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Assessment and management of anxiety in children and youth for family physicians.
- 1. www.pspbc.ca Childhood & Adolescent Anxiety Todd Kettner, Ph.D. R.Psych. Kootenay Lake Hospital April 18, 2013
- 2. Mastery and Confidence Recognizing children’s anxiety and helping them overcome their fears
- 3. We want our patients and our own kids to: Learn well Be socially competent Be successful in life Other wishes for our children and teens?
- 5. Anxiety gets in the way of…
- 6. Learning
- 13. Actions Thoughts Emotions Managing our anxiety and depression AND improving our physical health outcomes
- 14. Prevalence of anxiety disorders in children and adolescents 8% to 20%
- 16. Main Types of Anxiety Disorders Separation Anxiety Panic Disorder Agoraphobia Specific Phobia Social Phobia (Social Anxiety) Obsessive Compulsive Disorder Posttraumatic Stress Disorder Generalized Anxiety Disorder
- 17. Recognizing worry and Anxiety in children and teens
- 22. Emotional Contagion Anxiety and Stress
- 23. peers
- 24. parents
- 25. educators
- 26. Behavioral and environmental interventions are first line for anxiety Strategies for Resilience
- 27. Maintaining Optimal Stress Levels the Yerkes Dodson Law
- 28. Modeling Parent, sibling, peer and health professional modeling
- 29. Relaxation Exercises Progressive Muscle Relaxation Relaxed Breathing Mindfulness
- 31. 31 CN Tower Toronto 533 meters
- 32. 32 ““Look what I just did!”Look what I just did!” MOREMORE IMPORTANTLY:IMPORTANTLY: ““look at who I am…”look at who I am…” BraveBrave AdventuresomeAdventuresome CapableCapable IndependentIndependent StrongStrong
- 34. Gentle Logic
- 35. Mood and Activity Tracking
- 36. Optimism Online iPhone App
- 37. Optimism Online Emailed to Health Care Provider (M.D., Counselor, Psychologist)
- 38. Behavioral Strategies Sleep hygiene Exercise Healthy Eating Social activities: drama, sports, art, music Information Resolve real issues Referral for support
- 39. 40 6 Key Steps 1.Identification of children at risk 2.Useful methods for screening and diagnosis 3.Treatment template 4.Suicide assessment 5.Safety/contingency planning 6.Referral flags Delivery of Effective Treatment for Anxiety Disorders
- 40. 41 Ideal position of first contact health providers Screen usual-risk youth at routine vaccination and start of school visits I. Identification of Children & Youth At Risk
- 41. 42 Anxiety Disorder Identification Table
- 42. 43 Educate about risk Obtain family history “Clinical review” threshold Standing “mental health check-up” Confidentiality, understanding & informed consent A Child is Identified At Risk
- 43. 44 Screen at-risk youth every 6 months 15 minute office/clinical visits every 6 months Standing “Mental Health Check-up” Anxiety symptoms worsen: - During school year -Before first weeks of school -Should not cause severe distress or dysfunction Anxiety symptoms decrease: - In summer months - After first few weeks of school
- 44. 47 Appropriate/Adaptive Anxiety › Short duration (< a few weeks) › Resolves spontaneously, or › Ameliorated by social supported or environmental modification Anxiety Disorder › Long duration (usually lasting many months) › Significantly interferes with functioning › Is often out of sync with magnitude of stressor › Usually require health provider intervention › Diagnosis made using DSM IV-TR criteria Differentiating Distress from Disorder
- 45. 49 Psychotherapeutic Support for Teens (PST) Kutcher Adolescent Depression Scale (KADS) › A screening tool for depression Teen or Child Functional Assessment (TeFA; CFA) › Self-report tool (child depending) › 3 minutes to complete › Assists in evaluating four functional domains of teen mental health School Home Work Friends Tool for Assessment of Suicide Risk (TASR-A) Useful Methods for Screening & Diagnosis
- 46. Use of SCARED in Assessment 50 Anxiety disorder is suspected: if score of 25 or higher 50
- 47. 51 Clinical Approach to Possible Child / Adolescent Anxiety Disorder Visit 1: SCARED Function Use PST & MEP as indicated and as time allows If SCARED is 25 or greater (parent and/or child) or shows decrease in function, review WRP/Stress management strategies and proceed to step 2 in 1-2 weeks. If SCARED < 25 and/or shows no decrease in function, monitor again (SCARED) in a month. Advise to call if feeling worse or any safety concerns. Visit 2: SCARED, Function. Use PST & MEP If SCARED > 25, and shows decrease in function, utilize PST strategies, review WRP and proceed to step 3 within a week. If SCARED <25 and shows no decrease in function, monitor again in a month. Advise to call if feeling worse or any safety concerns. Visit 3: SCARED, Function. Use PST & MEP If SCARED remains > 25 or shows decrease in function, proceed to diagnosis (DSM-IVTR criteria) and treatment If SCARED <25 and shows no decrease in function, monitor again (SCARED) in one month. Advise to call if feeing worse or any safety concerns.
