Normal vs. abnormal anxiety
Anxiety is a natural emotion that can serve a
protective function and heighten performance when present in mild to moderate
levels. Anxiety becomes a problem when it causes persistent distress in the
child's daily life or in family functioning. For example, when the child's
functioning is impaired significantly in the areas of academic performance, peer
and family relations, enjoyment of age-appropriate activities, and the will to
live, the child should be referred for treatment with a mental health
professional.
Familiarity with developmentally appropriate
anxiety can help physicians determine whether a child's or adolescent's fears
are out of the ordinary. Table 1 outlines the fears typically seen in children
of various ages. As long as these fears are not disrupting developmentally
appropriate activities, they would not meet criteria for an anxiety
disorder.
Cultural and social concerns should also be
considered when determining the clinical significance of anxiety symptoms. If
the worries or fears are excessive and out of proportion relative to the
situation, a referral for psychological follow-up should be considered. However,
children with reality-based fears that have a minimal impact on functioning
should not be diagnosed with an anxiety disorder. For example, if one encounters
a child of Middle-Eastern descent who has concerns that he may be mistaken for a
terrorist, the physician should be sensitive to the realities of discrimination
and the life experience of this child living in the US at a time of US military engagement in the Middle East. Likewise, a common concern for urban youth is
the safety of their parents traveling in a neighborhood overridden by gang
violence. As long as these concerns are not causing a significant decline in the
child's academic performance, social relationships, family interaction, or
another area of functioning, these presentations would not warrant the diagnosis
of an anxiety disorder.
Unique presentation of anxiety in children
In order to understand how anxiety presents in
children, one must understand the role of avoidance in the development and
sustenance of anxiety. Anxiety reactions include cognitive components (eg,
catastrophic thoughts), physical components (eg, rapid heart beat, shortness of
breath, nausea), emotional components (eg, fear, worry), and behavioral
components (eg, avoidance and escape). The behavioral responses provide
short-term relief from what the individual perceives as intolerable distress
and/or disastrous outcomes. As long as the avoidance/escape response is
practiced, the individual never has the opportunity to learn that the dreaded
outcomes are unlikely or actually harmless. In other words, the avoidance of the
feared stimuli serves to perpetuate the anxiety.
The desire to avoid or escape anxiety-evoking
situations is quite intense and can result in extreme behaviors. Children often
get increased attention from adults for externalizing problems, such as
oppositional, inattentive, angry, aggressive, and disobedient behavior. This
behavior is not well tolerated by teachers and parents and, therefore, more
often receives intervention at an earlier point compared to internalizing
symptoms. However, the fact that anxiety can masquerade in children as an
externalizing disorder with many of the same symptoms often is overlooked. A
child's temper tantrum and defiant behavior may be a manifestation of an
overwhelming desire to avoid an anxiety-provoking situation at all costs.
Inattention and forgetfulness can be attributed to the mental preoccupation and
rumination common to many anxiety disorders. Furthermore, explosive and
aggressive behavior may be explained by triggers (undetected by adults) that
evoke re-experiencing symptoms (ie, flashbacks) in traumatized
children.
Another consideration for detecting anxiety in
young children is the level of verbal and cognitive development. Many children
lack the verbal abilities and insight to be able to describe their internal
state. Instead, anxiety may be manifested through somatic symptoms, including
muscle aches, stomachaches/nausea, headaches, and sleep disturbance. Table 2
describes the most common anxiety disorders in children and the associated
symptoms that might be presented in pediatric and primary care
settings.
Adequate screening during primary care visits will
assist in early detection and intervention. Whenever possible, data should be
obtained from the child, parent, and teacher regarding the child's anxiety.
Children may be more aware of internal distress than parents and teachers and
may be able to shed light on the causes of externalizing problems (eg, attempts
to avoid particular anxiety evoking situations). Use of self-report instruments
for children age 8 years and over, such as the Multidimensional Anxiety Scale
for Children (MASC)[1] or Screen for Child Anxiety Related Emotional Disorders
(SCARED; available online)[2] can assist with screening and monitoring of
treatment response for generalized, social, and separation anxiety, as well as
panic symptoms and school refusal. The UCLA PTSD Index for DSM-IV (available
free of charge with author's permission)[3] assesses post-traumatic symptoms in
children 7 years of age and older.
Medication vs. psychotherapy
Options for evidence-based treatments for child
anxiety include psychotherapy, psychopharmacological intervention, and a
combination of these modalities. The referring physician should also be familiar
with the current practice parameters for the treatment of childhood anxiety from
the American
Academy of Child and
Adolescent Psychiatry4 in order to make informed recommendations to parents.
These parameters indicate that the first line of treatment for mild to moderate
anxiety should be psychotherapy. Moderate to severe anxiety may warrant
combining medication and psychotherapy from the start because these children
often have difficulty even attending therapy or discussing their fears without
the help of medication. Medication is not considered a cure for a child's
anxiety, but rather a tool to reduce severe anxiety symptoms and often to
facilitate engagement in psychotherapy.
