; Anxiety Disorders in Children
Learning Center
Plans & pricing Sign in
Sign Out
Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

Anxiety Disorders in Children


  • pg 1
									Anxiety Disorders in Children

Susan Baer, MD, FRCPC
Mood and Anxiety Disorders Clinic
BC Children’s Hospital
Anxiety Disorders
   Most common psychiatric disorder in
   10-15% of kids will have experienced
    difficulty with anxiety by teen years
   Onset early in life
   Under-recognized and under treated
       Often quiet, ―good‖ kids, don’t cause problems
        in school
   Often lifelong chronic disorders
Why are anxiety disorders so common?

   Protective role of anxiety
         Body’s warning system for danger
         Avoid separation from parents
         Be vigilant for predators/dangers
   Mild anxiety enhances concentration,
   Anxiety disorders--too much of a good
    thing—when level of anxiety overwhelms
    person’s ability to manage it
   Genetic:
        panic diathesis, OCD spectrum
       Temperament: behavioral inhibition, shyness,
        high negative affect
   Modeling: e.g. parental anxiety disorder
   Traumatic Event: e.g. bullying, choking
   Informational Transmission: warnings
Common precipitating stressors
   Divorce
   Death in family
   Transition to middle school, high school
   Family move OR friend moving away
   Poor performance on test
   Loss of pet
    Interaction of vulnerable physiology
    & environment
Presenting complaints:
How do kids show up in your office?

   Sleeping problems
   Refusals and avoidance
   Physical complaints
       Headaches and stomach aches
   Perfectionism and procrastination
   Irritability/tantrums
       Family “walking on eggshells”
Case 1

   ID: 11 year old girl, living with Mom and
    2 sisters, parents divorced ca. 3 years

   HPI: 6 mo. hx of reluctance attending
    school, calling Mom +++ from school,
    unable to be left at home alone, no longer
    wanting to go over to friend’s houses or
    visit with mat. Grandparents on own,
    complaining of frequent headaches and
Case 1, cont.
   Past Psych. Hx
       Some difficulties with transition to school in K and
        Grade 1, requiring Mom to stay at school for first 1-
        2 hours, resolved by Nov. Grade 1
   Med. Hx—healthy, normal development, no meds
   Fam. Hx.—Father hx of depression
   Personal Hx
       Relatively stable family with involved supportive
        extended family (mat. Grandparents)
       Parents relationship improved since divorce
       Regular contact with Father on weekends
       Father had a serious motorcycle accident 8 months
        ago; in hospital for 1 mo.; better now
Case 1

   What is the differential diagnosis?
   What medical workup is necessary,
    if any?
         Differential Diagnosis
   Normal Anxiety-mild and manageable
       Temperament—behavioral inhibition
       Developmental Stage (transient and typical)
            Toddler-separation; Preschool-fear of dark, animals;
             Elementary-school performance; middle school-social
       Situational: losses, moves, changes
   Excessive Anxiety-atypical and persistent
       Disproportionate or in absence of stressor
       Functionally impairing
       Doesn’t settle with support
     Differential Diagnosis
   Depression (vs. demoralization 2° anxiety)
        Ruminations about past events versus anxiety
         about future events
   Adjustment Disorder
   Bipolar Disorder
        Mood sx’s more prominent (up and down)
   Substance Use
   Psychotic disorder
        Non-specific anxiety--early warning sign
Differential Diagnosis

 Physical:
   thyroid disease
   hyper/hypoglycemia

   Anemia

   substance induced
       Caffeine—energy drinks
       sympathomimetics-ventolin, allergy meds
Case 1

   What is your preferred diagnosis?
Specific Anxiety Disorders

   Separation Anxiety Disorder
   Generalized Anxiety Disorder
   Panic Disorder +/- Agoraphobia
   Social Phobia
   Specific Phobia
   Post Traumatic Stress Disorder
   Obsessive Compulsive Disorder
Separation Anxiety Disorder

   Fears of separation from parent,
    school refusal, difficulty sleeping
    alone, nightmares, can’t be alone
   Social, but friends must come to
    their house, can’t do sleepovers
   Typical age of onset: school entry
   Rx: usually requires ++ family work
    with school and gradual exposure
    +/- medications
Case 1

   What are the components of a
    comprehensive treatment plan?
Treatment Principles

Consider age, severity, comorbidity,
 Environmental management

 Education about anxiety

 Cognitive Behavioral Therapy

 Medications
     Mostly SSRI’s
     Benzodiazepines in select situations
Environmental Management
   Home: consistent routines and structure
   Ensure adequate sleep
   Healthy diet-small frequent meals often
   Exercise
   Schedule time for homework and
    activities-avoid overload
   School involvement: accommodations,
    study block for teens,
   Address parental anxiety disorders
   Starts with initial consultation:
      aim for “therapeutic” assessment
   Explain nature of anxiety: physical,
    cognitive, emotional aspects
   Emphasize helpful, normal aspects of
    anxiety (warning mechanism for threats
    in environment)
   Problem comes when anxiety response is
    triggered by non-dangerous things—i.e.
    anxiety as ―oversensitive car alarm‖
Education, cont.
   Role of avoidance in perpetuating
       In short term, decreases anxiety
       In long term, increases anxiety and
        decreases functioning
Cognitive Behavioral Therapy
   Emphasis is on coping with anxiety rather
    than cure
   Train skills in anxiety management
   Increase child’s sense of control over
   Focus on regaining function as marker of
    improvement, rather than subjective sx’s
    of anxiety
Principles of CBT for anxiety

