Download Assessment and Treatment of Anxiety Disorders in Children and

13/10/2016
Assessment and Treatment of Anxiety Disorders in Children and Adolescents
Diane Benoit, MD, FRCPC
Faculty/Presenter Disclosure • Faculty: Diane Benoit
• Relationships with commercial interests: – Grants/Research Support: Ontario Mental Health Foundation
– Speakers Bureau/Honoraria: ‐
– Consulting Fees: ‐
– Other: Employee of the Hospital for Sick Children
Disclosure of Commercial Support
• Not Applicable
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Mitigation of Bias
• Not Applicable
Learning Objectives
1. Describe symptoms of anxiety disorders in children and adolescents
1. Describe psychological and pharmacological treatment strategies for managing anxiety disorders in children and adolescents
Epidemiology
• Prevalence rates for at least one anxiety disorder in children and adolescents = 10 to 15%
• Prevalence rates in preschool children = 9%
• The more severe the anxiety and the greater the impairment in functioning, the more likely it is to persist
• Children and adolescents with anxiety disorders are at risk of developing new anxiety disorders, depression, substance abuse
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Co‐morbidities
• Highly co‐morbid with other anxiety disorders
 40‐60% of children with one anxiety disorder will have another anxiety disorder (e.g., Last et al., 1996; Monga et al., 2015)
• Common co‐morbidities also include Depression, ODD, LD, ADHD
• Co‐morbidities need to be assessed and should be treated concurrently with the anxiety disorder
Factors Contributing to Anxiety Disorders
Family history of Anxiety disorders
Mood disorders
Substance abuse
Genetics
Temperament
Behavioral inhibition
High intensity of reactions
Low adaptability
Perfectionism
Sensory sensitivity
Assessment of Anxiety Disorders
• Take detailed history –
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Developmental history Personal mental health history
Symptoms Predisposing, precipitating, and perpetuating factors
Family mental health history • Assess for distress and functional impairment
• Consider self‐report and parent report tools (e.g., SCARED) 3
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Assessment of Anxiety Disorders
• Consider role of biological factors (i.e., medical illness, pain, etc.)
• Consider the role of environmental factors (home, school, peers)
• Consider further investigations (e.g., psycho‐
educational testing)
• Consider role of co‐morbidities in relation to the anxiety disorder (i.e., LD causing school related anxiety, ASD causing social problems and associated anxiety)
DSM‐5 – Anxiety Disorders
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Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder (Social Phobia)
Panic Disorder
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication‐Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
10. Other Specified Anxiety Disorder
11. Unspecified Anxiety Disorder
DSM‐5 Anxiety Disorders
1. Selective Mutism now = Anxiety Disorder
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Recognition that anxiety is driver for mutism
2. OCD moves into own category, together with
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Body dysmorphic disorder
Hoarding disorder
Trichotillomania (hair pulling disorder)
Excoriation (skin picking) disorder
Substance/medication‐induced O‐C and related disorder
O‐C and related disorder due to another medical condition
Other Specified O‐C and related disorder
Unspecified O0C and related disorder
3. PTSD moves into own category
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Separation Anxiety Disorder – DSM‐5
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:
1. Recurrent excessive distress when anticipating or
experiencing separation from home or from major attachment figures.
2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
Separation Anxiety Disorder – DSM‐5
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
7. Repeated nightmares involving theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.
Separation Anxiety Disorder – DSM‐5
B. Persistent, i.e., at least 4 weeks in children and adolescents and typically 6 months or more in adults.
C. Causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
D. Not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
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Selective Mutism – DSM‐5
A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations.
B. Interferes with educational or occupational achievement or with social communication.
C. Duration = at least 1 month (not limited to the first month of school).
D. Not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
E. Not better explained by a communication disorder (e.g., childhood‐onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.
Specific Phobia – DSM‐5
A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
Note: in children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.
Specific Phobia – DSM‐5
E. Persistent, typically ≥ 6 months.
F. Causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
G. Not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic‐like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in OCD); reminders of traumatic events (as in PTSD); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).
