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Pediatric Generalized Anxiety Disorder
Author: Dennis A Nutter Jr, MD, President and Director, North Georgia Neuropsychiatry, PC.
Dennis A Nutter, Jr, is a member of the following medical societies: American Academy of Child and
Adolescent Psychiatry and American Psychiatric Association.
Coauthor(s): Lene Holm Larsen, PhD, Instructor, Department of Child and Adolescent Psychiatry,
Children's Memorial Hospital of Chicago; Carrie Sylvester, MD, MPH, Senior Child and Adolescent
Psychiatrist, Sound Mental Health
Editors: Chet Johnson, MD, Center for Child Health and Development, Shiefelbusch Institute for Life
Span Studies, University of Kansas; Professor and Chair of Pediatrics, University of Kansas Medical
Center; Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference; Caroly Pataki, MD, Professor of
Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and
Adolescent Psychiatry, Keck School of Medicine of the University of Southern California.
Synonyms, Key Words, and Related Terms
generalized anxiety disorder, generalized anxiety disorder symptoms, generalized anxiety disorder causes,generalized anxiety disorder signs, generalized anxiety disorder treatment
Introduction
Background
Generalized anxiety disorder (GAD) is associated with persistent, excessive, and unrealistic worry that is
not focused on a specific object or situation. It was introduced in the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition ( DSM-IV ),1 replacing overanxious disorder of childhood ( Diagnostic and
Statistical Manual of Mental Disorders, Revised Third Edition [ DSM-III-R]).2, 3 (See History.)
Children with GAD worry more often and more intensely than other children in the same circumstances.
They may worry excessively about their performance and competence at school or in sporting events, about
personal safety and the safety of family members, or about natural disasters and future events.
The focus of worry may shift, but the inability to control the worry persists. Because children with GAD
have a hard time "turning off" the worrying, their ability to concentrate, process information, and engage
successfully in various activities may be impaired. In addition, problems with insecurity that often result in
frequent seeking of reassurance may interfere with their personal growth and social relationships. Further,
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children with GAD often seem overly conforming, perfectionistic, and self-critical. They may insist on
redoing even fairly insignificant tasks several times to get them "just right." This excessive structuring of
one's life is used as a defense against the generalized anxiety related to the concern about the individual's
overall and specific performance. (See Treatment.)
Little empiric data are available regarding the physiologic indicators of anxiety in children.4 The high cost,
lack of normative data, idiosyncratic patterns, and high sensitivity of cardiovascular and electrodermalmeasures in children contribute to the difficulties in physiologic assessment of anxiety in children.5 (See
Differentials.)
Go to Pediatric Obsessive-Compulsive Disorder , Pediatric Panic Disorder , and Anxiety Disorders for
complete information on these topics.
Complications
Potential complications of GAD include the following (see Prognosis):
Comorbid depression and other comorbid conditions
School truancy and withdrawal from other age-appropriate activities
Strained family relationships when the child's anxiety contributes to irritability, noncompliance,
demanding behavior, and/or chronic reassurance seeking
"Self-medication" leading to substance abuse by adolescents
Parents' inability to help in the child's treatment or to model adaptive coping/anxiety management
because of their own untreated anxiety (or other psychiatric condition)
Etiology
Multiple factors are thought to contribute to the development of generalized anxiety disorder (GAD) and to
the broad category of anxiety disorders. Biologic, familial, and environmental factors are considered
important. Behavioral inhibition, an early temperament associated with aversion to novel situations, has
been found to be associated with later development of anxiety disorders.
Research has demonstrated an association between parents with anxiety disorders and children with
behavioral inhibition. The tendency of anxiety to occur in families also has been established. Anxious
parents may genetically predispose their children to anxiety, model anxious behavior, and behave and/or
parent in ways that encourage and maintain anxious behavior in the child.
Environmental factors, such as other parental emotional problems, disrupted attachment, stressful life
events, and traumatic experiences, also may place the child at risk for developing GAD.
