This treatment-seeking sample had moderate to severe anxiety disorder(s). Given the relatively few exclusion criteria, wide age range, and multiple sites, the sample represents a real-world presentation of distressing anxiety among youth, particularly prepubertal youth. It is noteworthy that less than 25% of the sample met criteria for only one of the three targeted anxiety disorders, whereas 36% met criteria for all three disorders. These findings are consistent with other reports (e.g.,
Essau, Conradt, & Petermann, 1999;
Essau, Petermann, 1999;
Wittchen, Stein, & Kessler, 1999). In light of the high degree of anxiety comorbidity (
Foa et al., 2005), it is of interest to consider the degree to which anxiety presents as separate disorders in youth. Given that youth are more likely than adults to lack a fully developed understanding of emotions, social expectations, and the parameters of risk, and given the rapid changes in biological, social, and familial systems occurring during development, it may not be surprising that anxious symptom presentation by youth does not fall lock-step into specified categories. Development, almost by definition (
Lerner, 1986), suggests successive change, such that continuity of a specific anxiety disorder may not be expected. There may be a general problem with anxiety, yet differing presentations across development (see also
Last, Perrin, Hersen, & Kazdin, 1992;
Ollendick & King, 1994). With ongoing development in youth, an anxiety disorder may present differentially at different points in development (e.g., as separation when starting preschool and as social anxiety when entering adolescence). In contrast, although anxiety disorders in adults also evidence comorbidty (
Craske, Rauch, Ursano, Prenoveau, Pine, & Zinbarg, 2009), their presentation may be less variable. Perhaps as evidenced by the finding that adolescents were more likely to meet criteria for social phobia than younger children, increased age and development is required for specific anxieties to take form and be expressed. Nevertheless, the anxiety disorders in youth overlap in symptoms and are highly comorbid among themselves.
Although youth with a co-primary diagnosis for which a different disorder-specific treatment would be indicated were not included, the present sample was highly comorbid: 55.3% met criteria for at least one additional disorder. These findings are consistent with other studies (
Angold, Costello, & Erkanli, 1999;
Lewinsohn, Zinbarg, Seeley, Lewisohn, & Sack, 1997;
Verduin & Kendall, 2003) and further evidence that anxiety disorders in youth often do not present as single/focused disorder. These data also provide evidence that anxiety disorders often co-occur with externalizing problems, a finding that has treatment implications (
March et al., 2000).
The severity of the sample was evident across multiple measures. Mean scores on the ADIS CSR, CGI-S and CGAS were all indicative of marked illness and functional impairment. On the PARS, the sample was comparable to youth in other studies (e.g., The RUPP Fluvoxamine Study (
RUPP Anxiety Study Group, 2002)). The mean total score for the present sample on the CAIS-P, reflecting parental report anxiety-related functional interference, was significantly higher than that for the original CAIS-P validation sample (22.2 vs. 18.8, Hedges’ g=0.41, p<0.001). In addition, CBCL Anxiety/Depression, Internalizing, and total problem mean scores were all >1.5 SDs above the mean. Children’s mean self-talk (NASSQ) was in the negative and maladaptive range.
Consistent with prior literature (
Comer & Kendall, 2004), parent-reports of their children’s symptoms on the MASC and SCARED were higher than children’s self-reports. Children may present themselves as less impaired for a number of reasons including social desirability, avoidance of their anxiety, because they are uncomfortable with the mental health system, or lack developmental awareness of their anxiety as pathological. Likewise, parents may over-report anxiety in their children for a variety of reasons, including their own personal distress and motivation to receive treatment (
Connell & Goodman, 2002).
There were no meaningful differences in anxiety diagnosis and severity for gender or race. This finding is consistent with existing data (
Costello et al., 1996;
Ginsburg & Silverman, 1996;
Treadwell, Flannery-Schroeder, & Kendall, 1995). Although the sample was primarily Caucasian, race was not related to diagnostic status except for a higher percentage of Caucasians with GAD only. Further study is needed, but the present findings suggest that, among treatment-seeking anxious youth, the anxiety disorder presentation is consistent across the races and gender. With regard to age, it was not surprising that, among participants who met diagnostic criteria for only one of the three anxiety disorders, a significantly higher percentage of adolescents were diagnosed with SP. This likely reflects the increasing concerns with social relationships that emerge during adolescence (
Crawley, Beidas, Benjamin, Martin, & Kendall, 2008).
Despite the large sample, multisite recruiting, comprehensive assessment, and rigorous quality assurance, a few limitations warrant consideration. First, although the sample included the full range of SES, participants were predominately middle class or higher (75%) and European-American in background (78%). Second, study eligibility criteria precluded inclusion of youngsters with MDD, thus limiting our ability to examine the relationship between anxiety and depression. Finally, the sample does not include participants diagnosed with principal panic disorder, PTSD, or OCD of any severity.
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