Practice Parameter Provides Guidance on Childhood Anxiety

A new set of guidelines confirms the value of psychotherapy, medications-including SSRIs-and combinations of therapy in managing anxiety disorders in children. The revised practice parameter on anxiety disorders from the American Academy of Child and Adolescent Psychiatry, published recently in the academy's journal, covers most of the anxiety disorders, such as phobias, separation anxiety disorder (SAD), generalized anxiety disorder (GAD), and panic disorder (PD), but not posttraumatic stress disorder (PTSD) or obsessive-compulsive disorder, for which practice parameters already exist.¹

Developers of the parameter are psychiatrists Sucheta D. Connolly, MD, director of the Pediatric Stress and Anxiety Disorders Clinic at the University of Chicago, and Gail Bernstein, MD, director of the Child/Adolescent Anxiety Mood Disorders Clinic at the University of Minnesota. The academy's Work Group on Quality Issues aided them.

"We have many more studies confirming that cognitive-behavioral therapy [CBT] can be very effective for children and adolescents who have anxiety disorders . . . and there are more placebo-controlled studies with [SSRIs] that show they can really help children with anxiety disorders," Connolly told Psychiatric Times.

Because of the high prevalence of anxiety disorders in children and adolescents, ranging from 6% to 20%, the parameter also recommends routine screening for anxiety symptoms during the initial mental health assessment.

In emphasizing the importance of early diagnosis and effective treatment to help mitigate the impact of anxiety on academic and social functioning, the report noted that "anxiety disorders represent one of the most common forms of psychopathology among children and adolescents, but they often go undetected or untreated." Effective treatment may also reduce the persistence of anxiety disorders into adulthood, the report said.

Normal versus abnormal

Fears that arise during childhood represent a normal developmental transition and may begin in response to perceived dangers, Connolly explained, but they become problematic if they do not subside with time and if they impair the child's functioning.

Some guidance on what are normal fears and worries in various age groups is provided in the parameter, Connolly noted. For example, school-aged children may fear injury or natural events, such as storms, whereas older children and adolescents may worry instead about school performance, health, and sociability issues.

When an anxiety disorder is suspected, clinicians need to obtain information about anxiety symptoms from both the child and parents/teachers and to look for somatic symptoms, such as headaches or stomachaches, which may be indicators of anxiety disorders, she said. A screening tool that Connolly uses at her clinic and in school settings is the Multidimensional Anxiety Scale for Children.²

"It is something the child or adolescent completes, so usually the child needs to be able to read and understand," Connolly said. "It is [normalized] for 8 year olds and older, but we have used it in younger children, where we will read the questions to them."

Another self-report tool Connolly mentioned is the Screen for Child Anxiety Related Emotional Disorders.³ If the screening test indicates the presence of significant anxiety, then the clinician needs to conduct a formal evaluation to determine which anxiety disorder is present, as well as the severity and the degree of functional impairment, Connolly explained. "In some children, we may not be able to identify that they have all the symptoms of one specific anxiety disorder, but when we look at how it is impacting their ability to function academically or with peers, it may be quite impairing and require treatment," she said.

To identify and differentiate a specific anxiety disorder, Connolly uses the Anxiety Disorders Interview Schedule for DSM-IV: Child Version (ADIS-C).⁴ It gives the clinician symptoms that apply to children and adolescents, puts situations and anxieties into their language, provides ways to identify symptom severity, and includes a "feelings thermometer" to help children quantify and self-monitor levels of fear and interference with functioning, she said. Connolly added that clinicians can use sections of the ADIS-C to supplement their clinical interview. For the diagnostic interview of very young children, child psychiatrists may use play narrative assessment along with pictures, cartoons, and puppets.

The psychiatric assessment, according to the parameter, should consider differential diagnosis of other physical conditions and psychiatric disorders that may mimic anxiety symptoms, such as attention-deficit/hyperactivity disorder (ADHD) and possible adverse effects from caffeinated beverages and cold medicines. Comorbidity also needs to be carefully evaluated and considered in treatment planning, Connolly said.

The parameter stresses that children often have multiple anxiety disorders and that anxiety disorders commonly co-occur with ADHD, depression, and substance abuse. In Connolly's work with anxious children in an urban medical center, she has also observed comorbid developmental problems, such as Asperger syndrome and comorbid PTSD. She urged clinicians to particularly ask about trauma in the child's life.

Clinical studies have shown that as many as one third of the children with ADHD have co-occurring anxiety disorders.⁵ At her clinic, Connolly said she commonly sees depression with anxiety, but she is also finding bipolar disorder (BD) in a subset of anxious children. Once they reach adolescence, Connolly added, children with anxiety disorders are at greater risk for comorbid alcohol abuse or depression.

Multimodal treatment

A multimodal treatment approach for anxiety disorders, the parameter states, should consider education of the parents and the child about anxiety disorder, consultation with school personnel and primary care physicians, CBT, psychodynamic psychotherapy, family therapy, and pharmacotherapy.

The parameter notes that among the psychotherapies, exposure-based CBT has the most empirical support for treatment of children with anxiety disorders. Connolly said, "Often we start with [CBT] . . . to see if that alone can be effective. We add medications if we think that the child's anxiety is so severe that he or she may or may not be able to participate in CBT, such as where CBT exposures may make the child feel overwhelmed." She added that, despite the research support, CBT is not yet widely available throughout the United States for children who do have anxiety disorders.

