This is our second piece in our series on pediatric behavioral health conditions. Check out our first post on diagnosing, treating, and supporting children experiencing pediatric depression here.
Over the past few years, child and adolescent anxiety has become an increasingly common and concerning trend. And, over the past year, COVID-19 and the resulting school closures have only exacerbated the situation. As a pediatrician or healthcare organization providing pediatric behavioral health services, you’re likely experiencing the impact of that trend first-hand.
Keep reading for a breakdown of the increased demand on pediatricians, the most common anxiety orders in the DSM-5 anxiety disorders, best practices for screening and assessment for anxiety in primary care, and the algorithm for treating pediatric anxiety.
Anxiety disorders are the most common mental health condition for children and adolescents
Anxiety disorders have a 30% lifetime prevalence, meaning 30% of people in a population develop anxiety disorders at some point in their lives.
According to The Journal of Pediatrics, of the 4.4 million children aged 3-17 years with diagnosed anxiety, more than one in three have a behavioral disorder, and about one in three are experiencing depression. Only six in 10 children aged 3-17 years with anxiety received treatment. The disparity between the number of children with anxiety versus the number of children in treatment is alarming, and it speaks to the role providers must play in screening and raising awareness about anxiety disorders for children and families.
The DSM-5 classifies anxiety disorders in children
If you or your healthcare organization are providing behavioral health services to children and adolescents, you should be able to differentiate between the unique DSM-5 childhood anxiety disorders as you diagnose and treat patients.
The most common DSM-5 anxiety disorders we see include:
- Generalized anxiety disorder: excessive worry about a variety of subjects such as grades, family relationships, or relationships with peers.
- Separation anxiety disorder: developmentally inappropriate and excessive anxiety concerning separation from attachment figures.
- Selective mutism: a newly added anxiety disorder in DSM-5, selective mutism is a consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations.
- Specific phobia: marked and persistent fear of a specific object or situation that causes significant distress and interferes with usual activities.
- Social anxiety disorder: also known as social phobia, social anxiety disorder is an intense fear of social and performance situations and activities (for example, being called on in class or starting a conversation with a peer). Social anxiety can significantly impact school performance and attendance as well as the ability to socialize with peers and develop friendships.
- Panic disorder: diagnosed if a child suffers at least two unexpected panic or anxiety attacks followed by at least one month of concern over having another attack.
- Agoraphobia: fear of going into certain situations where they may experience panic or be uncomfortable and without help.
- Substance/medication-induced anxiety disorder
- Anxiety disorder due to another medical condition
As a healthcare provider treating pediatric anxiety, you should be wary of differential diagnoses
Many symptoms of anxiety disorders overlap with other conditions. It can be difficult to determine whether symptoms stem from real anxiety diagnoses or other diagnoses or reactions to acute events.
Some differential diagnoses include:
- Adjustment reactions to acute stressors
- General Anxiety Disorder vs. OCD
- Substance Use Disorders
- Autism Spectrum Disorder
- Excess caffeine/energy drinks and/or nicotine use
In addition to differential diagnoses, your medical workup of conditions that can present with anxiety symptoms should include investigating other conditions and reactions to medical treatments.
Screening for pediatric anxiety is quick, free, and easy
The Pediatric Symptom Checklist-17 is generally the first step for evaluating anxiety and screens for cognitive, emotional, and behavioral problems in children ages 4-17. If you see a total score of 15+ points, you should conduct a formal assessment.
After a score of 15+ points, your next steps will include a clinical interview and using the applicable symptoms rating scale.
Use SCARED (Screen for Child Anxiety Related Disorders) for ages 8-18
- 41 item inventory
- Parent and child version
- Score 25 or greater significant
Or GAD-7 (Generalized Anxiety Disorder 7) for ages 12 and up
- 7 item inventory
- 1-2 minutes to complete
- Score 10 is moderate, 15 is severe
Assessing for avoidance is the most important step, as avoidance of activities and circumstances that provoke anxiety often are the most disabling aspects of anxiety disorders for children and adolescents. Remember avoidant behaviors often become habitual and may be reinforced by family members and teachers.
In addition to avoidance, be sure to assess for acute and chronic stressors which may be contributing to presentation, current, or previous self-injurious behavior or suicidal ideation. Other common co-occurring psychiatric diagnoses include ADHD, depression, and Substance Use Disorders.
The patient and family-first approach to treating anxiety disorders
An anxiety disorder diagnosis can be scary for families new to mental health discussions. Be patient as you’re determining a treatment plan, and be sure to determine treatment based on the severity of the child’s anxiety disorder.
For subclinical to mild anxiety, you can prescribe supported self-management and follow-ups, including at-home guidance for children and families. For moderate depression or mild depression that does not respond to supported self-management, you’ll have to provide a therapy referral (Cognitive Behavioral Therapy preferred) or a medication trial. For severe anxiety, you should always refer patients for therapy (Cognitive Behavioral Therapy preferred) and medication until the child’s anxiety is stable. Be sure to establish clear goals, expectations, and communication workflows to support families through severe anxiety treatment — it can be an emotional time.
SSRIs: the gold standard
SSRIs are the gold standard of care for treating anxiety. Whenever you prescribe SSRIs, you should conduct an in-depth screening for family history of bipolar disorder or suicide, establish a plan for follow-up and emergency access to care, and educate the family about potential side effects and protocols for adequate trials. SNRIs can be used as a second option if SSRIs treatment isn’t successful.
Fluoxetine and Sertraline are the two most studied SSRIs and, consequently, are recommended the most. For both medications, you should give test doses and closely monitor the children’s response. If a child responds well to treatment, you or your providers can slowly taper them off the medication while reevaluating their reaction throughout.
Evidence from a 6-year CAMS (Child/Adolescent Anxiety Multimodal Study) indicated that a combination of Sertraline and Cognitive Behavioral Therapy showed the most benefits for patients compared to treating with just one or the other. This is an important reminder that medication is not a “cure-all” for all mental health conditions, and approaches to anxiety are often complex and multi-faceted.
Treating anxiety disorders requires a holistic regimen and candid conversations with children and families throughout the process to provide the best possible care.
Next steps: resources for providers
Treating childhood anxiety will become increasingly important as anxiety rates continue to rise. As always, Iris Telehealth is here as a resource for providers and healthcare organizations that need support. If your organization is feeling the weight of an influx of patients experiencing pediatric anxiety, contact us today. We’d love to talk to you about how we can help!