Youth Anxiety During Pandemic and Beyond With Dr Maletic

(Part 2 of 2)

Intro and Transcript:

Welcome back Psych Congress Network listeners. This is Meagan Thistle, your assistant digital editor. In part 2 of this podcast, Vladimir Maletic, MD, MS, Clinical Professor of Psychiatry at the University of South Carolina School of Medicine in Greenville, breaks down his conversation with Gavin in greater detail and explains the broader implications for clinicians and caretakers. 

If you haven't listened to the previous part 1, where Dr Maletic sits down with 9-year-old Gavin who explains his daily routine, anxieties, and experiences as a kid living through COVID-19, we recommend doing that first before continuing on with part 2.

Thank you, and enjoy the conclusion of this podcast.

Dr Maletic: In terms of anxiety disorders in children in general...I'm not talking any longer about COVID 19 impact. I'm just talking about anxiety disorders in children. They're quite common. Large meta analyses have found that approximately 10 percent of children, 1 in 10, suffer from some kind of anxiety disorder. These anxiety disorders in children have a sequence.

We're most likely to see specific phobias around the age of 6, 7. These would be circumscribed fears related to some object specific scenarios. A child is preoccupied thinking about it and trying to avoid this phobic object. This is something that does not necessarily interfere with the rest of their life. Again, it tends to be more circumscribed.
Later on, typically related to beginning of elementary school, children are more likely to start to experience separation anxiety. They're fearful when they're separated from parents. In school, they may have various somatic complaints, gastrointestinal complaints, headaches, vague aches and pains, difficulty breathing, going to the nurse's office asking to go back home.

It is also difficult to separate from parents in the morning. A child has a lot of worries during school about, number one, will parents be OK while they're apart? Number two, will they be reunited with their family members?

Later on this is usually around the age 10 to 12    children may start exhibiting some social anxiety. They're very self aware and self conscious in social situations. They tend to overread any kind of negative social cues.

Typically, if they're asked to have an overnight with friends around midnight to one o'clock in the morning, they will start feeling uneasy if there are a lot of children there who they do not know. This will often result in calls to the family members.

Reassurance tends to work pretty well in those situations. If the child has couple of friends, the friends can provide some comfort. Social anxiety will typically subside. Very often, children, when invited to go to a friend's birthday, may ask who all will be there. If most of the other children are known to them, they will feel fairly comfortable and will not have problems.

On the other hand, if they do not know many of the children, it may be a negative answer, "I don't want to go." Also, in school, if they're supposed to read their paper, they feel that their behavior is being evaluated and scrutinized. This is associated with great anxiety.
Very often, prior to this scenario, a child will in the morning feel sick or have various somatic complaints trying to avoid going to school. These are some of the more common anxiety disorders that one can encounter in childhood.

Later more towards adolescents, we tend to see generalized anxiety disorder where there are number of worries about all kinds of scenarios. There will be a lot of questions in current circumstances about family members' health. There will be preoccupation about new variants of COVID.

What will it mean? Will the vaccine that mom, dad, and grandma received protect them from these new strains? They will be worried because they heard that one of the asteroids is going to go pass close to Earth. Well, what if it hits us? Didn't an asteroid hit the Earth, and dinosaurs died? Can something like that happen to us?

There are a lot of worries and preoccupations regarding a large number of topics. In addition to that, the children will often have problems with sleep, nightmares, and multiple somatic complaints, gastrointestinal complaints, breathing complaints, headaches, aches and pains. Not uncommonly will there be irritability.

With all the anxiety problems, worries, and preoccupations that may interfere with school functioning, and obviously if things are not going well at home and if there is tension in the relationship between them and their parents, that makes the situation only worse.

You might imagine that in COVID 19 context, many of these factors are worse and more likely to contribute to distress in children and exacerbation of anxiety disorders. A big question is, what can we do about this? Well, the emphasis is on so called positive parenting but also increased participation in wellness behaviors.

