Director, Division of Child and Adolescent Psychiatry and Fellowship Training Program in Child and Adolescent Psychiatry, Mount Sinai Services - New York City Health + Hospitals/Elmhurst. Professor of Psychiatry, Icahn School of Medicine at Mount Sinai.
Dr. Abright has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CCPR: Welcome, Dr. Abright. Tell us how the American Academy of Child and Adolescent Psychiatry (AACAP) created the Clinical Practice Guideline on the Assessment and Treatment of Anxiety Disorders in Children and Adolescents (Walter HJ et al, J Am Acad Child Adolesc Psychiatry 2020;59(10):1107–1124).
Dr. Abright: The AACAP Committee on Quality Issues (CQI) is responsible for developing what are now called Clinical Practice Guidelines (CPGs). The CPG on anxiety disorders, which was published in JAACAP in October 2020, is the product of a dedicated team effort by a writing group comprised of five CQI members led by Dr. Heather Walter and followed by extensive internal and external review from topic experts and relevant stakeholders.
CCPR: How are these CPGs different from the AACAP Practice Parameters from 2007?
Dr. Abright: The Practice Parameters were based on the methodology for guideline development at that time. The new guidelines are updates based on current Institute of Medicine standards for developing professional guidelines. These range from critical review of the literature, with ratings of strength of evidence and graded recommendations for assessment and treatment, to stakeholder participation, external review, and freedom from conflicts of interest and transparency during the guideline development process. The guideline for anxiety disorders is the first AACAP CPG developed through this process. AACAP partnered with the government-funded Agency for Health Research and Quality (AHRQ), which conducted a systematic review of treatment of anxiety disorders in children and adolescents. The review was limited to social anxiety, generalized anxiety, separation anxiety, panic disorder, and specific phobia. It excluded posttraumatic stress disorder and obsessive-compulsive disorder on the basis that treatment approaches for these disorders generally differ from those used in other anxiety disorders.
CCPR: How common are anxiety disorders in children and adolescents?
Dr. Abright: Anxiety disorders were the most common condition found in a national comorbidity survey of adolescents, with a lifetime prevalence of 32% and median age of onset at 6 years (Merikangas KR et al, J Am Acad Child Adolesc Psychiatry 2010;49(10):980–989). Prevalence for specific anxiety disorders ranges from 20% for specific phobia to 9% for social anxiety disorder and 2% each for agoraphobia, panic disorder, and generalized anxiety disorder (Walter HJ et al, J Am Acad Child Adolesc Psychiatry 2020;59(10):1107–1124). Anxiety disorders are highly comorbid with each other as well as with other psychiatric disorders, with chronic physical illnesses such as diabetes and asthma, and with substance use. Any of these things may precede or exacerbate an anxiety disorder.
CCPR: What does the CPG tell us about the natural course of anxiety disorders in children and adolescents?
Dr. Abright: Anxiety disorders wax and wane in intensity but may become chronic and persist into adulthood. They can be homotypic, lasting into adulthood as the same disorder. For example, a child with generalized anxiety disorder may continue to have generalized anxiety disorder as an adult. Disorders can also be heterotypic, meaning that they present one way in childhood and differently in adulthood. For example, separation anxiety disorder in childhood might present as panic disorder or another anxiety disorder in adulthood.
CCPR: Is this conceptualization of anxiety disorders like the cross-diagnostic concept of anxiety in the NIMH Research and Diagnostic Criteria (RDoC)?
Dr. Abright: RDoC constructs regarding fear, anxiety, and arousal systems may prove useful in addressing issues related to heterogeneity and comorbidity in future studies of anxiety disorders, but they were not a focus in the current review.
CCPR: Do the disorders discussed in the CPG—social anxiety, generalized anxiety, separation anxiety, phobias, and panic disorder—share common characteristics?
Dr. Abright: Yes. Anxiety disorders are characterized by persistent symptoms associated with significant impairments that cut across multiple activities—school, home, athletics, socialization, and many other aspects of a young person’s life. These features distinguish anxiety disorders from worries that are expected responses to developmental or other life stressors. DSM-5 includes 11 anxiety disorder diagnoses. Their common symptoms can include hypervigilance, heightened reactivity to emotional and environmental stressors, avoidance of things that are triggering those feelings, and sometimes behavioral outbursts related to the avoidance. An example of these symptoms might be a child who is trying to avoid going to a family event that her parents expect her to attend—she is nervous about going and too embarrassed or ashamed to explain why.
CCPR: How are we doing as a field in identifying and treating anxiety disorders in children and adolescents?
Dr. Abright: Efforts to improve collaboration with pediatricians and other providers are in progress, but much remains to be accomplished. Psychotherapeutic and psychopharmacologic treatments can be effective in the short term for anxiety disorders in children. However, about 50% of patients receiving gold-standard treatments continue to have symptoms, and over half of individuals in this age group do not receive any treatment, while even fewer receive evidence-based treatments (www.childmind.org/2015-childrens-mental-health-report/#gap).
CCPR: What does the CPG tell us about assessment of anxiety disorders?
Dr. Abright: Engage and educate children and parents or other guardians; distinguish transient fears and worries associated with developmental stages from the persistent and impairing symptoms that characterize anxiety disorders; track symptom intensity and frequency and related impairments; treat psychiatric and medical comorbidities; and address traumatic and other stressors. These guideline statements regarding assessment are based on expert consensus as reflected in standard textbooks and other sources (Dulcan MK. Dulcan’s Textbook of Child and Adolescent Psychiatry. 2nd ed. Washington, DC: American Psychiatric Association Publishing; 2016).
CCPR: What does the CPG say about using scales and questionnaires to help with screening and assessments? Does it mention any specific instruments?
Dr. Abright: The US Preventive Services Task Force recommends universal screening for depression in adolescents but does not have a similar screening recommendation for anxiety disorders. Yet, screening for anxiety is important in specialty and non-specialty clinical settings as well as in schools and community agencies, especially in view of the high prevalence rates and associated distress and impairment in young people. Use rating scales and other measures that are brief, easy to administer and score, freely available, and compatible with electronic medical records. The online version of the CPG includes links to a broad-based and widely used instrument called the Pediatric Symptom Checklist (www.tinyurl.com/pv82dw5j). It can be used for screening for a range of conditions, including anxiety disorders. The CPG also links to anxiety disorder–specific scales such as the Generalized Anxiety Disorder 7 (GAD-7; www.tinyurl.com/yc5fy2f9) or the SCARED (Screen for Child Anxiety Related Emotional Disorders; www.tinyurl.com/vyerrsy7), which can be used to gauge level of anxiety and screen for specific types of anxiety disorders.
CCPR: What does the CPG tell us about treatment?
Dr. Abright: The key take-home messages from the guideline are the recommendations and suggestions for CBT and SSRIs (alone or in combination) as safe and effective treatments for anxiety disorders in children and adolescents, and for SNRIs as additional treatment options. The evidence is limited, so the guideline does not include recommendations for sequencing of treatment based on severity (mild, moderate, severe), preferential use of one SSRI over another, effectiveness of non-CBT psychotherapies, or long-term safety risks of pharmacologic treatments.
CCPR: So, what does this mean for treatment of specific patients?
Dr. Abright: Treatment planning for specific patients should be based on individualized assessment of each patient’s symptoms, history, and response to previous treatments; differential diagnosis; collaboration with patients and families in development of patient-specific goals; and consideration of treatment options that take into account available evidence for potential benefits and risks, but also feasibility and acceptability for patients and families.
CCPR: The older Practice Parameters had different levels of confidence in their guidance. Is that true of the CPG?
Dr. Abright: The CPG has two levels of guidance: recommendations and suggestions. Recommendations indicate high strength of evidence and confidence that treatment benefits outweigh risks. Suggestions indicate lower strength of evidence and less confidence that benefits outweigh risks. The guideline recommends CBT and SSRIs for treatment of anxiety and suggests SNRIs and combination treatment with CBT and SSRIs as additional options.