The role of the family in understanding child anxiety is important, particularly in situations in which the
needs of younger children who are developmentally limited in their ability to benefit from direct individual
intervention are considered.
Pathophysiology
Epidemiology
Incidence in the United States
The prevalence of generalized anxiety disorder (GAD) in children and adolescents ranges from 2.9-4.6%.
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Psychoeducation should be part of the treatment process. Patients and parents should have a good
understanding of the contributing and maintaining factors of anxiety. Also, they should be clear regarding
treatment goals, processes, and expectations.
For patient education information, see the Anxiety Center , as well as Anxiety, Panic Attacks, and
Hyperventilation.
United States
International
Mortality/Morbidity
Race
Sex
Age
Clinical
History
Children with generalized anxiety disorder (GAD) may experience somatic symptoms such as shortness of
breath, rapid heartbeat, sweating, nausea or diarrhea, frequent urination, cold and clammy hands, dry
mouth, trouble swallowing, or a "lump in the throat." Problems with muscle tension also can occur,
including trembling, twitching, a shaky feeling, and muscle soreness or aches. Patients often complain of
stomachaches and headaches. Despite these symptoms, few findings are noted on physical examination.
An evaluation for generalized anxiety disorder (GAD) should include data gathering through diagnostic
interviews with the child and parent, direct observation, and questionnaires. Family history of anxiety and
mood disorders, the child's early temperament and adjustment to school, and life stressors or disruptions are
among important factors to consider in GAD.
Structured interviews yielding DSM-IV diagnoses, such as the Diagnostic Interview Schedule for Children
(DISC) and the Anxiety Disorders Interview Schedule for DSM-IV Child and Parent Versions (ADIS-C/P),
can be employed.
Questionnaires, such as the Revised Children's Manifest Anxiety Scale (RCMAS), the Multidimensional
Anxiety Scale for Children (MASC),7 and the Screen for Child Anxiety Related Emotional Disorders
(SCARED) child and parent versions, can be used to further assess anxiety symptoms.
The DSM-IV requires the following to satisfy a diagnosis of GAD:
Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number
of events or activities
Difficulty controlling the worry
One of the following symptoms in association with the worry: restlessness, fatigue, poor
concentration, irritability, muscle tension, or sleep disturbance
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Focus of worry that is not confined to features of another Axis I diagnosis, eg, worry about having
a panic attack, social embarrassment, or separation from caregiver
Clinically significant distress or impairment experienced in social, school, or other important areas
Disturbance that is not due to a substance or general medical condition and that does not occur
exclusively during a mood disorder, a psychotic disorder, or in association with a pervasive
developmental disorder
Physical Examination
As previously mentioned, children with generalized anxiety disorder (GAD) may experience somatic
symptoms, including shortness of breath, rapid heartbeat, sweating, nausea or diarrhea, frequent urination,
cold and clammy hands, dry mouth, trouble swallowing, or a "lump in the throat." Problems with muscle
tension, such as trembling, twitching, a shaky feeling, and muscle soreness or aches, may also occur, and
patients often complain of stomachaches and headaches. Despite these symptoms, few findings are noted
on physical examination.
Causes
Differentials
Anxiety Disorder: Panic Disorder
Anxiety Disorder: Separation Anxiety and School Refusal
Attention Deficit Hyperactivity Disorder
Child Abuse & Neglect: Posttraumatic Stress Disorder
Eating Disorder: Anorexia
Hyperthyroidism
Hypothyroidism
Mood Disorder: Bipolar Disorder
Pediatric Obsessive-Compulsive Disorder
Thyroiditis
Diagnostic Considerations
Substance-induced anxiety disorder, anxiety disorder due to a general medical condition, an adjustment
disorder, or psychotic disorder also should be considered.
