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ANXIOUS KIDS A PRIMARY CARE APPROACH -­‐MEDS AND MORE
Trea7ng Childhood Anxiety Disorders C. Allen Musil Jr MD OBJECTIVES 1.  List 3 classes of medica7on commonly prescribed to treat childhood anxiety. 2.  List 2 appropriate reasons to ini7ate medica7on 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 interac7ng with school systems, when trea7ng a child/adolescent with school refusal 2nd to anxiety. Measuring Outcomes Ques9on: –  True Or False? You are trea7ng a 10-­‐year-­‐old child who refuses to aVend school because of anxiety, has truancy charges filed, and is at risk of removal from parents and placement in a residen7al group home. Individual and family therapy is in place for the last 6 months but there is liVle progress. Star7ng medica7on for anxiety is appropriate. Disclosure •  I am on the speaker panel for the drug company Novar7s. I will not be men7oning the Novar7s schizophrenia medica7on during this presenta7on. Outline • Defini7ons (DSM V) • Approach • Treatments DEFINITIONS (adult) •  Anxiety is an unpleasant state of inner turmoil, o^en accompanied by nervous behavior, such as pacing back and forth, soma7c complaints and rumina7on. It is the subjec7ve 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 expecta7on of future threat •  Anxiety can be appropriate, but when it is too much and con7nues too long, the individual may suffer from an anxiety disorder. Fear or ANXIETY?? DEFINITIONS •  Fear and anxiety can be differen7ated in four domains: (1) dura7on of emo7onal experience, (2) temporal focus, (3) specificity of the threat, and (4) mo7vated direc7on. Fear is defined as short lived, present focused, geared towards a specific threat, and facilita7ng escape from threat; while anxiety is defined as long ac7ng, future focused, broadly focused towards a diffuse threat, and promo7ng excessive cau7on while approaching a poten7al threat and interferes with construc7ve 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 emo7on –  Ongoing excessive worry, nervousness, and anxiety felt intensely and interfering-­‐could be a disorder –  Exaggerated and not appropriate for developmental age, pervasive, out of propor7on to the situa7on at hand-­‐ could be a disorder Working towards a DEFINITION of: •  ANXIETY DISORDERS -­‐ –  DSM-­‐IV & V Core Anxiety Criteria •  Persistent worry or fear (a required 7me period) •  Significant distress with/without avoidance •  Interferes with and results in daily dysfunc7on in school, play, home, work, social, developmental milestones •  Symptoms are 7me-­‐consuming •  Exclusion criteria (meds/substance, psychological effects, (Hiss)
medical condi7on) NORMAL or ABNORMAL?? Epidemiology/ Prevalence (HISTORICAL)
•  General –  Infant/toddler 100% –  Children 10% –  Adolescence 15% –  Adults 20% •  Females> Males (2:1) •  Gene7c 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 edi7on with introduc7on by T. Berry Brazelton MD) Jan a 2 year and 8 month old female who “reforms laughing 7ger”……”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 7me stories and policed his daily life for every conceivable source of danger, he would s7ll succeed in construc7ng 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) There is a normal developmental process to early infant/toddler anxiety •  Protec7on moves from parent over 7me to child. Each child’s reac7on and defenses to anxiety and fear are specific to them. The more a parent understands and fosters these specific abili7es, the more a parent helps their child deal with the fear/anxiety process. Imagina7on! •  “Now there is one place where one can meet a ferocious beast on you own terms and leave victorious. That place is the imagina7on. It is a maVer 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 imagina7on offers such solu7ons.” (p. 17) J. AACAP (49):10 Oct 2010 Great Smoky Mountain Anxiety Study •  1,420 par7cipants from 11 coun7es 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) 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 Overprotec7on –  Connolly & Bernstein 2007 What to look for: •  Repeated physical complaints-­‐headaches, stomachaches, drama7c presenta7ons of pain •  Problems falling asleep and mul7ple awakenings •  Ea7ng problems -­‐ too much or too liVle •  Avoidance •  Excessive need for reassurance •  InaVen7on/poor performance •  Outburst •  Dysfunc7on or lack of appropriate developmental steps •  Anxious parents ANXIETY DISORDERS (FLAVORS) DSM-­‐IV and V Separa7on anxiety disorder Selec7ve mu7sm 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, Tricho7llomania, Excoria7ng Disorder, OCD, others •  Trauma and Stressor Related Disorders (Needs correc7ng) – 
Reac7ve AVachment, Disinhibited social engagement, PTSD, Acute Stress , Adjustment, others 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 separa7on from those to whom the individual is aVached, as evidenced by at least 3 of the following: 1.  Recurrent excessive distress when an7cipa7ng or experiencing separa7on from home or from major aVachment figures 2.  Persistent and excessive worry about losing major aVachment 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 separa7on from a major aVachment figure 4.  Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separa7on 5.  Persistent and excessive fear of/or reluctance about being alone or without major aVachment 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 aVachment figure 7.  Repeated nightmares involving the theme of separa7on 8.  Repeated complaints of physical symptoms (i.e.. headaches, stomachaches, etc.) when separa7on for major aVachment figures occurs or is an7cipated 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, las7ng 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, occupa7onal, or other important areas of func7oning •  D. The disturbance is not beVer explained by another mental disorder…….