#50: Facing the (Core) Fear! Pediatric Anxiety Pt 1: Live the Exposure Lifestyle

May 11, 2022 | By Sam Masur

Summary

How much anxiety is too much anxiety? In the first part of a two episode series, Dr. Beth Brannan, a Triple Board Trained Physician, will talk with us about diagnosing anxiety disorders and the role of exposure therapy in treating anxiety.

Credits

• Producer and Writer: Sally Elliott MD and Becca Raymond-Kolker MD
• Executive Producer: Nicholas Lee MD
• Showrunner: Sam Masur MD
• Infographic: Sally Elliott MD 
• Cover Art: Chris Chiu MD
• Hosts: Justin Berk MD, Chris Chiu MD, Becca Raymond-Kolker MD
• Editor: Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Beth Brannan, MD

Pediatric Anxiety, Part 1: Pearls

1. Feeling anxious can be totally normal. Anxiety becomes a disorder when it is: excessive for the situation,  doesn’t go away, or leads to an impairment in function.
2. Widespread screening during primary care visits is important for early identification of anxiety disorders. 
3. Anxiety disorders are very common, they are treatable, and there are lots of comorbidities in adolescence and adulthood if left untreated.
4. First line treatment of anxiety and OCD in youth is a form of CBT called exposure therapy.
5. If the child has moderate to severe anxiety or OCD, then the combination of exposure based CBT and medication (SSRI) is more effective than either alone.
6. In order to treat an anxiety disorder, we need to understand what the child’s core fear is. 
7. In exposure therapy, the therapist exposes the child to the anxiety/fear provoking stimuli in a gradual manner. This process can be distressing and it is important to have conversations with the child’s caregivers about how to tolerate their child’s distress while supporting their child.

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Pediatric Anxiety Notes

Diagnosing Anxiety Disorders

When anxiety is time-limited and in the right context, it can be a helpful, adaptive response. Anxiety becomes a disorder when: it is excessive for the situation, it doesn’t go away, or it leads to impairment in functioning (DSM-5).

Signs and Symptoms of Anxiety Disorder

Signs and symptoms of anxiety disorders can include emotional symptoms (i.e. feeling fear, scared, unease), cognitive symptoms (i.e. thoughts about worry) and physical symptoms (i.e. heart racing, breathing quickly, headaches, stomachaches) (DSM-5).

When assessing for anxiety disorders, it is important to understand an individual child’s context around emotions. For example, if a child has grown up with less emotion focused vocabulary, they may express symptoms of anxiety more physically than emotionally.

Anxiety and the GI system

The GI system and the brain are connected and the majority of serotonin is in our GI system (Banskota, 2019). This helps explain why anxiety can present with GI symptoms and why it is invalidating to say “it’s all in your head” to someone who has physical symptoms of anxiety.

Screening Tools

The following are two screening tools that Dr. Brannan recommends to help give an overall picture of a child’s symptoms and their level of impairment. They are a good starting point and should be followed up with asking more questions.

• SCARED (Screen for Child Anxiety Related Disorders)
• RCADS (Revised Child Anxiety and Depression Scale)

Here are some tips to keep in mind when assessing a child for anxiety:

• Assess how far the child has deviated from their baseline. It is helpful to know what the baseline is for the child so that you don’t over pathologize a normal response or over normalize a change from a child’s baseline. 
• It is important to figure out what the core fear of the patient is. 
• Be curious and go on an exploration with the patient.
• Start with a broad scope before narrowing down. 
• It is helpful to get a sense of both the external picture as well as an internal picture as well as asking the child what they feel in their body, what they are scared of
• It can be helpful to ask questions such as: When did you first notice this? What are the range of worries? What does the fear look like?

Who should be screened for anxiety?

Dr. Brannan’s expert opinion is that we should have widespread screening for anxiety during primary care visits. This would help with early identification of anxiety disorders, which is important because anxiety disorders are very common, they are treatable, and there are lots of comorbidities in adolescence and adulthood if they go untreated.

Equity Concerns in the Treatment and Assessment of Anxiety Disorders

Anxiety disorders are under assessed and undertreated for all children, and particularly for children from minoritized ethnic and racial backgrounds. This is due to many factors (including implicit bias from physicians and inequitable distribution of mental health resources). Monnica Williams and her group have published research on mental health equity and anxiety disorders. 

Treatment of Anxiety Disorders

First line treatment of anxiety and OCD in youth is a form of CBT called exposure therapy. If the child has moderate to severe anxiety or OCD, then the combination of exposure based CBT and medication (SSRI) is more effective than either alone (CAMS and POTS). When referring a patient for CBT,, check to see if the therapist has experience with exposure therapy.

Exposure Therapy

Exposure therapy is a form of CBT that involves exposing the child to things that cause anxiety in a gradual way. For example, if someone has a fear of snakes, the child could first look at a picture of a snake. The next step could be having the child sit next to a pretend rubber snake. This process is uncomfortable and an exposure therapist will coach the child to sit with the anxiety. With time, the child will habituate and the anxiety will decrease (APA 2017).

Exposure Therapy Tips for Success (as recommended by Dr. Brannan):

• Have the patient participate in designing the exposures
• Have conversations with the child’s caregivers about not accommodating the anxiety. 
• Help the parents with shifting the frame (validating the child’s experience) and while also tolerating their child’s distress. 

Are there any patients for whom exposure therapy is not first line?

Dr. Brannan’s expert opinion: If a patient becomes unsafe in the context of being distressed, then they likely are not ready to do exposure therapy. The child would first need to learn skills to build a stronger foundation for tolerating distress.

Medication

If a patient has moderate to severe anxiety or OCD, then consider starting a patient on a medication (SSRI) in addition to exposure therapy.  CAMS (Child/Adolescent Anxiety Multimodal Study) is a seminal study for pediatric anxiety which showed that for patients with moderate to severe anxiety disorders, the combination of exposure-based CBT plus an SSRI is more effective than either alone.  The POTS (Pediatric OCD Treatment Study) showed similar findings for patients with OCD (exposure based CBT plus an SSRI is more effective than either alone).

Dr. Brannan’s expert opinion: If you have mild anxiety and you are able to access an exposure therapist, it is reasonable to start with exposure based CBT.  If you are in a region of the country where you don’t have access to an exposure therapist, it is reasonable to consider starting a child on an SSRI. 

Medications for OCD and anxiety are tools in the toolbox. A medication can help reduce the background level of anxiety to bring it down to a level where the child is able to engage in the exposures, but it is highly unlikely that a medication will completely eliminate all the anxiety.

Links

CAMS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2818613/

POTS: https://pubmed.ncbi.nlm.nih.gov/15507582/

Goal

Listeners will learn about screening, diagnosing and treating pediatric anxiety in the outpatient setting.

Learning objectives

After listening to this episode listeners will…  

1. Recognize the difference between normal worry and an anxiety disorder. 
2. Be familiar with screening tools for diagnosing anxiety disorders and OCD.
3. Learn about first line treatment for anxiety disorders.
4. Be familiar with the exposure therapy as a form of Cognitive Behavioral Therapy (CBT)
5. Recognize the importance of counseling caregivers about tolerating their child’s distress during exposure therapy.

Disclosures

Dr. Brannan reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Elliott S, Raymond-Kolker R, Brannan E, Lee N, Masur S, Chiu C, Berk J. “50: Facing the (Core) Fear! Pediatric Anxiety Pt 1: Living the Exposure Lifestyle”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ May 11, 2022.