In the Journals

Strategies to diagnose, treat anxiety disorders for primary care pediatricians

Sabrina Fernandez
Sabrina Fernandez

Anxiety disorders are the most common psychiatric disorders with onset in childhood, according to a report recently published in Pediatric Annals. A primary care pediatrician recently offered some tips to help health care professionals diagnose and treat some of the medical conditions.

According to the American Academy of Child and Adolescent Psychiatry, there is a “critical shortage” of mental health professionals for those aged younger than 18 years. In 2016, this group indicated there were about 8,300 practicing child and adolescent psychiatrists in the United States, but there were more than 15 million children and adolescents who needed the special expertise of such professionals.

“Pediatricians are often a trusted confidant for children and adolescents, and they may be the first people to hear when normal stress becomes overwhelming and progresses into an anxiety disorder,” Sabrina Fernandez, MD, primary care pediatrician at the University of California, San Francisco, wrote in the current report. “This article is intended for primary care pediatricians to help them identify normal stresses vs. anxiety disorders, and help their patients move, through psychotherapy and pharmacotherapy, toward wellness.”

Fernandez’s primer focused on general anxiety disorder, social anxiety disorder, separation anxiety disorder and panic disorder.

She stated that one treatment option for these disorders is psychotherapy, which involves cognitive-behavioral therapy. This entails:

•educating patients on how to track their feelings and recognizing their own pattern of thinking surrounding anxiety-provoking situations;

•teaching the patient specific skills such as diaphragmatic breathing, progressive muscle relaxation, mindfulness meditation, or guided imagery to promote calm in stressful situations;

•restructuring cognitive, maladaptive thoughts; and

•exposing patients gradually to a feared situation with the support of their therapist.

According to Fernandez, another treatment option for these disorders is pharmacology. She said this consists of prescribing selective serotonin reuptake inhibitors (SSRIs) as a first-line treatment, then moving onto serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants as second- and third-line agents if needed. When going this pharmacology route, Fernandez also suggested medical professionals keep the timeline for therapeutic effects and half-lives of medication in mind if medications need to be switched; checking in with patients weekly — either in person or with a phone call — for the first month to screen for side effects and to check a medication’s efficacy; and conducting an in-person appointment at least monthly during a patient’s first few months of treatment.

She stated that some commonly used SSRIs are fluoxetine, sertraline, escitalopram, citalopram and paroxetine, and some SNRI options include venlafaxine and duloxetine.

"... For mild-to-moderate anxiety, psychotherapy alone is a good first step. For more severe anxiety disorders, a combination of [cognitive behavioral therapy] and SSRI is recommended,” Fernandez wrote. “Primary care pediatricians should seek help from their psychiatry colleagues versed in pediatrics when any of the following are present: high risk for suicidal behavior, difficulty with diagnosis (such as presence of comorbid substance abuse, comorbid eating disorder, or psychotic symptoms), severe functional impairment, complicated psychosocial factors, no improvement with first-line treatment, or clinician discomfort in managing medications.” – by Janel Miller

Reference: American Academy of Child and Adolescent Psychiatry Web Page on Workforce Issues

Disclosure: Fernandez reports no relevant financial disclosures.

Sabrina Fernandez
Sabrina Fernandez

Anxiety disorders are the most common psychiatric disorders with onset in childhood, according to a report recently published in Pediatric Annals. A primary care pediatrician recently offered some tips to help health care professionals diagnose and treat some of the medical conditions.

According to the American Academy of Child and Adolescent Psychiatry, there is a “critical shortage” of mental health professionals for those aged younger than 18 years. In 2016, this group indicated there were about 8,300 practicing child and adolescent psychiatrists in the United States, but there were more than 15 million children and adolescents who needed the special expertise of such professionals.

“Pediatricians are often a trusted confidant for children and adolescents, and they may be the first people to hear when normal stress becomes overwhelming and progresses into an anxiety disorder,” Sabrina Fernandez, MD, primary care pediatrician at the University of California, San Francisco, wrote in the current report. “This article is intended for primary care pediatricians to help them identify normal stresses vs. anxiety disorders, and help their patients move, through psychotherapy and pharmacotherapy, toward wellness.”

Fernandez’s primer focused on general anxiety disorder, social anxiety disorder, separation anxiety disorder and panic disorder.

She stated that one treatment option for these disorders is psychotherapy, which involves cognitive-behavioral therapy. This entails:

•educating patients on how to track their feelings and recognizing their own pattern of thinking surrounding anxiety-provoking situations;

•teaching the patient specific skills such as diaphragmatic breathing, progressive muscle relaxation, mindfulness meditation, or guided imagery to promote calm in stressful situations;

•restructuring cognitive, maladaptive thoughts; and

•exposing patients gradually to a feared situation with the support of their therapist.

According to Fernandez, another treatment option for these disorders is pharmacology. She said this consists of prescribing selective serotonin reuptake inhibitors (SSRIs) as a first-line treatment, then moving onto serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants as second- and third-line agents if needed. When going this pharmacology route, Fernandez also suggested medical professionals keep the timeline for therapeutic effects and half-lives of medication in mind if medications need to be switched; checking in with patients weekly — either in person or with a phone call — for the first month to screen for side effects and to check a medication’s efficacy; and conducting an in-person appointment at least monthly during a patient’s first few months of treatment.

She stated that some commonly used SSRIs are fluoxetine, sertraline, escitalopram, citalopram and paroxetine, and some SNRI options include venlafaxine and duloxetine.

"... For mild-to-moderate anxiety, psychotherapy alone is a good first step. For more severe anxiety disorders, a combination of [cognitive behavioral therapy] and SSRI is recommended,” Fernandez wrote. “Primary care pediatricians should seek help from their psychiatry colleagues versed in pediatrics when any of the following are present: high risk for suicidal behavior, difficulty with diagnosis (such as presence of comorbid substance abuse, comorbid eating disorder, or psychotic symptoms), severe functional impairment, complicated psychosocial factors, no improvement with first-line treatment, or clinician discomfort in managing medications.” – by Janel Miller

Reference: American Academy of Child and Adolescent Psychiatry Web Page on Workforce Issues

Disclosure: Fernandez reports no relevant financial disclosures.