Journal of Anxiety Disorders 73 (2020) 102234

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Journal of Anxiety Disorders

journal homepage: www.elsevier.com/locate/janxdis

Generalized anxiety disorder: Prevalence, predictors, and comorbidity in T

children and adolescents
Mohammad Reza Mohammadia, Parandis Pourdehghana,*, Seyed-Ali Mostafavia,
Zahra Hooshyaria, Nastaran Ahmadib, Ali Khaleghia
a
Psychiatry and Psychology Research Center, Roozbeh HospitalTehran University of Medical Sciences, Tehran, Iran
b
Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

ARTICLE INFO ABSTRACT

Keywords: Generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders among children and ado-
Comorbidity lescents.
Generalized anxiety disorder Objectives: The purpose of this study is to determine the prevalence, sociodemographic variables, and co-
Predictors morbidity of GAD among children and adolescents to suggest the main predictors, using an analytical cross-
Prevalence
sectional study.
Method: Data were collected via a multistage random-cluster sampling method from 29,709 children and ado-
lescents aged 6–18 years old in Iran. We used the Persian present and lifetime version of the Kiddie Schedule for
Affective Disorders and Schizophrenia (K-SADS-PL). Then, we analyzed the data via descriptive analysis and
multivariate logistic regression analysis methods.
Results: The lifetime prevalence rate for GAD was 2.6 % (95 % Cl, 2.4%–2.8%). Overall, logistic regression
analyses revealed five variables with significant unique contributions to the prediction of GAD. Significant
predictors were: age, sex, mother history of psychiatric hospitalization, mother education, and residence.
Participants with these risk factors were between 0.23–2.91 times more likely to present with GAD. Besides, the
highest and lowest comorbidity rates of psychiatric disorder with GAD was 57.6 % and 0.3 % related to anxiety
and eating disorders, respectively. Age or sex also affects the comorbidity of GAD and some mental disorders
including behavioral, neurodevelopmental, elimination, and mood disorders.
Conclusion: This study, which was conducted in Iran, is located at the low end of the range of international
estimates for GAD. Awareness of the predictors and comorbidity of GAD could be used in the prevention of GAD
in children and adolescents.

1. Introduction
Epidemiologic studies in the past two decades worldwide have
shown that anxiety disorders are the most common mental disorders in
the general population (Alonso & Lepine, 2007; Kessler, Chiu, Demler,
Merikangas, & Walters, 2005). Anxiety disorders are a pervasive pro-
blem and globally, account for 1.08 % of total disability-adjusted life
years (DALYs); 0.82 %–1.37 % (Global Burden of Disease, 2017).
Generalized anxiety disorder (GAD) is known as one of the most
common anxiety disorder, carrying significant comorbidity, impair-
ment, and disability (Wittchen, 2002). There is some evidence that GAD
is the most frequently seen anxiety disorder across ages in primary care
settings (Grenier et al., 2018; Milanak, Magruder, & Frueh, 2013;
Davidson, Feltner, & Dugar, 2010). The prevalence rates for GAD in
primary care settings range from 3.7 % to 14.8 % (Kertz & Woodruff-
Borden, 2011; Wittchen et al., 2001). Some studies confirmed that GAD
accounted for more than 50 % of anxiety disorders seen in the primary
care setting (Roberge et al., 2015; Wittchen & Hoyer, 2001).
Moreover, GAD is associated with a significant economic burden
owing to decreased work productivity and increased use of health care
services, especially primary health care (Wittchen, 2002). The health
costs for patients with GAD were estimated 64 % higher compared with
those without GAD (Olfson & Gameroff, 2007). The recognition that
GAD accounts for a very substantial proportion of all mental disorders,
that comorbid GAD complicates more than half of all psychiatric and
medical conditions, and that GAD is related to considerably increased
disability and medical cost (Olfson & Gameroff, 2007) should mobilize
the field of study (Papp, 2009).

⁎
Corresponding author.
E-mail address: parandis.pourdehghan@gmail.com (P. Pourdehghan).

https://doi.org/10.1016/j.janxdis.2020.102234
Received 8 September 2019; Received in revised form 29 April 2020; Accepted 30 April 2020
Available online 12 May 2020
0887-6185/ © 2020 Elsevier Ltd. All rights reserved.
M.R. Mohammadi, et al. Journal of Anxiety Disorders 73 (2020) 102234

