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10/14/15 ANXIOUS KIDS A PRIMARY CARE APPROACH -­‐MEDS AND MORE
Trea<ng Childhood Anxiety Disorders C. Allen Musil Jr MD OBJECTIVES 1.  List 3 classes of medica<on commonly prescribed to treat childhood anxiety. 2.  List 2 appropriate reasons to ini<ate medica<on in an anxious child. 3.  List 3 common side effects of SSRI treatment in children. 4.  List two things a primary care provider can do when interac<ng with school systems, when trea<ng a child/adolescent with school refusal 2nd to anxiety. 1 10/14/15 Measuring Outcomes Ques9on: –  True Or False? You are trea<ng a 10-­‐year-­‐old child who refuses to aWend school because of anxiety, has truancy charges filed, and is at risk of removal from parents and placement in a residen<al group home. Individual and family therapy is in place for the last 6 months but there is liWle progress. Star<ng medica<on for anxiety is appropriate. Disclosure •  I am on the speaker panel for the drug company Novar<s. I will not be men<oning the Novar<s schizophrenia medica<on during this presenta<on. Outline • Defini<ons (DSM V) • Approach • Treatments 2 10/14/15 DEFINITIONS (adult) •  Anxiety is an unpleasant state of inner turmoil, o_en accompanied by nervous behavior, such as pacing back and forth, soma<c complaints and rumina<on. It is the subjec<ve unpleasant feelings of dread over something unlikely to happen, such as the feeling of imminent death DEFINITION •  Anxiety is not the same as fear, which is a response to a real or perceived immediate threat; whereas anxiety is the expecta<on of future threat •  Anxiety can be appropriate, but when it is too much and con<nues too long, the individual may suffer from an anxiety disorder. Fear or ANXIETY?? 3 10/14/15 DEFINITIONS •  Fear and anxiety can be differen<ated in four domains: (1) dura<on of emo<onal experience, (2) temporal focus, (3) specificity of the threat, and (4) mo<vated direc<on. Fear is defined as short lived, present focused, geared towards a specific threat, and facilita<ng escape from threat; while anxiety is defined as long ac<ng, future focused, broadly focused towards a diffuse threat, and promo<ng excessive cau<on while approaching a poten<al threat and interferes with construc<ve coping. – 
Sylvers, et all, (2011) “Differences between trait fear and trait anxiety”, Clinical Psychology Review 31 (1): 122-­‐37 Working towards a DEFINITION of: •  Anxiety Disorders-­‐ –  Most cases of anxiety are common, predictable, normal, a basic emo<on –  Ongoing excessive worry, nervousness, and anxiety felt intensely and interfering-­‐could be a disorder –  Exaggerated and not appropriate for developmental age, pervasive, out of propor<on to the situa<on at hand-­‐ could be a disorder 4 10/14/15 Working towards a DEFINITION of: •  ANXIETY DISORDERS -­‐ –  DSM-­‐IV & V Core Anxiety Criteria •  Persistent worry or fear (a required <me period) •  Significant distress with/without avoidance •  Interferes with and results in daily dysfunc<on in school, play, home, work, social, developmental milestones •  Symptoms are <me-­‐consuming •  Exclusion criteria (meds/substance, psychological effects, (Hiss)
medical condi<on) NORMAL or ABNORMAL?? 5 10/14/15 Epidemiology/ Prevalence (HISTORICAL)
•  General –  Infant/toddler 100% –  Children 10% –  Adolescence 15% –  Adults 20% •  Females> Males (2:1) •  Gene<c component Rynn et al. 2011 (6-­‐18%) “Laughing Tiger” The Magic Years – Understanding and Handling the Problems of Early Childhood Selma Fraiberg, SCRIBNER, 1957 (2008 edi<on with introduc<on by T. Berry Brazelton MD) Jan a 2 year and 8 month old female who “reforms laughing <ger”……”He doesn’t roar. He never scares children. He doesn’t bite. He just laughs. He has to learn to mind.” Anxiety is Normal (100%) “So there are no ways in which a child can avoid anxiety. If we banished all the witches and ogres from his bed <me stories and policed his daily life for every conceivable source of danger, he would s<ll succeed in construc<ng his own imaginary monsters out of the conflicts of his young life. We do not need to be alarmed about the presence of fears in the small child’s life if the child has the means to overcome them” (p.
