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Anxiety disorders Presented by Dr.T.

Chaired by Dr.Abhijeeth
in children


❖ Anxiety is a universal human experience.As an affective

state symptom of anxiety include sense of discomfort
and uneasiness aroual , fear and need to escape.
❖ Distinguishing normal anxiety from pathological anxiety
❖ If it limits developmentally appropriate behaviours and
causes functional limitations and distress.

What we will review

Normal vs pathologic anxiety
Separation anxiety
Social phobia
Generalised anxiety disorder

What is normal anxiety?
❖ 10-20%10 – 20% of children and adolescents suffer a diagnosable
anxiety disorder.
❖ Children have fears of separation from parent
❖ Children 6-7 yrs-fears that they find troubling
❖ 30% school going children worry about their competence and
require considerable reassurance
❖ Girls report ore stress than boys-this may be an artefact of social
❖ But most of thes stresses are outgrown or recede as children

Anxiety as a friend!!

Distinguishing normal from pathological

❖ Object
❖ Intensity
❖ Impairment
❖ Ability to recover

Separation Anxiety Disorder
❖ Universal human developmental phenomenon emerging in infants <1yr marking Childs awareness of
separation from mother or primary caregiver.
❖ Normal between 9-18 months, diminishes by 2 1/2 yrs
❖ Human response which has survival value.
❖ 15% of young children have behaviour inhibition.
❖ Behaviour inhibition is , intense persistent fear , shyness and social withdrawal, when faced with
unfamiliar settings and people.
❖ Such children are at higher risk for developing anxiety disorder.
❖ Physiological features in behaviourally inhibited children are higher than normal resting heart rate, higher
morning cortisol levels than avg, low heart rate variability.
❖ Seen in mean age group of 7-8 years.
❖ Kids which BI have higher risk of development of panic as they age (Smoller et all)
❖ BI is also heritable

DSM 5 criteria for Separation Anxiety

❖ A level of fear or anxiety regarding separation from their parents

or primary caregivers, which is beyond developmental
❖ Pervasive worry that harm may come to the parent upon
separation which leads to distress and nightmares.
❖ Symptoms are: refusal to go to school, fears and distress on
separation, physical symptoms like headaches and stomachache
when separation is anticipated, nightmares related to separation
❖ At least 3 symptom for at least 4 weeks.

Nosology SAD
❖ DSM III-first mentioned ,onset prior to age 18 duration at
least 2 weeks.3/9
❖ DSM IV- onset prior 18 yrs, 4 weeks, evidence of serious
distress or impairment was added.recurrent serious
distress anout anticipated or actual separation was
combined hence 3/8
❖ DSM 5- onset does not require prior 18 yrs onset,
duration >6 months so as not to over diagnose transient

Other AXIS I disorder which may
mimic SAD

❖ Developmentally normal separation anxiety

❖ generalized anxiety , OCD
❖ Social anxiety disorder
❖ Panic disorder
❖ Oppositional defiant disorder
❖ Bipolar disorder

Social Phobia/Social anxiety
❖ Intense discomfort and distress in social situations, and are impaired by the
fear of scrutiny or humiliation .
❖ Expressed as crying tantrums, avoidance, freezing, mute,
❖ DSM5 -The disorder is characterised by consistent and anxiety in almost all
social situations where the child feels exposed to possible scrutiny by
others which provoke fear and anxiety and will hence voice these feared
social situations.
❖ Diagnosed when its present when the child is with peers and not only with
❖ Despite the significant impairment caused unto 50% do not receive


❖ DSM III - first mentioned as social phobia. Minimal

❖ DSM IV-removal of avoidant disorder.overlap between
avoidant disorder and social phobia and its continuity
into adult social anxiety disorder lead to its removal.
❖ DSM 5 has performance only type.
❖ 6 month duration was for ages <18 but now applied to
all age group.

Clarks model for social anxiety
Phobic disorders

❖ Fear of objects that are not intrinsically dangerous like

animals situations heights
❖ Fear is considered extreme and it limits daily activities
and distress and leads to avoidance
❖ Classified based on the nature of feared object
❖ Exception blood injury phobia - sudden drop in BP and
pulse and fainting.

