Treatment Of Pediatric Anxiety Disorders Research Articles

Current and Future Approaches to Pediatric Anxiety Disorder Treatment.

This overview critically appraises the literature on the treatment of pediatric anxiety disorders. The two established treatments for these conditions comprise cognitive-behavioral therapy (CBT) and antidepressant medications. Many youths receiving these treatments fail to achieve remission, which creates a need for new treatments. After summarizing the literature on CBT and currently available medications, the authors describe research that lays a foundation for improvements in the treatment of pediatric anxiety disorders. This foundation leverages neuroscientific investigations, also described in the overview, which provide insights on mechanisms of successful treatment.

Gastrointestinal Symptoms in Pediatric Patients with Anxiety Disorders and Their Relationship to Selective Serotonin Reuptake Inhibitor Treatment or Placebo.

Gastrointestinal symptoms are commonly reported as adverse effects of selective serotonin reuptake inhibitors (SSRIs), the first-line pharmacologic treatment for pediatric anxiety disorders; however, the temporal course of these symptoms during treatment, although believed to be transient, has never been prospectively evaluated. Additionally, rates of gastrointestinal symptoms and functional gastrointestinal syndromes in anxious youth are poorly understood. We examined gastrointestinal symptoms in youth with anxiety disorders during a double-blind, placebo-controlled trial of escitalopram (n = 51). Then, in a separate sample of prospectively treated children and adolescents with generalized, social and/or separation anxiety disorders (n = 56), we examined the frequency of gastrointestinal symptoms based on the Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS) and ROME III criteria and the association of these symptoms with clinical and demographic characteristics using logistic regression. The frequency/severity of abdominal pain, diarrhea, bloating constipation or total gastrointestinal symptoms did not differ between patients receiving placebo (n = 25) or escitalopram (n = 26). However, escitalopram-treated youth had transient changes in nausea/vomiting and total upper gastrointestinal symptoms during the first two weeks of treatment. ROME III criteria for functional gastrointestinal syndromes were present in 12/56 patients (21.4%). QPGS-related functional gastrointestinal syndromes and symptoms were unrelated to treatment, treatment type, or clinical or demographic variables. Gastrointestinal symptoms are common in youth with anxiety and SSRIs produce transient-rather than sustained-gastrointestinal symptoms. Assessing gastrointestinal symptoms prior to pharmacotherapy and discussing factors that increase (or decrease) the likelihood of transient SSRI-related symptoms in youth may decrease patient uncertainty related to side effects and decrease medication-related anxiety.

Extinction Learning Across Development: Neurodevelopmental Changes and Implications for Pediatric Anxiety Disorders.

Alterations in extinction learning relate to the development and maintenance of anxiety disorders across the lifespan. While exposure therapy, based on principles of extinction, can be highly effective for treating anxiety, many patients do not show sufficient improvement following treatment. In particular, evidence suggests that exposure therapy does not work sufficiently for up to 40% of children who receive this evidence-based treatment.Importantly, fear learning and extinction, as well as the neural circuitry supporting these processes, undergo dynamic changes across development. An improved understanding of developmental changes in extinction learning and the associated neural circuitry may help to identify targets to improve treatment response in clinically anxious children and adolescents. In this chapter, we provide a brief overview of methods used to study fear learning and extinction in developmental populations. We then review what is currently known about the developmental changes that occur in extinction learning and related neural circuitry. We end this chapter with a discussion of the implications of these neurodevelopmental changes for the characterization and treatment of pediatric anxiety disorders.

Pharmacological Treatment for Pediatric Anxiety Disorders.

Pediatric anxiety disorders (PADs) occur in up to 20% of youth and can cause impairment across the lifespan. Coronavirus disease 2019 (COVID-19) added unique pressures on those with PADs, as children and adolescents endured the longest pandemic restrictions, stymieing their ability to develop socially, emotionally, and cognitively. Although first-line treatment for PADs is psychotherapy, those with severe anxiety symptoms will require pharmacological interventions. Selective serotonin reuptake inhibitor and serotonin norepinephrine reuptake inhibitor (SNRI) medications are effective in treating PADs, yet only duloxetine (a SNRI) is approved by the U.S. Food and Drug Administration for children aged >7 years with generalized anxiety disorder. Treatment of children and adolescents with benzodiazepines for PADs presents unique challenges with potential paradoxical reactions. Caution must be observed as well due to risk for misuse related to long-term use of benzodiazepines with PADs. [Journal of Psychosocial Nursing and Mental Health Services, 60(9), 6-9.].