14) 6 10/14/15 There is a normal developmental process to early infant/toddler anxiety •  Protec<on moves from parent over <me to child. Each child’s reac<on and defenses to anxiety and fear are specific to them. The more a parent understands and fosters these specific abili<es, the more a parent helps their child deal with the fear/anxiety process. Imagina<on! •  “Now there is one place where one can meet a ferocious beast on you own terms and leave victorious. That place is the imagina<on. It is a maWer of individual taste and preference whether the beast should be slain, maimed, banished, or reformed, but no one needs to feel helpless in the presence of imaginary beast when the imagina<on offers such solu<ons.” (p. 17) J. AACAP (49):10 Oct 2010 7 10/14/15 Great Smoky Mountain Anxiety Study •  1,420 par<cipants from 11 coun<es in SW North Carolina •  13 year study •  Ages 9 to 26 •  Ended 2010 •  Primary result= 1 in 5 met DSM IV criteria for anxiety disorder by early adulthood (age 26) 8 10/14/15 Meta-­‐analysis Anxiety Review 2011 Costello EJ, et all. The developmental epidemiology of anxiety disorders: phenomenology, prevalence, and comorbidity. Anxiety Disorders Children Adolescent 2011: 56-­‐75 • 
Risk Factors for Anxiety Disorders • 
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Shyness-­‐temperament trait Early age significant medical disorder Family history Chaos Overprotec<on –  Connolly & Bernstein 2007 9 10/14/15 What to look for: •  Repeated physical complaints-­‐headaches, stomachaches, drama<c presenta<ons of pain •  Problems falling asleep and mul<ple awakenings •  Ea<ng problems -­‐ too much or too liWle •  Avoidance •  Excessive need for reassurance •  InaWen<on/poor performance •  Outburst •  Dysfunc<on or lack of appropriate developmental steps •  Anxious parents ANXIETY DISORDERS (FLAVORS) DSM-­‐IV and V Separa<on anxiety disorder Selec<ve mu<sm Specific phobia Social anxiety disorder (Social Phobia) Panic Disorder Agoraphobia Generalized anxiety disorder Below got their own Chapter in DSM V •  Obsessive-­‐compulsive disorder and related • 
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–  Body Dysmorphic Disorder, Hoarding, Tricho<llomania, Excoria<ng Disorder, OCD, others •  Trauma and Stressor Related Disorders (Needs correc<ng) – 
Reac<ve AWachment, Disinhibited social engagement, PTSD, Acute Stress , Adjustment, others 10 10/14/15 Separa9on Anxiety Disorder Criteria: A,B,C,D
(MUST HAVE ALL 4 CRITERIA TO GIVE DIAGNOSIS) (DSM V)
•  A. Developmentally inappropriate and excessive fear or anxiety concerning separa<on from those to whom the individual is aWached, as evidenced by at least 3 of the following: 1.  Recurrent excessive distress when an<cipa<ng or experiencing separa<on from home or from major aWachment figures 2.  Persistent and excessive worry about losing major aWachment figures or about possible harm to them, such as illness, injury, disasters, or death 3.  Persistent and excessive worry about experiencing an untoward event (i.e.. Kidnapping, etc.) that causes separa<on from a major aWachment figure 4.  Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separa<on 5.  Persistent and excessive fear of/or reluctance about being alone or without major aWachment figures at home or in other seungs 6.  Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major aWachment figure 7.  Repeated nightmares involving the theme of separa<on 8.  Repeated complaints of physical symptoms (i.e.. headaches, stomachaches, etc.) when separa<on for major aWachment figures occurs or is an<cipated 11 10/14/15 Separa9on Anxiety Disorder Criteria: A,B,C,D
(MUST HAVE ALL 4 CRITERIA TO GIVE DIAGNOSIS) (DSM V)
•  B. Fear, anxiety, or avoidance is persistent, las<ng at least 4 weeks in children and adolescents and typically 6 months or more in adults •  C. The disturbance causes clinically significant distress or impairment in social, academic, occupa<onal, or other important areas of func<oning •  D. The disturbance is not beWer explained by another mental disorder…….(psychosis, au<sm, delusional disorder, etc.……..) Separa9on Anxiety Disorder •  Risk factors –  Precursor panic disorder, Social Phobia –  School refusal –  O_en come from close-­‐knit protec<ve families –  Parental factor Selec<ve Mu<sm •  Consistent failure to speak in specific social situa<ons (in which there is an expecta<on for speaking, e. g., at school) despite speaking in other situa<ons. •  The disturbance interferes with educa<onal or occupa<onal achievement or with social communica<on. •  The dura<on of the disturbance is at least 1 month (not limited to the first month of school). •  The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situa<on. •  The disturbance is not beWer accounted for by a Communica<on Disorder (e. g., StuWering) and does not occur exclusively in the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psycho<c Disorder. 12 10/14/15 Specific Phobia • 
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Marked and persistent fear that is excessive or unreasonable, cued by the presence or an<cipa<on of a specific object or situa<on (e.g., flying, heights, animals, receiving an injec<on, seeing blood). Exposure to the phobic s<mulus almost invariably provokes an immediate anxiety response, which may take the form of a situa<onally bound or situa<onally predisposed Panic AWack. –  Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. • 
The person recognizes that the fear is excessive or unreasonable. • 
The phobic situa<on(s) is avoided or else is endured with intense anxiety or distress. The avoidance, anxious an<cipa<on, or distress in the feared situa<on(s) interferes significantly with the person's normal rou<ne, occupa<onal (or academic) func<oning, or social ac<vi<es or rela<onships, or there is marked distress about having the phobia. In individuals under age 18 years, the dura<on is at least 6 months –  Note: In children, this feature may be absent. • 
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Social Anxiety Disorder (Social Phobia) •  High risk for depression •  High risk substance abuse •  High risk school refusal Panic disorder With/without agoraphobia •  Understand the difference between anxiety disorder and panic disorder •  Can present as anger aWacks 13 10/14/15 Generalized Anxiety Disorder •  Excessive anxiety and worry (apprehensive expecta<on), occurring more days than not for at least 6 months, about a number of events or ac<vi<es (such as work or school performance) •  The person 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 present for more days than not during the past 6 months). – 
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Note: Only one item is required in children. 1. restlessness or feeling keyed up or on edge. 2. being easily fa<gued. – 
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3. difficulty concentra<ng or mind going blank. 4. irritability. 5. muscle tension. 6. sleep disturbance (e.g., difficulty falling asleep, staying asleep, or restless sleep). •  The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupa<onal, or other important areas of func<oning. Obsessive-­‐compulsive disorder • 
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Obsessions Compulsions Bimodal presenta<on in children/adolescence Very common diagnosis PTSD-­‐ Post Trauma<c Stress Disorder •  Acronym –  A anxiety –  R re-­‐experience –  E experience –  A avoidance •  Good prognosis 14 10/14/15 Treatment Approach 1.  Prac9ce Parameters –  American Acad. of Child/Adol .Psychiatrist (www.aacap.org)
•  OCD 2012 •  PTSD 2010 •  Anxiety Disorders 2007 2. 