Specific types of phobias

Performance only type
❖ Such anxiety present in only in
specific social situation like public
speaking or performance anxiety.
❖ Manifests in school or academic
settings in front of classmates.
❖ Associated with Lower levels of
satisfaction in leisure activities,
increased rate of school dropouts,
less productivity in workplace as
adults, increased rates of remaining
❖ Performance anxiety can occur
independent of anxiety in social
situations but reverse is unusual. Type to enter a caption.

Generalised Anxiety disorder

❖ In contrast to SAD and social Anxiety who have only one trigger these children have multiple
triggers.excessive uncontrollable worry about number of anxiety provoking events.
❖ Children with this disorder have significant distress in ADL often focussed on Childs fears of
incompetence in many areas including school performance and in social settings.
❖ DSM 5 symptom checklist
❖ restlessness, easily fatigued ,”mind going blank” , irritability , muscle tension, Sleep disturbance.
❖ Expect more negative outcomes when faced with challenges compared with peers.
❖ Autonomic hyperarousal-tachycardia, shortness of breath, dizziness , sweating nausea and diarrhoes.
❖ Overtly concerned about natural disasters like earth quake and floods and these worries interfere with
their daily activity.
❖ Also seek excessive reassurance about their performance.
❖ Generally seen in children in mean age group 8-9 years


❖ DSM III overanxious disorder.GA was reserved for >18

❖ DSM IV - since it progressed into adulthood as adult
generalised anxiety also due to poor validity and poor
reliability of this category it ws termed as GAD.
❖ Change in terminology has not much affected the
characteristics of the cases.
❖ Criteria same for DSM 5

Panic disorder
❖ Recurrent attack or intense fear that occur unexpectedly(cued or uncured)
❖ Panic disorder vs panic attacks
❖ Cued can occur in any anxiety disorder
❖ Fear of death or going crazy
❖ Uncommon before the peri pubertal age
❖ Peak age of onset is 15-19 yrs
❖ Pani attacks+avoidant behaviour/fear of going cracy/fear of impending doom/concern
about having additional attacks/implictions and consequence sof the attack =panic
❖ Should not be due the effects of a substance
❖ Absence of agoraphobia

Panic attack in a child

❖ Physical symptoms rather than psychological symptoms

❖ Suddenly frightened or upset without reason
❖ Confusing behaviou to onlookers
❖ May not be able to articulate the intense fears that they
❖ Adolescents re better able to describe their attacks

❖ Lifetime prevalence ranges from 10-27%.common in
❖ Survey done in preschool age children by using Preschool
age Psychiatric assessment revealed that 6.5% GAD, 2.4%
Separation anxiety, 2.2% social phobia.
❖ Young children its more common .
❖ Onset in preschool years but common in 7-8 yrs age group.
❖ in adolescents the lifetime prevalence for panic disorder was
.6%, GAD 3.7%.


❖ From normal worry-the overall amount of anxiety, poor

anxiety control, the lack of amelioration with appropriate
reassurance and support and long term impairment.
❖ Children with GAD have co occurring social anxiety and
separation anxiety.
❖ GAD look like OCD.( doubt their perception is accurate
and hence recheck for the purpose of rechecking)


❖ Biophysical factors
❖ Social Learning factors
❖ Genetic Factors
❖ Attachment

Biophysical factors
❖ Parental psychopathology and parenting styles influence emergence of anxiety disorders.
❖ Longitudinal studies -parental overprotection and insecure parent child attachment.
❖ Maternal depression and anxiety disorders have increased risk for anxiety and depression in children.
❖ Psychosocial factors+childs temperament =influence the degree or separation anxiety evoked in brief
separation and exposure to unfamiliar environments.
❖ Traits of shyness and social withdrawal .
❖ External life stressors - death of relative, Childs illness, change in environment.
❖ In vulnerable children these changes intensify anxiety.
❖ Neuro physiological correlations-found with behavioral inhibition -higher resting HR,acceleraion of HR
when performing cognitive conc., elevated urinary catecholamine levels, elevated salivary cortisol level,
greater pupillary dictation.
❖ Neuroimaging studies-increased activation of amygdala, also maintain the hyper activation.
❖ Structural studies have shown conflicting results_increased and decreased volumes.