Cognitive-behavioral therapy
Cognitive-behavioral therapy (CBT) has emerged as
the psychotherapeutic approach to child anxiety with the most empirical support.
CBT typically involves psycho-education about anxiety, development of coping
skills (relaxation, problem-solving, cognitive restructuring), and practice
exercises involving gradual desensitization to anxiety-provoking
stimuli/situations. It is a short-term, goal-oriented treatment that often is
designed to be completed in 12–18 sessions. This therapy requires special
training and has components particular to specific anxiety disorders. Many
community mental health providers do not specialize in the delivery of CBT, but
rather psychodynamic play therapy or interpersonal/supportive therapy. The
challenge for the referring pediatrician is ensuring that one is referring to a
psychotherapist trained in CBT. This can be facilitated by accessing the
Association for Behavioral and Cognitive Therapies Web site
(http://www.aabt.org) and searching for a therapist.
Specifically, the exposure module is considered
the most potent ingredient of CBT. Exposure promotes the competing response to
avoidance: facing one's fears in a controlled manner. At the beginning of
treatment, the therapist works with the child and parent to construct a fear
hierarchy. The child then exposes him/herself gradually to anxiety-evoking
stimuli with the goal of habituation. Repeated exposures to feared situations
afford the child in vivo learning experiences, which demonstrate that
catastrophic consequences do not occur and that the child's anxiety is
manageable. These exercises also need to be practiced often and for extended
periods outside of therapy sessions in order to generalize treatment
benefits.
Specific phobias, social anxiety, separation
anxiety, and generalized anxiety:
Exposure exercises for these common forms of
anxiety break down frightening situations into manageable steps and allow the
child to do them 1 at a time until mastery is achieved. Steps may include
imaginal exposures, modeling by the therapist, tag-along procedures in which the
child is accompanied through the process by the therapist, and, ultimately,
increasingly independent attempts at facing fears.
Panic disorder: Interoceptive exposure is a
technique used specifically to expose the child to the physical sensations
common during panic attacks. During an exposure session, children perform
exercises that will cause them to experience rapid heart rate, dizziness, and
shortness of breath in a controlled setting so as to provide them with
opportunities to experience that these symptoms do not necessarily precipitate a
panic attack.
Obsessive-compulsive disorder (OCD): The exposure
component for OCD also includes a response-prevention component. Not only is the
child exposed imaginally and in vivo to frightening thoughts and
situations, but s/he also is prevented from making the compulsive response that
serves as an avoidance/escape strategy.
Post-traumatic stress disorder (PTSD):
Trauma-focused cognitive behavioral therapy, likewise, includes an exposure
component. In therapy, the child is asked to create a trauma narrative through
discussion, writing, and art detailing the traumatic events with feelings and
thoughts at the time of the events. Through repeated review of the trauma
narrative, the child gradually becomes habituated to the once highly distressing
narrative. After the trauma narrative is complete, cognitive restructuring
(correction of illogical or false ideas about what happened) and meaning making
can take place to help the child make sense of the event and to move forward in
a healthy way.
CBT can be delivered in individual, family, and
group formats. Treatment of PTSD is usually an individualized treatment. In
general, there is an inverse relationship between parent involvement and age of
the child in therapy (the younger the child, the more the parent is involved).
Parents often serve as coaches for conducting exposure practice exercises at
home. Group formats are particularly useful for children with social anxiety
because the group itself will provide an exposure exercise for the attendees in
addition to the other benefits, such as modeling, vicarious learning,
constructive feedback, and peer support. CBT groups are also available for other
types of anxiety disorders.
Conclusion
Anxiety disorders are some of the most frequently
occurring psychological problems in children. Pediatricians who are informed and
able to reliably identify clinical levels of anxiety in children, as well as the
best treatment practices, are invaluable in guiding families to appropriate
mental health professionals. Early intervention is essential in helping children
manage their anxiety so it does not adversely impact their educational
achievement, social lives, and family functioning during formative developmental
stages.
REFERENCES
[1.] 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;36:554-565.
[2.] Birmaher
B, Brent DA, Chiappetta L, et al. Psychometric properties of the Screen for
Child Anxiety Related Emotional Disorders Scale (SCARED): A replication study. J
Am Acad Child Adolesc Psychiatry
1999;38:1230-1236.
[3.] Steinberg
AM, Brymer MJ, Decker KB, Pynoos RS. The University of California at Los Angeles Post-Traumatic Stress Disorder
Reaction Index. Current Psychiatry Reports
2004;6:96-100.
[4.] Connolly
SD, Bernstein GA, et al. Practice parameter for the
assessment and treatment of children and adolescents with anxiety disorders.
Journal of the American Academy of Child and Adolescent Psychiatry
2007;46(2):267-283. |  |
