1. Copyright © The REACH Institute. All rights reserved. Assessment of Anxiety Disorders

2. Copyright © The REACH Institute. All rights reserved. Hidden Slide: Time Table Total time: 90 minutes Introduce learning objectives and agenda: 4’ Sue case presentation (Review role play in Faculty Training and Tips section) Review Sue’s PSC-17 and SCARED: 5’ Interview the Expert: 20’ Verbal/non-verbal Demo: 10’ 2 table activities: 8 Chad/Michelle role plays with MH card: 10’ Debrief: 5’ Summary, COLDER: 5’ Copyright © 2014The REACH Institute. All rights reserved. Unit D: Assessment of Anxiety Disorders

3. Copyright © The REACH Institute. All rights reserved. Learning Objectives Review how to screen and assess for anxiety disorders in children and adolescents in a primary care setting Analyze two clinical case vignettes on anxiety Score and interpret standardized anxiety questionnaires for use in assessment of anxiety.

4. Copyright © The REACH Institute. All rights reserved. Unit Agenda Observe an interview Interview the Expert: Facts and clinical “pearls” on assessing anxiety in pediatric primary care Table activity with Mental Health card Review anxiety tools Evidence based treatment strategies for anxiety disorders in children and adolescents

5. Copyright © The REACH Institute. All rights reserved. Hidden Slide-Faculty Directions Ask participants to: – –Take out the (white) Mental Health Card – –Open workbook to the PSC – 17 (D1.1) AND the SCARED ( D1.2& 1.3) Copyright © 2014The REACH Institute. All rights reserved.

6. Copyright © The REACH Institute. All rights reserved.

7. Hidden Slide-Faculty Directions Dr. and “Sue” and “Sue’s parent” role play briefly the case of 8 yo who comes for a health maintenance visit with stomachaches, mostly on school days. Dr. asks parent to complete PSC-17 After role play finishes, presenter reviews the PSC-17 and SCARED with participants Copyright © 2014The REACH Institute. All rights reserved.

8. Copyright © The REACH Institute. All rights reserved. Case Presentation Sue an eight year old girl in third grade Sue an eight year old girl in third grade During case, follow along with Mental Health card During case, follow along with Mental Health card

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10. 6 15 0 9 Father D 1.1 Workbook D 1.1 Copyright © 2014The REACH Institute. All rights reserved.

11. Copyright © The REACH Institute. All rights reserved. DSM 5 Criteria for Anxiety Disorders The Screen for Child & Adolescent Anxiety-Related Disorders (SCARED) The Screen for Child & Adolescent Anxiety-Related Disorders (SCARED)

12. Copyright © The REACH Institute. All rights reserved. Sue (D1.2&3)

13. Copyright © The REACH Institute. All rights reserved. Total Score = 34

14. Copyright © The REACH Institute. All rights reserved. Assessment Review relevant history (past medical history, medications, psychiatric family history) Assess function through symptoms & screeners Assess safety—May need to address this before going further in the evaluation Consider other rating scales besides SCARED and PSC, such as the SCAS (Spence Children's Anxiety Scale) Explore trauma, neglect/abuse. If appropriate, ask suicidality questions Consider any needed medical and additional mental health assessments

15. Copyright © The REACH Institute. All rights reserved. PTSD (or Traumatic Stress) (no longer listed as an “Anxiety Disorder in DSM-5) > 1 in 4 American children have had a traumatic event before age 16 > 1 in 4 American children have had a traumatic event before age 16 Look for Exposure plus Symptoms: Look for Exposure plus Symptoms: –Exposure: “Has anything frightening or dangerous, either recently or EVER happened to you or your child?” AND –Symptoms (changes in behavior/mood to suggest more anxious or distracted)

16. Copyright © The REACH Institute. All rights reserved. Traumatic Stress Symptoms in Children and Youth 1. 1. Re-experiencing: ImageryMisperceiving danger Nightmares Distress when cued Body memories 2. 2. Avoidance: Numbing out Diminished Interest DissociationSelf Isolation Detachment 3. 3. Hyperarousal: AnxietySleep Disturbance AnxietySleep Disturbance HypervigilanceIrritability or quick to anger HypervigilanceIrritability or quick to anger Startle responsePhysical Complaints Startle responsePhysical Complaints

