Child and Adolescent Psychiatric Disorders

Psychosocial Treatments for Separation Anxiety.

Environmental modifications are often important in the management of separation anxiety. Planned efforts to minimize the magnitude of separations (e.g., having the child transition between familiar adults [such as preferred school staff], constructing check-in notes from parents provided at various points during the preschool or school day, providing planned distracting or attractive activities as the child makes the transition) may all decrease separation fears.

Psychotherapy interventions, matched to the developmental level of the child, are often helpful. For younger children, identifying fears (that something may happen to their parent or to them, or to other adults or children) may provide clarity about the nature of the specific fear so that desensitization or successive approximations can be used to diminish anxiety. For example, for young children unable to sleep in their own rooms, sleeping on the floor, in the hall, or with a light or sibling nearby may prove viable once the child's particular distress becomes clear. Reinforcement for efforts toward sleeping alone is often needed to sustain the child's effort. Similarly, assessment of evidence that supports or negates fears, and steps to combat these fears (from relaxation techniques to keeping transitional objects, sometimes imbued with “special powers” to provide the child with strength or special skills) can replace the child's existing anxiety response. Sometimes a parent of the child with separation anxiety may similarly feel anxious around separations, so mindfulness about parent efforts and responses for separations may illuminate needs for reassurance and de-escalating acts for parents to decrease the cascade of anxiety that surrounds separations.

Pharmacotherapy for Separation Anxiety.

Antidepressants and benzodiazepines are frequently used together to enable children to both separate and tolerate separations. Selective serotonin reuptake inhibitors (SSRIs) are often initiated, while benzodiazepines are simultaneously provided for several weeks until the medication exerts significant effects. Low doses of clonazepam or lorazepam may be helpful and enable the child to separate and to acclimate to the parent-absent environment. In addition, some patients require evening doses of benzodiazepines initially to counter overwhelming anxiety as they anticipate separations at bedtime or the next day.

Psychosocial Treatment of Obsessive-compulsive Disorder.

A variety of therapies have been beneficial in the management of OCD. CBT, both with individuals and with groups of children having OCD, have proven efficacious, including “personifying” the obsessions (e.g., “Germy”), and identifying steps to “boss back Germy,” to recognize how much time the child plays with “Germy” instead of with peers (to make the obsessions more dystonic). Practicing compulsions differently to make them more uncomfortable and providing more appropriate “competing” responses to replace existing compulsions have been useful.

Pharmacotherapy of Obsessive-compulsive Disorder.

Pharmacotherapy with SSRI antidepressants remains the cornerstone of pharmacological treatments for OCD. Studies suggest that children with OCD respond in a fashion similar to adults, and may require doses up to four times the normal doses used to treat depression (i.e., 80 mg of fluoxetine instead of 20 mg daily). The SSRI antidepressants are Food and Drug Administration (FDA)-approved for OCD in the pediatric population (e.g., sertraline [Zoloft, initiated at 12.5 to 25 mg daily and titrated to 50 to 200 mg daily], fluvoxamine [Luvox, a more sedating drug that is initiated at 25 mg at bedtime and increased to 25 to 150 mg twice per day], and fluoxetine [Prozac, initiated at 5 to 10 mg and increased to 60 mg/day]).When SSRIs cannot be tolerated, or the patient is refractory to multiple SSRIs, the tricyclic antidepressant (TCA) clomipramine (Anafranil) has also been efficacious for pediatric OCD. A variety of additional pharmacotherapy strategies have been employed to augment SSRIs in severely impaired adolescents with OCD, including: atypical antipsychotics, such as aripiprazole, the amyotrophic lateral sclerosis (ALS) medication riluzole (although concerns about pancreatitis persist), emantine, and D-cycloserine. Despite these medication treatments, augmentation of CBT appears to be particularly efficacious.

Psychosocial Treatments for Generalized Anxiety Disorder.

Patient education about the chronic nature of GAD and the fluctuating course of symptoms often associated with the emergence or decrease in stressors may provide reassurance to patients and decrease general stress levels. Psychotherapeutic support, using relaxation, deep breathing, and progressive muscle relaxation, may help children counter escalations of anxiety. Cognitive-behavioral techniques for appraising situations more completely and logically, and for accessing other input from others or evaluating all the evidence (e.g., the likelihood of a terrorist attack in a rural county), may enable children to control anxiety with cognitive skills.

Pharmacotherapy for Pediatric Generalized Anxiety Disorder.

Treatment of GAD in children is similar to the treatment of GAD in adults; SSRIs, benzodiazepines, TCAs, and beta-blockers appear to be effective. Buspirone, a non-benzodiazepine anxiolytic without anticonvulsant, sedative, or muscle-relaxant properties, may provide some benefit alone or by using it in combination with an SSRI. The effective daily buspirone dose is estimated to range from 0.3 to 0.6 mg/kg.

Psychosocial Treatments of Acute Stress Disorder/Post-traumatic Stress Disorder.

Efforts to help children separate themselves from the traumatic event and from the victim role, are helpful. Environmental changes to reduce further risks for the child often require interventions by adults to create safety for the child. Cognitive-behavioral techniques to help the child resist traumatic recollections, and to counter recurrent distressing thoughts, to de-escalate anxiety, and to distinguish time or setting variables that surrounded the event to diminish generalization of fears can allay symptoms. Anticipatory planning with family members, if nightmares or flashbacks occur, can diminish re-traumatization during the child's recollection of past events.