Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Kavitha
Chaired by Dr.Abhijeeth
in children
1
Introduction
2
What we will review
Introduction
Normal vs pathologic anxiety
Separation anxiety
Social phobia
Generalised anxiety disorder
3
What is normal anxiety?
❖ 10-20%10 – 20% of children and adolescents suffer a diagnosable
anxiety disorder.
❖ Children have fears of separation from parent
❖ Children 6-7 yrs-fears that they find troubling
❖ 30% school going children worry about their competence and
require considerable reassurance
❖ Girls report ore stress than boys-this may be an artefact of social
expectation
❖ But most of thes stresses are outgrown or recede as children
mature.
4
Anxiety as a friend!!
5
Distinguishing normal from pathological
❖ Object
❖ Intensity
❖ Impairment
❖ Ability to recover
6
Separation Anxiety Disorder
❖ Universal human developmental phenomenon emerging in infants <1yr marking Childs awareness of
separation from mother or primary caregiver.
❖ Normal between 9-18 months, diminishes by 2 1/2 yrs
❖ Human response which has survival value.
❖ 15% of young children have behaviour inhibition.
❖ Behaviour inhibition is , intense persistent fear , shyness and social withdrawal, when faced with
unfamiliar settings and people.
❖ Such children are at higher risk for developing anxiety disorder.
❖ Physiological features in behaviourally inhibited children are higher than normal resting heart rate, higher
morning cortisol levels than avg, low heart rate variability.
❖ Seen in mean age group of 7-8 years.
❖ Kids which BI have higher risk of development of panic as they age (Smoller et all)
❖ BI is also heritable
7
DSM 5 criteria for Separation Anxiety
Disorder
8
Nosology SAD
❖ DSM III-first mentioned ,onset prior to age 18 duration at
least 2 weeks.3/9
❖ DSM IV- onset prior 18 yrs, 4 weeks, evidence of serious
distress or impairment was added.recurrent serious
distress anout anticipated or actual separation was
combined hence 3/8
❖ DSM 5- onset does not require prior 18 yrs onset,
duration >6 months so as not to over diagnose transient
fees.
9
Other AXIS I disorder which may
mimic SAD
10
Social Phobia/Social anxiety
disorder
❖ Intense discomfort and distress in social situations, and are impaired by the
fear of scrutiny or humiliation .
❖ Expressed as crying tantrums, avoidance, freezing, mute,
❖ DSM5 -The disorder is characterised by consistent and anxiety in almost all
social situations where the child feels exposed to possible scrutiny by
others which provoke fear and anxiety and will hence voice these feared
social situations.
❖ Diagnosed when its present when the child is with peers and not only with
adults.
❖ Despite the significant impairment caused unto 50% do not receive
treatment.
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Nosology
12
Clarks model for social anxiety
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Phobic disorders
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Specific types of phobias
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Performance only type
❖ Such anxiety present in only in
specific social situation like public
speaking or performance anxiety.
❖ Manifests in school or academic
settings in front of classmates.
❖ Associated with Lower levels of
satisfaction in leisure activities,
increased rate of school dropouts,
less productivity in workplace as
adults, increased rates of remaining
single.
❖ Performance anxiety can occur
independent of anxiety in social
situations but reverse is unusual. Type to enter a caption.
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Generalised Anxiety disorder
❖ In contrast to SAD and social Anxiety who have only one trigger these children have multiple
triggers.excessive uncontrollable worry about number of anxiety provoking events.
❖ Children with this disorder have significant distress in ADL often focussed on Childs fears of
incompetence in many areas including school performance and in social settings.
❖ DSM 5 symptom checklist
❖ restlessness, easily fatigued ,”mind going blank” , irritability , muscle tension, Sleep disturbance.
❖ Expect more negative outcomes when faced with challenges compared with peers.
❖ Autonomic hyperarousal-tachycardia, shortness of breath, dizziness , sweating nausea and diarrhoes.
❖ Overtly concerned about natural disasters like earth quake and floods and these worries interfere with
their daily activity.
❖ Also seek excessive reassurance about their performance.
