Anxiety Disorders in Children and Adolescents

1. Anxiety Disorders in Children and Adolescents Jess P. Shatkin, MD, MPH Vice Chair for Education NYU Child Study Center New York University School of Medicine

2. Learning Objectives • Residents will be able to: • Identify the primary anxiety disorders in children • Distinguish between developmentally “normal” anxiety and pathological anxiety • Describe the clinical presentation, epidemiology, etiology, diagnosis and treatment of the major childhood anxiety disorders

3. What is Normal? • 10 – 20% of children and adolescents suffer a diagnosable anxiety disorder • Many more children suffer with symptoms that do not meet diagnostic criteria (Walkup et al, 2008) • ~40% of grade school children have fears of separation from a parent • ~40% of children aged 6 – 12 years have 7 or more fears that they find troubling • ~30% of children worry about their competence and require considerable reassurance • ~20% of grade school children are fearful of heights, are shy in new situations, or are anxious about public speaking and social acceptance (Bell-Dolan et al, 1990) • Girls report more stress than boys – may be an artifact of social expectations • Most of these worries and stresses are outgrown or recede as children mature and develop

4. Anxiety can be your friend

5. Distinguishing Normal from Pathological 1. Object: Is this something a child of this age should be worrying about? 2. Intensity: Is the degree of distress unrealistic given the child’s developmental stage and the object/event? 3. Impairment: Does the distressinterfere with the child’s daily life? - Social functioning: unable to make friends - Academic functioning: failing classes - Family functioning: creating conflicts, limiting family choices 4. Ability to Recover/Coping Skills: Is the child able to recover from distress when the event is not present? - Tend to worry about future occurrences of event/object - Distress occurs across multiple settings

6. Normal Fear and Worry • Common in normal children • The clinician must distinguish developmentally normal from abnormal • Infants • Fear of loud noises • Fear of being startled • Fear of strangers (around 8 – 10 months)

7. Normal Fear and Worry (2) • Toddlers • Fears of imaginary creatures • Fears of darkness • Normative separation anxiety • School-age Children • Worries about injury and natural events (e.g., storms, lightening, earthquakes, volcanoes) • Children who are characterized as confident and eager to explore novel situations at 5 years are less likely to manifest anxiety in childhood and adolescence • Children who are passive, shy, fearful, and avoid new situations at 3 and 5 years are more likely to exhibit anxiety later in life (Caspi et al, 1995)

8. Normal Fear and Worry (3) • School Age Children (continued) • In general, girls tend to endorse more anxiety symptoms than boys • Younger children are more likely to experience anxiety symptoms than older children • Anxious children interpret ambiguous situations in a negative way and may underestimate their competencies (attribution bias) • The most common anxiety disorders in middle childhood are Separation Anxiety, GAD, and Specific Phobias

9. Normal Fear and Worry (4) • Adolescents • Fears related to school • Fears related to social competence • Fears related to health issues

10. Clinical Presentation • Children with anxiety disorders may present with fear or worry but may not recognize their fears as unreasonable • Younger kids often cannot articulate their feelings, and so we often see physical symptoms presenting first, which include: • Headaches, upset stomach or nausea, increased heart rate, diarrhea or constipation, sleep disturbance, increased vulnerability to common viruses, tightness in chest, tight neck or back, appetite change, fatigue & exhaustion

11. What To Look For • Physical complaints (H/A, GI, dramatic) • Sleep (early/middle insomnia, repeated visits to parent’s room) • Change in eating • Avoidance of outside and interpersonal activities (school, parties, camp, slumber parties, safe strangers) • Excessive need for reassurance (new situations, bedtime, school, storms, “is it bad?”) • Inattention and poor school performance • Not necessarily pervasive (some areas of function remain intact) • Explosive outbursts

12. Physical Symptoms (Provoked and Non-Provoked) • Anxious children listen to their bodies (too much!) • Headache & stomachache • Sick in the morning • Frequent urge to urinate or defecate • Shortness of breath • Chest pain, tachycardia • Sensitive gag reflex/fear of choking or vomiting • Difficulty swallowing solid foods • Dizziness • Tension/exhaustion • Derealization/depersonalization • Avoidance to present physical symptoms

