1. Childhood & Adolescent Anxiety disorders
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Childhood & Adolescent Anxiety disorders

2. Fast Facts About Anxiety in Children
 Childhood = toddlerhood to puberty (2-12 years of age)
 Anxiety is ubiquitous, appropriate in new situations, and in response to stressors
Arvind Balarvaman
Fast Facts about Anxiety in Children
Childhood is generally considered to be the years from toddlerhood to puberty (~2-12 years of age).
Anxiety is ubiquitous and is developmentally appropriate in new situations and in response to stressors (such as first day at school, some separations from parents, etc.).
Normal or expected anxiety must be differentiated from an anxiety disorder.
Anxiety disorders affect 8-10% of children.
Most anxiety disorders begin in childhood and adolescent years.
Many individuals with anxiety disorders complain primarily of physical symptoms and first present to their family physician or health care provider with a “physical” concern.
 Normal/expected anxiety vs. anxiety disorder
 Anxiety disorders affect 8-10% of children
 Most anxiety disorders begin in childhood and adolescent years
 Anxiety disorders often present with physical symptoms 2

3. Fast Facts About Anxiety in Children
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 (cont’d)
An individual can be affected by different anxiety disorders throughout their life course. Separation anxiety disorder is a common childhood anxiety disorder and can be a precursor for other anxiety disorders and depression in adolescents and young adults.
Onset of an anxiety disorder 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).
Anxiety disorders in children can have a significant impact on family, social and school functioning.
Chronic anxiety disorder can lead to poorer physical health outcomes and increased cardiovascular morbidity and mortality in mid-life.

4. Fast Facts About Anxiety in Adolescents
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 Adolescent Anxiety
Adolescence comprises the years from puberty to the mid-twenties
Anxiety disorders affect 8-10% of adolescents
Most anxiety disorders begin in childhood and adolescent years.
Anxiety disorders are hereditary
Many individuals with anxiety disorders experience physical symptoms and present to their family physician or health care provider.
An individual can be affected by different anxiety disorders throughout their lifespan. Separation anxiety disorder is a common childhood anxiety disorder and can be a precursor for other anxiety disorders in adolescents and young adults.

5. Fast Facts About Anxiety in Adolescents
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 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)

6. Delivery of Effective Treatment for Anxiety Disorders
6 Key Steps
Identification of children at risk
Useful methods for screening and diagnosis
Treatment template
Suicide assessment
Safety/contingency planning
Referral flags
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

7. I. Identification of Children & Youth At Risk
Ideal position of first contact health providers
To identify youth at risk to develop an anxiety disorder.
Screen usual-risk youth at routine vaccination and
start of school visits
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.
ID: stockxchng

8. Anxiety Disorder Identification Table
Significant
Risk Affect
Moderate
Possible “group” Identifiers
(not causal for anxiety disorder; may identify factors related to adolescent onset anxiety)
Family history of anxiety disorder
2. Severe and/or persistent environmental stressors in early childhood
Children with shy, inhibited and/or cautious temperament (innate personality type)
Family history of a mental illness (mood disorder, substance abuse disorder)
Have experienced a
traumatic event
School failure or learning difficulties
Socially or culturally isolated
Bullying (victim and/or perpetrator)
Gay, Lesbian, Bi-sexual, Transsexual
Substance abuse and mis-use (cigarettes & alcohol)
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.

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

10. Educate About Risk Not inevitable, but…
Even with numerous risk factors, mental health disorder is not inevitable, but may occur.
The sooner diagnosed and treated the better
More helpful to check possibility than ignore symptoms
Educate Parents
Educate about potential risks for anxiety in their children
Create awareness of familial risk for mental disorders
Entire family should be made aware
Youth awareness at appropriate age.
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.

11. Obtain Family History Part of routine for all patients Include:
Mental disorders
Substance abuse
Treatment type
Treatment outcome
Helps identify youth at risk
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.

12. Standing “Mental Health Check-up”
Screen at-risk youth every 6 months
15 minute office/clinical visits every 6 months
Anxiety symptoms worsen:
- During school year
Before first weeks of school
Should not cause severe distress or dysfunction
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.
Anxiety symptoms decrease:
- In summer months
- After first few weeks of school

13. Additional Questions for Child Anxiety & OCD
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
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?

