Anxiety Disorders

Childhood & Adolescent
Anxiety disorders
Fast Facts About Anxiety in Children
Childhood = toddlerhood to
puberty (2-12 years of age)
 Anxiety is ubiquitous, appropriate
in new situations, and in response
to stressors
Arvind Balarvaman
Normal/expected anxiety vs. anxiety disorder
 Anxiety disorders affect 8-10% of children
 Most anxiety disorders begin in childhood and adolescent years
 Anxiety disorders often present with physical symptoms
Fast Facts About Anxiety in Children
 Different anxiety disorders throughout life
› e.g. Separation anxiety disorder
 A common childhood anxiety disorder
 Can be a precursor for other anxiety disorders and depression in
adolescents and young adults
 Anxiety disorder can lead to:
› Poor economic, vocational, interpersonal outcomes
› Increased morbidity:
 comorbid anxiety disorders, major depressive disorder, and alcohol
and drug abuse) and mortality (suicide)
 Significant negative impact on family, social and school
 Chronic anxiety disorder can lead to:
› Poorer physical health outcomes
› Increased cardiovascular morbidity and mortality in mid-life
Fast Facts About Anxiety in Adolescents
Adolescence = puberty to mid-twenties
Anxiety disorders affect 8-10% of young people
Most anxiety disorders begin in childhood & adolescence
Anxiety disorders are often hereditary
Many individuals with anxiety disorders experience physical
symptoms that they present to their health care provider.
 An individual can be affected by different anxiety disorders
throughout their lifespan.
› Separation anxiety disorder can be a precursor for other
anxiety disorders in adolescents and young adults.
› Social Anxiety Disorder; Panic Disorder = teen onset
Fast Facts About Anxiety in Adolescents
 Effective treatments for most young people with an anxiety
disorder can be provided by first contact health providers
 Always assess parents for the presence of an anxiety disorder if a
diagnosis of anxiety disorder or depression has been made in a
 If a parent has an anxiety disorder or depression, successful
treatment of child will include effective treatment for the parent
Delivery of Effective Treatment
for Anxiety Disorders
6 Key Steps
Identification of children at risk
Useful methods for screening and diagnosis
Treatment template
Suicide assessment
Safety/contingency planning
Referral flags
I. Identification of Children & Youth At Risk
 Ideal position of first contact health providers
› To identify youth at risk to develop an anxiety disorder.
 Screen usual-risk youth at routine vaccination and
start of school visits
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Anxiety Disorder Identification Table
Risk Affect
1. Family history of
anxiety disorder
2. Severe and/or
stressors in early
Risk Affect
1. Children with shy,
inhibited and/or cautious
temperament (innate
personality type)
2. Family history of a
mental illness (mood
disorder, substance
abuse disorder)
3. Have experienced a
traumatic event
Possible “group” Identifiers
(not causal for anxiety disorder;
may identify factors related to
adolescent onset anxiety)
1. School failure or learning
2. Socially or culturally isolated
3. Bullying (victim and/or
4. Gay, Lesbian, Bi-sexual,
5. Substance abuse and mis-use
(cigarettes & alcohol)
A Child is Identified At Risk
Educate about risk
Obtain family history
“Clinical review” threshold
Standing “mental health check-up”
Confidentiality, understanding &
informed consent
Educate About Risk
 Not inevitable, but…
› Even with numerous risk factors, mental health disorder is not
inevitable, but may occur.
› The sooner diagnosed and treated the better
› More helpful to check possibility than ignore symptoms
 Educate Parents
› Educate about potential risks for anxiety in their children
› Create awareness of familial risk for mental disorders
 Entire family should be made aware
 Youth awareness at appropriate age.
Obtain Family History
 Part of routine for all patients
› Include:
Mental disorders
Substance abuse
Treatment type
Treatment outcome
 Helps identify youth at risk
Standing “Mental Health Check-up”
Screen at-risk youth every 6 months
15 minute office/clinical visits every 6 months
Anxiety symptoms worsen:
- During school year
- Before first weeks of school
- Should not cause severe distress or
Anxiety symptoms decrease:
- In summer months
- After first few weeks of school
Additional Questions for Child Anxiety & OCD
 Does your child worry more than other children you know?
 Do you need to reassure your child excessively and about the
same things over and over?
 Does your child have difficulty separating from you to go to school
or over to a friend’s house?
 What does your child worry about?
