Avoidance
Disorder of Childhood or Adolescence
The essential feature of this disorder is
an excessive shrinking from contact with
unfamiliar people that is of sufficient
severity to interfere with social functioning
in peer relationships and that is of at least
six months' duration. This is coupled with a
clear desire for social involvement with
familiar people, such as peers, the person
knows well and family members Relationships
with family members and other familiar
figures are warm and satisfying. The
diagnosis is not made if the disturbance is
sufficiently pervasive and persistent to
warrant the diagnosis of Avoidance
Personality Disorder.
A child with this disorder is likely to
appear socially withdrawn, embarrassed, and
timid when in the company of unfamiliar
people and will become anxious when even a
trivial demand is made to interact with
strangers. When social anxiety is severe, the
child may be inarticulate or mute, even if
his or her communication skills are
unimpaired.
Associated features. Children
with this disorder are generally unassertive
and lack self-confidence. In adolescence,
inhibition of normal psychosexual activity is
common. The disorder rarely occurs alone;
children with this disorder usually have
another Anxiety Disorder, such as Overanxious
Disorder.
Age at onset. The disorder
typically appears during the early school
years, within the context of increased
opportunities for social contact. It may,
however, develop as early as two and a half
years, after "stranger anxiety," as
a normal developmental phenomenon, should
have disappeared.
Course. The course seems
variable: some children improve
spontaneously, whereas others experience an
episodic or chronic course. How often this
disorder becomes chronic and continues into
adulthood, as a Social Phobia, Generalized
Type, or Avoidance Personality Disorder, is
unknown.
Impairment. Age-appropriate
socialization skills may not develop. The
impairment in social functioning is often
severe.
Predisposing factors. There
is some evidence that Specific Developmental
Disorders involving language and speech may
predispose to the development of this
disorder.
Complications. The most
serious complication is failure to form
social bonds beyond the family, with
resulting feelings of isolation and
depression.
Prevalence. The disorder is
not common
Sex ratio. The disorder is
apparently more common in females than in
males.
Familial pattern. There is
some evidence that Anxiety Disorders may be
more common in the mothers of children with
the disorder.
Differential diagnosis. Socially
reticent children are slow to warm up to
unfamiliar people, but after a short time can
respond, and suffer no impairment in peer
interaction. In Separation Anxiety Disorder,
the anxiety is focused on separation from the
home or major attachment figures rather than
on contact with unfamiliar people per se, but
both disorders may be present. In Overanxious
Disorder, anxiety is not focused on contact
with unfamiliar people, but, again, both
disorders may be present. In Major Depression
and Dysthymia, social withdrawal is commonly
present, but is generalized. In Adjustment
Disorder with Withdrawal, the withdrawal is
related to a recent psychosocial stressor and
lasts less than six months.
The diagnosis is not made if the disturbance
is sufficiently pervasive and persistent to
warrant the diagnosis of Avoidance
Personality Disorder.
Diagnostic Criteria for Avoidance
Disorder of Childhood or Adolescence
A. Excessive shrinking from
contact with unfamiliar people, for a period
of six months or longer, sufficiently severe
to interfere with social functioning in peer
relationships.
B. Desire for social
involvement with familiar people (family
members and peers the person knows well), and
generally warm and satisfying relations with
family members and other familiar figures.
C. Age at least 21/2 years.
D. The disturbance is not
sufficiently pervasive and persistent to
warrant the diagnosis of Avoidance
Personality Disorder.
Overanxious
Disorder
The essential feature of this disorder is
excessive or unrealistic anxiety or worry for
a period of six months or longer. A child
with this disorder tends to be extremely
self-conscious; to worry about future events,
such as examinations, the possibility of
injury, or inclusion in peer group
activities, or about meeting expectations,
such as deadlines, keeping appointments, or
performing chores; and to be concerned even
about past behavior. Because of his or her
anxieties, the child may spend an inordinate
amount of time inquiring about the
discomforts or dangers of a variety of
situations and need much reassurance. For
example, routine visits to the doctor may be
anticipated with excessive worry about minor
procedures. The child may also be overly
anxious about competence in a number of areas
and, especially, about what others will think
of his or her performance.