The Role of Intolerance of Uncertainty in Treatment for Pediatric Anxiety Disorders and Obsessive-Compulsive Disorder

ABSTRACT This study investigated the role of intolerance of uncertainty (IU) in an intensive group-based cognitive behavioral therapy (CBT) program with family involvement for children with anxiety disorders and obsessive-compulsive disorder (OCD). One hundred four children and adolescents, aged 8–19 years, who were patients in an intensive outpatient group-based treatment program and their parents participated in this intervention-based study. From both children’s and parents’ perspectives at admission, higher IU in children was associated with both higher levels of anxiety and functional impairment. Both children and parents reported significant reductions in children’s IU by discharge, and these reductions were associated with greater reductions in children’s anxiety and functional impairment. However, children who reported higher levels of IU at admission, reported fewer reductions in their anxiety and functional impairment. These findings demonstrate an association between IU and children’s anxiety and OCD intensive treatment outcomes. Those with higher levels of IU may benefit from more interventions that address tolerating uncertainty.

Pharmacogenetically Guided Escitalopram Treatment for Pediatric Anxiety Disorders: Protocol for a Double-Blind Randomized Trial.

Current pharmacologic treatments for pediatric anxiety disorders (e.g., selective serotonin reuptake inhibitors (SSRIs)) frequently use “one size fits all” dosing strategies based on average responses in clinical trials. However, for some SSRIs, including escitalopram, variation in CYP2C19 activity produces substantial variation in medication exposure (i.e., blood medication concentrations). This raises an important question: would refining current SSRI dosing strategies based on CYP2C19 phenotypes increase response and reduce side effect burden? To answer this question, we designed a randomized, double-blind trial of adolescents 12–17 years of age with generalized, separation, and/or social anxiety disorders (N = 132). Patients are randomized (1:1) to standard escitalopram dosing or dosing based on validated CYP2C19 phenotypes for escitalopram metabolism. Using this approach, we will determine whether pharmacogenetically-guided treatment—compared to standard dosing—produces faster and greater reduction in anxiety symptoms (i.e., response) and improves tolerability (e.g., decreased risk of treatment-related activation and weight gain). Secondarily, we will examine pharmacodynamic variants associated with treatment outcomes, thus enhancing clinicians’ ability to predict response and tolerability. Ultimately, developing a strategy to optimize dosing for individual patients could accelerate response while decreasing side effects—an immediate benefit to patients and their families. ClinicalTrials.gov Identifier: NCT04623099.

A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders

BackgroundTreatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn’t working well—whether to optimize the treatment already begun or to add the other treatment.MethodsThis is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8–17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first (“Main Effect 1”). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment (“Main Effect 2”). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBT➔CBT; CBT➔med; med➔med; med➔CBT) in non-remitters is significantly better or worse than predicted from main effects alone.DiscussionFindings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders.Trial registrationThis protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275.

Comparing neural correlates of conditioned inhibition between children with and without anxiety disorders – A preliminary study

Cognitive-behavioral therapy (CBT), a first-line treatment for pediatric anxiety disorders, is based on principles of threat learning and extinction. However, CBT does not work sufficiently for up to 40% of clinically anxious youth. The neural and behavioral correlates of conditioned inhibition might provide promising targets for attempts to improve CBT response. During conditioned inhibition, threat and safety cues appear together, forming a safety compound. Here, we test whether this safety compound elicits a reduced fear response compared to pairing the threat cue with a novel cue (novel compound). The current pilot study compares behavioral, physiological, and neural correlates of conditioned inhibition between children with (n = 17, Mage = 13.09, SDage = 3.05) and without (n = 18, Mage = 14.49, SDage = 2.38) anxiety disorders. Behavioral and physiological measures did not differ between children with and without anxiety disorders during fear acquisition. During testing, children with anxiety disorders showed overall higher skin conductance response and expected to hear the aversive sound following the novel compound more often than children without anxiety disorders. Children with anxiety disorders showed more activity in the right ventromedial prefrontal cortex (vmPFC) to the safety versus novel compound. Children without anxiety disorders showed the opposite pattern – more right vmPFC activity to the novel versus safety compound (F(1,31) = 5.40, p = 0.03). No group differences manifested within the amygdala, dorsal anterior cingulate cortex, or hippocampus. These pilot findings suggest a feasible approach for examining conditioned inhibition in pediatric anxiety disorders. If replicated in larger samples, findings may implicate perturbed conditioned inhibition in pediatric anxiety disorders and provide targets for CBT.

