Pediatric Pathways

A 9-year-old with Recurrent Stomach Pain Attention Problems and "Mood Swings"

After reading this article and answering the review questions the reader will be able to:

  1. List the signs and symptoms of Generalized Anxiety Disorder (GAD)
  2. Differentiate GAD from Attention-Deficit/Hyperactivity Disorder (ADHD), bipolar disorder, and social anxiety disorder
  3. Describe the components of cognitive behavioral therapy (CBT) and the role of pharmacotherapy

Case

Megan is a 9-year-old girl who presents to your office for evaluation of increasing school problems, mood swings, and stomachaches. Her parents state that these symptoms have been present for the past year, but progressively worse since the start of the current school year. Megan has always excelled at school, but now is more reluctant to attend school, as well as any activities away from home. She has had more difficulties with peers, which her parents feel are related to her tendency to be “bossy” and critical with friends, yet also being very sensitive to perceived criticism and possible rejection by them.

Megan’s parents describe her as highly structured in her approach to each day including attention to schedules at home and school. Transitions and change are very difficult for Megan. She has likewise always been “rule-bound” and becomes very frustrated when others do not follow the rules or disrupt the environment. Megan has had increasing difficulty falling asleep. She sometimes will get up to make sure her backpack is ready, and her homework done. At other times, she seeks out her parents during the night and asks to sleep with them, or demands that one of her parents sleep with her in her bed until she falls asleep.

Megan’s parents report that she is very different at home than at school, “it’s like Jekyll and Hyde.” Teachers describe her as the “perfect student,” “friendly, helpful to others,” “a pleasure to have in class,” and doing very well academically. At home, she is highly irritable, and has frequent “meltdowns” characterized by yelling, crying, and becoming inconsolable in general. These episodes occur randomly and over seemingly minor triggers.

Family members feel they are “walking on egg shells” and adjust their family plans and activities to try to avoid upsetting Megan. She has always achieved very high grades in school; however, she often becomes frustrated that she cannot concentrate well, and worries that she will not complete all of her homework or do it perfectly. Her parents recently learned that Megan will have the lead role in the school play, which confuses her parents even more given her tendency to not want to do anything outside of home and being somewhat shy.

Upon separate interview, Megan focuses on stomachaches that she has every morning and often in the evening. She also reports increasing problems with attention and problems completing her homework. She proudly tells you she “always” gets straight A’s, and becomes somewhat irritable with you when you suggest that it might be alright to sometimes get a B or C. When asked what she thinks may be causing her stomachaches, she acknowledges that she worries about having cancer or another illness. When discussing her concentration problems, she worries that her grades may slip, and that she therefore may not do well in middle and high school, and then won’t be able to get into a “good college.” With further discussion, Megan also describes worrying about the welfare of her pets, her parents’ safety, and her grades. She reports having “tons” of friends and denies avoiding interactions, citing her lead role in the school play.

On mental status exam, Megan is a thin girl, in no acute distress, but appears tired. She sits at the edge of the chair throughout the interview, and has frequent hand fidgeting. Her eye contact is relatively intense; her affect is anxious. There is no objective evidence of difficulty paying attention during the interview, or gross cognitive or developmental deficits. She denies thoughts of hurting herself or others. Her vital signs, physical exam, and screening labs (CBC, TSH) are all within normal limits.

Final Diagnosis: Megan’s clinical history and presentation meet diagnostic criteria for Generalized Anxiety Disorder (GAD).

Evaluation

The evaluation of a child with suspected anxiety ideally involves interviews of the parents and child separately, as well as together. When with parents, children with anxiety will often be more resistant to engage, may appear more regressed, for example, trying to hide their face by pressing against their parent’s arm or speak very quietly in one-word answers. When alone, they will often appear more guarded and tense in their posture and behavior. Their mood and affect are frequently anxious, with increased range of affect observed when discussing topics of interest to them. Children with anxiety will often deny parents’ concerns of possible anxiety, and either deny any problems at all, or focus on somatic problems such as stomachaches or headaches. They will generally relax somewhat during the interview, and discuss things that are “harder” for them or that they don’t like. They may describe worries when asked, but more often, will initially say “no” but later acknowledge specific things they feel “nervous” about, or that make them feel “frustrated” or “mad.” They may admit to becoming easily “mad” at home, and feeling bad afterwards that they “blew up.” It is always critical to also ask if they’ve ever felt so “nervous or mad” that they didn’t want to be alive or thought of hurting themselves or others. Many children may acknowledge, when asked, that they’ve had thoughts such as “I get so mad I wish I could just go away or fall asleep and not wake up,” or tell you that they have tried to hurt or kill themselves in the past with a specific plan.

