Evidence-based treatments for Anxiety Disorders in Children and - - PowerPoint PPT Presentation

Evidence-based treatments for Anxiety Disorders in Children and Youth

Christopher Bellonci, M.D. Vice President of Policy and Practice, Chief Medical Officer Judge Baker Children’s Center

Overview of Anxiety disorders

• Most common mental health disorder of childhood.
• Children with anxiety disorders can be shy, isolative, and

somatic or they can be agitated, aggressive and unfocused.

• How does one identify anxiety disorders in children and what

is the evidence base for treatment?

• This presentation will focus on Anxiety disorders, look for OCD

and PTSD to be addressed in separate presentations.

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DSM 5

• The DSM-5 organizes anxiety disorders by typical age of onset:

–separation anxiety disorder, –selective mutism, –specific phobia, –social anxiety disorder (social phobia), –panic disorder, –generalized anxiety disorder, –substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition, other specific anxiety disorder, and unspecific anxiety disorder (APA, 2013).

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– Fears and anxiety are a normal part of development. Toddlers often need to check the closets for imaginary creatures. School-age children fear injury or natural events – they may jump in bed with their parents during

• thunderstorms. And older children and teens worry about their academics,

friends and health. These fears are a normal part of development (AACAP, 2007). – Moreover, anxiety can be useful! For example, healthy anxiety can motivate children to study for tests and stay out of danger. – It’s when these fears interfere with daily functioning over a period of time that a disorder develops.

Differentiating from developmentally appropriate fears and worries

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Consequences of untreated childhood anxiety disorders are myriad

• Increased risk for educational underachievement, low-self

esteem, poor problem-solving, and impaired social development (AACAP, 2007).

• Increased risk for adult anxiety disorders, depression and

substance use (AACAP, 2007).

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• Broad range in presentations that can include both

internalizing and externalizing symptoms:

• Internalizing symptoms include excessive worry and somatic or

bodily complaints.

• Externalizing symptoms can include irritability and oppositional
• behaviors. Children may go to great lengths to avoid the situation
• r object that triggers their anxiety. When pushed to do something

that makes them anxious, they may become aggressive.

Clinical presentation

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Psycho- pathologically relevant symptoms of fear and anxiety

Sleep disturbances, nocturnal panic attacks,

• ppositional

defiant Crying, clinging, withdrawal, freezing, avoidance of salient stimuli, enuresis , sleep terrors Withdrawal, timidity, extreme shyness, feelings of shame

Normative Fears vs. Symptoms of Psychopathology by Developmental Age

Normative fears

Separation Shyness to strangers Fear of loss Death/dying Thunder, lightning, fire, animals, water, nightmares, imaginary creatures School anxiety, performance anxiety Fear of specific

• bjects, germs, natural

disasters, traumatic events Fear of negative evaluation Rejection from peers Infancy and toddlerhood Childhood School age Adolescence

3 6 12

Age

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Anxiety’s Potential Trajectories

Progressive Persistent Waxing and Waning Remitting

3 6 12

Infancy and toddlerhood Childhood School age Adolescence

Psycho- pathologically relevant symptoms of fear and anxiety Normative fears

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Prevalence Estimates for Anxiety Disorders Among US Adolescents (NCS-A)

DSM-IV Disorder Lifetime Prevalence by Sex % Female: Male: Lifetime Prevalence by Age % 13-14y 15-16y 17-18y 12-Month Prevalence % Agoraphobia 3.4 1.4 2.5 2.5 2.0 1.8 Generalized Anxiety DO 3.0 1.5 1.0 2.8 3.0 1.1 Social phobia 11.2 7.0 7.7 9.7 10.1 8.2 Specific phobia 22.1 16.7 21.6 18.3 17.7 15.8 Panic disorder 2.6 2.0 1.8 2.3 3.3 1.9 Separation Anxiety DO 9.0 6.3 7.8 8.0 6.7 1.6 Any Anxiety Disorder* 38.0 26.1 31.4 32.1 32.3 24.9

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Prevalence

• CDC reports 3% of children ages 3-17 years old have a current diagnosis
• f an anxiety disorder

(http://www.cdc.gov/childrensmentalhealth/data.html).

• Lifetime prevalence rates for having at least one anxiety disorder range

from 6% to 20% (Costello et. al., 2004).

• All anxiety disorder subtypes were more frequent in females (Merikangas

KR, et al., 2010).

• Few race/ethnic variations across anxiety disorders, with the exception of

increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (Merikangas KR, et al., 2010).

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Additional Variables

• Earlier onset of puberty is associated with increased risk for reporting

anxiety symptoms. This is true for both girls and boys, but is most strongly reported in girls (Carter R, Silverman WK, Jaccard J, 2011).

• 50% of adolescents with anxiety disorders in NCS-A had the onset of

their disorder by age 6 years (Merikangas KR, et al., 2010).

