The Child or Adolescent With Anxiety

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Identification of children and adolescents with anxiety is important, so consider the diagnosis in your differential. Always think: Could this be anxiety?

Pediatricians are well trained to rule out medical or other causes of anxiety. Questions to ask include: Is the child hypoxic? Does the patient have hypothyroidism? Is the anxiety caused by stress or social factors, including sexual and/or physical abuse? Do the symptoms come from a general adjustment disorder from a major life change or event, such as a move or divorce?

Does the patient have a secret she is afraid to share with anyone else? A shy child, for example, may have something she is afraid to discuss that, together with stressors, can lead her into a true anxiety disorder.

Panic attacks, in particular, can be clinically challenging. Is the attack anxiety driven or caused by an underlying medical problem? We tend to minimize cardiac symptoms, for example, in some children because it is easier to say these symptoms are related only to anxiety. But we need due diligence to rule out any major cardiac or pulmonary etiologies.

When screening patients for anxiety disorders, child and adolescent psychiatrists use comprehensive instruments like the Screen for Child Anxiety-Related Emotional Disorders (SCARED). In a busy primary care setting, I would recommend that pediatricians use the SCARED tool. It is available at no cost and features separate rating scales that can be completed by the child and parent.

For a more comprehensive screening tool, use the Child Behavior Checklist (CBCL), the Child Symptom Inventory (CSI), or the Behavior Assessment Symptom for Children (BASC). Other screening instruments are available that are more disease specific, such as the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) for obsessive-compulsive disorder (OCD).

It is appropriate for pediatricians to manage the treatment of an anxious child or adolescent when the patient is stabilized and continues to improve with treatment. In this way, a child with anxiety is managed no differently than a patient with asthma or diabetes.

Some pediatricians refer a child with a suspected anxiety disorder for an initial evaluation by a mental health specialist such as a child and adolescent psychiatrist, followed by annual consultations. We are happy to consult with pediatricians. One challenge, however, is an overall workforce shortage of child and adolescent psychiatrists. The American Academy of Child & Adolescent Psychiatry offers an online map of the United States that shows the number of specialists per county (www.aacap.org/cs/physicians.AlliedProfessionals/workforce_issues

When is it appropriate for a pediatrician to initiate medication in this patient population? Any time it is indicated! And that really depends on the diagnosis: for OCD, yes; for PTSD, maybe; and for social phobias, probably not. Medication use also is based on symptom severity, especially in generalized anxiety disorder. If the child is not sleeping well or participating in activities of daily living, you have to get him or her stabilized first. The bulk of our treatment for anxiety disorders is psychotherapy, but the child is less likely to benefit from therapy if anxiety impedes the ability to participate in therapy.

Referral to a specialist is indicated when anxiety symptoms interfere with activities of daily living. School refusal is another scenario that warrants immediate referral. Some parents will allow anxious children to stay out of school, so try to determine the reason: Is the parent making it more comfortable for the child to stay at home? Or is the patient avoiding school because they are the target of teasing?

Copies of a recent physical examination, growth chart, and any laboratory work already ordered are helpful with a referral to a child and adolescent psychiatrist. In addition, a detailed clinical assessment facilitates management by a child and adolescent psychiatrist. In other words, it is helpful to get a note that states: “Referring Johnny to you. He was a developmentally normal 5-year-old until he nearly drowned in a pool last summer. He now refuses to sleep alone.” In contrast, a less helpful note might read: “Here is a 5-year-old named Johnny. Please assess.”

Unless you suspect a true organic etiology, such as an abnormal neurologic examination, avoid ordering routine imaging studies for a child with anxiety prior to referral. I am concerned about the risks of sedation for pediatric patients and risks associated with radiation exposure (with CT scans, for example).

Avoid excessive laboratory testing as well, unless there is a clear indication that results could rule out a suspected medical diagnosis.

[email protected]

Identification of children and adolescents with anxiety is important, so consider the diagnosis in your differential. Always think: Could this be anxiety?

Pediatricians are well trained to rule out medical or other causes of anxiety. Questions to ask include: Is the child hypoxic? Does the patient have hypothyroidism? Is the anxiety caused by stress or social factors, including sexual and/or physical abuse? Do the symptoms come from a general adjustment disorder from a major life change or event, such as a move or divorce?

Does the patient have a secret she is afraid to share with anyone else? A shy child, for example, may have something she is afraid to discuss that, together with stressors, can lead her into a true anxiety disorder.

Panic attacks, in particular, can be clinically challenging. Is the attack anxiety driven or caused by an underlying medical problem? We tend to minimize cardiac symptoms, for example, in some children because it is easier to say these symptoms are related only to anxiety. But we need due diligence to rule out any major cardiac or pulmonary etiologies.

When screening patients for anxiety disorders, child and adolescent psychiatrists use comprehensive instruments like the Screen for Child Anxiety-Related Emotional Disorders (SCARED). In a busy primary care setting, I would recommend that pediatricians use the SCARED tool. It is available at no cost and features separate rating scales that can be completed by the child and parent.

For a more comprehensive screening tool, use the Child Behavior Checklist (CBCL), the Child Symptom Inventory (CSI), or the Behavior Assessment Symptom for Children (BASC). Other screening instruments are available that are more disease specific, such as the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) for obsessive-compulsive disorder (OCD).

It is appropriate for pediatricians to manage the treatment of an anxious child or adolescent when the patient is stabilized and continues to improve with treatment. In this way, a child with anxiety is managed no differently than a patient with asthma or diabetes.