13. Clinical Presentation: Separation Anxiety Disorder • Excessive fear when separated from home or attachment figures • Can be seen before separation or during attempts at separation • Excessive worry about their own or their parents’ safety and health when separated • Symptoms include difficulty sleeping alone, nightmares with themes of separation, somatic complaints, school refusal • Commonly, the earliest age of onset among anxiety disorders • Gender ratios are generally equal • These children often come from singe-parent and low SES homes • A nonspecific precursor to a number of adult psychiatric conditions, including depression as well as any anxiety d/o

14. Clinical Presentation: Phobias • Fear of a particular object or situation which is avoided or endured with great distress • More than one phobia is common (does not in and of itself constitute a diagnosis of GAD) • Adolescents and adults typically recognize that the fear is unreasonable; children often do not • Avoidance is key • Generally begins in childhood

15. Clinical Presentation: Generalized Anxiety Disorder • Characterized by chronic, excessive worry in a number of areas (e.g., schoolwork, social interactions, family, health/safety, world events, and natural disasters) with at least one associated somatic symptom • Affected children are often perfectionistic, seek reassurance, and struggle more than is evident to parents and teachers • Worry is most often present and not limited to a specific situation or object • These kids don’t just worry about performance and social concerns (e.g., social phobia) – these kids worry about the quality of their relationships rather than experiencing embarrassment or humiliation in social situations

16. Clinical Presentation: Social Phobia • Characterized by feeling scared or uncomfortable in one or more social settings (discomfort with unfamiliar peers and not just unfamiliar adults) or performance situations (e.g., sports, music) • Associated with a fear of scrutiny and of doing something embarrassing in social settings such as classrooms, restaurants, or extracurricular activities • May have difficulty answering questions in class, reading aloud, initiating conversation, talking with unfamiliar people, and attending parties and social events • The anxiety with social phobia dissipates when away from a social situation; unlike GAD where the anxiety is persistent • 90% of children with Selective Mutism have been shown to meet criteria for Social Phobia (SM should probably be viewed as a specific type of Social Phobia) • Differential with PDD

17. Clinical Presentation: Panic Disorder • Recurrent episodes of intense fear that occur unexpectedly (cued or uncued) • Panic disorder vs. panic attacks • Cued panic attacks can occur with any anxiety disorder, or independently, and are common among adolescents • Fear of death or going crazy • Uncommon before the peri-pubertal period (adult retrospective studies have shown that sx commonly begin in adolescence or young adulthood) • The peak age of onset of panic d/o is age 15 – 19

18. Clinical Presentation: Obsessive-Compulsive Disorder • Most patients experience both obsessions and compulsions • Changes in symptoms and in intensity over time • Parents often become unwilling collaborators in the illness • Symptoms commonly exist for years before reaching clinical attention

19. Trauma • Any or all anxiety symptoms • Symptoms may wax and wane • Symptoms typically worsen when confronted with reminders or situations reminiscent of the trauma

20. Etiology • Behavioral Inhibition • Genetic • Neuroimaging • Neurotransmitter • Neuroendocrine • Learned Responses • Attachment Research • Psychoanalytic

21. Behavioral Inhibition • “Behavioral Inhibition” (a lab-based temperamental construct) is defined as the tendency to be unusually withdrawn or timid and to show fear and withdrawal in novel and/or unfamiliar social and nonsocial situations • Those who are withdrawn in social situations only are considered “shy” • Both behavioral inhibition and shyness are associated with anxiety disorders in both children and adults • The tendency to approach or withdraw from novelty is an enduring temperamental trait

22. Behavioral Inhibition (2) • Kids with BI show a lot of physiological signs often associated with anxiety, including enhanced sympathetic nervous system tone (e.g., elevated resting heart rate and salivary cortisol), increased tension in the vocal cords and larynx, and elevations in urinary catecholamines (Kagan et al, 1988) • Kids with BI are more likely to have multiple psychiatric disorders and two or more anxiety disorders (especially Avoidant D/O, Separation Anxiety D/O, and Agoraphobia) • Kids with BI have a higher risk of panic is they age (Smoller et al, 2005) • Thus, Behavioral Inhibition is a risk factor for the development of anxiety disorders in children • BI is also heritable

