ANXIETY DISORDERS in children and adolescents Background

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inside Causes and long-term course Generalised and separation anxiety disorders Social phobia and selective mutism Obsessivecompulsive disorder Assessment and treatment

The author


in children and adolescents

DR SLOANE MADDEN, child and adolescent psychiatrist; senior staff specialist, department of psychological medicine; and co-director, adolescent eating disorder service, the Children’s Hospital at Westmead, NSW.

Background ANXIETY disorders are among the most common psychiatric disorders affecting children and adolescents. They cause significant functional impairment and distress, including behavioural difficulties, conflict between children and their parents, time away from school, withdrawal and frequent medical presentations. If left untreated, anxiety disorders may persist into adulthood, becoming associated with mood disorders, substance abuse, academic failure, social isolation and unemployment.

In studies during the past 20 years, anxiety disorders have been shown to affect anywhere between 3% and 23% of children, with most studies suggesting rates of about 10%. In many cases children have multiple anxiety disorders and up to one-third have comorbid depression. Children and adolescents are prone to the same anxiety disorders as adults, although different anxiety disorders tend to first present at different ages. In children the most common anxiety disorders include

separation anxiety disorder, generalised anxiety disorder and post-traumatic stress disorder (PTSD). In adolescents the most common presenting disorders are generalised anxiety disorder, social phobia, agoraphobia and panic disorder. Children presenting with anxiety disorders rarely do so complaining of worry or sadness but more commonly present with non-specific somatic symptoms, including headaches and abdominal pain, or with tantrums or oppositional

behaviour in response to anxietyprovoking situations. In assessing such children it is essential to obtain information from a wide variety of sources including parents and school. Despite their high frequency and the significant impairment anxiety disorders cause, they are highly treatable, with a growing evidence base supporting the safety and effectiveness of treatments including cognitive behaviour therapy (CBT), family therapy and antidepressant medication.

Wealth of experience





How to Treat next week looks at chronic abdominal pain in children. Most cases of abdominal pain in children will have a functional cause.

70 million patient-years in 68 countries, 8 years of experience in Australia

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How to treat – anxiety disorders in children and adolescents Anxiety and anxiety disorders ANXIETY is a normal and useful emotion, important in maintaining safety and improving performance. In children, specific anxieties are part of normal development — fear of strangers in infants; separation anxiety, fear of the dark and monsters in toddlers; and exam and peer concerns in older children. Anxiety disorders are not simply too much anxiety; they are developmentally inappropriate concerns characterised by irrational fears and the avoidance of situations associated with this. Anxiety disorders lead to impairment of day-to-day functioning associated with prolonged and intense distress. When faced with feared situations children may experience a variety of physical symptoms, including a racing heart, difficulty breathing, nausea, dizziness, sweating and shaking. These symptoms resolve rapidly after the child is removed from the feared situation, which indirectly encourages avoidance. When seeing children with anxiety disorders it is important to remember that onethird of all these children have two or more anxiety disorders, and that one-third of all children with an anxiety disorder will also have a major depressive disorder.

The long-term course of anxiety disorders The long-term course of anxiety disorders in children remains uncertain. While the initial anxiety disorder resolves in some children, many others develop new anxiety disorders in adolescence and early adulthood. Studies have shown that individuals who have had anxiety disorders as children have up to a threefold increase in risk of depression, anxiety and substance abuse as adults. Early recognition and treatment of childhood anxiety disorder reduces this risk as well as substantially reducing functional impairment, including learning difficulties, social isolation and school failure.

Early recognition and treatment of childhood anxiety disorder reduces ... the risk of depression, anxiety and substance abuse as adults.

What causes anxiety disorders While the exact cause of anxiety disorders remains unknown, we do know that genetics and environment both play a role. Studies of families have shown that children with anxiety disorders are much more likely to have parents or siblings with anxiety disorders. In adults, twin and adoption studies have confirmed a strong genetic contribution to anxiety disorders, with


| Australian Doctor | 5 October 2007

heritability thought to account for up to 73% of variance in presentation, and environmental factors the rest. It is not specific anxiety disorders that are inherited but rather the tendency towards anxiety, which responds to, and is shaped by, a person’s life experiences.

Separation anxiety disorder Separation anxiety disorder is the most common anxiety disorder in children, with rates of about 4%, primarily in children under 12. It affects both sexes equally, with the most common age of onset between six and eight years. It is important to recognise that separation anxiety is a normal part of development seen in infants and toddlers, particularly around the age of 18 months, and as such is not considered an anxiety disorder. Separation concerns should be considered pathological when they are developmentally excessive, resulting in distress and impairment in day-to-day function. Separation anxiety disorder is characterised by excessive fears about being apart from those most important to the child. The primary fear for the child is that harm may come to their carer or themselves. For example, children might fear that their parents may become the victims of an accident or a murder. Children with separation anxiety disorder are often unable to get to school, stay at friend’s places or school

camps, or even sleep alone. They complain of nightmares and often have multiple physical complaints, including headaches and stomach aches. Nearly three-quarters of children with separation anxiety disorder have associated school refusal. While considered a disorder of childhood, separation anxiety does continue into adulthood but often presents with symptoms of panic disorder and agoraphobia.

