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Anxiety in Children and Youth: Information for Primary Care

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Sommaire : Anxiety Disorders are the most common illness in children and youth. Treatments include psychotherapy/counseling (such as interpersonal/attachment approaches as well as CBT) as well as SSRI medication.
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Case

J. is a 17-yo male 17 year-old teen who normally lives with parents. Father recently deployed and will be away for 6-months. Always a worrier. Now episodes of breathing, shaking, palpitations, and sweating Starting to avoid school, due to worry about having future episodes at school

 

How are you going to help J.?

Anxiety During the Lifespan

Having just enough fears and worries is normal and protective, as it helps little humans avoid dangers. However, when these fears and worries become excessive to the point where they cause problem, it is known as "anxiety".

 

Age

Typical triggers for fears, worries and anxiety

Infants

Sensory triggers, such as loud noises; being dropped

Separation from caregivers

Toddlers

Separation anxiety

Phobias (e.g. fears of insects, storms, the dark, monsters), as toddlers are starting to explore the world around them

Preschoolers (age 3-5)

Safety fears

Mastery fears

School-age (age 6-12)

Performance and competency worries; social worries about rejection; worries about becoming ill

Adolescents (age 12-18)

Social competence and evaluation by others ; main worries are now social rather than physical.

Epidemiology

Anxiety disorders are the most common mental health conditions affecting children and youth with a point prevalence of 6%.

Presentation

Signs/Symptoms

  • Thoughts: Worry thoughts
  • Feelings: Anxiety and worry 
  • Behaviours: Avoidance of anxiety-provoking situations
  • Physical: Troubles with sleep, appetite, energy due to prolonged autonomic arousal 

Screening / Diagnostic Tools

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    Kutcher Generalized Social Anxiety Scale For Adolescents (K-GSADS-A)
    L'autorisation d'utiliser   Domaine public
    Produit par Dalhousie University
    Sujets abordés Social Anxiety Disorder
    Âges servis 12 - 20 ans
    Site web teenmentalhealth.org/for-health-professi...
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    Self-Report for Childhood Anxiety Related Disorders (SCARED), 41-item
    L'autorisation d'utiliser   Domaine public
    Âges servis 8 - 17 ans
    Site web www.wpic.pitt.edu/research
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    Self-Report for Childhood Anxiety Related Disorders (SCARED), 5-item
    L'autorisation d'utiliser   Droit d'auteur, mais peut être librement utilisée
    Produit par Dr. Boris Birmaher
    Sujets abordés Anxiety
    Âges servis 8 - 17 ans
    Complétez ce sondage sur eSantéMentale.ca
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    Spence Children's Anxiety Scale (SCAS)
    L'autorisation d'utiliser   Droit d'auteur, mais peut être librement utilisée
    Âges servis 2 - 12 ans
    Site web www2.psy.uq.edu.au/~sues/scas/

Hx/Interviewing Questions

Who to ask?

  • With younger children, most questions will be directed primarily towards the parents
  • With youth and older children, most questions can be directed at parents and the youth

General screen

  • Physician (to parent): “Does your child tend to be a worrier, or an anxious or nervous person?”
  • Physician (to child/youth): “Do you tend to be an anxious or nervous person?”
  • If patient answers positive, then screen for other anxiety conditions such as obsessive-compulsive disorder, phobias  and panic disorder.

DDx of Specific Anxiety Disorder

Is there, or are there...

Consider…

Any medical condition contributing to the anxiety?

Anxiety due to General Medical Condition

  • Anxiety symptoms are caused by a medical conditions, e.g. hyperthyroidism

Any significant psychosocial stressors contributing to anxiety?

Adjustment Disorder with Anxiety

  • Life stress that has been difficult to cope, which within 3-months, has led to anxiety symptoms resulting from the life stress

Fear of specific objects or situations?

Simple Phobia

  • Extreme, unreasonable fear of specific objection or situation that causes dysfunction
  • Top fears are heights; enclosed spaces; the dark; snakes; spiders; injections with needles; thunder and lightning; having a disease
  • Ask (to parent): “Does your child have any phobias (e.g. fear of the dark, insects, storms) that are so severe that it causes problems?”

Fear of separation from caregivers?

Separation Anxiety Disorder

  • Three or more of following must be present during the past four weeks
    • Distress when separated from home or major attachment figures (e.g. parents)
    • Complaints of physical symptoms when separating from major attachment figures
    • Concern about harm to major attachment figures
    • Fear of being alone at home and in other settings
    • Reluctance to go to sleep without a major meltdown

Fear of social situations?