GAD among children and adolescents having mean prevalence rates

between 2.2 % and 3.6 % (Costello, Egger, & Angold, 2005). The life-
time prevalence of GAD ranged from 0.3 % in Germany to 11 % in New
Zealand (Beesdo, Knappe, & Pine, 2009). The lifetime prevalence of
GAD in American adolescents was 3% (Burstein et al., 2011; Burstein,
Beesdo-Baum, He, & Merikangas, 2014). A survey of children and
adolescents in the UK stated 0.7 % had GAD (Green, McGinnity,
Meltzer, Ford, & Goodman, 2005). In another research prevalence of
GAD in the Netherlands was 2.9 % (Ormel et al., 2015). McEvoy, Grove,
& Slade (2011) found the lifetime prevalence of GAD ranges from 5.7 %
in the United States to 6.1 % in Australia.
All anxiety disorders more frequently occur among females than
among males (Beesdo et al., 2009). The US National Comorbidity
Survey showed that women were twice more likely to have GAD than
their male counterparts, with total lifetime prevalence rates of 6.6 %
and 3.6 %, respectively (McLean, Asnaani, Litz, & Hofmann, 2011).
Some studies in France, Canada, and Europe have found that young
women have the highest risk for GAD (Leray et al., 2011; Lieb, Becker,
& Altamura, 2005; Watterson, Williams, Lavorato, & Patten, 2017).
Moreover, McLaughlin, Behar, and Borkovec (2008) indicated that in-
dividuals with GAD were more likely to have family members with
anxiety problems. The presence of externalizing types of psycho-
pathology, such as alcohol and substance abuse among parents may
also increase the risk for GAD (Johnson, 2002).
Comorbid psychiatric disorders are common in persons with GAD
(Noyes, 2001). A consistent finding in clinical and epidemiological
studies of GAD is the high proportion of comorbidity with some diag-
noses including major depression, panic disorder, social and specific
phobia, and post-traumatic stress disorder (Noyes, 2001; Sadock,
Sadock, & Ruiz, 2014; Wittchen, 2002). Actually, rates of comorbidity
are especially high for other anxiety disorders. Individuals with GAD
are likely to have met, or currently meet, criteria for other anxiety
(American Psychiatric Association, 2013). GAD in children and ado-
lescents is highly comorbid, with only 14 % of one survey not having a Fig. 1. Flow Diagram of sampling method.
comorbid anxiety disorder (Gale & Millichamp, 2016). As many as 66 %
of patients with current GAD have an additional concurrent psychiatric 2. Method
disorder and they almost invariably (90 %) have a lifetime history of
another psychiatric disorder (Wittchen, 2002). Some studies described 2.1. Participants
the high comorbidity between GAD and separation anxiety disorder
(Silva Junior & Gomes, 2015; Verduin & Kendall, 2003). Copeland, The initial sample design included 30,532 children and adolescents,
Shanahan, Erkanli, Costello, and Angold (2013) tested the comorbid- based on individuals between 6–18 years old in provincial clusters
ities of common childhood psychiatric disorders in a research in which across Iran. As Fig. 1 indicates, 823 participants were dropped out due
generalized anxiety and depressive disorders displayed a very high level to incomplete interviews or a lack of validity detected in the random
of overlap. Albeit GAD does have a significant rate of comorbidity, data auditing process. From the initial raw sample, 29709 children and
now suggest that it is its unique condition and needs to be regarded adolescents which were 6 to18 years old, 14,545 male subjects, and
independently (Kessler, Keller, & Wittchen & Hoyer, 2001). 15,164 female subjects, participated in a national survey conducted in
Although the definition of GAD has changed over several iterations all provinces of Iran. The data were collected via a multistage random-
of the diagnostic and statistical of mental disorders (DSM), and now cluster sampling design. 170 blocks were selected at random according
GAD has its own distinct symptom cluster apart from major depression to the postal code. Then, of each cluster head, participants were se-
disorder (MDD), the epidemiology of GAD has lagged due to the shifting lected; 6 cases consist of 3 participants of each gender in different age
DSM nosology and worries about independence of GAD as its own groups (6−9, 10−14, and 15−18 years). The participants were se-
unique disorder. (Kessler, Keller, & Wittchen, 2001). Differences in lected from rural and urban areas in each province, proportionally.
prevalence estimates from different countries are unlikely reflective of The inclusion criteria included factors such as Iranian nationality
true regional differences. Most epidemiological studies examine the and 6–18 age groups. Those having severe physical illnesses were not
prevalence in western industrialized countries, such as the United included.
States and the UK that may differ from developing countries or other
populations. Additionally, basic national epidemiological data about
children and adolescents are limited in Iranian estimates, and incon- 2.2. Procedure
sistencies are seen in research methods applied in provincial and re-
gional surveys. This has left a major gap in our understanding of GAD in This research was a part of the first national study in Iranian
children and adolescents across Iran. Children and Adolescents Psychiatry (IRCAP) evaluating the prevalence
This study provides a further investigation into the cross-sectional of psychiatric disorders (Mohammadi et al., 2019; Mohammadi,
epidemiology of GAD. This research aims to determine the prevalence, Ahmadi, Kamali, Khaleghi, & Ahmadi, 2017). The data were obtained
sociodemographic characteristics, and comorbidity of GAD in Iranian from participants and their parents independently using a semi-struc-
children and adolescents to identify the main predictors. tured interview (K-SADS-PL) conducted by 250 clinical psychologists at
participants’ homes. It lasted 60−90 min. Furthermore,

