Monday November 10 2014
Adolescents were most likely to have a social anxiety disorder
"Teenage anxiety: Tailored treatment needed," BBC News reports, saying a "one-size-fits-all approach to treating teenagers with anxiety problems may be putting their futures at risk."
The news is based on research that looked at the diagnoses of a group of children and a group of adolescents – it did not look at how they were treated or how effective any treatment was.
But this research highlighted potential problems with assuming that "children" – defined as being aged 5 to 18 years – are affected by anxiety in the same way.
This study looked at different diagnoses among 100 children (aged six to 12 years) and 100 adolescents (aged 13 to 18 years) with anxiety problems referred to a specialist mental health service in England.
The findings showed that, despite children and adolescents often being considered as one group, their specific diagnoses – and therefore treatment needs – can differ.
In this sample, children more often had separation anxiety disorder, while adolescents were marginally (but not significantly) more likely to have generalised anxiety disorder and social anxiety disorder. Adolescents were also more likely than children to have mood disorder and have problems with school attendance.
However, as this study looked at a single consecutive sample of children and adolescents, it may not be representative of all young people with anxiety disorders: different results may be obtained from a different sample.
And this study does not provide evidence that children or adolescents are being incorrectly diagnosed or are receiving inadequate treatment.
Where did the story come from?
The study was carried out by researchers from the University of Reading and was supported by a Medical Research Council Clinical Research Training Fellowship awarded to one of the authors.
It was published on an open access basis in the Journal of Affective Disorders, a peer-reviewed medical journal.
The BBC News coverage is generally representative of this research.
What kind of research was this?
This was a case series reporting the diagnoses of 100 children (aged six to 12 years) and 100 adolescents (aged 13 to 18 years) who were consecutively referred to a specialist UK mental health service for anxiety problems.
The researchers report how little is known about the clinical characteristics of children and adolescents who are routinely referred for anxiety disorders.
And, when considered in studies, children and adolescents with anxiety disorders are often treated as one very similar (homogenous) group with an age range of five to 18 years, although they may differ in meaningful ways.
The researchers wanted to examine a series of cases of anxiety disorders to see whether there are key characteristics that distinguish children from adolescents referred for these conditions.
They expected that adolescents would have a higher anxiety severity, more social anxiety, disturbed school attendance and more frequent co-existing mood disorders.
What did the research involve?
The children and adolescents were consecutive referrals from general practice and secondary care to the care services at the Berkshire Healthcare NHS Foundation Trust Child and Adolescent Mental Health Service (CAMHS) Anxiety and Depression Pathway based at the University of Reading. CAMHS accepts referrals of children and adolescents with anxiety disorders from across the UK.
The child and adolescent assessments were conducted at one point in time, and involved separate diagnostic assessments or questionnaires with the child and their "primary caregiver" (usually a parent).
Child and adolescent diagnoses of anxiety disorders were determined using a structured interview called the Anxiety Disorders Interview Schedule for DSM IV – Child and Parent Version (ADIS-C/P). This assesses anxiety and other mood and behaviour disorders according to standard diagnostic criteria.
If the child or adolescent met diagnostic criteria, a clinician severity rating (CSR) was given from 0 (absent or none) to 8 (very severely disturbing or disabling), where 4 would be the score indicating a diagnosis.
The Spence Children's Anxiety Scale (SCAS-C/P) assesses symptoms reported by parents and the children themselves. These symptoms related to six domains of anxiety, rated on a scale from 0 (never) to 3 (always):
- panic attacks or agoraphobia
- separation anxiety
- physical injury fears
- social phobia
- generalised anxiety
- obsessive-compulsive symptoms
Other assessments include the Short Mood and Feelings Questionnaire (SMFQ-C/P) to assess self-reported depression, and the Strengths and Difficulties Questionnaire (SDQ-P) to assess parent-reported behavioural disturbance.
Caregivers' own psychological symptoms were assessed using the short version of the Depression Anxiety Stress Scales (DASS).
What were the basic results?
The majority of children and adolescents (84%) met a primary (main) diagnosis of anxiety disorder on the ADIS. Ten per cent of the children and 7% of adolescents did not meet any diagnostic criteria.
Six per cent of children and 9% of adolescents had non-anxiety primary diagnoses, including oppositional defiant disorder, attention deficit hyperactivity disorder (ADHD), and depression.
The results were based on the 84 children and 84 adolescents who met the criteria for a main diagnosis of anxiety disorder.
Children were significantly more likely than adolescents to have a diagnosis of separation anxiety disorder (affecting 44% of children versus 18% of adolescents).
Social anxiety disorder and generalised anxiety disorder were slightly more common in adolescents (affecting 52% and 55%, respectively) than children (affecting 45% and 49%, respectively), but the difference between children and adolescents was not statistically significant.
Although most children and adolescents had moderate severity anxiety, adolescents tended to have more severe diagnoses than children. The mean CSR score for anxiety was 5.33 for adolescents and 4.93 for children.
Mood disorders were also significantly more common in adolescents than children (affecting 24% of the total adolescent sample and 6% of children). School refusal was also significantly more frequent in adolescents (18%) than children (7%).
How did the researchers interpret the results?
The researchers conclude that, "The finding that children and adolescents with anxiety disorders have distinct clinical characteristics has clear implications for treatment.
"Simply adapting treatments designed for children to make the materials more 'adolescent friendly' is unlikely to sufficiently meet the needs of adolescents."
This is a useful exploratory study, which should give a good indication of the range of diagnoses among children and adolescents referred for anxiety disorders to specialist mental health services in England.
Children and adolescents, particularly in research, can often be placed into one homogenous group, and this study shows specific diagnoses can differ significantly between the groups. For example, this study showed that children more often had separation anxiety disorder.
And adolescents were marginally (but not significantly) more likely to have generalised anxiety disorder and social anxiety disorder. Adolescents were also more likely than children to have mood disorder and to have problems with school attendance.
The researchers warn they have considered childhood and adolescence as two distinct developmental periods, with age 13 being the turning point.
In reality, as they say, differences between diagnoses and treatment needs would be unlikely to occur in the same way in every growing child. They suggest that further studies focus on narrower age bands.
As the researchers also acknowledge, the people in this study were from a predominantly white British ethnic background and from relatively high socioeconomic backgrounds.
The study also did not include those with autism spectrum disorders, obsessive compulsive disorders, or post-traumatic stress disorder.
This study is likely to give a good indication of the proportion of children and adolescents with different anxiety diagnoses referred to this specialist mental health service, but we cannot be certain it is entirely representative of young people with anxiety disorders. Different results may be obtained from a different sample.
As the researchers say, their results highlight that children and adolescents with anxiety disorders are likely to have different treatment needs.
But this case study does not show that children and adolescents are being incorrectly diagnosed or are receiving inadequate treatment.
The present study focused solely on diagnosis, and not treatment. As the research did not look at treatments, it should not be assumed that children and adolescents are not receiving the appropriate treatment targeted at their diagnosis.
Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.