When I'm talking about positive parenting, it is something that does require time, and that is taking time to listen to what child's concerns are. Checking in, having conversations, and not being in a hurry to interpret, and to try to diminish or dismiss concerns. Better listening very carefully and asking questions.

If the child desires to answering those questions, but being there, being present to, being reassuring, again, providing positive messages. Also increased participation in pleasurable activities. Children love to play with their peers, so respecting health concerns as much as possible. Having conversations with peers, doing fun things with family members, being in the nature, walking. All these things have been known to be helpful.

Also making sure that sleep hygiene is good. It is not necessarily advisable to have screen time, aside from school which is a necessity, more than an hour and a half or two a day. That would be maximum. Anything beyond that can have detrimental effect.

Definitely not a good idea to have a lot of screen time in the evening because it may have negative influence on the quality of sleep. Again, sleep hygiene is really important. It is important the child has enough exercise. In terms of dietary recommendations, avoiding processed food, more fresh food, is something that is definitely advisable.

Now, of course, not all anxiety disorders will benefit solely from positive parenting, increased pleasurable play, and a lifestyle changes. Some children may require more concerted therapeutic effort. What would that entail? Some of the large studies have looked at the effect of pharmacology versus cognitive behavioral therapy.
In general, it seems that SSRIs and SNRIs, so serotonin norepinephrine reuptake inhibiting agents, selective serotonin reuptake inhibiting agents, provide approximately 55 percent response rate.

If one engages, if the child is involved in cognitive behavioral therapy, that produces about 60 percent response rate. It is a little bit more involved, it requires time, but it is a very, very effective modality. If there is combination of SSRI, SNRI, and cognitive behavioral therapy, one may anticipate about a 80 percent improvement rate.
Other agents have been tested. We do know that tricyclics do work, but there are various concerns about safety, adverse reaction profile, impact on heart function. These agents are not used commonly any longer.

Some data exist about serotonin, one a modulating agent such as buspirone. Data are equivocal, it is not very clear what kind of benefit children can expect from that.
There are quite a few studies about using benzodiazepines in children who suffer from anxiety disorders. Acute studies do point to some relief from benzodiazepine treatment, but on the other hand, long-term use does not seem to be an effective modality.

Again, this would not be my recommended first line of treatment by any means. In some very acute scenarios, a very brief and limited use may be warranted, but again, chronic benzodiazepine treatment to chilldhood adolescent population does not seem to be a fruitful treatment approach.

There are also some data regarding alpha 2 agonists. These are medicines that are otherwise used to treat ADHD, and limited data indicate that guanfacine extended release can be associated with [the] relief of anxiety symptoms.

When it comes to other psychotherapeutic modalities, a mindfulness-based cognitive therapy and dynamically oriented psychotherapy also have some evidence of benefit in child and adolescent anxiety disorders.

Finally, something else that we have to watch out. This is not so much children, it's more in adolescence. If they have anxiety disorder. Their risk of using substances, such as alcohol, tobacco, and [cannibus] is substantially increased. They may claim that use of these substances improves anxiety, the opposite may be true when it comes to [cannibus].

There are studies that indicate that even in adolescents had no prior history with anxiety disorders, after frequent [cannibus] use, anxiety disorders have merged. The part that is really interesting is that even after [cannibus] was stopped, anxiety persisted, suggesting that there may have been some enduring changes in brain function.

That, too, would provide vulnerability towards anxiety disorders in the future. Of course, it's very difficult to say if these individuals, even though they have not had clinical anxiety disorder, may have not had some predilection, which if anything could make [cannibus] use more likely.

Not very clear, but with reasonable control, we still have a high degree of suspicion that exposure to [cannibus] with frequency and earlier age may be a risk for developing subsequent anxiety disorders. With that, I will thank you for your attention and involvement with this program. I hope it was useful to you. Thank you, and goodbye.