A Community
Study
Javad
of Anxiety
H. Kashani,
M.D.,
The
authors used an epidemiologic approach to investigate rates, symptoms, and behavioral concomitants of anxiety across the child and adolescent age span. They drew 2 1 0 children aged 8, 12, and 1 7 in equal numbers from a community sample and evaluated them with structured diagnostic assessments. They found anxiety to be the most frequently reported type of psychopathology across all three age groups. Although the prevalence of any anxiety symptom remained constant, specific types of anxiety varied with age. Age differences in nonanxiety behavior f ound between subjects with and without anxiety, ticularly with regard to interpersonal dysfunction. (Am J Psychiatry 1990; 147:313-318)
were par-
T
he role of anxiety has been considered central to the understanding of the entire range of childhood psychopathology. Anxiety has clinical importance not only as a distinct set of disorders but also because it exerts an effect on other domains of functioning. Additionally, anxiety would appear to influence other disorders indirectly: many thought processes as well as behavioral and physiological responses may be dramatically altered under the influence of anxiety (1). Given its clinical importance, examination of the developmental progression of anxiety should be a research priority. However, until recently the study of anxiety in children and adolescents has been limited to descriptions of symptoms such as fears or phobias (2,3).
During the past several years the literature pertaining to anxiety and children has increased, including reports on children whose parents have anxiety disordens (4, 5) and studies of clinically referred children with anxiety (6-10). Regarding the latter, Last et al. (6) warned that findings in clinically referred children with anxiety disorders may not be applicable to the general population of children with anxiety. Because
Received Nov. 8, 1988; revisions received April 19 and Aug. 22, 1989; accepted Sept. 13, 1989. From the Department of Psychiatry, University
of
Missouri-Columbia,
Health Center, Columbia. Department of Psychiatry, pital
Drive,
The University
thank
MO
John
© 1990
Psychiatry
the
Mid-Missouri
Mental
65201.
C. Reid,
of Missouri-Columbia,
Copyright
Am]
Columbia,
authors
and
Address reprint requests to Dr. Kashani, University of Missouri-Columbia, 3 Hos-
American
147:3,
for
Ph.D., his
Professor help
Psychiatric
March
with
Association.
1990
of Statistics, data
analysis.
and
in Children
and Adolescents
Helen
Ph.D.
Orvaschel,
many children in the general population are neither referred nor treated, study of a representative community sample can provide a nonbiased database on anxiety symptoms in children and adolescents. Adding a developmental perspective to the epidemiologic approach would provide even more useful information on this type of psychopathology, particularly with regard to quantitative versus qualitative differences and continuities and discontinuities across ages ( 1 1). We recently reported rates of anxiety disorders and their associated characteristics in a community sample of mid-adolescent subjects (12). The current cross-sectional study provides data across a broader age group of children and adolescents with a focus on comparisons across ages. The objective of this paper is threefold: first, to examine rates and symptoms of anxiety across the age span; second, to compare patterns of nonanxiety behavior in anxious and nonanxious subjects across ages; third, to explore characteristics that differentiate anxious and nonanxious subjects at three age levels.
METHOD Subjects
and
Procedure
The sample consisted of 210 subjects chosen from a public school list of 4,810 children (1,745 8-year-olds, 1,578 12-year-olds, and 1,487 17-year-olds). (There is no private school in this city.) The subjects were selected by a stratified random method based on age (8, 12, and 17 years old) and by sex (105 boys and 105 girls), and every ith name was drawn. The sample size was determined by the financial restraint established by the granting agency. According to Hollingshead and Redlich’s social class index (13), 42 (20.0%) of the 210 students were in class I, 73 (34.8%) in class II, 57 (27.1%)
in class
III,
35
(16.7%)
in class
IV,
and
three
(1.4%) in class V. In regard to racial composition, 187 (89.0%) of the students were Caucasian, 19 (9.0%) were black, and four (1.9%) were Oriental or other. (The catchment area was 90% Caucasian, 8% black, 1% Oriental, and 1% Hispanic.) Of 377 families originally contacted, 289 (76.7%) agreed to participate; no information was available on the families who refused. We stopped interviewing when we reached the desired number of subjects from each age group and of each gender. The prospective
313
ANXIETY
TABLE
Type
IN CHILDREN
1. Prevalence
AND
of Anxiety
of Anxiety
Separation anxiety disorder Overanxious disorder Simple phobia Social phobia Anyanxiety
ADOLESCENTS
in 210 Children
and Adolescents
8-YearOlds
12-YearOlds
17-YearOlds
Boys
Girls
Total
(N=70)
(N=70)
(N=70)
(N =105)
(N =105)
(N=210)
N
%
N
%
N
%
N
%
N
%
N
%
13 6 2 0 18
18.6 8.6 2.9 0.0 25.7
6 8 2 1 11
8.6 1 1.4 2.9 1.4 15.7
8 12 3 1 15
11.4 17.1 4.3 1.4 21.4
S 10 1 1 14
4.8 9.5 1.0 1.0 13.3
22 16 6 1 30
21.0 15.2 5.7 1.0 28.6
27 26 7
12.9 12.4 3.3
