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Treating Anxiety in Children With Life-Threatening Anaphylactic Conditions
Associate Editor: Michael S. Jellinek, M.D.
CLINICAL PERSPECTIVES
Treating Anxiety in Children With Life-Threatening Anaphylactic Conditions SUNEETA MONGA, M.D.,
AND
Children with anxiety disorders have higher than expected rates of allergies, placing them at risk of severe anaphylactic reactions (Kovalenko et al., 2002). Conversely, children with allergies, especially those associated with severe anaphylaxis (most typically peanut or other severe food allergies or allergies to insect stings), are often anxious and are increasingly coming to the attention of child and adolescent psychiatrists. In the past, this anxiety was considered part of living with a lifethreatening condition, but increasing numbers of these children are being referred for psychiatric assessment because their primary physicians observe anxiety that seems extreme or restricts the child_s life beyond what is considered medically necessary. For the child and adolescent psychiatrist, these children can be challenging to assess and manage for several reasons including diagnostic confusion, heightened parental anxiety, and reluctance on the part of the family to see the issues as psychiatric. This article describes an approach to these challenges, based on our experience managing numerous such children in our specialized Anxiety Disorders Clinic. Although the majority of allergic children who present to an anxiety clinic have significant anaphylactic conditions, sometimes children with even simple allergies may develop anxiety symptoms. Accepted March 10, 2006. Both authors are with the Anxiety and Mood Disorders Program, Division of Child Psychiatry, Department of Psychiatry, University of Toronto. No funding or financial support was provided. All parents of case subjects provided consent for this report to be published. Correspondence to Dr. Suneeta Monga, Department of Psychiatry, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8; e-mail: [email protected]. 0890-8567/06/4508-1007 Ó2006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000222877.66538.f1
J. AM. ACAD. CHILD ADOLE SC . PSYC HIATRY, 45: 8, AUGUST 2006
KATHARINA MANASSIS, M.D.
ASSESSING THE ANXIOUS ALLERGIC CHILD
Children who present with allergies and secondary anxiety require a comprehensive assessment. Use of semistructured interviews such as the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions (Silverman and Albano, 1996) and self-report instruments such as the Multidimensional Anxiety Scale for Children (March et al., 1997) and the Screen for Child Anxiety Related Emotional Disorders (Birmaher et al., 1997) are helpful to clarify diagnostic issues. It is important to ascertain whether the child has heightened anxiety solely in allergy-related situations or meets criteria for another anxiety disorder in addition to the allergy-related anxiety. Given the high comorbidity among anxiety disorders (Bernstein et al., 1996) and between anxiety disorders and anaphylactic conditions (Kovalenko et al., 2002), many children with allergies may have one or more anxiety disorders. A review of the child_s history of anxiety symptoms is helpful in clarifying this question; however, even children without a history of anxiety may be vulnerable to anxieties unrelated to their allergic condition. Equally important is understanding the story about how the allergy was first discovered. When did the first allergic reaction occur? Under what circumstances did it occur? Who was present? These are important questions in understanding underlying issues, feelings, and reactions family members may have about the allergic reactions. The diagnostic difficulties often encountered are exemplified by the case of an 8-year-old boy with a severe peanut allergy who avoided separations from his mother because Bshe knew what was best.[ This behavior was initially seen as being related primarily to his peanut allergy as he articulated fear and worry about being away from his mother in case he had an
1007
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
MONGA AND MANASSIS
allergic reaction. Education about his allergy and cognitive-behavioral therapy focusing on his allergyrelated fears allowed him to become more independent in many situations, but he continued to sleep with his mother and have nightmares about harm coming to her. Only with further assessment did it become clear that he had a DSM-IV separation anxiety disorder in addition to his allergy-related anxiety because his fears of separation were broader based than just related to fear about having an allergic reaction. The focus of cognitive-behavioral therapy shifted to deal with these separation worries with good effect. In addition to interviewing the child and parent(s), it is often helpful to have a discussion with the referring physician regarding his or her concerns. It is important to be familiar with restrictions of age-appropriate activities that are warranted and those that are unwarranted, resulting in unnecessary impairment. For example, although it may be prudent for a child with severe food allergies to avoid meals at the homes of others, avoiding those homes entirely is excessive. PLANNING FOR INTERVENTION
