Cacp Chapter 4 Anxiety and Kids

7/27/2019 Cacp Chapter 4 Anxiety and Kids

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ANXIETY AND KIDSCACP CHAPTER 4


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PREVALENCE?

5-18% OF CHILDREN

THE MOST COMMON PSYCHIATRIC

ILLNESS IN KIDS

RESULT IN ACADEMIC AND SOCIAL

IMPAIRMENT

OFTEN PERSIST INTO ADULTHOOD


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Diagnostic Issues


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OCD For adults 2.5% lifetime prevalence rate

1-2 % for children and adolescents

Usually starts in early adolescence or

adulthood

Up to 1/3 before the onset of puberty

Age pattern for males: 6-15 years old

Age pattern for females: 20-29 years oldWith childhood onset, more common in

boys than girls (3:2)


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Considerations Compulsions must be so time consuming that

they take up one hour + per day, routines areintrusive, occupational or relational functioningare impaired.

Obsessive thoughts are more than normal dailyworry or concern

Adults recognize at some time that theirobsessions and compulsions are unreasonable

Kids dont have that awareness.


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In a small number of juvenile

patients.

OCD Is associated with streptococcal

infections like scarlet fever or strep throat.

(PANDAS: PEDIATRIC AUTOIMMUNE

NEUROPSYCHIATRIC DISODERS

ASSOCIATED WITH STREPTOCOCALINFECTIONS)


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Panic Disorder (with or without

agoraphobia) Childhood onset is rare for panic disorders

1-2 % lifetime prevalence

Onset is usually late adolescence to mid-30s

Because its so rare in kids, emergence of panicsymptoms can be an indication of severe

psychosocial stressors requiring a thorough

evaluation.


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Panic and kids, cont.

Anticipatory anxiety and panic areassociated features

May present as school failure, low selfesteem, and social isolation, crying,tantrums, freezing or shrinking fromsocial situations

Must occur in peer settings, not justw/adults


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Specific Phobias (simple phobias)

Lifetime prevalence rates range from 5-12%.

Initial symptoms usually occur in childhood(especially is object, situational, animal,and blood injection types)

Specific phobia is an enduring andunreasonable fear of a specific object orsituation that generally does not pose any

real danger (or poses only slight danger)


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MUST LOOK:

For underlying co-morbidities as seen in

many cases.


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GAD

Lifetime prevalence 5%

50% report childhood onset

Anxiety and dread are prominent and interferew/normal functioning, including work and socialrelationships

Symptoms: muscle tension, headaches, nausea,sweating, increased HR, exaggerated startleresponse.


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PTSD

Lifetime prevalence: 8%

Onset can be any age, but usually within

the first 3 months of a traumatice event

Develops when:

An event involving serious harm occurredor was perceived to threaten to occur; a

situation was witnessed; and the response

involved fear, helplessness, and horror.


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PTSD includes:

Reliving the event

Persistent avoidance and limited

responsivenessperson avoids situations and

activities associated w/event

Hyper-arousal including insomnia, irritability,

concentration problems, and exaggerated startleresponse. Kids may have stomach problems and

headaches


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Inhibited Temperament

(NOT DSM IV-TR) Fear of unfamiliar situations

Timid and shy

Behavioral inhibitions

Autonomic arousal (Sympathetic NS)

Associated w/significant anxiety disorder later inlife.


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Neurobiology


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Neurobiology of OCD in Kids

Family loading (genetic vulnerability)

Basal ganglia

Frontal Lobes (normally inhibits urges and the moreinstinctive drives and urges)

Maladaptive neural pathways

Pharmacological Treatment Effectiveness

(Because of selective responses to meds,

OCD is strongly suggestive of biological etiology)!


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Neurobiology of Other Anxiety

Disorders

Genetic predisposition (probably)

Other than OCD, most widely studiedAnxiety Disorder is Panic Disorder


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Neuro-anatomical hypothesis for PD

1. Locus Coeruleus: Increases

norepinephrine release, results in physiological andbehavioral arousal.

2. Peri-aquaductal gray areas: mediates defensive

behaviors, postural freezing.

3. Parabrachial nucleus: causes increased respiration.

4. Hypothalamic paraventricular nucleus: activates theHPA axis and release of adrenotorticoids.

5. Hypothamamic lateral nucleus: activates thesympathetic nervous system.


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Another naturally occurring biochemical factor

in anxiety is

GAMMA-AMINO-BUTERIC-ACID(GABA)

GABA reduces brain excitability

GABA promotes the passage of chloride

ions into the nerve cells and makes them

less excitable


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GABA, cont.

The receptor complex to which GABA

binds also contains a receptor site to

which BENZOS attach (BZs)

In theory, a person should be more or less

affected by stress depending on an

abundance or deficit of this chemical.


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OCD

SSRIs =first line of response

Chlormipramine (TCA) with serotonergicactivity (original studies in France beforemeds were widely used for OCD)

Response rate: 50-75% w/gradualsymptom reduction


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Fig. 2-5, p. 44


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Pharmacology for OCD

Time Course:

6 to 10 weeks

18-24 weeks

52 + Weeks & longer

Symptom Reduction:

25-30% reduction

40-50% reduction

50% reduction


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Other Information: Doses to treat OCD are generally HIGHER than

doses to treat depression.

See p. 59 CACP

Until recently, evidence for efficacy of TX kidsw/OCD was not clear but:

The Pediatric OCT Treatment Study (funded by

NIMH) has provided clarity.

Findings suggest that TX for pediatric OCDbegin with CBT alone or CBT combined with an

SSRI.


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Pharmacology for Other Childhood

Anxiety Disorders

The most convincing evidence to support

the use of MEDS in TX childhood anxietydisorders comes from a 2001 study by the

RESEARCH UNIT OF PEDIATRIC

PSYCHOPHARMACOLOGY


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Outcomes

Anxiety Symptoms reduction was noted in76% of fluovoxamine subjects (Luvox).

Findings strongly suggest a role for theuse of fluvoxamine to treat anxietydisorders, social phobia, and childhood

separation disorder (probably similarresults with other SSRIs per the authors.

(Preston, et al. 2006).


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Remember the concept of off label

use In spite of the lack of many evidenc based

studies, clinicians often use SSRIs to treat avariety of childhood anxiety disorders and allSSRIs seem to be effective in treating panic,

social phobia, and GAD.

When prescribed, initial doses should be lowwith slow titration.

For most childhood anxiety, psychotherapy,including CBT is the treatment of choice.


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Remember the Guiding Principle:

For Children and Adolescents,

pharmacologic treatment almost always is

accompanied by psychotherapy, includingfamily treatment,

Cacp Chapter 4 Anxiety and Kids

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