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Mary Gabriel, MD FAAP Children’s National Medical Center Division of Psychiatry and Behavioral Sciences March 24, 2016 Objectives Identify normal vs. pathological worry and fear Understand the development of anxiety, including risk factors and protective elements List different anxiety disorders and how they present in children vs. adults Understand different treatment modalities and appropriately refer What is worry? Anxious apprehension and thoughts focused on the possibility of negative future events What is fear? Response to threat or danger that is perceived as actual or impending. Fear and worry are common in normal children Developmentally appropriate vs. significantly impaired functioning Fears during childhood = normal developmental transition Normal fears and worries Infants: fear of loud noises, being startled or dropped, and strangers (later in infancy) Toddlers: fear of imaginary creatures (monsters), darkness, normative separation anxiety School-aged: fears about injury and natural events Older children and adolescents: worries about school performance, social competence, health issues Erikson’s psychosocial development Stage Basic Conflict Important Even ts Outcome Infancy (birth to 18 months) Trust vs. Mistrust Feeding Children develop a sense of trust when caregivers provide reliability, care, and affection. A lack of this will lead to mistrust. Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt Toilet Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt. Preschool (3 to 5 years) Initiative vs. Guilt Exploration Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt. School Age (6 to 11 years) Industry vs. Inferiority School Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority. Adolescence (12 to 18 years) Identity vs. Role Confusion Social Relationshi ps Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self. Young Adulthood (19 to 40 years) Intimacy vs. Isolation Relationshi ps Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation. Middle Adulthood (40 to 65 years) Generativity vs. Stagnation Work and Pare ntho od Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world. Maturity(65 to death) Ego Integrity vs. Despair Reflection on Life Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair. Train ing Clinical Presentation Crying, irritability, angry outbursts Misunderstood as oppositionality or disobedience Actually represent the child’s expression of fear or effort to avoid the anxiety-provoking stimulus at any cost Somatic complaints Headache Stomachache May not recognize their fears as unreasonable Epidemiology Prevalence rates: 6-20% Strict adherence to diagnostic criteria Consideration of functional impairment Slightly higher in girls, but this is more in specific phobia, panic disorder, agoraphobia, and separation anxiety Panic disorder often emerges later in mid-teen years Risk Factors Biological: Genetic Temperament Autonomic reactivity (cortisol dysregulation, irregular sleep patterns, GI reactivity) Anxiety sensitivity Environmental Attachment styles Parenting behaviors Peer/social problems Negative/stressful life events Long term Children may develop new anxiety disorders over time Higher risk of developing depression and substance abuse disorders as well The more severe the disorder and the greater the impairment, the more likely it is to persist Pine, et al, 1998 Sequelae Disruption of normal psychosocial development of the child: Social: poor self-esteem, underestimate their competencies Family Academic Anxiety Disorders in DSM5 GAD Separation Anxiety Disorder Social Anxiety Disorder Specific Phobia Panic Disorder Agoraphobia Selective Mutism SIAD/Due to MC/Other/Unspecified Trauma- and Stressor-Related Disorders PTSD– including PTSD for Children 6 Years and Younger RAD Disinhibited Social Engagement Disorder Adjustment Disorder Acute Stress Disorder Other/Unspecifed Case #1 CC: CW is a 10yo male with h/o ADHD who returns to clinic to reestablish care and address anxiety sx. Dad reports CW seeks constant reassurance from parents. Pt is very rigid and does not tolerate change or transitions well at all, "blow's up" when routine changes. Difficulty letting go of things-- will hold onto past events/experiences, especially focused on the negative aspects. Pt has a tendency to generalize his anxieties after a while Pt also worries about taking pills, especially on an empty stomach, and has been cheeking his sertraline for the last few months, which father discovered Socially, anxiety interferes with pt making friends. Pt used to have much difficulty relating to peers due to his focus of conversation being "whatever was in his head, rather than following what the group was discussing. Medically, anxiety interferes with eating and at times with defecation Pt will hit himself repeatedly in the chest when degree of anxiety is severe. Pt will also squeeze his bunny when he is very anxious. On interview, pt states that he is perfectionistic, gets distracted if things aren't the way he thinks they should be. He admits he will correct his younger sister who is "bossy." Nauseated when anxious, +muscle tension. Describes his feelings: 25% anxious, 25% happy, 25% neutral, 12/5% angry, 12.5% sad (Dad's observations of pt's feelings: 30% sad, 45% anxious, 25% happy, 12.5% angry). Generalized Anxiety Disorder Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). The individual finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six 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. 