Generalised anxiety disorder Generalised anxiety disorder, previously known as overanxious disorder, is the second most common anxiety disorder of children, with rates ranging from 3% to 4%. It is characterised by excessive worrying in a variety of areas, including future events, social acceptability, personal adequacy and competency. Children with generalised anxiety disorder often appear overly mature, attempting to carry out tasks and responsibilities perfectly. They regularly seek reassurance for their worries and doubts and are overly sensitive to criticism. They frequently present with a variety of non-specific physical symptoms, including headache, abdominal pain, hyperventilation (generally expressed as breathlessness and often confused with asthma), dizziness and chest pain.

Social phobia Social phobia, previously known as avoidant disorder

in children, affects about 1% of children and adolescents. It is characterised by avoidance of social or performance situations for fear of being negatively judged or doing something embarrassing. While some children may have very specific fears such as eating or writing in public, generally, most will fear many different types of social situations. Commonly feared situations include public speaking or performing, such as reading in class, social gatherings and interactions with strangers. Untreated social phobia has a high association with substance abuse in late adolescence and adulthood. While it is common for children with generalised anxiety disorder to have social concerns, these are more to do with the quality of their relationships rather than embarrassing themselves. Also, social concerns in generalised anxiety disorder represent one of many worries rather than the only worry.

Post-traumatic stress disorder Made famous in a variety of Vietnam War movies, PTSD is also seen in children exposed to a variety of lifethreatening or potentially life-threatening events. PTSD involves the constant reliving of the traumatic event to which one has been exposed, and avoidance of similar situations. Children with PTSD experience nightmares, recurrent intrusive thoughts and flashbacks (re-experiencing the trau-

matic event as if they are actually there). They are chronically over-aroused, reacting to even minor threatening situations with either explosive rage or complete shutdown. Events leading to PTSD in children include physical and sexual abuse, witnessing domestic violence, natural disasters such as fire and transport accidents.

Selective mutism Selective mutism is characterised by the absence of speech in specific situations and the presence of speech in others. Most children with selective mutism have symptoms of social phobia and it is now hypothesised that selective mutism represents an earlier developmental presentation of social phobia. Selective mutism is less common than social phobia (0.1%) and generally affects younger children, often those from bilingual backgrounds. Children tend to be more reluctant to speak to strangers, adults and in situations away from the family home such as school. Transient selective mutism is often seen in children first starting school (0.7%).

Specific phobia Despite being one of the more common anxiety disorders, specific phobias are among the least studied of childhood anxiety problems. Common themes include fears of needles or blood, fear of animals and fear of heights or flying. Exposure to feared situations commonly results in tantrums,

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panic or avoidance. Because of their circumscribed nature, specific phobias are not associated with the same levels of functional impairment as other anxiety disorders. For this reason children and adolescents with specific phobias do not commonly present for medical attention. The most common reason for seeking treatment in childhood is the presence of needle phobias in children requiring long-term or chronic medical care, including chemotherapy, transfu-

sions of blood products or regular insulin injections.

Obsessive-compulsive disorder — a different type of anxiety While considered part of the anxiety-disorder spectrum, obsessive-compulsive disorder (OCD) has a distinct pattern of aetiology, symptoms, treatment response and longitudinal course that sets it aside from other anxiety disorders commonly seen in children and adolescents. Previously considered a rare though severe illness,

OCD is now recognised as a common disorder, with prevalence rates ranging from 1% to 4%. OCD is characterised by the presence of persistent intrusive thoughts (obsessions) and repetitive behaviours, mental acts or rituals carried out to neutralise obsessional fears or reduce anxiety (compulsions). These thoughts and behaviours generate considerable distress, differentiating them from other repetitive or addictive behaviours such as gambling or substance

abuse, which are experienced initially as pleasurable. While the diagnosis of OCD in adults requires insight into the unrealistic and unhelpful nature of obsessions and compulsions, such insight is not required to make such a diagnosis in children. This insight is frequently absent in younger children, who often see their major problem as not being allowed to carry out their compulsion rather than the obsession or the compulsion itself. In more than 80% of cases

OCD begins before adulthood, often with a chronic course. Commonly it starts around the time of puberty and is somewhat more likely to present in boys rather than girls. Common obsessions include: ■ Contamination and germ fears. ■ Fear of harming or harm befalling oneself or family. ■ Sexual thoughts. ■ Fear of having severe or lethal medical illnesses. ■ Magical thinking regarding colours, lucky numbers or other lucky objects.

Common compulsions include: ■ Hand-washing or cleaning. ■ Checking locks, windows, doors and switches. ■ Repetitive rituals, including tapping, counting and reading. ■ Symmetry or ordering rituals. ■ Constant seeking of reassurance. When considering a diagnosis of OCD it is important to seek corroborative evidence, as many children carry out their rituals in secret to avoid embarrassment.

asthma, epilepsy, hypoglycaemia, migraines and common causes of abdominal discomfort, nausea and vomiting. Almost all these conditions can be ruled out through a thorough history, physical examination and basic blood tests. The treatment of child and adolescent anxiety disorder falls into two broad categories — medication management, and psychological therapies, of which CBT is the best supported by treatment studies.

