Diagnosis and Treatment Julie Lesser MD and Sarah Frankfurt LAMFT January 31 2020 Objectives Provide an overview of the epidemiology and diagnosis of anxiety disorders in children and adolescents ID: 917773
Download Presentation The PPT/PDF document "Pediatric Anxiety Disorders:" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Pediatric Anxiety Disorders: Diagnosis and Treatment
Julie Lesser, MD, and Sarah Frankfurt, LAMFT
January 31, 2020
Slide2Objectives
Provide an overview of the epidemiology and diagnosis of anxiety disorders in children and adolescents.
Discuss treatment modalities including psychotherapy approaches, and brief overview
of medication options
Cognitive Behavioral Therapy and Exposure Response Prevention
Review strategies for identifying and addressing anxiety in children in the school setting.
Slide3What is anxiety?
Anxiety is multidimensional…
Physical/somatic distress
Cognitive and subjective distress
Behavioral response and avoidance
~8-12% of children and adolescents ages 4-20 suffer from ≥1 anxiety disorders.
Slide4Epidemiology of anxiety disorders
Most common psychiatric disorder in childhood
Seen in all socioeconomic levels
Median Age of Onset: 6 years old
Female-to-male ratio
Equal in preadolescent children
Females are increasingly represented in adolescent years (except OCD)
80% of youth with a diagnosable anxiety disorder are not receiving treatment
Slide5Cross cultural perspective
White Americans shown in studies to endorse symptoms of anxiety disorders more than African Americans, Hispanic Americans and Asian Americans
Prevalence of OCD appears roughly consistent across ethnic groups in US
African and Caribbean Americans showed an OCD lifetime prevalence of 1.6%
Epidemiologic studies in other countries find similar rates cross nationally (Weismann et al., 1994)
Slide6Age
Fears
Symptoms
Early
infancy
0-6
m
-Loss
(e.g., of caregivers)
-Sensory
Late infancy
6-8 m
-Shyness
Anxiety with strangers
Toddlerhood
12-18 m
Separation anxiety
Sleep disturbance,
oppositional behavior
2-3 y
-Thunder, lightening,
water, fire, darkness, nightmares, animals, separation
Crying, clinging,
withdrawing, avoiding, enuresis
Early childhood
4-5 y
Death, dead themes
General worrying, panic
5-7 y
-Specific, natural disasters, illness, traumatic events/accidents,
-School performance
Withdrawal,
timid, extreme shyness, shame
Adolescence
12-18 y
-Rejection from peers
-Fear of
negative evaluation
Slide7When is fear/anxiety a problem?
Is it
out of proportion
to the situation?
Can it be
explained
or reasoned away?
Is the fear
beyond voluntary control
?
Unchanged
?
Does fear lead to
avoidance
of the situation?
Is the fear
appropriate
for the child’s age or stage?
Does the fear
interfere
with functioning?
Slide8Risk factors
Genetic
Twin studies suggest heritability for phobias, GAD, and panic disorder
Environmental
Negative life events
Biology
Cognitive approaches
Overactive fear circuit
Inflammation
Neurotransmitters
Decreased functioning of serotonin and GABA
Increased norepinephrine activity
Slide9Slide10Signs and symptoms of anxiety in youth
Recurrent fears and worries
Difficulty falling asleep or nightmares
Hard to relax
Difficulty separating from parents
Scared about going to school
Irritability, crying, tantrums
Discomfort in social settings
Slide11Children with anxiety disorders
At risk for developing other types of anxiety disorders or psychiatric disorders
75% of individuals with anxiety disorder meet the criteria for another psychiatric disorder
60% meet criteria for major depression
Half of individuals with anxiety disorder meet criteria for another anxiety disorder
Subthreshold symptoms common
Slide12Anxiety disorders
Generalized Anxiety Disorder
Social Anxiety Disorder
Separation Anxiety Disorder
Specific Phobia
Selective Mutism
Panic Disorder
Obsessive-Compulsive Disorder *
Slide13Assessments
Assessments at the beginning and through out treatment
For social anxiety: Leibowitz Social Anxiety Scale (LSAS)
For panic disorder: Child Anxiety Sensitivity Index (CASI)
For GAD/worry: Penn State Worry Questionnaire, Child (PSWQC)
For Obsessive Compulsive Disorder: Children’s Yale-Brown Obsessive-Compulsive Disorder scale (CY-BOCs)
Slide14Generalized Anxiety Disorder (GAD)
Excessive, chronic worry about common events and activities occurring for at least 6 months.
