-week, randomized, double-blind, placebo-controlled study in the treatment of GAD, social phobia, and separation anxiety disorder.55 Earlier, the effectiveness of fluoxetine in the treatment of childhood GAD was examined.56 Finally, the use of buspirone57,58 and clonazepam59 in the treatment of childhood GAD have received some attention. A review of these studies follows.

The effectiveness of two SSRIs, sertraline and fluvoxamine, was examined in the treatment of childhood GAD in a placebo-controlled trial. Rynn et al.54 evaluated 22 children ages 5 to 17 who met criteria for GAD underwent a 9-week, double-blind treatment phase in which they received either sertraline or a placebo medication. Random assignments were made in groups of four subjects, with each group receiving two placebo and two sertraline treatment assignments. Sertaline capsules contained 25 mg for the first week and 50 mg for weeks 2 through 9. Participants were instructed to take their medication once daily in the evening. Medication compliance was monitored using a pill count.

The results of the study indicate that sertraline was effective in the treatment of childhood GAD. Significantly more symptom reduction, based on psychiatrist- and patient-completed scales, was evidenced in patients who received sertraline than in those who received placebo. From week 4 through the end of treatment, significant treatment differences on the Hamilton Anxiety Scale total score and psychic and somatic factor scores and the Clinical Global Impression severity and improvement scale scores were present, in favor of sertraline. Furthermore, 90% of participants treated with sertraline improved at treatment endpoint, compared with 10% in the placebo group. No significant differences in adverse side-effects were reported between the sertraline and placebo groups.

Although the results of this study are promising and provide a solid foundation for future research, more studies are needed to replicate the findings. The authors noted that future studies are required to “examine minimum dose requirements, maximum duration of therapy, relapse rates after various treatment intervals, and a comparison of medication to cognitive behavioral treatments.”

The use of fluvoxamine in the treatment of GAD, separation anxiety disorder, and social phobia has received support from an 8-week, randomized, double-blind, controlled trial in which 128 pediatric patients (ages 6 to 17) received either fluvoxamine (n = 63) or placebo (n = 65) in conjunction with supportive psychotherapy.55 More than half of the sample met criteria for GAD (n = 73). Adolescents ages 12 to 17 received maximum daily doses of up to 300 mg per day, and children younger than 12 received maximum daily doses of up to 250 mg per day. The fluvoxamine dose was increased weekly in approximately 50-mg increments. Anxiety symptoms and functional impairment, as measured by changes in weekly scores on the Pediatric Anxiety Rating Scale (PARS)60 and the Clinical Global Impressions Improvement Scale (CGIS),61 served as measures of outcome.

Mean PARS score showed significant differences between fluvoxamine and placebo groups, evident by week 3 of treatment and peaking at week 6 of treatment. Additionally, 76% of patients receiving fluvoxamine, as compared with 29% in the placebo group, achieved scores lower than 4 on the CGIS scale. With regard to group differences, abdominal discomfort was reported more often in the fluvoxamine than placebo group (49% versus 28%). Increases in motor activity also showed greater likelihood in the fluvoxamine than placebo group (27% versus 12%), but this did not reach statistical significance. No specific data on children with GAD were reported.

Following completion of the randomized trial, participants were invited to enter a 6-month open-label treatment phase.62 Results indicated that, during 6 months of continued open label-treatment with fluvoxamine, treatment gains were maintained, with anxiety symptoms remaining low, in 33 of 35 (94%) patients who initially responded to fluvoxamine.

These results supporting the effectiveness of fluvoxamine in the treatment of childhood anxiety disorders are promising. However, additional studies are required to replicate the above reported findings. Furthermore, the implication of long-term use of fluvoxamine in children and long-term effects has yet to be examined.

The first open trial of fluoxetine in the treatment of childhood GAD was conducted in 1994 by Birmaher et al.56 in 21 children and adolescents presenting with overanxious disorder, social phobia, or separation anxiety disorder. Most of the patients presented with comorbid anxiety diagnoses, with only six patients presenting with pure overanxious disorder. Before being treated with fluoxetine, all the patients had been treated unsuccessfully with one or more psychotherapeutic interventions. The mean fluoxetine dose was 25.7 mg per day (range of 10 mg per day to 60 mg per day), and the length of treatment varied from 1 to 31 months, with an average of 10 months.

