www.pspbc.ca
Childhood & Adolescent Anxiety disorders
Fast Facts About Anxiety in Children
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Childhood = toddlerhood to
puberty (2-12 years of age)
Anxiety is ubiquitous, appropriate
in new situations, and in response
to stressors
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
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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
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Adolescence = puberty to mid-twenties Anxiety disorders affect 8-10% of young people Most anxiety disorders begin in childhood & adolescence Anxiety disorders are often hereditary Many individuals with anxiety disorders experience
physical symptoms that they present to their health care provider.
An individual can be affected by different anxiety disorders throughout their lifespan.
› Separation anxiety disorder can be a precursor for other anxiety disorders in adolescents and young adults.
› Social Anxiety Disorder; Panic Disorder = teen onset
Fast Facts About Anxiety in Adolescents
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Effective treatments for most young people with an anxiety disorder can be provided by first contact health providers
Always assess parents for the presence of an anxiety disorder if a diagnosis of anxiety disorder or depression has been made in a child
If a parent has an anxiety disorder or depression, successful treatment of child will include effective treatment for the parent
Fast Facts About Anxiety in Adolescents
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6 Key Steps
I. Identification of children at riskII. Useful methods for screening and diagnosisIII. Treatment templateIV. Suicide assessmentV. Safety/contingency planningVI. Referral flags
Delivery of Effective Treatment for Anxiety Disorders
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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
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I. Identification of Children & Youth At Risk
Anxiety Disorder Identification Table
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A. Educate about riskB. Obtain family historyC. “Clinical review” thresholdD. Standing “mental health check-up”E. Confidentiality, understanding &
informed consent
A Child is Identified At Risk
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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
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Part of routine for all patients
› Include: Mental disorders Substance abuse Treatment type Treatment outcome
Helps identify youth at risk
Obtain Family History
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Screen at-risk youth every 6 months
15 minute office/clinical visits every 6 months
Standing “Mental Health Check-up”
Anxiety symptoms worsen:
- During school year
-Before first weeks of school
-Should not cause severe distress or
dysfunction
Anxiety symptoms decrease:
- In summer months
- After first few weeks of school
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Does your child worry more than other children you know? Do you need to reassure your child excessively and about
the same things over and over? Does your child have difficulty separating from you to go to
school or over to a friend’s house? What does your child worry about? Does worry/anxiety ever stop your child from doing
something new or an activity they would enjoy? Does your child get a lot of stomach aches and headaches?
When do they occur? Are there any events/activities/people/places that your child
avoids because of fear or anxiety
Additional Questions for Child Anxiety & OCD
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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?
Additional Questions for Child Anxiety & OCD
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Ask parents, “How does your child compare to other children of similar age regarding such issues as…
› Being away from parent?
› Need for reassurance?
› Comfort with exploring new situations?
› Physical complaints?
If child shows substantially more anxiety type symptoms, assess for presence of anxiety disorder or other mental health problem.
Standing “Mental Health Check-up”: Screening
D. Standing “Mental Health Check-up”
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Standing “Mental Health Check-up”School reports and patterns- Difficulty concentrating- Declining grades- Frequent late arrival- Frequent absences
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Physical complaints
- Stomach aches- Nausea
- Headaches- School
mornings/end of weekend
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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
Education About Anxiety Disorders
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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
Differentiating Distress from Disorder
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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
Useful Methods for Screening & Diagnosis
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Psychotherapeutic Support for Teens (PST) Kutcher Adolescent Depression Scale (KADS)
› A screening tool for depression Teen or Child Functional Assessment (TeFA; CFA)
› Self-report tool (child depending)
› 3 minutes to complete
› Assists in evaluating four functional domains of teen mental health School Home Work Friends
Tool for Assessment of Suicide Risk (TASR-A)
Useful Methods for Screening & Diagnosis
Use of SCARED in Assessment
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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
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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
Child / Teen Anxiety Disorder is Suspected
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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
Child Anxiety Disorder is Suspected
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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)
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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)
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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
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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
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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
Teen Anxiety Disorder is Suspected
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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
Onset of anxiety disorder
is not an emergency
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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
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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
Out of proportion to actual danger
Anxiety response is extreme/unreasonable
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“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
General Anxiety Disorder (GAD)
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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 Phobia)
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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
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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 (OCD)
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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 (OCD)
Clinical Approach to Possible Child/Adolescent Anxiety Disorder
Visit 1: SCARED FunctionUse 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.
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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?
Additional Questions for Teen Anxiety & OCD
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Specific Factors
› Evidence based treatments: Structured psychotherapies (e.g. Cognitive Behavioral
Therapy - CBT) Medication
Non-specific Factors
› Activities Decrease stress, improve mood and general well-being
› Supportive psychological interventions PST in toolkit guide
III. Childhood Anxiety Treatment Template
Enroll the Help of Others
Who does the child want to help them?
Family
TeacherSchool Counselor
Coach Neighbor
Babysitter
Support Helps Reduce Stress For Children
Inquire about school performance;
academic supports may be needed
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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
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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
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Anxiety BC websitewww.anxietybc.com
Youth anxiety/depression treatment guideline algorithmwww.bcguidelines.ca/gpac/guideline_depressyouth.html#algorithm
American Academy of Child and Adolescent Psychiatry
www.aacap.org
Teen Mental Health www.teenmentalhealth.org
Suggested Websites