Associated with at least 3 of following:
Restlessness or feeling on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance
Slide15GAD: Other features
Perfectionistic, excessively critical of themselves
Excessive self-consciousness
Frequent reassurance seeking
Worry about negative consequences
Somatic complaints – GI distress, headaches, frequent urination, sweating, tremor
Slide16Separation anxiety
Excessive anxiety focused on separating from home or parent figure
Worry about parent’s health and safety
Difficulty sleeping without parents
Difficulty being alone in another part of the house
Somatic complaints
May refuse to go to school or playdates
Slide17Separation anxiety
Most commonly diagnosed in pre-pubertal children
More common in 5-7 and 11-12-year olds, with transition into elementary and middle school
Developmentally inappropriate
Typically occurs following a significant change or major life event
Slide18Social phobia
Excessive fear or discomfort in social situations or performance situations
Extreme fear of negative evaluation by others
Worry about doing something embarrassing in a variety of settings
Difficulty participating in class, working in groups, eating in front of others, making new friends, having pictures taken, talking on the phone
Often demonstrate diminished social skills, longer speech latency, fewer friends, school refusal
Slide19Selective mutism
Unable to speak in certain situations (school), despite being able to speak in other settings (home)
Difficulty speaking, laughing, reading aloud outside of family members
Speech/language development is most often normal
Often inadvertently reinforced by other individuals (i.e., parents) in the child’s daily life (e.g., speaking for the child, permitting the use of nonverbal communication)
Relationship between social phobia and selective mutism
Slide20Panic attacks
Sudden, discrete episodes of intense fear
Intense desire to escape
Feeling of doom
Activation of autonomic nervous system
Fight or flight
Symptoms – increased heart rate, sweating,
fast shallow breathing
Duration 20-30 minutes
Slide21Panic disorder
Recurrent panic attacks or intense fear
Inter-episode worry about having a panic attack which may lead to avoidant behaviors
Worry about implications and consequences
Changes in behavior
More common in adolescents
Slide22Specific phobia
Excessive fear of a particular object or situation
May avoid the feared object or situation
Anxiety may be expressed through crying, clinging, freezing
Common phobias: animals/insects, heights, storm, elevators, planes, costume characters, doctors, vomiting, choking
Slide23Obsessive-compulsive disorder (OCD)
Obsessions are
unwanted
and
distressing
so people try to resist them, get rid of them, or reduce their distress in some way:
avoidance of triggers
distraction
compulsive behaviors or thoughts
They are NOT excessive worries about real life problems
Differentiates from Generalized Anxiety Disorder
A compulsion is a behavior or mental act that a person
feels driven
to perform over and over again
to prevent or reduce anxiety, discomfort or distress
to “prevent” something bad from happening
Often performed in response to an obsession
Often performed according to rigid rules or until it feels “just right”
Slide24OCD: Putting it together
Obsession
Fear of contamination
Obsessive doubt/harm
Need for symmetry
Fear of losing things
Need for certainty
Intrusive image or thought
Compulsion
Washing/Cleaning
Checking
Ordering/Arranging
Hoarding
Reassurance/”just right”
Repeating/mental ritual
Slide25Manifestations of anxiety at school
Repeated approval seeking from teacher
Avoidance of school activities or peer activities
Not attending school
Excessive self-criticism
Poor transitioning from school to home
Poor test taking – especially timed tests
Inability to ask for help from others
Procrastination with schoolwork
Slide26OCD at school
Teachers may be first to observe child’s obsessions or compulsions
Compulsions can interfere with ability to complete homework, can be distracting, can upset sleep, and can increase absenteeism and tardiness
May increase risk for bullying as kids with OCD can be isolated or teased
Slide27Cognitive symptoms with anxiety
Memory impairment
Short-term memory
Impaired decision making
Inability to concentrate
Thought distortions
Poor judgment
