ISSUES IN THE FAMILY
Barbara J. Howard, MD, Assistant Professor of Pediatrics, Johns Hopkins University School of Medicine, Baltimore
| Anxiety: emotional uneasiness associated with anticipation of danger; essential for survival (sets people up for fight or
flight position when faced with danger); mastery of anxiety leads to sense of self-efficacy; anxiety essential for socialization
and for maintaining moral conduct
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| Fearfulness vs phobias: fears are normal reactions to real or imagined dangers or threats; phobias are marked and persistent
fears and have functional implications
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 | Normal fears in children: newborns—fear of falling; infants 6 to 7 mo of age—fear of sudden change in stimulus level
and loss of support; 8 to 18 mo of age—fear of separation from parents; fear of strangers, loud events, physical restraints,
large crowds, and water; 2 yr of age—fear of loud sounds, dark colors, large objects, animals, location
changes, and “going down the drain”; 2.5 yr of age—fear of sudden movements and unexpected events; 3 yr of
age—fear of masks and facial deformities; 4 yr of age—fear of noises, imaginary creatures, aggressive actions, and
threats; 5 yr of age—fear of bodily injury (eg, falls) and dogs; 6 yr of age—fear of supernatural events; 7 yr of
age—concern about self-esteem and things viewed in media; 8 and 9 yr of age—concerns about personal failure, illness,
and ridicule; 10 and 11 yr of age—concerns about criminals and possible catastrophes; 12 to 17 yr of age—
worries about body changes, sexual competence, loss of face, and world events
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| Tools for mastering anxiety: imaginative play; acquisition of knowledge; experience (eg, going through frightening
event)
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| Signs of anxiety disorders: avoidance behavior; underachievement; perfectionistic behavior; procrastination; inability to
make decisions; somatic complaints; cultural differences—in some cultural groups, anxiety presents with somatic complaints
only; northern Europeans tend to verbalize their concerns
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| Danger signs in schoolchildren: frequent visits to school nurse without obvious reasons; frequent absenteeism; learning
difficulties; trouble socializing; difficulties in doing well on tests and completing homework; inattentiveness; attention-
deficit/ hyperactivity disorder (ADHD)—key differential diagnosis; many children with anxiety disorders misdiagnosed
with ADHD
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| Prevalence of anxiety disorders: affect 12% to 20% of children; often not recognized by parents and undertreated
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| Classification of anxiety disorders: separation anxiety; generalized anxiety disorder (GAD); social and specific phobias;
panic disorder, with or without agoraphobia; post-traumatic stress disorder (PTSD); obsessive-compulsive disorder
(OCD)
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| Separation anxiety: actually good thing (otherwise, children would run away from parents); first appears around 6 to 8 mo
of age; tends to improve when children learn separation only temporary; often reemerges at later date; diagnosis should
be made with caution in children <5 yr of age and never in children <30 mo of age
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| Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) criteria: developmentally inappropriate
and excessive anxiety about separation from home or major attachment figures; presence of symptoms for at
least 4 wk before 18 yr of age; presence of at least 3 key manifestations
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| Key manifestations: 1) distress when separation occurs or anticipated; 2) worry about loss or harm to major attachment
figure; 3) worry that some untoward event will lead to separation (watch for “what if” questions); 4) refusal to go to
school (85% have mother with history of school refusal); 5) reluctance to be alone without being near major attachment
figure; 6) reluctance or refusal to go to sleep without being near major attachment figure or to sleep when away
from home; 7) nightmares about separation; 8) complaints of physical symptoms when separation occurs or anticipated
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| Points: high comorbidity rate with other psychiatric disorders (especially other anxiety disorders and major depressive disorder);
many children with separation anxiety develop major depression in teens; prevalence 2% to 5%; peak age for
separation anxiety 7 to 9 yr of age; situation exacerbated if anxious parent tells child, “I’ll be back if nothing happens”
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| Generalized anxiety disorder: characteristic features—excessive and persistent worry, occurring across many domains
on more days than not; difficulty controlling worry; development of significant distress or impairment in function; associated
features—restlessness; fatigue; concentration difficulties; irritability; muscle tension; sleep disturbances
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| Remarks: impairment due to GAD often results in failure to achieve expected level of functioning; somatic complaints common;
children frequently ask “what if” questions about possible disasters; cognitive distortions common; boys and girls