- 48. 54 Screen for depression › Use the Kutcher Adolescent Depression Screen (KADS) Screen for suicide risk › Use the Tool for Assessment of Suicide Risk (TASR) Mental Health Check-ups › Second visit one week from visit Can include TeFA and/or PST (15 – 20 mins) If suicide or depression concerns use KADS & TASR-A › Third visit two weeks later Repeat SCARED and other tools as indicated Make treatment plan as indicated Teen Anxiety Disorder is Suspected
- 49. 55 If Panic Disorder: › Complete Panic Attack Diary › Complete DPG:TD Diary If Social Anxiety Disorder › Complete K-GSADS-A Teen Anxiety Disorder is Suspected
- 50. 56 Don’t Get Overwhelmed Onset of anxiety disorder is not an emergency Onset of anxiety disorder is not an emergency
- 51. 57 Specific Factors › Evidence based treatments: Structured psychotherapies (e.g. Cognitive Behavioral Therapy - CBT) Medication Non-specific Factors › Activities Decrease stress, improve mood and general well-being › Supportive psychological interventions PST in toolkit guide III. Childhood Anxiety Treatment Template
- 52. Enroll the Help of Others Who does the child want to help them? Family Teacher School Counselor Coach Neighbor Babysitter
- 53. 60 Psychotherapy
- 54. 1. Anxious Teen by Holly 2. Learning by woodleywonderworks 3. Social Competence by Purhoor Photograpy 4. Lifelong Success by Jorge Franganillo 5. Amygdala - unknown 6. Spider by Dincordero 7. Spider on eye blog.ericlamb.net 8. Beach by Zanzibar 9. Yerkes Dodson – secretgeek.net 10. Scared Child by Espon Faugstad 11. Distressed Teen in Car by PLCjr 12. Peers by teapics 13. Parents by phub.com.au 14. Educators – apa.org 15. Classroom by horizontal.ingegration 16. Counselor in chair by Parker Knight 17. Staircase by Gwenael Piaser Photos credits (mostly from Flickr)
- 55. Resources Anxiety BC Main Website - FANTASTIC! Guides for relaxed breathing, muscle relaxation, shyness, test anxiety Quick Screening Questionnaires Tools for teaching students with mental health issues
Editor's Notes
- There will be a quiz!
- The Prevalence of Anxiety Among Middle and Secondary School Students in Canada Lucia Tramonte, PhD,1 Doug Willms, PhD2 Can J Public Health 2010;101(Suppl. 3):S19-S22. ABSTRACT Objectives: Adolescents’ anxiety is associated with individual and contextual characteristics. The purpose of this study is to estimate the prevalence of anxiety among adolescent youth in grades 6 to 12 and determine whether it is related to socio-economic status and perceptions of learning skills and challenges. Methods: Nationally representative cross-sectional data from the Tell Them From Me survey – Fall 2008 assessment – were used for this study. Item response theory estimates and a cut-off point for anxiety were developed from six Likert items pertaining to anxiety. Csikszentmihalyi’s theory of flow was applied to create four different combinations of learning processes and students’ skills. Results: Females had a higher prevalence of anxiety than males in both middle and secondary schools. The prevalence of anxiety did not vary substantially among schools for either middle or secondary schools. Less than one half of Canadian students can be considered “in flow”, that is, feeling confident in their skills and challenged in their classes. Students who lacked confidence in their skills were nearly twice as likely to experience anxiety. Conclusion: The relation between students’ skills, the challenges presented to them at school and anxiety problems deserves attention by parents and school staff. Further research could examine the relationship between direct assessments of students’ skills and measures of teaching practices andschool policies. Key words: Anxiety; adolescents; skills; learning challenge; flow; TTFM survey; schools Can J Public Health 2010;101(Suppl. 3):S19-S22.