Engaging the child and family is often difficult. Most parents need to be reassured that referral to a child and adolescent psychiatrist does not imply that physicians are dismissing their child_s difficulty or not considering it a real medical problem. It is important to discuss the fact that living with allergic conditions, especially those associated with anaphylaxis, is both frightening and potentially debilitating, and that your goal is to ensure that the child is not suffering more fear or disability than is necessary. Families must have a full understanding of the role of child and adolescent psychiatry before beginning to plan for intervention. Determining the child_s and family_s understanding of the allergic condition and its impact on the child_s life is an important first step in planning for intervention. Detailed information about day-to-day activities at home, at school, and in social situations is important. What is the child allowed or not allowed to do? Are there any situations that children with similar allergies may enter that this child avoids? What preparations have been made for the possibility of an anaphylactic reaction? Older children who may carry an EpiPen need to know how to use it correctly, whereas with younger children, it is important to know whether
1008
individuals with whom the child spends time (i.e., day care or school personnel) know how to deal with a reaction. Such discussion provides both an educational opportunity and a chance to plan initial steps of the intervention. Intervention typically begins with situations in which avoidance is greater than warranted or the child could be given more information or a greater role in managing the problem, thus encouraging mastery and reducing fear. HELPING THE PARENT OF THE ALLERGIC CHILD
Although parents need to provide appropriate reassurance and reminders to their child, their own heightened anxiety may interfere with their child_s need for increased independence, thus restricting their child_s abilities and making them more fearful. Parental anxiety may be related to an anxiety disorder or overprotection of their child and it is important that such parental anxiety is identified and addressed (Manassis, 1996). A goal is to help parents envision their child as a capable, competent individual who is able to handle situations. The importance of decreasing parental anxiety and encouraging parents to model effective and healthy coping strategies for their children is exemplified in the case of a 7-year-old boy with a severe peanut allergy who had begun to restrict his food intake because he was fearful that somehow his food may have become contaminated with peanuts. His food restriction and significant weight loss prompted a referral to our clinic. After a comprehensive assessment, it was clear that it was his mother_s heightened anxiety that was precipitating the boy_s avoidance of food rather than any significant anxiety coming from him. Working with his mother to help her understand the impact her anxiety was having on her son alleviated his excessive worry. His food restriction decreased, and he began to gain weight. Although it is important for parents to help their children plan for situations in which there is potential for allergic exposure, it is equally important that they provide a realistic assessment of the risk. Education about what is developmentally appropriate at different ages is critical. Many parents struggle with the normative need for increased independence and associated risk-taking behavior of adolescence, and helping parents find safe ways of allowing their
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
CLINICAL PERSPECTIVES
adolescent greater autonomy can be useful. Examining and dealing with the effect of a child_s allergic condition on family dynamics are also important. A child with allergies may be receiving undue attention, thus exacerbating sibling rivalry or even causing marital tension. Furthermore, support may be needed to help the parent with an allergic child advocate for his or her child_s safety in school, at extracurricular activities, and with parents of their child_s friends. Parents of allergic children may need help in firmly insisting on what their child requires, while understanding others_ reluctance to change. Support groups or other contact with parents of children with similar conditions can be beneficial in this regard. HELPING THE ALLERGIC CHILD
Children with allergies must have a realistic understanding of their allergy. Physiological symptoms of hyperventilation (i.e., dizziness, paraesthesia) can mimic an allergic reaction. Helping children distinguish between physical symptoms of anxiety and early symptoms of anaphylaxis is important so that allergy medications are not overused in response to anxiety. Using an EpiPen or a sympathomimetic in such a situation only worsens the symptoms. Teaching relaxation such as deep breathing and muscle tension relaxation exercises can be of benefit to even young children. In rare cases, the use of anxiety-reducing medications, such as selective serotonin reuptake inhibitors, may be necessary to help with associated anxiety. One well-informed 14-year-old girl was able to recognize her anxiety symptoms and distinguish them from anaphylaxis. She was able to use a few minutes of Bbox breathing[ instead of reaching for her EpiPen. She counted to four with inspiration, then held her breath to the same count, exhaled to the same count, and waited to the same count before the next breath. Symptoms of hyperventilation subsided when she did so, as did her anxiety. Living with allergies poses different challenges at different ages. Young children may feel overwhelmed with the responsibility of managing an allergy. It is important for them to know with whom to speak for reassurance in settings such as school. With adolescents, their feelings of invincibility may interfere with sensible management of the allergy. Reframing appropriate
