Approach Considerations
For patients for whom medication is prescribed, regular appointments with a child and adolescent psychiatrist or developmental-behavioral pediatrician are necessary for the duration of treatment. Parents and patients must be warned of the possible risks of activation and disinhibition and what to do in such circumstances.
Go to Pediatric Obsessive-Compulsive Disorder, Pediatric Panic Disorder, and Anxiety Disorders for complete information on these topics.
Patient therapy
Weekly outpatient therapy for 3–4 months with less frequent follow-up booster sessions may be sufficient.
A cognitive-behavioral approach is likely to be most beneficial. Treatment should consist of individual sessions with family involvement to support the treatment process. Cognitive therapy features may be incorporated into an eclectic approach by highly skilled and experienced therapists.
Psychodynamic therapies, including play therapy, are time-honored modalities, but most outcomes research has focused on the brief or intermediate therapies, which are more structured.
Behavioral and Cognitive-Behavioral Therapy
Behavioral and cognitive-behavioral therapies are among the most researched and promising treatments for childhood anxieties. Behavioral techniques (eg, relaxation training, modeling, imagining and visualizing, in vivo exposure) and cognitive techniques (eg, identifying and modifying self-talk, challenging irrational beliefs) often are used in combination with psychoeducation and contingency maintenance. Typically, children are taught to recognize early physiologic and cognitive signs of anxiety and to develop and implement coping techniques. [9, 10]
The importance of parental participation in the treatment process recently has received attention. Adding a family component focused on techniques such as contingency management, communication, and problem solving to individual child cognitive-behavioral therapy has produced favorable long-term treatment benefits in several clinical trials. [11, 12, 13]
Exercise, Caffeine Avoidance, Preoperative Relaxation Therapy
Regular exercise promotes a sense of well-being that is particularly beneficial in individuals with anxiety and mood disorders.
Limiting caffeine intake is appropriate.
Prior to a surgical procedure, children with an anxiety disorder are particularly likely to benefit from age-appropriate preparation, including relaxation practice for elective procedures.
Deterrence and Prevention
The following measures may aid in the prevention of generalized anxiety disorder (GAD) in children:
-
Consistent, stable, supportive home environment
-
Parenting practices that promote self-confidence, self-esteem, and effective coping skills
-
Minimal number of psychosocial stressors or traumatic events
-
Adaptive problem solving and coping skills modeled by parents and other significant people in the child's life
-
Psychoeducation
-
Family-based interventions
Ginsburg conducted a study to determine the effectiveness of preventive intervention in the prevention and/or amelioration of anxiety symptoms in children of parents with anxiety disorders and found evidence to support the concept that family-based intervention may yield benefits in children at risk for anxiety. [14] Forty children and their families were randomized to undergo an 8-week cognitive-behavioral intervention (the Coping and Promoting Strength [CAPS] program; 20 participants) or a wait list control condition (20 participants). After a 1-year follow-up, none of the children in the CAPS program developed an anxiety disorder, while 30% of the children in the wait list group did.
The authors of one study developed a novel prediagnosis intervention, Strongest Families, which includes trained nonprofessionals supervised by mental health professionals for children with disruptive behavior and/or anxiety disorders. The intervention provides care using a handbook, instructional videos, and weekly telephone contacts. The study results noted that these telephone-based treatments resulted in a significant decrease in the proportion of children diagnosed with disruptive behavior or anxiety disorders; this treatment may be an option for those patients who are unable to attend face-to-face sessions. [15]
Given that school and academics represent key components in child and adolescent development, classroom interventions have been increasingly utilized with success. Such programs should also be considered as a treatment along with utilization as a preventive intervention. [16]
Referrals
Early referral to a psychologist, psychiatrist, or behavioral-developmental pediatrician for evaluation and treatment can alleviate symptoms and stress that may be the early manifestations of a more severe disorder.
Family therapy referral also may be indicated, but that may be best managed by the mental health professional or the developmental and behavioral pediatrician who performs the consultative evaluation.
Medical Care
Studies support the tolerability and safety of selective serotonin reuptake inhibitor (SSRI) treatment for GAD and other pediatric anxiety disorders. These findings further suggest no differences in overall rates of adverse effects. Few differences occurred on specific adverse effect items. [17]