- http://www.nimh.nih.gov/statistics/1SOC_CHILD.shtml Merkingas KR, he, J, Burstein M, Swanson, SA et. Al. J Am Acad Child Adlesc Psychiatry. 2-1 Oct:49 (10):980-989. 5.5% of 13 to 18 year olds would have Social Anxiety during their teens.
- “ An epidemiologically selected sample of 776 young people living in upstate New York received DSM-based psychiatric assessments in 1983, 1985, and 1992 using structured interviews… In simple logistic models, adolescent anxiety or depressive disorders predicted an approximate 2- to 3-fold increased risk for adulthood anxiety or depressive disorders. ” Arch Gen Psychiatry. 1998 Jan;55(1):56-64. The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Pine DS , Cohen P , Gurley D , Brook J , Ma Y. http://www.ncbi.nlm.nih.gov/pubmed/9435761/ Extrapolating Canadian annual cost of anxiety disorders (direct and indirect) at $65 Billion from DuPont, R. L., DuPont, C. M. & Rice, D. P. (2002). Economic costs of anxiety disorders. In D. J. Stein & E. Hollander (Eds.). Textbook of Anxiety Disorders. American Psychiatric Publishing: Washington, D.C. referenced in Invited Submission to the Standing Senate Committee on Social Affairs, Science and Technology, prepared by the Anxiety Disorders Association of Canada/Association Canadienne des Troubles Anxieux, June 2003. http://www.anxietycanada.ca/english/pdf/kirby.pdf This submission also states that anxiety disorders are the most common mental health problems among Canadians with a 12% one year prevalence and >25% lifetime prevalence.
- Approximately 40% of most psychological characteristics (anxious/easygoing, optimistic/pessimistic) are genetically related. Makes sense when we think of heritability of height, set-point for body weight, propensity towards heart disease and towards alcohol misuse. Huge amount of variance left for modeling, socialization, and learning.
- Relaxed breathing exercise Or Progressive muscle relaxation
- Psychiatr Clin North Am. 2009 September; 32(3): 483–524. doi: 10.1016/j.psc.2009.06.002 Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V Katja Beesdo, PhD, a,* Susanne Knappe, Dipl-Psych, a and Daniel S. Pine, MD b http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3018839/ Prevalence was found to be 15 to 20%. Other studies have shown somewhat lower prevalence rates.
- Serotonin, Glutamate, Dopamine, GABA, Aceytocholine http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847471/ Neural Plast. 2007; 2007: 78171. Published online 2007 January 10. doi: 10.1155/2007/78171 PMCID: PMC1847471 Neurobiology of Memory and Anxiety: From Genes to Behavior Allan V. Kalueff * Adrenalin e and cortisol are also involved in motor and muscle responses to stress and anxiety, thus, to be simplistic, exercise helps “flush” these neurotransmitters out of the
- Think of a discuss a student, using a pseudonym, in groups with your school colleagues. Who is one of the most visibly anxious students you’ve taught? How does this student view the world? What behaviors are evident? Who is on of the most quietly and unobtrusively anxious students you’ve taught? How does this student view the world? What behaviors are evident?
