During my child and adolescent psychiatry fellowship at the University of Florida College of Medicine, I have had many opportunities to assess and treat children with various anxiety disorders. Specialty clinics such as the Obsessive-Compulsive Disorder Clinic provide children and their families not only the opportunity to be properly diagnosed and receive appropriate treatment recommendations but also hope for an improved quality of life.
Families recognize the child's anxiety disorder has affected the patient and the entire family system. “Anxiety” had become another, albeit not always welcomed, addition to the family requiring special academic, interpersonal, social, and extracurricular arrangements. “Anxiety” flourished on familial enmeshment and poor boundaries; although no one quite knew why “Anxiety” was there or how it had appeared, “Anxiety” was everywhere and not ready to depart. The long journey to rid “Anxiety” had been trying. Detours through medical clinics, therapy offices, and pharmacies resulted in a dead-end alley. Stop signs, speed bumps, and red lights stalled progress. Then, just as progress had thrust into full gear, “Anxiety” resurfaced.
This ubiquity of an anxiety disorder is not uncommon. Take, for example, 14-year-old Bobby, a spindly, somewhat disheveled appearing boy, who arrived with his biological parents for assessment of obsessive-compulsive disorder. Wearing a provocative black T-shirt depicting “crazy clowns,” military fatigues, and two different flip-flop sandals, Billy appeared annoyed and not at all interested in discussing his several year history of unusual behaviors. His parents were frustrated and scared for their son.
Bobby no longer slept in his room, due to his fear of contamination. Designated “contamination zones” were dispersed throughout the home. Although he was not afraid of contaminating his family, he could not tolerate others touching the clothes he had worn. When he witnessed his mother transferring his washed clothes from the washer to the dryer, the clothes had to be washed again. During a recent exacerbation of symptoms, he wore his clothes wet to school.
Bobby's parents had found him on his hands and knees sponge-cleaning the floor after the family pets had touched his clothes. His showers had become longer and more complex, occasionally lasting 1 to 3 hours each, up to four times per day. Bobby was using a full bottle of shampoo daily; if it was not available, Bobby substituted powdered dishwashing detergent and scrubbed his skin.
Bobby had developed severe oppositional features. His impulsive anger resulted in holes in the wall or door; he had thrown knives at his brother and choked his mother. An involuntary psychiatric hospitalization recently occurred after his father put his clothes too close to the “contamination zone”; Bobby began damaging property and hitting his mother uncontrollably.
Various clinicians had evaluated Bobby. Fifteen or more psychotropic medications, including selective serotonin reuptake inhibitors, tricyclics, antipsychotics, mood stabilizers, and naltrexone, had been tried without much success. Bobby had been encouraged to attempt cognitive-behavior therapy with exposure and response prevention; however, he refused.
The severity of Bobby's psychopathology, unfortunately, is not uncommon. The diagnosis is clear, but the success of treatment may be uncertain. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSMIV-TR),1 the primary psychiatric coding reference in the United States, generally does not discuss the cause, treatment, or management of the presenting anxiety disorder. Furthermore, when compared with adults, the unique symptoms observed in children with anxiety disorders may not always be reflected in DSM-IVTR. Nonetheless, DSM-IV-TR does provide some of the framework needed to construct an effective biopsychosocial or case formulation.
Too often, we overlook the importance of the case formulation as the clinician's primary guide to treatment. Like a roadmap, an individualized case formulation allows a clinician to clarify, identify, and compartmentalize the diagnosis, treatment goals, and desired outcome. Ideally, treatment will result in full remission of symptoms and progression through normal development. However, whereas one child may achieve the expected developmental milestones despite suffering from a severe anxiety disorder, another child with the same level of anxiety may be incapacitated. Using the multiaxial system found in DSM-IV-TR when creating the biopsychosocial formulation will therefore enable the clinician to assess the child on many levels.
In addition to the presenting Axis I anxiety disorder, concurrent internalizing or externalizing disorders must also be considered. Comorbid anxiety disorders, depression, tic disorders, or disruptive behavior disorders are common and rarely the exception in childhood anxiety disorders. However, overt or covert frustration, fear, worry, panic, or dysphoria may be a prominent clinical symptom found in other psychiatric diagnoses and may be the primary concern parents report during an initial assessment.
In addition to having the child and parents complete appropriate psychological scales, the astute clinician should carefully evaluate for a variety of differential diagnoses including specific learning disorders; disorders of communication, including problems with language or speech; enuresis and encopresis; gender and sexual identity disorders; adjustment disorders; eating disorders, including anorexia nervosa and bulimia nervosa; sleep disorders; psychotic disorders; and impulse-control disorders, such as trichotillomania. Children with a pervasive developmental disorder may have unusual preoccupations, obsessions, and ritualistic behaviors; they frequently suffer from tactile, auditory, or visual defensiveness with subsequent sensory overload.