equally affected until adolescence, then female predominance develops; prevalence 2% to 5% in children; factors playing
role in etiology include temperament (pattern of reactivity), genetics, neurophysiology, and environment
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| Behavioral inhibition syndrome: affects ≈20% of children; temperament issue; children typically highly reactive in unfamiliar
situations; manifestations include increased heart rate, elevated salivary cortisol, tension in larynx and vocal cords, dilated
pupils, and electroencephalographic (EEG) changes
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| Environmental stresses influencing development of GAD: child abuse and other trauma; family distress or dysfunction;
dangerous communities; lack of access to adequate support systems for normal development
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| Physical conditions that can mimic anxiety: hypoglycemia; hyperthyroidism; cardiac arrhythmias; caffeinism; pheochromocytoma;
seizures, migraine, and other central nervous system (CNS) disorders
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| Drugs that can cause anxiety: antihistamines (eg, diphenhydramine [Benadryl]); asthma medications (eg, theophylline);
sympathomimetics; steroids; antipsychotics
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| Comorbidities: one third of children meet criteria for ≥2 anxiety disorders; 15% to 24% of children with ADHD have separation
anxiety disorder or GAD; rates of depression as high as 28%; mitral valve prolapse associated with panic disorder;
children with anxiety disorders more likely to abuse substances and to have eating disorders
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| Diagnostic work-up of anxiety disorders: history—talk with parents and child separately; ask parents how child was at
younger ages; ask about family history of anxiety disorders; determine what family does when child becomes anxious
(may reinforce anxiety); physical examination—assess physical complaints and rule out other possible causes; modalities
for assessing degree of anxiety—Child Health and Development Interactive System (developed by speaker); Revised
Children’s Anxiety Scale; State-Trait Anxiety Inventory; Screen for Childhood Anxiety-related Emotional Disorders
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| Advice for parents: emphasize importance of routines (same routines every day for child); encourage regular use of same
reassuring phrases; always answer “what if” questions in same way; introduce only 1 new situation at a time; help child
plan ahead as means for coping with change; when big changes inevitable, break them down into small changes and consider
strategies for each one; explore most worrisome changes with child, then put them into perspective; practice working
through backup plans; use system of marks on child’s hand to reward child every time child does “something brave”
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| Treatment: received by <20% of affected children; goals—reduce symptoms and relieve distress; prevent complications;
minimize disability associated with disorder
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| Therapeutic modalities: demystify anxiety (not fatal); relaxation techniques and breathing exercises (practiced ahead of
time; used when upset); desensitization (couples exposure with relaxation response; speaker uses lollipops because sucrose
causes release of endorphins); teach children to talk through situations (self-talk); pharmacotherapy (use of selective
serotonin reuptake inhibitors [SSRIs] off-label for anxiety in children but sometimes quite helpful)
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| Medications: backup modality; reduce fears and most severe physical symptoms of anxiety; also reduce anxiety level and
long-term consequences; sertraline helpful for treating child with OCD; although SSRIs first-line agents for GAD, consider
using escitalopram (Lexapro); tricyclic antidepressants have some role, but fraught with problems
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| WORKING WITH DIFFICULT FAMILIES
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| Angry family members: typically feel helpless, scared, and sometimes guilty; sometimes anger aimed at physician and
child; easier for parents to feel angry than scared; underlying anxiety often expressed as aggression; sometimes anger
based on past experience with medical establishment
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| Angry parents need to: 1) have child’s medical problems solved; 2) be heard about content and emotions; 3) be made to
feel capable
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| Strategies for listening to angry families: echoing and pacing—involves matching pace of patient or parent to connect;
physician starts at same voice level and body posture used by patient or parent, then gradually brings them down; listening
exhaustively to patient—helpful; sitting side-by-side with individual—denotes body cues of cooperation, not
confrontation; using individual’s examples and modalities—reflect on what person is saying; answer in same modality
(eg, visual, auditory, or kinesthetic); elicit criteria for satisfaction—involves obtaining as many details as possible and
obtaining measurable feasible criteria relevant to problem; make action plan—involve parents or patient in setting priorities
and time frame; elicit some connection with past—toward end of office visit ask, “have you ever run into a
problem like this before?”
