Anxiety

Anxiety

Anxiety disorders are among the most common pediatric psychiatric disorders, affecting 15-20% of youth. They are characterized by excessive and difficult to control worry, which can lead to distress and disruptions in daily life. Common symptoms include the constant need for reassurance, sleep issues, avoidance of activities, as well as withdrawing from or feeling overwhelmed in group settings.  Frequently, a child with anxiety may appear to be shy, worried, home sick or nervous. Sometimes they may have pain or other body symptoms or angry outbursts when their anxiety is triggered. Young children may have melt downs, and their symptoms of anxiety may not be as clear. Older children display more typical symptoms of anxiety,

Early identification and intervention by a healthcare professional are essential when it comes to anxiety in children. Untreated anxiety places youth at higher risk for other challenges, including difficulties in school, strained relationships with adults and peers and an increase likelihood of a substance use disorder.

Common Types of Anxiety Disorders:

Generalized Anxiety Disorder: Generalized Anxiety Disorder may be indicated when a child worries too much about too many things. In children, this anxiety often focuses on performance in school or sports. It may drive the child to strive for perfection, creating extreme studying habits or practice routines. Children with this disorder can be very hard on themselves and may seek constant approval or reassurance from others. They also may present as being on-edge and they may over-think and be worried all the time.

Panic Disorder: Panic Disorder may be indicated when a child suffers from brief, but intense, unexpected panic or anxiety attacks. These attacks often have components of both physical sensations and psychological distress. Additionally, the onset of the attack is often sudden and without an apparent trigger. Children with panic disorders often find little relief in-between episodes; they are instead consumed with worry of another impending episode, and fear losing control, or “going crazy”. Panic attacks are seen in other anxiety disorders, but when they occur without clear triggers they may be classified as panic disorder. 

Separation Anxiety Disorder: Separation Anxiety Disorder may be indicated when a child (as old as 9)  cannot bear to be separated from a parent or other family member. Separation anxiety is typically normal for children aged 3 and under. Older children who struggle with separation anxiety may refuse to go to school, camp or sleepover at a friend’s house. They may also demand that someone stay with them at bedtime. 

Social Anxiety Disorder: Social Anxiety Disorder is characterized by an intense fear of social and performance situations. The child may experience persistent “stage fright” that can significantly impair school performance and attendance. It can also hinder a child’s ability to socialize and develop friendships among peers. 

When to Seek Treatment?

Fear and worry are normal, and in some cases, can even be healthy reactions. However, further assessment by a healthcare professional is needed when a child experiences symptoms of a more serious or persistent disorder. In general, these would cause significant disruption in their daily like or diminish overall quality of life, particularly if they persist for more than six months.

Clinical Pearl: Misdiagnosis and Comorbidity

Outbursts surrounding refusal to comply with a request or engage in a task can be caused by anxiety. These outbursts can be mislabeled as defiance or oppositional behaviors. 

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Reports of active suicidal planning or intent increase safety risk, and should prompt re-evaluation for comorbid disorders such as depression, anxiety and PTSD.

Screening and Assessment

Screening and Clinical Evaluation

Anxiety disorders require a clinical diagnosis, which is typically initiated by collecting information from the child and caregivers. The provider gathers information about anxiety symptoms, including inquiring about the nature of symptoms, when and how frequently they arise, what seems to cause anxiety to reduce, and the severity and level of functional impairment related to symptoms. Assessment begins by ruling out other medical conditions that may be causing the symptoms. Next, a comprehensive assessment is completed, which may include a combination of a clinical interview and the use of standardized rating scales. Standardized rating scales are neither definitively diagnostic, nor a definitive indication of a specific condition. Their purpose can be to screen for anxiety or to help point to ways that the symptoms are affecting the child by causing emotional, behavioral, academic, work-related, or peer- or family-related impairment. 

There are several validated rating scales designed for screening anxiety, including the SCARED (for children 9 to 18 years old and parents) and GAD-7 (for children 13 years old and older). Among these, the Screen for Child Anxiety-Related Emotional Disorders (SCARED) stands out as one of the most frequently used tools for detecting and tracking anxiety disorders in children and adolescents, as well as being freely available. 