J. AM. ACAD. CHILD ADOLE SC . PSYC HIATRY, 45: 8, AUGUST 2006
allergy management as a sign of maturity may be helpful. Strategies to enhance self-esteem and reduce the child_s vulnerability to negative peer pressure are appropriate for all ages. Discussion with the child should focus on realistic evaluation of risk, sensible precautions, and achieving tolerance for a lack of total control in every situation. Supporting children with allergies to return to avoided situations that are relatively safe can be done in a similar manner to graduated exposure to other feared stimuli. Finally, addressing cognitive distortions and anxiety symptoms unrelated to allergy or anaphylaxis is also important in optimizing the child_s functioning. HELPING THE SCHOOL
It is important to inquire about how the school is managing the situation because school responses can alleviate or exacerbate a child_s anxiety. Developing an ongoing dialogue between family and school is important. In some cases, consultation with the school, especially providing education about allergies and the associated anxiety may be of value. Many schools are now Bnut-free[ places, but it is not feasible to ban a long list of foods. Children should not be singled out because of their allergy, and it is critical that school responses such as making a child eat separately be recognized as stigmatizing. Ensuring that school personnel are capable of and willing to deal with allergic reactions and know how to use an EpiPen is also important. CONCLUSIONS
Anxiety and anaphylactic conditions are often comorbid, and many children with allergies develop anxiety symptoms. Conducting a comprehensive assessment and understanding the impact of the allergy are important first steps. Helping parents understand the potential therapeutic role that psychiatric support may play and fully engaging families is imperative. Once a family understands the impact that anxiety may be having on their child_s life, prioritizing symptoms according to which are most impairing is important (Manassis and Monga, 2001). Some symptoms may be more easily alleviated than others, and it is important that treatment start with small but accomplishable goals. As with all therapeutic interventions, it is critical that clear goals and expectations are laid out and that all parties (parent, child, therapist, school personnel) are
1009
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
MONGA AND MANASSIS
working together. Even with such guidelines, such children remain a challenge to treat because some of their anxiety remains about a realistic threat. Disclosure: Dr. Manassis receives royalties from her book Keys to Parenting Your Anxious Child, published through Barron_s Educational Series. Dr. Monga has no financial relationships to disclose. REFERENCES Bernstein GA, Borchardt CM, Perwien AR (1996), Anxiety disorders in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 35:1110Y1119 Birmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J,
McKenzie N (1997), The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry 36:545Y553 Kovalenko PA, Hoven CW, Wu P, Wicks J, Mandell DJ, Tiet Q (2002), Association between allergy and anxiety disorders in youth. Aust N Z J Psychiatry 35:815Y821 Manassis K (1996), Keys to Parenting Your Anxious Child. New York: Barron_s Educational Series Manassis K, Monga S (2001), A therapeutic approach to children and adolescents with anxiety disorders and associated co-morbid conditions. J Am Acad Child Adolesc Psychiatry 40:115Y117 March JS, Parker JDA, Sullivan K, Stallings P, Conners CK (1997), The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry 36:554Y565 Silverman WK, Albano AM (1996), The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. San Antonio, TX: The Psychological Corporation
Hospital Planning for Acts of Terrorism and Other Public Health Emergencies Involving Children S. Chung, M. Shannon Abstract: In today_s world the increased potential of terrorist attacks places unique burdens and consequences on health care workers. Hospitals and hospital personnel must now be prepared to react immediately to such events. They must also implement, in advance, policies to protect their own health care personnel while providing care to victims. In this review, we discuss the four major forms of mass casualty terrorism (biological, chemical, nuclear, and thermomechanical) including clinical signs and symptoms for each, the impact on health care personnel, and special considerations for children. We will then outline key principles of hospital preparation with regard to paediatrics in anticipation of such emergencies. Archives of Disease in Childhood 2005;90:1300 Y1307.