2
M.R. Mohammadi, et al.
sociodemographic variables including gender, age, parent education,
and place of residence were obtained. The pool of interviewers for this
research consisted of masters’-level psychologists (experienced in
working with children and adolescents). All K-SADS-PL interviewers
underwent intensive training regarding the instrument, diagnostic
classification, critical differential diagnostic issues, and the use of the K-
SADS-PL. The consistency between the interviewers was approved by
the inter-rater reliability of 91 %. Interviews were performed across
Iran between September 2016 and January 2018.
The IBM SPSS22 software was used to analyze the descriptive and
inferential statistics. The odds ratio (OR) and multiple logistic regres-
sion analyses were performed to determine which variables across di-
agnostic groups were statistically significant predictors of GAD.
2.3. Ethics
This study was conducted according to the Helsinki statement. The
informed consent form obtained from participants and/or their parents,
and the gathered information remained confidential. This work was
approved by the National Institute for Medical Research Development
(NIMAD). NIMAD Ethics Code for this study is
IR.NIMAD.REC0.1395.001.
2.4. Measures
2.4.1. Kiddie-SADS-present and lifetime version (K-SADS-PL)
The Kiddie-Schedule for Aff ;ective Disorders and Schizophrenia is a
semi-structured psychiatric interview that ascertains both lifetime and
current episodes of psychopathology based on DSM-IV criteria. K-SADS-
PL includes three components: introductory interview (demographic,
health, and other background information), screen interview (82
symptoms related to 20 diagnostic areas), and five diagnostic supple-
ments (Kaufman et al., 1997). The interview opens with questions
about basic demographics. Health and developmental history data
should also be obtained (Kaufman, Birmaher, Brent, Rao, & Ryan,
1996). The reliability and validity of the Persian version of K-SADS-PL
were before assessed, and it provided a reliable and valid psychiatric
diagnosis. The threshold diagnosis of GAD had the highest sensitivity
(100 %) and 91 % specificity. The consensual validity of GAD was
0.781. Moreover, there was good inter-rater reliability, positive and
negative predictive value for nearly all of the disorders (Ghanizadeh,
Mohammadi, & Yazdanshenas, 2006; Shahrivar, Kousha, Moallemi,
Tehrani-Doost, & Alaghband-Rad, 2010).
3. Results
3.1. Prevalence and sociodemographic correlates
The demographic characteristics of the Iranian children and ado-
lescents sample population in association with a lifetime prevalence of
GAD are shown in Table 1. Logistic regression was performed to further
analyze the demographic indicators with a lifetime prevalence of GAD.
The results of this multivariable analysis resembled the unadjusted es-
timates. Variables found to be significant included sex, age, residence,
mother education, mother history of psychiatric hospitalization.
Results showed a 2.6 % (95 % CI, 2.4%–2.8%) lifetime prevalence of
GAD. The lifetime prevalence of GAD amongst girls was 2.9 % (95 % CI,
2.6%–3.3%), whereas the prevalence amongst boys was 2.2 % (95 % CI,
1.9%–2.5%). A multivariate odds ratio (OR) of 1.35 (95 % CI,
1.12%–1.63%) indicated a significantly higher lifetime prevalence of
GAD in girls. As age rises, the chance of having GAD increases. Subjects
who were in 15−18 and 10−14 age groups had 2.91 and 2.03 times
higher odds of GAD, respectively, in comparison to those with 6−9
years old. Subjects living in rural areas were less likely to experience
GAD when compared with urban respondents (multivariate OR, 0.69;
95 % CI, 0.49 to 0.98). Father education (multivariate OR for primary
3
Journal of Anxiety Disorders 73 (2020) 102234
level education, 1.28; 95 % CI, 0.73–2.27) and father with a history of
psychiatric hospitalization (multivariate OR, 0.87; 95 % CI, 0.21–3.58)
were not significantly associated with GAD. Children who had Mothers
with primary level education had significantly 1.8 times higher ad-
justed OR (95 % CI, 1.04%–3.1%) compared to those who had illiterate
mothers. Other levels of mother education were not significant.
Subjects who had mothers without a history of psychiatric hospitali-
zation had a lower chance of GAD compared with those with mothers
having a history of psychiatric hospitalization (multivariate OR, 0.23;
95 % CI, 0.10 to 0.54).
Given to Fig. 2, we can see that the prevalence of GAD overall in-
creases with increasing age. Furthermore, the prevalence of GAD in
girls of all age groups (except 11 years of age) is higher than that of
boys.
3.2. Psychiatric comorbidity
Table 2 and Fig. 3 indicate comorbid psychiatric disorders with
GAD. According to the research results, the most comorbid mental
disorders with GAD were separation anxiety disorder (29.8 %), oppo-
sitional defiant disorder; ODD (22.4 %), specific phobias (21.2 %), so-
cial phobia (20.2 %), agoraphobia (18.2 %), depression (17.02 %), at-
