Diagnosis of Anxiety in Pediatric Patients

View episode transcript

Featured Guest: Christina LaRose

Objectives

• Apply the diagnostic criteria of major anxiety disorders including generalized anxiety, separation anxiety, panic attacks, OCD, specific phobias, PTSD, and unspecified anxiety.
• Determine age appropriate screening tools for anxiety disorders.

Resources

• Quick guide to anxiety in children. (Child Mind Institute, 2024) 
• The generalized anxiety disorder 7-item (GAD-7) scale in adolescents with generalized anxiety disorder: signal detection and validation. (Annual Clinical Psychiatry) 
• The management of anxiety and depression in pediatrics. (Cureus) 

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Transcript

Dr. Heidi Burns:

Hello and welcome to Season 3 of Breaking Down Mental Health, a podcast series developed to educate all healthcare professionals on various mental health topics. I'm Dr. Heidi Burns, a child and adolescent psychiatrist, and I'm joined by my co-hosts; nurse practitioner Dr. Christina Cwynar and social worker Syma Khan. This season is going to focus on pediatric anxiety. And to kick the season off, we're joined by an anxiety specialist, Dr. Christina LaRosa.

Dr. LaRosa is a psychiatrist at the Anxiety and OCD Treatment Center of Ann Arbor. She completed her adult psychiatry residency and child psychiatry fellowship at U of M, the University of Michigan, with a specific focus on the treatment of anxiety disorders and OCD. She has been with the center since 2017 and specializes in the treatment of both children and adults with severe anxiety and OCD. Treatment resistant OCD in particular is her main area of clinical interest. And a fun fact, Dr. LaRosa and I, did our residency and fellowship together. And she's a gem.

Dr. Christina LaRosa:

So is Dr. Burns.

Dr. Heidi Burns:

All right. So, Dr. LaRosa, we know that anxiety is an emotion that everyone experiences at some point in their life. Sometimes we start to become concerned about anxiety when it starts to interfere with our functioning. Can you start the conversation with some information about the neurobiology of anxiety?

Dr. Christina LaRosa:

Sure. When we think about anxiety disorders, particularly in the pediatric population, one of the first thing that comes to mind about what anxiety means is an idea of just feeling fearful or scared of something. So it makes sense that the areas of the brain that experience and respond to fear, namely the amygdala and the prefrontal cortex, have been noted to have abnormalities on both structural and functional neuroimaging in individuals who meet criteria for anxiety disorders. The anterior cingulate cortex, which is part of the limbic system and is responsible for integrating and processing cognitive and emotional information that comes from the frontal cortex, thalamus, and amygdala has also been noted to have abnormalities.

Syma Khan:

I think it's helpful to set the stage with some of that understanding of brain chemistry when it comes to anxiety, and I think especially referencing when working with youth in the pediatric settings, because we know that pediatrics is very different than adults and adult brains. Could you review what is considered developmentally appropriate anxiety based on different stages of development?

Dr. Christina LaRosa:

Yeah, absolutely. So at different stages of development, there's always going to be a variety of things in the environment that can elicit anxiety, some of which are considered in the realm of normal. For example, in infancy, babies have a startle reflex that's easily activated. As they progress through the first year of life, then they develop stranger danger, and this is considered normal and appropriate. As toddlers, common fears become things like; being separated from caretakers, being alone in the dark, and imaginary creatures or monsters under the bed, things like that. When you get into the preschool ages, we start to see the development of more specific phobias like animals or storms, heights or swimming. Getting into the school age, we start to see fear of more cognitively advanced topics. So that would be things like; bodily harm, death or natural disasters. Finally, as you get more into adolescence and the adult years, we get into concerns more about things like school performance and social status among peers, and then maybe even real health illness concerns.

Dr. Christina Cwynar:

I think it's really important that we started this conversation off with what's normal because everybody experiences anxiety, so it's good for us to understand that there's a normal progression to that anxiety as well. But now that we've defined normal anxiety, let's talk a little bit about anxiety disorders starting with generalized anxiety. Can you review the diagnostic criteria and how we would screen for it?

Dr. Christina LaRosa:

Sure. So generalized anxiety disorder, or GAD as I'm going to refer to it in short, occurs when the level of anxiety that someone is having about any of these issues becomes excessive to the point of interfering with their day-to-day functioning. Interference with functioning is pretty much the common uniting thread among all types of anxiety disorders. So GAD, like most other psychiatric conditions, is a clinical diagnosis that's based upon screening for specific symptoms that we know are commonly seen in anxious individuals. The most common screening tool used is the GAD-7, which is a really basic questionnaire of seven items in which the patient answers how frequently they experience the symptoms. Namely, a general feeling of anxiousness or worry, not being able to control that worry, worrying too much about specific things, having trouble relaxing, feeling restless or unable to sit still, getting irritated or annoyed easily, or just a general feeling that something bad is going to happen. And then based on how they answer those items, a number score for each is given and then added up and determines the severity level of the anxiety, namely; minimal, mild, moderate, or severe.