The Pediatrician and Disaster Preparedness David Markenson, MD, Sally Reynolds, MD, Committee on Pediatric Emergency Medicine and Task Force on Terrorism For decades, emergency planning for natural disasters, public health emergencies, workplace accidents, and other calamities has been the responsibility of government agencies on all levels and certain nongovernment organizations such as the American Red Cross. In the case of terrorism, however, entirely new approaches to emergency planning are under development for a variety of reasons. Terrorism preparedness is a highly specific component of general emergency preparedness. In addition to the unique pediatric issues involved in general emergency preparedness, terrorism preparedness must consider several additional issues, including the unique vulnerabilities of children to various agents as well as the limited availability of age- and weight-appropriate antidotes and treatments. Although children may respond more rapidly to therapeutic intervention, they are at the same time more susceptible to various agents and conditions and more likely to deteriorate if they are not monitored carefully. This article is designed to provide an overview of key issues for the pediatrician with respect to disaster, terrorism, and public health emergency preparedness. It is not intended to be a complete compendium of didactic content but rather offers an approach to what pediatricians need to know and how pediatricians must lend their expertise to enhance preparedness in every community. To become fully and optimally prepared, pediatricians need to become familiar with these key areas of emergency preparedness: unique aspects of children related to terrorism and other disasters; terrorism preparedness; mental health vulnerabilities and development of resiliency; managing family concerns about terrorism and disaster preparedness; office-based preparedness; hospital preparedness; community, government, and public health preparedness; and advocating for children and families in preparedness planning. Pediatrics 2006;117(2):e340Y e362.
1010
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
CLINICAL PERSPECTIVES
Treating Anxiety in Children With Life-Threatening Anaphylactic Conditions SUNEETA MONGA, M.D.,
AND
Children with anxiety disorders have higher than expected rates of allergies, placing them at risk of severe anaphylactic reactions (Kovalenko et al., 2002). Conversely, children with allergies, especially those associated with severe anaphylaxis (most typically peanut or other severe food allergies or allergies to insect stings), are often anxious and are increasingly coming to the attention of child and adolescent psychiatrists. In the past, this anxiety was considered part of living with a lifethreatening condition, but increasing numbers of these children are being referred for psychiatric assessment because their primary physicians observe anxiety that seems extreme or restricts the child_s life beyond what is considered medically necessary. For the child and adolescent psychiatrist, these children can be challenging to assess and manage for several reasons including diagnostic confusion, heightened parental anxiety, and reluctance on the part of the family to see the issues as psychiatric. This article describes an approach to these challenges, based on our experience managing numerous such children in our specialized Anxiety Disorders Clinic. Although the majority of allergic children who present to an anxiety clinic have significant anaphylactic conditions, sometimes children with even simple allergies may develop anxiety symptoms. Accepted March 10, 2006. Both authors are with the Anxiety and Mood Disorders Program, Division of Child Psychiatry, Department of Psychiatry, University of Toronto. No funding or financial support was provided. All parents of case subjects provided consent for this report to be published. Correspondence to Dr. Suneeta Monga, Department of Psychiatry, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8; e-mail: [email protected]. 0890-8567/06/4508-1007 Ó2006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000222877.66538.f1
J. AM. ACAD. CHILD ADOLE SC . PSYC HIATRY, 45: 8, AUGUST 2006
KATHARINA MANASSIS, M.D.