In general, psychological treatment would be seen as the treatment of first choice. Medication is reserved for children who have failed to respond to, or are unable to tolerate, psychological treatment, are at significant risk due to thoughts of self-harm or suicide, or have comorbid psychiatric illnesses. Even when the decision to use medication is made it is important that this is combined with psychological treatment to improve both

Author’s case study Obsessive-compulsive disorder RW, 15, was living with his mother in regional NSW and in year 8 at his local high school. He was a successful athlete and representative soccer player. He presented with a four-year history of intermittent checking behaviour. When reviewed, RW described a constant need to check his mobile phone to make sure he had not made unintended phone calls, and a constant need to check under his pillow and bedding for insects. His symptoms had arisen six months before presenting, in the context of a severing of contact with his father and the death of his grandmother, whose number he had made an inadvertent mobile phone call to after her death. He described his symptoms as being present predominantly at night, when on his own, but being able to manage his concerns during the day, through distraction. He recognised his concerns as being unreasonable but was unable to resist his symptoms, leading to significant distress and embarrassment. RW had a strong family history of OCD, with his mother and maternal aunt both experiencing similar symptoms during childhood. Previous

symptomatic periods of OCD had responded to brief counselling interventions. At review it was decided to recommend a course of individual CBT because of RW’s high level of motivation and insight and previous response to psychological treatment. Comment

This case highlights the concept of the interplay of genetic susceptibility and environmental stress in the genesis of OCD, particularly in its relapsing and remitting course. Further, it emphasises the need to treat individuals with comprehensive psychological therapies to prevent future relapses, even in cases where symptoms resolve rapidly. This case highlights the hidden nature of OCD. In RW’s case his ability to function academically, athletically and socially and prevent his symptoms when in company hid his intense distress and night-time impairment from OCD. A significant motivating factor for RW in seeking treatment was the offer of a boarding scholarship to a sporting school and his fear of embarrassing himself among his peers.

Assessing and treating anxiety disorders WHEN considering a diagnosis of anxiety it is important to obtain information from a variety of sources, including not only the child but also their parents and school. This is particularly important, as younger children may lack both insight into the nature of their anxiety disorder as well as the capacity to describe their symptoms, while older children may under-report their symptoms because of embarrassment or to avoid

treatment. It is important to remember that many children with

anxiety focus on and complain of the physical symptoms of anxiety rather than the underlying worries leading to these feelings. Similarly some parents are reluctant to consider the possibility of a psychological disorder, particularly when their child is complaining of significant physical symptoms. Despite this it is important to rule out physical conditions that may present with anxiety-like symptoms, including hyperthyroidism,

Effective pain relief

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Before prescribing, please review Product Information and PBS Information found in the primary advertisement in this publication. 1. McKenna F, et al. Scand J Rheumatol 2001;30:11-18. 2. Moskowitz RW, et al. Am J Ther 2003;10:12-20. 3. Emery P, et al. Lancet 1999;354:2106-2111. 4. Simon LS, et al. JAMA 1999;282:1921-1928. 5. Bensen WG, et al. Mayo Clin Proc 1999;74:1095-1105. 6. Kivitz AJ, et al. J Int Med Res 2001;29:467-479. 7. Pincus T, et al. Ann Rheum Dis 2004;63:931-939. Pfizer Australia Pty Ltd, ABN 50 008 422 348, 38-42 Wharf Road, West Ryde NSW 2114. Medical Information: 1800 675 229. Celebrex is a registered trademark of Pharmacia. Pharmacia is a wholly-owned subsidiary of Pfizer Inc. 09/07 PFI0922AD/CJB. ®

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How to treat – anxiety disorders in children and adolescents half-life, in particular, paroxetine, which has been shown to have a half-life in children of about 12 hours. Such agents have been associated with increased agitation, particularly in individuals with comorbid depression. It is worth considering that in individuals with comorbid depression only fluoxetine has been demonstrated to be effective in treating major depression in childhood. Evidence for the efficacy of SSRIs is similarly strong in the treatment of OCD (evidence-based medicine level 1a). In total, seven studies involving 861 participants have demonstrated the efficacy of SSRIs in this condition. Interestingly the size of the treatment effect is modest and less than that seen for clomipramine (supported by level 1b evidence), a serotonin-specific tricyclic antidepressant. Additionally, there is level 1b evidence demonstrating increased efficacy of the combination of medication and CBT over either treatment alone.

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acute outcomes and to reduce the risk of relapse, particularly when medication is stopped.

Cognitive behavioural therapy (CBT) CBT is now the first-line treatment for children with anxiety disorder, OCD and mild to moderate depression. It is a talking-based therapy arising from the link between thoughts, feelings and behaviour. Central to CBT is the belief that thoughts influence behaviours and feelings, that unhelpful thoughts generating anxiety can be identified and challenged, and that by replacing these thoughts with more realistic ones, behaviours and feelings can be changed. In practice CBT involves a clinician teaching children and their families coping skills to address anxiety symptoms, as well as a chance to practise these skills to provide a sense of power over such symptoms. CBT generally involves five specific components: ■ Psychoeducation (of children and their parents about the illness and its treatment). ■ Somatic symptom management (relaxation, controlled breathing and monitoring of somatic symptoms). ■ Cognitive restructuring (identifying and challenging negative thoughts). ■ Exposure (exposure to an increasing hierarchy of feared situations). ■ Relapse-prevention plans. Other elements that have been helpfully integrated with CBT include social skills training, problem solving, anger management, exercise and pleasant events. CBT can be given on an individual or group basis and typically involves anywhere between 12 and 20 sessions of between 30 and 60 minutes, provided on a weekly basis. CBT has been shown in several randomised controlled trials to be helpful in managing childhood anxiety when provided in either an individual or group format. Additionally, the involvement of parents in CBT treatment has been shown to improve outcomes, particularly when parents themselves are anxious. CBT has been shown to be effective in children from seven years of age (evidence-based medicine level 1a). Several child-specific packages have demonstrated efficacy in the treatment of childhood anxiety, including the Coping Cat Program and its Australian equivalent the Coping Koala Program. More recently the Coping Koala Program has been


