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argued that this is because the criteria are not sensitive to the presentation among children, while others suggest that it may reflect the reduced sense of past and future in children’s cognitive development. Posttraumatic stress disorder is discussed in detail in Chapter F.4. School refusal Although school refusal is not a formal diagnosis in either the DSM or ICD, a brief mention is warranted here due to its common discussion in various circles. There is little doubt that many children do not wish to attend school and in a small percentage of cases they may not attend for lengthy periods. This is often referred to as school refusal. School refusal is not an anxiety disorder and may be motivated by many factors aside from anxiety, but when it occurs, anxiety is a common underlying element. However, anxiety alone is not a sufficient explanation. School refusal involves both a motivation from the child to not attend school (sometimes due to anxiety) combined with a social and, usually, parental acquiescence to this demand. Naturally, this latter component will vary between societies depending on the laws for school attendance, social norms, and parental needs (such as extreme poverty). However, where laws and norms provide an expectation for school attendance (these days in most countries), school refusal commonly involves some difficulty within the family or at least one parent. For example, in some cases school nonattendance is partly encouraged by a parent who may wish the child to help with their own needs (e.g., a physical or mental disability) or the parent/child relationship may become pathological due to severe marital difficulties, and so on. In other words, chronic school refusal may reflect a variety of anxiety (or other) difficulties within the child (e.g., fear of the school work, separation anxiety, social fears, bullying, etc) combined with parental or family difficulties and in some cases with social support for nonattendance (see Chapter F.2 for further discussion). Social anxiety It should be noted that socially anxious children are not necessarily poor in social skills. They are commonly ignored or neglected rather than rejected. However, as a result of their anxiety, they may sometimes act in a socially awkward manner and may perform poorly in social situations. For example, they may not speak very much or may talk very quietly, they may show poor eye contact, or talk in a hesitant and uncertain manner. Anxiety disorders F.1 5 IACAPAP Textbook of Child and Adolescent Mental Health Comorbidity As mentioned earlier, it is common for discussions of childhood anxiety to focus broadly across anxiety (and sometimes related disorders) rather than focussing on only a single disorder. One of the main reasons for this is the strong overlap between the various anxiety disorders and between anxiety and other internalising disorders, especially depression. Clinically anxious children rarely meet criteria for only one disorder. Within treatment-seeking populations, around 80% to 90% meet criteria for more than one mental disorder. The majority, up to 75%, meet criteria for more than one anxiety disorder. A further 10% to 30% also meet criteria for an additional mood disorder. Age differences are apparent here – around 30% of treatment-seeking adolescents meet criteria for an additional mood disorder while only around 10% to15% of younger anxious children do so. About 25% of younger treatment-seeking anxious children will also meet criteria for an additional behavioural disorder. Similar figures are found in populationbased samples, although the proportion of children with a single anxiety disorder is slightly higher. Nevertheless, even in population-based samples, children with anxiety disorders are highly likely to have additional anxiety, mood, and behavioural disorders. Interestingly, anxious children do not appear to be at greater risk for substance abuse, most likely reflecting the fact that these children generally obey rules and do not take risks. However, an overlap between anxiety disorders and alcohol abuse begins to appear from late adolescence or early adulthood (Costello et al, 2003). EPIDEMIOLOGY Prevalence Prevalence estimates of child anxiety have been somewhat variable across countries and studies due to many factors including variations in criteria, assessment instruments and sampling. Overall, around 5% of children and adolescents meet criteria for an anxiety disorder during a given period of time in Western populations (Rapee et al, 2009). There is little data available from other cultures, but one study from Puerto Rico has shown similar rates (Canino et al, 2004). In most studies prevalence is highest for specific phobias and moderate for separation anxiety, generalised anxiety and social phobia. Gender distribution Anxiety disorders are more common in females than males in the general population. Most population studies estimate around 1.5-2 times as many females compared to males for most anxiety disorders. There is some evidence that this gender difference appears very early – as young as 5 years of age. In contrast, distributions within treatment-seeking samples in Western societies are more equal and even include slightly more males, possibly reflecting a social pressure for males not to experience anxiety. Age of onset Anxiety disorders are among some of the earliest disorders to appear and most commonly begin
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