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by middle childhood to mid adolescence. As will be discussed later, it is common for anxiety disorders to occur within a context of temperamental inhibition (see below) and fearfulness. Hence it is often difficult to determine exactly when the actual anxiety disorder first begins and, to some extent, anxious children can often be said to be anxious from birth. Estimates also differ depending on whether they are determined from pre-adult populations or from retrospective reports from adults. Estimates of average age of onset (these are Anxiety disorders F.1 6 IACAPAP Textbook of Child and Adolescent Mental Health averages, disorder can start earlier in individual cases) for the different disorders are as follows: • Animal phobias – early childhood (around 6-7 years) • Separation anxiety disorder – early to mid-childhood (around 7-8 years) • Social anxiety disorder – early adolescence (around 11-13 years) • Generalised anxiety disorder – widely varying estimates from mid adolescence to adulthood • Panic disorder – early adulthood (around 20-24 years). Course Anxiety disorders are among the most stable forms of psychopathology and show relatively little spontaneous remission. Anxious children are also at increased risk of developing other disorders during adolescence and into adulthood. Longitudinal research has shown that anxious children are at greater risk for anxiety, mood and externalising disorders in adolescence and for anxiety, mood, and substance use disorders as well as suicide in adulthood (Beesdo-Baum & Knappe, 2012; Bittner et al, 2007). Other demographic features Interestingly, anxiety in childhood is characterised by very few demographic risk factors. There is some evidence that low socioeconomic status might provide some risk for anxiety but the data are mixed and the degree of risk is small. Similarly, some research has hinted that socially anxious children in particular are more likely to be first born but other research has failed to support this finding. Most other demographic characteristics fail to predict anxiety (aside from gender, described earlier). Hence anxious children are not characterised by a given family size, parental marital status, educational attainment or intelligence (Rapee et al, 2009). ASSESSMENT Clinical evaluation generally includes a combination of questionnaires, diagnostic interview and behavioural observation. However, in most clinical settings, a diagnostic interview and a small number of questionnaires will be most appropriate. Diagnostic interview Several structured diagnostic interviews exist to assist in determining either DSM or ICD criteria for childhood disorders including anxiety. Most interviews include a large number of questions aimed to tap each of the relevant diagnostic criteria and generally differ in their degree of structure. Some widely used instruments include: • Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) • Development and Wellbeing Assessment (DAWBA) • Diagnostic Interview Schedule for Children (DISC). If the interest is in anxiety more specifically, then the Anxiety Disorders Interview Schedule for Children (ADIS-C) (Silverman & Albano, 1996) has a primary focus on these disorders. For very young children, the Preschool Age Psychiatric Assessment (PAPA) is a useful instrument (Egger et al, 2006). Most structured interviews involve separate interviews with the parents and the child (at Anxiety disorders F.1 7 IACAPAP Textbook of Child and Adolescent Mental Health least once the child is 8 years old or so) and the clinician is then faced with the task of combining the information in some way. Like most disorders of childhood, information from parents and children about anxiety disorders commonly contains several discordant aspects. Clinical judgement and experience needs to be applied to determine which information is more heavily weighted and how best to combine the information (see Chapter A.3 for a detailed discussion of this issue). Anxious children are often thought to “fake good” (Kendall & Chansky, 1991) – in other words, to deny feeling anxious or to provide answers that they think are socially acceptable. However, many parents are also anxious (discussed below) and in some cases will exaggerate the child’s difficulties due to their own distress. Hence, the interviewer needs to obtain sufficient detail to allow a judgement about which is the most accurate report and which aspects of the information may be inaccurate. Clinically, distinguishing between specific disorders can be difficult. As described above, it is important to determine the basic motivation behind particular behaviours in order to identify the relevant diagnosis. For example, young children who have a tantrum when their parents plan to go out may be doing so due to the attention and benefits they receive, or to a fear of some negative occurrence following separation. Clinically, once all behaviours, motivations, and diagnostic criteria have been assessed and it has been determined that a child meets criteria for two (or more) clearly distinct disorders, it is generally useful to determine which of the disorders is principal (also referred to as primary). Most authors conceptualise the principal disorder as the one that produces the greatest impact and interference in the child’s life. Hence this disorder is usually the initial focus in therapy. Most empirical
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