Consequently, the parameter discusses the main components of CBT for anxiety: psychoeducation about the illness and CBT, somatic management skills, cognitive restructuring, exposure methods, and relapse prevention. It also suggests some components of CBT that may be considered when a full program is not available, including educational support, psychoeducation based on CBT principles, parent training, and case management support that includes contact with the school.

The most widely used and best researched manual-based CBT protocol for youths with SAD, GAD, or social phobia is the Coping Cat program,⁶ Connolly said.

Although this program is designed for youths aged 7 to 14 years, there is a modification of it called the C.A.T. Project for older adolescents.⁷ For younger children, Connolly said she uses adaptations involving puppets, drawings, cartoons, or games to engage them. Another important part of the CBT program, Connolly added, is a positive reinforcement program that rewards anxious children for their efforts as well as successes.

Frequently, the standard CBT approaches are modified for different anxiety disorders, according to Connolly. "For children with PD, for example, an interoceptive exposure component is added to the CBT program," Connolly said. "Interoceptive exposure is exposing the child to the physical sensations, including dizziness or shortness of breath, he or she has that accompany the panic."

The clinician seeks to induce those feelings and sensations by having the child spin in a chair or run up and down stairs until he or she becomes dizzy or breathless. The child learns to understand what causes these feelings or sensations and develops coping strategies for when they occur.

For social phobia, the modification includes adding social skills training and increased social opportunities to the core CBT components.

A goal of CBT coupled with involvement of the family and school is to help the child learn to function independently. "Anxiety can lead you to become overly dependent on others, seeking reassurance and feeling incapable or incompetent that you can't do it yourself," Connolly said. In addition to psychiatrists, psychologists, social workers, and others can use CBT to help the child, according to Connolly, who trains many mental health professionals in these techniques.

She is also involved in educating youths with anxiety disorders and has coedited a book for teenagers called Anxiety Disorders⁸ that includes a discussion of anxiety disorders, how CBT works, as well as tips and insights from other teens who have received treatment for anxiety disorders.

Other psychotherapies were mentioned in the parameter but are not as well researched as CBT for anxiety disorders in children. For instance, clinical trials research for psychodynamic psychotherapy for childhood anxiety disorders is sparse, despite extensive clinical experience. "Since child-focused CBT is not effective for all children with anxiety disorders, the clinician needs to consider other interventions based on the child's and family's needs and circumstances," Connolly said.

Medications

As anxiety disorders become more severe, medication can assist with treatment, Connolly told Psychiatric Times.

The parameter recommends treatment with medication in addition to psychotherapy when anxiety disorder symptoms are moderate or severe, when impairment makes participation in psychotherapy difficult, or when psychotherapy results in a partial response.

"Giving medications has been difficult for some clinicians because of the black box warnings," Connolly added. (In 2004, the FDA advised clinicians to carefully monitor pediatric patients receiving antidepressants, including SSRIs, for worsening depression, agitation, or suicidality.)

The parameter describes several placebo-controlled studies showing efficacy for SSRIs in childhood anxiety disorders. Generally, SSRIs have been well tolerated, but Connolly recommends careful monitoring for adverse effects, particularly at the beginning of medication treatment and during dosage changes. Also, she noted that the frequency of somatic symptoms in anxious children can complicate the monitoring of adverse effects.

Beyond the SSRIs, the parameter really does not recommend other drugs. There is, however, some emerging research on serotonin-norepinephrine reuptake inhibitors, such as venlafaxine (Effexor), Connolly said. Controlled trials of extended-release venlafaxine have shown its efficacy for SAD and GAD in children and adolescents.^9-11

Studies on other medications without serotonin reuptake properties have been few, and the results have been mixed, Connolly said. In addition, some medications with promising results in adults have not shown similar results in children.

Because SSRIs and other antidepressants may exacerbate symptoms of BD, Connolly added that clinicians should always ask for any family history of BD or mood disorders.

Studies

Much more research needs to be done, according to Connolly, although some studies have been published recently with others under way. Bernstein, Connolly's coauthor on the parameter, recently completed a study investigating symptom presentation and school functioning in a nonclinical sample of 45 children with social phobia, identified via school-wide screenings and follow-up diagnostic interviews.¹²

Using the diverse population at her Chicago clinic as a study group, Connolly and her team are engaged in a risk and protective factors study. The team is evaluating such factors as family history of anxiety, family functioning, and stressors that may contribute to the development of childhood and adolescent anxiety disorders as well as social support and coping skills that may reduce the risk. The goal is to develop modifications to current anxiety interventions that will target some of the risk factors in children from various backgrounds.

Another study under way is the Child and Adolescent Anxiety Disorders study, sponsored by the NIMH. The 9-month study is comparing the effectiveness of sertraline (Zoloft), CBT, and the combination of these treatments with placebo. Recruitment is complete, but the data need to be analyzed, according to principal investigator, John S. March, MD, MPH, chief of child and adolescent psychiatry at Duke University. Recruitment also has begun on the Antidepressant Safety in Kids study, he added. That study is intended to evaluate the risks and benefits of treatment with an SSRI or SNRI in children and adolescents with a prespecified anxiety disorder or other disorders.

References:

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