Neurobiology of pediatric anxiety disorder

Dysfunction in the prefrontal amygdala based circuits.

the amygdala—which is charged with the initiation of central fear
responses—is frequently “overactivated” in functional magnetic resonance
imaging (fMRI) studies of youth with fear-based anxiety disorders
The ventero lateral prefrontal cortex -this structure regulates amygdala
activity and plays a pivotal role in extinction in the context of fear
conditioning and responds in tandem with the amygdala to emotional
The cingulate cortex which girdles the limbic system and subserves
motivation and cognitive control is hyperactivated in youth with anxiety
glutamatergic tone within the anterior cingulate cortex directly correlates
with the severity of anxiety in adolescents with GAD [

Type to enter a caption.

Social learning factors
❖ Fear in a variety of situations can be unwittingly transmitted from parents
to children. DIRECT MODELLING.
❖ Overprotective parenting in a behaviourally inhibited children ,
increases the risk of social anxiety disorder.
❖ Teaching the children to be anxiously exaggerating the dangers.
❖ parent might promote phobic concern in child by scolding them when
they express fear.
❖ Recent study found no correlation between psychosocial hardships and
behaviour inhibition in young children but temperamental predisposition to
anxiety disorders emerges as highly heritable constellation of traits.

Genetic factors
❖ Heritability for anxiety disorders ranges from 65% to 73% highest
estimates in younger children.
❖ Next to ADHD in most heritable condition .
❖ Main heritable characteristics are behavioural inhibition and
physiological hyper arousal.
❖ Although more prone 1/3 rd of such behaviourally inhibited children
do not develop anxiety disorder.
❖ Family studies suggest that children of parent with anxiety disorders
are more prone and also genetic predisposition puts them in an
increased risk developing GAD, Separation anxiety and social phobia.

How attachment affects development of

❖ Secure
❖ Insecure resistent- hyperactivatin
❖ Insecure avoidant-inhibited
❖ Disorganised no adaptive strategy-frightening
unpredictable parents/

Course of paediatric anxiety

❖ Though most of them spontaneously remit many show a

waxing and waning pattern.
❖ Syndrome shifts toothed anxiety syndromes
❖ Pure anxiety disorder in childhood. multiple anxiety in adulthood

❖ Homotypic continuity and heterotypic continuity

❖ Lead to a cascade of psychopathology

❖ Poor long term functioning with inter personal financial and educational difficulties
also suicidality.

Co morbidity in childhood anxiety
❖ Co morbidity is a rule.elevated in GAD unto 90% had another
comorbid anxiety disorder.
❖ Raised questions about diagnostic separation in the
❖ Non anxiety disorders- major depression.its strength rivals all
other differential psychopathology.
❖ Anxiety nd ADHD but only weak relation.
❖ Anxiety disorder also occurs with substance use and conduct

Axis II contributes to anxiety
❖ 40% children with ASD diagnosed with anxiety disorders
❖ Social phobia 17-30%
❖ Specific phobia 30-40%
❖ GAD 15-35%
❖ sep. anxiety 9-38%
❖ OCD 17-37%
❖ Gene polymorphism may modulate the effect of anxiety in ASD
❖ Glutamate transporter gene (SLC1A1)single nucleotide polymorphism.
❖ ASD with anxiety is amenable to CBT, particularly when clinicians target familial accommodations that
exacerbate/maintain anxiety and incorporate behavioral intervention plans into treatment
❖ Although not indicated for anxiety in youth with ASD, atypical antipsychotics have demonstrated efficacy
and have a US FDA indication for treating irritability and aggression among youth with ASD, which may
reflect anxiety symptomology
❖ SSRIs and serotonin and norepinephrine reuptake inhibitors appear most effective for typically
developing youth and atypical antipsychotics show promise, the added complexity of ASD leaves the
literature on pharmacotherapies with comorbid anxiety wanting.

Axis III contributes of anxiety

❖ Among children with ID anxiety may result due to cognitive impairment,

reduced adaptive behaviours, increased vulnerability to environmental
demands.(ollineck and ollineck 1982/ gualteiri and Matson 1989)
❖ Decreased social skills and dependency on familiar others may also lay
the groundwork for repeated high rates of anxiety .
❖ Clinically nearly 25% of the children with mild intellectual disability
experience clinically significant levels of anxiety(menolascino et al
1986, Fash 1986)
❖ Recognition difficult due to lack of skill for reporting. Clinician has to rely
on high index of suspicion.