Anxious or racing thoughts and constant worrying
Slide28Medication management of anxiety and OCD
Slide29Multi-center research:Child/Adolescent Anxiety
Mutimodal
Study (CAMS)
Randomly assigned 488 children 7- to 17-year olds to one of 4 treatment options:
CBT
SSRI (sertraline)
Combination treatment (CBT + sertraline)
Placebo
81% in combination treatment (CBT + sertraline) improved
Other groups
60% in CBT alone
55% of SSRI alone
24% of placebo
Slide30Child/Adolescent Anxiety Multimodal Study (CAMS)
Remission rates in COMB (68%) > CBT (46%) and SRT (46%) > PBO (24%)
PARS
(Walkup et al., 2008
, NEJM
)
Slide31Multi-center research:Pediatric OCD Treatment Study (POTS)
N=112 (children 7-17)
Randomized, placebo-controlled study
12 weeks of ERP
Sertraline
12 weeks of ERP + sertraline (combined)
Placebo
Looked at Clinical Remission rates (CYBOCS <10)
Slide32POTS Team (2004)
Slide33When to consider medication
Patient unable to participate in therapy due to severity of symptoms
Prominent daily impairment or avoidance
Co-occurring disorders
ADHD, depression, psychosis, bipolar disorder
Symptoms that do not respond to 6- to 8-week trial of CBT or ERP (with a family component)
Severe physiological symptoms of anxiety
Lack of availability of evidence-based therapy interventions
Slide34Selective Serotonin Reuptake Inhibitors (SSRIs)
First-line
medication for pediatric anxiety
Safer side effect profile
Typically require higher doses for OCD as compared to patients with depression or other anxiety disorders
May take 10-12 weeks in pediatric OCD to determine if medication is effective
SSRIs usually take 4-6 weeks to determine effectiveness
Slide35Other medication strategiesOther antidepressants
Atypical Antipsychotics
B-blockers
Clonidine
Mood stabilizers/anti-seizure medications
Gaba-ergic
Medications
Glutamate modulators
Slide36School role with medicationPart of treatment team
Observations of student during school invaluable
Dispense medication
Medication or side effects may impact behavior or learning
Impact on parent attitude toward medication
Slide37Cognitive behavioral therapy for anxiety disorders
Slide38Unmet need for anxiety treatment
Most people with anxiety never receive efficacious treatment
It is estimated that 84% of people with an anxiety disorder saw a health care provider but only 23% received appropriate treatment (Young et al. 2001)
Either with medication prescribed according to practice guidelines
< 4 sessions with a mental health specialist (11%)
Unmet need may be higher for children
Identification
Access
Cost
Slide39CBT for anxiety
Psychoeducation
Relaxation
Cognitive restructuring/coping skills
Problem solving
Exposure
Relapse prevention
Ask for help in
class = 8
Give speech to group of kids = 8
Talk to a new adult = 5
Talk to a new kid my age = 6
Trip in front of someone = 5
Drink water from a fountain and get some on my shirt = 4
Ask friend to come over to my house = 4
Answer the phone at home = 2
Ask security guard at school the time = 3
Slide40Psychoeducation
Psychoeducation about principles of CBT
Parent training to reduce accommodation of anxious behaviors, establish structure/routine, positive reinforcement and monitoring of symptoms
Co-therapist model with parents
Family-based CBT, has evidence of increased efficacy in school-age children
Coordinate treatment plan with school personnel
Slide41The anxiety-behavior cycle
(
Piacentini
et al., 2003; Storch, 2006)
Trigger
Safety Behavior
Fear/Anxiety
Reduction in
Distress
Negative Reinforcement
Slide42Why anxiety doesn’t go away…
Slide43Typical anxiety scenario
Response/Avoidance/Compulsion
(Time)
Slide44Cognitive behavioral model of anxiety
Physical Feelings/Emotions
e.g., tummy ache, headache, racing heart
Behaviors
e.g., clinging, avoidance
Thoughts
e.g., I can’t handle being away from my mom
Slide45Somatic management skills training
Respiratory control/diaphragmatic breathing
Muscle relaxation
Imagery/meditation
Slide46Cognition and anxiety disorders
People with anxiety disorders have biased information processing
Heightened level of attention to potential threat
View situations as being unrealistically dangerous or likely to cause harm
Underestimate ability to manage or cope with feared situations
Slide47Identifying and challenging anxious thoughts
Do I know for sure this is going to happen?