CCPR: So, for a child with, say, social anxiety disorder, the family might pick therapy, medication, or both. If medication is part of the plan, what if the family asks for an SNRI, for example if another family member did well with it?
Dr. Abright: The suggestion for use of SNRIs is not as strong as the recommendation for SSRIs, but clinicians must also consider individual factors and patient and family preferences. The goal of the guideline is to offer evidence-based guidance that may assist clinicians in making treatment decisions. The guideline is not meant to limit reasonable treatment options based on clinical assessment, or to serve as a standard of care.
CCPR: We recently reviewed an article that found SSRIs had more side effects (CCPR, Jun/Jul/Aug 2021). SNRIs had fewer side effects, but they weren’t as effective. What medications were covered in the review?
Dr. Abright: The two medication classes have differing side effect profiles. There is less confidence that the benefits of SNRIs outweigh their risks. For SSRIs, the AHRQ review covered sertraline, citalopram, escitalopram, fluoxetine, fluvoxamine, and paroxetine. For SNRIs, the AHRQ review covered duloxetine, venlafaxine, and the selective NRI atomoxetine. Fluoxetine and escitalopram have FDA approval for treatment of adolescent depression, and fluoxetine has an indication for depression down to age 8, but these medications and other SSRIs do not have an FDA indication for anxiety disorders in this age group. Duloxetine has FDA approval for treatment of generalized anxiety disorder for ages 7–17, but additional factors, including potential risks, are also important considerations in choosing a medication. The AHRQ also looked at benzodiazepines and found insufficient evidence for their effectiveness. The AACAP’s Anxiety Disorders: Parents’ Medication Guide is an excellent information resource for parents and clinicians regarding medications and other treatments (www.tinyurl.com/2p9f9tzc).
CCPR: Does the CPG have anything more to say about combinations of therapy and medications?
Dr. Abright: A major study, the Child/Adolescent Anxiety Multimodal Treatment Study (CAMS), found that combination treatment was superior to sertraline or CBT alone up to 24 weeks, but that this superiority was not maintained at longer-term follow-up (Compton SN et al, Child Adolesc Psychiatry Ment Health 2010;4:1). The AHRQ review concluded that there was insufficient evidence to support superior effectiveness of combination treatment over treatment with either CBT or SSRIs alone. The guideline classifies combination treatment as a suggestion rather than a recommendation, but notes that combination treatment may be a good choice for cases with moderate to severe symptoms and impairment or partial response to monotherapy. This topic is the subject of ongoing research and discussion (Hudson JL, Evid Based Ment Health 2009;12(3):88).
CCPR: Does the CPG offer additional guidance about specific treatments for specific disorders?
Dr. Abright: The AHRQ review did not find sufficient evidence to support specific treatment recommendations for any of the specific disorders. For example, it did not find evidence that SSRIs are better for generalized anxiety disorder than for panic disorder. This is partly because much of the evidence for treatment of these disorders is based on lumping together different studies and anxiety groupings into a combined analysis. Therefore, clinicians need to rely on their best clinical judgment in treating any individual child or teenager.
CCPR: What does the CPG say about treating anxiety disorders in children and adolescents from underrepresented racial groups or cultural populations?
Dr. Abright: The AHRQ review and the CPG highlight limitations in the current evidence base for treatment of anxiety disorders in minorities and other underrepresented populations as a significant area in need of further research, leaving clinicians to extrapolate results from existing studies without sufficient information about the effectiveness of treatments in these populations. Successfully providing high-quality care to youth from economically disadvantaged and minority backgrounds requires a comprehensive effort that includes partnership with primary care providers, schools, and community agencies; community outreach and education; continued advocacy by AACAP and other major professional organizations; and encouragement of funding for relevant research and clinical programs.
CCPR: This speaks to the interpretation of behaviors as acting out vs driven by anxiety.
Dr. Abright: ADHD and other disorders associated with behavioral problems are frequently comorbid with anxiety disorders, and it is important to address and treat underlying anxiety symptoms when these are identified as triggers for behavioral outbursts.
CCPR: Thank you for your time, Dr. Abright.
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