14. Additional Questions for Child Anxiety & OCD
Describe your child’s sleep routine (where, when, quality, night routine)?
Has your child ever missed school or had to come home from school early due to anxiety?
Has your child ever had an anxiety attack where their heart raced, they couldn’t catch their breath, they felt dizzy or lightheaded and thought they might be dying?
Does your child have ideas or images that come into their mind and they can’t control them?
Does your child have any routines or behaviours they need to do that don’t seem to make sense or be goal directed? (e.g. ask about germs/dirt worries and handwashing/cleaning, also counting and checking rituals)
What would be different for your child and for your family if they didn’t have anxiety/worry?
Screening Questions for Anxiety and OCD in a Primary Care Setting
(For parents, but can include older children)
• Describe your child’s sleep routine (where, when, quality, night routine)?
• Has your child ever missed school or had to come home from school early due to anxiety?
• Have your child ever had an anxiety attack where their heart raced, they couldn’t catch their
breath, they felt dizzy or lightheaded and thought they might be dying?
• Does your child have ideas or images that come into their mind and they can’t control them?
• Does your child have any routines or behaviours they need to do to that don’t seem to make
sense or be goal directed? (e.g. ask about germs/dirt worries and handwashing/cleaning,
also counting and checking rituals)
• What would be different for your child and for your family if they didn’t have anxiety/worry?

15. Standing “Mental Health Check-up”: Screening
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.
D. 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.

16. D. Standing “Mental Health Check-up”
School reports and patterns
- Difficulty concentrating
- Declining grades
- Frequent late arrival
- Frequent absences
Physical complaints
- Stomach aches
- Nausea
- Headaches
- School mornings/end of weekend
D. Arrange for standard “mental health checkup”
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.
ID stockxchng 16

17. Education About Anxiety Disorders
Education should include discussion of:
Risks and benefits of anxiety treatment
Confidentiality and informed consent to treatment
For both child and parents
Explain to parents
What they might expect their child to feel like
How the treatment will occur if it is necessary
Expected outcomes, side-effects and time lines
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.

18. Differentiating Distress from Disorder
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-V criteria
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-V criteria.
Tina Phillips freedigitalphotos.net

19. DISTRESS DISORDER Usually associated with an event or series of events
Functional impairment is usually mild
Transient – will usually ameliorate with change in environment or removal of stressor
Professional intervention not usually necessary
Can be a positive factor in life – person learns new ways to deal with adversity and stress management
Social supports such as usual friendship and family networks help
Counseling and other psychological interventions can help
Medications should not usually be used
* DSM- Diagnostic and Statistical Manual
* ICD – International Classification of Diseases
May be associated with a precipitating event, may onset spontaneously, often some anxiety symptoms predating onset of disorder
Functional impairment may range from mild to severe
Long lasting or may be chronic, environment may modify but not ameliorate
External validation (syndromal diagnosis: DSM*/ICD*)
Professional intervention is usually necessary
May increase adversity due to resulting negative life events (e.g.: anxiety can lead to school refusal and avoidance of normal developmental steps like independent activities with peers)
May lead to long term negative outcomes (social isolation, low self esteem, lack of independence, depression, substance abuse, etc.)
Social supports and specific psychological interventions (counselling, psychotherapy) are often helpful
Medications may be needed but must be used properly

20. Useful Methods for Screening & Diagnosis
Screen for Child Anxiety Related Emotional Disorders (SCARED)
41 item anxiety screen and monitoring tool
Child and youth self report
Parent report
Provide family with feedback on test results
Screen highly anxious youth for depression
Anxiety disorders increase risk of developing depression; more common to develop in adolescents
Important risk factor for self harm and suicide
2. Useful Methods for Screening and Diagnosis
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.
A self-test with good sensitivity and specificity should be used. It is helpful to have parent report as well, particularly when working with children. The SCARED has both a SCARED child self report and a SCARED parent report and can be used by clinicians at no cost. This instrument has been studied in clinical and population samples and demonstrated excellent sensitivity and specificity. Ensure that you provide the child and family with feedback on their results.
It is helpful to evaluate highly anxious children for depression as well, as anxiety disorders increase the risk of developing depression. The Center for Epidemiological Studies Depression Scale for Children (CES-DC) is a useful self report tool that is relatively easy to use and is available no cost. Results should be interpreted in the context of the child, taking into consideration other clinical factors such as history and presentation. Depression in children is not as common as in adolescents, but can occur and is an important risk factor for self harm and suicide.

