Current Clinical Insights Into Pediatric Anxiety Disorders

Pediatric anxiety disorders are one of the most common mental health conditions affecting children and adolescents, and in recent years there have been significance advances in our understanding and treatment of these disorders.

On Saturday, September 9th, at the 36th Annual Psych Congress in Nashville, Manpreet Singh, MD, MS, Associate Professor, Psychiatry and Behavioral sciences, Stanford University, presented her session entitled, “Advances in Pediatric Anxiety Disorders,” before an audiences of mental healthcare  professionals.

Psych Congress Network spoke with Dr. Singh about why pediatric anxiety disorders are so common today, evidence-based treatment approaches, and strategies for clinicians encountering challenges when creating treatment plans for this patient population.

For more insights direct from the session rooms, visit the Psych Congress newsroom.

Editor’s Note: Responses have been lightly edited for length and clarity.

Psych Congress Network (PCN): Can you provide an overview of why pediatric anxiety disorders are considered one of the most common mental health conditions affecting children and adolescents today?  

Manpreet Singh, MD, MS: When we talk about anxiety disorders, we are thinking about a variety of disorders, including specific phobias, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and generalized anxiety disorder.  

I think evolution has a lot of do with why anxiety disorders present early in human life.  The brain develops in a bottom-up fashion, with subcortical areas like the amygdala developing first and prefrontal cortical areas evolving later in development around adolescence. For our survival we need to have a healthy fight or flight response, therefore it shouldn’t surprise us that when this response is triggered, and not managed adaptively, anxiety disorders can ensue. Separation anxiety also makes sense to evolve first given that separation and individuation is an early developmental task, and then other environmental exposures can trigger specific phobias, social anxiety, agoraphobia, panic, and generalized anxiety.  

Other risk factors include parental history of anxiety disorders, socioeconomic stressors, exposure to violence, and trauma. 

PCN: Your session at Psych Congress 2023 promises evidence-based treatment approaches for pediatric anxiety disorders. Could you provide a look into some of these approaches? How do these treatments differ from conventional methods?  

Dr. Singh: There are few new innovations in evidence-based treatments; what we’ve mostly done in pediatric anxiety is demonstrated that SSRIs and SNRIs are efficacious and generally well tolerated by most youth at therapeutic doses and in conjunction with therapy.

Psychotherapy is an important first line treatment because individual, group, family, and online CBT-based therapies for most anxiety disorders do better than control conditions to alleviate anxiety symptoms. Matching people to the right evidence-based therapy requires a thorough diagnostic evaluation that understands the symptoms and their root causes. When you know what the cause of the anxiety is, you can narrow the treatment target, whether it’s in the patient or in the system within which the patient experiences the anxiety (home, school, with friends, etc.) 

PCN: Can you share insights into any challenges or limitations that professionals might face when implementing the evidence-based treatment approaches discussed in the session? How can these challenges be effectively addressed?  

Dr. Singh: If you can help a patient get access to the right psychotherapy to address anxiety, you will make significant gains in establishing engagement with and confidence in the treatment.  Sometimes, digital health tools can facilitate access to manualized cognitive behavioral therapy to get patients started on building tools while the family navigates alternative (e.g. in person) treatments in an evolving mental health system. Some treatment is better than no treatment, and some online tools may facilitate skills in an accessible way.  Busy clinicians can also use modular approaches to treatment matching (one example online are match protocols like PracticeWise) to pair patient symptoms with evidence-based psychotherapies. These kinds of tools cannot replace clinical acumen and a thorough diagnostic evaluation, but they can help practitioners plan treatment around core symptoms causing patient distress. 

When medications are necessary, and first-line treatments at therapeutic doses yield a partial response or don’t work, patients may need rational combination strategies to facilitate treatment engagement in therapy. In this instance, and in a time-limited fashion, patients can benefit from adjunctive treatments like benzodiazepines, even though the randomized controlled trials in pediatric anxiety to date do not demonstrate efficacy. There is a balance between acute and maintenance treatment for anxiety, and we need more long-term data to guide us on what medications work beyond the acute phase. 

PCN: With the increasing recognition of the importance of mental health, what role do you see these advances and developments playing in reducing the stigma surrounding pediatric anxiety disorders?  

Dr. Singh: I suppose one positive side effect of the pandemic is that it helped build some empathy as we all lived through some shared anxiety and stress. To shine a light on an entire constellation of symptoms that tend to be heavily cloaked by most will likely improve early recognition. If that shared experience could encourage more people to help address the workforce shortage, then that could also be a positive side effect. 

The fact remains, however, that we need to be able to filter normal, everyday anxiety from functionally-impairing and debilitating anxiety so that we can better match the level of treatment with the needs of our patients. This calls for us to reimagine how we deliver care for patients, and how we as a society implement effective social supports during times of distress. It’s also true that we may struggle to detect signals from new treatments (i.e. separate treatment from placebo effects) if we don’t figure out how to accurately delineate normal anxiety from disordered anxiety. 

Manpreet Singh, MD, MS, is Associate Professor of Psychiatry and Behavioral Sciences and leads a program aimed to accelerate understanding and treatment of youth with or at high risk for developing lifelong mood disorders. Dr. Singh earned her MD at Michigan State University and her MS at the University of Michigan. She completed her combined residency training in Pediatrics, Psychiatry, and Child and Adolescent Psychiatry at Cincinnati Children’s Hospital Medical Center. Dr. Singh leads a multidisciplinary team that evaluates and treats youth with a spectrum of mood disorders as young as age 2 and well into their 20s.