A 13-year-old male came to clinic for his well child examination. His mother gave a history of increasing stomachache at school that was also occurring at home. He had it several times a week and had missed a few days of school over the past several months because of it. “I thought it was just a sensitive stomach or constipation but that doesn’t seem to be the problem,” she noted. The stomachache wasn’t related to food, exercise, and doesn’t awaken him at night. He had no emesis, nausea or diarrhea. His bowel movements were usually every day to every other day and were soft. “He’s a nervous kid. Always has been. It got worse this fall when he started 7th grade. He says that other kids don’t really bother him, but he is worried they might. His school work is okay, but he also worries about that. He worries about the weather especially if there is a storm or snow. I get worried about some of the same things, and I’ve tried to help him realize that these things happen to everyone, but don’t know how else to help him,” she went on. The patient confirmed the history and also noted that he had times where he had problems going to sleep because he kept worrying about something. He also endorsed some muscle tension from time to time. He said he would try to listen to music or do something active to try to take his mind off things that worried him.
The past medical history showed general complaints of abdominal pain or headache in the past. The family history was positive for anxiety and depression. The review of systems was negative for palpitations, syncope, seizures, tremors, etc.
The pertinent physical exam showed a well-appearing male with normal growth parameters. HEENT was normal including a normal thyroid examination. Heart, lungs, abdominal and neurological examinations were normal.
The diagnosis of a child with normal growth and chronic stomachaches along with anxiety was made. The physician discussed potential options with the family. The mother did not want to pursue medication treatment at this time, but both she and the patient were interested in him learning better coping skills. The patient’s clinical course after about 3 months of behavioral therapy showed him to be more confident, less worried and having fewer stomachaches. The family continued to decline medication and wanted to continue the behavioral therapy.
Generalized anxiety disorder (GAD) is “…excessive anxiety and worry about a number of events and activities coupled with at least one physical symptom, which may include fatigue, poor concentration, restlessness, irritability, muscle tension, and sleep difficulties.” Other ways it presents to the primary care office may be abdominal pain, headache or heart palpitations, dizziness, syncope, numbness, trembling, paresthesia, memory loss, or urinary frequency. It has an estimated prevalence of 15% and is the second most common anxiety disorder in children after social anxiety disorder. GAD can commonly co-occur with attention deficit disorder, depression and other anxiety disorders (e.g. social anxiety or separation anxiety). There is a complex interaction between physical symptoms (including those with functional symptoms), pain (and especially pain threshold and how it is perceived) and the anxiety where one area can exacerbate the other. Anxiety itself is probably underdiagnosed because of these interactions. Anxiety in the adult population may have evidence of its beginning in childhood or adolescence.
History including psychosocial assessment and history of current stressors and/or current or past trauma can be very helpful along with appropriate anxiety screening tests for the appropriate age. Physical examination also helps with assesments for possible organic issues. Testing should be guided by the history and physical examination.
The differential diagnosis includes:
- Mental health/psychological issues
- Anxiety disorders including social anxiety, separation anxiety, panic disorders, fears
- Attention deficit disorder
- Depression including bipolar disorder
- Developmental disorders
- Learning disorders
- Oppositional defiant disorder
- Psychotic disorders
- Psychosocial stressors – death, separation/divorce, financial problems, housing or food insecurity, environmental stressors, etc.
- Trauma – past or ongoing including bullying
- Substance abuse
- Organic issues
- Cardiac arrhythmias
- Seizure disorder
- Substance use – caffeine, anti-asthmatics, antihistamines, antipsychotics, selective serotonin reuptake inhibitors (SSRI), steroids, and sympathomimetics
- Toxins – lead
Treatment for patients with GAD is often multimodal with behavior and medication therapy used in combination based on research outcomes. Behavioral therapy to help the patient and family to understand the problem, recognize the triggers and increase coping skills to manage their symptoms are the basics. Cognitive behavioral therapy (CBT) has been used to treat patients with success. Components of CBT may include “…cognitive restructuring, problem-solving, relaxation training, modeling, contingency management, imaginal and in vivo exposure and relapse prevention.” Relaxation methods often are very helpful to pediatric aged patients to manage their symptoms. Appropriate physical activity and exercise also can help patients with anxiety. School and home environments which offer consistency and reassurance seem to be beneficial for patients.
Selective serotonin reuptake inhibitors (SSRI) and selective noradrenaline reuptake inhibitors (SNRI) are usually the first type of medications used in addition to behavior therapy. SSRIs can have increased anxiety side effects including nervousness and agitation. SSRIs do carry a “black box warning” for a potential increase in suicidal ideation. Therefore this must be discussed with the patient and family along with a safety plan and close monitoring of the patient. SSRIs can take 4-8 weeks for clinical effect to be fully realized. Other medications can include antidepressants, and other medications have been used in adults but seem less commonly used in the pediatric age group.
Questions for Further Discussion
1. How do you differentiate fears and phobias? A review can be found here
2. What causes abdominal pain? A review can be found here
3. How common is post traumatic stress disorder? A review can be found here
- Symptom/Presentation: Abdominal Pain
- Specialty: Adolescent Medicine| General Pediatrics | Psychiatry and Psychology
| School | Social Services
- Age: Teenager
To Learn More
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Manassis K. Generalized anxiety disorder in the classroom. Child Adolesc Psychiatr Clin N Am. 2012;21(1):93-103, ix. doi:10.1016/j.chc.2011.08.010
Dillon-Naftolin E. Identification and Treatment of Generalized Anxiety Disorder in Children in Primary Care. Pediatr Ann. 2016;45(10):e349-e355. doi:10.3928/19382359-20160913-01
Strohle A, Gensichen J, Domschke K. The Diagnosis and Treatment of Anxiety Disorders. Dtsch Arztebl Int. 2018;155(37):611-620. doi:10.3238/arztebl.2018.0611
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa