Anxiety disorders in primary care

Table 1

Table 2

Table 3

Table 4

Additional nonpharmaceutical interventions for anxiety

Anxiety disorders are the most prevalent psychiatric condition in children and adolescents, affecting between 15% to 20% of youth.¹ Some data estimate an even higher prevalence, up to 31% in young persons aged 13 to 18 years.²

Recently reported data also highlight the steady rise in anxiety disorders in adolescents, showing an increased prevalence of 20% between 2007 and 2012.³ A further recent report highlighted that up to 30% will develop an anxiety disorder in their lifetime.⁴

The impact of these types of disorders in the young cannot be understated. Children and adolescents who struggle with an anxiety disorder face difficulties with academic, social, and family functioning, and are at increased risk for other mental health issues such as depression, substance abuse, and suicide.^1,2

Despite the high prevalence and associated negative impacts, pediatric anxiety disorders can go unrecognized as it can be difficult for parents and clinicians to differentiate an anxiety disorder from anxiety a child experiences as part of growing, developing, and adapting to new situations and experiences. Whereas this latter type of anxiety is characterized by transient fears as part of normal development, anxiety disorders are characterized by their persistence and the extensive distress and functional impairment they cause. In addition, a child with an anxiety disorder will typically respond with a disproportionate amount of fear to a threat that reason cannot allay.²

Early diagnosis and treatment of pediatric anxiety disorders are critical to both minimize the negative impacts on the child’s life as well as to lessen the negative impacts that can impair a child long into adulthood if left untreated. Data suggest that although the onset of anxiety disorders usually begins in childhood, these disorders typically are chronic and persistent and can evolve into a pattern of multiple anxiety disorders (ie, depressive or substance use disorders) into early adulthood.¹ Primary care clinicians play a key role in identifying and treating anxiety disorders in children and helping them to learn effective coping skills. This article summarizes some of the current data on screening, diagnosis, and treatment of pediatric anxiety disorders.

Clinical presentation and diagnosis

Differentiating an anxiety disorder from developmentally appropriate anxiety or other conditions that may mimic an anxiety disorder is challenging. To help make the differential diagnosis, recognizing the risk factors is important as well as knowing a number of hallmark features that present in adolescents with anxiety disorders (Tables 1 and 2). In addition, clinicians should be aware that children and parents/caregivers may describe anxiety-related symptoms in terms that misinterpret anxiety for something else (eg, parents may describe their child as sensitive, picky, or shy, or attribute symptoms of irritability, crying, or tantrums as signs of disobedience or oppositional behavior, while children may use words such as angry, upset, tense, or uncomfortable to describe their anxiety).²

A particular challenge is differentiating an anxiety-related disorder from other childhood problems, such as major depressive disorder, bipolar disorder, oppositional mood dysregulation disorder, and attention-deficit/hyperactivity disorder (ADHD)-all of which can share similar symptoms of inattention, difficulty sleeping and eating, behavioral outbursts, social difficulties, and restlessness.² Unlike these other childhood problems that are more pervasive across situations, one key distinguishing feature of an anxiety disorder is that it involves avoidance and distress that is more situational and triggered by a perceived threat. Identifying the source of the threat and the feared stimuli can help clinicians determine the type of anxiety disorder.² (See Table 3 for types of anxiety disorders).

Once the clinical presentation suggests a child may have anxiety, a number of standardized tests are available to assess the type and severity. Table 4 lists screening tools for both parents and children that are easy and quick to complete.

In 2015, the American Academy of Pediatrics (AAP) published guidance for pediatricians on how to implement behavioral and emotional screening in clinical practice. Among the key points highlighted is the need to establish office routines for screening in which children are screened for behavioral and emotional problems at regular intervals, similar to developmental screening. Such screening should be done with standardized measures beginning in infancy through adolescence.⁵

Treatment

Appropriate early treatment of anxiety disorders is crucial to prevent or reduce the negative impacts on children’s lives, as well as to reduce the long-term potential adverse effects into adulthood. Both nonpharmaceutical and pharmaceutical approaches are indicated.

The goal of all treatment approaches is to reduce symptoms of anxiety and increase a child’s ability to cope with his/her anxiety without avoiding the feared object or situation.² For children with milder forms of anxiety disorder, this goal may be accomplished by using nonpharmaceutical approaches such as cognitive behavioral therapy (CBT) and mindfulness-based therapies.¹ Cognitive behavioral therapy is one of the most commonly used approaches and has shown efficacy for patients with several types of anxiety disorders.^1,2,6,7 Key components of CBT include education of both the child and parents about the nature of anxiety; techniques for managing physical symptoms such as relaxation training and diaphragmatic breathing; reframing anxiety-provoking thoughts; as well as systematic exposure to feared stimuli or situations.¹ (See “Additional nonpharmaceutical interventions for anxiety.”⁸)

For a child with significant anxiety, the addition of a pharmacologic agent to CBT has been shown to be effective. Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment for pediatric anxiety.^1,2,6,7 Other agents used include serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants, but these are usually reserved as second- or third-line therapies because of more adverse effects.⁷ The use and efficacy of these agents to treat anxiety in children is based on a better understanding of the neurobiology of pediatric anxiety gained through imaging studies of children with anxiety disorders that show dysfunction in areas of the brain involved in the regulation of fear and emotion.¹

As with any medication, using an SSRI to treat anxiety in a child needs to be balanced against the risks. Adverse effects can include headache, gastrointestinal symptoms, and sleep disturbance.^6,7 Children on SSRIs need to be closely monitored to assess improvements in anxiety as well as adverse effects. It is also suggested that children be assessed for suicidal ideation at each follow-up given the black box warning on many antidepressants of an increased risk of suicide.⁷

References:

1. Wehry AM, Beesdo-Baum K, Hennelly MM, Connolly SD, Strawn JR. Assessment and treatment of anxiety disorders in children and adolescents. Curr Psychiatry Rep. 2015;17(7):591.

2. Chiu A, Falk A, Walkup JT. Anxiety disorders among children and adolescents. Focus. 2016;14:26-33.

3. McCarthy C. Anxiety in teens is rising: What’s going on? Healthychildren.org. Available at: https://www.healthychildren.org/English/health-issues/conditions/emotional-problems/Pages/Anxiety-Disorders.aspx. Published April 30, 2019. Accessed September 4, 2019.

4. Weitzman CC, Bridgemohan C. Up to 30% of youths will develop anxiety disorders; how you can help. AAP News. Available at: https://www.aappublications.org/news/2019/01/15/anxiety011519. Published January 15, 2019. Accessed September 4, 2019.

5. Weitzman C, Wegner L; Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial Aspects of Child and Family Health; Council on Early Childhood; Society for Developmental and Behavioral Pediatrics; American Academy of Pediatrics. Promoting optimal development: screening for behavioral and emotional problems. Pediatrics. 2015;135(2):384-395.

6. Panganiban M, Yeow M, Zugibe K, Geisler SL. Recognizing, diagnosing, and treating pediatric generalized anxiety disorder. JAAPA. 2019;32(2):17-21.

7. Fernandez S. Anxiety disorders in childhood and adolescence: a primary care approach. Pediatr Ann, 2017;46(6):e213-e216.

8. Neal P. Pediatric anxiety disorder: When to worry about the “worrier.” Presented at: 40th National Conference on Pediatric Health Care; March 7-10. 2019; New Orleans, LA. Available at:

. Accessed September 4, 2019.