21. Useful Methods for Screening & Diagnosis
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)
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)

22. Use of SCARED in Assessment
Anxiety disorder is suspected:
if score of 25 or higher
Use score items as a guide for further questioning
Scoring information can be found in the toolkit
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.

23. Child / Teen Anxiety Disorder is Suspected
SCARED score is 25 or higher
Discuss issues/problems in child’s life/environment
Ask about school, home, activities, friends & family
Anxiety disorders interfere with normal development tasks and functioning
Offer supportive non-judgmental problem solving assistance
Encourage general self-care of parent and child
Decreases stress
Regular, adequate sleep
Consistent physical activity
Healthy eating
Promote positive social activities
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.

24. Child Anxiety Disorder is Suspected
Screen for:
Depression & Suicide risk
Screen for suicide as appropriate
“When you feel sad or scared, do you ever think about not wanting to be alive?”
Ask parent to keep a diary
Record concerns
Signs and symptoms child expresses
How severe, impact of severity and response to problem
Schedule 2nd mental health checkup in 1 – 2 wks
If Anxiety Disorder is Suspected (cont’d)
Screen for depression- use the Center for Epidemiological Studies Depression Scale for Children (CES-DC) (slide 20)
Screen for suicide risk
Screen for suicide risk as appropriate. It is important to ask these questions in a developmentally appropriate way. For example, “When you feel sad or scared, do you ever think about not wanting to be alive?”
Ask parent to keep a diary
Ask the parent to keep a diary of their concerns. They should record the signs and symptoms that their child expresses, how severe they seem, what impact they have (for example, was the tummy ache so strong that the child did not go to school) and what their response to the problem was.
Schedule a 2nd mental health checkup in 1 – 2 wks

25. 2nd Mental Health Checkup (1 – 2 wks following initial visit)
More comprehensive
Include a functional assessment
Review DSM - V criteria
Supportive education and discussion with parents
Strategize with parents to deal with problems related to anxiety
2nd 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.

26. 3rd Mental Health Checkup (2 – 3 wks following 2nd visit)
Repeat SCARED
If symptoms persist review DSM-V 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)
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.

27. Teen Anxiety Disorder is Suspected
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
The SCARED is a self-report instrument that can be helpful in the diagnosis and monitoring of anxiety disorders in young people. Information on scoring of the SCARED is found on the instrument itself.
An anxiety disorder in an adolescent should be suspected if a SCARED score of 25 or higher is found at screening.
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.
If a SCARED score of 25 or higher is found during screening the following is suggested:
Discussion about important issues/problems in the youth’s life/environment. Complete or use the Teen Functional Activities Assessment (TeFA) to assist in determining the impact of the depression on the teens functioning.
Supportive, non-judgmental problem solving assistance – “supportive rapport” (use the Psychotherapeutic Support for Teens (PST) as a guide to this intervention) – strongly encourage and prescribe: exercise; regulated sleep; regulated eating; positive social activities

28. Teen Anxiety Disorder is Suspected
 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 (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 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.

29. Teen Anxiety Disorder is Suspected
If Panic Disorder:
Complete Panic Attack Diary
Complete (Difficult Places to Go and Things to Do)DPG:TD Diary
If Social Anxiety Disorder
Complete (Kutcher Generalized Social Anxiety Disorder Scale for Adolescents) K-GSADS-A

30. Onset of anxiety disorder
Don’t Get Overwhelmed
Onset of anxiety disorder
is not an emergency
Use clinical tools to assist with diagnosis
Integrate details in
assessment interviews
3 – 15 min visits
If concern for depression and/or suicide, screen at each visit.
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.