The physical exam of the anxious child should include a review of all major organ systems and consideration of baseline screening tests to rule out potential underlying medical problems that can contribute to symptoms of anxiety such as arrhythmias, thyroid function (hyper- and hypo-), anemia, or infection. Somatic symptoms commonly occur with anxiety and usually are not associated with primary medical abnormalities, but nevertheless, must be considered. Gastrointestinal symptoms such as stomachaches and constipation are very common.

The interview should also assess recent stressors or changes for the child or family such as a move, divorce, new school, death in the family, etc. Stressors frequently exacerbate symptoms that have been present for some time, but that the patient and family have been able to accommodate to. School itself is a significant stressor for many children with anxiety given the progressive academic and social/peer expectations associated with advancing years in school. Parents will often report that their child’s controlling behavior and “meltdowns” have become a major stressor in their marriage and for the family as a whole.

Overview of Generalized Anxiety Disorder (GAD)

GAD is among the most prevalent types of anxiety disorders in children, yet is also among the least commonly diagnosed. Other types of anxiety are more readily and easily identified, with more circumscribed symptoms (for example, separation or social anxiety), while symptoms of GAD are more diffuse and often concealed.

Diagnostic criteria of GAD include the following:

  • Excessive and multiple worries about a number of different events or activities (for example, school performance), and the worries are difficult to control. Worries may vary and encompass concerns about the future, such as an upcoming project or achievements they will have as an adult, and/or include day-to-day “fretting” about things that could go wrong that day (for example, if they forget to do part of their homework, if their parents might be late in picking them up, if they will get called upon in class).
  • Anxiety and worry are associated with:
    • Restlessness, tenseness, feeling “keyed up” or “on edge”
    • Fatigue
    • Difficulty concentrating or mind going “blank”
    • Irritability
    • Muscle Tension
    • Sleep problem
    • The anxiety and worry cause significant distress and/or impairment in school, social, or other important areas of function.

Generalized anxiety disorder is frequently misdiagnosed as attention deficit hyperactivity disorder (ADHD), a mood disorder such as bipolar disorder, or social anxiety disorder due to the overlapping symptoms with these other disorders. Key features to differentiate include:

Attention problems and academic decline: The diagnosis of ADHD is typically apparent early in grade school, and symptoms of inattention are pervasive (e.g. at school and at home), and generally also include problems with organization, completion of tasks, losing things, and being forgetful. Attention problems associated with GAD are: 1) often related to tenseness and vigilance to the surroundings e.g. watching who in the classroom might get “in trouble and make the teacher mad,” and 2) compounded by underlying worries and setting high expectations of themselves to do what is expected, and doing it well, to avoid perceived criticism or “disappointing” others. Their grades generally reflect their effort to excel and please. Procrastination may occur due to worry of not doing it “perfectly.” Perfectionism associated with GAD differs from that of obsessive compulsive disorder (OCD). A child with GAD will feel the need to complete his/her work exceedingly well due to a self-imposed expectation to please others, including teachers, and not wanting to “look bad.” In contrast, perfectionism related to OCD is typically due to an inner drive to have homework look and be perfect regardless of others’ perception of it.

“Mood swings” and “meltdowns”: GAD is commonly characterized by irritability that is easily and seemingly randomly triggered. Irritability is often described as “meltdowns” of intense outbursts of negative emotion (e.g. anger, crying, yelling, and hitting) that the child is unable to control, but feels remorseful about afterwards. These episodes most often occur at home, and rarely at school or elsewhere due to an underlying goal of publically appearing in control and not “losing face.” Stress and tension are experienced during the day, but kept quietly internal, with outflow within the familiarity of family and home. When GAD becomes increasingly severe, outbursts may begin to occur elsewhere (e.g. at school), which typically indicates increasing tension that becomes more difficult to publically hide and control. This is in contrast to a primary mood disorder e.g. bipolar disorder, in which symptoms are more pervasive in all domains, and associated with more global evidence of impaired mood, behavioral changes, and functional impairment.

Social withdrawal and social difficulties: Children with GAD frequently tend to avoid activities away from home as symptoms become more impairing. Reluctance to engage in things outside of home is typically related to the need to control things. Children with GAD frequently feel a strong desire to “be ready” for whatever comes up. Home is familiar, comforting, predictable, and controllable; and children with GAD are often allowed to further “have their way” in order to avoid meltdowns. There is increasing resistance to change and more problems with tolerating any degree of stress. Engaging in any activities outside of home becomes equated with feeling more vulnerable and unpredictable, and hence, being at increased risk of something happening and “catching me off-guard and not ready.” Activities that children with GAD previously enjoyed are increasingly avoided and resisted; their “world” becomes increasingly smaller, restricted, and controlled.