Dosage and side effects

CBT involves a clinician teaching children and their families coping skills to address anxiety symptoms.

| Australian Doctor | 5 October 2007

developed into the Friends for Life Program — a CBT package for preventing and treating childhood anxiety (see Online resources, page 37). Other commonly used programs include the ‘Cool Kids’ program developed through the Macquarie University anxiety research unit (see Online resources, page 37). Accessing CBT

In November 2006 the Federal Government introduced Medicare rebates for psychological services provided by psychologists registered through their state or territory registration board. Rebates are available for up to 12 individual or group treatments per calendar year when individuals are referred by their GP, psychiatrist or paediatrician. Information about this service can be obtained from the Australian Psychological Society (see Online resources, page 37). In addition to privately provided psychological services, treatment for anxiety disorder in children is provided through several specialist university-based research units.

SSRIs In 2003 the UK Department of Health issued a warning to doctors against prescribing any SSRI except for fluoxetine in depressed children and adolescents under 18. Following this, in September 2004 the US Food and Drug Administration mandated that a ‘black box’ warning be put on the label of all

SSRIs, indicating the increased risk of suicidal thoughts and behaviour in youth taking these medications. These warnings were based on a meta-analysis of 24 published and unpublished placebo-controlled trials assessing the use of antidepressants in treating children and adolescents with depression.1,2 It is important to note that this analysis did not indicate an increased risk of suicidal thoughts in treatment trials of anxiety disorders or OCD. It is also important to recognise that evidence for the efficacy of the SSRIs is greatest in the non-OCD anxiety disorders, intermediate in OCD and modest in adolescent depression.2 Despite these concerns, SSRIs are the medications of choice in the treatment of anxiety disorders in children and adolescents because of their demonstrated efficacy and safety. They act by increasing serotonergic activity in the brain by blocking the reuptake of serotonin by presynaptic neurons. While some limited research indicates altered serotonergic activity in both anxiety and depression, there is no means of measuring serotonergic level on a whole-brain level. SSRIs were initially trialled in depression and anxiety, based on the efficacy of tricyclic antidepressants, which, among other actions, increase synaptic serotonergic activity. It is felt that alterations in serotonergic activity selectively target

different regions of the brain in depression and anxiety, with some degree of overlap. The use of SSRIs in children with anxiety disorder is supported by level 1a evidence. Since 1990 there have been five double-blind, randomised placebo-controlled trials of SSRIs in children and adolescents. These studies have involved 561 children aged between five and 17 years, with a variety of anxiety disorders, including selective mutism, generalised anxiety disorder, social phobia and separation anxiety disorder. All five trials have shown the SSRIs paroxetine, fluoxetine, sertraline and fluvoxamine to be significantly superior to placebo. In addition, all five studies have demonstrated the SSRIs to be well tolerated and safe. Which SSRI?

There is no empirical evidence that one SSRI is more effective than another in the treatment of anxiety disorder in children and adolescents. The main differences between medications revolve around their half-life and preparations. Fluoxetine has a half-life of up to two weeks, compared with one day or less for sertraline and fluvoxamine — particularly useful for adolescents, who often miss or forget their medication. Also, fluoxetine is available in a liquid form to simplify smaller doses. In children and adolescents care needs to be taken with agents with a short

If prescribing SSRIs in children and adolescents it is worth remembering that up to 80% of individuals will experience mild transient side effects, the most common of which are abdominal discomfort, headache and sleep disturbance. While most side effects settle within 3-4 days, up to one in 12 children experience behavioural agitation or hypomania necessitating stopping the medication. This complication can be minimised by the use of low starting doses of medication, with gradual increases in dosage as required. In general most adolescents would start on half the normal adult starting dose of medication, while prepubertal children would start on one-quarter of the adult dose. In most cases adolescents need to be increased to a standard adult dose of medication. It is important to remember that effective SSRI doses in treating anxiety disorders are higher than that recommended for depression. As in adults, SSRIs are not lethal in overdose. Two other important side effects in children and adolescents taking SSRIs are sexual dysfunction and withdrawal symptoms on stopping medication. While rates of sexual dysfunction in adolescents taking SSRIs are unclear, it is a clinically significant phenomenon, particularly in young boys, who are unlikely to remain compliant with medication or discuss this problem if it occurs. Withdrawal phenomena,

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including agitation, restlessness, poor concentration, fatigue and insomnia, are experienced if antidepressant treatment is stopped abruptly. Also of concern is the possible increased risk of relapse associated with stopping medication rapidly. Withdrawing medication over a period of about two weeks reduces withdrawal symptoms. Though SSRIs have been demonstrated to be efficacious in treating anxiety disorders in the short term there is little evidence to guide us with regard to their long-term efficacy. Based on the action of

SSRIs in depression and in anxiety disorders in adults, treatment for a minimum of 6-9 months is recommended.

enough to be a significant consideration in individuals with epilepsy. The SSRIs have no impact on cardiac conduction, heart rate or blood pressure.