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Specific Phobia – DSM‐5
Specify if (code based on the phobic stimulus):
• Animal (e.g., spiders, insects, dogs)
• Natural environment (e.g., heights, storms, water)
• Blood‐infection‐injury (e.g., needles, invasive medical procedure), i.e., fear of
‐ blood ‐ injections and transfusions
‐ other medical care
‐ injury
• Situational (e.g., airplanes, elevators, enclosed spaces)
• Other (e.g., situations that may lead to choking or vomiting; in children, such as loud sounds or costumed characters).
Social Anxiety Disorder – DSM‐5
A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). Note: In children, must occur in peer settings and not just with adults.
B. Fears of acting in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
C. Almost always provoke fear or anxiety. Note: In children, may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
Social Anxiety Disorder – DSM‐5
D. The social situations are avoided or endured with intense fear or anxiety. E. Out of proportion to the actual threat posed by the social situation and to the sociocultural context.
F. Persistent, typically lasting for ≥ 6 months.
G. Causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
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Social Anxiety Disorder – DSM‐5
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Not due to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
I. Not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
Specify if:
Performance only: If the fear is restricted to speaking or performing in public
Panic Attack Specifier – DMS‐5
• Panic attack is NOT a mental disorder • Panic attack can occur in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorder, PTSD, substance use disorder) and some medical conditions (e.g., cardiac, respiratory, vestibular, GI).
Panic Attack Specifier – DSM‐5
• Abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four (or more) of the following symptoms occur:
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feelings of choking
Chest pain or discomfort
Nausea of abdominal distress
Feeling dizzy, unsteady, light‐headed, or faint
Chills or heat sensations
Paresthesias (numbness or tingling sensations)
Derealization (feelings of unreality) or depersonalization (being detached from oneself)
– Fear of losing control or “going crazy”
– Fear of dying
– Culture‐specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
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Generalized Anxiety Disorder ‐ DSM‐5
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for ≥6 months, about a number of events or activities (such as work or school performance).
B. Difficult to control the worry.
C. Associated with ≥3 of the following 6 symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children.
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Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
Generalized Anxiety Disorder ‐ DSM‐5
D. Cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. Not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (hyperthyroidism).
F. Not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social interactions in social anxiety disorder [social phobia], contamination or other obsessions in OCD, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in PTSD, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).
Substance/Medication‐Induced Anxiety Disorder – DSM‐5
A. Panic attacks or anxiety is predominant in the clinical picture
B. There is evidence from the history, physical examination, or laboratory findings of both 1. and 2.
1. The symptoms in A developed during or soon after substance intoxication or withdrawal or after exposure to a medication
2. The involved substance/medication is capable of producing the symptoms in A.
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Substance/Medication‐Induced Anxiety Disorder – DSM‐5
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Not better explained by an anxiety disorder that is not substance/medication‐induced as evidenced by: The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non‐
substance/medication‐induced anxiety disorder (e.g., a history of recurrent non‐substance/medication‐related episodes).
D. Does not occur exclusively during the course of a delirium.
E. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Substances: alcohol, caffeine, cannabis, phenyclidine, other hallucinogen, inhalant, opioid, sedative/hypnotic/anxiolytic, amphetamine (or other stimulant), cocaine, other (or unknown) substance
Management of Anxiety Disorders
• Healthy lifestyle choices
– Healthy food choices
– Regular exercise
– Sleep hygiene (+ no use of electronics for at least 1 hour before bed time)
– Limit use of social media to maximum of 2 hours per day
– No drugs of abuse, alcohol, tobacco
– Limit caffeinated beverages / energy drinks
Parent Resources
 What to Do When You Worry Too Much – A kid’s guide to overcoming anxiety (children aged 2‐12)
Dawn Huebner
 Keys to Parenting Your Anxious Child Katharina Manassis
 1‐2‐3 Magic (book and/or DVDs)
Thomas W. Phelan
 Raising Your Spirited Child
Mary Sheedy‐Kurcinka
 The Difficult Child Stanley Turecki
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Management of Anxiety Disorders – CBT
• Children older than 8 y.o.
 Kendall et al., 1994 ‐ Coping Cat
 Mendlowitz et al., 1999 – Involving parents = better coping
 Manassis et al., 2002 ‐ Individual CBT = Group CBT • Children younger than 8 y.o.
