Kk&s Ch.50 Child Anxiety Ds

Front 1

(Few, Some, Many, Most) cases of OCD begin in childhood or adolescence

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MOST

Front 2

The clinical presentation of OCD in childhood and adolescence is similar to that in adults and the only alteration in diagnostic criteria in the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) for children is that

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they do not necessarily demonstrate awareness that their thoughts or behaviors are unreasonable.

Front 3

Obsessive-compulsive disorder is common among children and adolescence with a point prevalence of about ? percent and a lifetime rate of ? percent to ? percent

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Obsessive-compulsive disorder is common among children and adolescence with a point prevalence of about 0.5 percent and a lifetime rate of 1 percent to 3 percent

Front 4

The rate of OCD rises exponentially with increasing age among youth, with rates of ? percent in children between the ages of ? years and ? years, rising to rates of ? percent among teens.

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The rate of OCD rises exponentially with increasing age among youth, with rates of 0.3 percent in children between the ages of 5 years and 7 years, rising to rates of 0.6 percent among teens.

Front 5

Rates of OCD among adolescents are (less, =, >) than rates for disorders such as schizophrenia or bipolar disorder

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greater than

Front 6

OCD and gender bias?

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Among young children with OCD there appears to be a slight male predominance which diminishes with age.

Front 7

Family studies have documented an increased risk of at least ? in first-degree relatives of early-onset OCD

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fourfold

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Molecular genetic studies have suggested linkage to regions of chromosomes ? and ?, in certain pedigrees with multiple members exhibiting early-onset OCD.

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2 and 9

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Family studies have pointed to a relationship between OCD and

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tic disorders like Tourette's

Front 10

The presentation of OCD in children and adolescence due to acute exposure to ? streptococcus represents a minority of OCD cases in this population.

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group A beta hemolytic

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NT's most linked to OCD?

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serotononin and dopamine

Front 12

What agents can exacerbate OCD?

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stimulant agents

Front 13

Both computed tomography (CT) and magnetic resonance imaging (MRI) of untreated children and adults with OCD have revealed ? compared to normal controls.

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smaller volumes of basal ganglia segments

Front 14

In children, there is a suggestion that thalamic volume is (decreased or increased).

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increased

Front 15

suggestion that thalamic volume is increased. Adult studies have provided evidence of (hypo or hypermetabolism) of frontal cortical-striatal-thalamo-cortical networks in untreated individual with OCD

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HYPER

Front 16

Interestingly, imaging studies of before and after treatment have revealed that both medication and behavioral interventions lead to a (increase or decrease) of orbit frontal and caudate metabolic rates in children and adults with OCD.

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Decrease

Front 17

The most commonly reported obsessions in children and adolescents include ? followed by .

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extreme fears of contamination, exposure to dirt, germs or disease,

worries related to harm befalling themselves, family members, or fear of harming others due to losing control over aggressive impulse

Front 18

In (few, some, many, most) cases of OCD among youth, obsessions and compulsions are present.

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MOST

Front 19

OCD: majority insidious or rapid onset?

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insidious
minority of males with early onset may have rapid onset

Front 20

OCD comorbities?

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other anxiety
Tics
ADHD

Front 21

Children with comorbid OCD and tic disorders are more likely to

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exhibit counting, arranging, or ordering compulsions and less likely to manifest excessive washing and cleaning compulsions.

Front 22

The rituals of preschoolers generally become less rigid by the time

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they enter grade school and school aged children usually do not have a surge of anxiety when they encounter small changes in their routine.

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Difference between GAD and OCD thoughts?

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obsessions are so excessive that they approach seeming bizarre
e.g. A child with generalized anxiety disorder might worry repeatedly about their performance on academic examinations, whereas a child with OCD is likely to have intrusive concerns that he may lose control and harm someone he loves.

Front 24

OCD with an onset in childhood and adolescence is characterized as a chronic, though waxing and waning disorder with a great variation in severity and outcome. Follow-up studies suggest that up to ? percent of children and adolescence affected experience recovery from OCD with minimal remaining symptoms.

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50%

Front 25

In a recent study of childhood OCD, treatment with sertraline resulted in close to ? percent of subjects experiencing complete remission and partial remission in another ? percent with a follow-up time of one year.

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50%
25%

Front 26

In a minority of cases, however, the OCD diagnosis may be considered a prodrome of a psychotic disorder which has been found to emerge in up to ? percent in some samples of children and adolescents with OCD.