In some cases physical concomitants of
anxiety are apparent; the child may complain
of a lump in the throat, or experience
gastrointestinal distress, headache,
shortness of breath, nausea, dizziness, or
other somatic discomforts. Difficulty falling
asleep is common. The child may constantly
appear nervous or tense.
Preoccupation with a neighbor or adult school
figure who seems "mean" or critical
has been observed. As the child becomes
older, such preoccupations usually focus on
more general forms of judgment, such as peer,
social, or athletic acceptance, and school
grades.
If another disorder is present (e.g.,
Separation Anxiety Disorder, Phobic Disorder,
Obsessive Compulsive Disorder), the anxiety
and worry extend beyond the focus of that
disorder. for example, if Separation Anxiety
Disorder is present, the anxiety and worry
are not exclusively related to separation.
A diagnosis of Overanxious Disorder is not
made if the disturbance occurs only during
the course of a psychotic disorder or a Mood
Disorder.
Associated features. Social
and Simple Phobia may also be present.
Children with this disorder may refuse to
attend school because of their anxiety in
that setting. They often seem hypermature
because of their precocious" concerns.
Perfectionist tendencies, with obsessional
self-doubt, may be evident; the child may be
excessively conformist and overzealous in
seeking approval. Sometimes excessive motor
restlessness or nervous habits, such as
nail-biting or hair-pulling, are observed.
The child may be reluctant to engage in
age-appropriate activities in which there are
demands for performance, such as sports.
Course. The onset may be
sudden or gradual, with exacerbation’s
associated with stress The disorder may
persist into adult life as an Anxiety
Disorder, such as General ized Anxiety
Disorder or a Social Phobia.
Age at onset. No
information.
Impairment. In unusually
severe cases, this disorder can be
incapacitating and result in inability to
meet realistic demands at home and in school.
Complications. Complications
may include unnecessary medical evaluations
for somatic symptoms.
Predisposing factors. This
disorder seems to be more common in eldest
children, in small families, in upper
socioeconomic groups, and in families in
which there is a concern about achievement
even when the child functions at an adequate
or superior level.
Prevalence. The disorder is
not uncommon. Most of the children without
the additional diagnosis of Separation
Anxiety Disorder seen in clinical settings
are 13 years or older; those with both
disorders are usually under 13.
Sex. The disorder is
apparently equally common in males and in
females
Familial pattern. There is
some evidence that Anxiety Disorders are more
common among mothers of children with
Overanxious Disorder than mothers of children
with other mental disorders.
Differential diagnosis. In
cases of Separation Anxiety Disorder
unassociated with Overanxious Disorder, the
anxiety is focused solely on situations
involving separation.
Children with only Attention-deficit
Hyperactivity Disorder may appear nervous and
jittery, but are not unduly concerned about
the future. The two disorders may coexist
however. In Adjustment Disorder with Anxious
Mood, the anxiety is related to a recent
psychosocial stressor and lasts less than six
months.
Overanxious Disorder should not be diagnosed
when the anxiety is a symptom of a psychotic
disorder or a Mood Disorder.
Diagnostic Criteria for
Overanxious Disorder
A. Excessive or unrealistic
anxiety or worry, for a period of six months
or longer, as indicated by the frequent
occurrence of at least four of the following
- excessive or unrealistic worry about
future events
- excessive or unrealistic concern
about the appropriateness of past
behavior
- excessive or unrealistic concern
about competence in one or more
areas, e.g., athletic, academic,
social
- somatic complaints, such as headaches
or stomachaches, for which no
physical basis can be established
- marked self-consciousness
- excessive need for reassurance about
a variety of concerns
- marked feelings of tension or
inability to relax
B. If another disorder is
present (e.g., Separation Anxiety Disorder,
Phobic Disorder, Obsessive Compulsive
Disorder)r the focus of the symptoms in A are
not limited to it. For example, if Separation
Anxiety Disorder is present, the symptoms in
A are not exclusively related to anxiety
about separation. In addition, the
disturbance does not occur only during the
course of a psychotic disorder or a Mood
Disorder.
C. If 18 or older, does not
meet the criteria for Generalized Anxiety
Disorder.
D. Occurrence not
exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or any
other psychotic disorder.
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