The results indicate that 95% of patients showed some improvement in anxiety and 81% showed moderate to marked improvement, as rated on the CGIS. Improvement began after 6 to 8 weeks of treatment with fluoxetine. Side effects reported included mild headache (n = 1), nausea (n = 3), insomnia (n = 3), anorexia (n = 1), and stomach aches (n = 1). Most of these side effects were reported as mild and transient.

These findings are preliminary and provide limited support for the use of fluoxetine in the treatment of childhood overanxious disorder, social phobia, or separation anxiety disorder. That fluoxetine was well tolerated in the children treated is encouraging. There were no treatment differences among patients who had overanxious disorder alone or with comorbid diagnoses. However, the findings reported must be interpreted with caution, given the limitations of relying on retrospective chart review data and open-label treatment. Further studies using double-blind, placebo-controlled methodologies are required.

The use of benzodiazepines, namely alprazolam and clonazepam, has also been explored in the treatment of childhood GAD or overanxious disorder. In a double-blind study of 30 children and adolescents with avoidant disorder or over-anxious disorder, Simeon63 found no difference between alprazolam and placebo. Furthermore, patients with overanxious disorder appeared even less responsive to alprazolam than the group as a whole. In another study, the results did not support the use of clonazepam in doses up to 2 mg per day in a sample of children with anxiety disorders (n = 57; overanxious disorder, n = 2).59 Overanxious disorder was insufficiently represented for a specific drug effect to be present. Given these findings, further study is needed before reaching a conclusion about the efficacy of benzodiazepines for the treatment of GAD in children.

Two studies support the effectiveness of buspirone in the treatment of childhood GAD. In an open trial, Kranzler57 reported that a 13-year-old boy with overanxious disorder and school refusal was successfully treated with busiprone at 10 mg per day. Additionally, results of a pilot study of adolescents with over-anxious disorder or GAD, using 15 mg to 30 mg of busiprone per day, indicate that ratings on the Hamilton Anxiety Scale significantly decreased after 6 weeks of treatment.58 Double-blind, placebo-controlled trials are recommended to further examine the efficacy of buspirone in the treatment of childhood GAD.

Given the indeterminate findings presented above, the lack of strong empirical data supporting the effectiveness of psychotropic medications in the treatment of childhood GAD, and the strong empirical support for the effectiveness of CBT, it is recommended that psychotropic medications for childhood GAD be used only after psychological therapies have been tried or in conjunction with psychological interventions. Additionally, when using psychotropic medications in children, practitioners must engage in ongoing assessment and monitoring in the domains of learning, psychosocial, and physical functioning.

Summary

GAD in children is characterized by excessive and uncontrollable worry about a number of events and activities in daily life. GAD is a prevalent and chronic disorder that is highly comorbid with other psychiatric disorders and has a significant affect on a child's life. Reliable and valid methods are available with which to assess childhood anxiety (eg, structured interviews and questionnaires). Furthermore, efficacious treatments for anxious children have emerged, with CBT the treatment of choice.

In recent years, our understanding of childhood anxiety disorders has grown exponentially. Much of our understanding of GAD, however, is still reliant on studies of children with a range of anxiety disorders. Future research is needed that specifically examines children with GAD compared with anxious, depressed children without GAD. Such research would aid in the identification of factors unique to GAD, improve assessment methods and potentially enhance treatments for children with GAD.

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Educational Objectives

  1. Explain the nature of generalized anxiety disorder (GAD) in children, including diagnostic criteria, prevalence, comorbid conditions, course, and onset.

  2. Discuss measures with which to assess GAD.

  3. Describe the use of cognitive-behavior therapy and pharmacotherapy for children with GAD.

Authors

Dr. Hudson is a senior lecturer and Ms. Deveney and Mr. Taylor are doctoral students, Macquarie University, NSW, Australia.

Address reprint requests to: Jennifer L. Hudson, PhD, Department of Psychology, Macquarie University, NSW 2109 Australia.

The authors have no industry relationships to disclose.

10.3928/00485713-20050901-04

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