The management of anxiety disorders in children and adolescents begins, as with any medical/neurologic disorder, with the diagnosis of a specific anxiety disorder. After a particular anxiety diagnosis is established, proper treatment planning can progress. This review will first briefly summarize the characteristics of childhood and adolescent anxiety disorders as they are currently classified. Treatment modalities - pharmacotherapy, behavioral/cognitive therapy, and individual psychotherapy - -will then be discussed.
DIAGNOSIS AND CLASSIFICATION OF CHILD AND ADOLESCENT ANXIETY DISORDERS
Mental health professionals can now investigate anxiety and other symptomatology with the aid of various empirical instruments designed for use with children and adolescents.1 Structured psychiatric interviews guide clinicians through a comprehensive survey of a child's history and mental state, including anxiety symptoms. The interview can then be supplemented with checklists completed by parents, teachers, and the child. Such rating instruments not only further identify anxiety symptoms, but also designate severity based on the normative data provided by the checklists.
Once basic clinical information has been collected, psychiatrists can diagnose anxiety disorders in children and adolescents according ro the Diagnostic and Statistical Manual of Mental Disorders, Third Edition - Revised (DSM-III-R).2 Although diagnostic issues remain (eg, concerning the co-existence of anxiety and depressive symptoms), this manual presents a classification system based on current working knowledge. In DSM-III-R, certain anxiety disorders are considered to begin in childhood and adolescence: separation anxiety disorder, avoidant disorder, and overanxious disorder. Other anxiety diagnoses may occur at any time in life, including simple phobia and obsessive-compulsive disorder. The primary diagnostic characteristics of these disorders, according to DSMIII-R, are summarized below.
Separation Anxiety Disorder
Separation anxiety disorder is particularly characterized by excessive anxiety for at least two weeks concerning separation from those to whom the child is attached. When separated, the child may feel anxiety to the point of panic. Such children should show at least three of the following symptoms: (I) unrealistic and persistent worry that possible harm will happen to major attachment figures, or that they will leave and not return; (2) similar worry that a calamitous event will separate the child from the major attachment figure; (3) persistent reluctance or refusal to go to school (or to go to sleep) in order to stay with a major attachment figure; (4) persistent avoidance of being alone; (5) repeated nightmares with the theme of separation; (6) physical complaints on school days or other occasions of anticipated separation; or (7) recurrent signs or complaints of excessive distress in anticipation of or at the time of separation from home or major attachment figures. Children and adolescents with this disorder often have a depressed mood and are frequently considered as demanding, intrusive, and in need of constant attention, complaining that no one loves them.
Children or adolescents with this disorder shrink from contact with unfamiliar people to the point of interference with social functioning and peer relationships. By contrast, they generally have warm and satisfying relationships with family members and other familiar figures. Such children often appear socially withdrawn and timid in the company of unfamiliar people, and they are generally unassertive and lack self-confidence. For the diagnosis of avoidant behavior to be made, these symptoms must be evident for at least six months.
Diagnosis of overanxious disorder is characterized by excessive or unrealistic anxiety or worry, for six months or longer. Children or teenagers with this disorder should show at least four of the following symptoms: (1) excessive or unrealistic worry (about future events, past behavior, or competence); (2) somatic complaints without physical basis; (3) marked self-consciousness; (4) excessive need for reassurance about a variety of concerns; or (5) marked feelings of tension or inability to relax. These youngsters may often appear hypermature, perfection istic, and overzealous in seeking approval.
The essential feature of this disorder is a persistent fear of a circumscribed stimulus, exposure to which provokes an immediate anxiety response. The phobic object or situation is avoided or endured with intense anxiety, while the child realizes that the fear is excessive or unreasonable. Such fear or avoidant behavior significantly interferes with the child's normal routine or social relationships.
This anxiety disorder is characterized by recurrent obsessions or compulsions sufficiently severe to cause marked distress or interference with the normal routine of a child or adolescent. Obsessions are defined as recurrent and persistent ideas, thoughts, impulses, or images which are experienced, at least initially, as intrusive or senseless, and which the child tries to ignore, suppress, or neutralize with some other thought or action. Compulsions are repetitive, purposeful, and intentional behaviors performed in response to an obsession; the behavior is designed to neutralize or prevent discomfort of some dreaded event, and is generally recognized as excessive or unreasonable. Depression and anxiety are common in children who contend with such symptoms.
Medication may prove helpful in acute, situational anxiety states. Diphenhydramine (25-50 mg) or diazepam (2-5 mg) should be used cautiously on a short term basis.3 In general, however, indications for the use of medication in specific anxiety disorders on a longer term basis is not yet clear.