(psychosis, au7sm, delusional disorder, etc.……..) Separa9on Anxiety Disorder •  Risk factors –  Precursor panic disorder, Social Phobia –  School refusal –  O^en come from close-­‐knit protec7ve families –  Parental factor Selec7ve Mu7sm •  Consistent failure to speak in specific social situa7ons (in which there is an expecta7on for speaking, e. g., at school) despite speaking in other situa7ons. •  The disturbance interferes with educa7onal or occupa7onal achievement or with social communica7on. •  The dura7on 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 situa7on. •  The disturbance is not beVer accounted for by a Communica7on Disorder (e. g., StuVering) and does not occur exclusively in the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psycho7c Disorder. Specific Phobia • 
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Marked and persistent fear that is excessive or unreasonable, cued by the presence or an7cipa7on of a specific object or situa7on (e.g., flying, heights, animals, receiving an injec7on, seeing blood). Exposure to the phobic s7mulus almost invariably provokes an immediate anxiety response, which may take the form of a situa7onally bound or situa7onally predisposed Panic AVack. –  Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. • 
The person recognizes that the fear is excessive or unreasonable. –  Note: In children, this feature may be absent. • 
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The phobic situa7on(s) is avoided or else is endured with intense anxiety or distress. The avoidance, anxious an7cipa7on, or distress in the feared situa7on(s) interferes significantly with the person's normal rou7ne, occupa7onal (or academic) func7oning, or social ac7vi7es or rela7onships, or there is marked distress about having the phobia. In individuals under age 18 years, the dura7on is at least 6 months 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 aVacks Generalized Anxiety Disorder •  Excessive anxiety and worry (apprehensive expecta7on), occurring more days than not for at least 6 months, about a number of events or ac7vi7es (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 fa7gued. – 
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3. difficulty concentra7ng 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, occupa7onal, or other important areas of func7oning. Obsessive-­‐compulsive disorder • 
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Obsessions Compulsions Bimodal presenta7on in children/adolescence Very common diagnosis PTSD-­‐ Post Trauma7c Stress Disorder •  Acronym –  A anxiety –  R re-­‐experience –  E experience –  A avoidance •  Good prognosis 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! 1. 
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AACAP Treatment Guidelines for Anxiety Disorders Journal of the American Academy of Child and Adolescent Psychiatry 46:2 February 2007
Rou7nely screen Formal evalua7on Differen7al diagnosis Treatment planning include mul7modal treatment approach 5.  Treatment planning consider severity and impairment 6.  Psychotherapy (CBT) 7.  SSRIs first line treatment (no specific sugges7on of SSRI) 8.  Medica7ons other than SSRIs 9.  Consider classroom-­‐based accommoda7ons 10.  Evaluate for comorbid condi7ons 11.  Consider preven7on DIFFERENTIAL DIAGNOSIS •  General Medical –  Medica7on 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 infec7on (PANDAS) »  No good resource DIFFENTIAL DIAGNOSIS •  Psychiatric/Environmental –  Mood disorders –  Pervasive developmental disorders –  ADHD –  Substance abuse (including caffeine) –  Ea7ng disorders –  Schizophrenia –  Personality disorders –  Normal reac7on to severe environmental stressors or dangers (e.g., ongoing vic7m abuse, divorce) –  take home principle is_______________ Anxiety Comorbidity •  20% to 40% of youth with anxiety disorders have comorbid aVen7on disorders –  (Faraone & Kunwar, 2007) •  11% to 69% of anxious youth suffer from a depressive disorder –  (Rosenbaum & Covino, 2005) Treatment Approach •  Nonmedical –  CBT (Cogni7ve Behavioral Therapy) –  Psychodynamic –  Parent-­‐child and family interven7ons •  Medical –  SSRI –  Others Cogni7ve Behavioral Therapy for Anxiety •  Children and adolescents learn to stop associa7ng s7mulus with anxiety response as well as learning coping mechanism –  Mo7va7on required –  AVendance required –  Family support –  Money Cogni9ve Behavioral Therapy for Anxiety •  Exposure based cogni7ve behavioral therapy has the most empirical support •  Most CBT incorporates –  Psych educa7on –  Soma7c management skills training –  Cogni7ve restructuring –  Exposure methods ( with desensi7za7on) –  Relapse preven7on plans –  Compton,Kratochvil & March 2007 –  BarreV et al. 2001 –  Galla et al. 2012 Interven9ons at School for Anxiety Disorders •  Establish check-­‐ins on arrival •  Accommodate late arrival •  Allow extra 7me for moving to another ac7vity/class •  Iden7fy a “safe” place •  Develop relaxa7on techniques/strategies •  Encourage small group interac7ons •  Reward a child’s efforts •  DON’T USE HOMEBOUND Specific Anxiety Disorder Treatment •  Nonmedical treatment maVers a liVle –  i.e. Trauma focused therapy for PTSD –  i.e. DO NOT USE HOMEBOUND with social phobia •  Medical treatment (choice does not maVer when it comes to efficacy-­‐ it is ok to choose any SSRI) (another words, the medica7on is not diagnosis specific-­‐ it is symptom specific) When to use medica9on? •  In the END, it comes down to the degree/severity of symptoms and “___________________”