Paediatrics: Anxiety disorders

Anxiety disorders

Diagnostic criteria

One disorder is specific to children and adolescence: separation anxiety disorder (SAD). Other anxiety disorders that may occur in children and adolescents include: generalized anxiety disorder (GAD), panic disorder (with and without agoraphobia), simple and social phobias, and post-traumatic stress disorder (PTSD). Specific physical and cognitive symp-toms are described for each disorder. Developmental principles apply.

·  Very young children experience ‘stranger danger’, later simple phobias , and SAD with the beginning of the school years.

·  Middle childhood presentations include fears of animals, the dark, burglars, and anxiety-related abdominal pain.

·  A recrudescence or first presentation of SAD may occur at the onset of secondary schooling.

·  Adolescents may experience social phobia, and panic with or without agoraphobia.

Prevalence

Rates vary by disorder. SAD and GAD are not uncommon presentations to tertiary clinics. Panic disorders are less common.

Differential diagnosis

Child abuse may present as an anxiety disorder. Anxiety and depression often co-occur and mood should always be assessed. Acting out behaviour may be due to anxiety. Truancy must be differentiated from school refusal s to separation anxiety. Prominent physical symptoms, esp. without typi-cal anxiety-related onset (e.g. Monday morning stomach pains), should be investigated. Occasionally, you must decide ‘who has the anxiety’, the child not wanting to go to school or the parent.

Treatment

CBT is the treatment of choice for anxiety disorders, general principles include the following:

·  Clarity of diagnosis and psycho-education of child and parents (over-investigation often causes more anxiety).

·  Helping child to face their fears, usually by hierarchical desensitization. Rapid exposure techniques (flooding or implosion) are rarely used.

·  Identification of unhelpful, distorted, or maintaining cognitions, challenging these cognitions, and practising more functioning thinking.

·  Skills acquisition, e.g. progressive muscle relaxation, guided imagery.

·  Parents as motivators and behavioural coaches.

·  Early relapse identification.

Medication is usually reserved for when there is either no response or only an incomplete response to psychological therapy. The selective serotonin reuptake inhibitors (SSRIs) have been shown to have short term benefit in the treatment of anxiety disorders, in children and adolescents.

Prognosis

Untreated anxiety disorders predict later internalizing conditions in girls and externalizing disorders in boys. Short-term outcome of treatment is positive, especially in conjunction with parental support.