SSRIs and concurrent medical illness

Tricyclic antidepressants

In general, SSRIs are safe in the chronically medically ill. They are largely metabolised by the liver, with their metabolites excreted by the kidneys. For this reason dosages should be reduced in individuals with renal and liver impairment. Theoretically the SSRIs may marginally decrease seizure threshold, although in reality this is not great

Since 1970 there have been five double-blind, randomised controlled trials of tricyclic antidepressants in child and adolescent anxiety disorders. Interestingly all of these trials have been in children with school refusal. In only two of these trials were tricyclic antidepressants shown to be significantly superior to placebo. As evidence for the effi-

cacy of tricyclic antidepressants remains equivocal, they are at best a second-line agent for the treatment of childhood anxiety disorders, with use confined to specialist clinics. This is particularly so, given that they have been associated with seven unexplained sudden deaths in the US and are potentially lethal in overdose. The exception to this rule is the use of clomipramine in OCD, which has been demonstrated in five randomised controlled trials to be superior to placebo. Further, these trials have suggested greater efficacy for clomipramine in the treat-

ment of OCD, compared with SSRIs (evidence-based medicine level 1b).

Benzodiazepines There have been four controlled trials of benzodiazepines in children and adolescents with anxiety, involving either clonazepam or alprazolam. These trials have not demonstrated a significant difference between benzodiazepines and placebo. Given problems of sedation, dependence, tolerance and withdrawal, there is little role for benzodiazepines in the treatment of child and adolescent anxiety.

Author’s case studies School refusal from separation anxiety KAREN, 14, was living with her parents and younger sister and in year 9 at her local high school. She presented in crisis, complaining of low mood, suicidal thoughts and auditory hallucinations. On review she described a fouryear history of poor school attendance. She had struggled to attend school regularly since year 6 and in high school had failed to attend more than 50% of scheduled classes. She initially missed school because of problems of recurrent sore throats. Over time she developed multiple non-specific symptoms, including headaches and nausea. Multiple medical investigations and specialist reviews failed to identify a specific cause for her illness. Over time Karen became increasingly socially isolated and sad, refusing contact with her friends and withdrawing from her favoured activities, including netball and the youth group. She became increasingly resistant to attending school and unable to spend time away from her parents. Attempts to have her attend school resulted in significant distress, including voices telling her to hurt herself. At these times Karen described trouble breathing, tachycardia, nausea, tremor and faintness. Interestingly, her symptoms resolved rapidly when removed from school by her parents and were only obvious when separated from her parents. She did not experience auditory hallucinations outside of her periods of panic and did not experience other psychotic symptoms. She was initially referred for psychological support with regular CBT,

assistance from her school counsellor and a graded reintroduction to school. Despite this assistance she did not improve significantly and was started on fluvoxamine 50mg/day. Over a period of four weeks Karen’s mood and anxiety improved significantly such that she was no longer depressed or suicidal and had stopped hearing voices. She remained anxious about school though, was attending two periods a day and had not had a panic attack for the previous two weeks. Comment

Karen’s presentation is similar to that seen in many young adolescents with school refusal and separation anxiety. Generally children in late primary school will present with school absenteeism on the basis of

Conclusion ANXIETY disorders are common in children and if left untreated may persist into adolescence and adulthood. They respond well to treatment and the evidence is accumulating that CBT, medication and other approaches can be helpful. There is a tendency for these children not to present with anxiety but with school refusal, physical symptoms and sometimes speech problems. Anxiety disorders can be anxiety provoking in us until we are familiar with the treatments available. In fact, treating anxiety is both rewarding and valuable long term in preventing the problems anxiety causes in adolescence and adulthood.

recurrent medical complaints. In such cases as Karen’s, when history, examination and investigations are unremarkable, it is always worth considering whether such symptoms are anxiety based, particularly when there is significant time away from school. In such cases it is extremely useful to take a history of school performance and social interactions, including bullying. It is not unusual for children to be relatively free of symptoms on weekends and school holidays and to have problems with learning and social interactions. Other considerations include fear of separating from parents or carers, including not only difficulties attending school but difficulties attending friends’ parties and sleep-overs. This case also highlights that cont’d page 37