subjects were approached by telephone; the caller explained the project and offered $50 per child as an incentive for participation. (The U.S. census indicates that about 4% of the households in this community would not have a telephone.) After the family agreed to participate, an appointment was made to conduct the interviews in the subject’s home. Both the child and the child’s mother were interviewed by structured interview (the Child Assessment Schedule and the Parents’ Child Assessment Schedule) (14, 15); additionally, the child completed an anxiety self-report form. All participating children and their parents provided informed consent to participation in the study after its nature had been explained to them. Interviewers
‘
was
Training
formally
1.0 21.0
been previously reported (14, 15). These instruments allow for the determination of DSM-III diagnoses. In addition, the Child Assessment Schedule assesses various areas of adjustment and functioning. Scores are then derived by summing the items in several broad areas of functioning (e.g., school, family, self-image). Symptoms relevant to a specific diagnosis can also be totaled into symptom complex scales to provide a more detailed picture of specific categories of behavior. High scores on these scales are indicative of greater difficulty. Revised Children’s Manifest Anxiety Scale. The Revised by
Children’s Reynolds
Manifest and
Anxiety
Richmond
Scale (17)
was
to
developed
assess
chronic
manifest subscale
The interviewers’ training was conducted by D.J. Burbach, who collaborated with K.K. Hodges (15; unpublished 1985 paper). The interviewers were doctoral students in psychology or child and family development who had previous experience working with children. Training included extensive review of relevant material (such as the Child Assessment Schedule manual), role playing, and rating and discussing videotaped Child Assessment Schedule interviews. In addition, the interrater reliability was assessed. These procedures were based on the recommendations of Hodges and Burbach (unpublished 1985 paper), who were involved in their implementation. During the role play, all interviewers met an initial item-by-item kappa criterion of 0.80. The interrater reliability
2 44
evaluated
by
requiring
inter-
viewers to rate videotaped Child Assessment Schedule interviews administered to clinically referred children. This procedure yielded a mean±SD kappa of 0.92± 0.02 (range=0.89 to 0.96). During the course of data collection, interviewers were continually monitored to minimize interviewer’s drift (16).
anxiety in children and adolescents. It yields scores in three areas of anxiety: physiological, oversensitive, and concentration. Higher scores on these subscales reflect greater anxiety. The Revised Children’s Manifest Anxiety Scale has a high degree of concurrent validity when compared with the trait measure on the State-Trait Anxiety Inventory for Children (18).
Statistical
by
Analyses
Frequency data using chi-square
for
the
three
analyses.
groups To
were
compare
compared differences
in medians between two and among three groups, we used Wilcoxon and Kruskal-Wallis analyses of ranks, respectively. All tests of significance used two-tailed p values. Specific group differences were examined by using post hoc nonparametric group comparison methods. Although some might think that use of a Bonferroni-corrected p value would be more appropniate than an uncorrected p value, we felt that this was too conservative for an exploratory study and therefore did not use a Bonferroni correction.
RESULTS Instruments
Child
Assessment Schedule. The Child Assessment Schedule is a semistructured diagnostic interview designed to assess child and adolescent psychopathology. A parallel form, the Parents’ Child Assessment Schedule, is administered to parents about their children. Reliability
314
and
validity
data
on
these
interviews
have
We examined several aspects of anxiety. examined the frequencies of and relationships categories of anxiety. Second, we examined cies
of specific
symptoms
of anxiety
Third, we explored the and nonanxious children
differences in the three
frequency
symptoms.
of
nonanxiety
Am]
Psychiatry
across
First, we among frequenage
groups.
between anxious age groups in the Finally, we com-
147:3,
March
1990
JAVAD FIGURE pared
anxious
and
nonanxious
children
in
each
children
had
1. Overlap
H. KASHANI
AND
HELEN
of the Types of Anxiety
ORVASCHEL
in 44 Adolescents
and
agc Childrena
category.
Forty-four
(21.0%)
according
to
(13.8%)
had
the
of the
Child
Assessment
anxiety
Assessment
according
Schedule.
reported
type
sample.
210
Anxiety
kappa
Schedule,
and
coefficient
reflecting
the
Social
29
to the Parents’ Child was the most frequently in this community
of psychopathology
The
anxiety
Separation
Phobia
Anxiety
agreement
between parent and child was 0.16, indicating that agreement between parent and child concerning anxiety was poor. Only 10 (4.8%) (six girls and four boys) of the children were found to have anxiety according to both the Child Assessment Schedule and the Parents’ Child Assessment Schedule. Children were diagnosed as having anxiety if they met the algorithm of the Child Assessment Schedule Manual (or the Parents’ Child Assessment Schedule) specifically
for
separation
anxiety
avoidant
anxiety
disorder,
Table
specific
8-,
12-,
the
types and
of
DSM-III
on phobia,
Child
and
anxiety
for
for
disorder, social
Assessment
17-year-olds.
criteria
overanxious
simple
1 provides
of
based
disorder,
phobia.
Schedule
boys
and
According
girls
to these
rates and
for
data,
the
8-year-olds had higher rates of separation anxiety disorder but the 17-year-olds had higher rates of overanxious disorder; the three groups had similar rates of phobic
disorders.
Girls
reported
significantly
more
anxiety than boys (27.13, df=1, p