Syma Khan:

I think it's great to understand the diagnostic criteria and understand what are parts of anxiety and how do we categorize it and think about it. In what settings would we use the GAD-7?

Dr. Christina LaRosa:

So the GAD-7 is really easy to administer, which makes it a nice tool that lots of different clinicians at different levels can administer. So for instance, primary care offices, this is a great one for screening any young children to pick up on potential underlying undiagnosed anxiety. It can be used in the ER if people are coming in for other various concerns, but maybe the doctor suspects that something's going on with anxiety and it doesn't take very long to administer. So that's kind of the nice thing about it.

Dr. Heidi Burns:

So earlier we talked about what's normal or expected in anxiety, and one of the things we talked about was separation anxiety being a normal developmental process, but what about when separation anxiety becomes more concerning? What does that look like and how is it diagnosed? And selfishly, I was just dealing with some of this with my three-year-old, so I'm very eager to hear more what you have to say.

Dr. Christina LaRosa:

Yes, yes. So as I mentioned earlier, some degree of separation anxiety is considered normal in early childhood, and that's typically when it's the most prevalent. We start to become concerned when that level of anxiety gets to the point where it's affecting the child's ability to participate in developmentally normal activities like; going to school, birthday parties, or other social outings with their peers. It's diagnosed like other anxiety disorders based on assessment of reported clinical symptoms, specifically related to separation from attachment figures. So you can use screeners such as the Children's Separation Anxiety Scale, or the CSAS, which can also be helpful in diagnosing.

Syma Khan:

I think that's the piece that's really helpful, kind of take away with separation anxiety is that it's very normative. We see a lot of kids with it, but that functioning piece, and I think of it's preventing kids from going to school or going to friends' houses, those types of things that we want to be more mindful of it and then maybe seek some treatment. I know one area of your expertise is OCD or obsessive-compulsive disorder. Can you share a little bit more about how is it diagnosed? How do we screen?

Dr. Christina LaRosa:

Oh yes, this is my bread and butter. So OCD is a very specific type of anxiety disorder that at its most basic core definition contains what we call intrusive thoughts. And intrusive thoughts are basically any kind of thought that causes distress. And no matter how hard the patient tries to push those thoughts out of their mind, they keep coming back. Now contrary to popular belief, you don't actually have to have the presence of compulsions such as checking, or ordering, or arranging to make the diagnosis. However, they will oftentimes present at some point during the course of the illness if it goes untreated. As you can imagine with such a basic definition, there's so many different kinds of intrusive thoughts and I could literally talk for another hour or hours about all of the different domains and categories we see when it comes to classifying intrusive thoughts.

So, you have to be very careful with questioning. So other than the careful questioning of each of those potential domains, which we don't have time to get into today, but there's many, the most common screening tools that we use to pick up symptoms of OCD specifically is the CY-BOCS in children or the Y-BOCS in adults, and this stands for the Yale Brown Obsessive Compulsive Scale, which is a semi-structured interview consisting of 10 items.

Christina Cwynar:

I think OCD is a really fascinating disorder. So I have so many questions for you. Trying to think of where to start next. I would be curious if there's an age of onset that you commonly see with OCD and some of the presenting features that it's most common. I know it can present in a lot of ways.

Dr. Christina LaRosa:

Oh my gosh, this is endlessly fascinating to me. So sometimes it takes people 20 years to realize they have OCD and it's even more satisfying honestly, when they come to you and you're the first person who gets it and they're like, where were you 20 years ago? And I'm like, I wish I had been there so we could figure this out. But in children, this is why I really like working with the pediatric population, it's so rewarding to pick it up early and get it under control because if you can identify it and treat it, it will never have power over the patient the way that it did before the treatment happened. And this is because you're learning skills through cognitive behavior therapy to manage those thoughts and how much they bother you.

The goal is, I mean, I tell my patients at the very least, if we can't make the thoughts ever go away, we can certainly get them to a point where the volume is turned down so much that they are in the background and maybe to a point don't even register in the patient's consciousness. So that's really my goal in working with the clinicians at the Anxiety and OCD Treatment Center. We work together. I do the med management piece, but I work very closely with them because they're doing the therapy piece.

