Principal Authors: Gail A. Bernstein, M.D. and Joan Kinlan, M.D. This Summary was developed by the Work Group on Quality Issues: John E. Dunne, M.D., Chair; Valerie Arnold, M.D., R. Scott Benson, M.D., William Bernet, M.D., Oscar Bukstein, M.D., Joan Kinlan, M.D., and Jon McClellan, M.D. AACAP Staff: L. Elizabeth Sloan, L.P.C. The full text of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders is available to Academy members on the World Wide Web (www.aacap.org) and appears in the October 1997 supplement to the JAACAP. The full text of these parameters was reviewed at the 1996 Annual Meeting of the American Academy of Child and Adolescent Psychiatry. Both the full text and this Summary were approved by AACAP Council in May 1997. © 1997 by the American Academy of Child and Adolescent Psychiatry.
Anxiety disorders is one of the most prevalent categories of psychopathology in children and adolescents. These revised practice parameters highlight the DSM-IV changes for anxiety disorders and review the iterature related to the assessment and treatment of anxiety disorders in children and adolescents. Up-to-date information on longitudinal outcome data, assessment of anxiety, parent-child interventions, and use of selective serotonin reuptake inhibitors has been added to the previous parameters, published in September 1993 Recommendations for evaluation and multimodal approaches to treatment are presented. Key Words: anxiety disorders, anxiolytics, practice parameters.
These parameters give clinicians direction in assessing and treating children and adolescents with anxiety disorders. Recommendations are based on extensive review of the scientific literature and clinical consensus among experts in the subject. The literature review, including references, and the rationale for specific recommendations are contained in the complete document (American Academy of Child and Adolescent Psychiatry, 1997).
Four of the anxiety disorders listed in DSM-IV are discussed in this parameter. These include separation anxiety disorder, generalized anxiety disorder, social phobia, and panic disorder. The essential feature of separation anxiety disorder is excessive anxiety about separation from attachment figures. Generalized anxiety disorder is characterized by excessive worry and anxiety that are hard to control and frequently accompanied by restlessness, fatigue, difficulty with concentration, irritability, muscle tension, and sleep disturbance. Social phobia is described as marked, persistent fear of social or performance situations in which the person is exposed to unfamiliar people or scrutiny. Selective mutism is characterized by failure to speak in specific social situations (e.g., school) while talking in other situations (e.g., home). Selective mutism has recently been conceptualized as a type of social phobia. Panic disorder is characterized by recurrent spontaneous episodes of panic that are associated with physiological and psychological symptoms.
A number of large, well-designed epidemiological studies employing structured psychiatric interviews indicate that anxiety disorders are one of the most prevalent categories of childhood and adolescent psychopathology. At least 1/3 of children with anxiety disorders meet criteria for two or more anxiety disorders. Twenty-eight to 69% have comorbid major depression. There is an association between attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders.
Children with anxiety disorders manifest a spectrum of symptomatology ranging from mild worry and distress to overwhelming, incapacitating anxiety that interferes with functioning. In some cases, children with anxiety disorders may follow a chronic course and may have a low remission rate. In other cases, the remission rate is high. In a longitudinal study of 734 non-referred children and adolescents, increased severity of psychiatric disorder was predictive of greater likelihood of persistence of diagnosis at follow-up. In a 3 to 4 year prospective study of children in an anxiety disorders clinic, separation anxiety disorder had the highest remission rate (96%) and panic disorder had the lowest remission rate (70%).
Important areas to assess when evaluating a child or adolescent with an anxiety disorder include history of the onset and development of the anxiety symptoms, associated stressors, medical history, school history, social history, family psychiatric history, developmental history with special considerations of temperament, and mental status evaluation. A comprehensive evaluation also may include structured or semi-structured psychiatric interviews to establish or confirm the anxiety diagnoses and comorbid psychotic disorders. In addition, clinical rating scales, self-report scales, and parent-report instruments may be used to determine types and severity of the anxiety symptomatology. It is advantageous to include instruments from a variety of perspectives, including from the child's or adolescent's perspective.