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). The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, 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). GAD: Clinical symptoms Excessive, unrealistic fears about day-to-day activities "What if" concerns that span far into the future Uncontrollable worry about multiple situations, performance, social, academic, health, financial Physical symptoms: headaches, stomachaches, inability to unwind Difficulty concentrating, always thinking what's next Low risk-taking; Need for reassurance and approval for small steps Perfectionism, great fear of making mistakes, fear of criticism; unrealistic unfavorable assessment of their grades, abilities Over-responsibility, feels that tragedies are preventable by worry, and if disaster happens that it's their fault Any negative piece of news that happens to others, fears will happen to them; everything is contagious by association: divorce, illness, car accidents, food poisoning Reviewing events to make sure that didn't hurt anyone's feelings or do anything wrong Sleep difficulties, irritability, fatigue WorryWiseKids.org GAD in children Content of anxiety: quality of performance or competence at school or sports Catastrophic events Perfectionistic, overly conforming Overzealous in seeking reassurance and approval Look for childhood adversities and parental behaviors GAD: Diagnosis Interview Collateral Beware: an anxious child’s desire to please adults and concerns about peformance may affect the child’s self-report Consider TFT’s Document somatic sx before starting meds to reduce mistaking them for medication SE’s after initiation of meds. GAD: diagnostic scales MASC (Multidimensional Anxiety Scale for Children) SCARED (Screen for Child Anxiety Related Emotional Disorders) GAD 7 Severity Measure for Generalized Anxiety Disorder— Child Age 11–17 ADIS-IV-C (Anxiety Disorders Interview Schedule for DSM-IV: Child Version) Child and Parent Interview Schedules Family assessment GAD: Treatment CBT Facilitates modification of negative thought patterns that lead to emotional distress– Cognitive restructuring Facilitates development of emotional regulation to modulate excessive arousal Shaping and strengthening adaptive behavior patterns– Problem solving Relaxation techniques May include parent training component and psychoeducation Pharmacotherapy SSRIs, venlafaxine* Parent-Child and Family Interventions GAD: Help for kids and caregivers SSRIs: the skinny Fluoxetine* 5-80mg daily Can be activating Long half-life no tapering needed Sertraline Drug Counseling 12.5-200mg daily 1. Side effects: Divide BID for patients under 14yo HA, Citalopram abdominal 5-40mg daily pain, Can be sedating HS dosing if needed activation QTc prolongation 2. Serotonin Escitalopram* syndrome 2.5-20mg daily Fewer side effects theoretically, but same as citalopram *FDA approved in children SSRIs: what NOT to do NO Paroxetine Very short half-life withdrawal symptoms Agitation or restlessness Serotonin syndrome Confusion Rapid heart rate and high blood dextromethorphan pressure Dilated pupils Loss of muscle coordination or SNRIs: trazodone (!), SSRIs, TCAs, twitching muscles rigidity MAOIs, St. John’s Wort, lithium, SGAs Muscle Heavy sweating Diarrhea Headache Tramadol Shivering Goose bumps Triptans ---------------------High fever Seizures linezolid Irregular heartbeat Unconsciousness Withdrawal syndrome SSRI Withdrawal Syndrome F I N I S H Flu-like symptoms Fatigue Lethargy General malaise Muscle aches/headaches Diarrhea Insomnia Nausea Imbalance Gait instability Dizziness/lightheadedness Vertigo Sensory disturbances Paresthesia “Electric shock” sensations– “brain zaps” Visual disturbance Hyperarousal Anxiety Agitation Case #2 CC: “She is always up my ass.” 6 yo JE is brought in by her mother due to tantrums and not being able to do anything by herself. She incessantly asks about mom, needing reassurance constantly, and refuses to go anywhere or do anything without mom. She “freaks out” when mom is late from work or separated from her: crying, hyperventilating, and refusing to go to sleep until mom returns from work at 9:30-11:30 PM. JE follows mom around the house, even into the bathroom, and will wait outside on the sidewalk with her blanket until mom returns home from work that night, regardless of the weather, including in snow and rain. She refuses to go to school regularly and will “clock-watch.” Separation Anxiety Disorder Excessive anxiety or worry about being separated from attachment figures or home something bad will happen to them or caregiver that results in permanent separation Developmentally inappropriate Causing significant disturbance in important areas of functioning At least 4 weeks of symptoms in children Early onset is onset > 6 yo **School refusal is the most common behavior and occurs 75% of the time** Separation Anxiety Disorder: Diagnostic Criteria Three (or more) of the following: recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated persistent and excessive worry about losing, or about possible harm befalling, major attachment figures persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped) persistent reluctance or refusal to go to school or elsewhere because of fear of separation persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home repeated nightmares involving the theme of separation repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated Separation Anxiety Disorder: What does it look like? Crying or hiding from parents Shadowing parents and refuse to go anywhere without them Nightmares of being kidnapped or taken away Somatic sx See risk factors for GAD, especially insecure attachment Separation Anxiety Disorder: Outcomes Longitudinal studies: some pt’s have resolution of sx, some don’t Predictors of persistence of sx: Comorbid