Distinguishing anxiety from developmentally appropriate fears is important. Throughout childhood and
early adolescence, children experience various transitory fears occurring concurrently with their ability to
recognize and understand potential dangers in their environment. A progression occurs from immediate,
tangible fears (eg, separation from caregiver, strangers) to anticipatory, less tangible fears (eg, bad dreams,
getting hurt, school failure). Children are expected to overcome and resolve these fears as part of the
developmental process.
Distinguishing anxiety from realistic worry is also imperative. Worry can be thought of as a feeling of
unease or concern about something. It represents an internal representation of a realistic threat. For
example, a child with a learning disability may worry about an upcoming examination, or a child with a
medical condition may worry about an upcoming surgery. This kind of worry is expected to be specific to a
situation, and it is expected to subside once the situation has passed. Thus, the temporal requirement for
generalized anxiety disorder (GAD) diagnosis (6 mo) is not met.
Conditions to consider in the differential diagnosis of GAD, in addition to those in the next section, include
the following:
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Oppositional defiant disorder
Peptic ulcer disease
Avoidant personality
Hypochondriasis
Social phobia and selective mutism
Specific phobia
Trichotillomania Asthma
Depression
Dysthymic disorder
Obstructive sleep apnea syndrome
Somatization
Go to Pediatric Obsessive-Compulsive Disorder , Pediatric Panic Disorder , and Anxiety Disorders for
complete information on these topics.
Workup
Approach Considerations
Consider urine drug screening, thyroid-stimulating hormone level assessment, and less common laboratory
tests based on history and physical findings.
Excessive laboratory exclusion of somatic complaints is to be avoided; however, careful interview and
physical examination assessment of stress-related symptoms should be repeated if the psychological
diagnostic picture is unclear.
Imaging Studies
Other Tests
Procedures
Histologic Findings
Staging
Treatment
Approach Considerations
For patients for whom medication is prescribed, regular appointments with a child and adolescent
psychiatrist or developmental-behavioral pediatrician are necessary for the duration of treatment. Parents
and patients must be warned of the possible risks of activation and disinhibition and what to do in such
circumstances.
Go to Pediatric Obsessive-Compulsive Disorder , Pediatric Panic Disorder , and Anxiety Disorders for
complete information on these topics.
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Patient therapy
Weekly outpatient therapy for 3-4 months with less frequent follow-up booster sessions may be sufficient.
A cognitive-behavioral approach is likely to be most beneficial. Treatment should consist of individual
sessions with family involvement to support the treatment process. Cognitive therapy features may be
incorporated into an eclectic approach by highly skilled and experienced therapists.
Psychodynamic therapies, including play therapy, are time-honored modalities, but most outcomes research
has focused on the brief or intermediate therapies, which are more structured.
Behavioral and Cognitive-Behavioral Therapy
Behavioral and cognitive-behavioral therapies are among the most researched and promising treatments for
childhood anxieties. Behavioral techniques (eg, relaxation training, modeling, imagining and visualizing, in
vivo exposure) and cognitive techniques (eg, identifying and modifying self-talk, challenging irrational
beliefs) often are used in combination with psychoeducation and contingency maintenance. Typically,
children are taught to recognize early physiologic and cognitive signs of anxiety and to develop and
implement coping techniques.
8, 9
The importance of parental participation in the treatment process recently has received attention. Adding a
family component focused on techniques such as contingency management, communication, and problem
solving to individual child cognitive-behavioral therapy has produced favorable long-term treatment
benefits in several clinical trials.10, 11, 12
Practically speaking, less successful real-world treatments are frequently encountered because of a dearth
of qualified child therapists and a failure to recognize the importance of directly or indirectly (family
component) treating parental anxiety. Several cognitive-behavioral therapy books, such as Helping Your
Anxious Child: A Step-By-Step Guide for Parents, by Sue Spence,13 and Keys to Parenting Your Anxious
Child (Barron's Parenting Keys), by Katharina Manassis, MD,14 are readily available for parents and their
children to work with at home and at school.
Exercise, Caffeine Avoidance, Preoperative Relaxation Therapy
Regular exercise promotes a sense of well-being that is particularly beneficial in individuals with anxiety
and mood disorders.