tention deficit hyperactivity disorder; ADHD (16.8 %), obsessive-
compulsive disorder; OCD (15.7 %). The comorbidity of separation
anxiety disorder with GAD was 29.8 % (95 % CI, 26.6%–33.1%), as the
most comorbid disorder. The least comorbidity of psychiatric disorders
with GAD was related to bulimia nervosa (0.3 %), encopresis (0.4 %),
and alcohol abuse (0.5 %). The other comorbid psychiatric disorders
with GAD were in a range of 0.7%–12.9%.
Table 3 demonstrates the comorbidity of GAD with psychiatric
disorders based on sex and age. At first glance, the most comorbid
disorder with GAD was anxiety disorders (57.6 %), and the least was
eating disorders (0.3 %). When comorbidity rates of mental disorders
with GAD were investigated based on sex, the comorbidity of just three
disorders was significant; behavioral, neurodevelopmental, and elim-
ination disorders. In all these disorders, being a girl was a protective
factor that means girls who had behavioral disorders were 0.66 (95 %
CI, 0.49 to 0.90) times less likely to experience GAD when compared
with boys having behavioral disorders. Likewise, the comorbidity of
GAD and neurodevelopmental or elimination disorders was higher in
boys related to girls. In other disorders, the results were not significant.
As an example, although the comorbidity of GAD and anxiety disorders
in girls (61.1 %) was higher than boys (57.2 %), it was not significant
(OR 1.17; 95 % CI, 0.87–1.58).
In studying the comorbidity of psychiatric disorders based on the
age group, the results of just mood and elimination disorders were
significant. Given Table 3, as age increases, the comorbidity rate of
GAD and mood disorders significantly increases. The odds ratios (OR)
of 1.02 (95 % CI, 0.57–1.8) and 2.03 (95 % CI, 1.20–3.44) indicated
significantly higher comorbidity between these disorders in 10−14 and
15−18 age groups, respectively, compared to 6−9 age group. In
contrast, the comorbidity of elimination disorders and GAD declined
with increasing age.
Concerning GAD, urban older girls whose mothers have a history of
psychiatric hospitalization and a low level of education were more
likely to have GAD rather than those who do not have any of these.
Moreover, the comorbidity of anxiety disorders and GAD was higher
than that of other mental disorders and GAD. However, the least co-
morbid disorder with GAD belonged to eating disorders. The co-
morbidity of behavioral, neurodevelopmental, elimination disorders
with GAD in boys was higher than in girls. The comorbidity of mood
disorders and GAD, in contrast to elimination disorders and GAD, in-
creases with increasing age.
M.R. Mohammadi, et al. Journal of Anxiety Disorders 73 (2020) 102234

Table 1
Distribution and Frequency of Sociodemographic Characteristics in children and adolescents with GAD (N = 29709).
Variables N (%) With GAD Disorders Regression logistic model

n(%unweighted) %weighted Univariate Multivariate

(CI95%) OR (CI95%) OR (CI95%)

Gender Boy 14545(49) 324(2.2) 2.2(1.9-2.5) Baseline

Girl 15164(51) 422(2.8) 2.9(2.6-3.3) 1.36(1.13-1.63)** 1.35(1.12-1.63)**
Age 6-9 10123(34.1) 152(1.5) 1.3(1.04-1.6) Baseline
10-14 10399(35) 275(2.6) 2.7 (2.4-3.2) 2.14(1.65-2.78)** 2.03(1.55-2.65)**
15-18 9187(30.9) 319(3.5) 3.9(3.4-4.4) 3.05(2.36-3.94)** 2.91(2.36-3.78)**
Types of settlement Urban 24765(83.4) 624(2.5) 2.6(2.4-2.9) Baseline
Rural 4944(16.6) 122(2.5) 2.2(1.7-2.9) .84(.61-1.14) .69(.49-.98)*
Father educations Illiterate 1289(4.5) 38(2.9) 2.4(1.5-3.8) Baseline
primary school 4619(16.1) 159(3.4) 3.3(2.7-4.1) 1.41(.83-2.38) 1.28(.73-2.27)
Guidance & high school 6383(22.3) 154(2.4) 2.7(2.3-3.3) 1.15(.68-1.92) 1.06(.59-1.89)
Diploma 8315(29.1) 197(2.4) 2.4(2-2.8) .99(.6-1.66) 1.00(.55-1.82)
bachelor 6034(21.1) 118(2) 2.2(1.8-2.7) .92(.55-1.56) .94(.5-1.76)
MSc or higher 1970(6.9) 38(1.9) 2.2(1.5-3.1) .89(.49-1.64) .96(.46-1.97)
Missing 1099 - -
Mother educations Illiterate 1692(5.9) 42(2.5) 1.9(1.2-3) Baseline
primary school 5473(18.9) 176(3.2) 3.4(2.8-4.2) 1.81(1.1-3)* 1.8(1.04-3.1)*
Guidance & high school 5648(19.5) 159(2.8) 3.1(2.6-3.8) 1.61(.98-2.67) 1.75(.99-3.1)
Diploma 9572(33.1) 218(2.3) 2.4(2-2.8) 1.23(.76-2.01) 1.43(.80-2.56)
Bachelor 5546(19.2) 119(2.1) 2.3(1.8-2.8) 1.17(.7-1.95) 1.47(.79-2.73)
MSc or higher 978(3.4) 15(1.5) 1.7(1-3) .92(.44-1.9) .69(.51-2.72)
Missing 800
History of psychiatric hospitalization in parents Father Yes 109(.4) 3(2.8) 3.4(.9-11.5) Baseline
No 29600(99.6) 743(2.5) 2.6(2.4-2.8) .74(.18-3.01) .87(.21-3.58)
Mother Yes 88(.3) 8(9.1) 9.7(4.5-19.6) Baseline
No 29621(99.7) 738(2.5) 2.5(2.3-2.8) .23(.10-.53)** .23(.10-.54)**
History of psychiatric disorder or physical illness in psychiatric No 29392(99.1) 647(2.3) 2.4(2.2-2.6) Baseline
children and adolescents Yes 256(0.9) 84(4.5) 4.4(3.4-5.7) 1.89(1.41-2.53)** 1.69(1.25-2.29)**
Missing 61 15 - - -
physical No 27595(93.6) 720(2.4) 2.5(2.3-2.7) Baseline
Yes 1879(6.4) 21(8.2) 8.4(5.2-13.2) 3.48(2.05-5.89)** 3.42(2.01-5.84)**
Missing 235 5
Total 29709(100) 746(2.5) 2.6(2.4-2.8)

Note. GAD: Generalized Anxiety Disorder.

that GAD- as defined by DASM-IV criteria- is a relatively rare disorder

Fig. 2. Prevalence rates of generalized anxiety disorder based on sex and age
groups in children and adolescents.
4. Discussion
This population-based study examined the prevalence and risk fac-
tors for GAD symptoms following comorbid mental disorders with GAD.
The findings provide the first lifetime prevalence data on GAD in a
nationally representative sample of Iranian children and adolescents.
Overall, from an Iranian perspective, the study cumulatively suggests
in the community with a prevalence of threshold GAD of about 2.6 %.
In general, the Iranian prevalence estimates among children and
adolescents in present research seem to be at the low end of the range of
international estimates. In this regard, the lifetime prevalence of GAD
in the United States (5.7 %) and Australia (6.1 %) is higher than in Iran
(McEvoy, Grove, & Slade, 2011). However, our results (lifetime pre-
valence of GAD at 2.6 %) are above estimates from Germany (0.3 %)
and the UK (0.7 %) (Green, Meltzer, & Goodman, 2005; Beesdo et al.,
2009; Green et al., 2005). Prevalence rates reported in studies are
varying considerably sometimes, depending on the sample, assessment
methods, or study design (Predescu, Asztalos, & Sipos, 2018). Con-
textual differences may be one explanation for the different prevalence
as compared to the studies done in the west. Many of the earlier
community studies used DSM-III and DSM-III-TR criteria, which differ
from the DSM-IV criteria used in our study. Such methodological dif-
ferences may also contribute to variation in prevalence estimates across
different studies. Additionally, the prevalence rates can remain highly
dependent on the training and experience of the interviewers (Papp,
2009).
The demographic indicators found in our study population are in
keeping with international studies, including being female, older age
ranges, residence, mother’s education and mother history of psychiatric
hospitalization (Beesdo et al., 2009; Leray et al., 2011; Lieb et al., 2005;
McLean et al., 2011; Watterson et al., 2017). In terms of sex differences,
several studies in the US, France, Canada, and Europe explained that
GAD more frequently occurs among females than males (Beesdo et al.,
2009; Leray et al., 2011; Lieb et al., 2005; McLean et al., 2011;
Watterson et al., 2017). Furthermore, according to Beesdo et al. (2009),
the prevalence of GAD increases with increasing age. Some studies have

4
M.R. Mohammadi, et al. Journal of Anxiety Disorders 73 (2020) 102234

Table 2
Comorbidity rates of psychiatric disorders in children and adolescents with GAD.
Psychiatric Disorders Number percent Confidence Interval

Min Max

Mood Disorders Depression 127 17.02 14.5 19.9

Mania 7 .9 .5 1.9
Hypomania 8 1.1 .5 2
Psychotic Disorders Psychosis 17 2.3 1.4 3.6
Anxiety Disorders Panic Disorder 11 1.5 .8 2.6
Separation Anxiety Disorder 222 29.8 26.6 33.1
Social Phobia 148 20.2 17.1 22.9
Specific Phobia 158 21.2 18.4 24.3
Agoraphobia 136 18.2 15.6 21.2
Obsessive Compulsive Disorder 117 15.7 13.3 18.5
Post-Traumatic Stress Disorder 40 5.4 4 7.2
Behavioral Disorders Attention deficit hyperactivity disorder 125 16.8 14.3 19.6
Conduct Disorder 32 4.3 3.1 6
ODD 167 22.4 19.5 25.5
Tic Disorder 40 5.4 4 7.2
Neurodevelopmental disorders Autism 5 .7 .3 1.6
Mental retardation 22 2.9 1.9 4.4
Epilepsy 36 4.8 3.5 6.6
Substance abuse disorders Tobacco use 37 5 3.6 6.8
Alcohol abuse 4 .5 .2 1.4
Elimination Disorders Enuresis 96 12.9 11 15.5
Encopresis 3 .4 .1 1.2
Eating disorders Anorexia – – – –
Bulimia 2 .3 .07 1
Total comorbid disorders 571 76.5 73.4 79.4

Note. GAD: Generalized Anxiety Disorder; ODD: Oppositional Defiant Disorder.