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–  Tennessee Behavioral Health Guidelines for Children and Adolescents from Birth to 17 years of age (
www.tennessee.gov/mental/policy/best pract children.shtml) Evidence-­‐based treatment/research, algorithms FDA approval Worst approach Worstest! AACAP Treatment Guidelines for Anxiety Disorders Journal of the American Academy of Child and Adolescent Psychiatry 46:2 February 2007
Rou<nely screen Formal evalua<on Differen<al diagnosis Treatment planning include mul<modal treatment approach 5.  Treatment planning consider severity and impairment 6.  Psychotherapy (CBT) 7.  SSRIs first line treatment (no specific sugges<on of SSRI) 8.  Medica<ons other than SSRIs 9.  Consider classroom-­‐based accommoda<ons 10.  Evaluate for comorbid condi<ons 11.  Consider preven<on 15 10/14/15 DIFFERENTIAL DIAGNOSIS •  General Medical –  Medica<on side effects (including akathisia) –  Hypoglycemic episodes –  Hyperthyroidism –  Cardiac arrhythmias –  Asthma/Chronic respiratory illness –  Pheochromocytoma –  Seizure disorders –  CNS disorders –  Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infec<on (PANDAS) »  No good resource DIFFENTIAL DIAGNOSIS •  Psychiatric/Environmental –  Mood disorders –  Pervasive developmental disorders –  ADHD –  Substance abuse (including caffeine) –  Ea<ng disorders –  Schizophrenia –  Personality disorders –  Normal reac<on to severe environmental stressors or dangers (e.g., ongoing vic<m abuse, divorce) –  take home principle is_______________ 16 10/14/15 Anxiety Comorbidity •  20% to 40% of youth with anxiety disorders have comorbid aWen<on disorders –  (Faraone & Kunwar, 2007) •  11% to 69% of anxious youth suffer from a depressive disorder –  (Rosenbaum & Covino, 2005) Treatment Approach •  Nonmedical –  CBT (Cogni<ve Behavioral Therapy) –  Psychodynamic –  Parent-­‐child and family interven<ons •  Medical –  SSRI –  Others Cogni<ve Behavioral Therapy for Anxiety •  Children and adolescents learn to stop associa<ng s<mulus with anxiety response as well as learning coping mechanism –  Mo<va<on required –  AWendance required –  Family support –  Money 17 10/14/15 Cogni9ve Behavioral Therapy for Anxiety •  Exposure based cogni<ve behavioral therapy has the most empirical support •  Most CBT incorporates –  Psych educa<on –  Soma<c management skills training –  Cogni<ve restructuring –  Exposure methods ( with desensi<za<on) –  Relapse preven<on plans –  Compton,Kratochvil & March 2007 –  BarreW et al. 2001 –  Galla et al. 2012 Interven9ons at School for Anxiety Disorders •  Establish check-­‐ins on arrival •  Accommodate late arrival •  Allow extra <me for moving to another ac<vity/class •  Iden<fy a “safe” place •  Develop relaxa<on techniques/strategies •  Encourage small group interac<ons •  Reward a child’s efforts •  DON’T USE HOMEBOUND Specific Anxiety Disorder Treatment •  Nonmedical treatment maWers a liWle –  i.e. Trauma focused therapy for PTSD –  i.e. DO NOT USE HOMEBOUND with social phobia •  Medical treatment (choice does not maWer when it comes to efficacy-­‐ it is ok to choose any SSRI) (another words, the medica<on is not diagnosis specific-­‐ it is symptom specific) 18 10/14/15 When to use medica9on? •  In the END, it comes down to the degree/severity of symptoms and “___________________” 19