Attention Alterations in Pediatric Anxiety: Evidence From Behavior and Neuroimaging

BackgroundPediatric anxiety disorders involve greater capture of attention by threatening stimuli. However, it is not known if disturbances extend to nonthreatening stimuli, as part of a pervasive disturbance in attention-related brain systems. We hypothesized that pediatric anxiety involves greater capture of attention by salient, nonemotional stimuli, coupled with greater activity in the portion of the inferior frontal gyrus (IFG) specific to the ventral attention network (VAN). MethodsA sample of children (n = 129, 75 girls, mean 10.6 years of age), approximately half of whom met criteria for a current anxiety disorder, completed a task measuring involuntary capture of attention by nonemotional (square boxes) and emotional (angry and neutral faces) stimuli. A subset (n = 61) completed a task variant during functional magnetic resonance imaging. A priori analyses examined activity in functional brain areas within the right IFG, supplemented by a whole-brain, exploratory analysis. ResultsHigher clinician-rated anxiety was associated with greater capture of attention by nonemotional, salient stimuli (F1,125 = 4.94, p = .028) and greater activity in the portion of the IFG specific to the VAN (F1,57 = 10.311, p = .002). Whole-brain analyses confirmed that the effect of anxiety during capture of attention was most pronounced in the VAN portion of the IFG, along with additional areas of the VAN and the default mode network. ConclusionsThe pathophysiology of pediatric anxiety appears to involve greater capture of attention to salient stimuli, as well as greater activity in attention-related brain networks. These results provide novel behavioral and brain-based targets for treatment of pediatric anxiety disorders.

Measurement-Based Care in the Treatment of Anxiety.

Treatment of pediatric anxiety disorders is complicated by their number, comorbidity, and the differential impact of a child's anxiety on the child and parents. Measurement-based care, using patient-level rating scales, can guide clinical decisions, track symptom improvement, and monitor treatment response. We review instruments for measurement-based care in pediatric anxiety. Measures used to track pediatric anxiety should be brief, accessible, sensitive to change, and reliable. Because parent-child agreement about a child's anxiety tends to be low, measures from both should be obtained. Measurements can also track functional improvement, expectancy related to treatment, and readiness to change.

School-Based Clinicians Sustained Use of a Cognitive Behavioral Treatment for Anxiety Disorders

Dissemination and use of cognitive behavioral therapy (CBT), the primary evidence-based psychosocial treatment for pediatric anxiety disorders, in school settings has been slow, occurring primarily in the context of randomized controlled trials (RCT). No data are available on the sustained use of CBT by school clinicians after research support ends. Filling this gap, the current study examined clinicians: (1) recall and attitudes toward a modular CBT (M-CBT), (2) sustained use of anxiety screening measures, (3) sustained use of M-CBT and modifications made, (4) perceived reasons and barriers to sustained use and (5) an exploratory examination of predictors of the sustained use of M-CBT. Participants included 43 school-based clinicians (77% of those originally trained in an RCT; 90% female, 73% White) who were contacted 3.43 years after their initial training to complete an online sustainability questionnaire. The results indicated that while most clinicians recalled and had positive attitudes about the M-CBT training (90%), 63% reported they continued to use M-CBT and a majority made modifications to the content, length and format. Predictors of the sustained use, based on 22 single predictor regression models, included greater perceived acceptability and benefits (for youth and clinicians) of the intervention and lower perceived difficulty of administering M-CBT components. Fewer administrative demands were also associated with greater sustained use. Findings suggest that additional efforts are needed to enhance the sustained use of M-CBT for anxiety in school settings. Targeting specific aspects of the intervention materials (difficulty, benefits) as well as lowering administrative demands might facilitate the sustained use of M-CBT by school clinicians.