The SCARED-5 can be used as an initial screener to identify patients who need a more in-depth evaluation of anxiety symptoms. Once it is clear that evaluation for anxiety is needed, the 41-item SCARED can give detailed information about specific symptoms and types of symptoms.

The SCARED-41 is a 41 item Likert scale assessment that is delivered to both the child or adolescent and a caregiver. The SCARED form is designed for both the child and their caregivers to complete. It prompts respondents to reflect on their experiences over the past three months, classifying statements as “very true or often true,” “somewhat true or sometimes true,” or “not true or hardly ever true” for the child. 

A total score of 25 or higher can suggest the presence of a potential anxiety disorder. However, the scale can also be used to evaluate specific anxiety disorders outlined in the DSM-5. Depending on how various items are scored, the assessment can provide insights into whether the child or adolescent may be dealing with a panic disorder, significant somatic symptoms, generalized anxiety disorder (GAD), separation anxiety disorder, social anxiety disorder, and/or school avoidance. This valuable information can then be employed to tailor individualized treatment plans. Healthcare practitioners are encouraged to utilize this instrument not only for initial diagnosis but also for ongoing monitoring, assessing medication responses, and evaluating the remission of symptoms. 

SCARED Screen

Clinical Pearl: Cycle of Avoidance

Avoidance of activities or situations are often the most disabling aspect of anxiety, but youth and parents may feel unable to break a cycle of avoidance, or unintentionally reinforce avoidance. For example, an anxiety disorder can lead to physical symptoms and school avoidance. It is therefore important to work through avoidance by encouraging patients set small, manageable goals towards the desired behaviors, like going to school or leaving the house.

 

Diagnostic Features

Common Diagnostic Features of Anxiety Disorders for Children and Adolescents include the following. For more complete diagnostic criteria, see DSM-5 Anxiety Disorders Diagnostic Features.

Differential Diagnosis

Since many symptoms of anxiety resemble those of other behavioral health disorders, it is important to assess these to ensure an accurate diagnosis. Some of the common differential diagnoses and distinguishing symptoms of anxiety are listed below:

• Common Comorbidities – The most common co-occurring diagnoses include ADHD, Depression, Substance Use Disorder.
• Anorexia Nervosa or Bulimia Nervosa – Anxiety or worry associated with fear of gaining weight.
• Bipolar Disorder, Depressive Disorders and Schizophrenia – Anxiety occurring as an associated feature but includes other specific symptoms characteristic of a mood or psychotic disorder.
• Obsessive-Compulsive Disorder – Repetitive anxiety provoking thoughts that are experienced as intrusive, unwanted, inappropriate along with a need to perform an action to reduce anxiety related to those thoughts.
• Post-Traumatic Stress Disorder or Acute Stress Disorder – Anxiety occurring to internal or external triggers that resemble an aspect of traumatic event, and it may manifest with hyperarousal and reactivity to such events.
• Somatic Symptom Disorder/Illness Anxiety – Focused exclusively on health, becoming ill, or the perceived seriousness of symptoms.
• Substance/Medication Induced – Arises during intoxication, withdrawal, or as a side effect of substance or medication use.

Treatment

A multi-modal approach involves management strategies that include non-medication interventions and medication interventions. 

Shared decision-making encourages children, teens, and caregivers to have a voice in their care.  The Ohio Minds Matter Shared Decision-Making Toolkit is a guide for youth and families to take an active role in their treatment, prepare for their appointment, consider treatment options, document their symptoms, and describe their goals.
 

Shared Decision Making

Non-medication interventions

Psychotherapeutic approaches often referred to as "Talk Therapy" are typically the first life of intervention. The primary goal is to help the patient recognize and modify their emotions, thoughts, and behaviors. Non-medication interventions can be highly effective and form integral parts of anxiety treatment. 