ODD, ADHD Maternal marital dissatisfaction Starting with SAD makes you more likely to have anxiety d/o as an adult Separation Anxiety Disorder: Treatment Parent training Particularly helpful with younger children Focus on teaching strategies to help manage anxiety, and identify and shape adaptive coping skills CBT Facilitates modification of negative thought patterns that lead to emotional distress Facilitates development of emotional regulation to modulate excessive arousal Shaping and strengthening adaptive behavior patterns May include parent training component and psychoeducation Pharmacotherapy SSRIs Case #3 A.P is a 14yo female with history of anxiety who is referred by her PCP for worsening school anxiety. Mom reports A.P. used to be “friendly,” has always been shy but able to make and keep friends. Now she avoids being around any peers at all, even family and cousins. She states people don't like her and don't care about her. She attends a girls group for group therapy in Winchester-- sometimes cannot even get out of car to go into building and attend. Pt then beats herself up after group for not being able to talk or speak like the other girls. Pt avoids going to school-- thinks everyone is against her and hates her. Level of functioning has decreased significantly since end of 2013: prefers not to got out, and is now in homebound schooling. Pt worries about what others think, afraid of “getting it wrong,” very sensitive and takes things very personally. On interview, she wants to be able to go to school and "be normal, and do things" such as have friends, go out and socialize, and feel happier. On exam A.P. is reluctant and reticent but cooperative, has intermittent-poor eye contact, withdrawn and guarded. Affect is constricted, tearful, severely anxious Social Anxiety Disorder– DSM5-Style A. B. C. D. E. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. (Note: In children, the anxiety must occur in peer settings and not just during interactions with adults) The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. The social situations are avoided or endured with intense fear or anxiety. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. Social Anxiety Disorder: Development and Course Median age of onset: 13yo Sometimes emerges out of a history of shyness Onset may follow a stressful or humiliating experience or insidious and slow First onset in adulthood is rare Younger patients = high levels of anxiety over specific situations Older patients = lower levels of anxiety over broader range of situations Remission: 30% remit in 1 yr, 50% in a few years, 60%-without treatment– takes several years or longer Separation Anxiety Disorder: Treatment Therapy: CBT psychodynamic graduated exposure therapy Pharmacological: SSRI’s hydroxyzine Case #4 CC: “My bad behavior” V.L. is a 9 yo adopted female who was referred in by her therapist for ongoing out of control behavior. Pt was adopted at 3½ yo and has always been defiant, manipulative, physically aggressive with significant tantrums, and impulsive. She is alternately overlyaffectionate and untrusting of her parents– cheating, stealing (esp food), lying. Past history is significant for severe neglect, “deplorable living conditions,” removal from home at 2yo, placement with 4 foster families within 18mos, and finally placement with current family. Reactive Attachment Disorder (DSM 5) A. Inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: The child rarely or minimally seeks comfort when distressed. The child rarely or minimally responds to comfort when distressed. B. A persistent social and emotional disturbance characterized by at least two of the following: Minimal social and emotional responsiveness to others. Limited positive affect. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers. RAD: Pathogenic Care Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). Disinhibited Social Engagement Disorder 1. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: Reduced or absent reticence in approaching and interacting with unfamiliar adults. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. Willingness to go off with an unfamiliar adult with minimal or no hesitation. ****not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behavior. **** 2. Pathogenic care is the same as RAD. Conclusions Not all worry and fears are pathological. Many are developmentally appropriate and reflect typically developing children While some risk factors are innate, many are not, and targeting these environmental influences can affect the trajectory of anxiety Specific anxiety disorders can morph into each other, making complete resolution difficult but possible. Therapy is the mainstay of anxiety treatment. Medications can enhance the process. Fine Case #3 CC: Mood swings 16 yo AB was referred from pediatric neurology following multiple ED visits for nonepileptic sz, which began 1 yr ago. Pt admits that 1 yr ago, she disclosed to her friend that her older brother had sexually abused repeatedly at age 6yo. Friend told the VP, who told pt’s uncle-guardian, after which pt began “acting out”: defiant, outbursts, breaking rules; alternating with quiet and withdrawn. Pt admits to having nightmares every night and was admitted for SI 3 mos ago. Pt also reports that she sees the abuse happening in her mind and feels numb. She sleeps in the same room the abuse occurred and feels terrified in her room. PGM-guardian reports that pt subsequently started therapy and, during one of these therapy sessions, pt had an episode in which she seemed to suddenly behave differently, “like a completely different persona,” for 10 minutes, followed by abrupt fatigue and amnesia of the episode. Post