Medical evaluation should include a complete medical history and a physical examination within the past 12 months, with special evaluation of conditions that may mimic anxiety disorders. These include hypoglycemic episodes, hyperthyroidism, cardiac arrhythmias, caffeinism, pheochromocytoma, seizure disorders, migraine, central nervous system disorders, and medication reactions. Medication reactions may be to antihistamines, antiasthmatics, sympathomimetics, steroids, haloperidol and primiozide (neuroleptic-induced separation anxiety disorder), selective serotonin reuptake inhibitors (SSRIs), antipsychotics (akathisia), and nonprescription preparations including diet pills and cold medicines.
In making the diagnosis, it is important to note that there are developmental differences in the presentation of anxiety disorders. For example, in separation anxiety disorder, children aged 5 to 8 years most commonly report unrealistic worry about harm to parents or attachment figures. Children aged 9 to 12 years usually manifest excessive distress at times of separation. Adolescents most commonly manifest somatic complaints.
It is important to recognize that isolated, subclinical anxiety symptoms (e.g., fears of harm to self or attachment figures, or excessive worries) are common in the general population. Also, one needs to differentiate developmental fears, such as fear of the dark, which are often transient, from phobias. Psychiatric disorders that may be comorbid with or misdiagnosed as anxiety disorders include mood disorders, ADHD, adjustment disorders, substance use disorders, borderline or other personality disorders, eating disorders, somatoform disorders, tic disorders, trichotillomania, reactive adjustment disorder, pervasive developmental disorders, schizophrenia, and sleep terror disorder.
The treatment of anxiety disorders in children and adolescents usually involves a multimodal approach. Comprehensive treatment may include education of the patient and parents about the disorder, consultation with school personnel and primary care physician, behavioral intervention, psychodynamic psychotherapy, family therapy, and pharmacotherapy.
Behavioral therapy targets the patient's behavior and emphasizes treatment in the context of family and school instead of focusing on intrapsychic conflict. Cognitive-behavioral therapy combines a behavioral approach with changing the cognitions associated with the patient's anxiety. Patients are instructed to restructure their thoughts into a more positive framework resulting in more assertive and adaptive behavior. Case reports suggest specific behavioral techniques such as systematic desensitization and exposure are of benefit in treating children with school refusal. Other behavioral techniques used to treat anxiety in children and adolescents include modeling, role-playing, relaxation training, and rewards.
One study of children with school refusal compared behavioral therapy, psychiatric hospitalization, and psychotherapy in combination with home tutoring. At 1 year follow-up, 83%, 31%, and 0% of the three groups, respectively, were attending school regularly. A study comparing phobic children treated with systematic desensitization, psychodynamic therapy, and waiting list found the first two types of therapy were superior to the waiting list, as measured by parents' reports.
A more recent study compared 16 weeks of cognitive-behavioral therapy and 8 weeks of waiting list control for children with anxiety disorders. The group receiving the cognitive-behavioral treatment compared with the waiting-list control showed a significant improvement in anxiety and depressive symptoms. Furthermore, subjects who received the cognitive-behavioral intervention were less likely to meet criteria for an anxiety disorder post-treatment and at 1 year follow-up.
The clinical data on the psychoanalytic treatment of childhood anxiety consist largely of case reports on the treatment of children with phobias, school refusal, or anxiety symptoms comorbid with other difficulties. Review of the Anna Freud Centre's records of 352 children retrospectively diagnosed with DSM-III-R disorders, primarily anxiety and depressive disorders, who were treated with psychoanalysis or psychodynamic therapy showed a 72% improvement in adaptation. Predictors of positive outcome were longer duration of treatment, greater frequency of sessions, younger age, and phobic symptoms.