ASSESSING THE ANXIOUS ALLERGIC CHILD
Children who present with allergies and secondary anxiety require a comprehensive assessment. Use of semistructured interviews such as the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions (Silverman and Albano, 1996) and self-report instruments such as the Multidimensional Anxiety Scale for Children (March et al., 1997) and the Screen for Child Anxiety Related Emotional Disorders (Birmaher et al., 1997) are helpful to clarify diagnostic issues. It is important to ascertain whether the child has heightened anxiety solely in allergy-related situations or meets criteria for another anxiety disorder in addition to the allergy-related anxiety. Given the high comorbidity among anxiety disorders (Bernstein et al., 1996) and between anxiety disorders and anaphylactic conditions (Kovalenko et al., 2002), many children with allergies may have one or more anxiety disorders. A review of the child_s history of anxiety symptoms is helpful in clarifying this question; however, even children without a history of anxiety may be vulnerable to anxieties unrelated to their allergic condition. Equally important is understanding the story about how the allergy was first discovered. When did the first allergic reaction occur? Under what circumstances did it occur? Who was present? These are important questions in understanding underlying issues, feelings, and reactions family members may have about the allergic reactions. The diagnostic difficulties often encountered are exemplified by the case of an 8-year-old boy with a severe peanut allergy who avoided separations from his mother because Bshe knew what was best.[ This behavior was initially seen as being related primarily to his peanut allergy as he articulated fear and worry about being away from his mother in case he had an
1007
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
MONGA AND MANASSIS
allergic reaction. Education about his allergy and cognitive-behavioral therapy focusing on his allergyrelated fears allowed him to become more independent in many situations, but he continued to sleep with his mother and have nightmares about harm coming to her. Only with further assessment did it become clear that he had a DSM-IV separation anxiety disorder in addition to his allergy-related anxiety because his fears of separation were broader based than just related to fear about having an allergic reaction. The focus of cognitive-behavioral therapy shifted to deal with these separation worries with good effect. In addition to interviewing the child and parent(s), it is often helpful to have a discussion with the referring physician regarding his or her concerns. It is important to be familiar with restrictions of age-appropriate activities that are warranted and those that are unwarranted, resulting in unnecessary impairment. For example, although it may be prudent for a child with severe food allergies to avoid meals at the homes of others, avoiding those homes entirely is excessive. PLANNING FOR INTERVENTION
Engaging the child and family is often difficult. Most parents need to be reassured that referral to a child and adolescent psychiatrist does not imply that physicians are dismissing their child_s difficulty or not considering it a real medical problem. It is important to discuss the fact that living with allergic conditions, especially those associated with anaphylaxis, is both frightening and potentially debilitating, and that your goal is to ensure that the child is not suffering more fear or disability than is necessary. Families must have a full understanding of the role of child and adolescent psychiatry before beginning to plan for intervention. Determining the child_s and family_s understanding of the allergic condition and its impact on the child_s life is an important first step in planning for intervention. Detailed information about day-to-day activities at home, at school, and in social situations is important. What is the child allowed or not allowed to do? Are there any situations that children with similar allergies may enter that this child avoids? What preparations have been made for the possibility of an anaphylactic reaction? Older children who may carry an EpiPen need to know how to use it correctly, whereas with younger children, it is important to know whether
1008
individuals with whom the child spends time (i.e., day care or school personnel) know how to deal with a reaction. Such discussion provides both an educational opportunity and a chance to plan initial steps of the intervention. Intervention typically begins with situations in which avoidance is greater than warranted or the child could be given more information or a greater role in managing the problem, thus encouraging mastery and reducing fear. HELPING THE PARENT OF THE ALLERGIC CHILD
