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Is anxiety normal or pathological? Age of onset is key



NEW YORK – Anxiety has become a common descriptor for fears, worries, or concerns, but the diagnosis of anxiety as a pathological affective disorder in children requires attention to the age of onset and the types of triggers, according to a presentation at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

“Normal anxiety involves predictable triggers like a test in school,” explained John T. Walkup, MD, director of the division of child and adolescent psychiatry at Children’s Hospital, Northwestern University, Chicago. In the absence of the trigger, the symptoms abate or resolve.

John T. Walkup, MD, Director of the Division of Child and Adolescent Psychiatry, Children's Hospital, Northwestern University, Chicago. Ted Bosworth/Frontline Medical News

Dr. John T. Walkup

In contrast, the symptoms of pathological anxiety are provoked by normal developmental experiences like going to bed or ordering food in a restaurant. These symptoms may abate in the absence of triggers, but it is the excessive and debilitating reactions to normative experiences that help identify pathology.

“Age of onset is an important clue,” said Dr. Walkup, reporting that signs of pathological anxiety typically develop between the ages of 6 and 12 years. In comparison, symptoms of ADHD and autism spectrum disorder typically begin at younger ages, while the onset of affective disorders, such as depression or bipolar disease, typically occur at older ages.

Persistent symptoms may not be limited to children with pathological anxiety. Dr. Walkup said many children contend with “bad schools, troubled homes, and interpersonal violence,” creating “a huge population that meets the criteria for anxiety disorder,” even when the solution is eliminating the triggers rather than seeking an underlying psychiatric disorder.

Conversely, families of children with clear manifestations of anxiety might resist this diagnostic label.

“Parents tell me that their kids are not anxious; they are stressed out,” Dr. Walkup recounted. “These families see the external world as the problem for a kid who actually has internal problems regulating their anxious state.”

Rather than quibbling about terminology, patients should be educated about the very real threat posed by persistent and untreated symptoms, Dr. Walkup suggested. Pathological anxiety, regardless of the term used, is not a phase.

“Some of these kids do recover from childhood onset anxiety, but more often, the condition tracks to adolescence or adulthood,” Dr. Walkup said. The consequences can be serious because of accumulating disability produced by maladaptive behaviors, such as avoidance or social isolation. He contended that many adults with personality disorders are experiencing the consequences of distorted thinking and problematic emotional responses that began with childhood anxiety.

Boy with head in hands, children with rucksacks sitting on the stairs near school AGrigorjeva/Thinkstock
Currently, duloxetine is the only pharmacologic therapy approved for the treatment of anxiety disorder in children. But evidence-based strategies, including other types of selective serotonin reuptake inhibitors as well as cognitive-behavioral therapy, increasingly have been well defined. Strategies should be individualized and combined, Dr. Walkup argued.

“Children with anxiety need to learn to cope. If you medicate them to control the anxiety, it does not necessarily mean that they will learn how to live anxiety free,” Dr. Walkup said, reiterating that pathological anxiety often persists indefinitely even after effective therapy diminishes the symptom burden. To improve a supportive family environment for an anxious child, he encouraged educating parents about the condition.

“One of the many books published on childhood anxiety may be all they need,” said Dr. Walkup, listing several examples, such as “You and Your Anxious Child” (New York: Avery, 2013) coauthored by Anne Marie Albano, PhD, a professor of child psychiatry at Columbia University in New York.

As anxiety is such a ubiquitous human experience, many parents trivialize the pathological variety, Dr. Walkup said. Educating patients about the immediate and long-term risks of pathological anxiety is important. The associated symptoms are not a phase, as some parents are likely to contend. He believes that early diagnosis and effective management can change the trajectory of a lifelong threat.

Dr. Walkup reported no potential conflicts of interest.

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