31. Separation Anxiety Disorder
Fear something bad will happen to them or loved one when apart
Avoid being apart from parent or caregiver
Significant distress/anxiety when separated or anticipating separation
Criteria for diagnosis:
School age & have experienced distress for at least 4 weeks
Physical symptoms: headache, stomach ache, behavioral outbursts, crying, clinging and/or yelling.
Difficulty with babysitters, sleeping alone, getting to school.
Child misses out on social opportunities
Interferes with development of age appropriate independence and academic success.
Separation Anxiety Disorder
Separation Anxiety Disorder is one of the most common anxiety disorders in children. Separation anxiety is a normal stage of early development, however if it continues into school age, it can cause significant distress and interfere with normal developmental tasks such as going to school and sleeping in one’s own room.
Fear something bad will happen to them or loved one when apart
Children with separation anxiety disorder fear something bad will happen to them or someone they love (usually parents or caregiver) when they are apart. This fear causes children to avoid being out of sight from the parent or caregiver, or to have significant distress and anxiety when they are separated or anticipate separation.
Criteria for Diagnosis:
To meet the criteria of separation anxiety disorder, the patient will have experienced this distress for at least 4 weeks. Anxiety symptoms can manifest as physical complaints such as headache and stomach ache on school mornings (that do not occur on weekend mornings), and/or behaviour outbursts, crying, clinging and yelling. Parents with children with separation anxiety disorder will describe not being able to leave their child with a babysitter, their child not able to sleep in their own bed (parent falls asleep with them, or they sleep in parents room), and difficulty getting the child to school in the morning. Often parents will be called from school by children with separation anxiety disorder seeking reassurance that their parent is okay, checking when they will be picked up, or insisting on coming home because they feel sick (due to anxiety). Children with separation anxiety disorder miss out on social opportunities with friends, such as play date or sleepover, because they do not want to be away from home or their parent. This disorder can cause significant distress and dysfunction for the child and family, and significantly interfere with development of age appropriate independence and academic success.

32. Fear of object or situation Out of proportion to actual danger
Specific Phobia
Fear of object or situation
Out of proportion to actual danger
Anxiety response is extreme/unreasonable
Criteria for diagnosis
Persist for 6 months
Significant distress & impairment of functioning
Avoidant behavior
Distress and/or panic attacks
Treat or not treat
Specific Phobia
Fear of object or situation
Many people have fears. Some of the more common things people are afraid of include heights, spiders, snakes, blood and needles. A specific phobia is fear of an object or situation that is out of proportion to the actual danger and the anxiety response is extreme and unreasonable.
Most common anxiety disorder
Specific phobias are the most common type of anxiety disorder.
Criteria for diagnosis:
This specific fear must be present for at least 6 months and cause the child significant distress and/or impairment in functioning. Children cope with this fear by avoiding the situation or object, or they may have intense anxiety (possibly panic attack) and distress when faced with it.
Rare to cause significant impairment
It is rare for this disorder to cause significant impairment in function in children, as parents will often help their children avoid triggering situations whenever possible.
In some cases such as fear of needles where the child requires blood work or a vaccine, or refusing to go outside due to a fear of a particular trigger such as seeing spiders, the phobia has to be addressed. Fear of choking on certain foods is common specific phobia which can cause significant physical health concerns if oral intake is restricted.
Traumatic Events
Specific phobias are sometimes preceded by a traumatic event (such as becoming afraid of dogs after experiencing being bitten by a dog).
Genetic Predisposition, Stress in Environment or Modeling Behaviors
Onset can also be associated with genetic predisposition, increased stress in environment, and modeling behaviours.

33. General Anxiety Disorder (GAD)
“Master Worriers”
Excessive, unrealistic and unhelpful distress and worry around everyday events and responsibilities
Persists for at least 6 months
Distress mentally and physically
Tension, irritability, muscle aches & pains, difficulty concentrating, tiredness, headache, stomach ache, nausea & lightheadedness, difficulty sleeping, avoidance patterns, seeking excessive reassurance
Lack of enjoyment and avoidance of daily activities
Generalized Anxiety Disorder (Generalized Anxiety Disorder DSM-IV-TR diagnostic criteria)
Master Worriers
Generalized Anxiety Disorder (GAD) can begin in both the childhood and adolescent years.
Youth with Generalized Anxiety Disorder are “master worriers”.
Their anxiety centers around everyday events and responsibilities in their life, however, their distress and worry is excessive,
unrealistic and/or unhelpful, and persists for at least 6 months.
Distress Mentally and Physically
GAD sufferers have significant distress both mentally and physically due to their anxiety. Children may report feeling tense,
irritable, frequent muscle aches and pains, and difficulty concentrating due to the intensity and chronicity of the worried thoughts and feelings. Other physical symptoms of anxiety common in children are tiredness, headache, stomach ache, nausea and light headedness. They excessively worry about everyday things such as school, friends, health, future, and finances.
Adult Type Worries
However, the intensity and degree of worry is extreme and/or the worries are “adult” type and not
developmentally appropriate. These symptoms can make it difficult to fall asleep, or to get restful
sleep, and this in turn increases distress. Individuals with GAD may have academic performance
anxiety that interferes with starting and completing assignments and taking tests, due to fear of
failure. A pattern of avoidance can develop to prevent “failure” or “something bad happening”,
and the youth may seek excessive reassurance from others that “everything will work out or be
okay”.
Lack of Enjoyment
These anxious behaviours lead to increased anxiety, interfere with overall function, and
lead to lack of enjoyment and avoidance of everyday activities.

