Feb. 22, 2000 (Washington) -- The quiet wheel -- not just the squeaky -- needs attention too, according to a report on anxiety disorders in youth released Monday by the National Institute of Mental Health (NIMH) and the Anxiety Disorders Association of America (ADAA).
According to the report, this range of so-called "internalized" disorders is poorly understood, imperfectly diagnosed, undertreated, and inadequately researched in trials.
"It's relatively unknown because these kids don't cause problems in school," Deborah Beidel, PhD, psychology professor at the University of Maryland in College Park, and chairwoman of the ADAA's task force on children. "Kids with anxiety disorders are usually very inhibited. They sit in their seat and they do their work. They're suffering inside, but they're not making trouble for the teacher and therefore nobody's really paying attention to them."
"Of the money that we spend on children, only a small portion is in the area of anxiety," says Steven Hyman, MD, director of the NIMH. He tells WebMD, "The major investments have [primarily] been in attention deficit disorder, conduct disorder, and ... adolescent depression. This is, to me, very upsetting."
The lack of understanding on these conditions is not because the problem is small. In fact, the U.S. Surgeon General's 1999 report on mental health estimated that anxiety disorders are the most common mental disorders among youth, affecting 13% of those aged 9-17. The conditions have long-term consequences if untreated, with recent research suggesting links to alcoholism and depression later in life.
But the new report noted that fewer than 20 well-controlled trials have examined treatments for these disorders. "We're still really in the dark about how these disorders manifest themselves and can best be treated in youngsters," says Jerilyn Ross, MA, president of the ADAA.
Societal attitudes also conspire against a full understanding of these conditions. Hyman tells WebMD that children with anxiety disorders have been "at the crossroads of two stigmas." For one, he notes, children may suffer quietly because they are ashamed that they have a mental condition. For the other, "even if parents are aware, often they either hope that it is just a passing phase or they're afraid if they bring a child to the pediatrician that they may be blamed."
Moreover, Hyman says, these disorders have also had to escape from the shadow of outmoded theory. "This was the last area of psychiatry to be liberated from Freudian dogmas," he tells WebMD, recalling from psychiatric residency in the early 1980s that "it was dogma that children could not be depressed because depression required the full development of this theoretical entity called the superego."
"We really need some research that clarifies the nature of these disorders in children -- when [children] get them, how they develop, how they might change as children age," Beidel tells WebMD. "We also need to know what factors might contribute to either the onset or particularly the maintenance of these disorders. Once we understand the disorder itself, then we can develop more effective interventions."
But there is a lack of qualified researchers. "I have been [more] prepared to allocate more money to the area of treatment trials in children than I've had highly rated applications to spend it on," Hyman tells WebMD. "There is a really dangerous shortage of investigators who could do the research."
Even with trained investigators, major ethical issues over risk and informed consent plague clinical trials involving children. "We wouldn't have a control with no treatment. The alternative would have to have some sort of appropriate psychosocial treatment," Hyman tells WebMD.
Now for the good news. As limited as the evidence still is, the report reflects consensus in the field that behavioral therapy is generally effective for treating the disorders, and that selective serotonin re-uptake inhibitors (SSRIs) are effective for treating obsessive-compulsive disorder and possibly other anxiety disorders. More news may emerge in the relatively near future on the latter front, as SmithKline Beecham is now conducting a trial of Paxil (paroxetine) for treating social phobia in youth.
Beidel tells WebMD that parents should think about seeking medical intervention if their child appears to be exceptionally fearful or shy for at least six months. "Kids should be joining sports teams, going to birthday parties, going to school and talking, having friends, sleeping over at other kids' houses." She recommends that parents seek care from a pediatrician, clinical psychologist, or psychiatrist.
- Anxiety disorders are largely under-studied and under-recognized by researchers, doctors and parents, according to a new report.
- Experts suggest parents should seek help from their pediatrician, psychiatrist, or psychologist if their child seems overly fearful or shy for at least six months.