Limiting caffeine intake is appropriate.
Prior to a surgical procedure, children with an anxiety disorder are particularly likely to benefit from age-
appropriate preparation, including relaxation practice for elective procedures.
Deterrence and Prevention
The following measures may aid in the prevention of generalized anxiety disorder (GAD) in children:
Consistent, stable, supportive home environment
Parenting practices that promote self-confidence, self-esteem, and effective coping skills
Minimal number of psychosocial stressors or traumatic events
Adaptive problem solving and coping skills modeled by parents and other significant people in the
child's life
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Psychoeducation
Family-based interventions
Ginsburg conducted a study to determine the effectiveness of preventive intervention in the prevention
and/or amelioration of anxiety symptoms in children of parents with anxiety disorders and found evidence
to support the concept that family-based intervention may yield benefits in children at risk for anxiety .15
Forty children and their families were randomized to undergo an 8-week cognitive-behavioral intervention(the Coping and Promoting Strength [CAPS] program; 20 participants) or a wait list control condition (20
participants). After a 1-year follow-up, none of the children in the CAPS program developed an anxiety
disorder, while 30% of the children in the wait list group did.
The authors of one study developed a novel prediagnosis intervention, Strongest Families, which includes
trained nonprofessionals supervised by mental health professionals for children with disruptive behavior
and/or anxiety disorders. The intervention provides care using a handbook, instructional videos, and weekly
telephone contacts. The study results noted that these telephone-based treatments resulted in a significant
decrease in the proportion of children diagnosed with disruptive behavior or anxiety disorders; this
treatment may be an option for those patients who are unable to attend face-to-face sessions.16
Referrals
Early referral to a psychologist, psychiatrist, or behavioral-developmental pediatrician for evaluation and
treatment can alleviate symptoms and stress that may be the early manifestations of a more severe disorder.
Family therapy referral also may be indicated, but that may be best managed by the mental health
professional or the developmental and behavioral pediatrician who performs the consultative evaluation.
Medication
Medication is ideally adjunctive to psychological treatment of generalized anxiety disorder (GAD).
Unfortunately, lack of experienced and qualified therapists may preclude an adequate trial of cognitive-
behavioral therapy.
Selective serotonin reuptake inhibitor (SSRI) antidepressants are currently first-line medications in the
pharmacotherapy of anxiety disorders in children. These antidepressants are powerful anxiolytics with a
broader spectrum that may improve comorbid affective disorders and symptoms of anxiety.
Benzodiazepines have a relatively favorable adverse effect profile but are generally not chosen as first-line
treatments for anxiety in children and adolescents. These agents may cause behavioral disinhibition in
young children. They also have street value as drugs of abuse.
Buspirone (BuSpar) is an anxiolytic agent whose efficacy in the treatment of anxiety disorders in children
and adolescents has not yet been demonstrated. BuSpar is slow to work in adults but does not cause
habituation or disinhibition. Antihistamines and antipsychotics are not recommended for treatment of
childhood-onset anxiety disorders.
Pregabalin (Lyrica), an anticonvulsant, has been approved for use in adults by the European Commission
(EC) and the US Food and Drug Administration (FDA) for the management of diabetic peripheral
neuropathy, postherpetic neuralgia, and adjunctive treatment of partial-onset seizures. On March 27, 2006,
the EC approved a new indication for pregabalin, allowing its use in adults for the treatment of GAD in the
European Union.
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Pregabalin is not FDA approved for treating adult or pediatric GAD in the United States. EC approval was
based on a review of data from 5 randomized, double-blind clinical trials in more than 2000 patients, which
showed that pregabalin provided rapid and sustained efficacy in treating GAD, yielding significant relief
from psychic and somatic symptoms within the first week of treatment.
Most adverse events were mild to moderate in intensity and generally dose-related. Dizziness and
drowsiness were most frequently reported.