And we have seen, I mean I can say right now I actually have a four-year-old who has OCD, it's legitimate. And we see a lot of, actually quite a few different types of symptoms in kids, not just one. We see a lot of cognitive rigidity. So this is where the kid has preferences, but if they don't get their way, it's a full-on meltdown. It's not a normal response like, I don't like this. I don't want to do this. It's my way or the highway and I'm going to pitch a fit if I don't get this.

As you can imagine, this can cause problems in lots of different areas of the kid's life. So of course parents trying to parent a kid like this, but also with peers, right? Peers are going to pick up on this and be like, why are you so upset about this? So rigidity is one thing that I see a really, really fascinating area of intrusive thoughts that I kind of classify as being Taboo. Taboo thoughts are when you have intrusive thoughts where the content is very disturbing. So there's some really common themes with Taboo OCD. I would say the most common threads are usually inappropriate sexual thoughts or harm thoughts. So, you're having thoughts about hurting yourself or someone else, that are what is known as ego-dystonic. And this is in contrast to ego-syntonic harm thoughts, which is typically what people think of if someone comes to you and says, I'm suicidal, basically it means that your thoughts are aligning with how you actually feel.

With OCD, those thoughts are intrusive, which means that they're upsetting, which means that you don't necessarily agree with them. So you could be having intense visualizations that you are going to crash your car if you drive. That could lead to avoidance of driving. We see that a lot. In little kids, it could just be feeling scared, like, I'm worried that I'm going to hurt mom and dad. I think I had a seven-year-old who was afraid he was going to stab his parents in the middle of the night, and we literally as an exposure made the parents sleep with a knife next to the bed and to show him and prove to him that he would not actually do this because he was so freaked out by the idea. So we go to some pretty intense extremes at the Anxiety and OCD Treatment Center because that's what's necessary to get the OCD to go away.

But my favorite kid case, going back to your question, sorry, that was a tangent. My favorite kid case was at when I was in training at U of M and Fellowship, I had this little seven-year-old boy come in with his mom and I said, "What's going on?" And he said, "I'm having these thoughts that I don't like." And I said, "Oh, tell me about that." And he's like, "I don't want to. It's embarrassing." And I said, "It's okay. This is a safe place to talk about this." And he goes, "I can't stop thinking about this girl's underwear that I saw on the playground, and I don't want to." I don't know if you want to include this or not, but it was so cute because he was clearly very distressed that he couldn't stop thinking about this. And he again, didn't want to be thinking about this and was going to mom and asking for reassurance like, "Why can't I make this go away?" That's actually how I identified the OCD, and we were able to start a low dose of an SSRI and get him into some cognitive behavior therapy, and he got better within a couple months.

Syma Khan:

I appreciate you sharing a little bit about ego dystonic thoughts 'cause I think for providers, especially if you're not in mental health and a youth says this to you, it can really cause a lot of panic. And as a provider like, oh my God, what do I do with this? And so, I think some gentle probing and supportive exploration of those thoughts, understanding where are they coming from, are they causing distress, can really then help you be calm in how you approach the youth and kind of explaining to them, this is okay, this happens. It's treatable. We're going to make sure you're safe. We're going to get you the right providers. Because I think if a healthcare provider can respond in a really supportive way, it can really help that youth and that family feel confident going forward seeking care.

Dr. Christina LaRosa:

Yes, and related to that, I think this is really important information for the parents because if your kid comes to you and says, "Mom and dad, I want to kill myself." I mean, who isn't going to freak out? So part of what really helps my parents feel okay about doing these crazy exposures sometimes that we ask them to do is that we explain to them that the likelihood of the kid actually doing the upsetting thought is actually less than the average population because of how much it upsets them. So they're literally going to avoid it at all costs because it upsets them. I worry much more, and I think Dr. Burns and Christina and Syma, you guys all know what I'm talking about, the kids who don't talk about when they're depressed and are not vocal, those are the people that you worry about where something, a suicide attempt comes out of nowhere and no one was expecting it and nobody saw it coming. I always reassure parents that the fact that the kid is talking about it is also very good.

Dr. Christina Cwynar:

I think, not to switch gears here, but we have a little bit more about anxiety to talk about. So one of the things that we commonly see actually presenting to our ER is individuals with panic attacks just because how debilitating those things can feel and seem, especially in the moment. So could you tell us a little bit about what panic attacks are and how we could support someone with a panic attack?