❖ Generally seen in children in mean age group 8-9 years
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Nosology
18
Panic disorder
❖ Recurrent attack or intense fear that occur unexpectedly(cued or uncured)
❖ Panic disorder vs panic attacks
❖ Cued can occur in any anxiety disorder
❖ Fear of death or going crazy
❖ Uncommon before the peri pubertal age
❖ Peak age of onset is 15-19 yrs
❖ Pani attacks+avoidant behaviour/fear of going cracy/fear of impending doom/concern
about having additional attacks/implictions and consequence sof the attack =panic
disorder
❖ Should not be due the effects of a substance
❖ Absence of agoraphobia
19
Panic attack in a child
20
Epidemiology
❖ Lifetime prevalence ranges from 10-27%.common in
preschoolers.
❖ Survey done in preschool age children by using Preschool
age Psychiatric assessment revealed that 6.5% GAD, 2.4%
Separation anxiety, 2.2% social phobia.
❖ Young children its more common .
❖ Onset in preschool years but common in 7-8 yrs age group.
❖ in adolescents the lifetime prevalence for panic disorder was
.6%, GAD 3.7%.
21
D/D
22
Etiology
❖ Biophysical factors
❖ Social Learning factors
❖ Genetic Factors
❖ Attachment
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Biophysical factors
❖ Parental psychopathology and parenting styles influence emergence of anxiety disorders.
❖ Longitudinal studies -parental overprotection and insecure parent child attachment.
❖ Maternal depression and anxiety disorders have increased risk for anxiety and depression in children.
❖ Psychosocial factors+childs temperament =influence the degree or separation anxiety evoked in brief
separation and exposure to unfamiliar environments.
❖ Traits of shyness and social withdrawal .
❖ External life stressors - death of relative, Childs illness, change in environment.
❖ In vulnerable children these changes intensify anxiety.
❖ Neuro physiological correlations-found with behavioral inhibition -higher resting HR,acceleraion of HR
when performing cognitive conc., elevated urinary catecholamine levels, elevated salivary cortisol level,
greater pupillary dictation.
❖ Neuroimaging studies-increased activation of amygdala, also maintain the hyper activation.
❖ Structural studies have shown conflicting results_increased and decreased volumes.
24
Neurobiology of pediatric anxiety disorder
25
Type to enter a caption.
26
Social learning factors
❖ Fear in a variety of situations can be unwittingly transmitted from parents
to children. DIRECT MODELLING.
❖ Overprotective parenting in a behaviourally inhibited children ,
increases the risk of social anxiety disorder.
❖ Teaching the children to be anxiously exaggerating the dangers.
❖ parent might promote phobic concern in child by scolding them when
they express fear.
❖ Recent study found no correlation between psychosocial hardships and
behaviour inhibition in young children but temperamental predisposition to
anxiety disorders emerges as highly heritable constellation of traits.
27
Genetic factors
❖ Heritability for anxiety disorders ranges from 65% to 73% highest
estimates in younger children.
❖ Next to ADHD in most heritable condition .
❖ Main heritable characteristics are behavioural inhibition and
physiological hyper arousal.
❖ Although more prone 1/3 rd of such behaviourally inhibited children
do not develop anxiety disorder.
❖ Family studies suggest that children of parent with anxiety disorders
are more prone and also genetic predisposition puts them in an
increased risk developing GAD, Separation anxiety and social phobia.
28
How attachment affects development of
anxiety
❖ Secure
❖ Insecure resistent- hyperactivatin
❖ Insecure avoidant-inhibited
❖ Disorganised no adaptive strategy-frightening
unpredictable parents/
29
Course of paediatric anxiety
disorders
❖ Poor long term functioning with inter personal financial and educational difficulties
also suicidality.
30
Co morbidity in childhood anxiety
disorders
❖ Co morbidity is a rule.elevated in GAD unto 90% had another
comorbid anxiety disorder.
❖ Raised questions about diagnostic separation in the
disorders.
❖ Non anxiety disorders- major depression.its strength rivals all
other differential psychopathology.
❖ Anxiety nd ADHD but only weak relation.
❖ Anxiety disorder also occurs with substance use and conduct
disorders.
31
Axis II contributes to anxiety
disorders
❖ 40% children with ASD diagnosed with anxiety disorders
❖ Social phobia 17-30%
❖ Specific phobia 30-40%
❖ GAD 15-35%
❖ sep. anxiety 9-38%
❖ OCD 17-37%
❖ Gene polymorphism may modulate the effect of anxiety in ASD
❖ Glutamate transporter gene (SLC1A1)single nucleotide polymorphism.