17. Copyright © The REACH Institute. All rights reserved. Trauma creates toxic stress which is linked to: Disrupted autoimmune system dev & function More/earlier smoking, alcohol & drug use Increased violent behavior Increased JJ involvement Chronic health & MH problems 1-3 – –ACE Study: Adverse Childhood Experiences Trauma-Informed Care: Why It Matters 1 Felitti VJ, Anda RF, et al.. The relationship of adult health status to childhood abuse and household dysfunction. Am J Prev Med 1998; 14: 245-258 2 Dube SR,, et al. Childhood abuse, household dysfunction and the risk of attempted suicide throughout the life span. JAMA 2001; 286: 3089-3096 3 Heckman J, et al. Economic, Neurobiological, and Behavioral Perspectives on Building America’s Future Workforce. PNAS 2006; 103:10155-10162

18. Copyright © The REACH Institute. All rights reserved. Hidden Slide: Interview the Expert Interviewer: Choose your character persona (Anderson Cooper, Stephen Colbert, etc.) and interview the expert. The expert will answer important clinical questions and use the slides to review and reinforce the points. Interviewer will lead this next segment interview the expert. Copyright © 2014The REACH Institute. All rights reserved.

19. Copyright © The REACH Institute. All rights reserved. The Facts and Clinical Pearls on Assessing for Anxiety in Children and Adolescents Interview the Expert with Audience Q&A Copyright © 2014The REACH Institute. All rights reserved.

20. Copyright © The REACH Institute. All rights reserved. Hidden Slide Interviewer asks questions and waits for response. – –As the expert provides the answer, the interviewer shows the next slide. – –Move to the “answer” slide towards the end of the expert’s answer, so as not to distract the participants from the expert. Interviewer: “When you typically suspect anxiety, tell us how you generally approach the work-up?” Copyright © 2014The REACH Institute. All rights reserved.

21. Copyright © The REACH Institute. All rights reserved. Anxiety in Children and Adolescents Presentation Differential – –Medical – –Psychiatric – –Substance-induced Sorting out which anxiety disorder Developmental considerations

22. Copyright © The REACH Institute. All rights reserved. Hidden Slide Interviewer: “How common is anxiety among children and adolescents and what are some of the symptoms?” Copyright © 2014The REACH Institute. All rights reserved.

23. Copyright © The REACH Institute. All rights reserved. Anxiety Disorders Prevalence: up to 8% of all children and adolescents Symptoms: – –Recurring and/or increasing fears and worries about routine parts of everyday life – –Physical complaints, like stomachache or headache – –Trouble concentrating – –Trouble sleeping – –Fear of social situations – –Fear of leaving home – –Fear of separation from a loved one – –Refusing to go to school Developmental Considerations – –Separation from primary caregiver – –Situational anxieties which are developmentally appropriate D 1.0

24. Copyright © The REACH Institute. All rights reserved. Hidden Slide Interviewer: “Would you say a little bit more about developmental considerations?” The following slide should be displayed immediately so the speaker can discuss… Copyright © 2014The REACH Institute. All rights reserved.

25. Copyright © The REACH Institute. All rights reserved. Developmental Considerations InfancyPreschool Middle Childhood AdolescenceYoung Adulthood Inciting Situation Parent leaving Social interaction Performance anxiety Social Performance Post-high school moratorium Developmental Skill Object Permanence Emerging executive functions Transitioning from home to larger community Individuation/ separation Executive functions Other Factors Language understanding, expression Expressive language; temperament Cognitive skills: language, memory Body image, adult modeling, group normative expectations Cognitive ability, developmental strengths profile; familial expectations Developmentally “normal” ? Yes Yes –within limits Yes Example Separation anxiety BitingTest anxiety “Pack identification” in clothing The 6 year bachelor’s degree

26. Copyright © The REACH Institute. All rights reserved. Hidden Slide Interviewer: “What medical conditions are a part of your differential diagnosis?” Copyright © 2014The REACH Institute. All rights reserved.

27. Copyright © The REACH Institute. All rights reserved. Evaluation Consider differential diagnosis of physical conditions that may mimic anxiety symptoms: – –Hyperthyroidism – –Caffeinism (including from carbonated beverages) – –Migraine – –Asthma – –Seizure disorders – –PANDAS–Pediatric autoimmune neuropsychiatric disorders associated with strep infections – –Lead intoxication – –Less Common: Hypoglycemia Pheochromocytoma CNS disorder (delirium or brain tumor) Cardiac arrhythmias

28. Copyright © The REACH Institute. All rights reserved. Hidden Slide Interviewer: “What psychiatric disorders mimic anxiety?” Copyright © 2014The REACH Institute. All rights reserved.