Axis IV contributes to anxiety disorder

❖ Anxiety may also relate to organic brain disease, seizure disorder,

endocrine disorder, (Insel and Winslow 1992)
❖ CNS injury to left prefrontal cortex may leat to catastrophic
anxiety.intense dysphasia in response to novel or unpredictable
environmental demands.
❖ In clients with epilepsy and complex partial seizures -difficult to
distinguish from panic attacks especially when there is a combination of
epileptic and non epileptic seizure.(Charney , Nagi et al 1996)
❖ Endocrinopathis _thyroid abnormality-anxiety or increased moodiness)
❖ CVS-mitral valve prolapse -related to panic disorder (Katon 1989)

Developmental course
❖ The expression of Anxiety as well as clinical syndromes follows a developmental
course(Black 1993)
❖ Infants-react to novel or unexpected events with over aousal.brain systems that regulate
arousal involve gaze aversion , stereotypic behaviour, intensified attachment behaviour.
❖ Later separation anxiety stranger anxiety and behaviour inhibition may result forebrain
maturation as well as temperamental vulnerabilities.
❖ Later forms of anxiety include body integrity, natural environmental events, school
performance, increasing concern with social adequacy (Allen Hetson 1998).
❖ Also dependent on maturation of neurotransmitter system.Eg;Panic disorder -present in
late teen and early adulthood. And later decrease with aging.
❖ This may parallel the maturation and regulation of the noradrenergic or sympathetic
nervous system.

Diagnosis and Clinical
❖ Overlapping symptoms and comorbid disorders .
❖ Separation anxiety is extreme anxiety precipitated by separation from parent home
or other familiar surrounding .morbid fears, ruminations preoccupations.fear that
someone close to them will be hurt..fears of being lost being kidnapped and losing
their ability to keep in touch with their family.
❖ Gad is fear extended towards to negative outcomes for all kinds if
recurrent symptom of restlessness, poor conc., irritability, muscle tensions.
❖ Social phobia-fear peaks during social performance, concerns over being
embarrassed humiliated and judged.the fear is more than that is normally
expected for the Childs developmental level.
❖ Common is the preoccupied with health and worry that their friend or family will
become ill.

❖ Prominent features- clinging crying irritability, difficult eating refusing to
go to camp, new school or friends house.
❖ Adolescents express it in behaviour patter-engaging in solitary actibties
discomfort in leaving home, or distress when away from home.
❖ Self imposed isolation.
❖ Sleep disturbance.
❖ Fear of dar. Lurking under the bed.
❖ Easily brought to tears.
❖ frequent somatic compalints.

Type to enter a caption.
Selective Mutism
❖ Persistent lack of speaking in one or more specific social situations
most typically the school setting.
❖ Completely silent or new silent or in some cases whisper in school.
❖ Often begins before 5 yrs but not apparent until he goes to school.
❖ Convergence of social anxiety +underlying speech and language
❖ Communicate through eye contact , few may speak fluently at
home .
❖ Related to social anxiety.

Parental Interactions

❖ Maternal over protection

❖ Predisposed to selective mutism after early exposure to
emotional or physical trauma
❖ Hence also called as traumatic mutism.


DSM IV-it was included under disorders usually first diagnosed in

infancy, childhood or adolescence.

Due to logical fit between social anxiety and SM.

Diagnosis of SM does not require fear or anxiety.

ICD 10 elective mutism- marked emotionally determined selectivity in anxiety withdrawal anxiety ad resistance.


❖ Genetic contribution
❖ Parental interaction
❖ Speech and language factors

Genetic contribution

❖ same etiological factors leading to the emergence of

social anxiety disorder.
❖ Greater risk of delayed onset of speech or speed
abnormalities will be contributory.
❖ 90% met diagnostic criteria for social phobia.
❖ Maternal anxiety , depression and heightened
dependence needs ar eofen noted in families of such
children .


❖ DSM 5 0.03 to 1% depending on whether clinical or

community sample is studied.
❖ young children more vulnerable.UK 0.06% of 7 yr old
had selective mutism.
❖ Young children sponteneously outgrow this disorder.
Longitudinal course is yet to be studied.

Speech and language factors

❖ History of speech delay.

❖ Higher risk for a disturbance in auditory processing
which may interfere with efficient processing of incoming
❖ Though these problems are mostly subtle.

