Assessing, Diagnosing & Treating Anxiety in the Pediatric Primary Care Practice — A Focus on Children 0-7
The following article on Anxiety in children ages 0 to 7 will provide you with the basics if you have never engaged in this work, or will provide additional information if you have only done it a few times. It is hoped that for those of you fully engaged in offering comprehensive services surrounding Anxiety and related disorders in your practices, it will strengthen and further support your work.
Anxiety in children 0-7 is common and presents differently as a function of developmental age. Nonverbal children may act clingy, fearful, tearful, irritable. They may tantrum, hide, run away, eat poorly, sleep poorly, regress developmentally, vomit, be unable to be alone, unable to explore, to play. Those with language may verbalize their fears, play out their worries, complain of headaches, stomachaches, pains here and there, suffer from nightmares.
All children have anxiety some of the time.s Most children manifest separation anxiety at some time between 6 and 36 months as they develop a separate sense of self and learn that caregivers come back. Most children will be fearful of some situations some of the time. Until fantasy can consistently be distinguished from reality, monsters may inconveniently seem oh so real. Children with anxiety disorders, however, are inconsolably disabled by fear in at least two everyday activities or relationships over 1-2 months. Often they exhibit sympathetic arousal. They suffer functional impairment in developmental tasks such as exploring the world around them, trusting others, empathizing with others, developing friendships, developing a sense of self as competent. Family function is often disrupted.
Trauma-related disorders present similarly to primary anxiety disorders and must always be ruled out. The distinguishing feature is that trauma symptoms arise following an identifiable event, whereas anxiety disorder symptoms appear de novo. The possibility of unknown or undisclosed trauma must be probed, particularly in the preverbal child who has multiple caregivers.
For children 0-5, a separate algorithm from the DSM 5 has been developed and is described in the DC:0-5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood.* As in older children, the commonest anxiety disorders include Separation Anxiety, Social Anxiety and Generalized Anxiety. These three are equally prevalent (2-10%). Less common diagnoses include Selective Mutism and Inhibition to Novelty Disorder. The latter is rare, diagnosed only in children under age 24 months, and requires “overall and pervasive difficulty in approaching new situations, toys, activities and persons.” It generally tracks after age 3 to other anxiety disorders.
Anxiety disorders in young children are best treated in the context of relationship involving the child and caregiver(s). Anxious children often have anxious parents, whose own anxiety may be triggered by distress in their child. The primary care provider can use his/her relationship with the family to be a trusted psychoeducator regarding the autonomic arousal roots of symptoms experienced in anxiety. The PCP can compassionately model what it is like to be a secure base in the face of intense worry. Therapy can begin in the pediatric office by teaching and practicing strategies to dampen sympathetic hyperactivity, such as attending to breathing, belly breathing, muscle relaxation (let your muscles feel like cooked spaghetti), etc.
The mainstay of anxiety treatment in children 0-7 is therapy. At least four modalities have an evidence base: Cognitive Behavioral Therapy with Exposure Response Prevention, Parent-Child Interaction Therapy, Circle of Security, and Child-Parent Psychotherapy. Parental involvement is always needed. Therapists for very young children can be difficult to find. Project TEACH keeps information on therapists throughout the state and can help match family with therapist. Medication for anxious children under 7 is rarely indicated and lacks FDA-approval. Consultation with a child psychiatrist is suggested is before prescribing. A free phone and/or face-to-face consultation with a Project TEACH Child and Adolescent Psychiatrist could provide such a service.
All New York pediatricians have access to Project TEACH services at no cost. For more details on Project TEACH, visit the website at https://projectteachny.org. Please also follow Project TEACH on Facebook at https://www.facebook.com/ProjectTEACHNY.
A visit to the website will also provide you with the call in numbers for psychiatric consultations, and access to staff with knowledge of regional and local mental health resources for children and families in your community. This service can help you find the right services for the children and families in your practice beyond what you can provide. It can also help you develop strong referral relationships and establish feedback loops to assure continuous information sharing about your patient’s progress.
We look forward to hearing from you about the usefulness of these newsletters, and whatever other help and support you think would help you better serve your patients with mild-to-moderate mental health challenges.
* ZERO TO THREE. (2016). DC:0-5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Washington, DC: Author
Funded by a grant from the New York State Office of Mental Health’s Project TEACH
New York State American Academy of Pediatrics (NYS AAP)