29. Copyright © The REACH Institute. All rights reserved. Evaluation Consider differential diagnosis of other psychiatric disorders that may mimic anxiety symptoms: – –ADHD (restlessness, inattention) – –Psychotic disorders (restlessness and/or social withdrawal) – –PDD, esp Asperger’s (social awkwardness and withdrawal, social skills deficits, communication deficits, repetitive behaviors, adherence to routines) – –LD (generate persistent worries about school performance) – –Bipolar (restlessness, irritability, insomnia) – –Depression (poor concentration, sleep difficulty, somatic complaints)

30. Copyright © The REACH Institute. All rights reserved. Hidden Slide Interviewer: “When entertaining an anxiety disorder, what other environmental and medical considerations should you take into account?” Copyright © 2014The REACH Institute. All rights reserved.

31. Copyright © The REACH Institute. All rights reserved. Other Considerations Substance use* Adjustment disorder Abuse Bullying Threatening environment Pregnancy Drug Side Effects Prescription: Antiasthmatics, sympathomimetics, steroids, SSRIs, antipsychotics (akathisia) Nonprescription: Diet pills, antihistamines, and cold medications * Tools - CRAFFT

32. Copyright © The REACH Institute. All rights reserved. Hidden Slide Interviewer: “When you suspect an anxiety disorder, factors go into the treatment?” Copyright © 2014The REACH Institute. All rights reserved.

33. Copyright © The REACH Institute. All rights reserved. Evaluation If impression/screening suggests possible anxiety, the clinician should conduct a formal evaluation to determine: – –Which anxiety disorder may be present – –The severity of anxiety symptoms – –Functional impairment

34. Copyright © The REACH Institute. All rights reserved. Hidden Slide Interviewer: “Are there other anxiety- related conditions we need to consider, and are there ways to identify them?” Copyright © 2014The REACH Institute. All rights reserved.

35. Copyright © The REACH Institute. All rights reserved. Other Anxiety Disorders Post-traumatic Stress Disorder Post-traumatic Stress Disorder – –PTSD is no longer under Anxiety Disorders in the DSM-5. – –Post-Traumatic Stress Reaction Index (PTSRI) Obsessive Compulsive Disorder Obsessive Compulsive Disorder – –DSM Criteria – –Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

36. Copyright © The REACH Institute. All rights reserved.Copyright © 2014The REACH Institute. All rights reserved. Audience Q&A

37. Copyright © The REACH Institute. All rights reserved. Hidden Slide Interviewer: WRAP UP BY INTERVIEWER What key messages would you like us to take home? Copyright © 2014The REACH Institute. All rights reserved.

38. Copyright © The REACH Institute. All rights reserved. Assessment Key Points Watch for co-existing disorders, in particular ADHD and depression, which are not uncommon Use standardized anxiety tools (SCARED) to aid in the assessment but also listen to parent concern and your own concern from interviewing the child Remember the importance of reading non- verbal information with Anxiety disorders

39. Copyright © The REACH Institute. All rights reserved. Hidden Slide: Non-Verbal Communication Presenter explains why you are doing this exercise in “slo-mo.” – –“Non-verbals often missed in busy practice; we have to hone our skills. Esp. important for anxiety, depression, compliance issues, etc.” – –Role players: Keep EYE contact, Go slow, pause 3-5 seconds to feel the feeling or message sent by the other person…LONG pauses. Same statement repeated x3 with each objective. Don’t tell participants which one you are doing, but start with C, then B, then A. – –Presenter: After each scenario, ask participants to write down their vote, “Was the non-verbal message A? B? C?” – –Presenter: Ask participants who voted A, B, or C for each scenario, then ask parent what was the message. SECOND – Presenter: Instruct doctor to ask the parent his/her question, doing the “think out loud” procedure: – –Doctor: Talk to participants before each response - Tell them what you are thinking to illustrate how you got to a very different place with each of the 3 scenarios by hearing and responding to non-verbals. Copyright © 2014The REACH Institute. All rights reserved.

