Psychiatric comorbidities among adolescents with and without anxiety disorders: a community study

Comorbidades psiquiátricas entre adolescentes com e sem transtornos de ansiedade: um estudo da comunidade

Estácio Amaro da Silva Júnior Camila Albuquerque de Brito Gomes About the authors

ABSTRACT

Objective

To evaluate, in a community sample of adolescents, the presence of comorbidities in different anxiety disorders.

Methods

This is a cross-sectional study, initially composed of 2,457 adolescents, aged between 10-17 years old, from public schools of the area covered by the Basic Health Unit of a university hospital. We applied the Screen for Child Anxiety Related Emotional Disorders (SCARED) to assess for anxiety disorders. Then, 138 positive cases in the screening were assessed for mental disorders through the Schedule for Affective Disorder and Schizophrenia for School-Age Children – Present and Lifetime Version (K-SADS-PL).

Results

Patients with anxiety disorders had more association with other anxiety disorders, as well as depression, and enuresis. The most common comorbidity described in our study was between generalized anxiety disorder and separation anxiety disorder (OR = 4.21, 95% CI 1.88, 9.58). Significant association was observed between other disorders such as enuresis and separation anxiety disorder (OR = 3.81, 95% CI 1.16, 12.49), as well as depression and generalized anxiety disorder (OR = 3.40; 95% CI 1.52, 7.61).

Conclusion

Our study showed a relevant presence of comorbidities adolescents with anxiety disorders, selected from a community sample, especially regarding other anxiety disorders. Nevertheless, further studies are needed to confirm our findings.

Child psychiatry; anxiety disorders; psychiatric comorbidities; depression; enuresis

RESUMO

Objetivo

Avaliar, em uma amostra comunitária de adolescentes, a presença de comorbidades nos distintos transtornos de ansiedade.

Métodos

Estudo transversal, composto por 2.457 adolescentes de 10 a 17 anos, provenientes das escolas públicas da área de abrangência da Unidade Básica de Saúde de um hospital universitário, que foram avaliados para transtornos de ansiedade, por meio da Screen for Child Anxiety Related Emotional Disorders (SCARED). Desses, 138 casos foram positivos pela SCARED e avaliados para transtornos mentais, por meio do Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL).

Resultados

Pacientes com transtornos de ansiedade apresentavam mais comorbidades com outros transtornos de ansiedade, bem como com depressão e enurese. As comorbidades mais frequentes descritas em nosso estudo foram transtorno de ansiedade generalizada e transtorno de ansiedade de separação (OR = 4,21; IC 95% 1,88; 9,58). Foi observada associação significativa com outros transtornos, tais como enurese com transtorno de ansiedade de separação (OR = 3,81; IC 95% 1,16; 12,49) e depressão com transtorno de ansiedade generalizada (OR = 3,40; IC 95% 1,52; 7,61).

Conclusão

A presença de comorbidades em adolescentes com transtornos de ansiedade selecionados de uma amostra comunitária foi frequente. Estudos complementares para confirmar nossos resultados são necessários.

Psiquiatria infantil; transtornos de ansiedade; comorbidades psiquiátricas; depressão; enurese

INTRODUCTION

Anxiety disorders comprise a heterogeneous group of illnesses that have in common heightened and excessive levels of fear, which often leads to functional impairment and adverse physical symptoms. Include generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobia, separation anxiety disorder and now reorganized for DSM-5 as separate categories post-traumatic stress disorder and obsessive-compulsive disorder1Helton SG, Lohoff FW. Serotonin pathway polymorphisms and the treatment of major depressive disorder and anxiety disorders. Pharmacogenomics. 2015;16(5):541-53.,2American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013..

Anxiety disorders composes the most common group of mental illnesses that affects adolescents3Rapee RM, Schniering CA, Hudson JL. Anxiety disorders during childhood and adolescence: origins and treatment. Annu Rev Clin Psychol. 2009;5:311-41.,4Ramtekkar U, Ivannenko A. Sleep in children with psychitric disorders. Sem Pediatr Neurol. 2015;22:148-55., with a cumulative prevalence of 10% by the age of 16 years old5Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. 2003;60(8):837-44., and a lifetime prevalence of 29%6Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.. When impairment in daily functioning is considered, prevalence rates of 5% to 10% are reported7Bodden DH, Dirksen CD, Bögels SM. Societal burden of clinically anxious youth referred for treatment: a cost-of-illness study. J Abnorm Child Psychol. 2008;36:487-97.. A cohort study, from a national sample of 755 children and adolescents referred to a psychiatric service, in Denmark, between 2004 and 2007, describes a prevalence of anxiety disorder of 5.7%8Esbjørn BH, Hoeyer M, Dyrborg J, Leth I, Kendall PC. Prevalence and co-morbidity among anxiety disorders in a national cohort of psychiatrically referred children and adolescents. J Anxiety Disord. 2010;24(8):866-72.. The presence of anxiety disorder is associated with low self-esteem, difficulties in relationships with peers and family, difficulties in the development at school, and also with disruptive behavior disorders9Ezpeleta L, Keeler G, Erkanli A, Costello EJ, Angold A. Epidemiology of psychiatric disability in childhood and adolescence. J Child Psychol Psychiatry. 2001;42(7):901-14..