34. Social Anxiety Disorder (Social Phobia)
Onset
Junior high or middle school
Symptoms
Shy or introverted (inaccurate)
Severe anxiety in social situations
Avoidance and isolation
Impacts development of
identity and independence
Risks
Depression, substance abuse and school drop out
Social Anxiety Disorder (Social Anxiety Disorder DSM-IV-TR diagnostic criteria)
Social Anxiety Disorder (Social Phobia) is not a common anxiety disorder in childhood, but is the
most common anxiety disorder in teens. This change in prevalence is likely linked to the
increased individuation and the importance of peers in adolescent social and emotional
development. Onset usually occurs in junior high or middle school years.
Symptoms
Socially anxious youth are identified as “shy” or “introverted”, which is not accurate.
Youth who suffer from social anxiety disorder have severe anxiety in social situations that is very distressing and can lead to
avoidance and significant deterioration in overall function.
Youth with social anxiety disorder describe an overwhelming fear of drawing attention to themselves or saying something stupid or
embarrassing around others, especially peers. This can lead to not asking questions in class, not
talking in front of or to others, avoiding social events and group activities.
When social anxiety disorder is quite severe it can result in isolation to the point where the individual rarely leaves
their home, doesn’t have contact with friends and stops attending school.
Social anxiety disorder has significant developmental and functional impact on youth at a time when they should be
developing their own identity and independence.
Risks
Without treatment these youth can develop depression, have higher risk of substance abuse and higher rates of not completing school.

35. Panic Disorder Acute symptoms
Panic attacks  Occur ‘out of the blue’ with no warning  Think they are having heart attack, asthma attack, stroke, seizure
Anxiety & fear of additional attacks
Rapid debilitation in daily life
Risks
Avoidance patterns & agoraphobia
Depression
Suicide
Panic Disorder (Panic Disorder DSM-IV-TR diagnostic criteria)
Acute Symptoms
Panic disorder usually has onset in adolescent years, but sometimes occurs in children. Although
not the most common anxiety disorder, this illness can become debilitating quite rapidly.
Patients with panic attacks (Panic Attacks DSM-IV-TR diagnostic criteria) most commonly first present to
an emergency room or urgent care clinic because the physical symptoms are acute and escalate quickly. Individuals may think they are having a heart attack, asthma attack or even a stroke or seizure.
The individual becomes extremely afraid and believes they are dying or that something
terrible is going to happen. Panic attacks can occur in any anxiety disorder or high distress
situation. However, in panic disorder these attacks occur “out of the blue” without clear
precipitants or warning. This causes extreme fear and anxiety of having another attack,
particularly in a place where others might see them or escape or help might not be possible.
Individuals with panic disorder will avoid any situation they associate with having feeling panicky,
or places where they fear that if they did have an attack they would not be able to manage or get
help.
Risks
In many individuals this can lead to staying closer to home to the point where they will not
go to places where there may be groups of people or crowds (agoraphobia).
In teens with panic disorder, they may stop all extracurricular activities, refuse to go anywhere without their parent,
and may stop going to school (or have extreme distress with school attendance). This deterioration can happen quite rapidly for some individuals after only one or two panic attacks.
Individuals with panic disorder can develop depressive symptoms quite rapidly and have a higher
associated risk of suicide than other anxiety disorders. 35