23. Neurobiology of Anxiety • Systems involved in sensing and responding to threat are redundant and involve numerous brain systems to promote survival • Reticular Activating System (a network of ascending, arousal-related neural systems) • Locus coeruleus NA mobilizes in response to real or perceived threat • Dorsal raphe 5HT mediates the locus coeruleus • Lateral dorsal tegmentum cholinergic & mesolimbic & mesocortical DA neurons affect brain sensitivity and interpretation of threat

24. Limbic System (1) • Anxiety is believed to recognized at the amygdala • The hippocampus is the storage site of cognitive and emotional memories and is very sensitive to stress • Threat alters the ability of the hippocampus and connected cortical areas to store certain types of cognitive information (verbal) but not nonverbal information • Many of the cognitive distortions that are associated with anxiety disorders may be related to anxiety related alterations in the tone of the hippocampus and associated cortical areas

25. Limbic System (2) • Neuronal systems are capable of making remarkably strong associations between paired cues (e.g., growl of a tiger and threat) • This capacity of the brain to generalize from a specific event renders humans vulnerable to false associations and over generalizations • Once these specific cues (e.g., snakes) become linked with limbic mediated responses (e.g., anxiety), it is the sensitivity of the individual’s stress response system which determines if the alarm system (anxiety) will be activated

26. Genetics of Anxiety • There are thousands of genes which, if abnormal, could result in altered development or functioning of neurotransmitter and neuroanatomical regions involved in regulating anxiety • Strong familial trends in anxiety disorders • No clear data support a specific genetic etiology for childhood anxiety disorders • Heritability estimates of Panic Disorder (48%) and Generalized Anxiety Disorder (32%) exist (Hettema et al, 2001) • Given these estimates, it is clear that genes account for only some portion of the increase in risk among family members of an affected individual • Environmental factors (e.g., perinatal exposures and developmental experience) must play a major role

27. Learned Responses • Most specific fears (phobias) are related to paired or mispaired internalization of cues with anxiety from previous experience • Some anxieties may involve genetically fixed patterns developed over eons of evolution (e.g., snakes) • During infancy and childhood children mirror their caretakers’ responses when interpreting internal states of pain, arousal, and anxiety • Over time children may come to label a host of external cues as potentially threatening and certain internal sensations as fearful; this is the hypothesized mechanism of GAD, specific phobias (Kendall and Ronan, 1990), and some types of PTSD (Main and Hesse, 1990)

28. Etiologic Example: OCD • Genetic: Likely a vulnerability is genetically transmitted, based upon increased concordance rates among monozygotes vs. dizygotes and increased rates among 1st degree relatives of probands • Neurophysiology: Increased metabolism in orbitofrontal and caudate systems (e.g., hyperactive caudate; PET scans); abnormalities supposed in circuits linking basal ganglia and frontal lobes (Baxter et al, 1992) • Neuroendocrine: Individuals with OCD have shown elevated levels of Oxytocin (behavioral effects of which typically contribute to cognitive, grooming, affiliative, and reproductive behaviors in animals)

29. Attachment • Secure • Insecure Resistant - Hyperactivating • Insecure Avoidant - Inhibited • Disorganized - No adaptive strategy • Frightening, unpredictable parents

30. Attachment Research • Insecure attachment may be a risk factor for the development of childhood anxiety disorders • An attachment study showed that 80% of children born to insecure mothers were classified as insecurely attached children • The presence of behavioral inhibition does not seem to increase the risk of being insecurely attached and vice versa

31. The Impact of Trauma Is Developmentally SensitiveAffect Regulation Cloitre et al., 1997

32. The Impact of Trauma Is Developmentally SensitiveInterpersonal FunctioningInventory of Interpersonal Problems Cloitre et al., 1997

33. Psychoanalytic • The key idea is that phobias develop as a defense against anxiety which is produced by repressed id impulses. • Anxiety is displaced from the id impulses to a fear object that is linked symbolically (and generally more acceptable). • By avoiding the phobic object, one avoids dealing with repressed childhood conflicts.