Research Review: Pediatric anxiety disorders - what have we learnt in the last 10years?

Anxiety disorders first emerge during the critical developmental periods of childhood and adolescence. This review synthesizes recent findings on the prevalence, risk factors, and course of the anxiety disorders; and their neurobiology and treatment. For this review, searches were conducted using PubMed, PsycINFO, and clinicaltrials.gov. Findings related to the epidemiology, neurobiology, risk factors, and treatment of pediatric anxiety disorders were then summarized. Anxiety disorders are high prevalence, and early-onset conditions associated with multiple risk factors including early inhibited temperament, environment stress, and structural and functional abnormalities in the prefrontal-amygdala circuitry as well as the default mode and salience networks. The anxiety disorders are effectively treated with cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Anxiety disorders are high prevalence, early-onset conditions associated with a distinct neurobiological fingerprint, and are consistently responsive to treatment. Questions remain regarding who is at risk of developing anxiety disorders as well as the way in which neurobiology predicts treatment response.

1.4 PSYCHOPHARMACOLOGIC TREATMENT OF PEDIATRIC ANXIETY DISORDERS: AN UPDATE

The goals of this session are to summarize and compare the differential efficacy and tolerability of pharmacotherapy for the treatment of pediatric anxiety disorders and to describe predictors of treatment response.

Longitudinal Study of Sleep and Internalizing Problems in Youth Treated for Pediatric Anxiety Disorders.

The current study examined prospective bidirectional links between dysregulated sleep, and anxiety and depression severity across 4years, among youth with a history of anxiety disorder. Participants were 319 youth (age 11-26years), who previously participated in a large multisite randomized controlled trial for the treatment of pediatric anxiety disorders, Child/Adolescent Anxiety Multimodal Study (CAMS), and subsequently enrolled in a naturalistic follow-up, Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS), an average of 6.5years later. They participated in four annual visits that included self-report items of dysregulated sleep and semi-structured multi-informant interviews of anxiety and depression. Dysregulated sleep was bidirectionally associated with clinician-rated anxiety and depression symptom severity across adolescence and young adulthood. However, these bidirectional relationships were attributable to youth mean levels of dysregulated sleep, and anxiety and depression severity over the 4 years. Elevations in dysregulated sleep at each visit, relative to mean levels, did not predict worse anxiety or depression severity 1 year later. Likewise visit-specific elevations in anxiety and depression severity, as opposed to average levels, did not predict higher levels of dysregulated sleep at the next visit. Having higher levels of dysregulated sleep or more severe internalizing problems across the four-year period, as opposed to reporting a relative increase in symptom severity at a particular visit, posed greater risk for poor mental health. Interventions should continue to assess and treat persistent sleep problems alongside anxiety and depression.

Psychotherapy Claims Surrounding Pharmacotherapy Initiation in Children and Adolescents with Anxiety Disorders.

Psychotherapy is an effective, recommended treatment for pediatric anxiety disorders. Nevertheless, individuals with mental health conditions often do not receive psychotherapy, with variation across provider types. This study sought to examine psychotherapy claims surrounding medication initiation in U.S. children with diagnosed anxiety disorders. The study cohort included privately insured children (3-17 years) with a diagnosed anxiety disorder initiating a medication to treat anxiety from 2004 to 2014. We examined psychotherapy claims in the 3 months before and 3 months after medication initiation and described children with multiple (2+) psychotherapy claims per 3-month period. Of the 75,024 children initiating a medication for anxiety (median age = 14 years, 58% female), 35% had multiple psychotherapy claims before medication initiation, with variation by age, anxiety disorder, and psychiatric comorbidity and with little change across time. Psychotherapy claims after medication initiation varied by whether the child had prior psychotherapy: 80% in children with prior psychotherapy and 30% in children without prior psychotherapy claims (44% of children diagnosed by a psychiatrist, 21% of children diagnosed by a pediatrician). Many privately insured children do not have claims for psychotherapy before or after pharmacotherapy initiation for anxiety. Findings can inform future research and efforts to ultimately increase appropriate psychotherapy utilization in children with anxiety disorders.