 Monga et al., 2009 ‐ Children as young as 5 can benefit from CBT
Positive DBPC Trials of SSRIs for Pediatric Non‐OCD Anxiety (published)
• Fluoxetine (Prozac)
– Birmaher et al., 2003 (SAD, GAD, SP)
– Beidel et al., 2007 (SP)
• Paroxetine (Paxil)
– Wagner et al., 2004 (SP)
• Sertraline (Zoloft)
– Rynn et al., 2001 (GAD)
– CAMS, 2008 (SAD, GAD, SP)
• Fluvoxamine (Luvox)
– RUPP Anxiety Study Group, 2001 (SAD, GAD, SP)
Effect size = 0.4‐1.9; NNT = 1‐4
Child‐Adolescent Anxiety Multimodal Study – CAMS (Walkup et al., NEJM, 2008)
• Federally funded, multisite RCT; n = 488 (7‐17 y.o.) with primary diagnosis of non‐OCD anxiety disorder (SAD, GAD, SP)
• 4 treatment groups (12 weeks):
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Sertraline 25 mg/day to 200 mg/day over 8 wks (SER)*
CBT** (14 sessions – Coping Cat)
Combination of SER up to 200 mg/day + CBT (COMB)*
Placebo (PBO)*
* Blinded **Unblinded
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CAMS: Efficacy Results (Walkup et al., NEJM, 2008)
• Response rates (CGI – “much” or “very much” improved):
– COMB (81%) > CBT (60%) = SER (55%) > PBO (24%)
• Pediatric Anxiety Rating Scale (PARS) results revealed a similar ordering of outcomes:
– COMB > SER = CBT > PBO
• Remission rates (based on loss of Dx):
– COMB (46% to 68%) > SER (34% to 46%)
CBT (20% to 46%) > PBO (15% to 27%)
CAMS: Efficacy Results (Walkup et al., NEJM, 2008)
• Effect sizes and NNT:
– COMB: – SER: – CBT: ES = 0.86, NNT = 1.7
ES = 0.45, NNT = 3.2
ES = 0.31, NNT = 2.8
• 24‐36 week outcome
– Responders (active arms) had 6 monthly booster sessions
– Combination remain superior to monotherapy of Sertraline or CBT
CAMS: Other Findings (Mohatt, Bennett & Walkup, AACAP, 2014)
• Having more severe and impairing anxiety, greater caregiver strain, and a principal diagnosis of social phobia were associated with less favorable outcome • Naturalistic follow‐up at 6 years (59% of sample): – 50% were in remission
– responders more like to be in remission (OR = 1.83)
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CAMS: Adverse Events (Walkup et al., NEJM, 2008)
• There were significantly more reports of the following adverse events in SER vs. CBT group:
– Insomnia (8% vs. 1%)
– Fatigue (6% vs. 0%)
– Sedation (5% vs. 0%)
– Restlessness or fidgeting (4% vs. 0%)
• However, no physical, psychiatric, or harm‐
related adverse event was significantly more frequent in the SER vs. PBO group
SSRIs: Adverse Effects
• GI: vomiting, esp. for younger children
• Headaches
• Dizziness
• Activation (especially in younger children)
• Triggering of manic symptoms in individuals with a bipolar diathesis
• Akathisia
• Mania
• Increased prolactin
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Irritability
Insomnia Somnolence
Appetite decrease or increase
Diaphoresis Sexual dysfunction Serotonin syndrome
Flu‐like symptoms during discontinuation
Suicidality
SSRI and Suicide Controversy
• Hammad et al., 2006: – FDA meta‐analysis of 24 placebo‐controlled trials (4,582 subjects) of 2nd‐generation antidepressants (SSRIs, venlafaxine, mirtapazine, nefazodone, bupropion) for the treatment of pediatric MDD (N= 16), OCD (N=4), GAD (N=2), SP (N=1), or ADHD (N=1)
• Results:
– The risk ratio for suicide‐related events (SREs) for all trials and indications was 1.95 (95% CI: 1.28‐3.98)
– The risk difference for all trials and indications was 2% (95% CI: 1‐3%)
– The risk ratio for SSRIs in depression trials was 1.66 (95% CI: 1.02‐2.68)
• Bottom line:
– No suicides occurred in these trials
– Overall, the average risk of SREs was • 4% on drug vs. 2% on placebo
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SSRI & Suicide Controversy
• Bridge et al., 2007:
• Meta‐analysis of 27 DBPC trials (N = 5310) of 2nd‐
generation antidepressants (SSRIs, venlafaxine, mirtazapine, nefazodone) for the treatment of pediatric MDD, OCD, or non‐OCD anxiety disorders • Pooled risk differences (antidepressants vs. placebo) in responder status by indication:
• MDD: 11% (61% vs. 50%)
– Corresponds to NNT=10 (similar to the results of Tsapakis et al., 2008)
– For children <12 y.o., only fluoxetine showed benefit over placego
• OCD: 20% (52% vs. 32%)
– Corresponds to NNT=6
• Non‐OCD anxiety: 37% (69% vs. 39%)
– Corresponds to NNT=3
SSRI & Suicide Controversy
Bridge et al., 2007
• “Relative to placebo, antidepressants are efficacious for pediatric MDD< OCD, and non‐
OCD anxiety disorders.”