For many children with anxiety disorders, psychodynamic psychotherapy focusing on underlying fears and anxieties is often an appropriate component of treatment. Anxious children generally benefit from mastering themes of separation, autonomy, self-esteem, and age-appropriate behavior. Parents should be involved in the treatment so they learn to understand the patient's need for reassurance and to encourage their child to be more independent. Parents may need to resolve their own issues about separation and other sources of anxiety, to avoid exacerbating the patient's fears or communicating ambivalence about safety, security, and autonomy.
In a 12 year longitudinal study of more than 800 children, early temperamental traits of passivity and shyness in girls aged 3 to 5 years were associated with subsequent reports of anxiety symptoms. Behavioral inhibition, a temperamental characteristic of showing fear and withdrawal in novel or unfamiliar situations, is associated with increased risk of developing anxiety disorders in childhood. In addition, insecure mother--child attachment is a risk factor for developing anxiety disorders in childhood or adolescence. Therefore, attention to temperament and to the parent--child relationship is vital for preventing and treating anxiety symptoms. Parent--child interventions may include helping parents encourage children to face new situations rather than withdrawing. Infant--parent psychotherapy is recommended for treatment of attachment problems in infant--parent dyads.
Family theory postulates that anxiety symptoms represent problems in the family system. It is suggested that working with the family system is the key way to decrease the anxiety symptoms experienced by the child. The aim of the therapy with the family is to disrupt the dysfunctional family interactional patterns that promote family insecurity and to support areas of family competence.
Pharmacotherapy should not be used as the sole intervention, but as an adjunct to behavioral or psychotherapeutic interventions that help promote active mastery and are important to preventing symptom return after discontinuation of medication.
Current, commonly selected medications for treating anxiety symptoms include tricyclic antidepressants (TCAs) and SSRIs. Selection of the medication is guided by several factors, including comorbidity pattern. Benzodiazepines may be used on a short-term basis for anxiety symptoms. Less commonly used anxiolytics include buspirone and beta-blockers.
Selective Serotonin Reuptake Inhibitors Literature is starting to emerge about the use of SSRIs for children with anxiety disorders. Fluoxetine has been studied in open trials for anxiety disorders with improvement as documented by parent and self-report. Case reports, an open trial, and a controlled study suggest that fluoxetine may be beneficial in the treatment of selective mutism. Advantages of SSRIs include the low side-effects profile and relative safety in overdose with almost no anticholinergic or cardiac side effects. Transient anxiety and agitation may occur when initiating or increasing the dosage of SSRIs.
Four double-blind placebo-controlled studies of TCAs for separation anxiety disorder or school refusal in combination with separation anxiety disorder provide contrasting results. Clinical experience, however, suggests that some children and adolescents with anxiety-based school refusal improve on TCAs. There are case reports of children and adolescents with panic disorder receiving benefit from TCAs.
Case reports and several studies indicate that benzodiazepines may be useful in treating anxiety disorders. Two studies indicate that benzodiazepines are beneficial for anxiety associated with medical procedures in children. Clinical trials indicate that benzodiazepines are tolerated by children with minimal adverse effects. Sedation, drowsiness, and decreased mental acuity are the most common side effects. Because of the potential for tolerance and dependence in children and adolescents, it is recommended that benzodiazepines be used for only short-term treatment.
Due to lack of data on their use in children, beta-blockers are generally not considered unless other treatments have failed.
There are few case reports and open trials showing decrease in anxiety symptoms after buspirone treatment. Some clinical experience with buspirone suggests limited antianxiety effects.
There are virtually no controlled studies evaluating the efficacy of antihistamines for anxiety disorders in children and adolescents. Antihistamines have been replaced by anxiolytics in treatment of children and adolescents.
Because of the risks of impaired cognitive functioning and tardive dyskinesia, neuroleptics are not recommended for treating anxiety symptoms in children and adolescents in the absence of indications such as Tourette's syndrome or psychosis.
American Academy of Child and Adolescent Psychiatry (1997), Practice Parameters for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders. J Am Acad Child Adolesc Psychiatry, 36(10suppl)