• Psychotherapy:
  • Cognitive Behavioral Therapy is an evidence-based treatment for anxiety which is based on the concept that thoughts, feelings, and behaviors are connected and that changing one will cause changes in the others. Providers can help patients identify distorted thoughts and improve their thoughts, feelings, and behaviors by utilizing various skills.
  • Dialectical Behavioral Therapy (DBT) targets the improvement of anxiety symptoms by honing four key skills: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. DBT teaches skills around acceptance to tolerate anxious feelings and skills around adjusting behavioral responses to anxiety.
  • Parent -Child and Family Interventions involve parent(s) or other relevant family members in the treatment of a child’s anxiety. This approach focuses on what other members of the family can do to support the child in their recovery from anxiety disorder.
• School Interventions:
  • School-based interventions encompass teacher and classroom interventions, including accommodations like designating a trusted staff member to speak with or providing a safe space to go when experiencing anxiety. A priority is helping children stay in school.
  • An Individualized Education Program (IEP) can be requested to secure accommodations in classwork and homework. For additional school resources and information about Individualized Education Programs, you can refer to the Ohio Department of Education and Workforce.
• In Office Non-medication Interventions:
  • Here are some techniques you can use in your own practice with your patients. You can provide psychoeducation and recommend gradually increasing exposure to feared objects or activities. You can also teach relaxation strategies such as breathing techniques, positive self-talk, thought stopping or substitution, and thoughts of a safe space which is a form of guided imagery. It is also important to reward brave behaviors, such as confronting a feared situation and using positive coping skills. 

Clinical Pearl: Psychotherapeutic Considerations

Psychotherapeutic treatment of anxiety typically involves graded exposure to anxiety-provoking stimuli, which can lead to short-term increases in distress. Primary care providers play a vital role in reinforcing the value of psychotherapy, even when it is difficult.

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Cognitive behavioral therapy for youth with anxiety is effective but is less effective if there is comorbid ADHD that is untreated or if CBT is administered late in the day after ADHD medication has worn off.

Medication Management

When psychotherapy alone doesn't yield a satisfactory response, consider adding medication to the treatment plan. Selective serotonin reuptake inhibitors (SSRIs) are the primary choice for pharmacological treatment. They are not only extensively studied but also recognized as highly effective, despite the fact that they may not have FDA approval specifically for pediatric anxiety disorders. 

You can find additional information on the Ohio Minds Matter Antidepressants SSRIs page. 

For SSRI prescribing guides see Antidepressant Medication Aid.

See the Ohio Department of Medicaid Unified Preferred Drugs List for information about prescription coverage for children enrolled in Medicaid.

Medicaid Unified Preferred Drugs List

For additional resources, visit the Ohio Medicaid Pharmacy Program. 
 

Monitoring of Treatment Plan

Active monitoring of a treatment plan includes recommended follow-up every four weeks until stable, regular follow-up at least every three months with patient via telehealth and/or in-person, and monitoring the effects of therapy. It can be useful to utilize symptom rating scales as treatment proceeds to determine level of severity and impairment.

Prescribing Principles

When starting an SSRI medication in a patient who has never taken this type of medication, it is important to start at a low dose for the patient’s age and weight.  

This allows clinicians to assess the patient’s tolerability of the medication. After two weeks, the medication should be increased in regular intervals (2 to 4 weeks) until the patient’s symptoms are significantly improved, they cannot tolerate a dose high enough to achieve symptom relief or the maximum dose of the medication is reached. 

SSRI Box Warning

SSRIs carry a Box Warning due to a concern for suicidal thoughts and behaviors in the initial stages of treatment. It is important to talk about the boxed warning with families during medication management visits and direct them to notify a provider if suicidal thoughts or behaviors develop or intensify. A more detailed discussion of suicide risk can be found on the Ohio Minds Matter Suicide and Suicide Risk page. Most studies suggest that the potential benefits of adding SSRI treatment for moderate to severe anxiety or depression treatment far outweigh the minimal potential risk that patients will experience increased suicidal ideation. 

In discussing the boxed warning with patients and families, it can be helpful to link the discussion to the need to notify a provider if suicidal thoughts or behaviors develop or intensify, regardless of the reason. For instance: “I mention this not because I think the medication will cause you to be suicidal – that does not seem at all likely to happen – but because if you were having suicidal thoughts (or more frequent or intense suicidal thoughts), it would be important for you to talk with an adult you trust, like me, your therapist, or your caregiver about them.” There is evidence of reduced suicide risk when adolescents receiving antidepressant medication also receive psychotherapy.

Typical Starting Doses of SSRI’s:

For more information, visit the Antidepressant Medication Aid.

Approximate Dosing Equivalents

Typical Maximum Doses of SSRIs

Side Effects

• Common Side Effects Include:
  • Nausea; stomach discomfort; diarrhea, typically transient resolving within a week.
  • Sleep insomnia, or increased sleepiness, with or without intense dreams.
  • Headache, body aches, or fatigue.