• While children and adolescents with a diagnosis of anxiety disorder are

more likely than peers to report anxiety disorders as adults, the stability of anxiety disorders over time is relatively low (Last CG, Perrin S, Hersen M, & Kazdin, AE 1996)

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Genetics

• Twin studies suggest there is a strong genetic component to

anxiety disorders (Eley, 2001 in AACAP PP 2007).

• “Children of parents with an anxiety disorder have a

substantially increased risk to also develop an anxiety disorder ” (Beesdo-Braum, K, Knappe, S, 2012)

• Risk is even higher when both parents suffer from an anxiety

disorder and for children of parents with severe anxiety disorders (Beesdo-Braum, K, Knappe, S, 2012).

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Environment

• Parents with anxiety disorders may model anxious approaches

to their children

• Overprotective, controlling and critical parenting styles can

interrupt normal development of autonomy and mastery and lead to anxiety disorders (AACAP, 2007)

• Parental unemployment is associated with anxiety disorders in

children (Beesdo-Braum, K, Knappe, S, 2012).

• Protective factor: Coping skills (AACAP, 2007), which form the

basis for many of the evidence-based psychosocial interventions.

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Treatment starts with assessment

• AACAP recommends obtaining data from multiple informants,

including the youth and adults (parents/teachers), because children may be more aware of internal distress than adults, but adults are often more aware of the functional impact of a child’s anxiety disorder (AACAP, 2007).

• Tools for assessment: Two commonly used, well-validated and

publically available tools to screen for anxiety disorders are the Screen for Child Anxiety Related Disorders (SCARED) and the Spence Children’s Anxiety Scale (SCAS) (Holly, LE, Little, M, Pina, AA, Caterino, LC, 2015).

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SCARED

Child version: http://psychiatry.pitt.edu/sites/default/files/Documents/assessments/SC ARED%20Child.pdf Parent Version: http://www.psychiatry.pitt.edu/sites/default/files/Documents/assessment s/SCARED%20Parent.pdf SCARED is also available in numerous translations, including Arabic, Chinese, French, German, Italian, Thai, Spanish, and Tamil (Sri Lanka). http://www.pediatricbipolar.pitt.edu/content.asp?id=2333 There is also a five-item brief version

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SCAS

• 38-item questionnaire rating the symptoms experience on a four-point

scale that is available in 28 languages (http://www.scaswebsite.com).

• Recent research “indicated that the SCAS is a fairly robust measure

across ethnicity (i.e., Hispanic/Latino, NHW) and sex, with more variations for the latter” – girls were slightly less likely to report anxiety symptoms on some measures as compared to boys (Holly, LE, Little, M, Pina, AA, Caterino, LC, 2015).

• What sets SCAS scales specific to preschoolers:

http://www.scaswebsite.com.

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Differential Diagnosis

• Other psychiatric disorders:

– ADHD (restlessness, inattention) – Psychotic disorders (restlessness, social withdrawal) – Autism Spectrum Disorders (social awkwardness and withdrawal, social skills deficits, communication deficits, adherence to routines, repetitive behaviors) – Learning disabilities (concerns about school performance) – Bipolar disorder (restlessness, irritability, insomnia) – Depression (poor concentration, difficulty sleeping, somatic complaints).

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Medical Conditions and Substances that can cause Anxiety Symptoms

• Side effects of medications, including SSRIs, steroids, antipsychotics,

antihistamines, diet pills, other cold medications.

• Medical disorders:

– Hyperthyroidism – Migraine – Asthma – Seizure disorders

• Substances

– Lead intoxication – Caffeine

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Treatment choice

• Based on symptom severity, functional impairment and a child’s

developmental capacity to access different therapeutic or coping tools.

• AACAP recommends a multimodal treatment approach for all levels of

anxiety disorder.

• AACAP recommends mild anxieties be treated with psychotherapy:

– Patient and parent education, support, and encouragement to resume normal activities gradually. – Family encouragement to maintain routines (Ramsawh H, Chavira DA, and Stein MB, 2010).

• Exposure-based CBT has the most evidence behind it (AACAP, 2007)

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5 Components of CBT for childhood anxiety disorders

1. Psychoeducation 2. Somatic management skills training 3. Cognitive restructuring 4. Exposure methods 5. Relapse prevention

(Albano and Kendall, 2002)

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Psychoeducation

• Teach the family about the disorder.
• Teach parents skills to manage anxiety symptoms so they

can provide support to the child (or themselves) at home.

• Additional points: positive incentives to practice skills are
• kay, parents are seen as CBT coaches. (AACAP, 2007)
• Education about parental accommodation.

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Somatic management skills training

• These skills address the autonomic arousal and related

psychological responses children have to their feared stimuli.

• Relaxation training is used to teach children awareness and

control over their physiological reactions.

