Anxiety Disorders in Children and Adolescent PDF

**Child & Adolescent Psychiatry** **Anxiety Disorders in Children and Adolescent** **Dr. Elina Dirani** Most of the common psychiatric disorder in child and adolescents. Usually starting during childhood and persisting into adulthood. Less than one-half of the youth needing treatment actually r...

**Child & Adolescent Psychiatry** **Anxiety Disorders in Children and Adolescent** **Dr. Elina Dirani** Most of the common psychiatric disorder in child and adolescents. Usually starting during childhood and persisting into adulthood. Less than one-half of the youth needing treatment actually receive it. Untreated anxiety disorders usually **progress towards depression**. **Anxiety disorders in DSM-5:** 1. **Separation anxiety disorder** It's a condition very frequent in youth and adolescent. Excessive fear and anxiety from being separated from his parents of parental figures. - Refusal to stay alone - Described as dependent - Irrational fears - Illusions at night - School refusal, refuse to go to camp or sleep at a friend's house - When separation attempted: tears, pleading tantrums, physical resistance, panic reactions - When separated: misery, withdrawal, apathy, sadness, difficulty concentrating, homesickness **!!** Fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents. 2. **Selective mutism** Normal communication with close family members, yet they don't speak in specific situations, where there is a judgmental expectation. - Shyness, social anxiety, and social withdrawal. - Academic difficulties - Clinging, negativism, opposition, tantrums - Sometimes use non-verbal means - Willing to participate in activities that don't require speaking - Comorbid with anxiety disorder (separation anxiety, social anxiety disorder) Should be present for 1 month where the patient is failing to speak in specific social situations, yet normal in other familiar situations. 3. **Social Anxiety Disorder** It's the continuum of SAD and selective mutism. Marked by fear and anxiety related to social situations where the individual is exposed to possible judgment by others. In children, the anxiety must occur in peer settings and not just during interactions with adults. Expressed by crying, tantrums, freezing, shrinking, or failing to speak in social situation. - Phobic situations: observation, performance, assertiveness, self-revelation, mundane interactions - Fear before and during the situation & Shame during and after the situation - Postural rigidity, avoidant eye contact, verbal inhibition or low speaking voice - Shy bladder syndrome = avoiding public toilets A lot of people with social anxiety disorder would go into alcohol to become "stronger" and to beat anxiety. We have to specify if the fear is restricted to speaking or performing in public performance only. 4. **Specific Phobia** Marked fear or anxiety to a specific object, idea, or place. Phobias can be limited (e.g., spiders but not worms), generalized (e.g., needles and by extension hospitals), by proxy (i.e., for themselves and their family), and associated (e.g., heights and snakes). Anxiety may occur in the presence of the phobic object or in anticipation. Degree of expressed anxiety can vary according to nature of exposure, duration, presence of others. Hypervigilance (state of sensing potential threats around you) Sympathetic hyperactivity (tachycardia, increased BP), except in blood-injection-injury subtype → vagal discharge (bradycardia, decreased BP, syncope) Avoidance can be overt or covert Sometimes, counterphobic attitude = seeking out and confronting the phobic objects (e.g., a teenager with fear of heights takes bungee jumping classes In children, the fear or anxiety may be expressed by crying tantrums, freezing, or clinging. **!!** Duration of putting the diagnosis is 1 month. 5. **Panic disorder** Panic attacks can be found in any anxiety disorder (specific phobias, social anxiety disorder, generalized anxiety disorder, etc.). A diagnosis of panic disorder requires recurrent unexpected panic attacks + worry about additional panic attacks occurring. Panic attacks can also occur at night waking up the patient. Patients can have anxiety related to physical health (e.g., fear of cardiac problems, of having a brain tumor), or mental health (e.g., fear of going crazy) Becomes a disorder when the number of attacks would increase to every day or every week for a month. Continuous panic attack and persistence worry, and the individual would stop doing everything in life because he is fearing a panic attack and fearing he won't be able to adapt. In such situations, we discuss a panic disorder that should be treated. Stressful situations and caffeine are triggering. - Palpations, accelerated heart rate - Shaking - Shortness of breath - Choking - Chest pain discomfort - Abdominal distress - Dizziness -- fainting -- heat sensations - Feeling numb - Derealization - Fear of gong crazy and losing control - Fear of dying 6. **Agoraphobia** Similar to phobia, but related to a certain situation where he cannot run from such as, heights, malls, cinema, theatre, busy places, etc. Extreme cases: total home reclusion Children are particularly worried when outside their home often with fear of getting lost 7. **Generalized Anxiety Disorder** Not frequent in children. Incontrollable excessive worry and fear about everything. - Always on edge - Easily fatigued - Problem in concentration - Irritability increase - Muscle tension - Problems in sleeping In adults we need 3/6 symptoms In children, only one symptom is enough. - Perfectionism - Constant need to be reassured by others - Other somatic symptoms: tremor, fasciculations, muscle pain, sweating, nausea, diarrhoea - Increased startle response - Irritable bowel syndrome, migraines - Usually infrequent in children, look for separation anxiety, social anxiety or OCD **Extra Notes:** SAD & selective mutism more present in children, rare in adults. To differentiate between social phobia and specific phobia, we need to see where the symptoms are occurring. **!!** Separation anxiety, selective mutism, panic disorder (panic attack alone is not problematic, problematic when it has severe effect on the person's life). Anxiety disorders are highly comorbid together and other psychiatric disorder and sleep disorders. Suicidal risk is globally increased in anxiety disorders both with or without comorbid depression Risk is exceptionally high in case of anxious raptus = sudden and acute panic reaction that can lead to committing impulsive acts out of panic. Prevalence for all anxiety disorders = 7% More prevalent in girls. Median age of onset = age 11; however each disorder has its own age of onset - 0-6: separation anxiety, selective mutism - 5-11: specific phobias - 10-16: social anxiety - 15-21: panic disorder, agoraphobia, GAD **Pathophysiology** - **!!** Genetic predisposition with life course events that might lead to anxiety disorders - Early emotional deprivation - Parenting style - Poor social integration - Stressful and traumatic life events **Natural History** - Onset usually acute, during childhood - Course is chronic, often waxing and waning - Anxiety is polymorphic and the anxiety-provoking agent can vary with age Some individuals have high diagnostic stability of a certain anxiety disorder that started in childhood Others see their anxiety take different forms, verifying criteria for a different diagnostic category at different points in time, each the pathological extreme of normative fears of that specific developmental stage **Developmental Stage** **Normative Fears** **Anxiety Disorders** ---------------------------------------- ---------------------------------------------------------- ----------------------------------------------------------- **Preschool/ early school-age** Separation, stranger shyness Separation anxiety, selective mutism **School-age** Thunder, fire, darkness, animals, blood, etc. Specific phobias **Late-school age/ early adolescence** Peer rejection, school performance Social anxiety **Adolescence/ early adulthood** Loss of control, going crazy, empty places illness, etc. Panic disorder, agoraphobia, generalized anxiety disorder **Separation anxiety** in childhood usually predicts **panic disorder**, **agoraphobia** and **depression** in adolescence and adulthood. **Selective mutism** in childhood usually predicts **social anxiety** in adolescence and adulthood. Consequences of untreated anxiety disorders in childhood and adolescence: - Depression, suicidal thoughts and attempts - Alcohol, substance or medication abuse - Social, educational, occupational impairment The assessment should be done with the family and the child. **Management** The treatment is not always medication. **psychoeducation**: explaining the symptoms and the disorder, as well as the evolutive risk of an untreated anxiety disorder. Therapeutic lifestyle changes: - Reducing exciting products (nicotine, alcohol, caffeine, etc.) - Reducing and stopping anxiolytic medications (benzodiazepines, antihistamines...) - Adopting a healthy diet - Maintaining good sleep hygiene and sleeping habits - **Maintaining a regular physical activity** - Relaxation and meditation **Psychotherapy**: cognitive behavioral therapy is 1^st^ line for children between 6 and 18 In moderate to severe cases, medication (i.e., antidepressants) is associated to CBT when psychotherapy is not enough or from the start if symptom severity is high, in children aged 6 and above. Antidepressants have anti-anxiety therapeutic effects that are independent of their anti-depressive effects. **Conclusion and Key Messages** Among the most common mental disorders in children and adolescents. Separation anxiety, selective mutism, specific phobia, social anxiety, panic disorder, agoraphobia, generalized anxiety disorder. Presentation may vary with age for the same individual going from one characterized diagnosis to another. For others, diagnostic stability is high, as they retain the same diagnosis throughout life. High prevalence of comorbidity: with other anxiety disorders, mental disorders, neurodevelopmental disorders. Increased suicidal risk irrespective of comorbid depression. Treatment consists of psychoeducation, therapeutic lifestyle changes, CBT, and in some cases, antidepressant medication.