When in doubt, decrease dose and consult with a psychiatrist.

Clinical Pearl: Black Box Warning

The discussion of the boxed warning about suicidal thoughts and behaviors may cause some patients and families to be nervous about pharmacotherapy. It is better for them to have the topic broached by a provider they can trust instead of obtaining information from less reliable sources. Some of theses resources may have an anti-medication agenda and spread false information. In discussing the boxed warning with patients and families, it can be helpful to link the discussion to the need to notify a provider if suicidal thoughts or behaviors develop or intensify, regardless of the reason. For instance: “I bring this up not because I think the medication will cause you to be suicidal – that does not seem at all likely to happen – but because if you were having suicidal thoughts (or more frequent or intense suicidal thoughts), it would be important for you to talk with an adult you trust, like me, your therapist, or your caregiver about them.

Managing Side Effects

"Failure" of an SSRI Medication

To say that a patient has failed a trial of an SSRI, they must have reached a maximum tolerated dose for four weeks and have been on medication for a total time of over eight weeks without receiving meaningful benefit.

Example: 12 y/o patient started on fluoxetine 5 mg and titrated up to 20 mg without side effects or symptomatic relief over 12 weeks. This is not a treatment failure as they did not reach a maximum dose, either by tolerability or dosing threshold. This patient should have the fluoxetine increased. 

Example: 16 y/o patient started on escitalopram 10 mg and increased to 20 mg over eight weeks. Patients had significant somnolence and GI symptoms at the higher dose and did not achieve symptom relief. Escitalopram should be discontinued due to treatment failure.

Cross Tapering

When a patient has failed their first SSRI, the next step is to switch to another SSRI. This can be done by cross tapering or starting a second medication and increasing its dose at the same time the first medication is being weaned down. One can think of this as going up on the dose of a new medication in a stepwise manner while going down on the dose of the ineffective medication in the same stepwise manner. This approach reduces potential side effects that can emerge at the time of SSRI discontinuation and allows clinicians to achieve dose equivalence of the newly started SSRI relatively quickly.

There are no agreed upon time intervals for dose adjustments during a cross taper. In general, dose changes can take place after a few days or a week. The longer a patient has been on a medication, the longer it should take to wean.

Example of a Cross Tapering Schedule: patient currently on fluoxetine 40 mg and switching to sertraline -week 1: decrease fluoxetine to 20 mg and start sertraline 25 mg -week 2: decrease fluoxetine to 10 mg and increase sertraline to 50 mg, check in with clinician -week 3: stop fluoxetine and increase sertraline to 100 mg.

SSRI Discontinuation

The goal of treatment with SSRIs is to achieve symptom remission. Once a patient has significant improvement in their symptoms, an SSRI should be continued for 12 months before it is weaned off. In this instance, the SSRI should be weaned slowly to allow for adequate monitoring of potential symptom recurrence.

Example of discontinuation schedule: 15 y/o patient has been on fluoxetine 40 mg for 12 months with symptom remission

• Month 1: fluoxetine 30 mg daily and follow up visit to monitor symptoms 
• Month 2: fluoxetine 20 mg daily and follow up visit to monitor symptoms
• Month 3: fluoxetine 10 mg daily and follow up visit to monitor symptoms
• Month 4: stop fluoxetine and have family monitor for reemergence of depressive symptoms and follow up in 2 months.

Ongoing Management

Primary Care Management

Managing anxiety in primary care is akin to managing a chronic condition. It demands patient and family education, ongoing treatment, and follow-up care. If you have further questions or need additional information, please don't hesitate to ask. 

Patient and Family Education

In addition to medication management, guidance becomes a vital component. This entails providing practical tips and interventions to empower individuals with the resilience and tools they need to navigate life's challenges more effectively. For more in-depth insights on this, you can access valuable resources like the Ohio Minds Matter Resilience page. 

Ongoing Treatment and Follow-up Care

In the initial stages, our focus often revolves around providing effective medication treatment. This involves fine-tuning medication doses within therapeutic ranges and keeping a close eye on medication compliance, symptom progress, and any potential side effects. 