Pregabalin is a structural derivative of GABA. Its mechanism of action is unknown. It binds with high
affinity to the alpha2-delta site (a calcium channel subunit). In vitro, pregabalin reduces the calcium-
dependent release of several neurotransmitters, possibly by modulating calcium channel function.
Pregabalin is FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or
postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.
Drug Category: Selective serotonin reuptake inhibitors
SSRIs are antidepressant agents chemically unrelated to the tricyclic or tetracyclic agents or to other
available antidepressants. They inhibit neuronal reuptake of serotonin, thus potentiating serotonergic
activity in the brain, with the regulation of hypervigilance and other aspects of anxiety. These changes also
may have a weak effect on norepinephrine and dopamine neuronal reuptake. Several SSRIs are nowavailable.
SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of
SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk
associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide
risk must always be considered when treating a child or adolescent with mood disorder.
Physicians are advised to be aware of the following information and use appropriate caution when
considering treatment with SSRIs in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an
advisory that most SSRIs are not suitable for use by persons younger than age 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the
benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit
ratio in the treatment of depressive illness in patients younger than 18 years.
In 2004, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of
suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder.
This advisory reported suicidality (ideation and attempts) in clinical trials of various antidepressant drugs in
pediatric patients. The FDA has asked that additional studies be performed, because suicidality occurred in
treated and untreated patients with major depression and thus could not be definitively linked to drug
treatment.17
However, a study of more than 65,000 children and adults treated for depression between 1992 and 2002 by
the Group Health Cooperative in Seattle found that suicide risk declined, rather than rose, with the use of antidepressants. This has been the largest study to date to address this issue.
Currently, evidence does not exist to associate obsessive-compulsive disorder (OCD) and other anxiety
disorders treated with SSRIs with an increased risk of suicide.
Drug Name Fluoxetine (Prozac)
Description Fluoxetine has the longest history of use in children and adolescents and is
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now available in generic preparations. The drug’s long half -life is an
advantage and a drawback. If fluoxetine works well, an occasional missed
dose is not a problem; if problems occur, eliminating all active metabolites
takes a long time.
Adverse effects of SSRIs seem to be quite idiosyncratic; thus, relatively
few reasons exist to prefer one to another at this point if dosing is startedat a conservative level and advanced as tolerated.
Adult Dose
5 mg/d PO initially; may advance by 5-mg increments q3-5d to 20 mg/d
Then, advance in this manner again after about 6 wk; for GAD, higher
doses commonly used for other anxiety disorders or depressive disorders
usually are not required
Pediatric Dose
<18 years: Not approved
2 mg/d in young children or extremely anxious adolescents initially; may
benefit from doses of 5-10 mg/d; rate of dosage advance should be more
conservative than in adults
Drug Name Fluvoxamine (Luvox CR)
Description
Fluvoxamine enhances serotonin activity due to selective reuptake
inhibition at the neuronal membrane. It does not significantly bind toalpha-adrenergic, histamine, or cholinergic receptors and thus has fewer
adverse effects than tricyclic antidepressants.
Fluvoxamine has been shown to reduce repetitive thoughts, maladaptive
behaviors, and aggression and to increase social relatedness and language
use.
Adult Dose
50 mg PO qhs initially as single dose, increase dose in 50-mg increments
q4-7d as tolerated until maximum therapeutic benefit achieved; divide
total daily dose into 2 doses; if doses are unequal, administer larger dose
hs; not to exceed 300 mg/d
Pediatric Dose
<8 years: Not established
8-17 years: 25 mg PO qhs initially as single dose, increase dose in 25-mgincrements q4-7d as tolerated until maximum therapeutic benefit achieved,
divide total daily doses higher than 50 mg into 2 doses; if doses are
unequal, administer larger dose hs
Females children may respond to lower doses
Age up to 11 years: Not to exceed 200 mg daily
Adolescents may require higher doses up to adult maximum of 300 mg
daily
Drug Name Sertraline (Zoloft)
Description Zoloft selectively inhibits presynaptic serotonin reuptake.