 Does worry/anxiety ever stop your child from doing something
new or an activity they would enjoy?
 Does your child get a lot of stomach aches and headaches?
When do they occur?
 Are there any events/activities/people/places that your child
avoids because of fear or anxiety
Additional Questions for Child Anxiety & OCD
 Describe your child’s sleep routine (where, when, quality, night routine)?
 Has your child ever missed school or had to come home from school early
due to anxiety?
 Has your child ever had an anxiety attack where their heart raced, they
couldn’t catch their breath, they felt dizzy or lightheaded and thought they
might be dying?
 Does your child have ideas or images that come into their mind and they
can’t control them?
 Does your child have any routines or behaviours they need to do that don’t
seem to make sense or be goal directed? (e.g. ask about germs/dirt worries
and handwashing/cleaning, also counting and checking rituals)
 What would be different for your child and for your family if they didn’t have
Standing “Mental Health Check-up”: Screening
 Ask parents, “How does your child compare to other children
of similar age regarding such issues as…
› Being away from parent?
› Need for reassurance?
› Comfort with exploring new situations?
› Physical complaints?
 If child shows substantially more anxiety type symptoms,
assess for presence of anxiety disorder or other mental
health problem.
School reports and patterns
- Difficulty concentrating
- Declining grades
- Frequent late arrival
- Frequent absences
Physical complaints
- Stomach aches
- Nausea
- Headaches
- School mornings/end
of weekend
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Education About Anxiety Disorders
 Education should include discussion of:
› Risks and benefits of anxiety treatment
› Confidentiality and informed consent to treatment
 For both child and parents
 Explain to parents
› What they might expect their child to feel like
› How the treatment will occur if it is necessary
› Expected outcomes, side-effects and time lines
Differentiating Distress from
 Appropriate/Adaptive Anxiety
› Short duration (< a few weeks)
› Resolves spontaneously, or
› Ameliorated by social supported or
environmental modification
Anxiety Disorder
› Long duration (usually lasting many
› Significantly interferes with functioning
Tina Phillips
› Is often out of sync with magnitude of stressor
› Usually require health provider intervention
› Diagnosis made using DSM-V criteria
Usually associated with an event or
series of events
Functional impairment is usually mild
Transient – will usually ameliorate with
change in environment or removal of
Professional intervention not usually
Can be a positive factor in life – person
learns new ways to deal with adversity
and stress management
Social supports such as usual friendship
and family networks help
Counseling and other psychological
interventions can help
Medications should not usually be used
* DSM- Diagnostic and Statistical
* ICD – International Classification of
May be associated with a precipitating event, may
onset spontaneously, often some anxiety symptoms
predating onset of disorder
Functional impairment may range from mild to severe
Long lasting or may be chronic, environment may
modify but not ameliorate
External validation (syndromal diagnosis:
Professional intervention is usually necessary
May increase adversity due to resulting negative life
events (e.g.: anxiety can lead to school refusal and
avoidance of normal developmental steps like
independent activities with peers)
May lead to long term negative outcomes (social
isolation, low self esteem, lack of independence,
depression, substance abuse, etc.)
Social supports and specific psychological
interventions (counselling, psychotherapy) are often
Medications may be needed but must be used
Useful Methods for Screening & Diagnosis
 Screen for Child Anxiety Related Emotional Disorders
› 41 item anxiety screen and monitoring tool
› Child and youth self report
› Parent report
› Provide family with feedback on test results
› Screen highly anxious youth for depression
› Anxiety disorders increase risk of developing depression; more
common to develop in adolescents
› Important risk factor for self harm and suicide
Useful Methods for Screening & Diagnosis
 Psychotherapeutic Support for Teens (PST)
 Kutcher Adolescent Depression Scale (KADS)
› A screening tool for depression
 Teen or Child Functional Assessment (TeFA; CFA)
› Self-report tool (child depending)
› 3 minutes to complete
› Assists in evaluating four functional domains of teen
mental health
 Tool for Assessment of Suicide Risk (TASR-A)
Use of SCARED in Assessment
Anxiety disorder is suspected:
if score of 25 or higher
Use score items as a guide for further questioning
Scoring information can be found in the toolkit
Child / Teen Anxiety Disorder is Suspected
 SCARED score is 25 or higher
› Discuss issues/problems in child’s life/environment
 Ask about school, home, activities, friends & family
 Anxiety disorders interfere with normal development tasks and
› Offer supportive non-judgmental problem solving assistance
› Encourage general self-care of parent and child
Decreases stress
Regular, adequate sleep
Consistent physical activity
Healthy eating
Promote positive social activities
Child Anxiety Disorder is Suspected
 Screen for:
› Depression & Suicide risk
 Screen for suicide as appropriate
 “When you feel sad or scared, do you ever think about not
wanting to be alive?”