- Crying Muscle tension Headaches Stomach aches Nail biting Picking at skin Fidgetiness Increased heart rate Sweating Shallow breathing Dizziness Fatigue Disrupted sleep Feeling of choking Feeling nauseas Tightness in chest Trembling Numbness or tingling sensations Extreme anxiety can lead to hair loss, trichotillomania, rashes
- Difficulty concentrating Fear of illness – “I must be having a heart attack” Fear of losing it – “I’m going crazy” Fear of abandonment – “My girlfriend might leave me” Fear of failure – “I’m going to flunk the exam” Fear of rejection – “Nobody will like me at Trafalgar” Fear of fear – “I know I’ll have a panic attack if I go the Bombers basketball game” Fear of criticism – “My teacher won’t like the story I wrote.” “My parents will think the money they spent on my new hockey equipment was a complete waste” Fear of success – “I don’t want to try out for choir because my friends think I have a good voice and if I made it, then I’d have to be on stage” Fear of death Fear of loss Fear of catastrophy if something isn’t in the right order or sequence
- AVOIDANCE School refusal Skipping class Dropping out of sports Alcohol, pot, other drugs to avoid anxiety or other challenging emotions “ Losing homework” Not wanting friends over Refusal of overnights at friends, relatives, school trips, summer camps Tantrums Yelling Sometimes even physical aggression – “had to drag him kicking and screaming”
- Emotional Contagion (Studies in Emotion and Social Interaction) [Paperback] Elaine Hatfield , John T. Cacioppo Richard L. Rapson 1993 Popularized in Malcolm Gladwell’s 2002 Bestseller “The Tipping Point.” Examples: EMTs and ER nurses. Teachers who talk quieter and more calmly in order to “infect” their loud and boisterous students with their calm and quiet.
- Fast Facts About Adolescent Anxiety Onset of anxiety can lead to poor economic/vocational/interpersonal outcomes and increased morbidity (comorbid anxiety disorders, major depressive disorder, and alcohol and drug abuse) and mortality (suicide). Chronic anxiety can lead to poorer health outcomes and increased cardiovascular morbidity and mortality. Effective treatments that can be provided by first contact health providers are available Early identification and early effective treatment can decrease short-term morbidity and improve long-term outcomes (including decreased mortality)
- Effective treatment for Anxiety can be appropriately delivered to children by primary health care providers. Here ’ s how… Key Steps 1. Identification of children at risk for anxiety disorders 2. Useful methods for screening and diagnosis of anxiety in the clinical setting 3. Treatment template 4. Suicide assessment 5. Safety/contingency planning 6. Referral flags
- Identification of Children at Risk for Anxiety Disorder First contact health providers are in an ideal position to identify youth who are at risk to develop an anxiety disorder. As children generally visit health care providers infrequently, screening should be applied to both high risk and usual risk youth at scheduled clinical contacts. Routine vaccination and start of school visits provide an excellent opportunity to screen for mental health. Next Page: The following table has been compiled from the scientific literature and can be used by a health provider to identify those children who should be periodically monitored for onset of anxiety.
- Identification of Children at Risk for Anxiety Disorder Table: Anxiety Disorder in Youth Identification Table The following table has been compiled from the scientific literature and can be used by a health provider to identify those children who should be periodically monitored for onset of anxiety.
- What to do if a child is identified as at risk? A. Educate about risk Even with numerous risk factors, an anxiety disorder is not inevitable but it may occur. If it occurs, the sooner it is diagnosed and effectively treated, the better. It is more helpful to check out the possibility that problems may be anxiety related than to ignore symptoms if they occur. Primary care health professionals who provide services to families are well placed to educate parents about potential risks for anxiety in their children. Family members (youth included at an appropriate age) should be made aware of their familial risk for mental disorders the same way they are made aware of their family risk for other disorders (e.g.: heart disease, breast cancer, etc.). Click here to access resources for parents about childhood anxiety. SIDE NOTE: “Many school districts throughout BC are offering the FRIENDS program, which is a school-based early intervention and prevention program, proven to be effective in building resilience and reducing the risk of anxiety disorders in children.” More information about the program can be obtained at _________________________. “ Many school districts throughout BC are offering the FRIENDS program, which is a school-based early intervention and prevention program, proven to be effective in building resilience and reducing the risk of anxiety disorders in children.” More information about the program can be obtained at http://www.mcf.gov.bc.ca/mental_health/friends.htm B. Obtain and record a family history of mental disorder Primary health care providers should take and record a family history of mental disorders (including substance abuse) and their treatment (type, outcome) as part of their routine history for all patients. This will help identify young people at risk on the basis of family history. C. Agree