Adult Dose50 mg PO qd; if needed, may titrate upward by 50-mg/d increments q7d;
not to exceed 200 mg/d
Pediatric Dose
<6 years: Not established6-12 years: 25 mg PO qd initially; if inadequate response, may increase
gradually at intervals of at least 1 wk; not to exceed 200 mg daily
13-17 years: 50 mg PO qd initially; if inadequate response, may increase
gradually at intervals of at least 1wk; not to exceed 200 mg daily
Drug Name Paroxetine (Paxil, Pexeva)
DescriptionThis is unlabeled use. Paroxetine is a potent selective inhibitor of neuronal
serotonin reuptake. It also has a weak effect on norepinephrine and
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dopamine neuronal reuptake. For maintenance dosing, make dosage
adjustments to maintain the patient on the lowest effective dosage, and
reassess the patient periodically to determine the need for continued
treatment.
Adult Dose
Initial therapy: Start with 10 mg/d PO and increase in 10 mg/d increments,
if necessary
Dose changes should occur at intervals of at least 1 wk; usual dose range
is 10-80 mg/d; not to exceed 80 mg/d
Pediatric Dose<18 years: Not established
>18 years: Administer as in adults
Drug Category: Benzodiazepines
These agents depress all levels of the central nervous system (eg, the limbic and reticular formations),
possibly by increasing the activity of gamma-aminobutyric acid (GABA). Benzodiazepines also increase
the frequency of chlorine channel opening in response to GABA binding. GABA receptors are chlorine
channels that mediate postsynaptic inhibition, resulting in postsynaptic neuron hyperpolarization. The final
result is a sedative-hypnotic and anxiolytic effect.
Benzodiazepines have been used in children for a variety of indications, including the reduction of
anticipatory or acute situational anxiety. Note the importance of using caution, and use these drugs only in
conjunction with psychotherapy aimed at reducing the length of time on benzodiazepines.
Many pediatricians are most familiar with diazepam (Valium), and no particular reason exists to prefer
another benzodiazepine in children, because diazepam is available as a generic preparation and has a
smooth, longer action that may be advantageous.
Lorazepam (Ativan) has the advantage of being quite short acting in the event of disinhibition, but it is not
as useful for the treatment of generalized anxiety disorder (GAD) because of the frequent dosing.
Clonazepam (Klonopin) has been studied in severe anxiety disorders but has been anecdotally (incorrectly)noted to have some increased risk of behavioral disinhibition. Alprazolam (Xanax) has been most studied
in anxiety disorders in children.
Drug Name Diazepam (Valium)
Description
Individualize dosage, and increase cautiously to avoid adverse effects.
Necessary to use for shortest time possible when abrupt discontinuation is
not a risk. Further, should not be continued if patient discontinues
psychotherapy.
Adult Dose 2-10 mg PO q3-4h, repeat q2-4h prn; not to exceed 30 mg in 8 h
Pediatric DoseInfants and young children: 0.1-0.3 mg/kg/d PO
Older children and adolescents: 1-2.5 mg PO tid/qid
Drug Category: Antianxiety Agents
Buspirone is the anxiolytic in this category. It has a high affinity for serotonin receptors and a moderate
affinity for dopamine receptors, and it does not have cross-tolerance with benzodiazepines. No reports of
dependence exist. One drawback is that buspirone takes 1-4 weeks to become effective.
Drug Name Buspirone hydrochloride
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Description
This is a 5-HT1 agonist with serotonergic neurotransmission and some
dopaminergic effects in the CNS. Buspirone hydrochloride has an
anxiolytic effect, but it may take up to 2-3 wk to reach full efficacy. A
relative disadvantage to the administration of this drug is a lack of official
approval for its use in individuals under age 18 years.