Has this happened before?
How many times?
Has this happened to anyone I know?
What else could happen instead?
What am I missing out on due to worry?
I’m going to fail this test and then I won’t be able to go to college and get a good job!
Slide48Problem solving
Problem solving as a way to detour worrying (worry as the “default” setting)
“
That must be tough, what are you going to do about it?”
Elements:
Problem identification
Possible solutions-all ideas are fair game
Assess all solutions and choose one (chance to take a risk)
Assess effectiveness of solution – continue or pick another
Slide49What is exposure therapy?
Slide50Slide51Exposure therapy
Placing an individual in feared situations without response engagement
Needs to be
prolonged
enough to lead to within trial habituation (at least 50% reduction in anxiety)
Needs to be
repetitive
enough to lead to between trial habituation (until causes minimal to no anxiety)
Needs to be
graduated
(increases compliance)
Slide52Exposure
CBT for anxiety is unique in that it requires a client to experience increased anxiety in order for new learning to take place
Exposure is the key active ingredient (
Peris et al., 2014)
Yet…
some view exposure-based treatments as demanding, challenging, and perhaps even mean (Olatunji et al., 2009)
therapists may fear damaging their clients with exposure procedures (Rosqvist, 2005)
may be even more of a problem for therapists who work with children
Slide53Typical Phobic Scenario
High
(Anxiety)
Low
60 sec
Trigger
10 min
(Time)
Slide54Typical Phobic Scenario
High
(Anxiety)
Low
Response/Compulsion
60 sec
10 min
(Time)
Slide55Exposure Therapy
High
(Anxiety)
Low
Exposure
10 min
60 sec
(Time)
Slide56Exposure Therapy
High
(Anxiety)
Low
Exposure
Response Prevention
10 min
Habituation
60 sec
(Time)
Slide57Exposure Therapy
High
(Anxiety)
Low
Exposure
Response Prevention
10 min
60 sec
(Time)
Slide58Exposure and response prevention
How does it work?
Create a list of events that cause rituals/responses
Easiest to hardest
Be creative and ‘intense’
Identify subtle changes in SUDS ratings
Incorporate reductions in family accommodation
Progress up the list slowly where the person
does not engage in rituals/responses
First exposures should have high likelihood of success
Slide59Exposure and response prevention
How does it work?
(continued)
Tackle things one at a time
Give child choices
Therapist should model exposure
In vivo works best (but can do it through imagination)
Don’t leave the situation until anxiety drops
Slide60Some FALSE assumptions about exposure
Exposure is difficult to control with clients
Conducting exposure increases risk of client dropout
Exposure cannot be conducted with children or adolescents
Slide61General strategies to help kids with anxiety at home and at school
Slide62Teaching a child about anxiety
Anxiety is
normal
Everyone experiences anxiety at times
Anxiety is
not
dangerous
Although anxiety may feel uncomfortable;
it does not last long and will eventually decrease
Anxiety is adaptive
Anxiety helps us prepare for real danger. We perform our best at moderate levels of arousal (Yerkes-Dodson curve)
Advantages of the “fight or flight” response
Anxiety can become a problem when our bodies react to normal situations as if they were
real
dangers
Slide63Active ignoringActive reinforcement of positive behaviors
Active ignoring of unwanted behaviors to extinguish (complaining, crying, somatic complaints)
Temporary increases in problem behaviors are expected
Helps children learn to try coping skills and problem solve
Slide64Training parents/caregivers to reduce reassurance
Give the child the opportunity to answer the question themselves:
WHAT DO YOU THINK?
