Pediatric Anxiety –

Related DisordersBehavior and Development Talk 2010/2011

OutlineCase Presentation

Screening

SCARED

ADIS

Types

Separation Anxiety

GAD

Panic Disorder

Childhood-Onset Social Phobia

OCD

PTSD

Specific Phobia

Treatment Options

Case Presentation

3 y/o male referred to Behavioral

Pediatrician and OT/ST by PCP

for:

Limited integration skills for age;

Difficulty with change and trying new

things;

Late-end of spectrum for milestones.

Case Presentation

Areas of concern reported by family:Late to sit, crawl, and walk

Attached to his towel; sucks thumb

Difficulty with articulation

VERY intense – “absolute opposite of laid-back and easy-going” “quick to get upset”

VERY sensitive

VERY ritualistic & resistant to try new things.

Easily frustrated but infuriated by offer of help

Very interested in other children – sometimes plays openly with smiles but other times seems scared

Case PresentationDevelopmental/Behavioral Evaluation

Autism Diagnostic Observation Schedule

(ADOS)

CATEGORY ASD Cut-off Pt Score

Communication 3 5

Reciprocal Social

Interaction

4 6

Communication

+RSI total

7 11

Imagination/Creat

ivity

2

Stereotyped

Behaviors/Restric

ted Interests

5

Case PresentationDevelopmental/Behavioral Evaluation

Gilliam Asperger Disorder Scale

Social interaction

Restricted Patterns of Behavior

Cognitive Patterns

Pragmatic Skills

Disorder quotient > 80 possibility of Asperger

Disorder

Pt scored 88 high probability

Case PresentationOT Evaluation

Outcome Summary

Limited effort to complete motor tasks (put shirt,

socks on).

Cried with all new activities.

Goals

Puts on t-shirt without cry

Assists in toothbrushing without cry

Imitates vertical line, strings 3 beads

Hand-on-hand tolerance for one messy activity

(eg painting) without cry

Case PresentationOT Evaluation

Non-Autistic

• 0-30

Mildly-Moderately Autistic

• 31-37

Severely Autistic

• 38-60

Childhood Autism Rating Scale (CARS)

Anxiety – Related Disorder

• Capable yet upset with ADLs (dressing, brushing teeth)

• Plays openly with others yet seems scared at times.

• No messes allowed at home.

• Limited hand use secondary to sensitivity to touch.

ASD

• Ritualistic – same routines, spoons, food.

• Late-end for milestones

• Resistant to try new things.

• ADOS ASD

• GADS High probability for Asperger disorder

Developmental Dyspraxia

• Difficulties with motor planning

• Weakness and motor incoordination during fine motor and self-care skills.

PEDIATRIC ANXIETY

MOST COMMON PSYCHIATRIC DISORDER OF

CHILDHOOD

5-18% OF ALL CHILDREN AND ADOLESCENTS

PEDIATRIC ANXIETY

Identifiable progression:Stranger anxiety at 7-9 months

Behavioral inhibition to the unfamiliar around 12 months

Specific fears ( dark, animals) in preschoolers

Other fears ( harm – “vaccinations”) childhood

Social anxiety and general worrying (school, family) common in adolescence

SCREENING

TOOLS1. SCARED

2. ADIS –C

1. Anxiety Disorders Interview

Schedule for Children

SCARED Screen for Child Anxiety

Related Disorders

List of 41 statements describing how people

feel.

Parent and child respond to same 41

statements:

0 = Not True of Hardly Ever True

1 = Somewhat True or Sometimes True

2 = Very True or Often True

1. When I feel frightened,

it is hard to breathe.

9. People tell me I look

nervous.

17. I worry about going to

school.

2. I get headaches when

I’m at school.

10. I feel nervous with

people I don’t know well.

18. When I get

frightened, my heart

beats fast.

3. I don’t like to be with

people I don’t know well

11. I get stomach aches

at school.

19. I get shaky.

4. I get scared if I sleep

away from home.

12. When I get

frightened, I feel like I am

going crazy.

20. I have nightmares

about something bad

happening to me.

5. I worry about other

people liking me.

13. I worry about

sleeping alone.

21. I worry about things

working out for me.

6. When I get frightened,

I feel like passing out.

14. I worry about being

as good as other kids.

22. When I get

frightened, I sweat a lot.

7. I am nervous. 15. When I get

frightened, I feel like

things are not real.

23. I am a worrier.

8. I follow my mother or

father wherever they go.

16. I have nightmares

about something bad

happening to parents.

24. I get really frightened

for no reason at all.

25. I am afraid to be

alone in the house.

31. I worry that

something bad might

happen to my parents.

37. I worry about things

that have already

happened.

26. It is hard for me to

talk with people I don’t

know well.

32. I feel shy with people

I don’t know well.

38. When I get

frightened, I feel dizzy.

27. When I get

frightened, I fee like I am

choking.

33. I worry about what is

going to happen in the

future.

39. I feel nervous when I

am with other children or

adults and I have to do

something while they

watch me (read, play etc)

28. People tell me that I

worry too much.

34. When I get

frightened, I feel like

throwing up.

40. I feel nervous when I

am going to parties,

dances, or any place

where there will be

people that I don’t know

well.

29. I don’t like to be away

from my family.

35. I worry about how

well I do things.

41. I am shy.

30. I am afraid of having

anxiety (or panic) attacks.

36. I am scared to go to

school.

SCARED Scoring

SCORING: A total score of > 25 may indicate the presence of an Anxiety Disorder. Scores higher that 30 are more specific.

A score of 7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder or Significant Somatic Symptoms.

A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder. A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder. A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder. A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance.