on a “ clinical review ” threshold If a child is feeling very anxious, distressed, sad and/or irritable, and they are not functioning as well (avoidance, poor coping) at home, school or socially, for more than several weeks, this should trigger an urgent clinical review. The onset of suicidal ideation, a suicide plan or acts of self-harm must trigger an emergency clinical review. D. Arrange for a standing “ mental health check-up ” These could be 15 minute office/clinical visits every 6 months during the childhood years in which a clinical screening for anxiety is applied for at risk youth. Anxiety symptoms are generally worse during the school year and better in the summer months. Some increased anxiety in the few weeks before school is seen in most children, but should not cause severe distress or dysfunction and should improve within the first few weeks of school. The Screen for Child Anxiety Related Emotional Disorders (SCARED) is a 41 item anxiety screen with child and youth self report as well as parent report found in links below. One potentially useful approach is to ask the parent to bring in the youth ’ s school reports. Check for a pattern of declining grades, frequent late arrival or frequent absences. These patterns may indicate a mental health problem. Children with anxiety also report a lot of physical complaints, particularly on school mornings or before an event. Children who have frequent stomach aches and nausea and/or headaches on school mornings or at the end of the weekend, but have no evidence of being sick (no fever, not vomiting) could have symptoms related to anxiety. These symptoms usually improve once they are in school for the day, but may also occur in school throughout the day in new situations and in response to stressors. It is useful to ask parents about how their child compares to other children of a similar age regarding such issues as: being away from the parent; need for reassurance; comfort with exploring novel situations; physical complaints. If their child shows substantially more anxiety type symptoms it is useful to assess for the presence of an anxiety disorder or other mental health problem. E. Confidentiality and understanding that treatment is by informed consent Part of the education should include a discussion about risk and benefits in proceeding with anxiety treatment, as well as confidentiality and informed consent to treatment for both the child and the parents. For parents, knowing what they can expect in terms of being informed about their child may help them feel more comfortable about how treatment will occur if it becomes necessary.
- D. Arrange for a standing “ mental health check-up ” These could be 15 minute office/clinical visits every 6 months during the childhood years in which a clinical screening for anxiety is applied for at risk youth. Anxiety symptoms are generally worse during the school year and better in the summer months. Some increased anxiety in the few weeks before school is seen in most children, but should not cause severe distress or dysfunction and should improve within the first few weeks of school. Next Page: The Screen for Child Anxiety Related Emotional Disorders (SCARED) is a 41 item anxiety screen with child and youth self report as well as parent report found in links below. One potentially useful approach is to ask the parent to bring in the youth ’ s school reports. Check for a pattern of declining grades, frequent late arrival or frequent absences. These patterns may indicate a mental health problem. Children with anxiety also report a lot of physical complaints, particularly on school mornings or before an event. Children who have frequent stomach aches and nausea and/or headaches on school mornings or at the end of the weekend, but have no evidence of being sick (no fever, not vomiting) could have symptoms related to anxiety. These symptoms usually improve once they are in school for the day, but may also occur in school throughout the day in new situations and in response to stressors. It is useful to ask parents about how their child compares to other children of a similar age regarding such issues as: being away from the parent; need for reassurance; comfort with exploring novel situations; physical complaints. If their child shows substantially more anxiety type symptoms it is useful to assess for the presence of an anxiety disorder or other mental health problem.
- Screening Questions for Anxiety and OCD in a Primary Care Setting (For parents, but can include older children) • Does your child worry more than other children you know? • Do you need to reassure your child excessively and about the same things over and over? • Does your child have difficulty separating from you to go to school or over to a friend ’s house? • What does your child worry about? • Does worry/anxiety ever stop your child from doing something new or an activity they would enjoy? • Does your child get a lot of stomach aches and headaches? When do they occur? • Are there any events/activities/people/places that your child avoids because of fear or anxiety?
- Arrange for standard “ mental health checkup ” It is useful to ask parents about how their child compares to other children of a similar age regarding such issues as: being away from the parent; need for reassurance; comfort with exploring novel situations; physical complaints. If their child shows substantially more anxiety type symptoms it is useful to assess for the presence of an anxiety disorder or other mental health problem.