Limit the number of worry questions/day/hour:
ONE WORRY QUESTION / HOUR
Insert a predetermined length of time before answering questions to increase tolerance for uncertainty:
DELAY REASSURANCE
(ask child to rate their fear)
Use rewards to increase motivation to tolerate anxiety:
COINS IN THE POCKET TO USE FOR REASSURANCE
With compliancy issues, perform a cost-benefit analysis to increase insight :
LONG-TERM VS. SHORT TERM GAIN
Practice responding to reassurance questions in session :
ROLE MODEL RESPONSES
Slide65Coping cardsReminder that physical symptoms of anxiety are
normal
Reminder that anxiety may
feel
dangerous, but is not
Identify a name your child can give anxiety (e.g., Mr. Meany, pest, monster)
Realistic thought challenges (e.g., How many times have I worried about this and it has turned out fine? What would I tell a friend to do in this exact situation?)
Use of coping skills (e.g., respiratory control, deep muscle relaxation, reading, talking to a friend, etc.)
Slide66Addressing family accommodation in OCD
Symptom accommodation:
“
…actions taken by the family members
*
to:
Acquiesce to the child’s demands
e.g., allowing child to miss activities to minimize discomfort
Participate in the child’s rituals/symptoms
e.g., changing clothes when entering the house, opening doors for child
Provide reassurance
to the child
e.g., answer questions repeatedly
Decrease child’s responsibility
e.g., minimize attempts at discipline
Assist with or complete tasks
for the child
e.g., provide extra assistance with homework, chores, and so on
(Storch et al., 2010; p. 207-208).
*
Applies to adults, siblings and non-family members as well
Slide67Examples of accommodation
Physically assisting a child to hand wash
Opening doors or turning on light switches
Having an uncontaminated place for a child to turn in schoolwork
Providing reassurance
Repeating phrases or actions
Avoiding having a child participate in activities or being around others (social anxiety or contamination concerns)
Slide68What’s the problem with accommodating?
Associated with poorer treatment outcomes in children and adults with OCD
Reduces effectiveness of CBT and long-term outcomes
Linked to more family dysfunction and stress
Ends up consuming increasing amounts of time for the family
Leads to unintended changes in the family routine
Slide69Parent/teacher involvementAdult can model calmness and problem-solving approaches
Find middle ground: encourage child to face the fear but do this in tolerable doses
Give prompts, but resist rescuing
Focus on positives, build competence & autonomy for child
Slide70School-based interventionsArrange school personnel who can regularly meet child and be available to help
Discourage leaving school
Encourage self-monitoring (i.e. feelings thermometer)
Reinforce attempts to use relaxation/coping strategies
Slide71School-based interventions
Accommodate late arrivals
Modify assignments
Shorter school days to transition children with separation anxiety
Testing in private
Allow extra time for transitions
Have a “safe” place if child develops increased anxiety or panic attacks
Slide72Internet resources
American Academy of Child and Adolescent Psychiatry
(aacap.org)
“Facts for Families” handouts on many topics
Latest news on hot topics
ParentsMedGuide.org
Question and answer material about depression, suicide and black box warning
Links for parents and physicians
Up-to-date, well-organized, English-Spanish
Slide73Resources
Anxiety Disorders Association of America (ADAA):
ADAA.org
Anxiety Disorders Association of British Columbia:
anxietybc.com
International OCD Foundation (IOCDF):
ocfoundation.org
Massachusetts General Hospital: School Psychiatry Program:
www2.massgeneral.org/schoolpsychiatry/
Slide74Thank you!
Rogers Behavioral Health has two clinic locations in the Twin Cities area:
6442 City West Parkway Suite 200
Eden Prairie, MN 55344
576 Bielenberg Drive, Suite 180
Woodbury, MN 55125
Call us
844-599-8959