These anxiety disorders present high rates of comorbidity among them, and with depression1010 Axelson DA, Birmaher B. Relation between anxiety and depressive disorders in childhood and adolescence. Depress Anxiety. 2001;14(2):67-78.,1111 Beidel DC, Turner SM, Morris TL. Psychopathology of childhood social phobia. J Am Acad Child Adolesc Psychiatry. 1999;38(6):643-50.. Studies with community samples have found rates of comorbidity among anxiety disorders and other disorders raging from 14% to 39%1212 McGee R, Feehan M, Williams S, Anderson J. DSM-III disorders from age 11 to age 15 years. J Am Acad Child Adolesc Psychiatry. 1992;31(1):50-9.,1313 Kashani JH, Orvaschel H. A community study of anxiety in children and adolescents. Am J Psychiatry. 1990;147(3):313-8.. The common presentation is anxiety preceding depression, and thus, anxiety is considered one of the most common mental disorders in childhood1414 Canino G, Shrout PE, Rubio-Stipec M, Bird HR, Bravo M, Ramirez R, et al. The DSM-IV rates of child and adolescent disorders in Puerto Rico: prevalence, correlates, service use, and the effects of impairment. Arch Gen Psychiatry. 2004;61(1):85-93.,1515 Breton JJ, Bergeron L, Valla JP, Berthiaume C, Gaudet N, Lambert J, et al. Quebec child mental health survey: prevalence of DSM-III-R mental health disorders. J Child Psychol Psychiatry. 1999;40(3):375-84., while depression rates increase significantly in adolescence1616 Roza SJ, Hofstra MB, van der Ende J, Verhulst FC. Stable prediction of mood and anxiety disorders based on behavioral and emotional problems in childhood: a 14-year follow-up during childhood, adolescence, and young adulthood. Am J Psychiatry. 2003;160(12):2116-21.,1717 Hankin BL, Abramson LY, Moffitt TE, Silva PA, McGee R, Angell KE. Development of depression from preadolescence to young adulthood: emerging gender differences in a 10-year longitudinal study. J Abnorm Psychol. 1998;107(1):128-40..

It is also important to mention that studies reveal that anxiety causing events appear to be the main reason for enuresis in adolescence1717 Hankin BL, Abramson LY, Moffitt TE, Silva PA, McGee R, Angell KE. Development of depression from preadolescence to young adulthood: emerging gender differences in a 10-year longitudinal study. J Abnorm Psychol. 1998;107(1):128-40.. Enuresis after the age of 10 years may be associated with a poor self-concept or other psychological problems. In addition, bed-wetting after the age of 10 years is associated with small but detectable increases in risk of conduct problem, attention deficit behaviors, and anxiety/withdrawal in early adolescence1818 Ramam S, Venkata RR, Santhoshi LG, Jyothi B, Divya BD, Vidya BK. A study on pevalence of nocturnal enuresis among rural pediatric and adolescent population. Int J Pharm Clin Res. 2015;7:92-5.,1919 Elbahnasawy HT, Elnagar MA. Psychological impact of nocturnal enuresis in self-esteem of school children. Am J Nurs Res. 2015;3:14-20..

There is a lack of studies using community samples of children and adolescents focused on studying the presence and patterns of different comorbidities. Although many studies investigate comorbidities in childhood and adolescence, only a few evaluate elimination disorders. In addition, even though the excretion disorders (enuresis and encopresis) are classified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as well as in the International Classification of Diseases (ICD-10), they are not found to be a usual subject of study in Psychiatry researches2American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013..

