Anxiety Disorders

As with depression, anxiety in the pediatric population has often been overlooked or minimized as normal childhood experiences. Currently, it is recognized that anxiety disorders in children and adolescents can cause substantial impairment and negatively affect their social, familial, educational, and developmental functioning, and may also affect their physical well-being. Point prevalence for any anxiety disorder in the pediatric population has been estimated to be between 3 and 5 percent, and up to 20 percent of children and adolescents exhibit significant subclinical or clinical symptoms of anxiety. Without treatment, most of the symptoms continue into adulthood, and risk for additional disorders, like depression and alcohol/substance abuse, increases. It is important to recognize and treat these disorders as early as possible, since successful treatment is likely to improve adoptive functioning as well as overall psychological, social, and physical development.

Recognizing anxiety in children may be obscured by expectations about what constitutes normal functioning. While it is expected for very young children to exhibit stranger anxiety and difficulties sleeping alone, by the time the child reaches school age, these should long disappear. However, some parents and professionals may consider the continued presence of these problems to be an extension of normal childhood experiences. Unfortunately, doing so often delays recognition that such behaviors are no longer developmentally appropriate and likely signal a developing anxiety disorder.

Symptoms Of Anxiety

While adults may experience a wide range of anxiety disorders, this chapter will concentrate on those anxiety disorders that are most common in children and adolescents. Most commonly, children experience separation anxiety disorder (SAD) where developmentally inappropriate anxiety occurs when the child is separated from the home or the primary caretaker. Some children and adolescents also experience generalized anxiety disorder (GAD), where daily functioning is characterized by persistent and excessive worry. Obsessive compulsive disorder (OCD) impairs functioning because persistent obsessions cause anxiety that is temporarily relieved by compulsions that often occupy a major portion of the day. Finally, some types of phobias are especially common during childhood.

Core Symptoms

For children, adolescents, and adults, the necessary symptoms for diagnosis of an anxiety disorder are similar; and usually include anxiety, fear, and hyperarousal that may be situational or may be present for most of the day. Usually, the following diagnoses are mutually exclusive ― generalized anxiety disorder and obsessive compulsive disorder are likely to impair functioning most of the time and in most situations, while separation anxiety disorder and phobias are usually evident in specific situations, and functioning at other times and in other settings is not impaired.

Phobias

Phobias are diagnosed when a specific stimulus or setting precipitates an anxiety reaction. Phobias are generally divided into those that involve social situations, and those where the fear is precipitated by a specific stimulus (commonly referred to as simple phobias, or specific phobias). Specific phobias are common and are considered to be the most frequently occurring psychological disorder during adulthood (APA, 2000). Specific phobias are usually categorized into those where the feared stimulus is an animal (for example, a spider or a snake), a natural phenomenon (a storm, or water), a stimulus associated with blood or injury (an injection, or the sight of blood), a specific situation (being in enclosed places, or flying in an airplane), or other stimuli (for example, fear of contracting an illness). Some of these are especially common during childhood, including fear of insects, storms, dark, germs, or costumed characters (like clowns). These specific phobias usually result in anxiety only while the feared situation or object is present, and functioning through other parts of the day is not usually impaired. For this reason, specific phobias are rarely treated pharmacologically, especially in children and adolescents, and are usually treated psychologically by administering a cognitive-behavioral treatment known as exposure with response prevention, which may be administered by gradually increasing the exposure (as in systematic desensitization).

Phobias involving social situation, however, may present with more debilitating symptoms. Individuals with social phobia experience anxiety whenever they are among other people (not members of family), and often avoid social situations. This impairs their ability to build friendships and develop appropriate social skills. Individuals with social anxiety disorder may present with significant isolation and may prefer solitary activities. This may especially impair the functioning of an adolescent, who will shy away from friends and seem very awkward while among peers. These teens are more likely to become victims of bullies, thus further exacerbating their social discomfort. One variant of social phobia that is especially common during childhood is school phobia. Children with this disorder avoid school and present with severe anxiety when taken to school and forced to separate from the parent. As with separation anxiety disorder, the anxiety reaction may take a form of severe tantrums. While school phobia commonly occurs in individuals who present with separation anxiety disorder, in some cases children do not seem anxious during other times of separation from parents or the home, except when they are required to go to school. Because social phobias usually impair daily functioning more so than simple phobias, they are sometimes treated pharmacologically.

