Anxiety among youth, Part 2: Screening, treatment and prevention (CME)

CME

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 1 and 2 of this activity.

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 1 and 2 of this article and log on to www.contemporarypediatrics.com and click on the "Earn CME Credit" button on the right-hand side. 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 August 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.

Part 2 of "Worried Sick: Anxiety among youth" provides some practical guidelines for child health practitioners about screening, treatment, and prevention of anxiety in children and adolescents. We recommend that all child health practitioners familiarize themselves with at least one screening tool, be able to provide treatment for children with mild or transient anxiety, and have identified referral sources for moderate or severe anxiety.

Approaches to screening

Pediatricians can choose a specific checklist for anxiety, or a more behaviorally comprehensive screen that can differentiate among several disorders. Because so many children who have anxiety disorders also have a comorbid disorder, it may be best to consider a tool that screens for several disorders, including depression, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct disorder.

Bright Future's Pediatric Symptom Checklist(PSC), for instance, is a psychosocial screen designed to help recognize cognitive, emotional, and behavioral problems. It features a parent questionnaire and a youth self report (Y-PSC)¹ both of which can be completed before or during an office visit. An additional resource is the Child Behavior Checklist(CBCL),² a screening tool often used in research and in practice, which also tests for several disorders including anxiety, depression, ADHD, oppositional defiant disorder, and conduct disorder. The CBCL has versions for children aged 1½ to 5, and an other version for 6- to 18-year-olds, divided into boy and girl questionnaires. A recent study, however, showed that the CBCL and Y-PSC, while they are able to screen for several disorders, are only moderately effective at predicting anxiety disorder compared to the DSM-IV criteria.³

Another screening tool used by psychiatrists or psychologists for screening psychosocial issues in adolescents is the Symptom Checklist-90-Revised(SCL-90-R).⁴ This tool is adapted from an adult tool, and can screen for nine different symptom dimensions in adolescents, including anxiety, depression, somatization, obsessive compulsive, and paranoid ideation.

When looking to screen for anxiety disorders alone, the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV)⁵ has been used most frequently within the research literature. ADIS-IV uses screens for individual anxiety disorders and has both parent and child forms. A recent study has found that the inter-rater level of agreement for individual anxiety disorders using the ADIS-IV was excellent. Agreement on common co-morbid conditions was also good.⁶ There are many youth self-rating scales for assessing anxiety and its disorders such as the Screen for Child Anxiety Related Emotional Disorders (SCARED)-(ages 8+),⁷Multidimensional Anxiety Scale for Children (MASC)-(ages 8 to 9),⁸ Revised Children's Manifest Anxiety Scale (RCMAS)-(ages 6 to 19),⁹ and the State-Trait Anxiety Inventory for Children (STAIC)-(ages 9 to 12).¹⁰ These self reports are designed to distinguish between anxious children and normal controls. Although some of these tools distinguish between the different types of anxiety, they are limited in distinguishing between anxious children and children with other mental health disorders.

The reliability of diagnosed anxiety disorders based on the self reports of children has ranged from moderate to excellent. Young children, ages 6 to 11 years, and those with learning disabilities, however, have shown the poorest retest reliability.¹¹ It should be noted that most self report measures of children's anxiety were developed on adult models without considering that children interpret language differently than do adults. For example, most adults associate "worry" with frequency of thought, whereas children under 10 years of age associate worry with aversiveness. In other words, young children interpret worry in terms of how bad they would find an event, rather than how often they think about an event.¹² An additional problem with self-report measures from children is that they have little interest or ability to observe, understand, and evaluate internal processes. This capacity is not fully developed until late adolescence.¹³

Clues in the body

There are several physiological parameters that are easily measured and may give insight into a child's level of anxiety. These parameters include increased heart rate, heightened blood pressure, increased galvanic skin resistance (sweat gland activity), decreased peripheral temperature, changes in pulse rate variability, and/or increased muscle tension.

Children may also exhibit individual physiologic profiles related to fear and anxiety. For example, one child may react with cold hands and an unchanged pulse while another may demonstrate an increased pulse rate and stable galvanic skin resistance. Fortunately, there are now small, portable monitoring devices that can help clinicians assess changes in body physiology that occur in the presence of anxiety. One such device is called the emWave Personal Stress Reliever (www.heartmath.com), a portable handheld device that measures heart rate variability as a means to illustrate the body's level of relaxation at that moment. In addition, there are peripheral skin temperature measuring devices that can be used to assess the body's state of relaxation or stress, such as Biotic Bands and Thermadots (www.biotempproducts.com), and biofeedback cards (www.cliving.org/stresscard.htm). The information obtained through these tools can then be shared with your child or adolescent patient.

The advantage of providing this feedback is that they can quickly comprehend that when they change their thinking from an anxious to a relaxed state, or vice versa, they change their body's response. Ex pressed another way, children can easily learn that they can cope with stress by simply changing their pattern of thinking.

Although long-term, follow-up studies of autonomic responses of children with anxiety disorders have not been conducted, some studies suggest that the antecedents of hypertension may be present from childhood. People who consistently have heightened blood pressure responses to acute stressors have a higher incidence of future hypertension.¹⁴ Studies have shown that disasters such as war and terrorist attacks have produced substantial and sustained increases in blood pressure.¹⁵ Children may develop conditioned blood pressure responses to stressors. As time goes on, the blood pressure baselines may increase until the child is diagnosed with hypertension.

Another area of concern is the hypothalamic-pituitary-adrenal system, one of the body's primary stress response systems. During stressful events, this system can generate increased levels ofglucocorticoids. Children who are subject to chronic stress (see "Sick children & anxiety: More than white-coat fever"), such as internationally adopted children from orphanages, have presented with chronically elevated levels of cortisol, while maltreated children with internalizing problems have been shown to have elevated basal cortisol levels.¹⁶ Chronically elevated cortisol levels have deleterious effects on health.¹⁷

Potential therapies

The treatment options for anxiety and its disorders can be just as varied as its causes, but some have shown more promise than others. Several studies indicate that cognitive behavioral therapy (CBT) is effective in reducing anxiety in children. A recent study compared the long-term effectiveness of CBT along with CBT plus family management. Both interventions were equally effective, with 85% of children no longer meeting the diagnostic criteria for any anxiety disorder an average of six years later post-treatment.¹⁸

CBT components include psycho-education; body awareness (including training in abdominal breathing and progressive muscle relaxation); cognitive restructuring, which helps children identify automatic thoughts and to think about more rational responses; exposure/response prevention (desensitization to situations that trigger anxiety); and emphasis on personal control through skill building. Clinical psychologists trained in CBT would be the best resource when looking for this kind of therapy.

Self-regulation (hypnosis) and biofeedback are also effective tools that can ameliorate anxiety. Self-regulation can be taught to a child or adolescent as a coping skill to gain control over his/her own body's physiological reactions. Trained child health professionals, including psychologists, pediatricians, developmental behavioral pediatricians, teachers, etc., are among the best suited to teach this skill. Training courses are usually three to five days long and are available through several organizations such as the Society for Developmental and Behavioral Pediatrics, American Society for Clinical Hypnosis, and Society of Clinical and Experimental Hypnosis. Clinicians may also consider biofeedback as a powerful adjunct to teaching self-regulation because it helps increase one's awareness of his/her body physiology.

When symptoms are severe, and other methods have failed, medication management is another option. Medications should not substitute behavioral therapies, but are used when necessary as an adjunct. In general, these are rarely used in children and more often in adolescents who have severe anxiety, and are best prescribed by a psychiatrist who is trained in the uses and potential complications of these medications.

In some areas, psychiatrists are not readily available to meet these needs. In these instances, at least one phone consult between a child psychiatrist and pediatrician should be conducted to gain guidance about when, how much, and how long a medication should be prescribed. More often than not, some of the same medicines used for depression are given in lower doses and are quite effective in decreasing symptoms of anxiety. Clinical studies examining/supporting the effectiveness of medications for the treatment of anxiety in children and adolescents, however, have been limited in number.^19,20

Heading off anxiety

Prevention of anxiety disorders includes child-focused methods, parent-focused methods, and environmental restructuring. From early childhood, parents can model healthy coping skills and provide their children with instruction in how to cope with fear and anxiety (see Parent Guide). Pediatricians can provide parents with guidance in how they can model appropriate behavior, reduce their own anxious behaviors, and avoid focusing on potentially threatening aspects of the environment (eg, disturbing TV news coverage, violent video games, etc.)

There are many ways to teach children stress-management coping skills, such as teaching deep breathing, muscle relaxation, meditation, yoga, and using the child's creativity with drawing, music, and drama, etc. There are also a number of established anxiety prevention programs that are widely used. One resource is a book called Ready...Set... R.E.L.A.X.²¹ designed for children aged 5 to 13. It involves teaching about stress, and teaching tools to overcome anxiety through use of music, muscle relaxation, and storytelling. It can be used in schools, by teachers, counselors, parents, etc.

School teachers and administrators can also implement anxiety prevention programs of their own. A recent study showed the effectiveness of a short daily intervention performed by a teacher in the classroom. It found that children who practiced a stress-management intervention 10 minutes a day under the guidance of a teacher had a significant drop in anxiety scores, and significant increases in their ability to relax. These effects continued after one year, even when the children were no longer receiving the intervention in the classroom. This indicates that the school can be an effective setting to teach children a positive coping mechanism to help them with daily stressors.²²

There is also evidence to suggest that building resilience in a child or adolescent is an effective tool for the prevention of anxiety and its disorders. Resilience is the ability to deal with adversity without becoming overwhelmed by it. When youth become overwhelmed by stressors they face, they often develop anxious or depressed thoughts and behavior patterns. These feelings of powerlessness or loss of control can be prevented or changed if the youth develops resilience. There are various aspects of a child's life that can promote resilience. A child who has good social supports from his/her family and community, encouragement in developing inner strengths, such as self esteem and confidence, and development of interpersonal and problem-solving skills is likely to grow up having strong resilience.

A pediatrician's role

While all children are exposed to stressors, the prevention and early diagnosis of anxiety can help children as they manage stress throughout their lives. Pediatricians have an opportunity to screen when needed and refer children for the appropriate management of anxiety disorders. The pediatric office is also an ideal setting for instructing parents and children about the importance of managing their stress. If taught early, children can learn coping skills to help them for a lifetime.

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References

1. Bright Futures' Pediatric Symptom Checklist. Available at: www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf. Accessed May 21, 2007

2. Achenbach, TM: The Child Behavior Checklist (CBCL) Copyright 2001, ASEBA, Burlington, University of Vermont, Department of Psychiatry

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8. March JS, Parker JD, Sullivan K, et al: The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry 1997;36:554

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14. Menkes MS, Matthews KA, Krantz DS, et al: Cardiovascular reactivity to the cold pressor test as a predictor of hypertension. Hypertension 1989;14:524

15. Gerin W, et al: Sustained blood pressure increase after an acute stressor: The effects of the 11 September 2001 attack on the New York City World Trade Center. Hypertens 2005;23:279

16. Tarullo AR, Gunnar MR: Child maltreatment and the developing HPA axis. Horm Behav 2006;50:632

17. Sapolsky R, Romero L, Munck A: How do glucocorticoids influence stress responses? Integrating permissive, stimulatory, and preparative actions. Endocr Rev 2000;21:55

18. Barrett PM, Duffy AL, Dadds MR, et al: Cognitive-behavioral treatment of anxiety disorders in children: Long-term (six year) follow-up. J Consult and Clin Psych 2001;69:135

19. Clark DB, et al: Fluoxetine for the treatment of childhood anxiety disorders: Open-label, long-term extension to a controlled trial. J Am Acad Child Adolesc Psychiatry 2005;44:1263

20. Walkup J, et al: Treatment of pediatric anxiety disorders: An open-label extension of the research units on pediatric psychopharmacology anxiety study. J Child Adolesc Psychopharmacol 2002;12:175

21. Allen JS, Klein RJ: Ready... Set... R.E.L.A.X.: A Research-Based Program of Relaxation, Learning and Self-Esteem for Children. Publisher Inner Coaching, 1996

22. Bothe D, Olness K: Effects of a Stress Management Intervention on Elementary School Children, presented at the Society for Developmental and Behavioral Pediatrics National Meeting, September 17, 2006