Anxiety: a Primer for the Pediatrician

Abstract

This paper focuses on the assessment and treatment of pediatric anxiety disorders targeted at pediatricians. It reviews the prevalence, role of the pediatrician in differentiating anxiety disorders from age-appropriate fears or normative responses to stressors, use of assessment tools, evidence-based treatment, and provides psychoeducation resources for children, parents, and clinicians. It reviews considerations for treatment modality and evidence for use of cognitive-behavioral therapy and psychopharmacology. First-line treatment of mild severity anxiety disorders is guided by well-established evidence and supported by randomized controlled trials that includes psychoeducation and psychotherapy, particularly cognitive-behavioral therapy (CBT). When anxiety is moderate to severe in intensity or impairment, initiation of psychopharmacology is considered in combination with CBT. Selective serotonin reuptake inhibitors (SSRIs) have the most evidence in randomized double-blind placebo-controlled trials and are recommended as first line for anxiety disorders, starting with low doses. It is important to discuss and monitor for potential adverse effects. Complementary and alternative medical (CAM) therapies are often used by youth, though there is limited evidence for benefit in children and adolescents with anxiety disorders, and potential risks need to be considered. Pediatric anxiety disorders are among the most common psychiatric disorders in children and adolescents and can result in significant impairment and morbidity. Pediatricians have an important role in identifying and facilitating treatment for youth with anxiety disorders, and CBT and psychopharmacology, particularly SSRIs, have the most evidence. However, accessing CBT for many families remains challenging. Pediatricians can provide psychoeducation and resources as a first step and initiate medications if indicated. Further research into integration of mental healthcare in pediatric settings could increase access to CBT and decrease morbidity. In addition, more randomized controlled trials and comparison studies for medications, CAM therapies, and combination treatments for pediatric anxiety disorders are needed.