Although parents need to provide appropriate reassurance and reminders to their child, their own heightened anxiety may interfere with their child_s need for increased independence, thus restricting their child_s abilities and making them more fearful. Parental anxiety may be related to an anxiety disorder or overprotection of their child and it is important that such parental anxiety is identified and addressed (Manassis, 1996). A goal is to help parents envision their child as a capable, competent individual who is able to handle situations. The importance of decreasing parental anxiety and encouraging parents to model effective and healthy coping strategies for their children is exemplified in the case of a 7-year-old boy with a severe peanut allergy who had begun to restrict his food intake because he was fearful that somehow his food may have become contaminated with peanuts. His food restriction and significant weight loss prompted a referral to our clinic. After a comprehensive assessment, it was clear that it was his mother_s heightened anxiety that was precipitating the boy_s avoidance of food rather than any significant anxiety coming from him. Working with his mother to help her understand the impact her anxiety was having on her son alleviated his excessive worry. His food restriction decreased, and he began to gain weight. Although it is important for parents to help their children plan for situations in which there is potential for allergic exposure, it is equally important that they provide a realistic assessment of the risk. Education about what is developmentally appropriate at different ages is critical. Many parents struggle with the normative need for increased independence and associated risk-taking behavior of adolescence, and helping parents find safe ways of allowing their
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
CLINICAL PERSPECTIVES
adolescent greater autonomy can be useful. Examining and dealing with the effect of a child_s allergic condition on family dynamics are also important. A child with allergies may be receiving undue attention, thus exacerbating sibling rivalry or even causing marital tension. Furthermore, support may be needed to help the parent with an allergic child advocate for his or her child_s safety in school, at extracurricular activities, and with parents of their child_s friends. Parents of allergic children may need help in firmly insisting on what their child requires, while understanding others_ reluctance to change. Support groups or other contact with parents of children with similar conditions can be beneficial in this regard. HELPING THE ALLERGIC CHILD
Children with allergies must have a realistic understanding of their allergy. Physiological symptoms of hyperventilation (i.e., dizziness, paraesthesia) can mimic an allergic reaction. Helping children distinguish between physical symptoms of anxiety and early symptoms of anaphylaxis is important so that allergy medications are not overused in response to anxiety. Using an EpiPen or a sympathomimetic in such a situation only worsens the symptoms. Teaching relaxation such as deep breathing and muscle tension relaxation exercises can be of benefit to even young children. In rare cases, the use of anxiety-reducing medications, such as selective serotonin reuptake inhibitors, may be necessary to help with associated anxiety. One well-informed 14-year-old girl was able to recognize her anxiety symptoms and distinguish them from anaphylaxis. She was able to use a few minutes of Bbox breathing[ instead of reaching for her EpiPen. She counted to four with inspiration, then held her breath to the same count, exhaled to the same count, and waited to the same count before the next breath. Symptoms of hyperventilation subsided when she did so, as did her anxiety. Living with allergies poses different challenges at different ages. Young children may feel overwhelmed with the responsibility of managing an allergy. It is important for them to know with whom to speak for reassurance in settings such as school. With adolescents, their feelings of invincibility may interfere with sensible management of the allergy. Reframing appropriate
J. AM. ACAD. CHILD ADOLE SC . PSYC HIATRY, 45: 8, AUGUST 2006
allergy management as a sign of maturity may be helpful. Strategies to enhance self-esteem and reduce the child_s vulnerability to negative peer pressure are appropriate for all ages. Discussion with the child should focus on realistic evaluation of risk, sensible precautions, and achieving tolerance for a lack of total control in every situation. Supporting children with allergies to return to avoided situations that are relatively safe can be done in a similar manner to graduated exposure to other feared stimuli. Finally, addressing cognitive distortions and anxiety symptoms unrelated to allergy or anaphylaxis is also important in optimizing the child_s functioning. HELPING THE SCHOOL
It is important to inquire about how the school is managing the situation because school responses can alleviate or exacerbate a child_s anxiety. Developing an ongoing dialogue between family and school is important. In some cases, consultation with the school, especially providing education about allergies and the associated anxiety may be of value. Many schools are now Bnut-free[ places, but it is not feasible to ban a long list of foods. Children should not be singled out because of their allergy, and it is critical that school responses such as making a child eat separately be recognized as stigmatizing. Ensuring that school personnel are capable of and willing to deal with allergic reactions and know how to use an EpiPen is also important. CONCLUSIONS
