A new set of guidelines confirms the value of psychotherapy, medications—including SSRIs—and combinations of therapy in managing anxiety disorders in children. The revised practice parameter on anxiety disorders from the American Academy of Child and Adolescent Psychiatry, published recently in the academy's journal, covers most of the anxiety disorders, such as phobias, separation anxiety disorder (SAD), generalized anxiety disorder (GAD), and panic disorder (PD), but not posttraumatic stress disorder (PTSD) or obsessive-compulsive disorder, for which practice parameters already exist.1
Developers of the parameter are psychiatrists Sucheta D. Connolly, MD, director of the Pediatric Stress and Anxiety Disorders Clinic at the University of Chicago, and Gail Bernstein, MD, director of the Child/Adolescent Anxiety Mood Disorders Clinic at the University of Minnesota. The academy's Work Group on Quality Issues aided them.
"We have many more studies confirming that cognitive-behavioral therapy [CBT] can be very effective for children and adolescents who have anxiety disorders . . . and there are more placebo-controlled studies with [SSRIs] that show they can really help children with anxiety disorders," Connolly told Psychiatric Times.
Because of the high prevalence of anxiety disorders in children and adolescents, ranging from 6% to 20%, the parameter also recommends routine screening for anxiety symptoms during the initial mental health assessment.
In emphasizing the importance of early diagnosis and effective treatment to help mitigate the impact of anxiety on academic and social functioning, the report noted that "anxiety disorders represent one of the most common forms of psychopathology among children and adolescents, but they often go undetected or untreated." Effective treatment may also reduce the persistence of anxiety disorders into adulthood, the report said.Normal versus abnormal
Fears that arise during childhood represent a normal developmental transition and may begin in response to perceived dangers, Connolly explained, but they become problematic if they do not subside with time and if they impair the child's functioning.
Some guidance on what are normal fears and worries in various age groups is provided in the parameter, Connolly noted. For example, school-aged children may fear injury or natural events, such as storms, whereas older children and adolescents may worry instead about school performance, health, and sociability issues.
When an anxiety disorder is suspected, clinicians need to obtain information about anxiety symptoms from both the child and parents/teachers and to look for somatic symptoms, such as headaches or stomachaches, which may be indicators of anxiety disorders, she said. A screening tool that Connolly uses at her clinic and in school settings is the Multidimensional Anxiety Scale for Children.2
"It is something the child or adolescent completes, so usually the child needs to be able to read and understand," Connolly said. "It is [normalized] for 8 year olds and older, but we have used it in younger children, where we will read the questions to them."
Another self-report tool Connolly mentioned is the Screen for Child Anxiety Related Emotional Disorders.3 If the screening test indicates the presence of significant anxiety, then the clinician needs to conduct a formal evaluation to determine which anxiety disorder is present, as well as the severity and the degree of functional impairment, Connolly explained. "In some children, we may not be able to identify that they have all the symptoms of one specific anxiety disorder, but when we look at how it is impacting their ability to function academically or with peers, it may be quite impairing and require treatment," she said.
To identify and differentiate a specific anxiety disorder, Connolly uses the Anxiety Disorders Interview Schedule for DSM-IV: Child Version (ADIS-C).4 It gives the clinician symptoms that apply to children and adolescents, puts situations and anxieties into their language, provides ways to identify symptom severity, and includes a "feelings thermometer" to help children quantify and self-monitor levels of fear and interference with functioning, she said. Connolly added that clinicians can use sections of the ADIS-C to supplement their clinical interview. For the diagnostic interview of very young children, child psychiatrists may use play narrative assessment along with pictures, cartoons, and puppets.
The psychiatric assessment, according to the parameter, should consider differential diagnosis of other physical conditions and psychiatric disorders that may mimic anxiety symptoms, such as attention-deficit/hyperactivity disorder (ADHD) and possible adverse effects from caffeinated beverages and cold medicines. Comorbidity also needs to be carefully evaluated and considered in treatment planning, Connolly said.
The parameter stresses that children often have multiple anxiety disorders and that anxiety disorders commonly co-occur with ADHD, depression, and substance abuse. In Connolly's work with anxious children in an urban medical center, she has also observed comorbid developmental problems, such as Asperger syndrome and comorbid PTSD. She urged clinicians to particularly ask about trauma in the child's life.
Clinical studies have shown that as many as one third of the children with ADHD have co-occurring anxiety disorders.5 At her clinic, Connolly said she commonly sees depression with anxiety, but she is also finding bipolar disorder (BD) in a subset of anxious children. Once they reach adolescence, Connolly added, children with anxiety disorders are at greater risk for comorbid alcohol(Drug information on alcohol) abuse or depression.Multimodal treatment
A multimodal treatment approach for anxiety disorders, the parameter states, should consider education of the parents and the child about anxiety disorder, consultation with school personnel and primary care physicians, CBT, psychodynamic psychotherapy, family therapy, and pharmacotherapy.