Anxiety Disorders in Children PDF

Anxiety Disorders Dr.Fidaa Almomani  About 10 to 15% of children experience an anxiety disorder at some point during childhood. Common to all anxiety disorders is a state of fear, or worry that greatly impairs the child's ability to function normally and is disproportionate to the...

Anxiety Disorders Dr.Fidaa Almomani  About 10 to 15% of children experience an anxiety disorder at some point during childhood. Common to all anxiety disorders is a state of fear, or worry that greatly impairs the child's ability to function normally and is disproportionate to the circumstances at hand.  Etiology The etiology of anxiety disorders seems to have a genetic basis but is heavily modified by psychosocial experience. The heritability is polygenetic and only a small number of the specific genes have been characterized so far. Anxious parents tend to have anxious children, which has the unfortunate potential of making the child's problems worse than they otherwise might be. In as many as 30% of cases, it is helpful to treat parental anxiety in conjunction with the child's anxiety  Symptoms, Signs, and Diagnosis The most common manifestation is “School refusal” or “school phobia.” Some children complain directly about their anxiety, describing it in terms of worries, eg, “I am worried that I will never see you again” (separation anxiety) or “I am worried the kids will laugh at me” (social phobia). Most children instead represent their discomfort in terms of somatic complaints: “I cannot go to school because I have a stomachache.”  Generalized Anxiety Disorder Generalized anxiety disorder is a persistent state of heightened anxiety characterized by excessive worrying and fear. Physical symptoms can include tremor, sweating, multiple somatic complaints, and exhaustion. Occasionally, GAD can be confused with attention- deficit/hyperactivity disorder. Children who are diffusely anxious often have difficulty paying attention, and their anxiety can also result in psychomotor agitation (ie, hyperactivity). A key difference is that children with ADHD tend to be no more prone to worries than children without ADHD, whereas children with GAD have many distressing worries.  Social Phobia Social phobia is a persistent fear of embarrassment, ridicule, or humiliation in social settings. Typically, affected children avoid situations that might provoke social scrutiny (such as school). School refusal is often the initial presentation of social phobia, particularly in adolescents. Complaints often have a somatic focus (eg, “My stomach hurts,” “I have a headache”). In some cases, social phobia emerges after an unfortunate and embarrassing incident. In severe cases, children may refuse to talk on the telephone or even refuse to leave the house. Behavioral therapy is the cornerstone of treatment. The child should not be allowed to miss school. Absence serves only to make the child even more reluctant to attend school.  SEPARATION ANXIETY DISORDER Separation anxiety disorder is a persistent, intense, and developmentally inappropriate fear of separation from a major attachment figure (usually the mother). Separation anxiety is a normal emotion in children between about age 6 and 24 mo; it typically resolves as children develop a sense of object permanence and realize their parents will return. In some children, separation anxiety persists beyond this time, or returns later, and may be severe enough to be considered a disorder.  Symptoms and Signs Like social phobia, separation anxiety disorder often presents as school (or preschool) refusal. However, separation anxiety disorder commonly occurs in younger children and is rare after puberty. Separation anxiety is often compounded by the mother's own anxiety symptoms. Her own anxiety exacerbates the child's anxiety, leading to a vicious circle that can only be interrupted by sensitive and appropriate treatment of both the mother and child simultaneously. The child also may refuse to sleep alone and may even insist on always being in the same room as the attachment figure. Separation scenes are typically painful for both mother and child. The child often develops somatic complaints.  OBSESSIVE-COMPULSIVE DISORDER (OCD) Obsessive-compulsive disorder is characterized by obsessions, compulsions, or both. The obsessions and compulsions cause great distress and interfere with academic or social functioning. Most cases of obsessive-compulsive disorder (OCD) have no clear etiology. However, a few cases are thought to be associated with group A β-hemolytic streptococcal infections. This syndrome is called pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS). PANDAS should be considered in all children with a sudden onset of severe OCD-like symptoms, because early antibiotic treatment may prevent or attenuate long-lasting impairment.  Symptoms and Signs Obsessions are typically experienced as worries or fears of harm: – eg, contracting a deadly disease, going to hell, or some form of injury to themselves or others. Compulsions are usually done for the purpose of neutralizing or offsetting obsessional fears: – eg, checking behaviors; excessive washing, counting, arranging; and many more. The connection between the obsessions and compulsions may have an element of logic, eg, hand washing to avoid disease. In other cases, the relationship may be illogical, eg, counting to 50 over and over to prevent grandpa from having a heart attack.  A common symptom is excessively long periods of time in the bathroom. Schoolwork may be done very slowly (because of an obsession about mistakes). Parents may note that the child engages in repetitive or odd behaviors such as checking door locks, chewing food a certain number of times, or avoiding touching certain things. These children make frequent and tedious requests for reassurance, sometimes dozens or even hundreds of times per day. Some examples of reassurance seeking include questions such as, “Do you think I have a fever? Could we have a tornado? Do you think the car will start? What if we're late? What if the milk is sour?  PANIC DISORDER AND AGORAPHOBIA Panic disorder is present when a child has recurrent, frequent (at least once/wk) panic attacks. Panic attacks are discrete spells lasting about 20 min during which the child experiences somatic or cognitive symptoms. Panic disorder can occur with or without agoraphobia. Agoraphobia is a persistent fear of being trapped in situations or places without a way to escape easily and without help. Diagnosis starts by physical examination to rule out medical causes of somatic symptoms.  ACUTE AND POSTTRAUMATIC STRESS DISORDERS (PTSD) Acute stress disorder (ASD) is a brief period (about 1 mo) of intrusive recollections (eg, flashbacks and nightmares), avoidance, and anxiety occurring within 1 mo of a traumatic incident. Posttraumatic stress disorder (PTSD) produces recurring, intrusive recollections of an overwhelming traumatic incident that persist > 1 mo. Because of differences in vulnerability and temperament, not all children who are exposed to a severe traumatic event develop a disorder. Traumatic events commonly associated with these disorders include assaults, sexual assaults, car accidents, dog attacks, and injuries (especially burns). In young children, domestic violence is the most common cause of PTSD.  Signs and Symptoms “Emotional numbing” describes a group of symptoms that includes general lack of interest, social withdrawal, and a subjective sense of feeling “numb.” The child may develop a foreshortened expectation of the future, eg, “I will not live to see my dad when he comes from his trip” Hyperarousal symptoms (difficulty relaxing). Sleep may be disrupted and complicated by frequent nightmares. Prognosis for ASD is much better than for PTSD but both benefit from early treatment. The severity of the trauma, associated physical injuries, and the underlying resiliency of the child and family all affect the final outcome.  Prognosis and Treatment Prognosis depends on severity, availability of competent treatment, and the child's resiliency. Childhood anxiety disorders are treated with: – Behavioral therapy (using principles of exposure and response prevention) The child is systematically exposed to the anxiety-provoking situation in a graded fashion. The child gradually becomes desensitized and the anxiety is diminished – Drug therapy. Selective Serotonin Reuptake Inhibitors SSRIs are the usual 1st choice when drug therapy is needed S/E of SSRI are upset stomach, diarrhea, or insomnia Benzodiazepines are 2nd choice. But S/E sedating and may greatly impair learning and memory In mild cases, behavioral therapy alone is usually sufficient In sever cases, behavioral and drug therapy are needed