Anxiety and anaphylactic conditions are often comorbid, and many children with allergies develop anxiety symptoms. Conducting a comprehensive assessment and understanding the impact of the allergy are important first steps. Helping parents understand the potential therapeutic role that psychiatric support may play and fully engaging families is imperative. Once a family understands the impact that anxiety may be having on their child_s life, prioritizing symptoms according to which are most impairing is important (Manassis and Monga, 2001). Some symptoms may be more easily alleviated than others, and it is important that treatment start with small but accomplishable goals. As with all therapeutic interventions, it is critical that clear goals and expectations are laid out and that all parties (parent, child, therapist, school personnel) are
1009
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
MONGA AND MANASSIS
working together. Even with such guidelines, such children remain a challenge to treat because some of their anxiety remains about a realistic threat. Disclosure: Dr. Manassis receives royalties from her book Keys to Parenting Your Anxious Child, published through Barron_s Educational Series. Dr. Monga has no financial relationships to disclose. REFERENCES Bernstein GA, Borchardt CM, Perwien AR (1996), Anxiety disorders in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 35:1110Y1119 Birmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J,
McKenzie N (1997), The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry 36:545Y553 Kovalenko PA, Hoven CW, Wu P, Wicks J, Mandell DJ, Tiet Q (2002), Association between allergy and anxiety disorders in youth. Aust N Z J Psychiatry 35:815Y821 Manassis K (1996), Keys to Parenting Your Anxious Child. New York: Barron_s Educational Series Manassis K, Monga S (2001), A therapeutic approach to children and adolescents with anxiety disorders and associated co-morbid conditions. J Am Acad Child Adolesc Psychiatry 40:115Y117 March JS, Parker JDA, Sullivan K, Stallings P, Conners CK (1997), The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry 36:554Y565 Silverman WK, Albano AM (1996), The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. San Antonio, TX: The Psychological Corporation
Hospital Planning for Acts of Terrorism and Other Public Health Emergencies Involving Children S. Chung, M. Shannon Abstract: In today_s world the increased potential of terrorist attacks places unique burdens and consequences on health care workers. Hospitals and hospital personnel must now be prepared to react immediately to such events. They must also implement, in advance, policies to protect their own health care personnel while providing care to victims. In this review, we discuss the four major forms of mass casualty terrorism (biological, chemical, nuclear, and thermomechanical) including clinical signs and symptoms for each, the impact on health care personnel, and special considerations for children. We will then outline key principles of hospital preparation with regard to paediatrics in anticipation of such emergencies. Archives of Disease in Childhood 2005;90:1300 Y1307.
The Pediatrician and Disaster Preparedness David Markenson, MD, Sally Reynolds, MD, Committee on Pediatric Emergency Medicine and Task Force on Terrorism For decades, emergency planning for natural disasters, public health emergencies, workplace accidents, and other calamities has been the responsibility of government agencies on all levels and certain nongovernment organizations such as the American Red Cross. In the case of terrorism, however, entirely new approaches to emergency planning are under development for a variety of reasons. Terrorism preparedness is a highly specific component of general emergency preparedness. In addition to the unique pediatric issues involved in general emergency preparedness, terrorism preparedness must consider several additional issues, including the unique vulnerabilities of children to various agents as well as the limited availability of age- and weight-appropriate antidotes and treatments. Although children may respond more rapidly to therapeutic intervention, they are at the same time more susceptible to various agents and conditions and more likely to deteriorate if they are not monitored carefully. This article is designed to provide an overview of key issues for the pediatrician with respect to disaster, terrorism, and public health emergency preparedness. It is not intended to be a complete compendium of didactic content but rather offers an approach to what pediatricians need to know and how pediatricians must lend their expertise to enhance preparedness in every community. To become fully and optimally prepared, pediatricians need to become familiar with these key areas of emergency preparedness: unique aspects of children related to terrorism and other disasters; terrorism preparedness; mental health vulnerabilities and development of resiliency; managing family concerns about terrorism and disaster preparedness; office-based preparedness; hospital preparedness; community, government, and public health preparedness; and advocating for children and families in preparedness planning. Pediatrics 2006;117(2):e340Y e362.
1010
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.