Conference Coverage

Use three phases of psychiatric disorders in children to guide treatment



Three steps in the progressive pathology of anxiety and other pediatric psychiatric disorders are important to recognize for their critical role in guiding treatment, John T. Walkup, MD, said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

After the onset of symptoms and over the course of time, those with untreated anxiety disorders are at risk for developing impairment in adaptation and coping, and also the development of maladaptive behaviors like substance abuse and suicidal behavior, said Dr. Walkup, chair of the department of psychiatry at Ann and Robert H. Lurie Children’s Hospital of Chicago.

The focus of his presentation was on the treatment of anxiety disorders in children, but Dr. Walkup said the impact of the three-tier progression is likely relevant to any psychiatric disorder that begins in childhood.

In essence, the scope of problems becomes more complicated over time, and without early treatment, children continue to be symptomatic. But they also develop a lifestyle based on avoidance coping and might engage in maladaptive behaviors, Dr. Walkup said. As a result, the complexity of treatment increases substantially beyond just symptom control.

Providing an example, Dr. Walkup described a child of 7 years of age with separation anxiety. If treated at the time symptoms begin, Dr. Walkup explained, cognitive-behavioral therapy and medication would be expected to be both straightforward and highly effective. If left untreated until age 14, the child might accumulate impairment in independent functioning (due to avoidance coping) at a particularly important time in development.

“In those kids, you can reduce their anxiety burden with acute treatments like [cognitive-behavioral therapy] or meds, but now you also have 7 or 8 years of accumulated impairment due to avoidance coping and parental accommodation,” Dr. Walkup said. “If those kids are going to catch up developmentally, they also need life skill support in addition to symptomatic treatment for their anxiety.”

In the case of any pediatric psychiatric disorder, early treatment has the potential to thwart progression to a more complex and treatment-resistant form, but anxiety is a particularly prominent example. In most children, anxiety is relatively easy to control if caught early but a greater challenge when fears are not contained and the child accumulates ongoing impairment.

The obstacle is that many children are not diagnosed at the time of onset, said Dr. Walkup. The solution, he suggested, is better training of pediatricians and other primary care physicians not only to identify those children but to initiate treatment in uncomplicated cases.

“The person who has that longitudinal relationship with the child is their primary care provider, and this is really the person who is going to do the best job in getting to these kids early and initiating treatment,” Dr. Walkup said.

“We have a program in Chicago where we have trained primary care physicians not only to treat anxiety and depression, but we have specifically focused them on the easiest cases in their caseload, the classic phenotypes,” Dr. Walkup reported. Using a collaborative care model, this approach has been effective in building the confidence of primary care clinicians and in reaching children when symptoms are easier to control.

Importantly, anti-anxiety medication delivered in primary care could be sufficient to help children to manage anxiety effectively when parents cooperate in helping their children manage their fears.

“People suggest that we always start with CBT, but there [are no data] to support that. I think it is a conclusion drawn from the fact that CBT works and medication has side effects,” Dr. Walkup said. He appreciates the evidence that CBT is effective, but he cautioned that this therapy is not available everywhere, and pharmacologic therapies may be as or potentially more effective for some anxiety symptoms like anxiety-related physical symptoms.

Conversely, some have expressed the opinion that drugs might be a better option in late adolescence, when the efficacy of CBT appears to diminish, but Dr. Walkup objected to that characterization as well.

“My sense is that if you treat a 7-year-old for symptoms that have lasted a year it’s very different from treating a 17-year-old who has had symptoms for a decade,” Dr. Walkup said. Referring back to the contention that psychiatric disease in children becomes more complicated with a longer duration, this might explain why “you don’t see as much immediate success” with CBT and medication in the older age groups even if this is an effective treatment tool.

Some psychiatric disorders in children, including anxiety, might resolve with age, but early recognition and treatment should be a goal because of the potential to reduce symptoms and avoidance coping, and improve long-term outcomes, Dr. Walkup reported. Ironically, it might not be just anxiety symptoms, but poor adaptation and coping that might be the most important driver of ongoing impairment.

Dr. Walkup has served as an unpaid adviser to the Anxiety Disorders of Association of America. In addition, he has received royalties from Wolters Kluwer for CME activity on childhood anxiety.

This story was updated 2/11/2019.

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