CBL Anxiety Disorders
CBL Seminars: Anxiety Disorders
3rd Year Medical Students
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CBL Seminars: Anxiety/School
Refusal
Addo Boafo
M. B., CH.B. (Legon, Ghana)
FRCPC (Ottawa)
MBA (Leicester, U.K.)
Inpatient Psychiatry 6E CHEO
Assistant Prof. (U. of O. Dept. of
Psychiatry)
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CBL Seminars: Anxiety/School
Refusal
 Caution:
Not an extensive review of:
1.
2.
3.
4.
Childhood Anxiety Disorders
School Refusal
Separation Anxiety
Slides
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CBL – Anxiety Disorders of Childhood
1.
2.
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6.
7.
What are the main childhood anxiety disorders?
What are the main causes of school refusal?
What are the clinical features of separation anxiety?
What are the predisposing factors in childhood anxiety disorders?
Describe possible characteristics of parents of anxious children.
Discuss the treatment of childhood anxiety disorders using a
biopsychosocial model.
Describe long-term complications of childhood anxiety disorders.
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Main Childhood Anxiety
Disorders (DSM 5)
1. Anxiety Disorder Due to a General
Medical Condition.
2. Substance/Medication Induced Anxiety
Disorder
3. Panic Disorder
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Childhood Anxiety Disorders
4. Separation Anxiety Disorder (75% have
school refusal)
5. Social Anxiety Disorder (Social Phobia)
6. Specific Phobia
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Childhood Anxiety Disorders
7. Generalized Anxiety Disorder
8. Selective Mutism (considered by some as a variant of social anxiety
disorder)
9. Agoraphobia
10. Other Specified Anxiety Disorder
11. Unspecified Anxiety Disorder
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Childhood Anxiety Disorders
No longer considered as Anxiety Disorders in DSM 5:
1.
2.
3.
4.
5.
PTSD
Acute Stress Disorder
Adjustment Disorder with Anxiety/Anxious Mood
OCD
The is no longer Anxiety Disorder NOS (replaced with Other
Specified Anxiety Disorder, and Unspecified Anxiety Disorder)
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Childhood Anxiety Disorders
1.
2.
3.
4.
5.
Developmentally inappropriate
Duration (prolonged/recurrent)
Distress factor
Impaired functioning
Number of symptoms
(Deciding what is an anxiety disorder)
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Causes/Sources of School
Refusal
1. Separation Anxiety Disorder (50%-80%)
2. Psychiatric Disorders
a. Mood Disorders:
Major depressive Disorder
Bipolar disorder
b. Other Anxiety Disorders
c. Overt Psychotic Disorder.
d. Other psychiatric conditions
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Causes/Sources of School
Refusal
3. Realistic fear of bodily harm in a
dangerous school setting (bullying, gangs)
4. Academic Underachievement
a. Learning disabilities
b. Language disorders
c. Developmental delay
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Causes/Sources of School
Refusal
5. Autism Spectrum Disorder
6. Stressors
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Signs and symptoms of Sep. Anxiety Disorder
1. Distress on Separation (actual/anticipated)
2. Death/Illness
3. Lost/Kidnapped
4. Cling/Shadow (fear of being alone)
5. Sleep times (onset)
6. Nightmares
7. Physical symptoms on separation (actual/anticipated)
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Features: Sep. Anxiety Disorder
1. Recurrent excessive distress when separated from
home or major attachment figures occurs or is
anticipated.
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Features: Sep. Anxiety Disorder
2. Persistent and excessive worry about losing, or
about possible harm befalling, attachment figures
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Features: Sep. Anxiety Disorder
3. Persistent and excessive worry that an untoward
event will lead to separation from a major
attachment figure (e.g., getting lost or being
kidnapped)
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Features: Sep. Anxiety Disorder
4. Persistent reluctance or refusal to go to school or
elsewhere because of fear of separation
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Features: Sep. Anxiety Disorder
5. Persistently and excessively fearful or reluctant
to be alone or without attachment figures at home
or without significant adults in other settings
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Features: Sep. Anxiety Disorder
6. Persistent reluctance or refusal to go to
sleep without being near a major
attachment figure or to sleep away from
home
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Features: Sep. Anxiety Disorder
7. Repeated nightmares involving theme of
separation
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Features: Sep. Anxiety Disorder
Repeated complaints of physical symptoms
(such as headaches, stomachaches, nausea,
vomiting, palpitations, dizziness, faintness)
when separation from major attachment
figures occurs or is anticipated.
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Features: Sep. Anxiety Disorder
Other:
1.
2.
3.
4.
Duration: 4 or more weeks
Significant Distress or Impairment
(social/academic/occupational, other)
Does not occur exclusively during the course of a
pervasive dev. disorder, psychosis; and not better
accounted for by panic disorder with agoraphobia
DSM 5: Can begin after age 18 years. No early/late onset.
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Predisposing Factors:
Childhood Anxiety Disorders
(Clinical)
1.
2.
Early temperamental traits of passivity and
shyness between ages 3-5 years.
Temperamental trait called Behavioural
Inhibition: a tendency to show fear and
withdrawal in new, unfamiliar situations
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Predisposing Factors:
Childhood Anxiety Disorders
(Clinical)
3. Insecure mother-child attachment in infancy,
toddlerhood and early childhood.
4. How parents, in general, respond to potentially
fear-producing situations. This is communicated
to the child in explicit or implicit ways.
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Predisposing Factors:
Childhood Anxiety Disorders
(Clinical)
5. One or both parents may have intense concerns
about the hazards of separation. This is
communicated to the child directly or indirectly.
6. Family accommodation: facilitating avoidance
Failure to accommodate: child becomes angry or abusive and anxiety
symptoms worsen.
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Predisposing Factors:
Childhood Anxiety Disorders
(Clinical)
7. Role reversal in the family, with the
child/adolescent carrying too much power and
the parents, for example, unable to influence a
return to school.
8. Abuse and Trauma
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Treatment of Childhood Anxiety
Disorders (biopsychosocial
model)
1.
2.
3.
4.
Take a good history, with collateral information.
Do a good mental status examination.
Physical Examination and Relevant laboratory Studies.
Get input from interdisciplinary team: (psychology, social work,
occupational therapy, school teacher, frontline (nurses, child and youth
counsellors).
5.
Assess Suicide Risk
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Treatment: Biopsychosocial
Model
6. Rule out Substance/Medication induced anxiety disorder.
7. Rule out anxiety disorder due to a medical condition.
8. Determine if there is more than one anxiety disorder. Anxiety triad (GAD,
Social Anxiety Disorder, and Separation Anxiety Disorder), Panic Features.
9. Determine if there is a co-morbid Psychiatric Disorder
10. Determine if there is a co-morbid Medical Disorder.
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Treatment of Anxiety Disorders
 In general:
 1. School interventions
 2. Talk therapy
 3. Possibly a Medication.
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Treatment: Biopsychosocial
Model
 A. Cognitive-Behavioural Therapy (CBT)
1.
2.
3.
4.
Shortest duration of treatment (mean 6 mo)
Best outcome: about 50-60% efficacy rate.
Training and certification needed.
Could be in individual/family/group forms
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Treatment: Biopsychosocial
Model
 CBT’s six essential components:
1.
2.
3.
Psychoeducation
Physiologic management
Cognitive Restructuring
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Treatment: Biopsychosocial
Model
 CBT
4. Problem solving skills
5. Exposure
6. Relapse prevention
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Treatment: Biopsychosocial
Model
School Interventions
May involve:
1. Addressing bullying, teasing, violence, abuse
2. Appropriate remediation and placement.
3. School psychoeducation
4. Others
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Treatment: Biopsychosocial
Model
Psychotropics
Remember:
1. Psychoeducation of family and child/adolescent
is very important.
2. Informed consent is needed.
3. Need monitoring strategies for outcome and
side effects.
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Treatment: Biopsychosocial
Model
 Reasons to use medications as an add-on
1.
2.
Level of functional impairment is moderate to
severe and need to prevent further loss.
Facilitate or hasten positive outcomes of
behavioural interventions.
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Treatment: Biopsychosocial
Model
Psychotropics:
1.
2.
3.
4.
SSRIs seem to be the treatment of choice for most
pervasive and impairing anxiety disorders in youth.
TCAs are a second-line treatment due to side effects
and less overall efficacy.
Benzodiazepines are less commonly used due to risk of
dependency, better alternatives, disinhibition.
Atypical antipsychotics may have a role.
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Treatment: Biopsychosocial
Model
Treatment by Disorder Type