36. Obsessive Compulsive Disorder (OCD)
Obsessions
Distressing intrusive thoughts, urges and/or images
Common themes – Illness and danger
Compulsions
Repetitive behaviours or rituals performed to relieve distress and anxiety associated with obsessions
Common themes - cleaning, washing and checking behaviors
Causes significant distress
Take up more than 1 hour each day
Repetitive images or thoughts (e.g. violent, religious or sexual)
Lead to compulsions of praying or counting
Avoidance behaviors & efforts to suppress obsessive thoughts
Obsessive Compulsive Disorder (Obsessive Compulsive Disorder DSM-IV-TR diagnostic criteria)
Obsessive Compulsive Disorder (OCD) is an anxiety disorder involving:
Obsessions - Distressing intrusive thoughts and/or images
- The most common obsession themes are illness and danger related.
Compulsions - Repetitive behaviours or rituals performed to relieve distress and anxiety associated with the obsessions
- The most common compulsions are cleaning and washing rituals, and checking behaviours.
Cause Significant Anxiety
Both obsessions and compulsions are unwanted, cause significant anxiety, and interfere with functioning (taking up more than one hour per day).
Sometimes OCD does not involve any observed compulsions, and the individual could suffer from repetitive images or thoughts (e.g. of violent, religious or sexual nature) which are extremely distressing. The compulsions could be mental rituals such as counting or praying. There could also be avoidance of and distress around things that are associated with or trigger obsessions (e.g. having all the knives removed from the house in someone who has violent obsessive thoughts) and efforts to try and suppress obsessive thoughts.

37. Obsessive Compulsive Disorder (OCD)
Two peaks of onset
Childhood (pre puberty)
Later Adolescence
Obsessions or compulsions are irrational
Children/youth may not realize this
Frustration and anger if can’t keep OCD satisfied
Most often a gradual onset
Difficulty concentrating, getting out of the house, getting dressed or decreased food intake
Negative impact on family functioning
Family members often help out with routines
High rates of depression
Obsessive Compulsive Disorder (cont’d)
Individuals suffering from OCD often suffer in silence for many years before seeking help. Parents may notice symptoms that are interfering with functioning at home or school, and bring their child or teen to their health care provider to find out what is wrong.
Two peaks of onset
OCD generally has two peaks of onset, in childhood (pre puberty) and in later adolescence.
Obsessions or compulsions are irrational
Children with OCD generally have poor insight into their illness and may not recognize that the
obsessions and compulsions are irrational. They may truly believe they need to carry out the
compulsions or something very bad will happen, and they can become frustrated and angry if
they are not able to complete rituals properly or control their environment to keep OCD “satisfied”.
Most often a gradual onset
OCD can have a sudden onset of symptoms, but generally has a gradual onset with worsening of
symptoms over time. Children suffering from OCD may have trouble going to school, find they
are unable to concentrate in class, have difficulty getting out of the house or getting dressed, and
have decreased food intake related to obsessions and compulsions.
Negative impact on family functioning
In children, it is quite common for parents and other family members to be involved in OCD routines and compulsions,
and this illness can have a significant negative impact on family functioning.
High rates of depression
Children and youth with OCD have higher rates of developing depression as the illness progresses.

38. 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-V 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.
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.

39. Additional Questions for Teen Anxiety & OCD
Do you worry more than other teens you know?
What do you worry about?
Does worry/anxiety ever stop you from doing something that you would like to be able to do?
Are there any events/activities/people/places that you avoid because of fear or anxiety?
Describe your sleep routine (where, when, quality, night routine)?
Have you ever missed school or had to come home from school early due to anxiety?
Have you ever had anxiety where your heart raced, you couldn’t catch your breath, you felt dizzy or lightheaded and thought you might be dying?
Do you get a lot of stomach aches and headaches?
Do you have trouble concentrating?
Do you have ideas or images that come into your mind and you can’t control them?
Do you have any routines or behaviours you need to do to relieve anxiety or distressful thoughts or images? (e.g. ask about germs/dirt worries and hand washing/cleaning, also counting and checking rituals)
What would be different for you if you didn’t have anxiety/worry?

40. III. Childhood Anxiety Treatment Template
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
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.

41. Enroll the Help of Others
Who does the child want to help them?
Family
Babysitter
Teacher
School Counselor
Neighbor
Coach
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.
Support Helps Reduce Stress For Children
Inquire about school performance;
academic supports may be needed

42. Parent/Caretaker Involvement
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
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.

43. Psychotherapy First line treatment Cognitive Behavioral Therapy (CBT)
Strong evidence based practice with CBT alone
Often improves anxiety without medication
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
Psychotherapy
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.

44. Suggested Websites Anxiety BC website www.anxietybc.com
Youth anxiety/depression treatment guideline algorithm
American Academy
of Child and Adolescent Psychiatry
Teen Mental Health
Suggested Websites
• Resources for youth and families can be found on Anxiety BC website -
• Treatment guideline algorithm for health care providers in treatment of anxiety disorders and depressive disorders in youth -
• American Academy of Child and Adolescent Psychiatry -
• Sun Life Financial Chair in Adolescent Mental Health –