Abstract

Considerable work has advanced understanding of the nature, causes, management, and prevention of anxiety disorders in children and adolescents over the past 30 years. Prior to this time the primary focus was on school refusal and specific phobias. It is now recognised that children and adolescents experience the full gamut of anxiety disorders in very similar ways to adults and that anxiety disorders in the paediatric years can predict a lifelong mental-health struggle. Given the vast array of specific studies in this field, the current review summarises current knowledge about these high prevalence disorders, points to overarching limitations, and suggests potentially important future directions. Following a brief historical overview, the review summarises knowledge about demographic and epidemiological characteristics, distal and proximal risk factors, current treatment directions, and prevention. There is still a great deal to learn about the causes and treatments of child and adolescent anxiety disorders. By amalgamating our current knowledge, this review provides a window to the research directions that are likely to lead to future advances.

Introduction and historical overview

Like much research in applied psychology, the history of treating anxiety in young people1 can be traced back over a century. For the most part, the history of evaluating treatment for anxiety disorders in young people can be described as rigorous, highly informative, and an exemplar of incremental science. In short, much has been learned (Higa-McMillan et al, 2015; Southam-Gerow & Prinstein, 2014) and reasonable confidence can be ascribed to the findings, given the overall methodological quality of the work.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) exemplifies such progress, and across the several editions and even within versions of the DSM, the labels for the anxiety disorders in young people have evolved. For example, overanxious disorder was described in the third edition of the DSM reflecting excessive worry, concerns about personal competence, need for reassurance, and self-consciousness. This specific disorder was later eliminated partly due to its overlap with social phobia. Thus, most young people who would have met criteria for this diagnosis would now be diagnosed with the more clearly delineated generalised anxiety disorder, reflecting persistent and excessive worry, with excessive concern about routine matters and difficulty managing worry. Social phobia has been renamed social anxiety disorder, the persistent fear of social/performance situations involving potential scrutiny by others. In contrast, the label separation anxiety disorder, referring to young people who have an unusual-for-their-level-of-development severity of intense anxiety tied to separating from a caregiver, has remained over time. The more recent iterations of DSM, to its credit, provide detailed diagnostic criteria that are useful, though not without limitations, for making differential diagnoses. For example, selective mutism has appropriately now been moved into the anxiety disorders (American Psychiatric Association, 2013) from its previous placement among a broad range of disorders first evident in childhood. However, strong overlap with social anxiety disorder (Milic, Carl, & Rapee, 2020), raises serious questions about whether these disorders really require separate diagnostic labels. On the other hand, obsessive compulsive disorder has been moved out of the group of anxiety disorders with the publication of the DSM-5. However, the marked overlap between obsessive compulsive disorder and anxiety disorders (Stein et al., 2010), its similar response to treatment (Hudson, Rapee, et al., 2015), and its historical conceptualisation as an anxiety disorder, raise questions about this decision. Similar concerns exist for post-traumatic stress disorder, which was also moved outside of the anxiety disorder category in DSM-5.

Conclusion

Scientific research into paediatric anxiety disorders has increased dramatically over the past 30 years. As a result, we now have far greater knowledge about key characteristics, risk and maintaining factors, treatments, and prevention of these highly prevalent disorders. Nonetheless, the field has a long way to go. As an example, although we now have very well-established programs for the treatment of anxiety disorders in young people, less than half are free of all anxiety disorders immediately following treatment (James et al., 2020). This proportion typically increases over the following months (Hudson et al., 2009; Rapee, Abbott, Baillie, & Gaston, 2007), but the fact remains that a significant proportion of young people with anxiety disorders continue to meet criteria for their disorder even following our current best efforts at treatment. This, combined with the very low proportion of anxious young people in the community who receives empirically-validated treatment (Gandhi et al., 2022; Reardon et al., 2020) makes paediatric anxiety disorders a serious risk for long-term disability (King et al., 2020; Swan et al., 2018). By summarising the current state of the literature into paediatric anxiety disorders, we have highlighted key gaps in our knowledge and potentially important directions for future research. Among the many remaining important issues, a few in particular, stand out.