Children with Axis II mental retardation are at high risk for comorbid anxiety. Characterized by limitations in intellectual and adaptive functioning, most children with mental retardation are in the mild range. These children potentially have the same or more psychiatric problems when compared to children of normal IQ. Specific anxiety symptoms may be associated with genetic abnormalities, including food hoarding in children with Prader-Willi syndrome or heightened anxiety in Williams and Fragile X syndromes.
Medical problems on Axis III also may contribute to the child's underlying anxiety. Many disorders may precipitate anxiety, including pain, cardiovascular (eg, arrhythmias, hemodynamically unstable heart defects), pulmonary (eg, asthma, hyperventilation), endocrine (eg, thyroid dysfunction, Cushing's syndrome), metabolic (eg, electrolyte disturbances, nutritional deficiencies), infectious, or neurologic (eg, seizures, migraines, syncope). Prescription medications (eg, sympathomimetics, anticholinergics, psychotropics) and over-the-counter medications (eg, herbal preparations, dextromethorphan) can cause anxiety, especially in children who may have paradoxical reactions to commonly prescribed preparations.
Psychosocial and environmental stressors listed in Axis IV may be of further importance. Close attention must be given to past, immediate, or future changes, especially in the areas of school or academic maladjustments; social, family, peer relationship problems; moving; inadequate housing; financial distress; unemployment; legal problems; health problem or death of family member, loved one, or pet; environmental disasters such as hurricanes, flooding, fires, earthquakes; or insufficient access to health care. A longitudinal timeline carefully identifying the environmental changes and resulting anxiety exacerbation may aid in treatment. However, clinicians must be cautious not to underestimate or overestimate the stressor(s) involved; namely, previous exposure, predisposition and resilience of the child may determine the course of anxiety.
Finally, the children's global assessment scale on Axis V allows the clinician to measure the psychological, social, and school functioning of a child. The continuum of this scale may assist the clinician in determining the level of care appropriate for the child.
Once the evaluation and mental status have been completed and a case formulation has been established, treatment can be initiated. The patient and guardians will benefit from a detailed outline identifying the diagnosis and recommended treatment options. Anxiety disorders in children frequently are complex and require a comprehensive multidisciplinary treatment team approach. Foremost, does the child pose an imminent risk to himself or others? If yes, acute inpatient psychiatric hospitalization may be necessary, although the least restrictive form of treatment is always desired.
When outpatient follow-up has been determined as the treatment of choice, the clinician and patient will profit from early detection of anxiety caused by treatable medical problems. Physical examination, vital signs, electrocardiogram, and routine blood draw, including thyroid function panel, is recommended. Collateral contact with the patient's pediatrician can assist in expediting these diagnostic tests, especially if evaluation by other medical specialties is required. Educating the patient and family regarding healthy diet and exercise under the pediatrician's observation is encouraged; supplements with scientific support for use in children may be of added benefit.
Additional referral sources frequently forgotten include an audiology and speech-language evaluation to assess for hearing impairment, auditory processing deficits, and receptive or expressive language disorders. Occupational therapy to assess for fine motor and sensory processing deficits and physical therapy to evaluate for gross motor delays may be warranted. In children and adolescents where substance abuse is suspected, obtaining a urine drug screening and referral to outpatient or inpatient substance abuse treatment should be discussed. Observing the child in the classroom and collaborating with the teacher to determine the most appropriate educational mi-lieu may also help in ameliorating the anxiety. A referral to a clinical psychologist for psychological testing, including IQ and achievement testing if indicated, may help to establish the diagnosis. Special academic accommodations under the Individuals With Disabilities Educational Act may be applicable.
The complexity of the anxiety disorder calls for a multifaceted treatment approach. Options available include psychpharmacologic and psychotherapeutic interventions. The selective serotonin reuptake inhibitors (eg, sertraline, fluoxetine, fluvoxamine) have clearly become an established form of treatment for most anxiety disorders. Although considered by some to be second line, the tricyclic clomipramine is approved by the Food and Drug Administration for the treatment of obsessions and compulsions in patients at least age 10. Various other non-FDA approved medications can also be helpful. Alpha-2-agonists, including clonidine and guanfacine, may reduce anxiety, impulsivity, and hyperarousal. Atypical antipsychotics, such as risperidone, aripiprazole, and quetiapine, may modulate poor impulse control or augment the beneficial effects of the antidepressant. Short-term administration of a benzodiazepine may be helpful in decreasing incapacitating anxiety, especially until the anti-anxiety features of a concomitantly prescribed antidepressant take effect.