Dr. Christina LaRosa:

Oh, absolutely. Yes. So panic attacks really at their most basic definition are sudden intense episodes of fear that can manifest in a variety of both physical and mental symptoms, and these can last anywhere from minutes to hours. Some really common symptoms that we see pretty regularly that are physical are things like shortness of breath, chest tightness, GI upset, and racing heart, which coincidentally are also symptoms that can be seen when someone's having an acute coronary event. As such, these are the symptoms that most often lead people to go to the ER because they think they're having a heart attack.

Panic attacks can be very, very debilitating, we know this, but fortunately, they can actually be managed quite well with medications, specifically SSRIs or selective serotonin reuptake inhibitors. I also want to note that benzodiazepines, while immediately effective and therefore most often used in the ER to quickly decrease symptoms, are not good maintenance drugs for someone that's experiencing frequent panic attacks due to their ability to cause tolerance and dependency if they're taken on a regular basis. So they should only be used very sparingly, if at all in the outpatient setting. It should also be noted that benzos are not indicated for any type of anxiety symptoms in the pediatric population. There is no evidence in the scientific literature to support their use.

Apart from SSRIs, which can decrease the frequency and severity of the attacks. If someone does experience a panic attack that is accompanied by shortness of breath or other fight or flight type of symptoms, a focus on controlling breathing or breathing deeply into a paper bag can help calm the sympathetic nervous system quickly, which gets overly activated during those attacks. If they continue breathing too rapidly, that can lead to hyperventilation, which will then cause them to feel dizzy or lightheaded and can trigger the autonomic nervous system response even more.

Dr. Heidi Burns:

So the old paper bag trick that you see in the movies is actually something that people could use.

Dr. Christina LaRosa:

It actually is.

Dr. Heidi Burns:

That's really helpful. I think the everyday person may come across someone having a panic attack, those who work in the ER who work in outpatient settings, there's lots of potential places that people may run into people having that. So it's always helpful to have a couple of ideas about what to do, staying calm and a few interventions maybe that they might be able to think of. Let's talk a little bit more about a different area. There's lots of different categories under this big umbrella of anxiety, and we actually categorize things like PTSD and acute stress reactions and acute stress disorders as well under the umbrella of anxiety. Can you share some of the diagnostic criteria as well as maybe differentiate between them?

Dr. Christina LaRosa:

Yeah, sure. So an acute stress response is defined by experiencing very fast onset of specific symptoms immediately following a traumatic stressor of some kind. More specifically symptoms like avoidance of where that trauma happened, hypervigilance or being really on edge, nightmares, flashbacks, irritability, panic, and sometimes even dissociative symptoms. These are the same symptoms that define post-traumatic stress disorder, PTSD. However, the diagnoses differ based on the length of time the person experiences those symptoms. So with acute stress, the symptoms must resolve within one month of the trauma occurring, whereas if they persist beyond that, then they meet criteria for PTSD. And PTSD also includes more of a broader range of symptoms than acute stress, such as riskier destructive behaviors or even things that can overlap with depression like, just increased interest in activities.

Dr. Christina Cwynar:

So before we wrap up today, maybe we can talk a little bit about what the early signs are that anxiety's becoming debilitating.

Dr. Christina LaRosa:

Sure. There's a couple really easy ones to pick up on that you should definitely kind of have your antenna up if you see. One would be an acute sleep disturbance. So, kids having trouble going to sleep, staying asleep, telling you they're waking up during the night, waking you up during the night when they're not normally doing that. School's the other really big setting where first of all, the school themselves might actually be calling you and saying, "We're seeing these things and we're concerned," but even if they don't, any resistance to going to school or if the child is going to the office and asking to call home a lot, those are definitely pretty common manifestations of anxiety.

Dr. Christina Cwynar:

I was going to say, the other thing I feel like we see is those kids who repeatedly call home and say, I have a headache, I have a stomach ache, and those physical symptoms, but they may not be expressing like, I'm worried I'm scared, this test, those types of things.

Dr. Christina LaRosa:

Yes, thank you for bringing that up 'cause that's so important. A seven-year-old is not going to be able to say, "Mom, I'm anxious sometimes." They're just going to say, "My tummy hurts" or "My head hurts." So physical symptoms that maybe you go to the pediatrician and they say, doesn't look like there's anything wrong with Johnny, but they're still feeling those symptoms. Yeah, that is more commonly how anxiety would present in a youngster rather than them actually verbalizing, I'm scared or I'm worried. It can just be that.

Dr. Christina Cwynar

And I think that's part of therapy is learning how to identify those feelings, put a name to it so children learn to develop that emotional language to describe what they're experiencing.