Separation Anxiety Disorder

Separation anxiety disorder may be thought of as a form of specific phobia that is relatively common in young children and more rare during adolescence. Children with separation anxiety disorder exhibit age-inappropriate and excessive anxiety about being separated from an attachment figure (usually, the parent who spends the most time with the child), or going out of the home. This usually occurs at times when the separation takes place (or is about to take place), but in some cases the children worry well in advance of the separation. In addition, children exhibit fear that either the child or the parent will become hurt or lost, or another harmful event may occur, like being kidnapped. When separation takes place, children may resort to temper tantrums, pleading, screaming, and other avoidance behaviors, and these symptoms tend to gradually intensify. When away from home or the parent, some children may require constant reassurance that the parent is OK (for example, by asking the parent to call them frequently). Children with separation anxiety disorder may refuse to attend school or daycare, may avoid extracurricular activities and social events, and often ‘shadow’ the parent, following him or her from room to room. Bedtime is also difficult, and children with separation anxiety disorder often insist on sleeping in parent’s bed. During the night, nightmares may commonly occur and the content may be associated with the child or the parent getting hurt. While most cases seem idiopathic, in some cases separation anxiety disorder may occur after a stressful event.

Generalized Anxiety Disorder

At one time, the childhood version of this disorder was called overanxious disorder of childhood, but this disorder is now considered to be a childhood presentation of generalized anxiety disorder. A child or adolescent with generalized anxiety disorder must present excessive anxiety or worry for the majority of the time in a 6 month period of time. The individual cannot control their worry or seems to worry for little or no reason. Most of the time the worries are unrealistic or excessive (for example, worrying that a robber may break into the house), although the youngster may also exhibit worries about adult concerns, such as family finances and the safety of their home. Sometimes, symptoms may present as notable restlessness. Sleep disturbance may also be evident, including difficulties falling asleep, problems staying asleep, or restlessness during sleep. Fatigue and difficulties with concentration are often reported, and may stem from the sleep disturbance of the cumulative effects of autonomic hyperarousal. Muscle tension is also common, and more likely to be reported by adolescents. Other physical symptoms may also accompany the anxiety, including heart palpitations, sweating, trembling, and dry mouth. Patients may also experience respiratory reactions and gastrointestinal symptoms, such as nausea or diarrhea.

Obsessive Compulsive Disorder

Like generalized anxiety disorder, obsessive compulsive disorder is also likely to present impairing symptoms through most of the day, and the severity of symptoms usually is much more notable. While either obsessions or compulsions are minimally sufficient for the diagnosis, most patients present a combination of both groups of symptoms (APA, 2000). Obsessions are recurrent and persistent thoughts, impulses, or images that happen intrusively and occur at improper times, causing anxiety or distress. Compulsions are repetitive acts or behaviors that a child or adolescent feels he or she needs to carry out in response to the obsessions in order to reduce the anxiety. The compulsions temporarily reduce the distress, but the obsessions reoccur, precipitating more compulsions. Unlike adults, children with this disorder do not usually recognize that their behavior is excessive or unreasonable, but adolescents may begin to recognize that the obsessions and compulsions are not rational. However, recognition of the nonsensical nature of these components does not help increase the control over these symptoms, and individuals with obsessive compulsive disorder often feel even more distress when they recognize that the obsession and compulsions are unnecessary, but cannot stop them from occurring.

In children and adolescents, most common obsessions include fears of contamination; fears of harm to self or others; need for symmetry, exactness, or order; concerns with religious or moral conduct; or forbidden sexual or aggressive thoughts. Most common obsessions in children include decontamination rituals (like excessive hand washing), checking, ordering, and rearranging, but counting, confessing, praying, reassurance seeking, touching, or tapping may also be evident. These obsessions and compulsions are very time consuming and interfere with most daily functioning at home, in school, and with peers.

Secondary Symptoms

Children or adolescents with anxiety disorders experience autonomic hyperarousal that may precipitate various physical symptoms, including headaches, stomachaches, nausea, vomiting, and heart palpitations. Over time, these may result in significant health problems, including gastrointestinal disorders and cardiovascular problems. When a child or adolescent has exhibited symptoms of anxiety for a long time, especially when these are accompanied by physical complaints, an in-depth medical examination is necessary.

