Anxiety Disorders in Children and Adolescents

Educational Objectives

The goal of this program is to improve management of anxiety disorders in children and adolescents. After hearing and assimilating this program, the clinician will be better able to:

1. Use screening tools to identify children and adolescents with anxiety disorders.
2. Optimize use of medications in pediatric patients with anxiety disorders.

Summary

The spectrum of anxiety disorders: anxiety affects 6% to 20% of children and adolescents; anxiety is a normal adaptive characteristic, but it can be difficult to identify when it crosses over from being useful and adaptive to becoming a pathology that requires treatment; developmental considerations — it is normal for toddlers to be anxious about separation from adult caregivers; school-aged children may experience a fear of being alone or may avoid school; fear of harm to family can appear similar to early-onset obsessive compulsive disorder (OCD) but is developmentally normal; in teenagers, fear of not fitting in is common, and school pressure and performance anxiety can contribute to anxiety

Developmental vs anxiety disorders: developmental and learning disorders (eg, dyslexia) can cause anxiety; once the student has support, the anxiety often resolves; consider medication side effects; hyperthyroidism, hypoglycemia, caffeine intoxication, malignancy, asthma, epilepsy, anemia, or obstructive sleep apnea can present as an anxiety disorder

Family temperament: anxiety disorders can be inherited genetically or learned (ie, from parental anxiety); anxiety behaviors can develop as a mechanism to cope with life events; offer to help the parent by suggesting therapy as a way to help parent and child

Behavioral health comorbidities: are extremely common; depression, poor concentration, and attention-deficit/hyperactivity disorder (ADHD) may co-exist in patients with anxiety and may mimic each other; untreated ADHD can cause anxiety

Psychosocial stressors: trauma, higher Anxiety Scale for Autism score, political trauma, racism, and natural disasters can influence anxiety disorders

Screening for anxiety disorders: ask patients whether they feel like they are out of control, whether the fear prevents them from desired activities or is disruptive to activities of daily living, whether it is possible to locate fear in a certain part of the body, and whether they worry about saying the wrong thing or being embarrassed in a social setting; the General Anxiety Disorder (GAD)-7 scale is a useful screening tool that is specific to generalized anxiety disorder and not necessarily sensitive enough to detect OCD or social anxiety disorder; the 41-question Screen for Anxiety Related Disorders (SCARED) online assessment offers a more nuanced sense of diagnosis for the major anxiety disorders; the speaker uses the GAD scale for younger children, but it is validated for ≥12 yr of age

Treatment roadmap: validate for patients that anxiety is normal and treatable, although they may feel a tendency toward anxiety; refer for cognitive behavioral therapy (CBT) or other types of therapy; provide concrete, free resources that patient can have access to immediately; listing 5 to 10 most fear- or anxiety-inducing situations and ranking them in order is helpful; when families are waiting for therapy, they can try exposure therapy to the least fear-inducing item on the list; selective serotonin reuptake inhibitors (SSRIs) can also be started while waiting for therapy

Cognitive behavioral therapy (CBT): primary care providers (PCPs) do not provide CBT, but they can explain it to patients; CBT can help patients change their automatic thoughts, which help them feel better and, therefore, more able to participate in activities; CBT is highly effective for anxiety disorders, but the effect, response, recovery, and remission depends on the patient’s rapport with the therapist

Medications: SSRIs have the most empiric support for anxiety disorders in teenagers; however, the serotonin norepinephrine reuptake inhibitor (SNRI) duloxetine (Cymbalta) is the only drug approved by Food and Drug Administration for child and adolescent anxiety; the Child/Adolescent Anxiety Multimodal Study (CAMS) was a 6-yr randomized controlled trial assessing CBT, psychotherapy, sertraline (Zoloft), or CBT plus sertraline; the combination of sertraline and CBT had better results and achieved results more quickly; it is also better for long-term remission

