CHAPTER FIVE Childhood I Anxiety Disorders Anne Marie Albano Bruce F. Chorpita David H. Barlow nxiety disorders are widely recognized as opmentally appropriate descriptors for accurate the most common class of psychiatric disorders diagnosis in children. The present chapter exam- affecting children and adolescents (Anderson, ines the prevalence, expression, and develop- Williams, McGee, & Silva, 1987; Bell-Dolan & mental patterns of specific anxiety disorders in Brazeal, 1993; Kashani & Orvaschel, 1988; children and adolescents. Attention is directed to- Orvaschel & Weissman, 1986). Although tran- ward clinical variables (e.g., age at onset, sever- sient fears and anxieties are considered part of ity, comorbidity) and sociodemographic variables normal development, for a significant proportion (e.g., gender, race, socioeconomic status) relative of children, the anxiety experience becomes a to each disorder. Clinical impairment in function- stable negative force in their lives. Anxiety is as- ing is specified within a developmental context. sociated with severe impairment in functioning, These issues are discussed in terms of the course expressed in its most disabling form through a of childhood anxiety disorders. The chapter con- child's avoidance of activities such as school, peer cludes with a review of current issues in the study involvement, and autonomous activities (Bell- of childhood anxiety and future directions. Dolan & Brazeal, 1993; Kendall et al., 1992). Since the publication of the third edition of the Diagnostic and Statistical Manual of Mental Dis- BRl EF HISTORICAL CONTEXT orders (DSM-111; American Psychiatric Associa- tion, 1980), a multitude of studies have docu- The study of children's anxieties and fears has mented the incidence and prevalence of anxiety been described in the literature for decades (see disorders in children and adolescents. Advances Barrios & O'Dell, 1989, for a review). Case stud- in child psychopathology research focused on ies of childhood fears formed the foundation for these anxiety disorders have resulted in the re- the development of both psychoanalytic and be- cent nosological changes evident in DSM's fourth havioral theory. In the classic case study of "Little edition (DSM-IV; American Psychiatric Associa- Hans," Freud (1909/1955) defined and described tion, 1994). Although separation anxiety disorder several key unconscious processes operating in (SAD) is the only remaining childhood anxiety the development of phobia, such as the ego de- disorder per se, the criteria of the "adult" anxiety fense mechanisms of repression and displace- disorders have been modified to include devel- ment. Further, this case provided Freud with rich5. Childhood Anxiety Disorders 1 197 clinical data for the explication of the "oedipal classification systems have acknowledged the stage," perhaps the most controversial and criti- presence of pathological phobic reactions for only cal stage of psychosexual development. Although the past four decades. The publication of DSM's the study of Little Hans has since been reformu- first edition (American Psychiatric Association, lated beyond Freud's initial conceptualization 1952) first identified phobias as psychoneurotic (e.g., A. Freud, 1965), its value and place in psy- reactions, and subsequently in DSM-I1 (Ameri- choanalyhc theory remain firmly ingrained. Simi- can Psychiatric Association, 1968), the diagnos- larly, the conditioned fear of a white laboratory tic category changed to phobic neuroses. DSM- rat in young Albert provided early support for the I1 introduced overanxious reaction as a distinct i classical conditioning of anxiety and behavioral diagnostic category for children and adolescents. theory (Harris, 1979; Watson & Rayner, 1920). These early DSM systems were heavily tied to Repeated pairings of a neutral stimulus (rat) and psychoanalytic theory, purporting an unconscious an aversive stimulus (loud noise), and the sub- process or conflict as the etiological mechanism sequent reaction of fear of the rat in 1-year-old for the phobic or overanxious reaction (Barlow, Albert, provided Watson and Rayner with empiri- 1988). The inclusion of overanxious reaction in cal support for behavioral theory. Additional sup- the psychiatric nomenclature marked the begin- port for the theory was soon to follow in yet ning, albeit meager, of attention to anxious chil- another case study of a child, as Jones (1924a, dren and adolescents. 1924b) validated the behavioral tenet that all Over the past two decades, clinically significant behavior is learned and hence can also be un- phobias and anxiety conditions in childhood have learned. Utilizing techniques incorporating mod- begun to receive serious attention by clinicians and eling and desensitization, Jones described the researchers alike. The failure to attend to child- treatment of 3-year-old Peter's fear of rabbits, hood anxiety conditions may be due, in part, to which was successfully resolved. long-standmg disagreements within the field as to Although these and similar case studies of chil- what constituted a clinical anxiety state from tran- dren served to further the interest and support for sient developmental fears and anxieties (Barrios & specific theoretical models and related therapeu- Hartmann, 1988; Strauss & Last, 1993). DSM- tic interventions, the study of pathological anxi- I11 (American Psychiatric Association, 1980) and ety conditions in children was (until relatively DSM-111-R (American Psychiatric Association, recently) essentially ignored. There exists a wealth 1987) represent the first attempts in the history of information and research spanning several of modem classification systems of psychopathol- decades on the developmental progression of chil- ogy to delineate developmentally appropriate di- dren's fears and phobias, and several comprehen- agnostic criteria for anxiety and phobic disorders sive reviews outline the historical progression of in children and adolescents. Separation anxiety dis- this research (Barrios & Hartmann, 1988; Barrios order, avoidant disorder of childhood and adoles- & O'Dell, 1989; King, Hamilton, & Ollendick, cence, and overanxious disorder earned notoriety 1988; Ollendick & King, 1991). To summarize, as the three distinct anxiety disorders of childhood. prior to the publication of DSM-111 (American In total, children could be diagnosed with