Anxiety Disorders in Children

 

I.               Normal fears vs. phobias

a.     Normal fears

                                               i.     Do not affect daily activities, play, or development

                                             ii.     Respond to reassurance, extinguished by distraction

                                            iii.     Plausible event as cause

                                            iv.     Age specific

1.     Stranger anxiety (7-8 mo)

2.     Separation anxiety (

3.     Fear of dark, monsters (preschool)

4.     Fear of bodily harm (school age)

 

b.     Phobias

                                               i.     May affect daily activities, play, and development

                                             ii.     Do not respond to reassurance or distraction

                                            iii.     Not rational response to plausible event

                                            iv.     Common types of phobias:

1.     Animal type is fear elicited by animals or insects

2.     Natural environment type (e.g., heights, storms, water)

3.     Blood/injection/injury type is fear related to seeing blood, injuries, or injections, or having an invasive medical procedure

4.     Situational type is fear caused by specific situations (e.g., airplanes, elevators, enclosed places)

5.     Other type (e.g., fear of choking, vomiting, or contracting an illness; in children, fear of loud sounds or costumed characters)

                                             v.     Treatment of phobias: cognitive behavioral therapy, SSRIs

 

II.             Separation anxiety disorder:

a.     Unrealistic fear of harm to the child or his/her primary caregivers, difficulty going to sleep without being near the parents, and reluctance to go to school. 

b.     Tx: cognitive behavioral therapy, family therapy, SSRIs.

 

III.           Social phobia:

a.     Excessive anxiety in social situations, especially school, that lead to social isolation, though there is a desire for social interation with peers. 

b.     There is often a history of shyness. 

c.     Tx: CBT, SSRIs

 

IV.           Panic disorder:

a.     Recurrent, discrete episodes where there is abrupt onset of marked fear accompanied by physical symptoms of palpitations, sweating, shaking, shortness of breath, dizziness, chest pain, and nausea. 

b.     Uncommon before adolescence. 

c.     Tx: CBT, SSRIs

 

V.             Generalized anxiety disorder:

a.     Unrealistic worries about future evens or about the appropriateness of past behavior and their own competence.  

b.     Frequently present with somatic symtpoms and may have other co-morbid anxiety disorders. 

c.     Often present in adolescence. 

d.     Tx:  CBT, SSRIs may be used in severe cases.

 

 

 

VI.           OCD:

a.     Specific repetitive thoughts that invade consciousness (obsessions) or repetitive rituals or movements that are driven by anxiety (compulsions).

b.     The most common obsessions are concerned with bodily wastes and secretions, the fear that something calamitous will happen, or the need for sameness.

c.     The most common compulsions are handwashing, continual checking of locks, and touching. At times of stress (bedtime, preparing for school), some children touch certain objects, say certain words, or wash their hands repeatedly. 

d.      In 10% of children with OCD, the symptoms are triggered or exacerbated by group A beta-hemolytic streptococcal infection.  This subtype is known as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). 

e.     Tx: CBT, exposure therapy, SSRIs.

 

VII.         Post-traumatic stress disorder:

a.     Cluster of symptoms following life-threatening events that pose harm to the child or caregiver, including re-experiencing the trauma, avoidance of situations that remind the child of the trauma, and hyperarousal. 

b.     Re-experiencing may occur through intrusive memories, nightmares, and reenactment in play. 

c.     Avoidance of reminders may also involve the numbing of emotional responsiveness, isolation, and amnesia. 

d.     Symptoms of hyperarousal include hypervigilance, poor concentration, extreme startle response, and sleep problems. 

e.     Tx: individual, group, and/or family therapy, cognitive behavioral therapy, and possible use of pharmacotherapy such as clonidine for sleep disturbance or SSRIs for affective numbing and comorbid depression.

 

References:

1. Dieleman GC, Ferdinand RF.  Pharmacotherapy for social phobia, generalised anxiety disorder and separation anxiety disorder in children and adolescents: an overview. Dutch Journal of Psychiatry. 2008; 50(1): 43-53.

2. Overview of fears and specific phobias in children.  www.uptodateonline.com.

3. Kliegman (2007) Nelson Textbook of Pediatrics, 18th edition. Saunders, An Imprint of Elsevier.

4. Thienemann M, Hamilton JD. Learning evidence-based practices for anxious children.

Journal of the Americal Academy of Child and Adolescent Psychiatry. Oct 2007; 46(10):1367-74.