Treating anxiety in children
What does the child who can’t say goodbye to a parent without breaking down have in common with the child who is cripplingly terrified of dogs and the one who gets a bad stomach ache reliably on Monday morning?
Anxieties and worries of all kinds are common in children, necessarily part of healthy development, but also, when they interfere with the child’s functioning, the most common pediatric mental health problems. From separation anxiety to social anxiety to school avoidance to phobias to generalized anxiety disorder, many children’s lives are at some point touched by anxiety that gets out of hand.
“I often tell parents, anxiety and fears are totally a normal and healthy part of growing up,” said Dr. Sabrina Fernandez, an assistant professor of pediatrics at the University of California, San Francisco, who has written about strategies for primary care doctors to use in dealing with anxiety
disorders. “I worry that it’s becoming something more when it interferes with the child’s ability todo their two jobs: to learn in school and to make friends.”
Children whose lives are being seriously derailed by their anxieties often get psychotherapy or medication, or both. And ameta- analysis published in November in JAMA looked at the two best- studied treatments for anxiety disorders, cognitive behavioral therapy and psychotropic medication. The technique of ameta- analysis allows scientists to pull in a whole range of different studies, weight the results according to the size and rigor of the research, and then consider the wider array of data gleaned from multiple investigations.
“We included panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder and separation anxiety,” said the lead author, Zhen Wang, an associate professor of health services research at the Mayo Clinic College of Medicine and Science ( they
did not include children with post- traumatic stress disorder or obsessive- compulsive disorder). The study looked at the effectiveness of treatments in reducing the symptoms of anxiety, and at ending the anxiety disorder state. And they also looked at any reports of adverse events associated with the treatments, from sleep disturbances to suicide.
The authors examined 115 different studies, for a total of 7,719 patients, and concluded that certain kinds of anti depressant medications — especially the selective serotonin reuptake inhibitors, or S. S. R. I. s — were effective in reducing anxiety symptoms in children; the mean age of the children in the study was 9.2 years, with a range of 5 to 16.
There were only a few studies that directly compared them, but they suggest that cognitive behavioral therapy may be even more effective at reducing symptoms and at resolving the anxiety disorders, and that the combination of medication and C. B. T. may be better than either was alone. The drugs were associated with a variety of adverse events, though they did not find the association with suicide attempts that has led to a black box warning on S. S. R. I. s. Still, they have not ruled out those dangers: “The difference maybe due to underreporting and monitoring of suicide attempts in clinical trials,” Dr. Wang said.
Dr. Stephen P. H. Whiteside, the director of the Pediatric Anxiety Disorders Clinic at the Mayo Clinic, who was oneof the authors of the meta analysis, said, “if your child has difficulties with anxiety, first of all, it’s treatable. There are a variety of interventions that can be helpful.”
So which of those children — the parent- clinger, the dog- fearer, the school avoider — needs psychotherapy or psychopharmacology?
“Anxiety happens in kids,” said Dr. Christopher K. Varley, a professor in the department of psychiatry at the University of Washington School of Medicine in Seattle. “It does not always need treatment.” And it does not always look exactly like what adults think of as anxiety, he said. Kids can have physical symptoms, or become disruptive; headaches and stomachaches and tantrums can all mean that a child is anxious.
“The important questions tome are, is this a problem, is it getting in the way of functioning, is it creating stress for the child and the family, is it causing pain and suffering?” he said.
“A big thing for families is that sometimes anxiety can lead to avoidance behavior in social settings and in school,” Dr. Fernandez said. But staying away from school is only going to make the problem worse, she said. “As a parent, all you want to do is make your child feel safe and feel comfortable, and if they’re saying, I only feel safe and comfortable home with my door shut, that can only exacerbate the problem.”
The most helpful form of therapy, Dr. Whiteside said, according to the evidence, is exposure- based cognitive behavioral therapy, which involves helping kids face their fears in a supportive environment. “If they’re afraid of dogs, they have to practice petting dogs; if they’re afraid of talking to people, practice talking to people.” That seems to be of greater value for children with these problems than, forexample, therapies based on changing thought patterns, or distractions, or even therapy aimed at deeper insight intothe fears.
The message of exposure therapy, Dr. Whiteside said, is that the situations the child is avoiding are not as dangerous as the child’s anxiety would suggest, and that the child can cope with the anxiety. “It’s an uncomfortable feeling that you can handle,” he said, and the more the child handles it, the more proficient the child will become.
But this takes skill and experience on the therapist’s part, and an investment of time and resources by the family. “Wefound that C. B. T. reports the most consistent outcomes compared to placebo, but it’s time- consuming and sometimes in rural areas it’s not available,” Dr. Wang said.
The question of medication may arise for children with moderate to severe anxiety, and perhaps ideally for a child who is already getting psychotherapy. But of course, not everyone has access to the experts, or to the recommended forms of therapy. Psychotropic medications are often prescribed by primary care doctors,
pediatricians or family physicians, doing their best to help their patients, sometimes getting guidance from a psychiatrist by phone.
“Even though it’s a common problem and there are treatments that work, there are still profound problems in the United States with access to psychotherapists who are versed in psychotherapy techniques that have been demonstrated to help,” Dr. Varley said. “And there clearly is a paucity of child psychiatrists.”
In an editorial accompanying the recent meta-analysis, researchers hailed the large numbers of children included, but warned that many children don’t respond fully to treatment, and that children who suffer from one form of anxiety disorder are often at high risk to develop another.
“The good news is I’ve had lots of patients who’ve had much better experiences and were able to deal with those ups and downs of life, who went to therapy and learned tools to deal, or needed a little help with medication,” said Dr. Fernandez.