Diagnosis and clinical
❖ My develop gradually or suddenly after disturbing episode .
❖ Age of onset 4 to 8 yrs.
❖ Mostly in school selective cases mute at home.also have
separation anxiety school refusal and delayed language
❖ Behavioural disturbance like temper tantrums and
oppositional behaviours may also occur in home.
❖ Less social competence and more social anxiety.

Differential Diagnosis
❖ Communication disorder
❖ Autism spectrum disorder
❖ Social anxiety disorder
❖ Intellectual disability
❖ Pervasive developmental disorders
❖ Expressive language disorder
❖ In mutism secondary to conversion disorder the mutism is pervasive.
❖ While learning a new language. Should be diagnosed only when they
refuse to speak their own gained language.

Course and prognosis
❖ Shy during preschool years but onset of the full disorder is usually not evident until
5-6 years.
❖ Many children have spontaneous remission .
❖ Academic difficulties due to lack of participation.
❖ Fluoxetine may influence the course.
❖ Rigidity negativism tempertantrubs oppositional and aggressive behaviour at
❖ Children who do not improve by 10 years have long term course and worse
❖ 1/3 rd without treatment may develop other psychiatric disorders other anxiety
disorders and depression.

Assessment scales

❖ Old scales- RCMA(revised children’s manifest anxiety scale),

STAIC(State trait anxiety inventory for children),CBCL( children’s
behaviour checklist. Generated a non specific factor of emotional
disturbance called as internalising factor.
❖ Not able to differentiate between anxiety and depression
❖ Variation between parent and child report
❖ Test retest reliability, diversion validity from depression
measures, reasonable correlation with clinical levels of anxiety
severity, sensitivity to treatment effects.

Assessment scales >8 yrs
❖ Multidimensional assessment scales for children
❖ Screen for child anxiety and emotional related disorder(SCARED)
❖ SCAS spence children’s anxiety scale
❖ Test retest reliability, diversion validity from depression measures,
reasonable correlation with clinical levels of anxiety severity, sensitivity
to treatment effects.
❖ Age 2.5 -6.5-preschool anxiety scale -parent reported adapted from
❖ Paediatric anxiety rating scale -commonly used to assess
psychopharmacological trials of youth is clinician rated scale used to
assess the severity of anxiety symptoms and change over time.

Assessment scales in social

❖ The Social Anxiety scale

❖ The Social Worries Quetionnaire
❖ Social phobia subscae of SCARED

Diagnostic interviews
Newer + -
Test retest Researc
DISC Validity K-SADS reliability h tool
Predictive Skilled
CAPA significanc Teachin
DICA professi
e g tool


Pathology and Lab
❖ Because they can mimic other medical disorders it is important t rule out other medical causes
❖ Endocrine -TSH/TFT
❖ hypoglycemia-AC/PC/RBS
❖ Pheochromocytoma-VMA/metyrapone test
❖ CNS-brain imaging /EEG
❖ ECG- cardiac causes -arrythmia ,
❖ Respiratory isorders -asthma
❖ Lead intoxications
❖ Baseline blood investigation- low HB -fainting spells
❖ History of consumption of any coffee/energy drinks/SSRI/antipsychotics (akathesia)
sympathomimetics /steroids/anti asthma medication .


❖ Psychological treatments Mindfulness -based


❖ Psychopharmacological interventions


❖ Coping cat programme.

❖ FRIENDS programme
❖ PCIT -parent child interation therapy
❖ Coping koala programme

Coping cat programme

PICT-Parent Child Interation Therapy

❖ Adapted for children aged 4-8 yrs with SAD

❖ Child directed interction
❖ Bravery directed interaction
❖ Parent directed interaction

The FRIENDS programme

❖ 10 session CBT intervention

❖ Delivered in a group format
❖ Acronym
❖ Children to learn from peers experience and helps
families to develop supportive social network.

