ANXIETY AND KIDS

CACP CHAPTER 4

PREVALENCE?
5-18% THE

OF CHILDREN

MOST COMMON PSYCHIATRIC ILLNESS IN KIDS IN ACADEMIC AND SOCIAL IMPAIRMENT PERSIST INTO ADULTHOOD

RESULT

OFTEN

Diagnostic Issues

OCD
For

adults 2.5% lifetime prevalence rate 1-2 % for children and adolescents Usually starts in early adolescence or adulthood Up to 1/3 before the onset of puberty Age pattern for males: 6-15 years old Age pattern for females: 20-29 years old With childhood onset, more common in boys than girls (3:2)

Considerations

Compulsions must be so time consuming that they take up one hour + per day, routines are intrusive, occupational or relational functioning are impaired. Obsessive thoughts are more than normal daily worry or concern Adults recognize at some time that their obsessions and compulsions are unreasonable Kids dont have that awareness.

In a small number of juvenile patients.

OCD

Is associated with streptococcal infections like scarlet fever or strep throat.

(PANDAS: PEDIATRIC AUTOIMMUNE NEUROPSYCHIATRIC DISODERS ASSOCIATED WITH STREPTOCOCAL INFECTIONS)

Panic Disorder (with or without agoraphobia)

Childhood onset is rare for panic disorders 1-2 % lifetime prevalence

Onset is usually late adolescence to mid-30s

Because its so rare in kids, emergence of panic symptoms can be an indication of severe psychosocial stressors requiring a thorough evaluation.

Panic and kids, cont.

Anticipatory

anxiety and panic are associated features present as school failure, low self esteem, and social isolation, crying, tantrums, freezing or shrinking from social situations occur in peer settings, not just w/adults

May

Must

Specific Phobias (simple phobias)

Lifetime

prevalence rates range from 5-

12%.
Initial

symptoms usually occur in childhood (especially is object, situational, animal, and blood injection types) phobia is an enduring and unreasonable fear of a specific object or situation that generally does not pose any real danger (or poses only slight danger)

Specific

MUST LOOK:
For

underlying co-morbidities as seen in many cases.

GAD

Lifetime prevalence 5% 50% report childhood onset Anxiety and dread are prominent and interfere w/normal functioning, including work and social relationships

Symptoms: muscle tension, headaches, nausea, sweating, increased HR, exaggerated startle response.

PTSD
Lifetime Onset

prevalence: 8%

can be any age, but usually within the first 3 months of a traumatice event when: An event involving serious harm occurred or was perceived to threaten to occur; a situation was witnessed; and the response involved fear, helplessness, and horror.

Develops

PTSD includes:

Reliving the event Persistent avoidance and limited responsivenessperson avoids situations and activities associated w/event Hyper-arousal including insomnia, irritability, concentration problems, and exaggerated startle response. Kids may have stomach problems and headaches

Separation Anxiety Disorder

Prevalence is 4% in children and adolescents SX when separated from home or from an attachment figure School avoidance may develop Fear, anger, and attention seeking may also occur. SX wax and wane

Inhibited Temperament (NOT DSM IV-TR)

Fear of unfamiliar situations Timid and shy Behavioral inhibitions Autonomic arousal (Sympathetic NS)

Associated w/significant anxiety disorder later in life.

Neurobiology

Neurobiology of OCD in Kids

Family loading (genetic vulnerability)

Basal ganglia
Frontal Lobes (normally inhibits urges and the more instinctive drives and urges) Maladaptive neural pathways

Pharmacological Treatment Effectiveness

(Because of selective responses to meds, OCD is strongly suggestive of biological etiology)!

Neurobiology of Other Anxiety Disorders

Genetic Other

predisposition (probably)

than OCD, most widely studied Anxiety Disorder is Panic Disorder

Neuro-anatomical hypothesis for PD

1.

Locus Coeruleus: Increases norepinephrine release, results in physiological and behavioral arousal. Peri-aquaductal gray areas: mediates defensive behaviors, postural freezing. Parabrachial nucleus: causes increased respiration. Hypothalamic paraventricular nucleus: activates the HPA axis and release of adrenotorticoids. Hypothamamic lateral nucleus: activates the sympathetic nervous system.

2.

3. 4.

5.

Another naturally occurring biochemical factor in anxiety is GAMMA-AMINO-BUTERIC-ACID (GABA)

GABA GABA

reduces brain excitability

promotes the passage of chloride ions into the nerve cells and makes them less excitable

GABA, cont.
The

receptor complex to which GABA binds also contains a receptor site to which BENZOS attach (BZs) theory, a person should be more or less affected by stress depending on an abundance or deficit of this chemical.

In

Pharmacology

OCD
SSRIs

=first line of response

Chlormipramine

(TCA) with serotonergic activity (original studies in France before meds were widely used for OCD) rate: 50-75% w/gradual symptom reduction

Response

Fig. 2-5, p. 44

Pharmacology for OCD

Time Course: 6 to 10 weeks 18-24 weeks 52 + Weeks & longer Symptom Reduction: 25-30% reduction 40-50% reduction 50% reduction

Other Information:

Doses to treat OCD are generally HIGHER than doses to treat depression. See p. 59 CACP Until recently, evidence for efficacy of TX kids w/OCD was not clear but: The Pediatric OCT Treatment Study (funded by NIMH) has provided clarity. Findings suggest that TX for pediatric OCD begin with CBT alone or CBT combined with an SSRI.

Pharmacology for Other Childhood Anxiety Disorders

The most convincing evidence to support the use of MEDS in TX childhood anxiety disorders comes from a 2001 study by the RESEARCH UNIT OF PEDIATRIC PSYCHOPHARMACOLOGY

Outcomes
Anxiety

Symptoms reduction was noted in 76% of fluovoxamine subjects (Luvox).

Findings

strongly suggest a role for the use of fluvoxamine to treat anxiety disorders, social phobia, and childhood separation disorder (probably similar results with other SSRIs per the authors. (Preston, et al. 2006).

Remember the concept of off label use

In spite of the lack of many evidenc based studies, clinicians often use SSRIs to treat a variety of childhood anxiety disorders and all SSRIs seem to be effective in treating panic, social phobia, and GAD. When prescribed, initial doses should be low with slow titration.

For most childhood anxiety, psychotherapy, including CBT is the treatment of choice.

Remember the Guiding Principle:

For Children and Adolescents, pharmacologic treatment almost always is accompanied by psychotherapy, including family treatment,