Traumatic Stress Disorder T rauma R e-experiencing A voidance U nable to function M onth A rousal PTSD: Risk factors in children Girls > boys Poorer performance on neurocognitive tests prior to trauma = ↑ vulnerability to developing PTSD Emotional problems before 6yo Childhood adversity Lots of comorbidities: MDD, anxiety, ADHD, ODD, CD, substance use ***Social support is protective*** Post Traumatic Stress Disorder T rauma R e-experiencing A voidance U nable to function M onth A rousal PTSD: Trauma DSM IV the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others the person's response involved intense fear, helplessness, or horror. DSM 5 Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: Note: In children, this may be expressed instead by disorganized or agitated behavior Directly experiencing the traumatic event(s). Witnessing, in person, the event(s) as it occurred to others. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. PTSD: Trauma in Children Child abuse (physical, sexual) Violence: community, domestic, school Disasters War or terrorism Medical traumas Serious accidents Sudden or violent death of someone close to the child Post Traumatic Stress Disorder T rauma R e-experiencing A voidance U nable to function M onth A rousal PTSD: Re-experiencing Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Post Traumatic Stress Disorder T rauma R e-experiencing A voidance U nable to function M onth A rousal PTSD: Avoidance DSM IV efforts to avoid thoughts, feelings, or conversations associated with the trauma efforts to avoid activities, places, or people that arouse recollections of the trauma ---------------------------------------------------------- inability to recall an important aspect of the trauma markedly diminished interest or participation in significant activities feeling of detachment or estrangement from others restricted range of affect (e.g., unable to have loving feelings) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) Continued… DSM 5 Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). PTSD: DSM 5 Cognitive and Mood Changes DSM IV inability to recall an important aspect of the trauma markedly diminished interest or DSM 5 Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). Markedly diminished interest or participation in significant activities. Feelings of detachment or estrangement from others. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). participation in significant activities feeling of detachment or estrangement from others restricted range of affect (e.g., unable to have loving feelings) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) Post Traumatic Stress Disorder T rauma R e-experiencing A voidance U nable to function M onth/Mood A rousal Post Traumatic Stress Disorder T rauma R e-experiencing A voidance U nable to function M onth/ Mood A rousal PTSD: Arousal Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. Reckless or self-destructive behavior. Hypervigilence. Exaggerated startle response. Problems with concentration. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). PTSD: Specifiers DSM 5 With dissociative symptoms: in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). Specify if: With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate). PTSD: DSM 5-- for Children 6 Years and Younger Trauma Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures. Re-experiencing/Intrusive sx Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment. Dreams: it may not be possible to ascertain that the frightening content is related to the traumatic event. Avoidance + Cognitive/Mood changes Markedly diminished interest or participation in significant activities, including constriction of play. Includes socially withdrawn behavior Arousal sx Including extreme temper tantrums ****The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior. **** PTSD in kids: More of what it looks like In young children, developmental regression, such as loss of language Children may not manifest fearful reactions (may focus on imagined interventions in their play or story-telling) In addition to avoidance, children may become preoccupied with reminders Children may experience co-occurring traumas (physical abuse and witnessing domestic violence) In chronic circumstances, may not be able to identify onset of sx Avoidance can also look like: exploratory behavior in young children reduced participation in new activities in school-aged children reluctance to pursue developmental opportunities in teens (dating, driving) older kids and teens may judge themselves as cowardly Teens: may harbor beliefs of being changed in ways that make them socially undesirable and estrange them from peers or lose aspirations for the future. PTSD: Diagnosis The challenge: how do you make a child talk about something that their condition is making them avoid or who are not developmentally capable of describing their experiences Collateral: pediatrician, forensic evaluator, police, CPS, child advocacy centers UCLA PTSD Reaction Index (for DSM IV) CPSS (Child PTSD Symptom Scale) PsySTART (13-item questionnaire for rapid triage) Zero to Three PTSD: Treatment *****Trauma-Focused CBT***** P sychoeducation, parenting skills R elaxation A ffective modulation C ognitive Processing T rauma narrative I n vivo mastery of trauma memories C onjoint child-parent sessions E nhancing safety PTSD: Treatment CBITS (Cog-Behavioral Interventions for Trauma in Schools) Same as TF-CBT but done in groups at school So no parents CPP (Child-Parent Psychotherapy) For very young children Cognitive-based CBT TST (Trauma Systems Therapy) More intensive Wrap-around services Medications– NO GOOD EVIDENCE FOR ANY