No increased CV risk compared to non-selective NSAIDs1-8†



†CV risk = risk of cardiovascular thromboembolic events. Non-selective NSAIDs = naproxen, diclofenac and ibuprofen at commonly used doses. Celebrex is contraindicated for the peri-operative treatment of pain in patients undergoing coronary artery bypass graft (CABG) surgery, in patients with unstable or established ischaemic heart disease, peripheral vascular disease and/or cerebrovascular disease. Celebrex should be used with caution in patients at high risk of cardiovascular disease including those with significant and multiple risk factors. The lowest possible dose should be used for the shortest possible duration. Before prescribing, please review Product Information and PBS Information found in the primary advertisement in this publication. 1. McGettigan P, et al. JAMA 2006;269:1633-1644. 2. White WB, et al. Am J Cardiol 2002;89:425-430. 3. Solomon DH, et al. Circulation 2004;109:2068-2073. 4. Whelton A. Presented at American College of Cardiology (ACC), 53rd Annual Scientific Meeting; March 2004; New Orleans, LA. Abstract. 5. Graham DJ, et al. Lancet 2005;365:475-481. 6. Kimmel SE, et al. Ann Intern Med 2005;142:157-164. 7. White WB, et al. Am J Cardiol 2007;99:91-98. 8. White WB, et al. Am J Cardiol 2003;92:411-418. Pfizer Australia Pty Ltd, ABN 50 008 422 348, 38-42 Wharf Road, West Ryde NSW 2114. Medical Information: 1800 675 229. Celebrex is a registered trademark of Pharmacia. Pharmacia is a wholly-owned subsidiary of Pfizer Inc. 09/07 PFI0921AD/CJB. ®

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hallucinations are not always part of a psychotic illness. In children, particularly young children, hallucinations are commonly seen in anxiety. In such cases they occur in times of panic or high stress but are not otherwise present and not associated with other psychotic symptoms, including delusions and thought disorder.

Anxiety from multiple causes, with nausea and vomiting Haverj, 12 and of Armenian background, lived with her mother and brother and attended year 7 at a large regional Catholic high school. She presented with recurrent nausea, weight loss and intermittent vomiting. Examination and investigations including basic blood tests (FBC, LFTs, TFTs, ESR, blood sugar level, amylase and electrolytes, urea and creatinine) and urine screens were unremarkable. Haverj’s symptoms were associated with increasing school absences. On questioning, Haverj complained of rapid fullness and nausea on eating, with intermittent vomiting when forced to eat when full. She had not experienced symptoms of constipation or diarrhoea. She denied concerns about fatness and expressed a desire to put on weight. A review of Haverj’s diet revealed that she consumed small amounts of food infrequently, with a preference for chicken nuggets, chips, chocolate spread sandwiches and flavoured milk. She

denied worry or sadness and expressed a desire to return to school after her nausea settled. A more thorough review of Haverj’s history revealed that her father had died when she was 10. Since the death of her father Haverj had become the major spokesperson for the family because of her mother’s inability to speak English. Also, she had recently moved from her small local public school to a large regional Catholic high school, leaving behind many of her primary school friends. Since this transition she had become increasingly socially isolated and increasingly focused on her schoolwork, spending many hours

anxiously completing her school assignments. Comment

When assessing children like Haverj it is important to exclude causes of nausea and weight loss, including infection, reflux, peptic ulcer disease and malabsorption. In most presentations this can be achieved with a thorough history, examination and basic blood tests. Even when physical causes have been apparently excluded, it is important to remember that the diagnosis of a psychiatric illness needs to be based on clear precipitants. In Haverj’s case there were several stresses that commonly precipitate anxiety disorders in children,

including the death of a parent, the transition to high school, cultural conflict with parents and the loss of friends. Several other issues are highlighted in this case. First, it is important to understand that not all cases of eating difficulties and weight loss are anorexia nervosa. In Haverj’s case a preference for high-fat foods was inconsistent with such a diagnosis. Also, it is important to recognise that anxious children frequently present complaining of physical symptoms and often deny anxiety or depression. In cases such as Haverj’s it is important to consider behaviour as well as expressed concerns, including school refusal. The difficulty in cases such as Haverj’s is the lack of motivation or target symptoms to address with psychological therapy. In such cases it is important to engage parents and to consider medication. Psychological therapy needs to be more generic and focus on relaxation, control of panic symptoms (nausea and vomiting in this case) with controlled breathing, social skills, and planning and organisation to address school and work concerns. Focusing on areas of importance to the child, including schoolwork, is helpful in engaging patients in therapy. Haverj was started on fluvoxamine, which, with a trial of refeeding and general support with social skills and schoolwork, reversed her symptoms. Medication was continued for 12 months.

References 1. Mann J, et al. ACNP Task Force report on SSRIs and suicidal behaviour in youth. Neuropsychopharmacology 2006; 31:473-92. 2. Bride JA, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in paediatric antidepressant treatment; a meta-analysis of randomized controlled trials. Journal of the American Medical Association 2007; 297:1683-96.

Further reading Available on request from [email protected]

Online resources ■

GP’s contribution

Case study


JAY, 10, was brought in by his mother, Vicki, complaining of recurrent headaches. Vicki says the school has rung her five times in the first two weeks of term because of Jay’s reports of headache. On each occasion Jay appeared well and the headaches resolved quickly when he got home. Jay has been a frequent attender since early childhood. His parents separated acrimoniously when he was five. He was investigated for recurrent abdominal pains around this time and no organic cause was found.

Examination was normal and a headache diary was completed over the next fortnight. An organic explanation for the headache appeared highly unlikely.