Mindfulness based therapy
“the intentional, accepting, and non-judgmental focus of one’s attention on the
emotions, thoughts, and sensations occurring in the present moment”

Mindfulness based stress reduction Mindfulness based cognitive behavioural therapy

Catani et al. found meditation-based relaxation to be as effective as trauma-

focused CBT in the treatment of children with PTSD from war and tsunami in
Lierh & Diaz [56] found a mindfulness intervention to be effective in
decreasing symptoms of anxiety and depression in a group of minority

Psychodynamic psychotherapy

Type to enter a caption. Type to enter a caption.

one trial of 4-10 year old children with anxiety disorders , using a quasi-experimental wait-
list children (N=30) with were treated with 20-25 sessions of manualized, short-term
Psychoanalytic Child Therapy (PaCT). In this study 67% of patients no longer met criteria
for any anxiety disorder compared to 0 children in the wait-list group. In parallel,
internalizing and total problems significantly declined during treatment and gains were
maintained at 6 months, post-treatment 60
Behaviour therapies for SAD

❖ Systemic desensitisation
❖ Flooding implosive
❖ Contingency management
❖ Modeling -live modelling /participant modelling /symbolic

Relaxation techniques

❖ Deep breathing
❖ Imagery
❖ Progressive muscle relaxation
❖ Proposed mechanish-incresed control over sympathetic
servous system, decreased physiological symptoms.

Psychopharmacological treatment

❖ First line -SSRI .a Cochrane systematic review showed that there are 7 short term <16
weeks RCT( n treatment =453 control=389)testing the efficacy of SSRI on changes in
impairment in anxiety disorders in young people with an overall RR response of 2.38 over
❖ CAMS showed mono therapy with sertraline 55% as effective as CBT 60% when compared
with places 24% and combined therapy 81%.
❖ SSRIs and SNRI as a class, are considered effective for pediatric anxiety disorders A meta-
analysis of 16 randomized trials on published between 1992 and 2008 found a number of
SSRI and SNRI medications – fluoxetine, sertraline, fluvoxamine, paroxetine, and
venlafaxine – to be superior to placebo in the treatment of pediatric anxiety
❖ . Among the SNRIs clinical trials suggest that venlafaxine SR, in particular, is effective for
these disorders.
❖ A 2015 trial suggested that duloxetine may benefit youth with GAD . Some children
experienced weight loss, increased cholesterol, and changes in vital signs while taking the

SSRI associted by disinhibition, agitation , worsening of anxiety.

Headache gastric disturbance sleep disturbance increased suicidal behaviour , suicidal

thoughts in children taking SSRI.

The concern were based on a review of studies f adolescents with depression rather than
young people with anxiety.

US FDA has issued a black box warning in 2004 against SSRI .FDA additionally
recommended close monitoring of patient’s clinical status during the early weeks of
antidepressant treatment and limiting the duration of their use. Drug monitoring to be followed

Weekly for the first four weeks

Biweekly beginning the second monthly
Monthly beginning the third month (ie, 12 weeks following the start of medication)
Though there are no head to head trials testing comparative efficacy of SSRI and SNRI the
adverse effect of SNRI are less well tolerated .
Due to different pharmacodynamic action t can be considered a third line of treatment when
two trial with different SSRI prove ineffective.

Type to enter a caption.

The reason why SSRI is better then SNRI?
The serotenergic system mature even before the norepinephrogenic syst

Prior to the SSRI and SNRI, TCAs were used.

RCT of TCA for youth with anxiety disorders has yielded a

conflicting result

Anti cholinergic side effects need for frequent cardiac


Lethality in overdose have limited their use in pediatric


❖ Combination therapy more effective

❖ Effects were durable and sustained
❖ 50% relapsed at followup
❖ Anxiety disorders require intensive and extended
treatment to maintain the acute gains

69 Type to enter a caption.

❖ Bind to the GABA receptors hence potentiate the inhibitory
neurotransmitter GABA.
❖ Very limited evidence available .and its restricted to few randomised
control trials.
❖ Youth aged 8-17 yrs with GAD
❖ alprazolam/placebo=no difference also dry mouth and fatigue with
❖ Clonazepam/placebo= clonazepam reduced anxiety to comparable
levels as placebo. Also side effects of irritability drowsiness and
oppositional behaviour noted.

Other drugs

Atomoxetine has been evaluated in youth with ADHD and a co-occurring anxiety
disorders (SAD, GAD and/or SoP; PARS score ≥15) in a 12-week, multicenter,
double-blind, placebo-controlled study.
Reduction in both ADHD and anxiety symptoms were noted.

Unpublished RCT.paediatric patients 6-17 yrs with GAD

Buspiron /placebo=no statistical serious adverse effects with

Guanefecine-in paediatric patients with SoP/GAD/SAP-recently completed.

Predictors of treatment response

❖ Poor prognosis-First degree relative

❖ Older age at onset
❖ Increased caregiver strain
❖ Good prognosis-better family functioning .