negatively. The exact mechanisms by which the living environment

Fig. 3. Comorbidity rates of psychiatric disorders with generalized anxiety
disorder in children and adolescents.
found that European data in combination with non-European data
suggest that GAD is the most common anxiety disorder among older age
groups (Lieb et al., 2005). Our data were consistent with the findings
that GAD occurs more frequently with increasing age.
Rural living was protective for GAD in our data, in keeping with
similar results found in Scotland (McKenzie, Murray, & Booth, 2013).
Anxiety seems to be far more common in the urban and modern en-
vironment, compared to the rural context. On the other hand, some
diverse study designs are having heterogeneous results (Jin et al., 2014;
Solmi, Dykxhoorn, & Kirkbride, 2017). The inconsistency between these
results and our data could be the utilization of different sample sizes
and/or different assessment tools. Furthermore, little research has been
conducted on anxiety among rural persons (Liu, Shi, Auden, & Rozelle,
2018). Our population-based study showed that how the social and
physical environment may affect our mental health- both positively and
influences mental health are unknown, but the identification that
multiple factors may contribute individually and in interaction with
each other has resulted in developing an integrated model. Galeaa,
Freudenbergc, and Vlahov (2005) propose a conceptual framework
suggesting that health is a function of urban living conditions that are
composed of factors such as population demographics, the physical and
social environment, and infra-structure of formal and informal health
and social services.
Low levels of mother’s education were found to be associated with
GAD. Our findings are in accordance with other studies concerning
anxiety and education (Miech, Caspi, Moffitt, Wright, & Silva, 1999). A
longitudinal study showed that anxiety was negatively associated with
the educational level of the respondent’s parents (Miech et al., 1999).
Generally, the explanation of this association is difficult to decipher,
because of insufficient and inconclusive data on this issue. Whereas,
some investigators have found the parenting factors in relation to GAD
(Rapee, 1997). Moreover, our population-based data on the relation-
ship between mother history of psychiatric hospitalization and GAD in a
child are in line with other studies. This suggests that environmental
influences within families, such as parental psychopathology or family
dynamics, may be involved in its etiology. The majority of risk factors
associated with future onset of GAD were related to the quality of the
home environment. Specifically, maternal internalizing symptoms were
associated with GAD onset (Moffitt et al., 2007).
As expected, GAD was found to be highly comorbid with multiple
psychiatric conditions including separation anxiety disorder, ODD,
Specific Phobias, social phobia, agoraphobia, depression, ADHD, OCD,
and Enuresis. This rate of high comorbidity has historically supported
the view that GAD is a prodromal, residual, or severity marker of other
psychiatric disorders (Kessler et al., 2001). In similar to our results,
some studies in Brazil and the US described the comorbidity between
GAD and separation anxiety disorder (Silva Junior & Gomes, 2015;
Verduin & Kendall, 2003). Besides, Masi, Mucci, Favilla, Romano, and
Poli (1999)) demonstrated that separation anxiety disorder was more
frequent in Italian children than in Italian adolescents (42 % v 10 %),
which is in line with the decreasing trend in our research.

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M.R. Mohammadi, et al. Journal of Anxiety Disorders 73 (2020) 102234

Table 3
Comorbidity rates of psychiatric disorders in children and adolescents with GAD based on sex and age group.
Psychiatric Disorders Total Sex: Male (1), Female (2) Age group: 6−9(1), 10−14(2), 15−18(3)

n(p) n(p) OR(CI) n(p) OR(CI)

mood disorders 135(18.1) 1 57(18.1) Baseline 1 21(14) Baseline

2 78(19.1) 1.07(.73−1.56) 2 38(14.2) 1.02(.57−1.8)
3 76(24.8) 2.03(1.20−3.44)**
Psychos 17(2.3) 1 9(2.8) Baseline 1 1(.7) Baseline
2 89(1.9) .69(.26−1.79) 2 7(2.6) 4(.49−32.8)
3 9(2.9) 4.5(.57−35.8)
anxiety disorders 430(57.6) 1 179(57.2) Baseline 1 95(62.9) Baseline
2 251(61.1) 1.17(.87−1.58) 2 170(63.4) 1.02(.68−1.55)
3 165(54.1) .69(.47−1.04)
Behavioral Disorders 255(34.2) 1 128(40.4) Baseline 1 60(40) Baseline
2 127(31) .66(.49−.90)** 2 99(36.4) .86(.57−1.29)
3 96(31.5) .69(.46−1.03)
Neurodevelopmental disorders 50(5.7) 1 Baseline 1 10(6.6) Baseline
2 .45(.25−.82)** 2 18(6.7) 1.01(.46−2.26)
3 22(7.1) 1.08(.5−2.35)
Elimination Disorders 96(12.9) 1 65(20.2) Baseline 1 29(19.2) Baseline
2 31(7.5) .32(.20−.51)** 2 43(15.9) .79(.47−1.34)
3 24(7.7) .35(.20−.63)**
Eating Disorders 2(.3) 1 2(.6) Baseline 1 0 Baseline
2 – – 2 1(.4) –
3 1(.3) –

Note. GAD: Generalized Anxiety Disorder.

The comorbidity of anxiety and ODD is highest during middle
childhood and then decreases in adolescence (Loeber & Keenan, 1994).
In our results, there was significant comorbidity between GAD and
ODD, and a decreasing trend from childhood to adolescence. Although
previous studies have found that boys tend to present more oppositional
behaviors than girls (Trepat & Ezpeleta, 2011), our results showed that
when ODD is accompanied by GAD, boys are more prevalent rather
than girls. While some studies illustrated that girls with ODD presented
higher comorbidity (43.8 %) with anxiety (Trepat & Ezpeleta, 2011).
These results suggest that therapeutic approaches with boys and girls
with ODD and GAD should include different elements.
A study conducted in Italy illustrated a 29 % comorbidity rate of
specific phobias with GAD among children and adolescents, which is
consistent with our study (Masi et al., 1999). However, in an American
study (Verduin & Kendall, 2003), a 48.6 % comorbidity rate between
these was reported that is about twice as high as our result. According
to a review study, lifetime GAD comorbidity rates with social phobia
were found to be between 0.6 % and 27 %, which our result consisted of
this range (Koyuncu, Ince, Ertekin, & Tukel, 2019). In a study con-
ducted in New York, patients with social phobia 23.8 % also met the
criteria for an additional diagnosis of GAD (Mennin, Heimberg, & Jack,
2000), which was nearly seen in our results. However, in Verduin and
Kendall (2003) study in the US, 31.2 % of comorbid social phobia with
GAD was reported that was considerably higher than our results. The
inconsistency could be due to the diff ;erent sample size or assessment
tools.
According to prior research, the lifetime prevalence of comorbid
agoraphobia in patients with GAD was about 25 % (Simon, 2009). Our
finding of an 18.2 % comorbid agoraphobia with GAD is more than
rates reported (13 %) in a study in Italy (Masi, Favilla, Mucci, &
Millepiedi, 2000). A large prospective study of a clinical sample of
patients with GAD found that the presence of agoraphobic avoidance
increased recurrence and decreased the chance of recovery of these
anxiety disorders (Bruce et al., 2005).
Depression is strongly associated with GAD children (Melegari et al.,
2018). The lifetime comorbidity rates of depression within anxiety
disorders in children and adolescents were estimated at 15.9%–61.9%
in a review study conducted by Al-Asadi, Klein, and Meyer (2015)), and
our findings are in keeping with this. Our results are also consistent
with the American Psychiatric Association (2013) stating GAD persons
are likely to have criteria for unipolar depressive disorders. Co-
morbidity findings here also share a great deal in common with pre-
vious community studies on GAD and depression related to increasing
age. The results herein stated that the comorbidity of GAD with de-
pression increases with age increase. Actually, anxiety has an earlier
age of onset (Fichter, Quadflieg, Fischer, & Kohlboeck, 2010) and is
generally more prevalent in childhood than depression, whereas de-
pression is more prevalent in adolescence (Cohen, Cohen, & Brook,
2010; Woodward & Fergusson, 2001). That is why the degree of co-
morbidity may increase based on age.
In a study conducted in New York, ADHD symptoms were associated
with GAD symptom groups (Drabick, Gadow, & Loney, 2007). In other
studies in Rome and the US also 16 % and 18.3 % of children with
ADHD displayed comorbidity with GAD (Melegari et al., 2018; Verduin
& Kendall, 2003), which are close to our result. On the other hand, in
line with our results, McLean et al. (2011) in a US national comorbidity
survey found that women with an anxiety disorder were significantly
less likely to be diagnosed with ADHD, compared to men. In contrast, in
a study conducted in Norway, by using K-SADS, co-existing anxiety
diagnosis within the females with ADHD was more than within the
group of males by 8.1 % and 4.7 %, respectively (Skogli, Teicher,
Andersen, Hovik, & Qie, 2013). This difference could be related to
sample size or population-specific factors.
There is consistent evidence that comorbidity of OCD and GAD in
children and adolescents is lower compared to adults. In contrary to our
results, Verduin and Kendall (2003) reported a low comorbidity rate
(1.8 %) in the US. While, comorbid OCD with GAD in another study in
Italy found 10 % (Masi et al., 1999), which is more similar to our result.
Besides, the comorbidity of GAD in American children and adolescents
with enuresis was found 0.9 %, which is much less often than our re-
sults (Verduin & Kendall, 2003). The prevalence of enuresis decreases
with age increase (American Psychiatric Association, 2013). There are
many studies about the strong comorbidity of enuresis and anxiety
disorders. As a consequence, we can cautiously say that comorbidity of
GAD and enuresis in childhood reduces with increasing age in adoles-
cence. Moreover, our results showed that comorbidity of GAD and en-
uresis is more likely among boys rather than girls. In this respect,
several pieces of research on enuresis demonstrate that enuresis is as-
sociated with anxiety disorders, and males are over twice as likely to
have a lifetime diagnosis than females (Kessel et al., 2017), yet further