   Relaxation skills training—muscle
    relaxation, breathing
   Cognitive restructuring--challenge
    negative thoughts, practice ―coping‖
   Exposure and desensitization
    ―facing fears‖
Case 1 Treatment Plan
   Education around anxiety during the assessment
       ―you’ve got real talent for worrying –you must have a
        good imagination‖
       ―those worries really boss you around-don’t let you do
        the things you want to do‖
       ―worries are like bullies—the more you give in to them,
        the stronger they become‖
   Gave her Taming Worry Dragons book to learn
    ―worry fighting strategies‖
   Suggested structuring phone calls home: started
    with schedule of 4 times per day then gradually
   Mom to contact school so they are aware of plan
Case 1--Outcome
   At 1 month followup, feeling much better,
    phone calls much decreased, working
    towards a sleep over with friend
   Why the quick and easy response?
       Motivated and intelligent
       Lack of comorbidity
       Previous high-functioning with relatively short
        duration of anxiety
       ―bought in‖ to anxiety model
Case 1: take home messages
   Anxiety is normal
          goal of treatment is to learn to cope with it
   Mild anxiety disorders can often be
    treated with education, and self-help CBT
   Reframe anxiety as ―a talent for worrying‖
    and an ―sensitive alarm system‖
   Motivation is key!—consider incentives,
    e.g. ―bravery stickers‖
   Involve parent and school to help
Case 2
   9 year old girl, living with parents and 2 siblings
   Many year history of generalized worries
   6 month history of ++anxiety following stomach
    flu with worries about vomiting
   Onset of compulsive rituals—lucky and unlucky
    numbers, repetitive questioning, repeated
    touching—to ―protect‖ her from getting sick
   Avoidant of eating and school because of worry
    about getting sick—weight loss ca. 3kg
   Panic attacks with anticipatory anxiety about
    further attacks (had vomited with at least one
    panic attack)
Case 2

   Past Psych Hx: multiple previous
    assessments, 1 previous trial group
    CBT, 2 previous trials individual
   Med Hx: ―itchy skin‖, skin picking
   Family Psych Hx: mother-anxiety,
    brother-ADHD and depression
Case 2
   Development: normal, poor attention at
    school, normal academics
   Personal Hx: Mother at home with kids,
    Father works full time; both parents
    anxious, conflict with older brother who
    ―puts her down‖
   MSE: pale, thin, fidgety, picking at skin,
    difficulty focusing, preoccupied with
    worries about somatic symptoms
Case 2-discussion

   What are diagnoses?
Specific Anxiety Disorders

   Separation Anxiety Disorder
   Generalized Anxiety Disorder
   Panic Disorder +/- Agoraphobia
   Social Phobia
   Specific Phobia
   Post Traumatic Stress Disorder
   Obsessive Compulsive Disorder
Specific Phobia
   Most common anxiety disorder in kids
   Fear of specific thing or situation: animal,
    natural environment, blood-injection-
    injury, situational (e.g. bridges)
       Includes choking and swallowing phobias
   Fear severe enough to interfere with
   Often associated with situational panic
   Rx: gradual exposure; medications only
    in severe cases
Obsessive-Compulsive Disorder
   Obsessions &/or Compulsions x 1hr/day
   obsessions=recurrent unwanted thoughts
    or images, e.g. my hands are
   Compulsions= repetitive behaviors in
    response to obsessive worry, e.g.
    repetitive washing
   Rituals can get very elaborate and
    family’s can get involved
   Mild OC symptoms are very common
       peak in early adolescents-19%
        most resolve spontaneously
Generalized Anxiety Disorder
   Excessive, uncontrollable worry for at
    least 6 months plus ≥ 1 other symptom:
       sleep, fatigue, restlessness, irritability, muscle
        tension, difficulty concentrating
   Overlaps with anxious temperament:
       perfectionistic “worry warts”
       worry about school work, health issues,
   Commonly starts in intermediate years of
Case 2-discussion

   What makes this case more
    challenging than the first?
Case 2-poor prognostic factors

   Long duration of symptoms
   Poor response to previous
   Family mental health issues
   Family dynamic issues
   Somatic hypersensitivity
   Severity of symptoms (weight loss)
   Comorbidity
Case 2-discussion

   Father asks if you recommend a
    medication. What do you say?
When to consider?
     Severity: ++functional impairment
     Acuity/Urgency
          ↓↓sleep, ↓↓eating
     Failure to improve despite CBT
     Patient preference
Medications, cont.