• Benefit of antidepressants:
– Non‐OCD anxiety > OCD > MDD
• “Benefits of antidepressants appear to be much greater than risks from suicidal ideation/attempt across indications.”
Choosing an SSRI
• For pediatric OCD and anxiety disorders, “the antidepressant of choice” is arguably sertraline, as it has FDA approval for OCD and was studied in both POTS and CAMS
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SSRIs – Psychopharmacology
• SSRI –Before start: CBC + LFTs + electrolytes
– May take up to 1‐2 months for full effect
– If good response, take for 9‐12 months
– Weekly face‐to‐face contact with patient or family during 1st 4 weeks, then @ 12 weeks, and as clinically indicated after 12 weeks
SSRIs – Psychopharmacology
• If no response to a second and third SSRI, could try Venlafaxine (Effexor‐XR)
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37.5 mg; wait for ≥ 1 week between dose increases
Takes 4‐6 weeks for clinical response at a given dose
Maximum daily dose: 225 mg
Adverse effects:
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GI:  appetite, abdominal discomfort/pain
Suicidal ideation
Dizziness
Hostility
Hallucinations
SSRIs – Psychopharmacology
• FDA recommends against use of Paroxetine (Paxil) in youth, re., problems with withdrawal
• Discontinue SSRI slowly over weeks
• Abrupt cessation: nausea, vomiting, insomnia, somnolence, dizziness, agitation, asthenia, dry mouth, abnormal dreams, sensory disturbances (paresthesia, electric shock sensation), anxiety, decreased concentration, headache, tremor, sweating
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Psychopharmacology
• AVOID benzodiazepines
Barriers to Change
References
1. Birmaher B, Axelson, DA, Monk K, et al. Fluoxetine for the Treatment of Childhood Anxiety Disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 42(4): 415‐423. 2003.
2. Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L & Brent DA. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment: A Meta‐analysis of Randomized Controlled Trials. JAMA, 297(15):1683‐1696. 2007. doi:10.1001/jama.297.15.1683.
3. Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM‐5). American Psychiatric Association. Washington, DC. 2013.
4. Hammad TA, Laughren TP & Racoosin JA. Suicide Rates in Short‐
term Randomized Controlled Trials of Newer Antidepressants. Journal of Clinical Psychopharmacology, 26(2): 203‐207. April 2006. doi: 10.1097/01.jcp.0000203198.11453.95
References
5. Hughes CW, Emslie, GJ, Crismon ML et al. Texas Children's Medication Algorithm Project: Update From Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(6): 667‐686. June 2007.
6. Mohatt J, Bennett SM & Walkup JT. Treatment of Separation, Anxiety, and Social Anxiety Disorders in Youth, American Journal of Psychiatry, 171(7): 741‐748. 2014
7. Walkup JT, Albano AM, Piacentini J et al., Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety. N Engl J Med 359:2753‐2766. 2008. 8. Wallace AE, Neily J, Weeks, WB, & Friedman MJ. A Cumulative Meta‐
Analysis of Selective Serotonin Reuptake Inhibitors in Pediatric Depression: Did Unpublished Studies Influence the Efficacy/Safety Debate? J of Child and Adolesc Psychopharm, 16(1‐2): 37‐58. 2006. 16