Children and adolescents with anxiety disorders exhibit problems in many settings, especially including school. Those with generalized anxiety disorder or obsessive compulsive disorder are likely to experience relentless, persistent fears and worry, and their ability to concentrate on learning usually is significantly impaired. The quality of work may suffer, they may forget to write down assignments, and may miss significant portions of lectures and class work, because their mind is preoccupied with the anxiety. Their grades are likely to drop, and they may also exhibit reluctance about (or downright refusal of) attending school. When anxiety about school is present, the child’s or adolescent’s morning routine is likely to be affected, and procrastination about getting ready in the morning is likely to be evident.

Many children and adolescents with anxiety disorders also present difficulties in social settings. If they have situational fears, they may exhibit symptoms when such a situation occurs. When others recognize the anxiety, the child or adolescent exhibiting it may get picked on or teased. Those who exhibit obsession and compulsions are likely to find it difficult to interact with peers, since the repetitive nature of the obsessions and compulsions will interfere with the ability to participate in play dates, sporting events, and other situations in which children and adolescents commonly are involved. Overall, when children and adolescents present significant symptoms of anxiety, they are likely to exhibit impairment in many aspects of their lives. Thus, treatment of these symptoms is needed to help them return to normal functioning and become able to participate in age-appropriate activities and pursuits.

Anxiety Disorders: Rule-Outs And Comorbid Disorders

PANDAS

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Steptococcus (PANDAS), also discussed in Chapter 10, is a syndrome of various symptoms associated with strep infections, one of pediatric, infection-triggered autoimmune neuropsychiatric disorders (PITANDs). Symptoms of PANDAS usually include anxiety and, in some cases, fullblown obsessions and compulsions are evident. While in some cases a child appears totally anxiety free before a strep infection, and develops symptoms afterwards, in other cases some prodromal symptoms are evident and PANDAS significantly exacerbates prior anxiety.

Although causal factors have not yet been sufficiently identified, it is presumed that some children are born with genetic vulnerabilities to anxiety and obsessions/compulsions, and when these children experience Group-A beta-hemolytic streptococcal infection, antibodies are produced that then affect cells in the basal ganglia, particularly in the caudate nucleus and putamen. Thus, the symptoms result from an interaction of these antibodies with neurons in those regions of the brain, and neuroinflammatory factors may also be involved.

Treatment of PANDAS is different than treatment of strep-unrelated anxiety. The presence of antibodies is usually verified by performing a blood test, although in some cases symptoms appear to be strongly correlated with strep infections but blood tests come out negative for strep antibodies. PANDAS is often treated with the administration of immunomodulatory therapies, usually intravenously, and plasma exchange treatment has also been utilized, with varying degrees of success. Since symptomatic treatment of anxiety is often done concurrently with medical interventions to address the immunological problems, treatment of PANDAS is usually performed by medical, pediatric specialists (most frequently, pediatricians, pediatric neurologists, or pediatric psychiatrists).

Anxiety Disorders: Supplements With Likely Efficacy

Anxiety Disorders: Supplements With Possible Efficacy

Anxiety Disorders: Supplements Not Likely To Be Effective

Summary

In order to help clinicians select the compounds that are most likely to be effective. Patients with no history of depression may start with a cautious trial of kava, and if insufficient response is evident, patient should switch to inositol. If needed, St. John’s Wort or tryptophan/5-HT may be added or switched to as monotherapy, but because of similarities in their action, the two should not be used together. Valerian may also be added to this combination, or used as monotherapy. In descending order, theanine, ginger, taurine, passion flower, and chamomile may also be attempted, and no more than two of these should be combined with each other.

Instead of starting with kava, patients with obsession and/or compulsions should start with inositol, and then switch to or add St. John’s Wort, since these two compounds appear to reveal at least some efficacy in clinical trials for treatment of symptoms of obsessive compulsive disorder. If these are not sufficiently effective, valerian may be added or used as monotherapy. If needed, theanine, ginger, taurine, passion flower, and chamomile may also be attempted, and no more than two of these should be combined with each other.

If multiple supplements are being administered, extreme caution must be exercised and, ideally, medical monitoring should be utilized.