One double-blind study4 found Imipramine significantly more beneficial than placebo in the treatment of school phobia, a common symptom of separation anxiety disorder. Medication was accompanied by therapy of the child and family. At the end of the sixweek trial, Imipramine dosage averaged 152 mg/day. Drowsiness, dry mouth, constipation, and dizziness occurred in 25% or more of the patients. A second study did not find significant medication-placebo differences in school phobic children using another tricyclic, clomipramine, in lower doses.5
Promising results were demonstrated in one doubleblind study for the use of clomipramine in adolescents with obsessive-compulsive disorder.6 Compared with their placebo response, 19 teenagers (15 of whom had undergone previous trials of one or several other medications) showed significant improvement after five weeks on a mean dose of 141 mg/d. Tremors, dry mouth, dizziness, and constipation were common side effects. Studies have also begun to investigate the efficacy of fluoxetine in teenagers with obsessive-compulsive disorder.
No conclusive evidence has yet been established for the use of medication in children or adolescents with overanxious or avoidant disorder. Studies of diphenhydramine, diazepam, chlordiazepoxide, and other minor tranquilizers in youth with anxiety disorders are scarce and suffer methodologically. Phenothiazines and barbiturates have not proven useful and are now generally considered to be contraindicated.
Too few scientific findings have been established to recommend the safe use of medication in childhood and adolescent anxiety disorders. At this point, pharmacotherapy may prove the most useful in obsessivecompulsive disorder, and Imipramine can be considered in school phobia unresponsive to nonmedication treatment. Other general recommendations are not yet possible and await the results of much needed future research.
In contrast to pharmacotherapy, more research has been conducted in the behavioral-cognitive treatment of anxiety symptomatology in children and adolescents. Such forms of therapy include active behavioral intervention with children, as well as teaching selfmanagement techniques. The most common focus of investigation has been fear and phobias, although research has also considered the treatment of school phobia, shyness and social withdrawal, and obsessivecompulsive illness.
Excellent descriptions of the behavioral treatment of children's fears and phobias are presented in the reviews of Graziano and his colleagues7 and Morris and Kratochwill.8 The principal approaches are systematic desensitization (gradual exposure proceeding to the real situation), flooding (rapid live exposure), contingency management (positive reinforcement of gradual exposure), modeling (with live or videotaped exposure), and self-control (cognitive techniques to manage live exposure). Modeling and self-control appear particularly promising. However, the reviewers have criticized previous research for being primarily limited to laboratory studies of mildly to moderately fearful children rather than actual severe clinical cases. Furthermore, they also suggest that evidence must be established for the individual and environmental conditions necessary to produce efficacy and for proof of successful outcome through better and more comprehensive measurement techniques.
The behavioral treatment of school phobia depends on a cooperative effort by the child, family, school staff, and therapist.9 Important components of the flexible treatment approach include clarification of factors that precipitated and maintain the school refusal, a coordinated plan of action to include selfmanagement techniques for the child, understanding of the child's refusal by and specific advice for the parents and school staff, return to school with appropriate escort, and follow-up for maintenance. As with the behavioral-cognitive treatment of other anxiety symptomatology in children and adolescents, more comprehensive understanding still depends on evolving research.
Behavioral-cognitive approaches are currently limited for use in youth with extreme shyness or obsessivecompulsive illness. Treatment of shy children and adolescents may include a plan composed of reduction of anxiety, development of asserti veness, improvement of communication skills, overcoming feelings of inadequacy, and work with specific, influential parent factors. Specific behavioral help for young obsessivecompulsive patients may incorporate the often successful adult techniques of exposure in vivo (ie, exposure to stimuli that evoke discomfort until the patient is used to them) and thought stopping. Rarents may help by preventing the child from responding to the stimuli until self-management is possible.
A final form of treatment is individual psychotherapy based on the traditional psychoanalytic approach. A therapeutic alliance is established with the child to permit a "working through" of the anxiety psychopathology. The goals are to encourage the young patient to express feelings verbally, which with the help of the therapist will lead to increased selfknowledge and eventual self-mastery of the original symptoms. As with the previous discussion of treatment modalities, research is required to establish the efficacy of and indications for this form of therapy.
Behavioral-cognitive treatments appear to be most promising therapeutic approaches to care for children and teenagers with anxiety disorders. Nevertheless, thus far such treatment has generally been investigated primarily in children with mild to moderate symptoms and not in children and adolescents with serious anxiety disorders in actual clinical circumstances. Overall, it appears that behavioral-cognitive treatment will commonly involve work by the family and acquisition of self-management skills by the youth.
The first step in the pediatric management of anxiety disorders is to determine whether a child or adolescent has acute, situational anxiety symptoms or a pervasive, chronic anxiety disorder. Such anxiety symptoms can most frequently be handled with reassurance and practical advice to the child and the parents, and followed by monitoring. However, if an anxiety disorder is suspected, then referral to a mental health professional is in order for confirmation of the diagnosis and institution of comprehensive treatment. Medication currently has a limited role in the treatment of any anxiety disorder, although psychopharmacologic treatment may become part of the overall care of obsessive-compulsive disorder in the future. Pediatricians may wish to learn more about behavioralcognitive treatment approaches used by mental health professionals in the treatment of anxiety symptoms and disorders in children and adolescents. An excellent general text has been edited by R. Gittelman, Anxiety Disorders of Childhood. 10
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