9/9/2016 Anxiety disorders are the most common mental health - PDF document

9/9/2016 “Anxiety disorders are the most common mental health diagnoses in youth, and carry risks for ongoing impairments and subsequent development of other psychiatric [and medical] comorbidities into adulthood. ” PEDIATRIC ANXIETY DISORDERS: TIPS AND TECHNIQUES FROM A CHILD PSYCHIATRIST Karen Seroussi DO Vibrant Minds Child and Adolescent Psychiatry Austin, TX DISCLOSURES Policies and standards of the Texas Medical Association, the Accreditation Council for • Continuing Medical Education, and the American Medical Association require that speakers and planners for continuing medical education activities disclose any relevant financial relationships they may have with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients whose products, devices or services may be discussed in the content of the CME activity. The planners and speakers have no relevant relationships to disclose. I do not intend to discuss an unapproved/investigative use of a commercial • product/device in my presentation. OBJECTIVES  Review the clinical presentation of anxiety in children and adolescents  Discuss evidence-based treatment modalities,  therapies  medication  Identify environmental supports for the anxious child  parent-mediated interventions  community and educational resources. 1

9/9/2016 NEED FOR INTERVENTION IN PRIMARY CARE • ~20% of children experience mental health issues • >50% of mental health issues start before age 14 • Delay of onset of treatment for youth is 8-10 yr • Increased risk for co-morbid disorders that affect behavior and learning • Access to mental health services; only 20% receive treatment • Pediatricians are considered the “first resource” for parents 5); ); NIMH (2005 ). EPIDEMIOLOGY Prevalence: • • Any anxiety disorder 6-20% (often comorbid) Separation Anxiety disorder ; children 4.1-12.% and adolescents 1.3%  school refusal • Social Anxiety disorder; 3.9 – 6.9% • • GAD; 2.9-4.6% Gender distribution is equal in children and female > male in adolescents • • Risk factors 2-3x risk of depression as an adult • • Increased risk of underachieving as young adults Increased rate of substance use disorders • INFANCY OF PEDIATRIC ANXIETY Predisposition to sensitive temperament • Environmental component • • Traumatic event(s) • Change(s) in care Childcare/parenting interaction • Repetitive behavior pattern, often with identifiable trigger: • Separation • Social interaction • • Trying new things • Theory = genetic variant (ie SNP or receptor predisposition) +/- neuronal circuitry changes 2

9/9/2016 CASES + STRESSOR • Jessica: Separation anxiety Age 3 – new baby in the NICU • Age 4 – uncle gets Leukemia • Max: Generalized Anxiety • • Age 1-3 – Isolated at home with sick sibling • Age 4 – Bullying in preschool • Age 5-8 – Undiagnosed learning disorder Alena: Social Anxiety • • Questions to ask: when did this first start? what was going on when this happened? Then what? Take Home: kids are less resilient than most people think • ROLE OF PARENTAL MATCH/MISMATCH Match/mismatch coined by Temperament research in the 1960’s (Chess and Thomas) – “goodness of fit” • • Mental Health psychopathology in the parent • Higher risk for co-morbidities and lifelong mental health issues Higher risk for lifelong health issues (ACES study) • Decreased ability to make changes to their behavior • Recommendations • • Stronger need for Family Therapy Monitor for comorbid disorders • • More likely to need medication treatment High functioning parents • • Decreases the level of treatment needed Parents can rapidly improve the environment • PRESENTATION Internalizers • Fear without recognizing it is unreasonable or out of proportion • Refusal to do age-appropriate behavior • Somatic complaints • Self-critical statements • Seek excessive reassurance • Often perfectionistic • • Misinterpret social interaction and their own performance or behavior • Externalizers Irritable • Angry outbursts • Phobic behavior • Risk of substance use • 3

9/9/2016 SCREENING • Considered a minimum standard in pediatric mental health treatment • Initial evaluation Tracking progress • Question is who to screen?? • Parents • • Often poor identifiers of the child’s inner experience Good assessment of impact on family and school fxn • Children -- Risk to results if the child wants to please or not worry the interviewer or is not cooperative • Validated Tools • • SCARED – general screen and also subscales available SPIN – Social Phobia inventory • GAD-7 – only 7 questions, not for young children • Screen for Child Anxiety Related Disorders (SCARED) PARENT Version —Page 1 of 2 (to be filled out by the PARENT) Developed by Boris Birmaher, M.D., Suneeta Khetarpal, M.D., Marlane Cully, M.Ed., David Brent, M.D., and Sandra McKenzie, Ph.D., Western Psychiatric Institute and Clinic, University of Pittsburgh (October, 1995) . E-mail: birmaherb@upmc.edu See: Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38 (10), 1230–6. Name: __________________________________________ Date: __________________________________ Directions : Below is a list of sentences that describe how people feel. Read each phrase and decide if it is “Not True or Hardly Ever True” or “Somewhat True or Sometimes True” or “Very True or Often True” for your child. Then, for each statement, fill in one circle that corresponds to the response that seems to describe your child for the last 3 months . Please respond to all statements as well as you can, even if some do not seem to concern your child. 0 1 2 Somewhat Not True True or Very True or Hardly Sometimes or Often Ever True True True 1. When my child feels frightened, it is hard for him/her to breathe O O O PN 2. My child gets headaches when he/she am at school. O O O SH 3. My child doesn’t like to be with people he/she does't know well. O O O SC 4. My child gets scared if he/she sleeps away from home. O O O SP 5. My child worries about other people liking him/her. O O O GD 6. When my child gets frightened, he/she fells like passing out. O O O PN 7. My child is nervous. O O O GD O O O 8. My child follows me wherever I go. SP O O O 9. People tell me that my child looks nervous. PN O O O 10. My child feels nervous with people he/she doesn’t know well. SC O O O 11. My child gets stomachaches at school. SH O O O PN 12. When my child gets frightened, he/she feels like he/she is going crazy. O O O SP 13. My child worries about sleeping alone. 14. My child worries about being as good as other kids. O O O GD 15. When my child gets frightened, he/she feels like things are not real. O O O PN 16. My child has nightmares about something bad happening to his/her parents. O O O SP 17. My child worries about going to school. O O O SH 18. When my child gets frightened, his/her heart beats fast. O O O PN 19. He/she child gets shaky. O O O PN 20. My child has nightmares about something bad happening to him/her. O O O SP 4

9/9/2016 D/DX • Medical comorbidities or primary disorders Pulmonary (allg, asthma) Medication SE • • Endocrine (DM, thyroid) ASD/ ADHD/learning disorders • • CNS issues Abuse • • Cardiac (ie conduction defect) Caffeinism • • • Anxiety disorders Separation Anxiety Disorder Panic Attack Specifier • • Social Anxiety Disorder Agoraphobia • • • Generalized Anxiety Disorder • Substance/Medication-Induced Selective Mutism Secondary to Medical Condition • • Specific Phobia (animal, nature, Other Specified Anxiety Disorder • • med, situation, other) Unspecified Anxiety Disorder • Panic Disorder • TREATMENT • Multi-modal is standard of care Environmental support • Environment Therapy Home • • School • Community programs Therapeutic modalities • Medication • Medicati on • When is medication necessary? TREATMENT CONSIDERATIONS Acuity • • Severity of sx Duration of sx • • Parent psychopathology Parenting interaction pattern = match/mismatch • Educational Setting • Family’s ability or desire to participate in treatment • Child’s ability and willingness to actively engage in treatment • • CAMS = Child and Adolescent Anxiety Multimodal Study • RCT – 448 patients 5