Adult Dose
15 mg/d PO divided tid initially; may increase by 5 mg/d q2-4d; not to
exceed 60 mg/d
Pediatric Dose
<18 years: Not approved; not established; suggested dose based on limited
data
Children: 2.5 mg/d PO; may increase by 2.5 mg q3-4d, adding doses to
achieve tid dosing with a total daily dose of 20 mg/d
Adolescents: Titrate as for children with eventual adult dose
Note that younger individuals and developmentally delayed individuals
may respond to lower doses than adults, thus conservative advancing is
prudent
Follow-up
Further Inpatient Care
Further Outpatient Care
In/Out Patient Meds
Transfer
Deterrence/Prevention
Complications
Prognosis
Patient Education
Miscellaneous
Medical/Legal Pitfalls
Special Concerns
Test Questions
Question 1:
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A 10-year-old boy is having difficulty completing his homework and is having many arguments with his
mother about this issue. She reports that he repeatedly works on a small part of the homework and
complains that it is not perfect enough, so he never moves on to the other work. She says that he has had
very good grades but always compares himself with his older sister, who is an A student. Lately, he also
has been complaining of stomachaches and asking to remain home from school. Which of the following
should be the next step?
A. Order an imaging study of his upper gastrointestinal tract.
B. Talk with the mother about sibling rivalry issues.
C. Tell her that this is classic school phobia and that he simply needs to be sent to school.
D.Refer them to a child psychologist, psychiatrist, behavioral developmental pediatrician, or other
mental health professional for evaluation and possible treatment.
E. Refer them to a social worker or counselor for therapy since this is clearly simple anxiety.
The correct answer is D: This case actually has somewhat of a broad differential diagnosis within the
spectrum of anxiety and depressive disorders. Many experienced social workers may make a correct
diagnosis and provide competent therapy, but it is important to know that the patient and parent are referred
to an individual who can provide comprehensive evaluation and treatment. The management of generalized
anxiety disorder, obsessive-compulsive disorder, a depressive disorder, a subtle learning disorder in a childwho had succeeded to that point, and a variety of family factors or other life stressors may be needed and is
best performed by trained mental health professionals.
Question 2:
A 12-year-old girl is undergoing a sports physical. She confides that she is very worried about participating
this year because, at times, she has had to wait alone after dark to be picked up after practice. Her mother
separately states that her daughter has seemed very nervous about school activities this year and wonders
about a mental health referral. Which of the following should be the next step?
A. Compliment the mother on her astute observation, and refer them to a social worker, psychologist, or psychiatrist.
B.Explore how truly dangerous the environment is and what other worries the child might have before
discussing an alternative plan with the girl and her mother together.
C.Offer the girl a prescription for an antianxiety medication so that she will not worry so much and will
enjoy her activities.
D.Tell the mother that it is better that the girl take a year off from the activities as she will grow out of
her fearfulness in due time.
E. Assure the girl that lots of children have these concerns and that it is simply normal worry.
The correct answer is B: This is most likely normal worry, but the circumstance warrants some
examination. Few situations exist in which a child or young adolescent safely can wait after dark,
especially in an urban area. If the child has been stressed by this kind of situation, she may be generalizingher fears. Also important is getting some idea of why she is being left without alienating the parent or
causing difficulty between the girl and her mother.
Question 1 (T/F):
Generalized anxiety disorder is more common in prepubertal girls than in prepubertal boys.
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The correct answer is False: Generalized anxiety disorder is observed equally in boys and girls until
puberty, when the female-to-male ratio gradually rises to 6:1.
Question 2 (T/F):
Generalized anxiety disorder tends to be familial.
The correct answer is True: The cause for the familial nature of the disorder may be a combination of
genetic temperament, modeling of anxious behavior, or other aspects of parenting style.
Question 3 (T/F):
Fluoxetine (Prozac) is the drug of choice for generalized anxiety disorder.