*For children ages 8 to 11, it is recommended that the clinician explain all questions, or have the child answer the questionnaire sitting with an adult in case they have any questions.

Separation Anxiety

• Usually peaks between 10-18 months and fades by last half of 2nd year

• Often coincides with Stranger Anxiety

• Disorder excessive anxiety over separation from a caretaker or familiar surroundings

• School refusal is a specific manifestation of this disorder

• Recognized by DSM IV

First sign may be after extended period

at home (holiday, illness)

Parents often unable to be assertive in

returning child to school ( illness,

divorce)

Cognitive behavioral therapy is

beneficial.

Data supports use of SSRI.

Controlled studies have found TCA

(Imipramine) and Bzd not effective

Separation AnxietyAAP Recommendations:

1. Don’t make a fuss over leaving. Create distraction (ie bath, new toy), say goodbye, and slip away quickly.

2. If taking to sitter, don’t just drop her/him off and leave. Spend a few minutes playing with child in the new environment. Then, reassure child that you will be back later.

3. More likely if child is tired or hungry. Schedule departure to occur after nap or meal.

"Caring for Your Baby and Young Child: Birth to Age 5." 2004 American Academy of Pediatrics, updated 5/05.

Generalized Anixiety

DisorderCharacterized by excessive or unrealistic

anxiety or worry that is uncontrollable and

significantly inferferes with daily functioning

Occurring more days than not for a period of 6

months or longer

Not due to physiologic effects of a drug (abuse

or medication) or a medical condition

(hyperthyroidism)

Generalized Anxiety

DisorderPsychosomatic manifestations:

Restlessness Irritability

Tiredness Unusual muscle tension

Difficulty concentrating Sleep Disturbance

GAD

Often does not manifest until puberty

Often good candidates for cognitive

behavioral therapy

Can give trial of SSRI

Recovery rate of 80%

Panic Disorder• Syndrome of recurrent episodes of paralyzing

fear, known as panic attacks

• Involves at least four of the following

symptoms:palpitations chest pain/discomfort fear of losing control

sweating nausea fear of dying

trembling/shaking dizziness/lightheaded

ness

numbness/tingling

shortness of breath depersonalization chills or hot flashes

choking sensation derealization worrying about

recurrence

Panic Disorder

Attacks can last seconds, but typically last 20-

30 minutes with peak of symptoms at 10

minutes

Often accompanied by agoraphobia

Anticipatory fear of another attack can cause

significant disruption of normal behavior

Rare in young children – Most common onset is

between ages 15 and 19

www.healthychildren.org/English/health-issues/conditions/emotional-problems/pages/Panic-

Disorder.apx

Panic Disorder

SSRI have shown effectiveness

decrease number of episodes

Bzd (Clonazepam) acute

Recovery rate of 70%

Childhood-Onset

Social PhobiaMarked and persistent fear of situations

where person is exposed to unfamiliar

people

School refusal common

Younger children Separation

Anxiety Disorder

Older children Social Phobia

Childhood-onset

Social PhobiaParents should be coached to calmly send child to school and reward child for each completed day.

SSRI is pharmacotherapy of choice.

o Selective mutism

o disorder that overlaps with social phobia.

o Talk almost exclusively at home with refusal to do so in other settings

o Associated with stressors (new classroom)

o Rx behavioral therapy + Fluoxetine if severe

Obsessive –

Compulsive DisorderObsessions – specific repetitive thoughts that invade consciousness

Compulsions – repetitive rituals or movements driven by anxiety

Symptoms show increased frequency during times of stress (bedtime, school)

Neuroimaging studies show abnormalities in frontal lobes and basal ganglia

50% treated with CBT + pharmacotherapy will show remission

Paroxetine has FDA approval for OCD ages 7 and up.

OCD

Pediatric Autoimmune Neuropsychiatric

Disorders Associated with Streptococcal

infection (PANDAS)

Subtype of OCD

Sudden and dramatic onset or exacerbation of

OCD or tic symptoms associated with recent

Streptococcal infection

GABHS trigger antineuronal antibodies that

cross-react with caudate neuron tissue

Accounts for 10% of pediatric OCD cases

PTSD

Results from a severe stressor that falls outside the sphere of normal human existence

Diagnosis based on 3 types of symptoms:

1. Re-experiencing

1. Nightmares, reenactment in play, recollections

2. Avoidance

1. Amnesia, isolation

3. Hyperarousal

1. Extreme startle responses, agitation, poor concentration, sleep problems

**May see regression of developmental milestones

PTSD

Individual, group, school-based, family therapy

Transform child’s concept of her/himself to that

of survivor

Sleep disturbance

Rx clonidine

Comorbid depression

Rx SSRI (sertraline, paroxetine)

PTSD

Individual, group, school-based, family therapy

Transform child’s concept of her/himself to that

of survivor

Sleep disturbance

Rx clonidine

Comorbid depression

Rx SSRI (sertraline, paroxetine)

Specific Phobia

Avoidance of specific objects

Storms, heights, animals, injections, enclosed

places

Prevalence in childhood: 0.5-2%

May treat with systemic desensitization

o Gradual exposure while teaching relaxation

techniques

DOI: 10.1542/peds.2006-0215 2006;118;1248-1251 Pediatrics

Daniel J. Safer Major Depressive and Anxiety Disorders?

Should Selective Serotonin Reuptake Inhibitors Be Prescribed for Children With

http://www.pediatrics.org/cgi/content/full/118/3/1248located on the World Wide Web at:

The online version of this article, along with updated information and services, is

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elkpublication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

by on October 30, 2010 www.pediatrics.orgDownloaded from

AMA. 2007;297(15):1683-1696. doi: 10.1001/jama.297.15.1683

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