Anxiety among youth, Part 1

Accreditation

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of CME², Inc. ("cme²") and Contemporary Pediatrics. cme² is accredited by the ACCME to provide continuing medical education for physicians.

cme² designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit™. Two credits will be awarded after the successful completion of both Parts I and II of this activity. Part II is scheduled to appear in the August 2007 issue of Contemporary Pediatrics.

Target audience: Pediatricians and primary care physicians

EDUCATIONAL OBJECTIVES

• Identify the types of anxiety found in children, describe the factors that contribute to anxiety in this age group, and recognize the variations in the symptoms of anxiety that are related to a child's developmental stage
• Name the likely presenting symptoms and describe the screening tools available in the diagnosis of anxiety disorder
• Recognize the behavioral treatment options for available children with anxiety, including cognitive behavior therapy (CBT), hypnosis, medication, and technologies for self-monitoring
• Describe the key components of anxiety prevention programs, define "resilience," and explain why building resilience is an effective means of preventing anxiety

To earn CME credit for this activity

Participants should study Parts I and II of this article. A link to the activity can be found at the end of the article. Participants must pass a post-test and complete an online evaluation of the CME activity. After passing the post-test and completing the online evaluation, a CME certificate will be e-mailed to them. The release date for this activity is July 1, 2007. The expiration date is August 1, 2008.

Disclosures

Editors Toby Hindin, Jeannette Mallozzi, Jeff Ryan, and Karen Woldman disclose that they do not have any financial relationships with any manufacturer in this area of medicine.

Manuscript reviewers disclose that they do not have any financial relationships with any manufacturer in this area of medicine.

Authors Denise Bothe, MD, and Karen Olness, MD, disclose that they do not have any financial relationships with any manufacturer in this area of medicine.

Resolution of conflict of interest
cme² has implemented a process to resolve conflicts of interest for each continuing medical education activity, to help ensure content validity, independence, fair balance, and that the content is aligned with the interest of the public. Conflicts, if any, are resolved through a peer review process.

Unapproved/off-label use discussion

Faculty may discuss information about pharmaceutical agents, devices, or diagnostic products that are outside of FDA-approved labeling. This information is intended solely for CME and is not intended to promote off-label use of these medications. If you have questions, contact the medical affairs department of the manufacturer for the most recent prescribing information. Faculty are required to disclose any off-label discussion.

All children experience some level of anxiety in their lives. In infants, normal separation and stranger anxiety begins when the child starts to understand object permanence and form an attachment to their parents. Preschool-aged children, who are in the midst of learning the difference between fantasy and reality, typically experience anxiety/fear of the dark, monsters, and/or costumed characters. School-aged children and adolescents also go through anxiety-provoking stages as they begin to understand some of the realities of the world, which may be frightening or disappointing.

These feelings fall in line with the normal course of a child's development. But for some young children and adolescents, anxiety becomes part of their daily lives, robbing them of that precious carefree time of life. As primary care providers, pediatricians are poised to help these children achieve a healthier mental state-given the right knowledge.

Definitions and types

Anxiety has been defined as a future-oriented emotion, characterized by perceptions of uncontrollability and unpredictability over potentially aversive events, and a rapid shift in attention to the focus of potentially dangerous events or one's own affective response to these events.¹ From the point of view of a small child, the feeling of being afraid and out of control is probably a more practical definition.

Classic reference sources such as The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provide the following definitions of anxiety disorders in children and adolescents:²

DSM-IV anxiety diagnoses/descriptions*

• Separation anxiety disorder-Excessive and developmentally inappropriate anxiety concerning separation from home or attachment figures that begins prior to 18 years of age, has been present for at least four weeks, and causes clinically significant distress or impairment in important areas of functioning.
• Generalized anxiety disorder (GAD)-Excessive anxiety and worry that is difficult to control, not focused on a specific situation or object, and unrelated to a recent stressor. GAD occurs most days over a six-month period and is associated with at least one physical symptom, and causes clinically significant impairment.
• Social phobia-Marked and persistent fear of situations in which there is a likelihood of social interaction, lasting at least six months. Social phobia leads to avoidance or attempts at avoidance of situations and causes significant impairment.
• Specific phobia-Marked, excessive, persistent fear in either the anticipation of a specific object, or an event that is developmentally inappropriate (eg, an excessive fear of dogs or bad weather). Specific phobia also leads to avoidance or attempts at avoidance of situations and causes clinically significant distress or impairment.
• Panic disorder-Sudden occurrence of a cluster of symptoms (eg, palpitations, sweating, trembling, feeling short of breath, chest pain, nausea, dizziness) that peaks within 10 minutes. Panic disorder recurs unexpectedly and is associated with at least one month of chronic worry or fear about future attacks, consequences regarding attacks, and leads to avoidance of situations that might trigger a panic episode.
• Obsessive-compulsive disorder (OCD)-Characterized by obsessive thoughts, impulses, and/or images, which last over one hour a day, leading to marked distress and clinically significant impairment. In OCD, attempts are made to ignore obsessions; relieve distress by performing compulsions.
• Post-traumatic disorder-Exposure to a traumatic event leads to persistent flashbacks (eg, intrusive thoughts or images), persistent avoidance of situations of persons associated with the event, and increased arousal (eg, hypervigilence, sleep disturbance, etc.) present for at least one month.

*Adapted from the DSM-IV (Text Revision), American Psychiatric Association, 1994

The American Academy of Pediatrics' manual on mental health disorders in children and adolescents (The Classification of Child and Adolescent Mental Diagnosis in Primary Care, Diagnostic and Statistical Manual for Primary Care [DSM-PC]³) goes further and lists anxiety disorders that do not meet criteria in the DSM-IV, but are nonetheless significant:

DSM-PC anxiety diagnoses*

• Anxiety disorder, not otherwise specified-Includes disorders with prominent anxiety or phobic avoidance that does not meet criteria for any specific anxiety disorder.
• Anxiety disorder due to a medical condition-An anxiety problem involving excessive worry or fearfulness that causes significant distress, but not intense enough to qualify for an anxiety disorder or adjustment disorder with anxious mood.
• Anxiety variation-Consists of transient responses or fears that are normal for developmental level and do not affect normal development.

*Adapted from DSM-PC

Prevalence in pediatric population

Looking at the literature, the prevalence of children who suffer from anxiety complaints severe enough to interfere with daily life and functioning varies widely from 2.5% to 41%.⁴ This large variation in prevalence may be a reflection of the different methods employed in studies to diagnose anxiety in the children, or to variations in the numbers of stressors in different environments.

The most common anxiety disorders found among children are generalized anxiety, social phobia, and separation anxiety. As discussed earlier, generalized anxiety disorder (GAD) is defined as excessive anxiety and worry about events or situations during most days over a six-month period, coupled with impaired functioning. The excessive worrying characteristic of GAD occurs across a multitude of circumstances, such as school, sports, home, or social situations, and is associated with one or more of the following symptoms: irritability, muscle tension, sleep disturbance, restlessness, difficulty concentrating, and being easily fatigued. Other conditions, such as social anxiety disorder, have shown a lifetime prevalence of 12% and typically begin during the early teenage years.⁵ At the bottom of the spectrum is panic disorder, which has shown to have a very low prevalence in children.

Some overlap between anxiety and depressive disorders in children and adolescents has been found, but comorbidity rates vary greatly. One interesting finding is that there is a tendency for children with anxiety alone to be younger than children with depression alone.⁶ A few prospective studies also suggest that anxiety disorders in children are much more fluid than formerly believed. One study found that, over three to four years, 82% no longer met criteria for the original anxiety disorder at follow-up, but 15% of children were diagnosed with a different anxiety disorder, and an additional 13% shifted to a depressive diagnosis.⁷

Anxiety and depressive disorders have been referred to as internalizing disorders, and behavior disorders such as conduct disorders as externalizing disorders. However, there is limited evidence to support the clear differentiation between internalizing and externalizing disorders.

Comorbidities of anxiety and behavior disorders have also been reported, often with an overlap in symptoms. For example, some children with social phobia avoid situations that cause anxiety, which may be misinterpreted as oppositional behavior.⁸

What could be the cause?

Both genetic and environmental factors contribute to the development of anxiety. Although genetic factors may contribute to making a child more susceptible to anxiety, having a susceptibility doesn't mean one will develop anxiety. Environmental factors, such as a parent or caregiver's stress exposures, can also fuel a child's development of anxiety. Studies throughout the medical literature have demonstrated that children of anxious parents are more likely to develop an anxiety disorder than children of parents without anxiety.

Transitions in the lives of children, such as the start of daycare or school, can generate certain levels of anxiety as well. Most children recover from these typical transitions within a short period of time, but some will have persistent anxiety symptoms that may require intervention. Times of more significant stresses, such as a death in the family, violence, divorce, and/or natural disaster, may disrupt a child's life and sense of control to a great degree, thus creating anxiety.

Making a diagnosis

Diagnosis of anxiety usually begins with a parent or caretaker's perception that a child is manifesting certain behaviors that seem abnormal, and they then seek help from their pediatrician. Common red flags can be seen below.⁹

When to suspect anxiety in a child or adolescent*

• Easily distressed or agitated when involved in a stressful situation
• Repetitive reassurance questions, "what if" concerns, inconsolable, or irresponsive to logical arguments
• Headaches and/or stomachaches. Regularly too sick to go to school
• Anticipatory anxiety-worrying hours, days, or weeks ahead
• Sleep disruption with difficulty falling asleep, nightmares, or not wanting to sleep alone
• Perfectionism, self-critical, high standards
• People-pleasing, overly responsible, overly concerned that others are upset with him/her, excessive/unnecessary apologizing
• Exhibiting excessive avoidance, such as refusing to participate in expected activities and/or school
• Disruption of child or family functioning, difficulty going to school, friend's houses, religious activities, family gatherings, etc.

*©worrywisekids.org, Tamar Chansky, PhD, 2007

Diagnostic procedures must take into account that there is significant comorbidity between pediatric bipolar disorder and anxiety disorders. Every child who has bipolar disorder should be evaluated by their pediatrician for the presence of comorbid anxiety disorders.¹⁰

Moreover, pediatricians should familiarize themselves with one or two anxiety-based screening scales (see Editor's note), recognizing that abnormal scores will require further diagnostic assessments. If a child's symptoms are abnormal in the context of the child's age and development, then referral to a therapist may be indicated for more extensive diagnosis and treatment.

Editor's Note: Look for "Worried sick: Anxiety among youth, Part II: Screening, treatment, and prevention" in the August 2007 issue.

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References

1. Barlow DH: Anxiety and its disorders: The nature and treatment of anxiety and panic (ed. 2) New York, Guilford Press, 2002

2. Diagnostic and Statistical Manual of Mental Disorders, (ed. 4), Text Revision(DSM-IV-TR). Washington, D.C., American Psychiatric Association, 1994

3. Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version. The classification of child and adolescent mental diagnoses in primary care. Wolraich ML, Felice ME, Drotar D (eds). Elk Grove Village, Ill., American Academy of Pediatrics,1996

4. Cartwright-Hatton S, McNicol K, Doubleday E: Anxiety in a neglected population: prevalence of anxiety disorders in pre-adolescent children. Clin Psychol Rev 2006;26:817

5. Schneier FR: Social Anxiety Disorder. N Eng J Med 2006;355:1029

6. Strauss CC, Last CG, Hersen M, et al: Association between anxiety and depression in children and adolescents with anxiety disorders. J Abnorm Child Psych 1988;16:57

7. Last CG, Perrin S, Hersen M, et al: A prospective study of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 1996;35:1502

8. Schniering CA, Hudson JL, Rapee RM: Issues in the diagnosis and assessment of anxiety disorders in children and adolescents. Clinical Psych Review 2000;20:453

9. Chansky T, Siqueland L: Common red flags. Available at: www.worrywisekids.org. Accessed May 21, 2007

10. Wagner KD, Hirschfeld RM, Emslie GJ, et al: Validation of the mood disorder questionnaire for bipolar disorders in adolescents. J Clin Psychiatry 2006;67:827