Childhood Anxiety Disorders for the Pediatrician

1. Childhood Anxiety Disorders for the Pediatrician Mary Gabriel, MD FAAP Children’s National Medical Center Division of Psychiatry and Behavioral Sciences March 24, 2016

2. Objectives • Identify normal vs. pathological worry and fear • Understand the development of anxiety, including risk factors and protective elements • List different anxiety disorders and how they present in children vs. adults • Understand different treatment modalities and appropriately refer

3. What is worry? • Anxious apprehension and thoughts focused on the possibility of negative future events What is fear? • Response to threat or danger that is perceived as actual or impending.

4. Fear and worry are common in normal children Developmentally appropriate vs. significantly impaired functioning Fears during childhood = normal developmental transition

5. Normal fears and worries Infants: fear of loud noises, being startled or dropped, and strangers (later in infancy) Toddlers: fear of imaginary creatures (monsters), darkness, normative separation anxiety School-aged: fears about injury and natural events Older children and adolescents: worries about school performance, social competence, health issues

6. Erikson’s psychosocial development

8. Clinical Presentation • Crying, irritability, angry outbursts • Misunderstood as oppositionality or disobedience • Actually represent the child’s expression of fear or effort to avoid the anxiety-provoking stimulus at any cost • Somatic complaints • Headache • Stomachache • May not recognize their fears as unreasonable

9. Epidemiology Prevalence rates: 6-20% Strict adherence to diagnostic criteria Consideration of functional impairment Slightly higher in girls, but this is more in specific phobia, panic disorder, agoraphobia, and separation anxiety Panic disorder often emerges later in mid-teen years

10. Risk Factors • Biological: • Genetic • Temperament • Autonomic reactivity (cortisol dysregulation, irregular sleep patterns, GI reactivity) • Anxiety sensitivity • Environmental • Attachment styles • Parenting behaviors • Peer/social problems • Negative/stressful life events

11. Long term Pine, et al, 1998 Children may develop new anxiety disorders over time Higher risk of developing depression and substance abuse disorders as well The more severe the disorder and the greater the impairment, the more likely it is to persist

12. Sequelae • Disruption of normal psychosocial development of the child: • Social: poor self-esteem, underestimate their competencies • Family • Academic

13. Anxiety Disorders in DSM5 • GAD • Separation Anxiety Disorder • Social Anxiety Disorder • Specific Phobia • Panic Disorder • Agoraphobia • Selective Mutism • SIAD/Due to MC/Other/Unspecified

14. Trauma- and Stressor-Related Disorders • PTSD– including PTSD for Children 6 Years and Younger • RAD • Disinhibited Social Engagement Disorder • Adjustment Disorder • Acute Stress Disorder • Other/Unspecifed

15. Case #1 • CC: CW is a 10yo male with h/o ADHD who returns to clinic to reestablish care and address anxiety sx. • Dad reports CW seeks constant reassurance from parents. • Pt is very rigid and does not tolerate change or transitions well at all, "blow's up" when routine changes. • Difficulty letting go of things-- will hold onto past events/experiences, especially focused on the negative aspects. Pt has a tendency to generalize his anxieties after a while • Pt also worries about taking pills, especially on an empty stomach, and has been cheeking his sertraline for the last few months, which father discovered • Socially, anxiety interferes with pt making friends. Pt used to have much difficulty relating to peers due to his focus of conversation being "whatever was in his head, rather than following what the group was discussing. • Medically, anxiety interferes with eating and at times with defecation • Pt will hit himself repeatedly in the chest when degree of anxiety is severe. Pt will also squeeze his bunny when he is very anxious. • On interview, pt states that he is perfectionistic, gets distracted if things aren't the way he thinks they should be. He admits he will correct his younger sister who is "bossy." Nauseated when anxious, +muscle tension. Describes his feelings: 25% anxious, 25% happy, 25% neutral, 12/5% angry, 12.5% sad (Dad's observations of pt's feelings: 30% sad, 45% anxious, 25% happy, 12.5% angry).

17. Generalized Anxiety Disorder • Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). • The individual finds it difficult to control the worry. • The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): • Note: Only one item is required in children. • Restlessness or feeling keyed up or on edge. • Being easily fatigued. • Difficulty concentrating or mind going blank. • Irritability. • Muscle tension. • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). • The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). • The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

18. GAD: Clinical symptoms • Excessive, unrealistic fears about day-to-day activities • "What if" concerns that span far into the future • Uncontrollable worry about multiple situations, performance, social, academic, health, financial • Physical symptoms: headaches, stomachaches, inability to unwind • Difficulty concentrating, always thinking what's next • Low risk-taking; Need for reassurance and approval for small steps • Perfectionism, great fear of making mistakes, fear of criticism; unrealistic unfavorable assessment of their grades, abilities • Over-responsibility, feels that tragedies are preventable by worry, and if disaster happens that it's their fault • Any negative piece of news that happens to others, fears will happen to them; everything is contagious by association: divorce, illness, car accidents, food poisoning • Reviewing events to make sure that didn't hurt anyone's feelings or do anything wrong • Sleep difficulties, irritability, fatigue WorryWiseKids.org

