David Brill
Pediatric anxiety disorders are “under-recognized and under-treated” and could be contributing to depression, drug abuse and educational underachievement in later life, a leading US psychiatrist has warned.
As many as 20 percent of children have some sort of anxiety problem but few are likely to be receiving optimal therapy, Professor Graham Emslie wrote in a recent New England Journal of Medicine editorial. [2008 Dec 25;359(26):2835-6]
Specialists at KK Women’s and Children’s Hospital (KKH) in Singapore, where referrals for pediatric anxiety disorders are low but rising, agreed that the problem is under-recognized and called for greater awareness among medical practitioners.
Emslie, a professor of psychiatry and pediatrics at the University of Texas Southwestern Medical Center, said that children often develop avoidance or coping strategies which can mask the true extent of the problem and contribute to the diagnosis being missed. Genuine anxiety disorders may also be dismissed as “normal, developmentally appropriate worries, fears and shyness,” he said.
The success of the CAMS* study, published in the same edition of the journal, highlights that the treatment options for pediatric anxiety are now more effective than ever before, Emslie said. The researchers found that 81 percent of children showed significant improvements in their anxiety levels when cognitive behavioral therapy (CBT) was combined with the selective serotonin-reuptake inhibitor sertraline. [N Engl J Med 2008 Dec 25;359(26):2753-66]
CBT is typically employed as the first line treatment at KKH but may also be combined with medications in severe cases, according to principal psychologist Ms. Frances Yeo. The number of children with anxiety disorders seen at the hospital rose from 26 in 2007 to 48 in 2008.
Yeo noted that the under-recognition of pediatric anxiety disorders may result from children’s inability to vocalize their worries and fears, which may subsequently manifest themselves as behavioral problems and lead to the child being wrongly labeled as lazy or difficult.
“Children usually show signs of their anxiety through physical symptoms such as stomachaches, headaches, hyperventilation, heart palpitations and tightness in the chest. These symptoms are rather vague and can overlap with many other disorders which make it difficult to distinguish,” she added.
“The first step for the medical community is awareness. GPs need to be alert for children with vague physical symptoms which cannot be explained by medical illnesses,” she said.
Pediatric anxiety disorders comprise a spectrum of conditions including social phobias, separation anxiety disorder, and generalized anxiety disorder. Children who are affected at ages 14 – 16 are more likely to have poor educational, mental health and social role outcomes at ages 16 – 21, a study of 1,265 New Zealand adolescents showed. [J Am Acad Child Adolesc Psychiatry 2001 Sep;40(9):1086-93]
Emslie noted that the exposure component seems to be the most effective part of CBT for children with avoidance strategies, suggesting that they should be encouraged to tackle their phobias head on. Doctors have an important role to play in this, he said, adding that they can unwittingly “collude” with avoidance coping by writing medical notes which give anxious children an excuse to miss school.
Dr. Ng Koon Hock, visiting consultant psychiatrist to the Mental Wellness Service at KKH, said that parents may be failing to recognize anxiety disorders because they tend to downplay a child’s emotions and focus overly on their behavior as a disciplinary issue. “There is less tendency to look at things from the child’s perspective,” he said.
Ng believes that doctors are generally reluctant to liberally grant medical leave to children who regularly makes suspicious-looking health complaints, but noted that this can be a difficult balancing act.
“If the child is very stressed and wants to escape from the problem then in the long-term it’s not helpful, but sometimes it does allow them to get by in the short term,” he said.
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*CAMS: Child-Adolescent Anxiety Multimodal Study
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