 Ask parent to keep a diary
› Record concerns
› Signs and symptoms child expresses
 How severe, impact of severity and response to problem
 Schedule 2nd mental health checkup in 1 – 2 wks
2nd Mental Health Checkup
(1 – 2 wks following initial visit)
 More comprehensive
 Include a functional assessment
 Review DSM - V criteria
 Supportive education and
discussion with parents
› Strategize with parents to deal with
problems related to anxiety
3rd Mental Health Checkup
(2 – 3 wks following 2nd visit)
 Repeat SCARED
› If symptoms persist review DSM-V criteria.
› Make a treatment plan for anxiety disorder
 If concerns of depression persist
› Treatment is best applied in a specialty mental health setting
or with guidance of child psychiatrist
› If depression suspected, refer to appropriate service, but start
treatment for anxiety disorder.
Teen Anxiety Disorder is Suspected
SCARED score is 25 or higher
 Discuss issues/problems in the youth’s life/environment.
 Teen Functional Activities Assessment (TeFA)
 Supportive, non-judgmental problem solving assistance
– Psychotherapeutic Support for Teens (PST) as a guide
 Strongly encourage and prescribe:
 Exercise
 Regulated sleep
 Regulated eating
 Positive social activities
Teen Anxiety Disorder is Suspected
 Screen for depression
› Use the Kutcher Adolescent Depression Screen (KADS)
 Screen for suicide risk
› Use the Tool for Assessment of Suicide Risk (TASR)
 Mental Health Check-ups
› Second visit one week from visit
 Can include TeFA and/or PST (15 – 20 mins)
 If suicide or depression concerns use KADS & TASR-A
› Third visit two weeks later
 Repeat SCARED and other tools as indicated
 Make treatment plan as indicated
Teen Anxiety Disorder is Suspected
 If Panic Disorder:
› Complete Panic Attack Diary
› Complete (Difficult Places to Go and Things to Do)DPG:TD
 If Social Anxiety Disorder
› Complete (Kutcher Generalized Social Anxiety Disorder Scale
for Adolescents) K-GSADS-A
Don’t Get Overwhelmed
Onset of anxiety disorder
is not an emergency
 Use clinical tools to assist with
› Integrate details in
assessment interviews
 3 – 15 min visits
 If concern for depression and/or
suicide, screen at each visit.
Separation Anxiety Disorder
 Fear something bad will happen to them or loved one when apart
› Avoid being apart from parent or caregiver
› Significant distress/anxiety when separated or anticipating
 Criteria for diagnosis:
› School age & have experienced distress for at least 4 weeks
› Physical symptoms: headache, stomach ache, behavioral outbursts,
crying, clinging and/or yelling.
› Difficulty with babysitters, sleeping alone, getting to school.
› Child misses out on social opportunities
› Interferes with development of age appropriate independence and
academic success.