34. Epidemiology • Anxiety is the most prevalent mental health disorder in children and teens • Estimated at 6 – 20% • Difficult numbers because subthreshold anxiety (not meeting DSM criteria) can also cause severe disability • Developmental progression of anxiety disorders in adulthood • Untreated childhood anxiety typically continues into adulthood • Leads to an increased risk of depressive disorders • Albano, Chorpita, & Barlow (2003). Childhood Anxiety Disorders. In Mash & Barkley (Eds.). Child Psychopathology: Second Edition. (pp. 279-329). New York: Guildford Press. • Costello et al, 2004

35. Epidemiology (2) • Girls are more likely than boys to report an anxiety disorder, esp. specific phobia, panic, agoraphobia, & separation anxiety disorder • Children often develop new anxiety disorders over time (even if the old ones go away) • Anxiety or depressive disorders in adolescence predict a 2-3x increase risk of anxiety or depression in adulthood (Pine et al, 1998) and lower academic achievement (Woodward & Fergusson, 2001) • Anxiety in the 1st grade has been shown to predict anxiety and low academic achievement in reading and math in the 5th grade (Ialongo et al, 1995)

36. Epidemiology (3): Non-Referred • High prevalence of anxiety disorders in non-referred children: • 3.5% for Separation Anxiety D/O • 2.9% for Overanxious D/O • 2.4% for Simple Phobia • 1% for Social Phobia (Anderson et al, 1987) • Bowen (1990) reported 3.6% prevalence of Separation Anxiety D/O and 2.4% prevalence of Overanxious D/O in 12 – 16 y/o population • Lifetime prevalence of panic d/o was 0.6% and for GAD 3.7% (Whitaker, 1990)

37. Epidemiology (4) • A pediatric primary care sample of 7 – 11 y/o revealed a 1-year prevalence of anxiety d/o of 15.4%; Simple Phobia (9.2%), Separation Anxiety D/O (4.1%), and Overanxious D/O (4.6%) were most common (Benjamin 1990) • A 3 – 4 year f/u study of children/adolescents with anxiety d/o showed a high remission rate with 82% no longer meeting criteria for their initial anxiety d/o (Last et al) • Separation Anxiety D/O had the highest recovery rate (96%) and panic the lowest (70%); during this f/u period, 30% of children developed new psych d/o and half developed new anxiety d/o

38. Risk and Protective Factors • Behaviorally inhibited young children have a greater likelihood of anxiety disorders in middle childhood • Offspring of parents with anxiety disorders have a greater risk of anxiety disorder and high levels of functional impairment • Insecure attachment relationships with caregivers (specifically anxious/resistant attachment) increases the risk of childhood anxiety disorders

39. Clinical Course • The usual course of most anxiety disorders is chronic with waxing and waning over time • Individuals sometime “trade” one anxiety disorder for another over time • Commonly those with GAD report they’ve felt anxious their entire life; over half presenting for treatment report onset in childhood or adolescence; but onset occurring after 20 is not uncommon; chronic but fluctuating course • With Panic D/O, typically attacks become less severe if they occur more often • Some anxieties, such as specific phobias, often dissipate with age, but those that persist into adulthood remit only infrequently (20%)

40. Clinical Course (2) • Social Phobia, on the other hand, most often sets on in childhood and is commonly lifelong and continuous, although it may fluctuate in intensity with life stressors and demands • Most individuals with OCD show improvement with time, but about 15% show progressive deterioration and 5% have episodic course; however, an NIMH 2 – 7 year f/u study found 43% still meeting diagnostic criteria with only 11% totally asymptomatic • As with other anxiety disorders, the symptoms of PTSD often vary over time. Complete recovery occurs within 3 months in about half of cases. • Separation Anxiety Disorder may develop after a stressor (e.g., death of a relative or pet, relocation, etc.) and occur as early as preschool; adolescent onset is rare; typically it waxes and wanes; although it may be expressed as Panic Disorder in adults, most children are free from anxiety disorders as they adults

41. DSM Diagnoses (1) • DSM III-R included only 3 childhood anxiety disorders: (1) Separation Anxiety Disorder (which remains); (2) Overanxious Disorder, which is now subsumed under GAD; and (3) Avoidant Disorder, which is now subsumed under Social Phobia

42. DSM Diagnoses (2) • DSM-IV disorders include: • Separation Anxiety Disorders • Panic Disorder • Specific Phobia • Social Phobia (Social Anxiety Disorder) • Obsessive-Compulsive Disorder • Posttraumatic Stress Disorder • Acute Stress Disorder • Generalized Anxiety Disorder • Others: • Selective Mutism • Somatic symptoms • Trichotillomania