40. Copyright © The REACH Institute. All rights reserved. Reading Non-Verbal Information Real messages often hidden by words A person may or may not use the right words to describe their real needs What is the person’s inner needs? Example: Doctor: How can I help you? Parent: I don’t think you can help me… A. A. To Antagonize B. B. To Get Help C. C. To Get Respect

41. Copyright © The REACH Institute. All rights reserved. Hidden Slide: Instructions Non-verbal “doctor”: Do not respond to patient immediately: Instead, feel what they are saying nonverbally, use your own non-verbals. Then review the mental health card, and find the question that best fits what you feel fits the message they are sending. When finding the best question from the MH card: Scan the phrase quickly, be sure your non-verbals are working and in sync with your words, re-establish eye contact, say what needs to be said, and see what message you are getting from the patient. Always pause to experience the need of your patient and to adjust to that need in order to achieve your own objective of helping them. Non-verbal “patient”: Do not “perform” or “act” your needs. Instead, fel them, and internalize what you want. Try to get it from the doctor. Feel the role of your character. This exercise will have many pauses, but they will be pauses that are filled with the dynamics of the interaction. Briefly share how people felt during the exercise. Copyright © 2014The REACH Institute. All rights reserved.

42. Copyright © The REACH Institute. All rights reserved. Table Activity (in pairs) Applying it to Anxiety: Two role plays with cases - Chad/Charlotte (D 1.4) and Michelle/Michael (D1.5) Go slow, pause, see what you get back, adjust your response to what you feel from the patient, ask best-fitting questions from MH card Do not “read” lines – “speak from the heart” to Chad/Michelle only after making eye contact Change roles and scripts

43. Copyright © The REACH Institute. All rights reserved. Hidden Slide 20 Minutes: Chad and Michelle Role Plays – –Split into pairs – –Complete both role plays - One member of pair interviews other member using the Mental Health Card. – –Switch to other vignette and reverse roles Debrief COLDER AT VERY END, TELL THEM WHY ALL THE EXTRA “CODING SLIDES” ARE IN THEIR BOOK…TO BE COVERED IN A LATER LECTURE ON CODING. Copyright © 2014The REACH Institute. All rights reserved.

44. Copyright © The REACH Institute. All rights reserved. COLDER: Your Mental Health Interview Characteristics Characteristics Onset Onset Location Location Duration Duration Exacerbation Exacerbation Relief Relief * Also found on MH card

45. Copyright © The REACH Institute. All rights reserved. Summary Role of rating scales Stop, Look, and Listen for underlying needs and emotions Mental Health Card and COLDER

46. Copyright © The REACH Institute. All rights reserved. REMINDER: REMINDER: Please fill out Unit D evaluation

47. Copyright © The REACH Institute. All rights reserved. Getting it Paid For: Self-Study Do you know how to code these cases so you will get paid? Do you know when to use these coding variations?

48. Copyright © The REACH Institute. All rights reserved. Sue’s Diagnostic Code ICD-9-CM/DSM-IV: 290-319 codes Despite all the commotion about ‘mental health parity’ –may be ‘carved out’ by insurers as “mental health” – –Only “approved” mental health specialists may be paid for services provided for these conditions (this is an insurer’s decision) We don’t want fraud –but we DO want fair payment for rendered services

49. Copyright © The REACH Institute. All rights reserved. ICD-9-CM Options for Sue 799.2 Signs and symptoms involving emotional state (excl. anxiety and depression) 789.05 Abdominal pain, periumbilic Try to stay out of v-code land for primary dx.! Secondary dx –ok

50. Copyright © The REACH Institute. All rights reserved. Sue’s Procedures 96110: Developmental Screening (Developmental Testing, limited until 2013) per standardized form, w/ interpretation and report May be used for standardized developmental rating scales –including behavioral rating scales

51. Copyright © The REACH Institute. All rights reserved. Rating Scales Must be standardized Informal checklists don’t qualify Ex: ASQ-SE, PEDS, M-CHAT, Vanderbilt ADHD, SCARED, PSC, PHQ-9, Connor’s ADHD, CBCL, BASC-2, BRIEF, CDS May assign one unit of 96110 for each form completed, scored, interpreted and noted in the medical record

52. Copyright © The REACH Institute. All rights reserved. Sue’s Visit: Option 1 99383 99214-25 (2) 96110 (PSC, SCARED) This is for insurers who allow -25 and multiple units of a procedure

53. Copyright © The REACH Institute. All rights reserved. Sue’s Visit: Option 2 99383 99214-25 96110 96110-76 This is for insurers who permit -25, but want each procedure on a separate line AND who do not adhere to CMS guidelines

54. Copyright © The REACH Institute. All rights reserved. Sue’s Visit: Option 3 99383 99214 96110-59 This could be used for payers who do not permit -25 use and who also follow CMS guidelines regarding -76.