6
M.R. Mohammadi, et al.
studies are needed to identify gender differences in children with GAD-
enuresis.
Epidemiological data suggest that the high prevalence of co-
morbidity in the eating disorders adolescent population meets the cri-
teria for GAD (Pan, 2009). This is much more than our results which
may be related to the age increase. Additionally, according to the
American Psychiatric Association (2013), Comorbidity of GAD with
substance abuse, conduct, psychotic, and neurodevelopmental dis-
orders are less common (American Psychiatric Association, 2013),
which is in accordance with our results.
5. Limitations
The results of this study should be considered in light of a number of
limitations. First, the design of the study is a cross-sectional survey, and
so the onset of comorbid disorders are unidentified. Moreover, no
causality can be implied in our results due to the cross-sectional design.
6. Conclusion
Our findings demonstrate that GAD affects a significant number of
children and adolescents, with rates higher in females than in males.
Iran seems to be at the low end of the range of international estimates.
Patterns of comorbidity and predictors of GAD in this setting also
broadly share a great deal with previous findings from western com-
munity studies. However, this finding is not entirely consistent. Age,
sex, mother history of psychiatric hospitalization, mother’s education,
and residence were found as the significant predictors of GAD in chil-
dren and adolescents. The prevalence estimates and the identification
of predictors and comorbid mental disorders have important implica-
tions for service, training, and research planning. Our findings suggest
that awareness of the comorbidity between GAD and the other mental
disorders could be helpful for clinicians when identifying therapeutic
goals.
Availability of data
The data that support the findings of this study are available on
request from the first author. The data are not publicly available due to
privacy or ethical restrictions.
Declaration of Competing Interest
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Acknowledgment
We would like to show our gratitude to the research participants
and their families for assistance. This study was funded by a grant from
the National Institute for Medical Research Development (NIMAD)
Grant 940906.
References
Al-Asadi, A. M., Klein, B., & Meyer, D. (2015). Multiple comorbidities of 21 psychological
disorders and relationships with psychosocial variables: A study of the online as-
sessment and diagnostic system within a web-based population. Journal of Medical
Internet, 17(2), e55.
Alonso, J., & Lepine, J. P. (2007). Overview of key data from the European study of the
epidemiology of mental disorders (ESEMeD). The Journal of Clinical Psychiatry,
68(2), 3–9.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental dis-
orders (5th ed.). Washington, D.C: Author.
Beesdo, K., Knappe, S., & Pine, D. S. (2009). Anxiety and anxiety disorders in children and
adolescents: Developmental issues and implications for DSM-V. The Psychiatric Clinics
of North America, 32(3), 483–524.
Bruce, S. E., Yonkers, K. A., Otto, M. W., Eisen, J. L., Weisberg, R. B., Pagano, M., et al.
7
Journal of Anxiety Disorders 73 (2020) 102234
(2005). Influence of psychiatric comorbidity on recovery and recurrence in gen-
eralized anxiety disorder, social phobia, and panic disorder: A 12-year prospective
study. American Journal of Psychiatry, 162(6), 1179–1187.
Burstein, M., He, J. P., Kattan, G., Albano, A. M., Avenevoli, S., & Merikangas, K. R.
(2011). Social phobia and subtypes in the national comorbidity survey-adolescent
supplement: Prevalence, correlates, and comorbidity. Journal of the American
Academy of Child and Adolescent Psychiatry, 50(9), 870–880.
Burstein, M., Beesdo-Baum, K., He, J. P., & Merikangas, K. R. (2014). Threshold and
subthreshold generalized anxiety disorder among US adolescents: Prevalence, so-
ciodemographic, and clinical characteristics. Psychological Medicine, 44(11),
2351–2362. https://doi.org/10.1017/S0033291713002997.
Cohen, P., Cohen, J., & Brook, J. S. (2010). An epidemiological study of disorders in late
childhood and adolescence: II. Persistence of disorders. Journal of Child Psychology
and Psychiatry, 34, 869–877.
Copeland, W. E., Shanahan, L., Erkanli, A., Costello, E. J., & Angold, A. (2013). Indirect
comorbidity in childhood and adolescence. Frontiers in Psychiatry, 4(144), https://
doi.org/10.3389/fpsyt.2013.00144.
Costello, E. J., Egger, H., & Angold, A. (2005). 10-year research update review: The
epidemiology of child and adolescent psychiatric disorders: I. Methods and public
health burden. Journal of the American Academy of Child and Adolescent Psychiatry,
44(10), 972–986.
Davidson, J. R., Feltner, D. E., & Dugar, A. (2010). Management of generalized anxiety
disorder in primary care: Identifying the challenges and unmet needs. Primary Care
Companion to The Journal of Clinical Psychiatry, 12, 2. https://doi.org/10.4088/PCC.
09r00772blu.
Drabick, D. A. G., Gadow, K. D., & Loney, J. (2007). Source-specific oppositional defiant
disorder: Comorbidity and risk factors in referred elementary schoolboys. American
Academy of Child and Adolescent Psychiatry, 46(1), 92–101.
Fichter, M. M., Quadflieg, N. N., Fischer, U. C., & Kohlboeck, G. G. (2010). Twenty-five-
year course and outcome in anxiety and depression in the Upper Bavarian
Longitudinal Community Study. Acta Psychiatrica Scandinavica, 122(1), 75–85.
Gale, C. K., & Millichamp, J. (2016). Generalised anxiety disorder in children and ado-
lescents. BMJ Clinical Evidence, 1, 1002.
Galeaa, S., Freudenbergc, N., & Vlahov, D. (2005). Cities and population health. Social
Science and Medicine, 60(5), 1017–1033.
Ghanizadeh, A., Mohammadi, M. R., & Yazdanshenas, A. (2006). Psychometric properties
of the Farsi translation of the Kiddie schedule for affective disorders and schizo-
phrenia-present and lifetime version. BMC Psychiatry, 6(1), 6–10.
Global Burden of Disease (2017). Institute for health metrics and evaluation. Seattle, WA.
Available athttp://vizhub.healthdata.org/gbd-compare/.
Green, M. G., Meltzer, F., & Goodman (2005). Mental health of children and young people in
Great Britain, (2004). New York: Palgrave Macmillan.
Grenier, s., Desjardins, F., Raymond, B., Payette, M. C., Rioux, M. E., Landreville, P., et al.
(2018). Six‐month prevalence and correlates of generalized anxiety disorder among
primary care patients aged 70 years and above: Results from the ESA‐services study.
International Journal of Geriatric Psychiatry. https://doi.org/10.1002/gps.5023.
Jin, Y., He, L., Kang, Y., Chen, Y., Lu, W., Ren, X., et al. (2014). Prevalence and risk factors
of anxiety status among students aged 13-26 years. International Journal of Clinical
and Experimental Medicine, 7(11), 4420–4426.
Johnson, P. (2002). Predictors of family functioning within alcoholic families.
Contemporary Family Therapy: An International Quarterly, 24, 371–384.
Kaufman, J., Birmaher, B., Brent, D., Rao, U., & Ryan, N. (1996). The schedule for affective
disorders and schizophrenia for school-age children. Pittsburgh: University of Pittsburgh
Medical Center.
Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., et al. (1997). Schedule
for affective disorders and schizophrenia for school-aged children-present and life-
time version (K-SADS-PL): Initial reliability and validity data. Journal of the American
Academy of Child and Adolescent Psychiatry, 36(7), 980–988.
Kertz, S. J., & Woodruff-Borden, J. (2011). Human and economic burden of GAD, sub-
threshold GAD, and worry in a primary care sample. Journal of Clinical Psychology in
Medical Settings, 18(3), 281–290. https://doi.org/10.1007/s10880-011-9248-1.
Kessel, E. M., Allmann, A. E. S., Goldstein, B. L., Finsaas, M., Dougherty, L. R., Bufferd, S.
J., et al. (2017). Predictors and outcomes of childhood primary enuresis. Journal of
the American Academy of Child & Adolescent Psychiatry, 56(3), 250–257.
Kessler, R. C., Keller, M. B., & Wittchen, H. U. (2001). The epidemiology of generalized
anxiety disorder. Psychiatric Clinics of North America, 24(1), 19–39.
Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005).
Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National
Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627.
Koyuncu, A., Ince, E., Ertekin, E., & Tukel, R. (2019). Comorbidity in social anxiety