Questions for the author What initial questions for both Jay and Vicki are useful to elucidate a possible history of separation anxiety disorder? Separation anxiety disorder is characterised by excessive fears about being apart from those most important to the child. The primary fear for the child is that harm may

come to their carer or themselves. In children such as Jay it is important to ask not only about difficulties getting to school but also difficulties with sleep-overs, visiting friends houses or with school camps. Children with separation anxiety will commonly call parents late at night to be picked up and returned home in such situations. Important questions to ask children are whether they worry about something bad happening to their mum or dad, such as their parents getting hurt or sick.


compared to non-selective NSAIDs

Resources The University of Sydney anxiety clinic based at the Children’s Hospital at Westmead is currently recruiting children for a free treatment trial of OCD. Contact Dr Angela Dixon or Ms Karen Munro: (02) 9845 2005.

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Superior upper and lower GI safety 1-5

Friends — preventing and treating anxiety in children and youths: Australian Psychological Society: Macquarie University anxiety research unit: MUARU



†GI safety = incidence of clinically meaningful GI events, i.e. ulcer complications (bleeding, perforation, gastric outflow obstruction). Celebrex does not eliminate the risk of GI haemorrhage. Vigilance should always be exercised in follow-up. ‡Non-selective NSAIDs = naproxen, diclofenac and ibuprofen at commonly used doses. Before prescribing, please review Product Information and PBS Information found in the primary advertisement in this publication. 1. Mamdani M, et al. BMJ 2002;325:624-627. 2. Singh G, et al. Am J Med 2006;119:255-266. 3. Goldstein JL, et al. Am J Gastroenterol 2000;95:1681-1690. 4. Deeks JJ, et al. BMJ 2002;325:619-623. 5. Rahme E, et al. Rheumatology (Oxford) 2007;46:265-272. 6. Goldstein JL, et al. Clin Gastroenterol Hepatol 2005;3:133-141. 7. Goldstein JL, et al. Aliment Pharmacol Ther 2007;25:1211-1222. Pfizer Australia Pty Ltd, ABN 50 008 422 348, 38-42 Wharf Road, West Ryde NSW 2114. Medical Information: 1800 675 229. Celebrex is a registered trademark of Pharmacia. Pharmacia is a wholly-owned subsidiary of Pfizer Inc. 09/07 PFI0919AD/CJB. ®

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How to treat – anxiety disorders in children and adolescents with anxiety disorders, medications are indicated if children are too distressed to participate effectively in therapy, particularly when that distress is associated with thoughts of, or actual, selfharm, or when children fail to respond to psychological treatment and continue to experience distress and impairment Medication should always be accompanied by ongoing psychological treatment, although it is often worth having children on medication for up to four weeks before resuming therapy to allow the medication a chance to begin to work.

from previous page

In Jay’s case it would be important to distinguish separation fears from worries about schoolwork and negative interactions with other children at school. In the latter case we would expect Jay to be able to spend time away from home with friends and relatives, particularly sleep-overs, without concern. What resources, especially web-based, are available for Jay’s parents to better understand his anxiety disorder? Macquarie University has an excellent Internet site that provides useful information for parents about anxiety disorders in children and adolescents, including information about different types of anxiety disorders and treatment programs for anxiety disorders (see Online resources, page 37).

General questions for the author

Macquarie University anxiety research unit web site. Jay’s disappointing response to therapy. What criteria should we use to decide if SSRI medication would be indicated in Jay’s case? While CBT is the firstchoice treatment for children

Jay was referred to a child psychologist, and he attended 12 weekly CBT sessions. The psychologist expressed concerns about

How common are specific phobias in primary-schoolaged children? How are these phobic disorders best managed? Specific phobias are relatively common, affecting about 10% of the population. While there are limited data from studies of children, studies of young adults

How to Treat Quiz


Anxiety disorders in children and adolescents — 5 October 2007

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1. Which TWO statements are correct regarding anxiety disorders in children? ❏ a) They respond well to treatment ❏ b) They affect about one in every 100 children ❏ c) It is unusual and abnormal for young children to have a variety of specific anxieties as they grow ❏ d) Anxiety becomes a disorder when the amount of distress and its persistence interfere with normal daily activities 2. Anxiety disorders in children can be treated effectively with which THREE therapies? ❏ a) Cognitive behaviour therapy (CBT) ❏ b) Insight-oriented psychotherapy ❏ c) Family therapy ❏ d) Medication 3. Tyler, nine, presents with episodes of abdominal pain and headache over the past 5-6 months. Her mother has recently returned to work after maternity leave and has a past history of anxiety and depression. Tyler fears for her mother and the baby when she is away from them. At a sleepover last weekend she became distressed and tearful, needing to be picked up early. Which TWO statements are true? ❏ a) Tyler should be assessed for physical causes of abdominal pain and headache ❏ b) In children somatic symptoms are an uncommon manifestation of anxiety ❏ c) Tyler is at risk of developing tantrums or oppositional behaviour ❏ d) You can reassure Tyler’s mother that her

