Pediatric Generalized Anxiety Disorder

Both children and adolescents occasionally experience the anxiety that accompanies stressful events. Alarmingly, it isn't uncommon that many children and teens in the US are diagnosed with an anxiety disorder. Anxiety disorders and co-occurring disorders like depression and separation anxiety disorder (SAD) have a dramatic effect on a child's quality of life. Generalized anxiety disorder is one of the most common types of anxiety disorders, and unfortunately, it affects a large portion of the pediatric population.

Children with a generalized anxiety disorder (GAD) are described as having uncontrollable feelings of fear that are overwhelming and excessive in nature. These children persistently worry about before, during, and after a daily activity has happened. Generalized anxiety disorder is estimated to affect 15% of children in the US with an age of onset of 8.5 years. The exact cause of pediatric GAD is unclear and disputed among many professionals; however, it's widely believed that there are both biological and environmental etiologies.

For example, parents with pre-existing anxiety may transfer the same affliction to their children genetically. Alternatively, children who are being raised by overprotective parents attempting to reduce anxious behaviors are at-risk of manifesting GAD. Children and adolescents will report private events like physical pains that include: heart palpitations, muscle tension, stomach aches, and headaches. Some notable overt behavioral manifestations include insomnia, latching onto family members, and a severe lack of attention. Covert behaviors are marked by feelings of nervousness, fatigue, stress, and restlessness. Involuntary actions such as sweating, hyperventilation, increased heart rate, and trembling are commonly observed symptoms.

Surprisingly, children with isolated GAD do not typically produce anxious behaviors when conversing, and they can maintain normal conversation with their peers. There are skills that are slightly impacted, but these issues are not significantly problematic when it comes to a child's communication repertoire. Children with GAD have problems with assertiveness, give minimal eye contact with partners, interject with fewer comments, and ask fewer questions during conversation. In addition, children with GAD have smaller groups of friends, yet they are still preferred over children with other anxiety disorders, especially those with social phobia (SP). Although GAD does not have a profound effect on communication by itself, social skills are greatly impaired when other disorders are present. For example, in children with ASD and comorbid GAD: the social use of language is weakened; thus, maintaining conversation is difficult. Retrieval of verbal cues is also disrupted because of increased anxiety which ultimately leads to communication breakdown.

As for the behavioral dimension of GAD, we unfortunately see more problem behaviors associated with this disorder. Parents often report their children avoiding their responsibilities by complaining too much. Clinicians will find that these patients will worry excessively about themselves and their family members, and sometimes think a natural disaster will threaten their safety. A prominent avoidance behavior involves avoiding going to school because they worry about their performance in school and other extracurricular activities; these kids strive for perfection which results in low self-esteem. Despite having relatively small social difficulties, children and teens with GAD can have strained relationships with family and friends because they unrealistically seek constant reassurance from them. Finally, they may exhibit an aggressive temper or act downtrodden when they receive critique that appears to be harsh from teachers or parents.

Treatment interventions for GAD can vary depending on a child's personality, their level of development, and familial background. Positive reinforcement would be the most effective therapy option for clinicians treating pediatric GAD. Depression, social anxiety disorder/social phobia (SP), and separation anxiety disorder (SAD) are common comorbid disorders which can have a detrimental effect on a child's self-esteem and self-image. Negative reinforcement could potentially have a negative effect on a child's well-being and may trigger an anxiety attack. This is especially true if the stimulus is something especially unpleasant like a buzzer or a siren, which may lead the child to believe they are in imminent danger. Clinicians should consider using positive reinforcers like candles (olfactory), music (auditory), and coloring books (tangible) that will allow the child to alleviate stress and provide a relaxing atmosphere while they work on their goal for the day. An intermittent reinforcement schedule would be the most effective reinforcement schedule for children with GAD since these children are usually beyond the phase of acquisition; therefore, no continuous reinforcement schedule is necessary. A ratio schedule of reinforcement is the most suitable since it will lend no element of surprise to the child.

The child knows they'll be reinforced after they accurately perform the correct number of responses; nevertheless, it's best to start with a fixed schedule and then fade into a variable one. Starting with a variable schedule when first treating a child could increase a child's paranoia; thus, rendering therapy obsolete. A task analysis is another potential intervention for children with GAD. Anxiety is marked by increased stress, and these patients will need to learn how to cope with exasperating situations. Clinicians can perform an empirical task analysis by modeling activities like meditating, yoga, and exercise. A rational task analysis which involves asking a therapist is another option for treating GAD. Therapists may recommend combining cognitive-behavioral therapy (CBT) with medication most notably, selective serotonin reuptake inhibitors (SSRIs).

Pediatric generalized anxiety disorder affects many teens and children in the United States, and it unfortunately goes under-recognized because many clinicians assume that worrying is a normative part of childhood development.

Although, communication is not severely impaired, behavioral symptoms are significantly profound and recognizable. It is important that we lend our attentions to these children as this disorder can worsen over time. Offering the child or teen a relaxing atmosphere and combining different strategies can help with treatment. A cohesive collaboration between a team of professionals can drastically help and make way for successful outcomes.

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