❖ ASD with anxiety is amenable to CBT, particularly when clinicians target familial accommodations that
exacerbate/maintain anxiety and incorporate behavioral intervention plans into treatment
❖ Although not indicated for anxiety in youth with ASD, atypical antipsychotics have demonstrated efficacy
and have a US FDA indication for treating irritability and aggression among youth with ASD, which may
reflect anxiety symptomology
❖ SSRIs and serotonin and norepinephrine reuptake inhibitors appear most effective for typically
developing youth and atypical antipsychotics show promise, the added complexity of ASD leaves the
literature on pharmacotherapies with comorbid anxiety wanting.
32
Axis III contributes of anxiety
33
Axis IV contributes to anxiety disorder
34
Developmental course
❖ The expression of Anxiety as well as clinical syndromes follows a developmental
course(Black 1993)
❖ Infants-react to novel or unexpected events with over aousal.brain systems that regulate
arousal involve gaze aversion , stereotypic behaviour, intensified attachment behaviour.
❖ Later separation anxiety stranger anxiety and behaviour inhibition may result forebrain
maturation as well as temperamental vulnerabilities.
❖ Later forms of anxiety include body integrity, natural environmental events, school
performance, increasing concern with social adequacy (Allen Hetson 1998).
❖ Also dependent on maturation of neurotransmitter system.Eg;Panic disorder -present in
late teen and early adulthood. And later decrease with aging.
❖ This may parallel the maturation and regulation of the noradrenergic or sympathetic
nervous system.
35
Diagnosis and Clinical
features
❖ Overlapping symptoms and comorbid disorders .
❖ Separation anxiety is extreme anxiety precipitated by separation from parent home
or other familiar surrounding .morbid fears, ruminations preoccupations.fear that
someone close to them will be hurt..fears of being lost being kidnapped and losing
their ability to keep in touch with their family.
❖ Gad is fear extended towards to negative outcomes for all kinds if activities.one
recurrent symptom of restlessness, poor conc., irritability, muscle tensions.
❖ Social phobia-fear peaks during social performance, concerns over being
embarrassed humiliated and judged.the fear is more than that is normally
expected for the Childs developmental level.
❖ Common is the preoccupied with health and worry that their friend or family will
become ill.
36
❖ Prominent features- clinging crying irritability, difficult eating refusing to
go to camp, new school or friends house.
❖ Adolescents express it in behaviour patter-engaging in solitary actibties
discomfort in leaving home, or distress when away from home.
❖ Self imposed isolation.
❖ Sleep disturbance.
❖ Fear of dar. Lurking under the bed.
❖ Easily brought to tears.
❖ frequent somatic compalints.
37
Type to enter a caption.
38
Selective Mutism
❖ Persistent lack of speaking in one or more specific social situations
most typically the school setting.
❖ Completely silent or new silent or in some cases whisper in school.
❖ Often begins before 5 yrs but not apparent until he goes to school.
❖ Convergence of social anxiety +underlying speech and language
problem.
❖ Communicate through eye contact , few may speak fluently at
home .
❖ Related to social anxiety.
39
Parental Interactions
40
Nosology
41
Etiology
❖ Genetic contribution
❖ Parental interaction
❖ Speech and language factors
42
Genetic contribution
43
Epidemiology
44
Speech and language factors
45
Diagnosis and clinical
features
❖ My develop gradually or suddenly after disturbing episode .
❖ Age of onset 4 to 8 yrs.
❖ Mostly in school selective cases mute at home.also have
separation anxiety school refusal and delayed language
acquisition.
❖ Behavioural disturbance like temper tantrums and
oppositional behaviours may also occur in home.
❖ Less social competence and more social anxiety.
46
Differential Diagnosis
❖ Communication disorder
❖ Autism spectrum disorder
❖ Social anxiety disorder
❖ Intellectual disability
❖ Pervasive developmental disorders
❖ Expressive language disorder
❖ In mutism secondary to conversion disorder the mutism is pervasive.
❖ While learning a new language. Should be diagnosed only when they
refuse to speak their own gained language.
47
Course and prognosis
❖ Shy during preschool years but onset of the full disorder is usually not evident until
5-6 years.
❖ Many children have spontaneous remission .
❖ Academic difficulties due to lack of participation.
❖ Fluoxetine may influence the course.
❖ Rigidity negativism tempertantrubs oppositional and aggressive behaviour at
home.
❖ Children who do not improve by 10 years have long term course and worse
prognosis.