• Tools include: diaphragmatic breathing, self-monitoring,

progressive muscle relaxation, imagery. A narrative approach can help younger children remember how to use these tools. For example, tighten the muscles in your feet as if your were tip-toeing on rocks.

• Ultimately the goal is to help children be aware of and tolerate

arousal resulting from anxiety.

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Cognitive restructuring

• Challenge negative thoughts and expectations.
• Identify and correct negative self-talk – teach

positive self-talk.

Exposure methods

• Gradual desensitization based on a fear hierarchy.
• Teach how to couple relaxation techniques with fear

stimuli.

• One might start treating a specific phobia by reading

a book about or drawing pictures of the feared stimuli.

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Relapse prevention

• Homework is used to practice skills outside of

therapy sessions

• Booster sessions are scheduled as needed.

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Medications

• AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when:

– Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy. – There is a comorbid disorder that requires treatment with medication.

• Of note, the AACAP Anxiety practice parameter was written

before the Child/Adolescent Anxiety Multimodal Study (CAMS) was published. CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP, 2007)

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Anti-anxiety Medications

• Also used to treat depressive disorders.
• Pooled response rate for active treatment was 69% for

non-OCD anxiety disorders (95%CI, 65% to73%) and 39% (95% CI, 35% to 43%) for placebo (Bridge, JA, et al, 2007).

• Number Needed to Treat (the number of patients that

need to be treated to see a response in at least one patient): 3 (95% CI, 2 to 5) (Bridge, JA, et al, 2007).

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SSRIs/SSNRIs

• Fluoxetine, Fluvoxamine, Sertraline, and Paroxetine, and Venlafaxine ER
• utperformed placebo in studies of children and adolescents, although

some of these studies were quite small (Peters, TE and Connolly, S, 2012).

• Adolescents responded better than children, but both groups showed

significant and positive effects (Bridge, JA, et al, 2007).

• Side effects are possible:

– SSRI-SSNRI related activation is a risk for anxious pediatric patients. Risk of activation is higher in younger patients and with more rapid dose increases (Strawn et al., 2015). – Unlike in adults, SSRIs/SSNRIs don’t statistically increase risk for GI symptoms (Strawn et al., 2015).

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Child/Adolescent Anxiety Multimodal Study (CAMS)

• Established the standard of care.
• NIMH funded six-year, six-site randomized placebo-controlled

trial that examined the relative efficacy of cognitive-behavior therapy, sertraline (Brand name Zoloft), and their combination against pill placebo for the treatment of separation anxiety disorder, generalized anxiety disorder and social phobia in 488 children and adolescents ages 7-17 years old.

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CAMS Outcomes

• Percentage of those who measured very much or much

improved on Clinician Global Impression-Improvement scale:

– 80.7% for combination therapy (P<0.001) – 59.7% for cognitive behavioral therapy alone (P<0.001) – 54.9% for sertraline alone (P<0.001) – All therapies were superior to placebo (23.7%).

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CAMS Conclusions

• CBT, sertraline and their combination are all effective

treatments for anxiety disorders in children and adolescents.

• Combination treatment with sertraline and CBT was the

most effective.

• Placebo alone was not effective treatment (Walkup et al,

2008).

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Black box warning about risk for suicide from anti-anxietal meds

• FDA issued its warning based on 24 placebo-controlled

trials (assessing more than 4,400 youth), which concluded that antidepressant medications double the risk for suicidal ideation and behavior (4% on SSRIs versus 2% on placebos- NOTE, even those youth given placebos saw an increase in suicidal ideation) (US FDA, 2004).

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Other considerations

• Ensuring these evidence based interventions are available in the

service array and accessible

• Workforce development (training, coaching, supervision, certificate

programs)

• Fiscal issues (e.g. incentives for implementing EBPs, $ for training and
• ngoing professional development) need attention in the system to

ensure providers to whom youth may be referred are capable of implementing the most effective programs for depressive disorders… esp in light of the 10-15% prevalence rate in adolescents

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Other considerations (cont’d)

• Ensuring that care coordinators / wrap facilitators are aware of

the need to access relevant EBPs for depression (and other diagnostic categories) when planning with a youth/family/team, and know who provide such treatments

• Building capacity for peer to peer support in a system and

service array so that there are other relevant supports readily available, esp. to adolescents who may be struggling with depression and other challenges

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References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Washington, DC: American Psychiatric Publishing

• Baldwin, D, Anderson, I, Nutt, D, Bandelow, B, Bond, A, Davidson, JRT, den Boer, JA, Fineberg, NA, Scott, J,

Wittchen, HU, Knapp, M. (2005). Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology . Journal of

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• Bridge, JA, Iyengar, S, Salary, CB, Barbe, RP, Birmaher, B, Pincus, HA, Ren, L, & Brent, DA. (2007). 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

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References (cont’d)

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