Thinking about the next edition of the DSM, it is important to investigate comorbidities in order to better understand the clinical presentation of anxiety disorders. This study focuses on generalized anxiety disorder, social anxiety disorder, specific phobia, separation anxiety disorder and panic disorder. It excludes the obsessive-compulsive disorder and posttraumatic stress disorder because they have specific characteristics that differentiate them from others, as indicated by the DSM-5 as a separated category of disorder2American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013..

The intent of this study is to evaluate the presence of comorbidities in a community sample of adolescents diagnosed with anxiety disorder.

METHODS

Sample selection

A total of 2,457 students (adolescents), aged from 10 to 17 years old, enrolled in six public schools belonging to the areas assisted by the primary care unit of a university hospital – Hospital de Clínicas de Porto Alegre (HCPA) – participated in the community study. Most of the adolescents resided with their biological mother, and siblings. The majority did not have the paternal figure present in their homes, and a smaller portion had their grandparents residing together with their mother, and siblings, in the same house. They were assessed through the SCARED, a questionnaire designed to screen for the presence of DSM-IV anxiety disorders in children and adolescents aged 9-18 years old2020 Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry. 1999;38(10):1230-6..

All subjects above the 75th percentile (n = 160) in the screening scale (SCARED), and their parents, were invited to a semi-structured interview (K-SADS-PL)2121 Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, et al. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry. 1997;36(7):980-8., performed by six interviewers (four child psychiatrists and two Psychiatry residents with inter-rater reliability resulting in Kappa = 0.93 for the anxiety disorders module); 138 adolescents evaluated had an anxiety disorder (86.25%).

The SCARED was applied at school, in the classroom. School directors and teachers granted authorization prior to the process, and the K-SADS-PL was performed in a hospital room, lasting on average two and a half hours. When cases of anxiety were detected, the adolescents were referred to psychologists, members of our research group, who provided a brief behavioral therapy intervention. In addition, child psychiatrists evaluated the adolescents at the beginning, middle and end of each therapeutic group, and outpatient care was indicated when needed.

The contact with the subjects to undergo clinical evaluation was made by phone, by the interviewers themselves. Students who did not have a telephone, or who did not know their telephone numbers, were excluded from the study. A loss of contact was defined after 5 calls, in different days, or in different periods of the day (at least one morning, one afternoon, one night and one day of weekend). Possible cases (n = 160), according to SCARED, and their parents were evaluated. Adolescents diagnosed with social anxiety disorder, generalized anxiety disorder, separation anxiety disorder or panic disorder, according to the K-SADS-PL, were selected. Enuresis was diagnosed by the diagnostic criteria of DSM-IV-TR, and there were no reported cases of anatomical abnormalities or neurological disability or chronic illness. The refusal to participate is described in figure 1.

Figure 1
Flowchart showing each step of sample selection.

After complete description of the study to the subjects, all parents provided written informed consent for participating in the study, and the adolescents provided written assent. This study was approved by the Research and Ethics Committee of HCPA (08-017).

Statistical analysis

The categorical variables were described as numbers and percentages (%). Also, continuous variables were expressed as mean and standard deviation (SD). We considered having or not having anxiety disorder as the outcome variable. Moreover, Pearson chi-square or the Fisher exact test was used to verify the association among categorical variables, and student t test was used to compare the average age among the groups. In addition, we used a logistic regression model to estimate the odds ratio (OR) for each comorbidity on the outcomes, adjusted for age, sex and social class. IQ below 70 was considered an exclusion criterion.

We established a level of significance of 5%, as well as a confidence interval (CI) of 95% was used in all tests. The analyses were performed through the SPSS (Statistical Package for Social Science) version 18.0.

RESULTS

The total number of adolescents with anxiety disorders assessed by the K-SADS- PL was 138. The total sample comprised 68.1% females (n = 94) and the mean age in years was 13.4 (SD = 2.38). Most of the sample was composed by Caucasians (n = 95; 68.8%), and by individuals with low socio-economic status (n = 85; 61.5%).

Considering gender, significant associations were found between Attention Deficit Hyperactivity Disorder and male gender, as well as between specific phobia and the female gender. Moreover, anxiety in lifetime, as a group, were present more frequently in females (Table 1).

Table 1
Relation between gender and psychiatric disorders

From 138 cases of anxiety disorders (generalized anxiety disorder, panic disorder, social anxiety disorder, and separation anxiety disorder) identified in the sample, 68.8% were diagnosed with generalized anxiety disorder (n = 95), 41.3% with social anxiety disorder (n = 57), 35.5% with separation anxiety disorder (n = 49), and 6.5% with panic disorder (n = 09). Considering the number of comorbidities, 58.2% of the cases had only one anxiety disorder, 30.6% had two anxiety disorders and 10.4% had three or four anxiety disorders during lifetime.

