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  INTRODUÇÃO 10.1007%2Fs11920-010-0173-z.pdf Epidemiologic studies show 12-month prevalence estimates of 10  –  20% and lifetime  prevalence rates only slightly higher [1] Longitudinal data suggest that anxiety disorders in childhood predict a range of  psychiatric disorders in adolescence, including other anxiety disorders, panic attacks, conduct disorder, and attention-deficit/hyperactivity disorder, and precede the onset of depression in late-childhood Anxiety disorders with onset in childhood put children at greater risk of low achievement scores later in childhood [4], educational underachievement as young adults [5], development of substance abuse and conduct problems, and increased use of long-term psychiatric and medical services, and they result in greater overall functional impairment [6, 7] Research confirms that anxiety disorders are highly comorbid with other anxiety disorders [8] and with other psychiatric disorders, including depression [9], attention- deficit/hyperactivity disorder [10], and substance abuse [11]. connolly2007.pdf Early identification and effective treatment may reduce the impact of anxiety on academic and social functioning in youths and may reduce the persistence of anxiety disorders into adulthood Caraterização clinica connolly2007.pdf The sequelae of childhood anxiety disorders include social, family, and academic impairments. These children are often perfectionistic, show high reassurance seeking, and may struggle with more internal distress than is evident to parents or teachers Apresentação da criança Deprima2016 Typical presentation Children/adolescents with anxiety disorders may not realize that their fear or worry is excessive, and parents may not recognize that it is developmentally inappropriate. Conversely, parents may present children with developmentally ‐ appropriate fears or worries thinking that something is wrong. Alternatively, anxiety may not be the chief complaint: often the child will present with somatic complaints (e.g., gastrointestinal, headaches); concentration problems may lead to academic issues; mood lability (e.g., irritability, crying) and behavioral outbursts may be misinter- preted as oppositionality; children may also  express fear/anxiety by tantrums, freezing, clinging, shrinking, failing to speak, etc. When anxiety is not the chief complaint, investigating the context and timing of the somatic and  behavioral symptoms can help bring to light the presence of an underlying anxiety disorder. Masi1999 These children are often considered overly mature be- cause they try to perform perfectly in all of their activities, they seek reassurance for their self- doubt, they are very sensitive to criticism, and they seek to please others. The worries of children and adolescents with GAD are mostly related to school performance, but they can apply to social situations, natural  phenomena, and ar- riving on time and are later characterized by continu- ous self-doubt, high sensitivity to criticism, and need for reassurance (Wagner, 2001) Avaliação 10.1007%2Fs11920-010-0173-z.pdf The evaluation should include differentiating anxiety disorders from developmentally appropriate worries, fears, and responses to stressors. Stressors or traumas should be considered to determine their contribution to the development or maintenance of anxiety symptoms. Also, children may not recognize their fear or worry as unreasonable. Screening for childhood anxiety disorders involves asking about the presence of anxiety symptoms and their impact on the child’s functioning. Variable agreement among informants requires obtaining information about anxiety symptoms from multiple sources, including the child, parents/caregivers, and teacher [16]. Young children may lack the understanding and language needed to communicate anxiety symptoms or impairment, and parental report is essential. Significant anxiety symptoms reported from any informant should lead to further evaluation for anxiety disorders. Deprima2016 ã   Always take into account the patient’s age, disease severity, comorbid disorders,  psychosocial stressors, attitudes of the patient/family regarding different interventions, and access to and affordability of different interventions. connolly2007.pdf ã   Fear and worry are common in normal children. Clinicians need to distinguish normal, developmentally appropriate worries, fears, and shyness from anxiety disorders that significantly impair a child_s functioning. ã   The crying, irritability, and angry outbursts that often accompany anxiety disorders in youths may be misunderstood as oppositionality or disobedience, when i n fact they represent the child’ s expression of fear or  effort to avoid the anxiety-provoking stimulus at any cost    Sintomas 10.1007%2Fs11920-010-0173-z.pdf Anxiety in children may manifest as crying, irritability, or tantrums and be misunderstood by adults as oppositionality or disobedience. These behaviors represent the child’s distress and efforts to avoid the anxiety -provoking stimulus. Plano de tratamento   10.1007%2Fs11920-010-0173-z.pdf Treatment planning should consider the severity and impairment of the anxiety disorder and impact of comorbid disorders Combination treatment with medication and psychotherapy may be necessary in children with moderate to severe anxiety for acute symptom reduction, concurrent treatment of a comorbid disorder, partial response to psychotherapy alone, and  potential for improved outcome with combined treatment Additionally, CBT seems just as effective when comparing short  —  (10 or fewer sessions) versus longer-term sessions, as well as individual versus group modalities [38, 39]. When cost-effectiveness is a consideration, group or shorter-term CBT may  be a useful treatment. Intervening with childhood anxiety disorders at an early age may improve child and  parent anxiety management skills and prevent impairment in the child’s self  -concept and improve socialization and learning over time [42 ã]. Empirically supported modifications to CBT for younger children (4  –  7 years of age) include age-appropriate self- instruction to manage anxiety, exposure exercises modified with games and immediate positive reinforcement, in- creased parental participation in modeling and reinforcing coping strategies, addition of parental anxiety management strategies, and  parental skills training [42 ã]. MONOTERAPIA vs CBT + FARMACOS (ARTIGO MONOTHERAPY!) 10.1007%2Fs11920-010-0173-z.pdf To investigate monotherapies versus combined treat- ment, the Child-Adolescent Anxiety Multimodal Study (CAMS), a multisite, randomized controlled trial, evaluated the relative and combined efficacy of CBT and selective serotonin reuptake inhibitors (SSRIs) in youth with moder- ate to severe separation anxiety disorder, generalized anxiety disorder, and/or social phobia  Youth participated in CBT, received sertraline or placebo drug alone, or received a combination of sertraline and CBT. At post-treatment evaluation, CBT (60% improved) and sertra- line (55% improved) showed relatively equal efficacy and were superior to placebo (24% improved). The combination of CBT and sertraline (81% improved) had a response rate superior to either modality. All three active treatments were recommended with consideration in each child of the availability of the specific treatment and individual prefer- ences of the family regarding type of treatment, time required, and cost factors Deprima2016 ã   Combined treatment with CBt and SSrI is more effective than treatment with either alone.
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