Social Anxiety Disorder

  • Is there fear of social situations, present for at least six months?
    • Fear of social situations where the child is exposed to unfamiliar people or to scrutiny by others
    • Exposure to the feared situation provokes anxiety
    • Anxiety must occur in peer settings (not just in interactions with adults)
    • The feared situation(s) are avoided or are endured with intense distress
  • Ask (to parent): “Is your child excessively shy? Does it lead your child to avoid social situations? Does this cause problems?”

Many worries, with physical symptoms related to worries

Generalized Anxiety Disorder (GAD)

  • Excessive anxiety and worry with at least one of the following symptoms during the past six months:
    • Restlessness
    • Fatigue
    • Difficulty concentrating
    • Irritability
    • Muscle tension
    • Sleep disturbance

Obsessions or compulsions?

Obsessive Compulsive Disorder (OCD)

  • Presence of obsessions (worries causing distress, e.g. worries about contamination) and compulsions (repetitive behavior that relieves distress, e.g. handwashing) 
  • Ask parent for obsessions: “Does your child have any habits or rituals, such as excessive handwashing, or checking things repeatedly?”
  • Ask child/youth: “Do you have any habits or rituals, such as checking things repeatedly or washing your hands over and over?”

Episodic bursts of severe anxiety?

Panic Attack

  • Period of intense fear peaking within 10-minutes with at least 4 or more of following symptoms, which include: palpitations; sweating, trembling, shaking, shortness of breath; dizziness or lightheadedness; sense of impending death; paresthesias
  • Developmentally less common in children  
  • Ask: “Do you have sudden times, out of the blue, when you get scared or panicky?”

Episodic bursts of severe anxiety plus avoidance of situations?

Panic Disorder

  • Recurrent unexpected panic attacks with a month of at least one of the following symptoms:
    • Concerns about having additional attacks
    • Worry about the consequences of the attack
    • Significant behaviour changes related to attacks
  • Developmentally less common in children
  • Ask: “Have you had to avoid where you can go because of your anxiety?

Anxiety symptoms don't fit in other categories?

Anxiety Disorder Not Otherwise Specified (Anxiety Disorder NOS)

  • Symptoms of anxiety, however symptoms do not clearly fit in any single diagnostic category

 

Differential Diagnosis

Psychiatric conditions that may mimic anxiety include:

 

Condition    How it may mimick anxiety
ADHD Restlessness, social withdrawal, anxiety from constantly not meeting expectations
Psychotic disorders Paranoia, restlessness, social withdrawal
Autism spectrum disorder (ASD) Anxiety from struggling with social skills, sensory overload, anxiety over routines and sensory overload
Sensory processing problems     Having sensory sensitivities can lead to 'fight, flight or freeze', including anxiety  
Bipolar disorder     Restlessness may appear to be anxiety
Depression Inattention, sleep problems, physical complaints may overlap with anxiety
Substance use Substance use may cause anxiety; withdrawal of substances may also cause anxiety 

 

Physical conditions that may present with anxiety like symptoms include:

 

Endocrine

Thyroid problems such as hyperthyroidism

Diet / Toxins

Caffeine from energy drinks, soft drinks 

Heavy metal (including lead poisoning)

Neurologic

Migraines

Respiratory

Asthma

Medication-induced

Steroid use (adrenal or glucocorticosteroids)

ADHD medications

Less common

Hypoglycemia

Phaeochromocytoma (less common)

CNS causes such as tumors, delirium

Cardiac arrthymias

Others

 

Cardiovascular

Postural orthostatic tachycardia syndrome (POTS)

 

Pain in young children

 

Physical Exam (Px)

There is no diagnostic physical exam for anxiety conditions. Physical exam is important to help rule out contributory medical conditions, and can also show signs consistent with anxiety conditions.