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10%

Front 27

Results from multiple randomized placebo-controlled trials of both medication and Cognitive-behavioral interventions in children and adolescents with OCD have confirmed the (LITTLE, SOME, MOST) evidence for successful treatment of this disorder compared to other anxiety disorders of childhood

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MOST

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What did Pediatric OCD Treatment Study (POTS) reveal?

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sertraline vs CBT vs combo ... combo is best

Front 29

Currently, ? SSRIs: ? have now received US Federal Drug Administration (FDA) approval for the treatment of OCD.

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sertraline (at least 6 yrs),
fluoxetine (at least 7 years), and
fluvoxamine (at least 8 years)

Front 30

? was the first serotonergic agent studied in the treatment of OCD in childhood and the only tricyclic antidepressant that has a US FDA approval for the treatment of anxiety disorders in childhood.

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Clomipramine

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Clomipramine was found to be efficacious in doses up to 200 mg, or 3 mg/kg, whichever is less, and may be chosen for children or adolescents who can not tolerate other SSRIs due to

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insomnia,
significant appetite suppression or
activation

Front 32

clomipramine is not recommended as a first line treatment due to its greater potential risks compared to other SSRI agents,

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cardiovascular risk of hypotension
and arrhythmia, and
seizure risk.

Front 33

In terms of pharmacologic interventions, acute treatment of childhood OCD has been shown to occur within ? to ? weeks of treatment.

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8 to 12

Front 34

PTSD occurs frequently in children and adolescents with up to ? percent of youth meeting criteria for this diagnosis at some point.

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6%

Front 35

In children and adolescents reexperiencing of a traumatic event is often observed through

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play, recurrent nightmares without recall of the traumatic events,

and behaviors that reenact the traumatic situation, along with agitation, fear, or disorganization

Front 36

A recent epidemiologic survey of preschoolers aged 4 to 5 years found a rate of ? percent of PTSD, whereas among children of 2 to 3 years of age, the full criteria for PTSD were not met.

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1.3%

Front 37

Epidemiologic studies of children from 9 to 17 years of age have found 3-month prevalence rates of PTSD ranging from ? to ? percent.

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0.5 to 4%

Front 38

Greatest risk for development of PTSD?

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Children exposed chronically to trauma, such as child abuse, or other traumas resulting in the dissolution of the family and ongoing exposure to broader disruption of entire communities, such as war, result in the greatest risk for the development of PTSD

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Children with PTSD have been found to ....

compared with age-matched controls

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increased excretion of
adrenergic and
dopaminergic metabolites,

smaller intracranial volume and corpus callosum,
memory deficits, and
lower intelligence quotients (IQs)

Front 40

Major social risk factor in development of PTSD after trauma exposure?

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maternal depression

Front 41

Most common traumatic exposures for children and adolescents include ?????

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physical or sexual abuse;

domestic, school or community violence;
being kidnapped;
terrorist attacks;
motor vehicle or household accidents; or
disasters, such as floods, hurricanes, tornadoes, fires, explosions, or airline crashes.

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how might avoidance and numbing show in children/teens?

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fter a traumatic event, children may experience a sense of detachment from their usual play activities (“psychological numbing)”

or a diminished capacity to feel emotions, whereas older adolescents may express a fear that they anticipate that they will die young (sense of foreshortened future).

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Sx of hyperarousal in children?

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hyperarousal that were not present before the traumatic exposure, such as difficulty falling asleep or staying asleep; hypervigilance regarding safety and increased checking that doors are locked; or exaggerated startle reaction. In some children, hyperarousal can present as a generalized inability to relax with increased irritability, outbursts, and impaired ability to concentrate.

Front 44

When all of the diagnostic symptoms of PTSD are met, but they resolve within ? months, acute PTSD is diagnosed. When the full syndrome of PTSD persists beyond ? months, it becomes designated as chronic PTSD.

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When all of the diagnostic symptoms of PTSD are met, but they resolve within 3 months, acute PTSD is diagnosed. When the full syndrome of PTSD persists beyond 3 months, it becomes designated as chronic PTSD.

Front 45

In one study, children and adolescents with severe PTSD were at risk for

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decreased intracranial volume,
diminished corpus callosum area
and lower IQs

Front 46

Tx for PTSD in children and teens?

