A Collaborative Approach to Childhood Anxiety

By Amy L. Lee, PhD, and Joseph M. Austerman, DO

Anxiety disorders involve excessive fear or worry about possible future threats, associated physiologic arousal and related behavioral disturbances.

Children with anxiety disorders often display emotional distress including crying, tantrums or extreme emotional outbursts. They also may engage in pervasive avoidance and vigilance behaviors. In addition, children experience physical symptoms including muscle tension, abdominal pain or sleep disturbance. These children typically hold a variety of mistaken beliefs or cognitions associated with their anxiety.

Common anxiety disorders exhibited in childhood and adolescence include separation anxiety disorder, selective mutism, phobias, generalized anxiety disorder and panic disorder.

High Prevalence and Physical and Functional Impacts

Anxiety disorders are widely recognized as the most common mental health problem experienced by children and adolescents. The prevalence of anxiety disorders among those younger than 18 years is estimated to be between 5.7 and 12.8 percent, which is a larger proportion than for attention deficit hyperactivity disorder or mood disorders. Anxiety disorders also tend to be chronic and when left untreated can lead to increased risk for adult psychiatric disorders.

Childhood anxiety disorders are often associated with school absenteeism and poor or lower than expected academic performance. Anxiety in children can lead to avoidance of activities associated with improved physical and mental health, such as exercise, play and social activity.

Anxiety disorders also are associated with physical complaints such as recurrent abdominal pain, nausea, limb pain, shortness of breath and headache. Due to the ambiguity of such symptoms, children may be subjected to potentially unnecessary medical tests and physician visits. Among children with medical illnesses such as asthma or gastrointestinal illnesses, anxiety symptoms may go untreated or unnoticed, leading to increased distress and decreased functioning. The complex relationship between anxiety and physical symptoms often leads to more healthcare utilization and a pattern of less than optimal symptom management.

Collaborative Treatment and Parent Training

Effective treatments for anxiety disorders combine cognitive behavioral therapies (CBT), parent training and medication. At Cleveland Clinic, we are developing collaborative treatments that teach children and youth how to manage their anxiety symptoms while instructing parents to support and participate in treatment goals.

With the benefit of electronic medical records, treatment goals are easily shared with key pediatric providers, allowing for complementary therapies and collaboration. For example, pediatricians, child psychologists and child psychiatrists can work together to positively reinforce a patient’s progress in managing fears or physical symptoms while also managing medical or medication aspects of treatment.

As one example, a brief group CBT protocol has been developed for initiating and reinforcing CBT for pediatric anxiety disorders. The four- to five-week program uses a didactic, child-centered approach in teaching the basic skills of CBT for anxiety ‒ for example, body calming, thought changing and behavioral practice. Each skill set is taught in weekly modules, with practice during group therapy sessions and weekly homework practice. Children are taught the relationship between body, mind and behavior in the first session and participate in reviews at each subsequent session as new anxiety management skills are added (Figure 1).

For example, one module teaches children to change anxious thought patterns to more neutral or positive ones. Engaging materials are used to teach children the nature of common thinking errors associated with anxiety. These thinking errors are referred to as “worry thoughts.”

Using a game-like sorting task, children learn to differentiate worry thoughts ‒ for example, “What if that dog chases me?” ‒ from neutral thoughts ‒ for example, “Some dogs are nice.” Children also learn to replace worry thoughts with “worry erasers,” and are given examples for homework practice.

The skills learned in group therapy are reviewed with parents each week. The parenting skills reviewed include methods for practicing with children at home, common parenting challenges and methods for responding to anxiety symptoms as they emerge. Parents also are involved in the weekly homework practice assigned to their child.

Figure 1. Anxiety cycle.

Medications

When administered in conjunction with psychotherapeutic modalities, psychopharmacologic options have shown benefit for pediatric anxiety disorders. Currently, selective serotonin reuptake inhibitors (SSRIs) are considered the first-line psychopharmacologic treatment. It is generally thought that the response rate is similar for all SSRI medications. Several randomized placebo-controlled trials have demonstrated the efficacy of these medications over placebo. Other studies have shown that the combination of SSRIs and CBT provides superior anxiety control over medications or CBT alone. SSRIs are generally well-tolerated, but common side effects and the FDA package insert warning should be reviewed carefully with parents and patients.

The use of benzodiazepines is not supported in the pediatric literature. Several older studies show conflicting results regarding efficacy, and there is an increased risk of benzodiazepine addiction as well as behavioral disinhibition associated with their use.

Older medications such as clomipramine or imipramine have shown efficacy in pediatric anxiety disorders, but due to complications in their use ‒ such as the need for cardiac monitoring, increased side effect profile and toxicity potential ‒ these medications have been relegated to use in treatment-refractory moderate to severe anxiety.

Dr. Lee is a pediatric psychologist with Cleveland Clinic Children’s. Her specialty interest is the diagnosis and treatment of childhood anxiety disorders as well as frequently co-occurring disorders such as ADHD, autism spectrum disorder and behavioral disorders.

Dr. Austerman is a staff physician in Cleveland Clinic’s Center for Pediatric Behavioral Health and Section Head of Child and Adolescent Psychiatry. His specialty interest is the acute care of children and adolescents with psychiatric disorders.

SUGGESTED READING

–Ramsawh HJ, Chavira DA, Stein MB. Burden of anxiety disorders in pediatric medical settings: prevalence, phenomenology, and a research agenda. Arch Pediatr Adolesc Med. 2010;164(10):965-972.

–Compton SN, Walkup JT, Albano AM, et al. Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods. Child Adolesc Psychiatry Ment Health. 2010;4:1.

-Weersing VR, Gonzalez A, Campo JV, Lucas AN. Brief behavioral therapy for pediatric anxiety and depression: piloting an integrated treatment approach. Cogn Behav Pract. 2008;15:126-139.

-Negreiros J, Miller LD. The role of parenting in childhood anxiety: etiological factors and treatment implications. Clinical Psychology: Science and Practice. 2014;21(1):3-17.

–American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th Ed. Washington, DC: American Psychiatric Association; 2013.