Dr. Christina LaRosa:

Absolutely. That's what we do a lot of at our clinic with the little kiddos. Obviously we're not going to do intensive cognitive behavioral therapy with a five-year-old, but we play games with them and we start having them maybe even think about their anxiety as being a bully that's running the show, that's making everybody miserable. And give a name to that bully and start to think about that as a separate entity from the person so that they realize that this is something that they have that's not who they really are, it's just something that they have.

And when they can start to identify that the thought itself is anxiety and can label it as such, that starts to take power away from the thought. They can identify right away, oh, yep, I'm having that thought again. I don't need to listen to this thought. This thought's not true. Just because I'm having it doesn't make it true. If you're having these really scary thoughts and you don't know why, you can imagine that would be very upsetting. So just having a clinician work with you and start to say, "Do you think this is actually true? What your brain is telling you?" That's really the basic start of cognitive work, just identification.

Syma Khan:

I think it can be helpful for pediatricians to be aware of that. A six-year-old is presenting a lot with physical complaints, not the idea to dismiss it or ignore it, but really saying, is there something else going on? Is there an underlying worry that this child has and how can we get them to a setting that they can communicate what they're feeling beyond body experiences?

Dr. Christina LaRosa:

Yes, absolutely.

Syma Khan: 

So I'd like to open it up for the table and just any kind of final thoughts today?

Dr. Heidi Burns:

Just piggybacking on what we were talking about. I think sometimes we actually see kids with anger and defiant behaviors as well that are often misunderstood as something else, like oppositional defiant disorder or something like that, where actually there's an underlying anxiety and at the core of that, and sometimes being able to get them in the right type of setting with a trusted person where they can talk through that can really help you identify what it is that's making that kid feel so strongly that they need to avoid or protect themselves from something that's leading to those behaviors. So sometimes we see kids who come in with their primary complaint as defiance and anger. That's really an anxious kid. And I don't think we explicitly sort of stated that when we think about the ages, school age children are really one of the primary areas where anxiety starts to show up. So it's not necessarily something that comes when you're older. It can start quite young as Dr. LaRosa was referencing some of her young kids that she sees.

Dr. Christina LaRosa:

Yes, and I would say one other thing that I wish parents would do more, and I'm actually seeing it much more now than ever, which is great, is not ignoring those signs. I think a lot of parents are scared to admit that there might be something wrong with their kid, and so they think that by burying it, ignoring it, pretending it's not there, that it will somehow just go away. Instead, it just gets worse, and sometimes by the time they end up in my office, it's a disaster. And I think, gosh, I really wish you guys had come in last year. We could have prevented this from getting to the point where now we're refusing to go to school for a year. We lost a whole year of school, but unfortunately, that does still happen a lot. So yeah, I mean, I really would just encourage parents to listen to the signs. Pay attention, don't ignore them, don't assume it's nothing. Follow through on it, ask about it. See if the kid needs help or if they want to talk to someone.

Dr. Christina Cwynar:

Yeah. And just because you go to see somebody for anxiety does not necessarily mean meds, but it does mean a lifetime of tools to help with all the variety of stresses that are thrown at us in life that you can't avoid. Right? Everybody's life is stressful.

Dr. Christina LaRosa:

Yes, and actually that's one of the reasons why I chose to be an anxiety specialist. Dr. Burns knows there's many different kinds of patients in our field that we take care of, people with thought disorders, people with major depression, and while I enjoy all areas of psychiatry, I'm really passionate about treating anxiety because it's so treatable. It really is, the data is very good in the literature. I always say it's kind of ironic that we call antidepressants, antidepressants because the literature actually shows that they're more effective for treating anxiety than depression sometimes. The SSRIs is kind of what I'm referring to. It's very rewarding to see someone progress so greatly when you look at where they started and several months later they're going back to school and they're playing with kids again and they're back on the soccer team and they're sleeping at night. It's just really, really rewarding to work with this population 'cause I love to see people get better.

Syma Khan:

Great little pivot here because we're going to talk about therapeutic interventions for anxiety too, because we know it's really something treatable and manageable, and we need to just connect our youth to the right people out in the community and help ensure that the colleagues that we work with in medical settings too feel equipped to support these youth.

Dr. Christina Cwynar:

Yeah, I believe that is the topic next week with Dr. Bilek. Okay, well, thank you for joining us today Dr. LaRosa. We truly appreciate your time and your expertise. Thank you to everybody that tuned in this week. Nurses, social workers and physicians can claim CMEs and CEs at uofmhealth.org/breakingdownmentalhealth. You're able to do this any time within three years of the initial air date. We hope that you'll join us next time.