Specific Phobia
Fear of object or situation
Out of proportion to actual danger
Anxiety response is extreme/unreasonable
 Criteria for diagnosis
› Persist for 6 months
› Significant distress & impairment of functioning
› Avoidant behavior
› Distress and/or panic attacks
 Treat or not treat
General Anxiety Disorder (GAD)
 “Master Worriers”
› Excessive, unrealistic and unhelpful distress and worry around
everyday events and responsibilities
› Persists for at least 6 months
› Distress mentally and physically
 Tension, irritability, muscle aches & pains, difficulty
concentrating, tiredness, headache, stomach ache, nausea &
lightheadedness, difficulty sleeping, avoidance patterns, seeking
excessive reassurance
› Lack of enjoyment and avoidance of daily
Social Anxiety Disorder (Social Phobia)
 Onset
› Junior high or middle school
 Symptoms
› Shy or introverted (inaccurate)
› Severe anxiety in social
› Avoidance and isolation
› Impacts development of
identity and independence
 Risks
› Depression, substance abuse and school drop out
Panic Disorder
Acute symptoms
Panic attacks
Occur ‘out of the blue’ with no warning
Think they are having heart attack,
asthma attack, stroke, seizure
Anxiety & fear of additional attacks
Rapid debilitation in daily life
Avoidance patterns & agoraphobia
Obsessive Compulsive Disorder (OCD)
 Obsessions
› Distressing intrusive thoughts, urges and/or images
› Common themes – Illness and danger
 Compulsions
› Repetitive behaviours or rituals performed to relieve distress and
anxiety associated with obsessions
› Common themes - cleaning, washing and checking behaviors
 Causes significant distress
› Take up more than 1 hour each day
› Repetitive images or thoughts (e.g. violent, religious or sexual)
 Lead to compulsions of praying or counting
› Avoidance behaviors & efforts to suppress obsessive thoughts
Obsessive Compulsive Disorder (OCD)
 Two peaks of onset
› Childhood (pre puberty)
› Later Adolescence
 Obsessions or compulsions are irrational
› Children/youth may not realize this
› Frustration and anger if can’t keep OCD satisfied
 Most often a gradual onset
› Difficulty concentrating, getting out of the house, getting
dressed or decreased food intake
 Negative impact on family functioning
› Family members often help out with routines
 High rates of depression
Clinical Approach to Possible Child/Adolescent
Anxiety Disorder
Visit 1: SCARED Function
as indicated and as time allows
If SCARED is 25 or greater (parent and/or child) or shows
decrease in function, review WRP/Stress management
strategies and proceed to step 2 in 1-2 weeks.
If SCARED < 25 and/or shows no decrease in function,
monitor again (SCARED) in a month. Advise to call if feeling
worse or any safety concerns.
Visit 2: SCARED,
Function. Use PST & MEP
If SCARED > 25, and shows decrease in function, utilize PST
strategies, review WRP and proceed to
step 3 within a week.
If SCARED <25 and shows no decrease in function, monitor
again in a month. Advise to call if feeling worse or any safety
Visit 3: SCARED, Function. Use
If SCARED remains > 25 or shows decrease in function,
proceed to diagnosis (DSM-V criteria) and treatment
If SCARED <25 and shows no decrease in function, monitor
again (SCARED) in one month. Advise to call if feeing worse or
any safety concerns.
Additional Questions for Teen Anxiety & OCD
Do you worry more than other teens you know?
What do you worry about?
Does worry/anxiety ever stop you from doing something that you would like to be able to
Are there any events/activities/people/places that you avoid because of fear or anxiety?
Describe your sleep routine (where, when, quality, night routine)?
Have you ever missed school or had to come home from school early due to anxiety?
Have you ever had anxiety where your heart raced, you couldn’t catch your breath, you
felt dizzy or lightheaded and thought you might be dying?
Do you get a lot of stomach aches and headaches?
Do you have trouble concentrating?
Do you have ideas or images that come into your mind and you can’t control them?
Do you have any routines or behaviours you need to do to relieve anxiety or distressful
thoughts or images? (e.g. ask about germs/dirt worries and hand washing/cleaning, also
counting and checking rituals)
What would be different for you if you didn’t have anxiety/worry?
III. Childhood Anxiety Treatment Template
 Specific Factors
› Evidence based treatments:
 Structured psychotherapies (e.g. Cognitive Behavioral Therapy CBT)
 Medication
 Non-specific Factors
› Activities
 Decrease stress, improve mood and general well-being
› Supportive psychological interventions
 PST in toolkit guide
Enroll the Help of Others
Who does the child want to help them?
School Counselor
Support Helps Reduce Stress For Children
Inquire about school performance;
academic supports may be needed
Parent/Caretaker Involvement
 Essential for information on child’s emotional state and
 Differing opinions between child and parent
› Joint discussion to clarify and appropriately plan
 Ensure confidentiality throughout process
 First line treatment
› Cognitive Behavioral Therapy (CBT)
 Strong evidence based practice with CBT alone
 Often improves anxiety without medication
› Barriers to CBT
 Long waiting lists, psychotherapies not available
 Family cannot access services
› If barriers to CBT
 Implement medications, wellness enhancing activities and
supportive rapport
 Monitor outcome regularly: refer if no change or worse
Suggested Websites
Anxiety BC website
Youth anxiety/depression treatment guideline algorithm
American Academy
of Child and Adolescent Psychiatry
Teen Mental Health

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