Anxiety - WordPress

anxietyPlease note: This guidance is based on the work of the World Health Organization (www.who.int) and may be updatedannually. Check “Feedback & Updates” periodically.Anxiety disorders (overanxious anxiety disorder,generalized anxiety disorder, panic disorder, separationanxiety disorder, agoraphobia, social phobia, avoidantdisorder, post-traumatic stress disorder [PTSD], obsessivecompulsive disorder [OCD], specific phobias) are amongthe most common mental health disorders in children andadolescents. From 6% to 20% of youth meet the diagnosticcriteria for any of the anxiety disorders,1 approximately halfexperiencing impairment of daily functioning.2 Anxietydisorders often occur concomitantly with chronic medicalconditions3 and with other psychiatric disorders—especiallydepression.4 Because of the prevalence and clinicalsignificance of anxiety among children and the potentialeffectiveness of primary care interventions, the AmericanAcademy of Pediatrics recommends that pediatric primarycare clinicians achieve competence in the care of childrenexperiencing anxiety.5Screening Results Suggesting AnxietyPediatric Symptom Checklist (PSC)-35: Total score 24for children 5 years and younger; 28 for those 6 to 16years; and 30 for those 17 years and older AND furtherdiscussion of items related to anxiety confirms a concern inthat area.PSC-17: Internalizing subscale is 5 AND furtherdiscussion of items related to anxiety confirms a concern inthat area.Strengths and Difficulties Questionnaire (SDQ): Totalsymptom score of 19; emotional symptom score of 7 to 10(see instructions at www.sdqinfo.com/ScoreSheets/e2.pdf);impact scale (back of form) score 2 indicates some degreeof impairment; AND further discussion of items related toanxiety confirms a concern in that area.Symptoms and Clinical FindingsSuggesting AnxietyHistory from youth or parent suggests Normal fears are exaggerated or persistent (eg, strangers,dark, separation, new social situations, unfamiliaranimals or objects, public speaking).D e c i s i o n S u p p o rt for C linicians Fears are keeping child from developmentallyappropriate experiences (eg, school refusal, extremeshyness or clinging, refusal to sleep alone). Tantrum, tearfulness, acting-out behavior, or anotherdisplay of distress occurs when child is asked to engagein feared activity. Child worries about harm coming to self or loved ones orfears something bad is going to happen. Behavior changes such as the following5 followed atraumatic experience such as abuse, witness to violence,loss of a loved one, or medical trauma: Infants and toddlers: Crying, clinging, change insleep or eating habits, regression to earlier behavior (eg,bed-wetting, thumb sucking), repetitive play or talk 3- to 5-year-olds: Separation fears, clinging, tantrums,fighting, crying, withdrawal, regression to earlierbehavior (eg, bed-wetting, thumb sucking), sleepdifficulty 6- to 9-year-olds: Anger, fighting, bullying,irritability, fluctuating moods, fear of separation orbeing alone, fear of recurring events, withdrawal,regression to earlier behavior, physical complaints(eg, stomachaches, headaches), school problems(eg, avoidance, academic difficulty, difficultyconcentrating) 10- to 12-year-olds: Crying, aggression, irritability,bullying, resentment, sadness, withdrawal, fears,suppressed emotions, sleep disturbance, concernabout physical health, physical complaints, academicproblems or decline 13- to 18-year-olds: Numbing, reexperiencing,avoidance of feelings, resentment, loss of trust,depression, withdrawal, mood swings, irritability,anxiety, anger, exaggerated euphoria, acting out,substance use, fear of similar events, appetite and sleepchanges, physical complaints, academic decline, schoolrefusalPage 1 of 8