Social anxiety disorder

Panic Disorder
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GAD

Agoraphobia

Separation Anxiety Disorder
Consider:
1. CBT
2. Antidepressant
3. Possible addition of benzodiazepine, atypical antipsychotics.
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Treatment: Biopsychosocial
Model
NB: “Anxiety Triad” : GAD, Separation A. Disorder, & Social Anxiety Disorder
Specific Phobia
Consider:
1. CBT
2. PRN benzodiazepine
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Treatment: Biopsychosocial
Model
Selective Mutism:
Consider:
1. Variety of Cognitive approaches: positive reinforcers, modeling, systematic
desensitization, in vivo exposure, in vivo graded exposure.
2. Antidepressants may help.
Clinical Course of Anxiety Disorders in youth:
About half of treated patient were in remission after an average of 6 years.
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Complications (Anxiety
Disorders)
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9.
Development of Mood Disorders (Depression)
Substance Use (street drugs/alcohol) Disorders
Prescription Medication abuse
Suicide ideation/attempts
Impaired school/work/relationship performance
Isolation/Social withdrawal
Sleep disorders
Physical Health (stomach
cramps/diarrhea/headaches/cardiovascular symptoms)
Others
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References
1.
2.
Reinblatt, SP & Walkup (2005) Psychopharmacological
Treatment of Pediatric Anxiety Disorders. Child
Adolesc. Psychiatric Clin N Am, 14: 877-908.
Practice Parameters for the Assessment and Treatment
of Children and Adolescents with Anxiety Disorders
(1997). J. Am. Acad. Child Adoles. Psychiatry, 36; 10
Supplement (69S-83S)
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References
3. Fremont WP (2003). School Refusal in Children and
Adolescents. Am Fam Physician, 68: 1555-60, 1563-4.
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