Unfortunately, managing the side effects of the above medications may become a challenge for both the patient and clinician. The recent addition of a “black box” warning on all antidepressants identifying an increased risk of suicidal thinking and behavior in children and adolescents has resulted in both positive and negative effects for child psychiatrists. The initial weekly monitoring recommended for children receiving an antidepressant allows the clinician to monitor the patient carefully in regular intervals. This may assist in expediting the rapport and therapeutic alliance necessary for successful treatment. On the other hand, many parents will be frightened by this warning and attempt to avoid antidepressants all together. Thus, children and adolescents who potentially would benefit from an antidepressant trial may be withheld from this treatment opportunity. Furthermore, family physicians and pediatricians who previously treated children with anxiety may choose to refer these children to already over-burdened child psychiatrists.
Fortunately, other effective treatment options are available. As discussed in the previous articles, individual and group cognitive-behavior therapy with parental involvement is a first-line treatment modality for most anxiety disorders. Maladaptive behaviors are observed and an anxiety hierarchy is constructed. Through exposure and response prevention, the child actively replaces anxious behaviors with more adaptable ones (eg, facing one's fears). Cognitive restructuring is added to objectively evaluate the validity of anxious thoughts. Patients are provided a chart where the precipitating incident and immediate thoughts are recorded. Subsequent feelings are identified and rated. Patients are then advised to challenge these thoughts and feelings; again they are encouraged to rate themselves and document the outcome. The efficacy of cognitive-behavior therapy is well established through well-designed controlled trials. A recent review on the neurobiology of psychotherapy showed that successful psychotherapy may produce detectable changes in brain activity superficially resembling comparison subjects; some of the changes may also be shared with those induced by pharmacotherapy whereas others may be specific for each treatment modality.2
As the treating psychiatrist, especially in a difficult patient such as Bobby, the treatment of anxiety disorders must be flexible and patient directed. During the past several decades, the pendulum in psychiatry has swayed in extreme directions. Although the times of the psychoanalytic psychiatrist devoid of psychotropic medications have passed, the days of a psychiatrist engaged solely as a psychopharmacologist are over as well. In addition to a palette of paints, today's psychiatrist must have an assortment of brushes and mediums to mix the colors, lay the groundwork, and complete a comprehensive picture.
Cognitive-behavior therapy may not always be adequately taught, yet residencies and fellowships in psychiatry are making efforts to instruct and engage residents in evidence-based therapies. Too often, however, patients are referred to “therapists” in the community for psychotherapeutic interventions. Although many are skilled in providing beneficial treatment to the patient, many therapists lack the experience or education necessary to make appropriate and lasting changes. Some community-based mental health centers attempt to provide pharmacologic and psychotherapeutic treatment to children; however, high turnover in personnel, limited allotted time for each patient, and unpredictable financial resources may interfere with continuity and quality of care.
Children such as Bobby may present with a medication-resistant anxiety disorder and are unwilling to engage in therapy. The child psychiatrist is then faced with yet another challenge. Realistically, not every child is a candidate for therapy. In addition to the chronological age, the child's strengths and needs may be based on his or her developmental, emotional, or cognitive limitations. Identifying the role the anxiety disorder plays in the immediate family is important. Has a goodness of fit been established in which remission of the child's anxiety may jeopardize familial homeostasis and existing fragile interpersonal relationships? The treating psychiatrist must also be able to distinguish pathologic anxiety in need of treatment from developmentally appropriate anxiety (eg, stranger anxiety at approximately age 8 months; separation anxiety from approximately age 18 months to 36 months).
The one-size-fits-all approach in treating anxiety disorders is surely destined to fail. Ideally, a cognitive-behavior treatment approach is initially attempted; however, some anxious children cannot or will not tolerate the active participation typical of this treatment form. To keep the patient engaged and not to compromise the goal of improving the child's quality of life, a nondirective, open-ended approach in the style of Dr. Virginia Axline may be warranted. Dr. Axline emphasized the need to accept the child as he is, develop a good rapport, maintain respect for the child, and allow the child to lead the way. The process is nonhurried and gradual; feelings are recognized by the therapist and reflected back, allowing the child to gain insight into his behavior.3
As my child psychiatry fellowship nears its end, I have learned how important it is to approach childhood anxiety disorders in an evidence-based manner. Correctly diagnosing the anxiety disorder and any comorbid illnesses, using a comprehensive biopsychosocial formulation tailored to the patient's needs, and engaging a multidisciplinary team likely will result in improvement of symptoms. The days of Oz are over; treatment is no longer obscured by mirrors, curtains, and smoke screens. Evidence-based psychotherapeutic interventions are available. It will be up to the psychiatric community, however, to elevate the standard of care and incorporate skills beyond the traditional psychopharmacologic model.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision]. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.
- Etkin A, Pittenger C, Polan HJ, Kandel ER. Toward a neurobiology of psychotherapy: basic science and clinical applications. J Neuropsychiatry Clin Neurosci. 2005;17(2):145–158. doi:10.1176/jnp.17.2.145 [CrossRef]15939967
- Axline VM. Play Therapy. New York, NY: Ballantine Books; 1969:73–75.