Social problems similarly stem from a need to control and avoid not being in control. This is often observed in needing to direct what group play will consist of, and what role each peer will assume in the play. This increases order, predictability, and feeling in control of others. This pattern of play unfortunately is also frequently associated with difficulties sustaining friendships and having more meaningful relationships with peers. Children with GAD will often describe having many friends, but will have difficulty describing them in any detail. They may also describe feeling lonely. In contrast, involvement in lead school activities such as the school play or singing a solo is common. Children with GAD often have a strong desire to please others and excel, thus receiving the accolades of adults for their accomplishments. Involvement in lead roles may seem counter-intuitive to trying to avoid risk of public scrutiny. This type of experience, however, fits perfectly for youth with GAD; the roles are highly scripted and can be (and are!) practiced extensively outside of school, hence minimizing any risk of not being prepared and maintaining control, and garnering the positive attention of adults. Children with social anxiety/phobia may exhibit similar patterns (i.e. involvement in public performance situations), but will generally have pronounced difficulties in unscripted settings (e.g. sitting at the lunchroom table or attending the school dance), due to a primary fear of social embarrassment vs. need to control and be seen positively.

Treatment

  1. Cognitive Behavioral Therapy (CBT): CBT is the most important treatment for children with GAD, and should be considered as first line treatment. CBT is a type of psychotherapy for anxiety that is symptom-focused, time-limited, and empirically supported by multiple studies of children and adults. The “cognitive” component of CBT focuses on the relationship between feelings of anxiety and anxious thoughts. Children are taught to increasingly identify worries and “automatic” anxious and (often catastrophic) negative thoughts associated with anxiety. Cognitive strategies include challenging the likelihood of worries, and “cognitive restructuring” of anxious thoughts to more neutral or positive thoughts. Behavioral components of CBT address features of tension and avoidance-related behaviors. Children and their parents learn relaxation interventions. Graduated exposure to situations that evoke anxiety (and that are generally avoided) is essential to decreasing and eliminating anxiety; children learn to use cognitive and behavioral strategies while experiencing anxiety in these graduated exposure situations. CBT emphasizes practice and use of these skills at home, at school, and any activities outside of home/school. Involvement of the child’s parents in their CBT is also critical in order to guide them on how to respond to their child’s anxiety symptoms at home, including encouragement of use of specific CBT strategies reviewed by the CBT therapist. Mindfulness-based interventions are also often beneficial in conjunction with CBT.

  2. Pharmacotherapy: For many children, treatment with CBT will effectively decrease/eliminate symptoms of anxiety and should be considered first-line. For those with more severe and impairing symptoms, medication may be used to augment CBT interventions. Serotonin reuptake inhibitors (SSRIs) are the only evidence-based medications for treatment of anxiety in youth. The SSRIs include fluoxetine, sertraline, citalopram, paroxetine, and escitalopram. The SSRIs require compliance with daily use, and an initial treatment period of 4 to 6 weeks to assess the efficacy of initial treatment doses. Side effects are generally limited or absent, and may include changes in sleep, appetite, or feelings of jitteriness that generally abate within 1 to 2 weeks. For some children, SSRIs may result in dis-inhibition and include appearance of impulsive, or activating, behaviors. SSRIs, like all anti-depressants, also carry FDA warnings of possible increase in self-harm ideation and behaviors. Parents should be advised to contact their primary care provider with any changes in behavior or related concerns after initiating SSRI treatment. Moreover, some children may have negative responses to one SSRI and not to another; there is unfortunately no way to know ahead of time if this may occur. The initial recommended treatment trial for an SSRI is 9 to12 months of sustained improvement and clinical stability. After this period, reassessment of dose/need for treatment should occur, with stepwise decrease in dose every 4 to 6 months thereafter if symptom stability is maintained. If symptoms re-emerge on a lower dose, the dose should be raised to the preceding dose for another 4 to 6 months. Treatment of anxiety with SSRIs should never be considered “lifelong” (i.e., symptoms should always be reassessed at regular intervals and adjustment of dose based upon clinical status).

    Other medications may be considered for short-term relief of anxiety symptoms in conjunction with SSRIs for severe and impairing anxiety (e.g., benzodiazepines) but should never be used as first-line treatment or for lengthy periods of time. Use of these medications should be judicious and for circumscribed periods of time, i.e. during initial 4 to 6 week period of SSRI treatment. As with SSRI’s, monitoring for behavioral dis-inhibition should also be undertaken. If used, longer acting agents such as clonazepam are generally preferable to avoid repeated use of shorter-acting agents during the day, and associated physiological and psychological rebound effect, which can further exacerbate feelings of anxiety and agitation.

Conclusion

GAD is very common among children and adolescents. The assessment should include questions about worries, in addition to behaviors indicative of avoidance, control, academic struggles, and difficulties with friendships, irritability, and sleep. Moreover, externalizing symptoms such as irritability and tantrums are typically very evident at home and absent at school in most cases. Treatment for all children with GAD should include consideration of cognitive behavioral therapy, with use of adjunct pharmacotherapy for more severe and/or refractory cases.

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References

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