The following article is a part of conference coverage from the 2021 American Association of Nurse Practitioners National Conference (AANP 2021), held virtually from June 15 to June 20, 2021. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading NPs. Check back for more from AANP 2021.
Current evidence-based guidelines for the management of pediatric anxiety in primary care were highlighted at the 2021 American Association of Nurse Practitioners National Conference (AANP 2021). Dawn Garzon PhD, CPNP-PC, PMHS, FAANP, FAAN, discussed assessing anxiety with a developmental lens and pharmacological and nonpharmacological options for treating anxiety in children.
“Primary care providers often manage adult mild to moderate illness and are trained to recognize and diagnose children and youth who have symptoms of mental health issues,” said Dr Garzon, who is a nurse practitioner (NP) at Advent Behavioral Health in St. Peters, Missouri. “What often is lacking is confidence in their ability to do so. Suicide is currently the second leading cause of death for our young people, so increasing primary care competence and confidence in treating children and youth is critical to providing another layer of safety net for your kids.”
Is it Fear, Phobia, or Anxiety?
Dr Garzon distinguished between fears (a drive to avoid a stimulus), phobias (irrational fears), and anxiety (a global sense of unease) in her presentation. She noted that fears are normal throughout childhood; for example, many toddlers fear anthropomorphism, and many teens fear disfigurement or lack of acceptance from their peers.
Approximately one-third of children with anxiety have comorbid depression and 37% have behavior issues. Attention-deficit/hyperactivity disorder (ADHD) is another common comorbidity of pediatric anxiety, Dr Garzon noted.
To best treat children with both anxiety and ADHD, Dr Garzon recommended referring to the Society for Developmental and Behavioral Pediatrics clinical practice guidelines on assessing and treating complex ADHD.
“I love that these guidelines are available and help to piece out the threads to managing complex disease,” she said. “It is important to go with the presenting problem that is most severe, usually the anxiety, but not in all cases. This requires getting the patient’s opinion about which [condition] is worse.”
Risk factors for anxiety among pediatric patients include having a parent with a psychiatric disorder; living in a neighborhood with negative social determinants of health; tendency toward a shy temperament or social withdrawal; sexual, physical, or substance abuse; genetics; and bullying. In cisgender patients, girls have a 2-fold higher risk for developing anxiety compared with boys of the same age after puberty. Reason for this difference is not yet well-understood, according to Dr Garzon.
“This indicates that differences in hormones and brain chemistry may play a role. However, the research into this isn’t as clear as many of us would like it to be. This is an important question because, should we understand it better, we might be able to tailor treatment to these root causes,” she said.
Rates of anxiety are high among LGBTQIA+ teenagers, largely due to social and environmental pressures they face as a result of their identity, Dr Garzon noted. “It is tough to be a teenager! But the stresses on our LGBTQIA+ youth is significantly higher and their suicide rates reflect that,” she said.
Signs and symptoms of generalized anxiety among the pediatric population may include irritability, sleep problems, impaired concentration, somatization, need for reassurance, and self-consciousness. Common worries for children involve school, athletics, and a fear of bad things happening.
The most common anxiety subtype in pediatrics is separation anxiety, defined as an abnormal reaction to an impending, imagined, or actual separation from a major attachment figure, home, or familiar surroundings.
Screening Tools for Anxiety in Children
Dr Garzon recommended that clinicians consult multiple sources, such as parents, teachers, and the child, about symptoms. For 9- to 12-year-old patients, a 20-item self-report questionnaire known as the Spielberger State-Trait Anxiety Inventory for Children (STAIC) can be used to screen for anxiety. For 8- to 18-year-old patients, the Multidimensional Anxiety Scale for Children (MASC), a 39-item self-report scale, can be used.
Cognitive behavioral therapy (CBT) was the main nonpharmacological management option for pediatric anxiety discussed in the presentation. Dr Garzon also mentioned the Creating Opportunities for Personal Empowerment (COPE) program, which incorporates CBT into a manual-based program designed to help children and teens cope with stress, anxiety, and depression.
Both selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are pharmacologic options for managing pediatric anxiety. Dr Garzon recommended starting at the lowest possible dose of these medications, and if the patient is stable after taking medication for 6 to 12 months, re-evaluate the dosing and consider a slow wean off medications.
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Garzon D. Pediatric anxiety disorder in primary care: When are worries a problem? Presented at: 2021 American Association of Nurse Practitioners National Conference; June 15-June, 2021.