anxiety Somatic features accompany worries—palpitations,stomachaches, headaches, breathlessness, difficultygetting to sleep, nausea, feeling wobbly (“jelly legs”),butterflies. Panic attacks occur in response to feared objectsor situations or happen spontaneously. These areunexpected and repeated periods of intense fear,dread, or discomfort along with symptoms such asracing heartbeat, shortness of breath, dizziness, lightheadedness, feeling smothered, trembling, sense ofunreality, fear of dying, losing control, or losing one’smind. Panic attacks frequently develop without warningand last minutes to hours.Conditions That May Mimic orCo-occur With AnxietyDifferentiate From Normal BehaviorAnxiety is a universal experience. It is often difficult todiagnose anxiety disorder in young children because amoderate level of anxiety is normative at certaindevelopmental stages. 8 to 9 months: Peak of stranger anxiety (children areusually able to separate easily by 3 years). 5 to 8 years: May have increase in worry about harmto parents or attachment figures. School-aged children of any age: Anxiety anddistress at the time of high-stakes testing; initialreluctance to socialize in new situations.Children with anxiety disorders have excessive fearand distress in response to everyday situations. Verbalolder children and adolescents are usually able todescribe their anxiety, but evaluating reports of youngerchildren’s anxiety may be challenging if the parentgiving information is also anxious, so it is importantto communicate directly with all children about thesesymptoms and to observe physiologic symptoms (eg,increased heart rate, shortness of breath, numbness,tingling).Learning problems or disabilities. If symptoms of anxietyare associated with problems of school attendance orperformance, the child may be experiencing academicdifficulties. (See Learning Difficulties guidance forexploring this possibility.)D e c i s i o n S u p p o rt for C liniciansSomatic complaints. Anxious children may present witha variety of somatic complaints, eg, gastrointestinalsymptoms, headaches, chest pain. These may elicit medicalworkups if they are not recognized. Conversely, acuteor chronic medical conditions or pain syndromes maycause anxiety.Depression. This can be very difficult to distinguish fromanxiety. Depression coexists in half or more of anxiouschildren. Marked sleep disturbance, disturbed appetite,low mood, or tearfulness in the absence of direct anxietyprovocation could indicate that a child is depressed.Bereavement. The vast majority of children will experiencethe death of a family member or friend sometime in theirchildhood. Other losses may also trigger grief responses—separation or divorce of parents, relocation, change ofschool, deployment of a parent in military service, breakupwith a girlfriend or boyfriend, or remarriage of a parent.Such losses are traumatic. They may result in feelings ofinsecurity and anxiety immediately following the loss orexacerbate existing anxiety. Furthermore, they may makethe child more susceptible to impaired functioning at thetime of subsequent losses. See also the discussion of PTSDon the next page.Autism spectrum disorders including pervasive developmentdisorder and Asperger syndrome. Children who have thesedifficulties also have problems with social relatedness (eg,poor eye contact, preference for solitary activities), language(often stilted), and range of interest (persistent and intenseinterest in a particular activity or subject). They often willhave very rigid expectations for routine or parent promisesand become anxious or angry if these expectations are not met.Exposure to adverse childhood experiences (ACE). Childrenwho have experienced or witnessed trauma, violence, anatural disaster, separation from a parent, parental divorceor separation, parental substance use, neglect, or physical,emotional, or sexual abuse are at high risk of developingemotional difficulties such as adjustment disorder or PTSD.Determination of the temporal relationship between thetrauma and onset of anxiety symptoms is essential. Denialof trauma symptoms does not mean trauma did not occur;questions about ACE should be repeated as a trustingrelationship is established.Page 2 of 8

anxietyPsychosis. Symptoms associated with psychosis, such ashallucinations or delusions, may occur in children withPTSD. They may also occur infrequently with adolescentonset of bipolar disorder and are features of schizophrenia,which may also have its onset in adolescence. The teenmay manifest fear without disclosing the hallucinationsor delusions.Physical illness. Medical issues that can mimic or provokeanxiety symptoms include thyroid disease, hypoglycemia,side effects of medications (eg, bronchodilators), andendocrine tumors (pheochromocytoma). Drug or alcoholwithdrawal is a consideration for teens (the latter potentiallya medical emergency).Selective mutism. Consider this if a child who has hadnormal language development suddenly stops talking incertain situations (most often in school and to adults outsidethe home). This can be confused with children making alanguage transition, eg, a child raised speaking Spanish whois suddenly placed in an English-speaking class.Tools for Further Assessmentof AnxietyScreen for Child Anxiety Related Disorders 2(SCARED), parent and child versions: Best for generalizedanxiety, panic disorder, significant somatic symptoms,separation anxiety, social anxiety, or significant schoolavoidance. Tool designed for children 8 years and older.chronic sexual or physical abuse. Parents may beunaware of exposures to trauma such as bullying atschool or in the community, and there may be majortraumas in the family (eg, serious illness in a parent,pending divorce) that are similarly not discussed ordisclosed; consequently, clinicians will need to interviewchildren and parents separately to elicit a completehistory. The 3 hallmark symptom clusters in PTSDare reexperiencing (often repetitive play in children),avoidance of memories or situations that recall thetrauma, and hypervigilance (eg, increased worry aboutsafety, startling or anxiousness at unexpected soundsor events). Children most at risk for developing PTSDfollowing trauma or loss are those with preexistingmental health conditions, those whose caregiversare experiencing emotional difficulties, those facingpreexisting or consequent family life stressors suchas divorce or loss of job, those with previous loss ortrauma experiences, those repeatedly exposed to mediacoverage of traumatic events, and those with a limitedsupport network.4 Clinicians can provide the child witha safe and comfortable environment to express his orher feelings and allow the child to control the interview,taking breaks or discontinuing as needed. Even childrenwith limited symptoms of PTSD after a trauma canbenefit from treatment.Evidence-Based and Evidence-InformedInterventions for Anxiety (as of April2010)Spence Children’s Anxiety Scale: Tool designed forchildren 2½ to 6½ years (parent report) and youth 8 to 12years (self-report).Updates are available at www.aap.org/mentalhealth.Individual evaluation—necessary for OCD and PTSD. Level 1 (best support): cognitive behavior therapy(CBT), CBT and medication, education, exposure,modeling Consider OCD in the presence of marked rituals orcompulsive behaviors. Most children have phases ofritualized behavior that can usually be distinguishedfrom OCD by the degree of distress caused if a ritual isinterrupted and the number of rituals present at any onestage. These children may complain of getting stuck oncertain thoughts. Consider PTSD if the onset of anxiety was precededby an extremely distressing experience(s) such aswitnessing violence, experiencing abuse, losing aloved one, undergoing medical trauma, or sufferingD ec i s i o n S u p p o rt for C liniciansPsychosocial Interventions for GeneralizedAnxiety Disorders6 Level 2 (good support): assertiveness training, CBTfor child and parent (child and parent receive CBTseparately, focusing on each of their concerns), CBTwith parents (includes parent and child, focusing on thechild’s concerns), family psychoeducation, hypnosis,relaxationPage 3 of 8