Comorbidities associated with anxiety disorders are very common, especially among them. The most frequently association found in our study was between generalized anxiety disorder and separation anxiety disorder (OR = 4.21, 95% CI = 1.88-9.58). We observed that patients with anxiety disorder have higher rates of enuresis and separation anxiety disorder (OR = 3.81, 95% CI = 1.16-12.49), depression and generalized anxiety disorder (OR = 3.40, 95% CI = 1.52-7.61), and depression and social anxiety disorder (OR = 2.57, 95% CI = 1.14-5.79). According to our study, patients with anxiety disorder had an increased risk of having another anxiety disorder as depicted on table 2. Individuals who have enuresis are 3.81 times more likely to have separation anxiety disorder than those without this comorbidity (OR = 3.81, 95% CI 1.16-12.49, p = 0.001).

Table 2
Odds ratio adjusted for age, gender and social class, and estimated for the outcomes of separation anxiety disorder, generalized anxiety disorder, and social anxiety disorder

DISCUSSION

Many authors reported that anxiety disorders could be studied as a unique group, once they have similar clinical presentation, etiology, outcome, as well as intervention2222 Andrade LHSG, Viana MC, Silveira CM. Epidemiology of women's psychiatric disorders. Rev Psiquiatr Clín. 2006;33:43-54.. Moreover, the high frequency of coexistence among them, described by the present study, is in agreement with what has been discussed in the literature1212 McGee R, Feehan M, Williams S, Anderson J. DSM-III disorders from age 11 to age 15 years. J Am Acad Child Adolesc Psychiatry. 1992;31(1):50-9.,2323 Benjamin RS, Costello EJ, Warren M. Anxiety disorders in a pediatric sample. J Anxiety Disord. 1990;4:293-316.,2424 Last CG, Strauss CC, Francis G. Comorbidity among childhood anxiety disorders. J Nerv Ment Dis. 1987;175(12):726-30..

Our study suggests that the presence of one anxiety disorder increases the risk of having another anxiety disorder or any other axis I disorder, as described in previous studies9Ezpeleta L, Keeler G, Erkanli A, Costello EJ, Angold A. Epidemiology of psychiatric disability in childhood and adolescence. J Child Psychol Psychiatry. 2001;42(7):901-14.,1111 Beidel DC, Turner SM, Morris TL. Psychopathology of childhood social phobia. J Am Acad Child Adolesc Psychiatry. 1999;38(6):643-50.,1212 McGee R, Feehan M, Williams S, Anderson J. DSM-III disorders from age 11 to age 15 years. J Am Acad Child Adolesc Psychiatry. 1992;31(1):50-9.,2323 Benjamin RS, Costello EJ, Warren M. Anxiety disorders in a pediatric sample. J Anxiety Disord. 1990;4:293-316.. For instance, it demonstrated that adolescents with enuresis, specific phobia, generalized anxiety disorder, and tic disorders are more likely to have separation anxiety disorder. Furthermore, those with social anxiety disorder, specific phobia, and depression are more likely to present with generalized anxiety disorder, as well as those with specific phobia, generalized anxiety disorder and depression are more likely to have social anxiety disorder. We also found a high association between generalized anxiety disorder and depression, which adds another point to the discussion of the validity of these conditions as distinct diagnosis or as part of the same nosological classification2525 Krueger RF. The structure of common mental disorders. Arch Gen Psychiatry. 1999;56(10):921-6.,2626 Wittchen HU, Carter RM, Pfister H, Montgomery SA, Kessler RC. Disabilities and quality of life in pure and comorbid generalized anxiety disorder and major depression in a national survey. Int Clin Psychopharmacol. 2000;15(6):319-28..

According to the study of Verduin and Kendall2727 Verduin TL, Kendall PC. Differential occurrence of comorbidity within childhood anxiety disorders. J Clin Child Adolesc Psychol. 2003;32(2):290-5., which assessed the comorbidities in children and adolescents between the ages of 8 and 13 years, with primary diagnoses of generalized anxiety disorder, separation anxiety disorder or social anxiety disorder, functional enuresis was more common in those with separation anxiety disorder. In agreement with this finding, we described a higher probability of individuals presenting enuresis to have separation anxiety disorder than those without this comorbidity. We also consider the hypothesis that enuresis could be a clinical manifestation of separation anxiety disorder, and not only a comorbid condition.