 

General

Signs of sympathetic nervous system (SNS) activation may be seen

Vitals may show elevated HR, blood pressure
Generalized anxiety disorder (GAD): Tremor, elevated heart rate, rapid breathing, sweaty palms, restlessness
Panic disorder: During acute panic, classic signs of sympathetic activation

Head

Loss of hair on the head, or eyebrows may indicate hair pulling (trichotillomania)

Skin

Excoriations from compulsive skin picking (excoriation disorder)

Signs of excessive hand washing (obsessive compulsive disorder)

Investigations

Investigation  What it might possibly intake 
Postural vitals Postural changes may indicate postural orthostatic tachycardia syndrome (POTS), i.e. increased HR of 30 or more when going from sitting to standing position

CBC, differential

Anemia; WBC elevation with infection

Monospot

Infectious mononucleosis

TSH

Thyroid problems

Liver tests, electronlytes, renal function tests

Chronic illness

Pregnancy test

Pregnancy

B12, folate, vitamin D

Nutritional deficiencies

 

Management in Primary Care

  • Education about anxiety for parents
    • Counsel parents about how to communicate, listen, and validate that the child is feeling worried
  • Lifestyle interventions
    • Sleep
    • Diet
    • Exercise
    • Relaxation
  • Counseling/therapy or referral to counseling/therapy
    • For more severe anxiety, or anxiety that does not respond to non-medication strategies, consider medications

School Letter

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About this letter: This is a sample “School Letter” that a health professional can write to a patient’s educators to support a student with anxiety. Feel free to cut/paste in your work.   Authors: This sample letter was written by Dr’s Olivia Macleod and the mental health professionals at the Children’s Hospital of Eastern Ontario (CHEO), in coll...
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There are many ways that schools can help a child with panic disorder succeed in the classroom. Meetings between parents and school staff, such as teachers, guidance counselors, or nurses, will allow for collaboration to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom. Examples of some accommodations, modifi...
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Medication Management in Primary Care

Medications for Anxiety in Adolescents

 
For moderate to severe anxiety that has not responded to non-medication approaches, consider medications (Kodish, 2011; UpToDate) 
 
1st line SSRI
  • Sertraline

  • 
Fluvoxamine

  • Fluoxetine 

2nd line SSRI
  • Choose an alternate SSRI that has not already been tried
3rd line SNRI, NRI
  • Venlafaxine (XR) (shown helpful in GAD trial) 


Medication Dosage Table for Anxiety in Children/Adolescents

Medication Dosage
Sertraline (Zoloft)
Age 6-12: Start 25 mg daily x 1 week; then 50 mg daily; max dosage 100 mg
Age 13-17: Start 50 mg daily x 1-week, then increase by 50 mg weekly; max 200 mg daily 
 
Fluoxetine (Prozac)
Age 6-12: Start 5 mg daily as liquid, or 10 mg capsule alternating days; max 20 mg daily.
Age 12-18: Start 10 mg daily; increase up to 60 mg (for OCD).
 
Fluvoxamine
Age 6-12: Start 25 mg daily; target therapeutic range 50-200 mg daily in children; max 200 mg daily.
Age 12-18: Start 25-50 mg daily; target range 50-300 mg daily in adolescents; max 

 

Complementary and Alternative Treatments

Particularly for families that are reluctant to try medications, consider the following evidence-based complementary/alternative treatments:
  • Yoga 
  • Mindfulness-based stress reduction (MBSR)
Evidence is (unfortunately) lacking for: 
  • Kava kava: No paediatric studies;  Rare cases of hepatotoxicity due to contamination by Aspergillus toxins
  • GABA; No paediatric studies.
  • Cycloserine: No effects in children/youth (Cochrane Review)

When to Refer to Mental Health Professionals

  • When the anxiety is not improving despite initial course of medication / non-medication treatment

Who to Refer to

  • Mental health clinics in hospitals or community mental health agencies
  • Private practice professionals
    • Psychiatrists
    • Psychologists
    • Certified clinical counselors (CCC)

Clinical Guidelines

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders, J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(2):267-283. 

 

Anxiety and depression in children and youth – diagnosis and treatment from the Guidelines and Protocols Advisory Committee (British Columbia) http://www.bcguidelines.ca/gpac/pdf/depressyouth.pdf

Readings for Primary Care

Carlatt J: The Psychiatric Review of Symptoms: A Screening Tool for Family Physicians, Am Fam Physician. 1998 Nov 1;58(7): 1617-1624. Retrieved Sep 9, 2012 from http://www.aafp.org/afp/1998/1101/p1617.html

About this Document

Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a qualified expert or health professional. Always contact a qualified expert or health professional for further information in your specific situation or circumstance.

Creative Commons License

You are free to copy and distribute this material in its entirety as long as 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes (non-commercial), 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/

Affichée le : Jun 13, 2013
Date de la dernière modification : Feb 15, 2018

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