- 2. Useful Methods for Screening & Diagnosis Anxiety for some children may only occur in specific situations or environments and for others can be more generalized. It is important to distinguish between appropriate and adaptive anxiety and stress, and an anxiety disorder. An anxiety disorder is of long duration (usually lasting for many months), significantly interferes with functioning, and is often out of synch with the magnitude of the stressor. Anxiety disorders will usually require health provider intervention, while stress induced anxiety is usually of short duration (less than a couple of weeks) and is likely to resolve spontaneously or be substantially ameliorated by social support or environmental modification alone. Diagnosis of Anxiety Disorders in children is currently made using DSM IV-TR criteria .
- Handout
- Psychotherapeutic Support for Teens (PST) * The PST based supportive rapport model should be used at every visit as a framework within which you can structure your interaction with your teenage patient. Kutcher Adolescent Depression Scale (KADS) The 6 item KADS (Kutcher Adolescent Depression Scale) and 18 item K-GSADS-A (Kutcher Generalized Social Anxiety Disorder Scale for Adolescents) may be used by clinicians. Clinicians who wish to use the KADS or K-GSADS-A in their work are free to apply it using the directions accompanying the scale. Clinicians who would like training on the KADS, K-GSADS-A, and the tool for assessing teen suicide risk (TASR) are encouraged to contact the office of the Sun Life Financial Chair in Adolescent Mental Health at (902) 470-6598.
- Use of the SCARED in the assessment of Anxiety Disorder in Children The SCARED is a self-report instrument that can be helpful in the diagnosis and monitoring of anxiety disorders in children. Information on scoring of the SCARED is found on the instrument itself. An anxiety disorder in a child should be suspected if a SCARED score of 25 or higher is found at time of evaluation. A high SCARED score (25 or higher) does not mean that a patient has a clinical anxiety disorder; it simply suggests a possible diagnosis and the score/items can be used as a guide for further questioning. Anxiety Disorder is Suspected If a SCARED score of 25 or higher is found during screening the following is suggested: Discussion about important issues/problems in the child ’ s life/environment. Ask about school, home, activities, friends and family. Anxiety disorders interfere in normal developmental tasks and functioning. Supportive, non-judgmental problem solving assistance – “ supportive strategies ” for parents. A child ’ s anxiety can significantly impact the family. Parents will often accommodate their child ’ s anxiety in order to maintain overall family functioning. General self-care of parent and child is important as this decreases overall stress. Strongly encourage and prescribe: regular and adequate sleep; physical activity; healthy eating; positive social activities and supports for primary caregiver.
- Visit 1, 2 & 3: Clinical Approach to Possible Anxiety Disorder in Children in Primary Care Setting * Alternatively, some health care providers may choose to “flush out” the child’s entrance complaint, determine if any safety or immediate referral issues are present (for example: not eating; not leaving house; suicidal – see below for more details), provide the SCARED and CESDC to the parent and child to complete and then schedule a longer visit in the near future to complete the assessment. The key issue here is to ensure patient safety while providing a long enough assessment period to allow for distress to be better differentiated from disorder.
- 2 nd Mental Health Checkup (1 – 2 wks following initial visit) More comprehensive mental health checkup Schedule a more comprehensive mental health check-up about 1-2 weeks following the initial visit. Include a functional assessment This second visit could also include a functional assessment Review DSM criteria Review of the DSM criteria Supportive education and discussion with parents Supportive education and discussion with parent(s) about possible strategies to deal with problems such as school attendance related anxiety.
- 3 rd Mental Health Checkup (2 – 3 wks following 2 nd visit) Repeat SCARED Schedule a third visit 2-3 weeks later to check in, repeat SCARED, and if the anxiety symptoms still persist, review diagnostic criteria (DSM) and make treatment plan as indicated. Repeat CES-DC If concerns about depression persist then the CES-DC should be utilized again. Childhood depression is uncommon and the treatment of depressed children is best applied within a specialty mental health setting or with the guidance of a child psychiatrist. If depression is strongly suspected in a child, referral should be made to the appropriate specialty service while treatment for the anxiety disorder is instituted.