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Trauma Focused CBT (1st line)
EMDR
SSRI's

Front 47

What are the steps of Trauma Based CBT

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1. Psychoed
2. Stress inoculation (relaxation)
3. Gradual Exposure
4.1 Cognitive Processing
4.2 Parental Treatment

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Explain each step of Trauma Based CBT

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This treatment is generally administered over 10 to 16 treatment sessions, including a number of components. The first component of trauma-focused CBT is psychoeducation regarding the nature of typical emotional and physiological reactions to traumatic events and PTSD. Next, stress inoculation in which children are guided to utilize muscle relaxation, focused breathing, affective modulation, thought-stopping, and cognitive coping techniques to diminish feelings of helplessness and distress. Gradual exposure may then be introduced as a technique for a child to recall, first in small segments and then in increasing amounts, the details of the traumatic exposure and describe the thoughts, feelings, and physical sensations experienced during the trauma as well as in the retelling of the event. Cognitive processing is the next step in identifying those associated thoughts, feelings, and ideas that may be inaccurate and serving to cause additional impairment to the victim, so that reframing of the thoughts and feelings can help them alleviate the sense of being incapacitated by them. At this time, during the cognitive processing, a parental treatment component is added that provides parent management strategies for the parent to use to enhance the child's ability to communicate proactively and elicit support from the parents.

Front 49

Other drugs besides SSRi's for C&A PTSD?

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Propranolol

Front 50

. Another open study of transdermal ? treatment of preschoolers with PTSD suggests that ? may be efficacious in this population in decreasing ??

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Clonidine
activation and hyperarousal

Front 51

case report indicated that guanfacine (Tenex) treated PTSD ?

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nightmares in children

Front 52

Normative separation anxiety peaks between? months and ? months and diminishes by about ? years of age, enabling young children to develop a sense of comfort away from their parents in preschool.

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Normative separation anxiety peaks between 9 months and 18 months and diminishes by about 2.5 years of age, enabling young children to develop a sense of comfort away from their parents in preschool.

Front 53

Approximately ? percent of young children display intense and persistent fear, shyness, and social withdrawal when faced with unfamiliar settings and people.

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15%

Front 54

Behaviorally inhibited children, as a group, exhibit characteristic physiologic traits, including

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higher than average resting heart rates,
higher morning cortisol levels than average, and
low heart rate variability.

Front 55

?? are the two anxiety disorders currently found in the child and adolescent section of DSM-IV-TR

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Separation anxiety disorder, along with selective mutism

Front 56

A child with ??? has a 60% percent chance of having at least one of the other two disorders as well.

Of children with one of the above anxiety disorders, ? percent have all three of them.

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separation anxiety disorder, generalized anxiety disorder, or social phobia

30%

Front 57

Lifetime prevalence of any anxiety disorder in children and adolescents ranges from ? to ? percent.

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8.3 percent to 27

Front 58

A recent epidemiologic survey using the Preschool Age Psychiatric Assessment (PAPA) found that ? percent of preschoolers met DSM-IV-TR criteria for any anxiety disorder, with ? percent exhibiting generalized anxiety disorder, ? percent meeting criteria for separation anxiety disorder, and ? percent meeting criteria for social phobia

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A recent epidemiologic survey using the Preschool Age Psychiatric Assessment (PAPA) found that 9.5 percent of preschoolers met DSM-IV-TR criteria for any anxiety disorder, with 6.5 percent exhibiting generalized anxiety disorder, 2.4 percent meeting criteria for separation anxiety disorder, and 2.2 percent meeting criteria for social phobia

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Separation anxiety disorder is estimated to be about ? percent in children and young adolescents

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4%

Front 60

Separation anxiety disorder and gender?

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boys =girls

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Sep Anx Ds
Onset most common?

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The onset may occur during preschool years, but is most common in children 7 to 8 years of age.

Front 62

The rate of generalized anxiety disorder in school-age children is estimated to be approximately ? percent, the rate of social phobia is ? percent, and the rate of simple phobias is ? percent. In adolescents, lifetime prevalence for panic disorder was found to be ? percent; the prevalence for generalized anxiety disorder was ? percent.

Back 62

The rate of generalized anxiety disorder in school-age children is estimated to be approximately 3 percent, the rate of social phobia is 1 percent, and the rate of simple phobias is 2.4 percent. In adolescents, lifetime prevalence for panic disorder was found to be 0.6 percent; the prevalence for generalized anxiety disorder was 3.7 percent.

Front 63

The temperamental tendency to be seems to be an enduring response pattern, and young children with this propensity are at higher risk of developing which anxiety disorders

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unusually shy or to withdraw in unfamiliar situations

separation anxiety disorder, generalized anxiety disorder, social anxiety disorders, or all three during their next few years of life.