Some pediatricians refer a child with a suspected anxiety disorder for an initial evaluation by a mental health specialist such as a child and adolescent psychiatrist, followed by annual consultations. We are happy to consult with pediatricians. One challenge, however, is an overall workforce shortage of child and adolescent psychiatrists. The American Academy of Child & Adolescent Psychiatry offers an online map of the United States that shows the number of specialists per county (www.aacap.org/cs/physicians.AlliedProfessionals/workforce_issues

When is it appropriate for a pediatrician to initiate medication in this patient population? Any time it is indicated! And that really depends on the diagnosis: for OCD, yes; for PTSD, maybe; and for social phobias, probably not. Medication use also is based on symptom severity, especially in generalized anxiety disorder. If the child is not sleeping well or participating in activities of daily living, you have to get him or her stabilized first. The bulk of our treatment for anxiety disorders is psychotherapy, but the child is less likely to benefit from therapy if anxiety impedes the ability to participate in therapy.

Referral to a specialist is indicated when anxiety symptoms interfere with activities of daily living. School refusal is another scenario that warrants immediate referral. Some parents will allow anxious children to stay out of school, so try to determine the reason: Is the parent making it more comfortable for the child to stay at home? Or is the patient avoiding school because they are the target of teasing?

Copies of a recent physical examination, growth chart, and any laboratory work already ordered are helpful with a referral to a child and adolescent psychiatrist. In addition, a detailed clinical assessment facilitates management by a child and adolescent psychiatrist. In other words, it is helpful to get a note that states: “Referring Johnny to you. He was a developmentally normal 5-year-old until he nearly drowned in a pool last summer. He now refuses to sleep alone.” In contrast, a less helpful note might read: “Here is a 5-year-old named Johnny. Please assess.”

Unless you suspect a true organic etiology, such as an abnormal neurologic examination, avoid ordering routine imaging studies for a child with anxiety prior to referral. I am concerned about the risks of sedation for pediatric patients and risks associated with radiation exposure (with CT scans, for example).

Avoid excessive laboratory testing as well, unless there is a clear indication that results could rule out a suspected medical diagnosis.

[email protected]

Identification of children and adolescents with anxiety is important, so consider the diagnosis in your differential. Always think: Could this be anxiety?

Pediatricians are well trained to rule out medical or other causes of anxiety. Questions to ask include: Is the child hypoxic? Does the patient have hypothyroidism? Is the anxiety caused by stress or social factors, including sexual and/or physical abuse? Do the symptoms come from a general adjustment disorder from a major life change or event, such as a move or divorce?

Does the patient have a secret she is afraid to share with anyone else? A shy child, for example, may have something she is afraid to discuss that, together with stressors, can lead her into a true anxiety disorder.

Panic attacks, in particular, can be clinically challenging. Is the attack anxiety driven or caused by an underlying medical problem? We tend to minimize cardiac symptoms, for example, in some children because it is easier to say these symptoms are related only to anxiety. But we need due diligence to rule out any major cardiac or pulmonary etiologies.

When screening patients for anxiety disorders, child and adolescent psychiatrists use comprehensive instruments like the Screen for Child Anxiety-Related Emotional Disorders (SCARED). In a busy primary care setting, I would recommend that pediatricians use the SCARED tool. It is available at no cost and features separate rating scales that can be completed by the child and parent.

For a more comprehensive screening tool, use the Child Behavior Checklist (CBCL), the Child Symptom Inventory (CSI), or the Behavior Assessment Symptom for Children (BASC). Other screening instruments are available that are more disease specific, such as the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) for obsessive-compulsive disorder (OCD).

It is appropriate for pediatricians to manage the treatment of an anxious child or adolescent when the patient is stabilized and continues to improve with treatment. In this way, a child with anxiety is managed no differently than a patient with asthma or diabetes.

Some pediatricians refer a child with a suspected anxiety disorder for an initial evaluation by a mental health specialist such as a child and adolescent psychiatrist, followed by annual consultations. We are happy to consult with pediatricians. One challenge, however, is an overall workforce shortage of child and adolescent psychiatrists. The American Academy of Child & Adolescent Psychiatry offers an online map of the United States that shows the number of specialists per county (www.aacap.org/cs/physicians.AlliedProfessionals/workforce_issues

When is it appropriate for a pediatrician to initiate medication in this patient population? Any time it is indicated! And that really depends on the diagnosis: for OCD, yes; for PTSD, maybe; and for social phobias, probably not. Medication use also is based on symptom severity, especially in generalized anxiety disorder. If the child is not sleeping well or participating in activities of daily living, you have to get him or her stabilized first. The bulk of our treatment for anxiety disorders is psychotherapy, but the child is less likely to benefit from therapy if anxiety impedes the ability to participate in therapy.

Referral to a specialist is indicated when anxiety symptoms interfere with activities of daily living. School refusal is another scenario that warrants immediate referral. Some parents will allow anxious children to stay out of school, so try to determine the reason: Is the parent making it more comfortable for the child to stay at home? Or is the patient avoiding school because they are the target of teasing?

Copies of a recent physical examination, growth chart, and any laboratory work already ordered are helpful with a referral to a child and adolescent psychiatrist. In addition, a detailed clinical assessment facilitates management by a child and adolescent psychiatrist. In other words, it is helpful to get a note that states: “Referring Johnny to you. He was a developmentally normal 5-year-old until he nearly drowned in a pool last summer. He now refuses to sleep alone.” In contrast, a less helpful note might read: “Here is a 5-year-old named Johnny. Please assess.”

Unless you suspect a true organic etiology, such as an abnormal neurologic examination, avoid ordering routine imaging studies for a child with anxiety prior to referral. I am concerned about the risks of sedation for pediatric patients and risks associated with radiation exposure (with CT scans, for example).

Avoid excessive laboratory testing as well, unless there is a clear indication that results could rule out a suspected medical diagnosis.