The Interplay of Familial and Individual Risk in Predicting Clinical Improvements in Pediatric Anxiety Disorders

Bioecological models of developmental psychopathology underscore the role of familial experiences of adversity and children’s individual-level characteristics in heightening risk for pediatric anxiety through direct, combined, and interactive effects. To date, much of the existing research dedicated to pediatric anxiety disorders has largely been examined in bioecological models of diathesis-stress using community samples. This study extends our understanding of children’s differential responsiveness to familial adversity by examining the diathesis-stress interaction of cumulative risk and children’s individual-level vulnerabilities (negative affectivity and coping efficacy) within a clinic-referred treatment study for pediatric anxiety disorders. A cumulative risk index assessing exposure to familial adversity (e.g., socioeconomic status [SES], parent psychiatric illness) and self-reported measures of children’s negative affectivity and coping efficacy were each measured at the intake of a randomized controlled clinical trial for the treatment of pediatric anxiety disorders (N = 488; 7–17 years of age). Trajectories of interviewer-rated anxiety symptoms were assessed across 12 weeks of treatment at baseline, 4 weeks, 8 weeks, and 12 weeks. Consistent with models of temperamental risk for mental health problems, negative affectivity predicted higher anxiety symptoms at intake. A significant diathesis-stress interaction between cumulative risk and coping efficacy emerged, as high risk and perceptions of lower coping efficacy attenuated declines in anxiety across 12 weeks. These patterns did not differ across treatment conditions. The results indicate that for youth experiencing high levels of stress, additional treatment efforts targeting familial stressors and coping efficacy may be important in maximizing treatment outcomes.

SSRIs Appear Superior to SSNRIs for Pediatric Anxiety, Study Shows

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessSSRIs Appear Superior to SSNRIs for Pediatric Anxiety, Study ShowsMark MoranMark MoranSearch for more papers by this authorPublished Online:5 Apr 2018https://doi.org/10.1176/appi.pn.2018.4a9AbstractThe serotonin system may mature earlier than the noradrenergic system, accounting for differences in how youth respond to selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SSNRIs).Selective serotonin reuptake inhibitors (SSRIs) appear to be superior to selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) in the treatment of pediatric anxiety disorders, though both are associated with statistically significant improvement after two weeks, according to a meta-analysis posted February 7 in the Journal of the American Academy of Child and Adolescent Psychiatry. “These results are meaningful to clinicians as they choose which antidepressant class to use when treating anxious youth,” wrote Jeffrey Strawn, M.D., of the University of Cincinnati College of Medicine and colleagues. “Additionally, given the magnitude and trajectory of SSRI response, relative to SSNRI response observed herein, clinicians might preferentially use SSRIs as first-line psychopharmacologic interventions in pediatric patients with anxiety disorders.” Strawn and colleagues searched the literature for prospective, randomized, placebo-controlled trials (RCTs) that evaluated the efficacy of SSRIs or SSNRIs in the treatment of social, generalized, and/or separation anxiety disorder in children and adolescents. Overall, nine double-blind RCTs (1,805 patients) conducted between 1997 and 2014 were included in the analysis. Four SSRIs were evaluated: fluoxetine, fluvoxamine, paroxetine, and sertraline. Three SSNRIs were evaluated: atomoxetine, duloxetine, and venlafaxine. Five studies were federally funded, and four were funded by industry. All studies were conducted in outpatient settings. The primary outcome for these analyses was the change in Pediatric Anxiety Rating Scale (PARS) total score from baseline to endpoint at week 12.Patients taking both SSRIs and SSNRIs improved significantly by week two over those taking placebo and continued to have statistically significant improvement throughout the study period. However, treatment response among those taking SSRIs was statistically greater at week two than among those taking SSNRIs, and that difference remained statistically significant over the subsequent 10 weeks of treatment.Over time, response did not differ between high-dose SSRI treatment compared with low-dose treatment. However, statistically significant improvement occurred earlier (week 2) with high-dose treatment. At week 12, both high-dose and low-dose treatments were associated with significant improvement compared with baseline.Strawn and colleagues said the superiority of SSRIs may be because the pathophysiology of anxiety involves more serotonergic dysfunction relative to noradrenergic dysfunction. Additionally, the serotonin system matures earlier than the noradrenergic system, and this developmental lag in the noradrenergic system may underlie differences in the effectiveness of SNRI antidepressants that mechanistically target norepinephrine and SSRIs that target serotonin. “Our results suggest that antidepressant response in pediatric patients occurs early in the course of treatment and occurs with a greater magnitude and more rapid trajectory with SSRIs compared to SSNRIs,” Strawn and colleagues wrote. “These data raise the possibility that SSRIs should be first-line antidepressants in youth with anxiety disorders and extend prior observations in pediatric patients with anxiety that more serotonergically selective agents may be more effective.” ■“The Impact of Antidepressant Dose and Class on Treatment Response in Pediatric Anxiety Disorders: A Meta-Analysis” can be accessed here. ISSUES NewArchived