disorder: Diagnostic and therapeutic challenges. Drugs in Context, 8, 212573.
Leray, E., Camera, A., Drapier, D., Riou, F., Bougeant, N., Pelissolo, A., et al. (2011).
Prevalence, characteristics and comorbidities of anxiety disorders in France: Results
from the “mental health in general population” survey (MHGP). European Psychiatry,
26(6), 339–345.
Lieb, R., Becker, E., & Altamura, C. (2005). The epidemiology of generalized anxiety
disorder in Europe. European Neuropsychopharmacology, 15(4), 445–452.
Liu, H., Shi, Y., Auden, E., & Rozelle, S. (2018). Anxiety in rural Chinese children and
adolescents: Comparisons across provinces and among subgroups. International
Journal of Environmental Research and Public Health, 15, 2087. https://doi.org/10.
3390/ijerph15102087.
Loeber, R., & Keenan, K. (1994). Interaction between conduct disorder and its comorbid
conditions: Effects of age and gender. Clinical Psychology Review, 14, 497–523.
Masi, G., Mucci, M., Favilla, L., Romano, R., & Poli, P. (1999). Symptomatology and
comorbidity of generalized anxiety disorder in children and adolescents.
Comprehensive Psychiatry, 40(3), 210–215.
M.R. Mohammadi, et al.
Masi, G., Favilla, L., Mucci, M., & Millepiedi, S. (2000). Depressive comorbidity in chil-
dren and adolescents with generalized anxiety disorder. Child Psychiatry and Human
Development, 30(3), 205–2015.
McEvoy, P. M., Grove, R., & Slade, T. (2011). Epidemiology of anxiety disorders in the
Australian general population: Findings of the 2007 Australian National Survey of
Mental Health and Wellbeing. The Australian and New Zealand Journal of Psychiatry,
45(11), 957–967.
McKenzie, K., Murray, A., & Booth, T. (2013). Do urban environments increase the risk of
anxiety, depression and psychosis? An epidemiological study. Journal of Affective
Disorders, 150(3), 1019–1024.
McLaughlin, K. A., Behar, E., & Borkovec, T. D. (2008). Familt history of psychological
problems in generalized anxiety disorder. Journal of Clinical Psychology, 64(7),
905–918.
McLean, C. P., Asnaani, A., Litz, B. T., & Hofmann, S. G. (2011). Gender differences in
anxiety disorders: Prevalence, course of illness, comorbidity and burden of illness.
Journal of Psychiatric Research, 45(8), 1027–1035.
Melegari, M. G., Bruni, O., Sacco, R., Barni, D., Sette, S., & Donfrancesco, R. (2018).
Comorbidity of attention deficit hyperactivity disorder and generalized anxiety dis-
order in children and adolescents. Psychiatry Research. https://doi.org/10.1016/j.
psychres.2018.10.078.
Mennin, D. S., Heimberg, R. G., & Jack, M. S. (2000). Comorbid generalized anxiety
disorder in primary social phobia: Symptom severity, functional impairment, and
treatment response. Journal of Anxiety Disorders, 14(4), 325–343.
Miech, R. A., Caspi, A., Moffitt, T. E., Wright, B. R. E., & Silva, P. A. (1999). Low so-
cioeconomic status and mental disorders: A longitudinal study of selection and
causation during young adulthood. The American Journal of Sociology, 104,
1096–1131.
Milanak, G., Magruder, B.-M., & Frueh (2013). Prevalence and features of generalized
anxiety disorder in Department of Veteran Affairs primary care settings. Psychiatry
Research, 209(2), 173–179.
Moffitt, T. E., Caspi, A., Harrington, H., Milne, B. J., Melchior, M., Goldberg, D., et al.
(2007). Generalized anxiety disorder and depression: Childhood risk factors in a birth
cohort followed to age 32. Psychological Medicine, 37(3), 441–452.
Mohammadi, M. R., Ahmadi, N., Khaleghi, A., Mostafavi, S.-A., Kamali, K., Rahgozar, M.,
et al. (2019). Prevalence and correlates of psychiatric disorders in a national survey
of Iranian children and adolescents. Iranian Journal of Psychiatry, 14(1), 1–15.
Mohammadi, M. R., Ahmadi, N., Kamali, K., Khaleghi, A., & Ahmadi, A. (2017).
Epidemiology of psychiatric disorders in Iranian children and adolescents (IRCAP)
and its relationship with social capital, life style and parents’ personality disorders:
Study protocol. Iran Journal of Psychiatry, 12(1), 66–72.
Noyes, R. (2001). Comorbidity in generalized anxiety disorder. Psychiatric Clinics of North
America, 24(1), 41–55. https://doi.org/10.1016/S0193-953X(05)70205-7.
Olfson, M., & Gameroff, M. J. (2007). Generalized anxiety disorder, somatic pain and
health care costs. General Hospital Psychiatry, 29(4), 310–316. https://doi.org/10.
1016/j.genhosppsych.2007.04.004.
Ormel, J., Raven, D., Van Oort, F., Hartman, C., Reijneveld, M., Veenstra, R., et al. (2015).
Mental health in Dutch adolescents: A TRAILS report on prevalence, severity, age of
onset, continuity and co-morbidity of DSM disorders. Psychological Medicine, 45(2),
345–360.
Pan, J. (2009). Eating disorders and comorbidity in childhood and adolescence: A comparison
between children and adolescents diagnosed exclusively with an eating disorder and those
diagnosed with another comorbid condition in addition to the eating disorder. Ontario,
Canada: McMaster University.
Journal of Anxiety Disorders 73 (2020) 102234
Papp, L. A. (2009). Phenomenology of generalized anxiety disorder. In D. J. Stein, E.
Hollander, & B. O. Rothbaum (Eds.). Textbook of anxiety disorders (pp. 159–171).
Washington, DC: American Psychiatric Publishing, Inc.
Predescu, E., Asztalos, A. B., & Sipos, R. (2018). Prevalence and treatment of anxiety
disorders comorbidities in a clinical Romanian sample of children and adolescents
with psychiatric disorders. In R. Woolfolk, & L. Allen (Eds.). Mental disordershttps://
doi.org/10.5772/intechopen.82083.
Rapee, R. (1997). Potential role of childrearing practices in the development of anxiety
and depression. Clinical Psychology Review, 17, 47–67.
Roberge, P., Normand-Lauziere, F., Raymond, I., Luc, M., Tanguay-Bernard, M., Duhoux,
A., et al. (2015). Generalized anxiety disorder in primary care: Mental health services
use and treatment adequacy. BMC Family Practice, 16, 146–157. https://doi.org/10.
1186/s12875-015-0358-y.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry:
Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia: Lippincott Williams &
Wilkins.
Shahrivar, Z., Kousha, M., Moallemi, S., Tehrani-Doost, M., & Alaghband-Rad, J. (2010).
The reliability and validity of Kiddie-Schedule for Affective Disorders and
Schizophrenia-Present and Lifetime version- Persian version. Child and Adolescent
Mental Health, 15(2), 97–102.
Silva Junior, E. A., & Gomes, C. A. B. (2015). Psychiatric comorbidities among adoles-
cents with and without anxiety disorders: A community study. Jornal Brasileiro de
Psiquiatria, 64(3), 181–186. https://doi.org/10.1590/0047-2085000000076.
Simon, N. M. (2009). Generalized anxiety disorder and psychiatric comorbidities such as
depression, bipolar disorder, and substance abuse. Journal of Clinical Psychiatry,
70(2), 10–14.
Skogli, E. W., Teicher, M. H., Andersen, P. N., Hovik, K. T., & Qie, M. (2013). ADHD in
girls and boys – Gender differences in co-existing symptoms and executive function
measures. BMC Psychiatry, 13(1), 298–310. https://doi.org/10.1186/1471-244X-13-
298.
Solmi, F., Dykxhoorn, J., & Kirkbride, J. B. (2017). Urban-rural differences in major
mental health conditions. In N. Okkels, C. B. Kristiansen, & P. Munk-Jørgensen (Eds.).
Mental health and illness in the City (pp. 1–106). Singapore: Springer.
Trepat, E., & Ezpeleta, L. (2011). Sex differences in oppositional defiant disorder.
Psicothema, 23(4), 666–671.
Verduin, T. L., & Kendall, P. C. (2003). Differential occurrence of comorbidity within
childhood anxiety disorders. Journal of Clinical Child and Adolescent Psychology, 32(2),
290–295. https://doi.org/10.1207/s15374424jccp3202_15.
Watterson, R. A., Williams, J. V. A., Lavorato, D. H., & Patten, S. B. (2017). Descriptive
epidemiology of generalized anxiety disorder in Canada. The Canadian Journal of
Psychiatry, 62(1), 24–29.
Wittchen, H. U. (2002). Generalized anxiety disorder: Prevalence, burden, and cost to
society. Depression and Anxiety, 16(4), 162–171.
Wittchen, H. U., & Hoyer, J. (2001). Generalized anxiety disorder: Nature and course. The
Journal of Clinical Psychiatry, 62(11), 15–19. https://www.ncbi.nlm.nih.gov/
pubmed/11414546.
Wittchen, H. U., Krause, P., Hoyer, J., Beesdo, K., Jacobi, F., Hofler, M., et al. (2001).
Prevalence and correlates of GAD in primary care. MMW Fortschritte Der Medizin,
119(1), 17–25.
Woodward, L. J., & Fergusson, D. M. (2001). Life course outcomes of young people with
anxiety disorders in adolescence. Journal of the American Academy of Child and
Adolescent Psychiatry, 40, 1086–1093.