Anxiety: Pediatric Mental Health Minute Series

Anxiety is a normal human emotion, triggered by expected challenges (taking a test) and the reaction is proportional. Normal anxiety can be severe and chronic if the life challenge is severe and chronic.

Scope in Pediatrics

• Pathological anxiety is triggered by normal developmental experiences (ie, going to school, ordering food in a restaurant); the reactions are disproportionate, unexpected and highly stereotypical across children.
• Family history is a key predictor of anxiety disorder in a child.
• Anxiety disorders first present prior to puberty and are arguably the most common psychiatric disorder in children.
• For the pediatrician, physical complaints will often be the first presenting symptom of an anxiety disorder.
• The 3 anxiety disorders with broad functional impact are separation, generalized, and social anxiety disorders
• Children with anxiety cope by avoiding their anxiety triggers (normal developmental experiences) and loving parents/caregivers often facilitate avoidance to relieve their child’s distress. However, it is important for families to know that engaging, and not avoiding, is key to the behavioral management of anxiety disorder symptoms.
• Treatment with cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitor (SNRIs) are effective and most effective when CBT and medication are combined.

Teaching Points

• Collecting a family history and knowing the early symptoms of anxiety is essential for early identification.
• Anticipatory guidance instructs parents and caregivers to help their child engage rather than avoid anxiety triggers, which slowly increases the child’s ability to tolerate distress.
• Combined medication treatment and CBT offer substantially better short term and long-term outcomes.
• A stepped care approach starting with CBT can be useful as long as the family understands that: 1) remission is the goal of treatment; and 2) if not remitted after 12-16 weeks of CBT, medication treatment is the next step.
• SSRIs are the medication treatment of choice for anxiety disorders. They are safe and effective. Benefit outweighs the risk. NNT = 2-3; Suicidal thoughts NNH = 140