Anterior cingulate activation to implicit threat before and after treatment for pediatric anxiety disorders

BackgroundResearch suggests that individuals with anxiety have difficulty ignoring threat distractors when completing tasks with competing stimuli. Studies examining the neural correlates of these emotional processing difficulties in youth anxiety highlight reduced recruitment of regions associated with goal-directed attention, such as the anterior cingulate cortex (ACC). In the current study, we examined neural activation during an emotional conflict task in youth with anxiety disorders before and after treatment. MethodsTwenty-five youth (ages 9–19 years) with generalized, separation, and/or social anxiety disorder and 25 healthy controls underwent 2 functional magnetic resonance imaging scans approximately 13 weeks apart. At each scan, participants completed a task in which they matched shapes in the context of emotional distractors (happy and threatening faces). Between scans, anxious youth were treated with the selective serotonin reuptake inhibitor (SSRI) sertraline or cognitive behavior therapy (CBT). ResultsPrior to treatment, anxious youth exhibited reduced activation of the medial prefrontal cortex, encompassing the rostral ACC, when matching shapes in the context of threat distractors relative to healthy controls. Activation in this region increased in anxious youth after treatment, but remained unchanged in the healthy control group. Increases in rostral ACC activation were related to greater reductions in social anxiety and avoidance symptoms following treatment. ConclusionsEffective treatments for pediatric anxiety may enhance rostral ACC response during attempts to filter out threat-relevant stimuli. Enhanced recruitment of this region may constitute one manner in which CBT and SSRI treatment reduce youth anxiety symptoms, particularly social anxiety and avoidance.

Anxiety: a Primer for the Pediatrician

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.

Mediators of Treatment Outcomes for Anxious Children and Adolescents: The Role of Somatic Symptoms

Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors are effective treatments for pediatric anxiety disorders. However, the mechanisms of these treatments are unknown. Previous research indicated that somatic symptoms are reduced following treatment, but it is unclear if their reductions are merely a consequence of treatment gains. This study examined reductions in somatic symptoms as a potential mediator of the relationship between treatment and anxiety outcomes. Participants were 488 anxious youth ages 7–17 (M = 10.7), 50.4% male, 78.9% Caucasian, enrolled in Child/Adolescent Anxiety Multimodal Study, a large randomized control trial comparing 12-week treatments of CBT, sertraline, a combination of CBT and sertraline, and a pill placebo. Causal mediation models were tested in R using data from baseline, 8-, and 12-week evaluations. Somatic symptoms were assessed using the Panic/Somatic subscale from the Screen for Child Anxiety Related Emotional Disorders. Youth outcomes were assessed using the Pediatric Anxiety Rating Scale and Children’s Global Assessment Scale. Reductions in somatic symptoms mediated improvement in anxiety symptoms and global functioning for those in the sertraline-only condition based on parent report. Conditions involving CBT and data based on child reported somatic symptoms did not show a mediation effect. Findings indicate that reductions in somatic symptoms may be a mediator of improvements for treatments including pharmacotherapy and not CBT. Although the overall efficacy of sertraline and CBT for anxiety may be similar, the treatments appear to function via different mechanisms.