The correct answer is False: Fluoxetine is a good choice because of its availability in generic form, long
use in children and adolescents, and efficacy in comorbid depression. However, little reason exists to prefer
one selective serotonin reuptake inhibitor over another. Further, advantages may exist in using a
benzodiazepine in some children with pure anxiety who need rapid relief for a relatively short duration
while engaging in therapy.
Question 4 (T/F):
Cognitive-behavioral therapy with family involvement is the currently recommended psychotherapy of
choice for children with generalized anxiety disorder.
The correct answer is True: Family involvement is essential for treatment of children with anxiety.
Cognitive therapy features may be incorporated into an eclectic approach by highly skilled and experienced
therapists. Psychodynamic therapies, including play therapy, are time-honored modalities, but most
outcomes research has focused on the brief or intermediate more structured therapies.
Further Reading
MULTIMEDIA
REFERENCES
1. APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Elk Grove, Ill: APA; 1994..2. APA. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Elk Grove, Ill: APA; 1987..
3. Keeton CP, Kolos AC, Walkup JT. Pediatric generalized anxiety disorder: epidemiology, diagnosis, and
management. Paediatr Drugs. 2009;11(3):171-83. [Medline].
4. Barrios BA, Hartmann DB. Fears and anxieties. In: Marsh EJ, Terdal LG, eds. Behavioral Assessment of
Childhood Disorders. 2nd ed. New York, NY: Guilford; 1988:196-264.
5. Kendall PC. Childhood Disorders. London, England: Psychology Press; 2000.
6. Last CG, Perrin S, Hersen M, Kazdin AE. A prospective study of childhood anxiety disorders. J Am
Acad Child Adolesc Psychiatry. Nov 1996;35(11):1502-10. [Medline].
8/2/2019 View Topic GAD 2-2-12
http://slidepdf.com/reader/full/view-topic-gad-2-2-12 15/15
7. March JS, Parker JD, Sullivan K, Stallings P, Conners CK. The Multidimensional Anxiety Scale for
Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc
Psychiatry. Apr 1997;36(4):554-65. [Medline].
8. Kendall PC, Chu BC, Pimental SS. Treating anxiety disorders in youth. In: Kendall PC, ed. Child &
Adolescent Therapy: Cognitive-Behavioral Procedures. 2nd ed. New York, NY: Guilford; 2000:235-87.
9. Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT, et al. Cognitive behavioral
therapy, sertraline, or a combination in childhood anxiety. N Engl J Med . Dec 25 2008;359(26):2753-
66. [Medline]. [Full Text].
10. Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult
Clin Psychol . Apr 1996;64(2):333-42. [Medline].
11. Last CG, Hansen C, Franco N. Cognitive-behavioral treatment of school phobia. J Am Acad Child
Adolesc Psychiatry. Apr 1998;37(4):404-11. [Medline].
12. Silverman WK, Kurtines WM, Ginsburg GS, Weems CF, Lumpkin PW, Carmichael DH. Treating
anxiety disorders in children with group cognitive-behaviorial therapy: a randomized clinical trial. J
Consult Clin Psychol . Dec 1999;67(6):995-1003. [Medline].
13. Spence S. Helping Your Anxious Child: A Step-By-Step Guide for Parents. Oakland, Calif: New
Harbinger Publications; 2000.
14. Manassis K. Keys to Parenting Your Anxious Child . Hauppage, NY: Barron's Educational Series; 1996.
15. {Best Evidence} Ginsburg GS. The Child Anxiety Prevention Study: intervention model and primary
outcomes. J Consult Clin Psychol . Jun 2009;77(3):580-7. [Medline].
16. McGrath PJ, Lingley-Pottie P, Thurston C, et al. Telephone-based mental health interventions for childdisruptive behavior or anxiety disorders: randomized trials and overall analysis. J Am Acad Child Adolesc
Psychiatry. Nov 2011;50(11):1162-72. [Medline].
17. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J
Psychiatry. Jan 2006;163(1):41-7. [Medline].
Acknowledgments
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Article Content Generated: 02/02/12 02:16:45 PM
by Nutter, Dennis A