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| People who hit their children in office: subgroup of angry parents; messages these people may convey—ashamed of
child’s behavior; frustration; helplessness; anger; fear child out of control or fear of hurting child; feelings of guilt
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| Strategies for dealing with this problem: 1) make observation about situation (eg, “boy, he’s really a handful, how is
that for you?”), then wait for response; 2) offer assistance (eg, “I know how to help you in managing your child’s behavior;
would you like to talk about these things with me?”) 3) schedule appointment to deal with problem, involving
all relevant people; 4) explore perceptions of child and past child rearing (try to find out what parents think about child;
ask how they were raised); 5) teach concrete skills (eg, “time out”) as substitute for hitting; 6) make contract to eliminate
or limit hitting 7) schedule follow-up visit in 2 to 3 wk
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| Other points: physicians should avoid disciplining child for bad behavior in office unless physically attacked; instead,
physician should ask parents to handle problem same way they would at home; reporting abuse sometimes necessary
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| Types of dependent family members: people dealing with significant illnesses; people with past real or imagined threats to
child (vulnerable child syndrome); individuals with dependent personality disorders or anxiety disorder; multiproblem families
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| People facing significant illness in child: dependence on physicians appropriate; medical management and patient education
required; get parents with ill children involved in care of child; suggest parents join support group
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| Dependent personality patients: tend to visit doctors frequently; have more medical problems than general public; often
at risk for obesity, bulimia, alcohol abuse, and smoking; tend to be more compliant but passive, ie, require detailed instructions;
often have much interpersonal sensitivity; have positive attitude about physicians and desire more feedback,
help, and support; some require mental health referral
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| Strategies for dealing with dependent family members: set structure for visits; gradually work toward having person
cope on own; specify length of visit at outset; ask person to bring list of prioritized concerns and address most troublesome
ones first; ecourage reflection on how they have coped in past situations (often helpful in identifying particular
strength or anchor for standing up for self); suggestions—think about real or imaginary role model; elicit associations
with current emotions; develop plans for dealing with stressful situation; enlist support from others, eg, relative; physician
should—anticipate phone calls and call first; offer frequent appointments at time when physician at best; offer
praise for increased signs of independence
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| Vulnerable child syndrome: definition—responding as though child at risk when current threat low or nonexistent;
what to do—sort out alleged threat; elicit reproductive history, including history of previous pregnancies, miscarriages,
and abortions; remarks—history of ≥1 abortions most likely risk factor (parents often feel guilty and think they killed
child); history of infertility another risk factor; parents with this syndrome often respond to same basic strategies as those
for dependent families, but also may require mental health referral; parent with severe case may engage in child abuse or
neglect
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| Multiproblem families: typically have multiple simultaneous crises; problems often complicated by struggles within family,
domestic discord, and financial problems; these people typically mistrust authority (including physicians), act out
feelings rather than reflecting on them, and have trouble making long-term commitments
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| Principles for working with these families: aim to gradually empower them, rather than rescuing them; assess social supports,
and determine those that address specific needs; help family develop social network (best social support one that
actively involves family members); emphasize natural supports (rather than agencies) whenever possible; sometimes
necessary to get most constructive force (eg, boyfriend, neighbor) into room to participate in dialogue and give support;
be patient with process
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Educational Objectives
| The goal of this program is to educate the listener about childhood anxiety and strategies for working with difficult families.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Recognize the clinical manifestations of generalized anxiety disorder (GAD) in children.
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| 2. Care for children with separation anxiety disorder.
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| 3. Treat anxious children with various modalities, including pharmacotherapy.
