Childhood & Adolescent Anxiety

Fast Facts About Anxiety in Children 2 Childhood = toddlerhood to puberty (2-12 yrs) 2

3  Different anxiety disorders throughout life › e.g. Separation anxiety disorder  A common childhood anxiety disorder  Can be a precursor for other anxiety disorders and depression in adolescents and young adults  Anxiety disorder can lead to: › Poor economic, vocational, interpersonal outcomes › Increased morbidity:  comorbid anxiety disorders, major depressive disorder, and alcohol and drug abuse) and mortality (suicide)  Significant negative impact on family, social and school functioning  Chronic anxiety disorder can lead to: › Poorer physical health outcomes › Increased cardiovascular morbidity and mortality in mid-life Fast Facts About Anxiety in Children

4  Adolescence = puberty to mid-twenties  Anxiety disorders affect 8-10% of young people  Most anxiety disorders begin in childhood & adolescence  Anxiety disorders are often hereditary  Many individuals with anxiety disorders experience physical symptoms that they present to their health care provider.  An individual can be affected by different anxiety disorders throughout their lifespan. › Separation anxiety disorder can be a precursor for other anxiety disorders in adolescents and young adults. › Social Anxiety Disorder; Panic Disorder = teen onset Fast Facts About Anxiety in Adolescents

5  Effective treatments for most young people with an anxiety disorder can be provided by first contact health providers  Always assess parents for the presence of an anxiety disorder if a diagnosis of anxiety disorder or depression has been made in a child  If a parent has an anxiety disorder or depression, successful treatment of child will include effective treatment for the parent Fast Facts About Anxiety in Adolescents

6 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

7  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

8 Anxiety Disorder Identification Table

9  Educate about risk  Obtain family history  “Clinical review” threshold  Standing “mental health check-up”  Confidentiality, understanding & informed consent A Child is Identified At Risk

10 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 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 Anxiety symptoms decrease: - In summer months - After first few weeks of school

11  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 Additional Questions for Child Anxiety & OCD

12  Ask parents, “How does your child compare to other children of similar age regarding such issues as… › Being away from parent? › Need for reassurance? › Comfort with exploring new situations? › Physical complaints?  If child shows substantially more anxiety type symptoms, assess for presence of anxiety disorder or other mental health problem. Standing “Mental Health Check-up”: Screening

13 D. Standing “Mental Health Check-up” 13 Standing “Mental Health Check-up” School reports and patterns Physical complaints

14  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

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16  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

Use of SCARED in Assessment 17 Anxiety disorder is suspected: if score of 25 or higher 17

18 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.

19 2nd Mental Health Checkup (1 – 2 wks following initial visit)

20  Repeat SCARED › If symptoms persist review DSM-IV criteria. › Make a treatment plan for anxiety disorder  If concerns of depression persist › Treatment is best applied in a specialty mental health setting or with guidance of child psychiatrist › If depression suspected, refer to appropriate service, but start treatment for anxiety disorder. 3rd Mental Health Checkup (2 – 3 wks following 2nd visit)

21 SCARED score is 25 or higher  Discuss issues/problems in the youth’s life/environment.  Teen Functional Activities Assessment (TeFA)  Supportive, non-judgmental problem solving assistance › Psychotherapeutic Support for Teens (PST) as a guide  Strongly encourage and prescribe:  Exercise  Regulated sleep  Regulated eating  Positive social activities Teen Anxiety Disorder is Suspected

22  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

23  If Panic Disorder: › Complete Panic Attack Diary › Complete DPG:TD Diary  If Social Anxiety Disorder › Complete K-GSADS-A Teen Anxiety Disorder is Suspected

24 Don’t Get Overwhelmed Onset of anxiety disorder is not an emergency Onset of anxiety disorder is not an emergency

25  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

Enroll the Help of Others Who does the child want to help them? Family Teacher School Counselor Coach Neighbor Babysitter

27  Essential for information on child’s emotional state and function  Differing opinions between child and parent › Joint discussion to clarify and appropriately plan  Ensure confidentiality throughout process Parent/Caretaker Involvement

28 Psychotherapy

29 Anxiety BC website Youth anxiety/depression treatment guideline algorithm American Academy of Child and Adolescent Psychiatry Teen Mental Health Suggested Websites