43. DSM: Separation Anxiety Disorder • Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by 3 or more: • Excessive distress upon separation from home or attachment figures occurs or is anticipated • Excessive worry about losing or harm befalling attachment figures • Excessive worry that an event will lead to separation from an attachment figure (e.g., kidnapping) • Reluctance to attend school b/c of fear of separation • Reluctance to be alone or without attachment figures at home or other locations • Reluctance to sleep alone or away from home • Repeated nightmares involving separation • Repeated complaints of physical symptoms when separation occurs or is anticipated • Duration at least 4 weeks

44. Separation Anxiety Disorder • Affected children tend to come from closely knit families • The kids may exhibit social withdrawal, apathy, and sadness or difficulty concentrating when separated • Concerns about death and dying are common • These children are often viewed as demanding • Adults with SAD are typically over-concerned about their children and spouses • Prevalence estimates about 4% in children and young adolescents • More common in 1st degree relatives than general population

45. Panic Attacks • NOT A DISORDER! • Quite common among adults

46. Panic Attacks • Can occur within the context of other mental disorders (e.g., Mood D/Os, Substance-Related D/Os, etc.) and some general medical conditions (e.g., cardiac, respiratory, vestibular, GI). • 3 characteristic types of panic: (1) Unexpected (uncued); (2) situation bound (cued); and (3) situationally predisposed. • Individuals who seek care will typically describe intense fear, report that they fear they’re about to die, go crazy, have an MI/stroke • Individuals typically report a desire to flee or leave where they’re at • With unexpected panic attacks, over time the attacks typically become situationally bound or predisposed, although unexpected attacks may occur • The occurrence of unexpected panic attacks is required for a dx of Panic D/O; situationally bound or predisposed attacks are common in Panic D/O but also occur in the context of other anxiety disorders (e.g., specific and social phobia, PTSD)

47. Relationship between PD and other Anxiety Disorders

48. What does a panic attack look like in a child? • Children generally report physical symptoms, rather than psychological symptoms • May suddenly appear frightened or upset without explanation • Often confusing behavior to onlookers • Children may explain their symptoms as responses to external triggers • Young children may not be able to articulate the intense fears they experience • Adolescents are generally better at describing what they experience, especially after the attack has ended • *rarer in children

49. DSM: Panic Disorder • Both (1) and (2): • recurrent unexpected Panic Attacks • at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: • persistent concern about having additional attacks • worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”) • a significant change in behavior related to the attacks • Absence of Agoraphobia • The Panic Attacks are not due to the direct effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism). • The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), OCD (e.g., on exposure to dirt in someone with an obsession about contamination), PTSD (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety D/O (e.g., in response to being away from home or close relatives).

50. Panic Disorder • Patients often are hypersensitive about physical cues and medication side effects • Reported rates of comorbid MDD are high, ranging from 10-65%; in 2/3 of these individuals depression co-occurs with panic d/o or follows panic; in the remaining 1/3, the depression precedes the panic • Comorbidity with other anxiety disorders is common – social phobia and GAD (15-30%), specific phobia (2-20%), and OCD (up to 10%). PTSD and Separation Anxiety are also strongly comorbid, along with hypochondriasis. • No consistent abnormalities in lab results, but compensated respiratory alkalosis (decreased bicarb/CO2 with almost normal pH) sometimes noted. • Lactate and elevated CO2 can be used to induce panic in sufferers • Correlation with numerous general medical symptoms, including dizziness, arrhythmias, hyperthyroidism, asthma, COPD, IBS; however, the nature of the association is unclear. • Debate about whether or not MVP and thyroid disease is more common among sufferers • Lifetime prevalence in community samples generally 1-2% (but reported as high as 3.5%); one-year prevalence rates 0.5-1.5%; higher rates in clinic samples (10% in individuals referred for mental health consultation); 10-30% in general medical clinics and up to 60% in cardiology clinics • 1/3 to ½ of community samples has comorbid agoraphobia, but the co-occurrence is much higher in clinical samples • Age at onset varies, but typically late adolescence/mid-30s; occasionally onset in childhood; after 45 y/o rare. • Agoraphobia typically develops within the first year, but can occur at any time • 1st degree biological relatives are up to 8x more likely to develop Panic D/O; if age of onset is <20 y/o, 1st degree relatives are up to 20x more likely to develop same.