Especially in the early phases of treatment, regular follow-up visits play a pivotal role. They serve a dual purpose: ensuring the individual's journey toward improved well-being and promptly recognizing any signs of symptom deterioration. Typically, this close monitoring continues for around 6 to 12 months. 

The following are components of ongoing treatment and follow-up care:

• Monitor medication compliance and side effects.
• Continue to monitor for 6 – 12 months.
• Titrate medicine within therapeutic dose range.
• Provide anticipatory guidance including interventions to build resilience.
• Seek consultation or refer to a specialist if any of the following occur: suicidal Ideation, prior suicide attempts, significantly impaired functioning, or serious trauma.
• Provide family psychoeducation
  • Parenting Anxious Kids
  • Nemours Kids Health

Escalated Care and Emergent Consultation

If an individual has a history of suicide attempts, faces severe challenges in their daily life, has encountered severe trauma, or has symptoms that persist after multiple interventions, it's time to consider involving a specialist. Seeking consultation or referring them to a specialist can provide the more targeted care needed in these complex situations. 
If a patient expresses suicidal ideations with a method or a plan, immediate steps should be taken to ensure patient safety. You'll find additional insights on this subject on the Ohio Minds Matter Suicide and Suicide Risk page. 

 
Family Support

Caregivers and family members play an important role in supporting youth navigating the challenges of anxiety. Their support can come in various forms, including offering social and emotional assistance, serving as positive role models, and helping the young individuals stick to their prescribed medication and treatment plans. 

In some cases, adding a bit more structure to the home environment can be quite beneficial. This might involve setting reasonable boundaries on the use of social media and gaming. It is also important for caregivers to make it a priority to attend regularly scheduled visits with the primary care provider. Staying informed and actively involved in the treatment process is key. 

Promoting a healthy lifestyle is another essential part of caregiving. This encompasses encouraging healthy eating habits, regular physical activity, and good sleep practices. Additionally, caregivers can work with the youth on developing resilience and equipping them with the skills they need to better handle life's challenges. To explore more about these resilience-building skills, you can visit the Ohio Minds Matter Resilience page.  
 

References

1. Anxiety Disorders Association of America (n.d). Anxiety Disorders in Children. https://adaa.org/sites/default/files/Anxiety%20Disorders%20in%20Children.pdf

2. Child Mind Institute. (n.d.) Parenting anxious kids. https://childmind.org/topics/anxiety/#parenting-anxious-kids

3. Compton, S. N., Walkup, J. T., Albano, A. M., Piacentini, J. C., Birmaher, B., Sherrill, J. T., Ginsburg, G. S., Rynn, M. A., McCracken, J. T., Waslick, B. D., Iyengar, S., Kendall, P. C., & March, J. S. (2010). Child/adolescent anxiety multimodal study (CAMS): Rationale, design, and methods. Child and adolescent psychiatry and mental health, 4. https://doi-org.proxy.lib.ohio-state.edu/10.1186/1753-2000-4-1

4. Dulcan, M. K. (2015). Dulcan's textbook of child and adolescent psychiatry (2nd ed.). American Psychiatric Association Publishing

5. Dulcan, M. (2022). Dulcan's textbook of child and adolescent psychiatry (3rd ed.). American Psychiatric Association Publishing

6. Feder, J., Tien, E., & Puzantian, T. (2018). Child medication fact book for psychiatric practice. Carlat Publishing, LLC

7. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A., Edwards, V., Poss, M.P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4) 774–786. https://doi.org/10.1016/s0749-3797(98)00017-8

8. First, M. B. (2014). Dsm-5-Tm Handbook of differential diagnosis. American Psychiatric Publishing

9. Foy, J.M., Green, C.M., Earls, M.F, & Committee on Psychological Aspects of Child and Family Health, Mental Health Leadership Work Group. (2019). Mental health competencies for pediatric practice. Pediatrics, 144(5). https://doi.org/10.1542/peds.2019-2757

10. Massachusetts Child Psychiatry Access Program. (n.d.). Anxiety “clinical pearls” for primary care providers. https://www.mcpap.com/pdf/AnxPearls.12.05.18.pdf

11. University of Pittsburgh. (n.d.). Screen for child anxiety related emotional disorders (SCARED). https://www.pediatricbipolar.pitt.edu/resources/instruments