19. GAD in children • Content of anxiety: • quality of performance or competence at school or sports • Catastrophic events • Perfectionistic, overly conforming • Overzealous in seeking reassurance and approval • Look for childhood adversities and parental behaviors

20. GAD: Diagnosis • Interview • Collateral • Beware: an anxious child’s desire to please adults and concerns about peformance may affect the child’s self-report • Consider TFT’s • Document somatic sx before starting meds to reduce mistaking them for medication SE’s after initiation of meds.

21. GAD: diagnostic scales • MASC (Multidimensional Anxiety Scale for Children) • SCARED (Screen for Child Anxiety Related Emotional Disorders) • GAD 7 • Severity Measure for Generalized Anxiety Disorder—Child Age 11–17 • ADIS-IV-C (Anxiety Disorders Interview Schedule for DSM-IV: Child Version) Child and Parent Interview Schedules • Family assessment

23. GAD: Treatment • CBT • Facilitates modification of negative thought patterns that lead to emotional distress– Cognitive restructuring • Facilitates development of emotional regulation to modulate excessive arousal • Shaping and strengthening adaptive behavior patterns– Problem solving • Relaxation techniques • May include parent training component and psychoeducation • Pharmacotherapy • SSRIs, venlafaxine* • Parent-Child and Family Interventions

24. GAD: Help for kids and caregivers

25. SSRIs: the skinny • Fluoxetine* • 5-80mg daily • Can be activating • Long half-life  no tapering needed • Sertraline • 12.5-200mg daily • Divide BID for patients under 14yo • Citalopram • 5-40mg daily • Can be sedating  HS dosing if needed • QTc prolongation • Escitalopram* • 2.5-20mg daily • Fewer side effects theoretically, but same as citalopram Drug Counseling Side effects: HA, abdominal pain, activation Serotonin syndrome *FDA approved in children

26. SSRIs: what NOT to do • NO Paroxetine • Very short half-life withdrawal symptoms • Serotonin syndrome • dextromethorphan • SNRIs: trazodone (!), SSRIs, TCAs, MAOIs, St. John’s Wort, lithium, SGAs • Tramadol • Triptans • linezolid • Withdrawal syndrome Agitation or restlessness Confusion Rapid heart rate and high blood pressure Dilated pupils Loss of muscle coordination or twitching muscles Muscle rigidity Heavy sweating Diarrhea Headache Shivering Goose bumps ---------------------- High fever Seizures Irregular heartbeat Unconsciousness

27. SSRI Withdrawal Syndrome F I N I S H

28. Case #2 CC: “She is always up my ass.” 6yo JE is brought in by her mother due to tantrums and not being able to do anything by herself. She incessantly asks about mom, needing reassurance constantly, and refuses to go anywhere or do anything without mom. She “freaks out” when mom is late from work or separated from her: crying, hyperventilating, and refusing to go to sleep until mom returns from work at 9:30-11:30 PM. JE follows mom around the house, even into the bathroom, and will wait outside on the sidewalk with her blanket until mom returns home from work that night, regardless of the weather, including in snow and rain. She refuses to go to school regularly and will “clock-watch.”

30. Separation Anxiety Disorder • Excessive anxiety or worry about being separated from attachment figures or home something bad will happen to them or caregiver that results in permanent separation • Developmentally inappropriate • Causing significant disturbance in important areas of functioning • At least 4 weeks of symptoms in children • Early onset is onset > 6 yo • **School refusal is the most common behavior and occurs 75% of the time**

31. Separation Anxiety Disorder: Diagnostic Criteria Three (or more) of the following: • recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated • persistent and excessive worry about losing, or about possible harm befalling, major attachment figures • persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped) • persistent reluctance or refusal to go to school or elsewhere because of fear of separation • persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings • persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home • repeated nightmares involving the theme of separation • repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

32. Separation Anxiety Disorder: What does it look like? • Crying or hiding from parents • Shadowing parents and refuse to go anywhere without them • Nightmares of being kidnapped or taken away • Somatic sx • See risk factors for GAD, especially insecure attachment

33. Separation Anxiety Disorder: Outcomes • Longitudinal studies: some pt’s have resolution of sx, some don’t • Predictors of persistence of sx: • Comorbid ODD, ADHD • Maternal marital dissatisfaction • Starting with SAD makes you more likely to have anxiety d/o as an adult

34. Separation Anxiety Disorder: Treatment • Parent training • Particularly helpful with younger children • Focus on teaching strategies to help manage anxiety, and identify and shape adaptive coping skills • CBT • Facilitates modification of negative thought patterns that lead to emotional distress • Facilitates development of emotional regulation to modulate excessive arousal • Shaping and strengthening adaptive behavior patterns • May include parent training component and psychoeducation • Pharmacotherapy • SSRIs