SSRI initiation: common side effects include gastrointestinal upset and headache that usually resolve in the first week of treatment; serotonin agents have an antiplatelet effect and may cause easy bruising; use the sedation and activation effects of SSRIs to best advantage; sertraline tends to be more sedating and fluoxetine (Prozac) more activating; if sertraline causes sleepiness, shift to a nighttime dose; use fluoxetine in the morning if it causes patient to feel activated at night; sexual dysfunction is a common side effect; 60% to 70% of patients have difficulty reaching an orgasm; night sweats are common and typically do not resolve; vivid dreams are fairly common; it is important to be upfront about possible side effects of medication; younger patients are often worried about the stigma of taking medication

Continuing medication: there is no good evidence to guide the duration of treatment after achieving remission; but the American Academy of Child and Adolescent Psychiatry recommends continuing for 1 yr; although parents often want to take children off medication more quickly, recurrence is more likely if medication is stopped too soon; during medication weaning, increase the therapy component

Choosing a medication: validate the diagnosis and check for safety concerns; review the family history; if a first-degree relative responded well to the SSRI, choose that one; obtain consent from the family and from the patient; clarify expectations, goals, and safety plans; emphasize that improvement will take time and effort, and that medication is a tool to help them engage in therapy; discuss that there is a statistically significant increase in risk for new suicidal thoughts

Dosing strategies for anxiety disorders: start at a low dose and increase as needed until the patient reports feeling better; 300 mg of sertraline may be required for OCD, but traditional doses are appropriate for anxiety disorders; the full effect of each dose adjustment is not seen for 4 to 6 wk; the number needed to treat with an SSRI for depression is 10 but for anxiety is 3, and the effect size is also much larger for anxiety; activation can manifest as impulsivity, disinhibition, or restlessness; it is more likely in younger patients and tends to happen across SSRIs in such cases; it is recommended to change to activation SNRI (duloxetine) in those with this adverse effect; they also have analgesic effects so may be good for patients with endometriosis

Readings

Cheever NA, Rosen LD, Carrier LM, et al. Out of sight is not out of mind: The impact of restricting wireless mobile device use on anxiety levels among low, moderate and high users. Computers in Human Behavior. 2014;37:290–297. Available at: https://doi.org/10.1016/j.chb.2014.05.002; DeMartini J, Patel G, Fancher TL. Generalized anxiety disorder. Ann Intern Med. 2019;170(7):ITC49-ITC64. doi:10.7326/AITC201904020; Fountoulakis KN, Apostolidou MK, Atsiova MB, et al. Self-reported changes in anxiety, depression and suicidality during the COVID-19 lockdown in Greece [published correction appears in J Affect Disord. 2020 Dec 1;:]. J Affect Disord. 2021;279:624-629. doi:10.1016/j.jad.2020.10.061; Kodish I, Rockhill C, Varley C. Pharmacotherapy for anxiety disorders in children and adolescents. Dialogues Clin Neurosci. 2011;13(4):439-52. doi: 10.31887/DCNS.2011.13.4/ikodish. PMID: 22275849; PMCID: PMC3263391; Smith WT, Londborg PD, Glaudin V, et al. Short-term augmentation of fluoxetine with clonazepam in the treatment of depression: a double-blind study. Am J Psychiatry. 1998;155(10):1339-1345. doi:10.1176/ajp.155.10.1339; Steimer T. The biology of fear- and anxiety-related behaviors. Dialogues Clin Neurosci. 2002;4(3):231-249. doi:10.31887/DCNS.2002.4.3/tsteimer.

Disclosures

For this program, members of the faculty and the planning committee reported nothing relevant to disclose. In her lecture, Dr. Downey includes information related to the off-label use of a product, therapy, or device.

Acknowledgements

Dr. Downey was recorded at the 46th Annual Melvin L. Cohen, MD Pediatric Update Conference 2023, presented by Phoenix Children's Hospital, held March 6-9, 2023, in Scottsdale, AZ. For information about CME activities from this presenter, visit https://phoenixchildrens.org/providers/continuing-medical-education. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

PD692302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.