What to use?
    SSRI’s: mainstay of treatment
        Fluoxetine (prozac), fluvoxamine (Luvox)
        Sertraline (Zoloft), Citalopram (celexa)
    Benzodiazepines:
        Ativan, clonazepam
    Other
        Buspirone-very little evidence it is helpful
        Low dose atypical neuroleptics-
         augmentation of SSRI’s with OCD
   Evidence for the SSRI’s
RUPP Anxiety Group NEJM 2001
       Fluvoxamine vs. placebo x 8 weeks
       N=128; social phobia, GAD, or sep.anxiety
       Results: partial or full response
                Luvox 76% vs. placebo 29%
                8% vs. 2% discont. due to adverse event
Birmaher 2003
       Fluoxetine (20mg) vs. placebo x 12 week
       N = 74, SP, GAD, SAD
       Results: much or very much improved
                Prozac 61% vs. placebo 35%
                13% vs. 0% discont. for agitation/adv.event
Walkup NEJM 2008
       CBT+sertraline vs. sert vs. CBT vs. placebo x 12 weeks
       N=488, SP,GAD, SAD
       Results: much or very much improved
                CBT+sert 81%, CBT 60%, sert 55%, placebo 24%
Case 2-discussion

   Father has read bad things about
    the SSRI’s in the newspaper and
    wants to know if they are safe in
    children. What do you say?
Review of Safety Issues
   Mostly well-tolerated
   Side effects same in depression and
   15-20% get psychiatric side effects:
    activation, emotional lability, agitation,
    giddy/silly, disinhibition, aggression,
    suicidal ideation
   Younger children, higher risk of activation
   Increased risk of suicidal ideation with
    ALL antidepressants (relative risk ~ 2)
Case 2

   Family remains apprehensive, but
    nervously agrees to a medication
    trial. How do you proceed?
Medication Initiation in anxious children
and families

   Anxious patients have low tolerance for side
    effects (hypervigilance of bodily sensations)
   Family anxiety can be high and lead to pressure
    to ―fix‖ the child quickly
   Higher medication doses and more rapid titration
    cause increased side effects (somatic and
   Can lead to premature discontinuation of
    medication because of family and physician
    concerns about activation
Suggested approach in anxiety

   Start low to minimize side effects
       5-10mg fluoxetine/citalopram (can be 2.5 mg in young
       12.5-25mg Sertraline/Fluvoxamine
   Titrate up with patient/family – phone or in office
    (weekly for 1st month)
   Use monitoring sheet to track efficacy and side effects
   Get to 10 mg FLX by 2 weeks (25 SER)
   Review effectiveness at 4 weeks
       If no response: ↑ to 20 mg; then, if nothing at 6 week ↑ to
        30 mg (if OCD═> at 8 weeks to 40 mg)
       If partial response at 4 weeks, work with CBT & wait till 6
        wk before increase above 10 mg
   Don’t eliminate all the anxiety-work with it!!
   If nothing at 8-10 weeks; switch, reassess CBT
Duration of treatment
   Typical duration of SSRI would be ca. 1
    year, before discontinuing.
   Longer duration of symptoms may require
    longer treatment.
   Taper dose and predict withdrawal
    symptoms so children don’t interpret
    these as anxiety returning.
   Combine medication taper with ―booster‖
    CBT strategies to help manage mild
    anxiety recurrence.
Case 2-Epilogue
   Referred to psychology for individual CBT
   I saw parents for supportive
    psychotherapy (primarily containment)
   Multiple SSRI trials, many discontinued
    quickly because of side effects
   Eventually settled on Paroxetine 30mg;
    anxiety partially improved, regained
   3 years later, discontinued SSRI due to
    concerns about poor growth.
   Remains very anxious, but functionally
    much improved—karate very helpful!
Case 2: Take Home Messages
   Mod-severe anxiety will require more intensive
       Psychology referral for CBT
       Consider SSRI
   Poor prognostic factors (comorbidity, family
    mental health issues, chronicity, poor response to
    treatment) indicate need for specialist referral.
   SSRI’s can be very helpful for child anxiety
       Combine with CBT whenever possible.
   ―Prescribe‖ behavioral and coping strategies
    (including exercise, sleep hygiene, exposure
    practice) as ―medically necessary‖ too
   Parenting books about anxiety
        Helping your anxious child: A step-by-step guide for parents. Ronald
         Rapee, New Harbinger Pub. 2000.
        Keys to Parenting your anxious child. Katharina Manassis, Barron’s
         Educational Series, 1996.
   Child/adolescent books about anxiety
        What to do when you worry too much: A kid’s guide to overcoming anxiety.
         Dawn Huebner, Magination Press, 2005.
        Taming Worry Dragons/Worry Taming for Teens, BC Children’s Hospital
         family resource library, email: famreslib@cw.bc.ca
        The anxiety workbook for teens: Lisa Schab, Instant help Publications,
   Useful web resources
        www.anxietybc.com
        www.anxietycanada,ca
   SSRI Monitoring/Information sheet
        http://www.bcchildrens.ca/NR/rdonlyres/25643C99-5CE2-48F4-9757-

To top