- Teen Anxiety Disorder is Suspected (cont ’d) Screen for depression- use the Kutcher Adolescent Depression Screen (KADS) Screen for suicide risk - use the Tool for Assessment of Suicide Risk (TASR) Mental health check-up about 1 week from visit. This visit could also include the TeFA and/or PST so schedule about 15-20 minutes. If concerns about depression or suicide then KADS and TASR should be utilized. A third visit 2 weeks later to check in, repeat SCARED and other appropriate screens, and make treatment plan as indicated.
- Don ’ t get overwhelmed! Use clinical tools There are a number of easy to use clinical tools to assist you with diagnosis and treatment of childhood anxiety disorders. Some clinicians may prefer to integrate the details found in the tools into their assessment interviews rather than use the tools separately. 3 – 15 minute office visits A full assessment of anxiety can be completed in three 15 minute office visits using the suggested framework above. If concern for depression and/or suicide screen at each visit If there is concern about depression and/or suicide risk, then these screens should be done at each visit. Onset of anxiety disorder is not an emergency Remember, the onset of an anxiety disorder in children is not an emergency. It is reasonable to conduct your clinical evaluation over a period of time (such as described above). This will allow you to obtain a clear picture of what is happening and will allow you to determine if the non-specific interventions you suggested were enough to address the problems. Persistent signs and symptoms associated with a negative impact on functioning and little or no response to non-specific interventions is diagnostically indicative of an anxiety disorder.
- Childhood Anxiety Treatment Template Treatment of childhood anxiety includes both specific and non-specific factors. Specific Factors Specific factors are evidence based treatments for anxiety disorders and include: structured psychotherapies (Cognitive Behaviour Therapy (CBT)) and medication. Non-specific Factors Non-specific factors include those activities which decrease stress, improve mood and general well-being PLUS supportive psychological interventions (use the PST in the toolkit to guide you) given by the health provider.
- Enrolling the Help of Others Children need support to reduce stress A child needs the support of their family to help in stress reducing strategies. If this is not possible within the family, ask if there are others (extended family, family friends) who could be involved in helping with stress reducing strategies. Other significant persons in the child ’s life may also be able to play a role (e.g. teacher, school counsellor, coach, neighbour, babysitter, etc.) It ’s a good idea to ask the child about who they want to help them, and to help get the family involved. Inquire about school performance Always inquire about school performance. Some children with anxiety may need extra educational interventions or a modified academic load, and school stress can make anxiety worse. Discussion with a school counselor (with permission from the patient) is recommended.
- Parent/Caretaker Involvement Remember that parental or caretaker involvement is necessary during the assessment and treatment of anxiety in a child. Whenever possible, information about the child ’s emotional state and function should be obtained from the parent or caretaker. It is not uncommon for children and parents/caretakers to have different opinions about the mental state and activities of the youth. When this occurs, joint discussion of the issue will be necessary for clarification and optimal intervention planning. However, it is essential to ensure that appropriate confidentiality is being maintained during this process.
- Psychotherapy First line treatment Cognitive Behavioral Therapy (CBT) Barriers to CBT Long waiting lists, psychotherapies not available Family cannot access services If barriers to CBT Implement medications, wellness enhancing activities and supportive rapport Monitor outcome regularly: refer if no change or worse Standard anxiety disorder treatment guidelines recommend the use of cognitive behavioural therapy (CBT) as first line treatment for children with anxiety disorders Cognitive Behavioural Therapy (CBT) is a strong evidence based practice whereby children often have improvement in their anxiety with CBT alone, and do not require medication intervention. However, if waiting lists for these therapies are long, these psychotherapies are not available, or the family is not able to access services, treatment may need to be implemented with medications, wellness enhancing activities and supportive rapport.
- ***** HANDOUT Suggested Websites • Resources for youth and families can be found on Anxiety BC website - www.anxietybc.com • Treatment guideline algorithm for health care providers in treatment of anxiety disorders and depressive disorders in youth - www.bcguidelines.ca/gpac/guideline_depressyouth.html#algorithm • American Academy of Child and Adolescent Psychiatry - www.aacap.org • Sun Life Financial Chair in Adolescent Mental Health – www.teenmentalhealth.org