Additionally, we observed a higher frequency of anxiety disorders among the female gender group, which is in agreement with one review that assessed the prevalence of psychiatric disorders among women2222 Andrade LHSG, Viana MC, Silveira CM. Epidemiology of women's psychiatric disorders. Rev Psiquiatr Clín. 2006;33:43-54.. However, this finding is not entirely consistent, once there are studies that failed to demonstrate significant gender differences in the prevalence of anxiety disorders1313 Kashani JH, Orvaschel H. A community study of anxiety in children and adolescents. Am J Psychiatry. 1990;147(3):313-8.,2828 Ford T, Goodman R, Meltzer H. The British Child and Adolescent Mental Health Survey 1999: the prevalence of DSM-IV disorders. J Am Acad Child Adolesc Psychiatry. 2003;42(10):1203-11..

Parents of children and adolescents suffering from separation anxiety disorder exhibited a significantly higher prevalence of psychopathology, mainly anxiety disorders and mood disorders. Mothers predominantly suffered from social phobia and specific phobia. Fathers most frequently suffered from obsessive-compulsive disorder and social phobia2929 Sackl-Pammer P, Popow C, Schuch B, Aigner M, Friedrich M, Huemer J. Psychopathology among parents of children and adolescents with separation anxiety disorder. Neuropsychiatr. 2015;29(1):23-8..

Nevertheless, our study had some limitations that should be acknowledged. The small sample size was due to many refusals to participate in this study. As the participants came from a community sample, subjects were not looking for treatment, and the participation in the study required a hospital visit demanding time and costs. Despite this, there was a clear association of certain comorbidities with the hypotheses investigated. Also, the confidence intervals are long, which shows low accuracy in the estimation of odds ratios. We planned to minimize our confounding factors by selecting a school sample from the same social class and neighborhood.

CONCLUSIONS

To summarize, we found a high prevalence of comorbidities and association of enuresis with separation anxiety disorder in this study in a community sample. The presence of anxiety disorders is frequent in adolescents and these conditions are responsible for a strong impact in the development of these individuals1Helton SG, Lohoff FW. Serotonin pathway polymorphisms and the treatment of major depressive disorder and anxiety disorders. Pharmacogenomics. 2015;16(5):541-53.,8Esbjørn BH, Hoeyer M, Dyrborg J, Leth I, Kendall PC. Prevalence and co-morbidity among anxiety disorders in a national cohort of psychiatrically referred children and adolescents. J Anxiety Disord. 2010;24(8):866-72..

Anxiety disorders when present in youth increase the risk of suicide attempts, as well as the risk of secondary mood and anxiety disorders, and are associated with significant morbidity and mortality3030 Strawn JR, Welge JA, Wehry AM, Keeshin B, Rynn MA. Efficacy and tolerability of antidepressants in pediatric anxiety disorders: a systematic review and meta-analysis. Depress Anxiety. 2015;32(3):149-57..

ACKNOWLEDGMENTS

Funding source: All phases of this study were supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and by Fundo de Incentivo à Pesquisa e Eventos do Hospital de Clínicas de Porto Alegre (FIPE-HCPA).