❖ 1/3 rd without treatment may develop other psychiatric disorders other anxiety
disorders and depression.
48
Assessment scales
49
Assessment scales >8 yrs
❖ Multidimensional assessment scales for children
❖ Screen for child anxiety and emotional related disorder(SCARED)
❖ SCAS spence children’s anxiety scale
❖ Test retest reliability, diversion validity from depression measures,
reasonable correlation with clinical levels of anxiety severity, sensitivity
to treatment effects.
❖ Age 2.5 -6.5-preschool anxiety scale -parent reported adapted from
SCAS
❖ Paediatric anxiety rating scale -commonly used to assess
psychopharmacological trials of youth is clinician rated scale used to
assess the severity of anxiety symptoms and change over time.
50
Assessment scales in social
phobia
51
Diagnostic interviews
Limitatio
Older
ns
Newer + -
Test retest Researc
DISC Validity K-SADS reliability h tool
Predictive Skilled
CAPA significanc Teachin
DICA professi
e g tool
onsls
ADIS
52
Pathology and Lab
Investigations
❖ Because they can mimic other medical disorders it is important t rule out other medical causes
❖ Endocrine -TSH/TFT
❖ hypoglycemia-AC/PC/RBS
❖ Pheochromocytoma-VMA/metyrapone test
❖ CNS-brain imaging /EEG
❖ ECG- cardiac causes -arrythmia ,
❖ Respiratory isorders -asthma
❖ Lead intoxications
❖ Baseline blood investigation- low HB -fainting spells
❖ History of consumption of any coffee/energy drinks/SSRI/antipsychotics (akathesia)
sympathomimetics /steroids/anti asthma medication .
53
Treatment
CBT
❖ Psychopharmacological interventions
54
CBT
55
Coping cat programme
56
PICT-Parent Child Interation Therapy
57
The FRIENDS programme
58
Mindfulness based therapy
“the intentional, accepting, and non-judgmental focus of one’s attention on the
emotions, thoughts, and sensations occurring in the present moment”
59
Psychodynamic psychotherapy
❖ Systemic desensitisation
❖ Flooding implosive
❖ Contingency management
❖ Modeling -live modelling /participant modelling /symbolic
modelling.
61
Relaxation techniques
❖ Deep breathing
❖ Imagery
❖ Progressive muscle relaxation
❖ Proposed mechanish-incresed control over sympathetic
servous system, decreased physiological symptoms.
62
Psychopharmacological treatment
❖ First line -SSRI .a Cochrane systematic review showed that there are 7 short term <16
weeks RCT( n treatment =453 control=389)testing the efficacy of SSRI on changes in
impairment in anxiety disorders in young people with an overall RR response of 2.38 over
placebo.
❖ CAMS showed mono therapy with sertraline 55% as effective as CBT 60% when compared
with places 24% and combined therapy 81%.
❖ SSRIs and SNRI as a class, are considered effective for pediatric anxiety disorders A meta-
analysis of 16 randomized trials on published between 1992 and 2008 found a number of
SSRI and SNRI medications – fluoxetine, sertraline, fluvoxamine, paroxetine, and
venlafaxine – to be superior to placebo in the treatment of pediatric anxiety
❖ . Among the SNRIs clinical trials suggest that venlafaxine SR, in particular, is effective for
these disorders.
❖ A 2015 trial suggested that duloxetine may benefit youth with GAD . Some children
experienced weight loss, increased cholesterol, and changes in vital signs while taking the
medication.
63
SSRI associted by disinhibition, agitation , worsening of anxiety.
The concern were based on a review of studies f adolescents with depression rather than
young people with anxiety.
US FDA has issued a black box warning in 2004 against SSRI .FDA additionally
recommended close monitoring of patient’s clinical status during the early weeks of
antidepressant treatment and limiting the duration of their use. Drug monitoring to be followed
64
65
Type to enter a caption.
66
The reason why SSRI is better then SNRI?
The serotenergic system mature even before the norepinephrogenic syst
67
Prior to the SSRI and SNRI, TCAs were used.
70
Other drugs
Atomoxetine has been evaluated in youth with ADHD and a co-occurring anxiety
disorders (SAD, GAD and/or SoP; PARS score ≥15) in a 12-week, multicenter,
double-blind, placebo-controlled study.
Reduction in both ADHD and anxiety symptoms were noted.
71
Predictors of treatment response
72
References
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