Front 64

Neurophysiological correlation is found with behavioral inhibition (extreme shyness); children with this constellation are shown to have a ? and ?

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are shown to have a higher resting heart rate and an acceleration of heart rate with tasks requiring cognitive concentration

Additional physiological correlates of behavioral inhibition include elevated salivary cortisol levels, elevated urinary catecholamine levels, and greater papillary dilation during cognitive tasks

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Mothers with ? disorders who are observed to show ? attachment to their children tend to have children with higher rates of anxiety disorders

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Mothers with anxiety disorders who are observed to show insecure attachment to their children tend to have children with higher rates of anxiety disorders

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Genetic studies of families suggest that genes account for at least ?of the variance in the development of anxiety disorders in children.

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one third

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two thirds of young children with behavioral inhibition (do or do not) appear to go on to develop anxiety disorders

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do NOT

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urrent consensus on the genetics of anxiety disorders suggests that what is inherited is a general predisposition toward anxiety, with resulting in ???

all of which increase the risk for the development of ???

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heightened levels of arousability,
emotional reactivity, and
increased negative affect

separation anxiety disorder,
generalized anxiety disorder,
and social phobia.

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Most common anxiety ds in childhood?

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Generalized anxiety disorder is the most common anxiety disorder in childhood

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in 30 percent of cases, a child with generalized anxiety disorder also exhibits

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seperation anxiety
social phobia

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The most common anxiety disorder that coexists with separation anxiety disorder is

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specific phobia, which occurs in about 1/3 of cases for SAD

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Panic disorder with agoraphobia is uncommon before ? years of age;

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18

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A follow-up study of children and adolescents with anxiety disorders over a 3-year period reported that up to ? percent no longer met criteria for the anxiety disorder at follow-up. Of the group followed, ? percent of those with separation anxiety disorder had a remission at follow-up.

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MOST
82%
96%

Front 74

(Few, some, many, most) children who recovered did so within the first year.

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MOST

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Factors that predict slower recovery in anxiety ds?

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Early age of onset and later age at diagnosis were factors that predicted slower recovery.

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membrane permeability

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blood-brain barrier -testis blood -placenta barrier

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Tx of GAD, SAD, Social Phobia?

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Multimodal: CBT (first line), Family eduation, Pharmacologic interventions

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Rx with best evidence for GAD, SAD, SP?

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Fluvoxamine

then Fluoxetine
then sertraline
then paroxetine

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(NIMH)-funded Child/Adolescent Anxiety Multimodal Treatment Study (CAMS)
study pop?
arms?

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300 C&A
Sertraline
CBT
S+C

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seperation anxiety mininum duration for dx

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4 weeks

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social phobia min duration for dx?
gad min duration

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no min

gad 6 months

Front 82

School refusal associated with separation anxiety disorder can be viewed as a

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psychiatric emergency.

Front 83

Selective mutism has been estimated to range between ? and ? per 10,000 children. Some surveys indicate that it may occur in up to ? percent of schoolchildren in the community.

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Selective mutism has been estimated to range between 3 and 8 per 10,000 children. Some surveys indicate that it may occur in up to 0.5 percent of schoolchildren in the community.

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selective mutism seems to have same etioligic factors as?

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social phobia

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In a recent survey, 90 percent of children with selective mutism met diagnostic criteria for

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social phobia

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Is there a lower than or higher than or or expected history of speech delay in children with selective mutism

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higher than expected

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seletive mutism usual age range of onset

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4 to 8

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ddx of selective mutism

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PDD
Anxiety Ds
MR
Expressive language ds
Conversion disorder

Front 89

Children introduced into an environment in which a different language is spoken may be reticent to begin using the new language. Selective mutism in these children should be diagnosed only

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when children also refuse to converse in their native language and when they have gained communicative competence in the new language but refuse to speak it.

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Selective mutism:
usual onset
usual duration

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Children with selective mutism are often abnormally shy during preschool years, but the onset of the full disorder is usually not until age 5 or 6 years

Most cases last for only a few weeks or months

Front 91

In one follow-up study, about ? of the children improved within 5 to 10 years.

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50%

Front 92

Tx of selective mutism

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1st line CBT
SSRI (fluoxetine) if psychosocial not suffice

Front 93

Meds used in social phobia

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flouxetine
fluvoxamine
sertraline
paroxetine