REFERENCES

  • 1
    Helton SG, Lohoff FW. Serotonin pathway polymorphisms and the treatment of major depressive disorder and anxiety disorders. Pharmacogenomics. 2015;16(5):541-53.
  • 2
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  • 3
    Rapee RM, Schniering CA, Hudson JL. Anxiety disorders during childhood and adolescence: origins and treatment. Annu Rev Clin Psychol. 2009;5:311-41.
  • 4
    Ramtekkar U, Ivannenko A. Sleep in children with psychitric disorders. Sem Pediatr Neurol. 2015;22:148-55.
  • 5
    Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. 2003;60(8):837-44.
  • 6
    Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
  • 7
    Bodden DH, Dirksen CD, Bögels SM. Societal burden of clinically anxious youth referred for treatment: a cost-of-illness study. J Abnorm Child Psychol. 2008;36:487-97.
  • 8
    Esbjørn BH, Hoeyer M, Dyrborg J, Leth I, Kendall PC. Prevalence and co-morbidity among anxiety disorders in a national cohort of psychiatrically referred children and adolescents. J Anxiety Disord. 2010;24(8):866-72.
  • 9
    Ezpeleta L, Keeler G, Erkanli A, Costello EJ, Angold A. Epidemiology of psychiatric disability in childhood and adolescence. J Child Psychol Psychiatry. 2001;42(7):901-14.
  • 10
    Axelson DA, Birmaher B. Relation between anxiety and depressive disorders in childhood and adolescence. Depress Anxiety. 2001;14(2):67-78.
  • 11
    Beidel DC, Turner SM, Morris TL. Psychopathology of childhood social phobia. J Am Acad Child Adolesc Psychiatry. 1999;38(6):643-50.
  • 12
    McGee R, Feehan M, Williams S, Anderson J. DSM-III disorders from age 11 to age 15 years. J Am Acad Child Adolesc Psychiatry. 1992;31(1):50-9.
  • 13
    Kashani JH, Orvaschel H. A community study of anxiety in children and adolescents. Am J Psychiatry. 1990;147(3):313-8.
  • 14
    Canino G, Shrout PE, Rubio-Stipec M, Bird HR, Bravo M, Ramirez R, et al. The DSM-IV rates of child and adolescent disorders in Puerto Rico: prevalence, correlates, service use, and the effects of impairment. Arch Gen Psychiatry. 2004;61(1):85-93.
  • 15
    Breton JJ, Bergeron L, Valla JP, Berthiaume C, Gaudet N, Lambert J, et al. Quebec child mental health survey: prevalence of DSM-III-R mental health disorders. J Child Psychol Psychiatry. 1999;40(3):375-84.
  • 16
    Roza SJ, Hofstra MB, van der Ende J, Verhulst FC. Stable prediction of mood and anxiety disorders based on behavioral and emotional problems in childhood: a 14-year follow-up during childhood, adolescence, and young adulthood. Am J Psychiatry. 2003;160(12):2116-21.
  • 17
    Hankin BL, Abramson LY, Moffitt TE, Silva PA, McGee R, Angell KE. Development of depression from preadolescence to young adulthood: emerging gender differences in a 10-year longitudinal study. J Abnorm Psychol. 1998;107(1):128-40.
  • 18
    Ramam S, Venkata RR, Santhoshi LG, Jyothi B, Divya BD, Vidya BK. A study on pevalence of nocturnal enuresis among rural pediatric and adolescent population. Int J Pharm Clin Res. 2015;7:92-5.
  • 19
    Elbahnasawy HT, Elnagar MA. Psychological impact of nocturnal enuresis in self-esteem of school children. Am J Nurs Res. 2015;3:14-20.
  • 20
    Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry. 1999;38(10):1230-6.
  • 21
    Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, et al. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry. 1997;36(7):980-8.
  • 22
    Andrade LHSG, Viana MC, Silveira CM. Epidemiology of women's psychiatric disorders. Rev Psiquiatr Clín. 2006;33:43-54.
  • 23
    Benjamin RS, Costello EJ, Warren M. Anxiety disorders in a pediatric sample. J Anxiety Disord. 1990;4:293-316.
  • 24
    Last CG, Strauss CC, Francis G. Comorbidity among childhood anxiety disorders. J Nerv Ment Dis. 1987;175(12):726-30.
  • 25
    Krueger RF. The structure of common mental disorders. Arch Gen Psychiatry. 1999;56(10):921-6.
  • 26
    Wittchen HU, Carter RM, Pfister H, Montgomery SA, Kessler RC. Disabilities and quality of life in pure and comorbid generalized anxiety disorder and major depression in a national survey. Int Clin Psychopharmacol. 2000;15(6):319-28.
  • 27
    Verduin TL, Kendall PC. Differential occurrence of comorbidity within childhood anxiety disorders. J Clin Child Adolesc Psychol. 2003;32(2):290-5.
  • 28
    Ford T, Goodman R, Meltzer H. The British Child and Adolescent Mental Health Survey 1999: the prevalence of DSM-IV disorders. J Am Acad Child Adolesc Psychiatry. 2003;42(10):1203-11.
  • 29
    Sackl-Pammer P, Popow C, Schuch B, Aigner M, Friedrich M, Huemer J. Psychopathology among parents of children and adolescents with separation anxiety disorder. Neuropsychiatr. 2015;29(1):23-8.
  • 30
    Strawn JR, Welge JA, Wehry AM, Keeshin B, Rynn MA. Efficacy and tolerability of antidepressants in pediatric anxiety disorders: a systematic review and meta-analysis. Depress Anxiety. 2015;32(3):149-57.

  • FINANCIAL DISCLOSURE
    The authors have no financial relationships relevant to this article to disclose.

Publication Dates

  • Publication in this collection
    Jul-Sep 2015

History

  • Received
    19 May 2015
  • Accepted
    7 June 2015
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