35. Case #3 • A.P is a 14yo female with history of anxiety who is referred by her PCP for worsening school anxiety. Mom reports A.P. used to be “friendly,” has always been shy but able to make and keep friends. Now she avoids being around any peers at all, even family and cousins. She states people don't like her and don't care about her. • She attends a girls group for group therapy in Winchester-- sometimes cannot even get out of car to go into building and attend. Pt then beats herself up after group for not being able to talk or speak like the other girls. • Pt avoids going to school-- thinks everyone is against her and hates her. Level of functioning has decreased significantly since end of 2013: prefers not to got out, and is now in homebound schooling. • Pt worries about what others think, afraid of “getting it wrong,” very sensitive and takes things very personally. • On interview, she wants to be able to go to school and "be normal, and do things" such as have friends, go out and socialize, and feel happier. • On exam A.P. is reluctant and reticent but cooperative, hasintermittent-poor eye contact, withdrawn and guarded. Affect is constricted, tearful, severely anxious

37. Social Anxiety Disorder– DSM5-Style • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. • (Note: In children, the anxiety must occur in peer settings and not just during interactions with adults) • The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated • The social situations almost always provoke fear or anxiety. • Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. • The social situations are avoided or endured with intense fear or anxiety. • The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

40. Social Anxiety Disorder: Development and Course • Median age of onset: 13yo • Sometimes emerges out of a history of shyness • Onset may follow a stressful or humiliating experience or insidious and slow • First onset in adulthood is rare • Younger patients = high levels of anxiety over specific situations • Older patients = lower levels of anxiety over broader range of situations • Remission: 30% remit in 1 yr, 50% in a few years, 60%-- without treatment– takes several years or longer

41. Separation Anxiety Disorder: Treatment • Therapy: • CBT • psychodynamic • graduated exposure therapy • Pharmacological: • SSRI’s • hydroxyzine

42. Case #4 CC: “My bad behavior” V.L. is a 9 yo adopted female who was referred in by her therapist for ongoing out of control behavior. Pt was adopted at 3½ yo and has always been defiant, manipulative, physically aggressive with significant tantrums, and impulsive. She is alternately overly-affectionate and untrusting of her parents– cheating, stealing (esp food), lying. Past history is significant for severe neglect, “deplorable living conditions,” removal from home at 2yo, placement with 4 foster families within 18mos, and finally placement with current family.

43. Reactive Attachment Disorder (DSM 5) A. Inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: • The child rarely or minimally seeks comfort when distressed. • The child rarely or minimally responds to comfort when distressed. B. A persistent social and emotional disturbance characterized by at least two of the following: • Minimal social and emotional responsiveness to others. • Limited positive affect. • Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.

44. RAD: Pathogenic Care • Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. • Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). • Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).

45. Disinhibited Social Engagement Disorder 1. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: • Reduced or absent reticence in approaching and interacting with unfamiliar adults. • Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). • Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. • Willingness to go off with an unfamiliar adult with minimal or no hesitation. ****not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behavior. **** 2. Pathogenic care is the same as RAD.

46. Conclusions • Not all worry and fears are pathological. Many are developmentally appropriate and reflect typically developing children • While some risk factors are innate, many are not, and targeting these environmental influences can affect the trajectory of anxiety • Specific anxiety disorders can morph into each other, making complete resolution difficult but possible. • Therapy is the mainstay of anxiety treatment. Medications can enhance the process.

47. Fine

48. Case #3 CC: Mood swings 16 yo AB was referred from pediatric neurology following multiple ED visits for nonepilepticsz, which began 1 yr ago. Pt admits that 1 yr ago, she disclosed to her friend that her older brother had sexually abused repeatedly at age 6yo. Friend told the VP, who told pt’s uncle-guardian, after which pt began “acting out”: defiant, outbursts, breaking rules; alternating with quiet and withdrawn. Pt admits to having nightmares every night and was admitted for SI 3 mos ago. Pt also reports that she sees the abuse happening in her mind and feels numb. She sleeps in the same room the abuse occurred and feels terrified in her room. PGM-guardian reports that pt subsequently started therapy and, during one of these therapy sessions, pt had an episode in which she seemed to suddenly behave differently, “like a completely different persona,” for 10 minutes, followed by abrupt fatigue and amnesia of the episode.

49. Post Traumatic Stress Disorder • T rauma • R e-experiencing • A voidance • U nable to function • M onth • A rousal

50. PTSD: Risk factors in children • Girls > boys • Poorer performance on neurocognitive tests prior to trauma = ↑ vulnerability to developing PTSD • Emotional problems before 6yo • Childhood adversity • Lots of comorbidities: MDD, anxiety, ADHD, ODD, CD, substance use • ***Social support is protective***