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| 4. Deal with angry family members in physician’s office, including those who regularly hit their children.
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| 5. Care for dependent family members, including those with the vulnerable child syndrome
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Discussed on This Program
Diphenhydramine HCl [Benadryl, others]
Epinephrine (several trade names)
Escitalopram oxalate [Lexapro]
Sertraline HCl [Zoloft]
Theophylline (several trade names)
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To locate lectures of related interest, or to see a complete listing of Audio-Digest CME Programs, including written
summaries.
Suggested Reading
Bernstein GA et al: Anxiety disorders in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc
Psychiatry 35:1110, 1996; Bernstein GA et al: Maternal phobic anxiety and child anxiety. J Anxiety Discord
19:658, 2005; Castellanos D, Hunter T: Anxiety disorders in children and adolescents. South Med J 92:946, 1999;
Doherty WJ, Baird MA: Family Therapy and Medicine New York City, The Gullford Press, 1983; Foley D et al: Informant
disagreement for separation anxiety disorder. J Am Acad Child Adolesc Psychiatry 43:452, 2004; Goodwin RD,
Gotlib IH: Panic attacks and psychopathology among youth. Acta Psychiatr Scand 109:216, 2004; Howard BJ et al:
The pediatrician’s role in the prevention of missing children. Pediatrics 114:1100, 2004; Howard BJ: Discipline in early
childhood. Ped Clin North Am 38:1, 1991; Hudson JL et al: Nature, assessment, and treatment of generalized anxiety
disorder in children. Pediatr Ann 34:97, 2005; Jurbergs N, Ledley DR: Separation anxiety disorder. Pediatr Ann 34:108,
2005; Kearney CA, Silverman WK: A critical review of pharmacotherapy for youth with anxiety disorders: things are
not what they seem. J Anxiety Discord 12:83, 1998; Masi G et al: Generalized anxiety disorder in referred children and
adolescents. J Am Acad Child Adolesc Psychiatry 43:752, 2004; McDaniel SH et al: Family-oriented Primary Care
New York City, Springer-Verlag, 1990; Pagel JF: Nightmares and disorders of dreaming. Am Fam Physician 61:2037,
2000; Panichelli-Mindel SM et al: Disclosure of distress among anxiety-disordered youth: differences in treatment outcome.
J Anxiety Discord 19:403, 2005; Regalado M et al: Parents’ discipline of young children: results from the National
Survey of Early Childhood Health. Pediatrics 113(Suppl 6):1952, 2004; Rifkin A et al: Psychotropic medication in adolescents:
a review. J Clin Psychiatry 47:400, 1986; Simpson KR: Time out: it’s time well spent. MCN M J Matern Child
Nurs 29:272, 2004; Son SE, Kirchner JT: Depression in children and adolescents. Am Fam Physician 61:2297, 2000;
Tyrrell M: School phobia. J Sch Nurs 21:147, 2005; Walsh TM et al: Relations between young children’s responses to
the depiction of separation and pain experiences. Attach Hum Dev 6:53, 2004; Weems CF, Costa NM: Developmental
differences in the expression of childhood anxiety symptoms and fear. J Am Acad Child Adolesc Psychiatry 44:656, 2005;
Ziervogel CF: Selective serotonin reuptake inhibitors in children and adolescents. Eur Child Adolesc Psychiatry 9(Suppl
1):120, 2000; Zimmerman GL et al: A “stages of change” approach to helping patients change behavior. Am Fam Physician
61:1409, 2000.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Howard discusses the off-label use of psychotropic agents for treating children and adolescents with anxiety.
Dr. Howard’s talk on anxiety was recorded April 14, 2005, at Advances in Pediatrics, sponsored by California Chapter 2 of
the American Academy of Pediatrics and held in Las Vegas, Nevada. Her talk on difficult families was given on January 29,
2005 at Contemporary and Future Pediatrics, sponsored by the Leonard Miller School of Medicine at the University of Miami
and held in Bal Harbour, Florida. The Audio-Digest Foundation thanks Dr. Howard and the sponsoring organizations for
making this program possible.
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