behaviour is appropriate for her age and is likely to improve with time 4. Which THREE diagnoses are the most common anxiety disorders in children of Tyler’s age? ❏ a) Post-traumatic stress disorder ❏ b) Separation anxiety disorder ❏ c) Panic attacks ❏ d) Generalised anxiety disorder 5. Regarding Tyler’s possible anxiety disorder, which TWO statements are true? ❏ a) She has about a 30% risk of concurrent depression ❏ b) Her mother’s history of anxiety does not increase her own risk of developing an anxiety disorder ❏ c) Separation anxiety disorder is more common in girls than boys ❏ d) Tyler may begin to refuse to go to school 6. James, 14, was required to give a class presentation. Two years ago he had tripped in class and several children had laughed. James was extremely anxious despite being well prepared for the task. He felt panicky and unable to do it. When called, he was clearly terrified. His teacher suggested he read aloud his prepared notes while sitting at his desk. He managed to complete his talk but was exhausted afterwards. Which TWO statements are true of social phobia? ❏ a) It affects about 4% of children and

indicate that specific phobias of animals and environmental features such as storms, water or heights have their onset between six and eight years of age, while fears of blood and injections begin around nine years and situational phobias of cars and lifts begin in the early teens. Specific phobias should be treated when they are causing significant impairment in day-to-day functioning or distress. They respond to the same treatments as other anxiety disorders, including CBT and antidepressant medication. In general practice, parents occasionally voice their concerns about ritualistic behaviours in toddlers and early primary-school-aged children, such as obsessive rattling or shaking of objects, children talking to themselves, and obsessive hair twirling. How concerned should we be with these behaviours? When should we refer children with isolated obsessive ‘habits’? Several conditions present

with obsessive behaviour in young children, including the habit disorders, the autistic spectrum disorders and less commonly OCD. The habit disorders are thought to be early manifestations of anxiety disorders and include skin picking as well as trichotillomania. Children presenting with these disorders may present with multiple skin lesions, bald patches or missing eyebrows. These disorders are clinically significant and need to be treated with CBT. In the autistic spectrum disorders, in addition to repetitive behaviours children have very significant social impairment and are intolerant of change. In young children OCD is characterised by compulsive behaviours that interfere with normal routine. Attempts to interrupt these behaviours result in tantrums or distress. In the absence of these additional symptoms, repetitive behaviours are best watched and usually resolve as children get older.

Complete this quiz to earn 2 CPD points and/or 1 PDP point by marking the correct answer(s) with an X on this form. Fill in your contact details and return to us by fax or free post.

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adolescents ❏ b) Children tend to fear criticism or embarrassing themselves in front of others ❏ c) James is at higher risk of future drug use ❏ d) It presents similarly to generalised anxiety disorder and as such it is nearly impossible to differentiate between the two 7. Regarding the treatment of social phobia in James, which TWO statements are true? ❏ a) CBT is the treatment of first choice ❏ b) CBT is not effective until at least age 12 ❏ c) Antidepressant medication is avoided because of increased risk of dependence when started in such early years ❏ d) Involving James’ parents would be helpful, particularly if they too are anxious 8. If medication is required for James, which TWO statements are true? ❏ a) An SSRI would be most appropriate ❏ b) The medication of first choice is paroxetine, because of its short half-life ❏ c) The common side effects of SSRIs in children are short lived and include abdominal discomfort, headache and sleep disturbance ❏ d) As they have long-term safety data available, tricyclic antidepressants continue to be most widely used in the treatment of anxiety disorders in children 9. Dean, 12, has developed anxiety and is preoccupied with homework and security. After school he returns to his locker repeatedly to

ONLINE for immediate feedback check he has all his books and frequently misses the bus. At night he gets out of bed often to check that his bag is packed and that his work is completed. His locker and bag both have two locks. He has complex rituals involving his bedroom and how his belongings are placed inside. His family is very frustrated. Which TWO statements about obsessivecompulsive disorder are true? ❏ a) It is uncommon in children ❏ b) It frequently begins at puberty and persists into adult years ❏ c) It is more commonly a problem in boys ❏ d) ‘Compulsions’ describe persistent, compelling and intrusive thoughts, and ‘obsessions’ describe the need to perform rituals to neutralise fear and reduce anxiety 10. Dean was referred for CBT. This therapy involves which TWO specific components? ❏ a) Play therapy, which teaches children to express their emotions through such activities as drawing, story telling and sand play ❏ b) Cognitive restructuring to identify and challenge negative thoughts, replacing them with more realistic thoughts to change behaviours and feelings ❏ c) Psychodynamic psychotherapy, the primary focus of which is to reveal the unconscious content of behaviours in an effort to alleviate anxiety ❏ d) Somatic symptom management, including relaxation, controlled breathing and monitoring of somatic symptoms

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HOW TO TREAT Editor: Dr Heather Knox Co-ordinator: Julian McAllan Quiz: Dr Heather Knox

The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.

NEXT WEEK Children with chronic abdominal pain are frequently seen in general practice and their management can be challenging. While in the vast majority the pain will be functional rather than organic, functional abdominal pain is nevertheless often a source of anxiety and distress for patients, parents and clinicians. Learn more on the best approach to chronic abdominal pain in children in next week’s How to Treat. The authors are Dr Katie Frith, paediatric registrar, Queen Elizabeth II Hospital, Welwyn Garden City, UK; and Professor Elizabeth J Elliott, professor in paediatrics and child health, the University of Sydney; and consultant paediatrician, the Children’s Hospital at Westmead, NSW.


| Australian Doctor | 5 October 2007

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