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Assessment and management of anxiety in children and youth for family physicians.
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www.pspbc.ca
Childhood & Adolescent Anxiety
Todd Kettner, Ph.D. R.Psych.
Kootenay Lake Hospital
April 18, 2013
Mastery and ConfidenceRecognizing children’s anxiety and helping them overcome their fears
We want our patients and our
own kids to:Learn wellBe socially competentBe successful in lifeOther wishes for our children and teens?
Unfortunately,
Anxiety gets in the way of…
Learning
Social Competence
Lifelong Success
Understanding Anxiety
Anxiety
Some Examples
Actions
Thoughts
Emotions
Managing our anxiety and depression AND improving our physical health outcomes
Prevalence of anxiety disorders in children and
adolescents
8% to 20%
Neuroanatomy of Anxiety
Main Types of Anxiety Disorders
Separation Anxiety Panic DisorderAgoraphobiaSpecific PhobiaSocial Phobia (Social Anxiety)Obsessive Compulsive DisorderPosttraumatic Stress DisorderGeneralized Anxiety Disorder
Recognizing worry and Anxiety in children and teens
Physical Symptoms
Cognitive Symptoms
Behavioural Symptoms
Emotional Contagion
Anxiety and Stress
peers
parents
educators
Behavioral and environmental interventions are first line for
anxiety
Strategies for Resilience
Maintaining Optimal Stress Levels
the Yerkes Dodson Law
Modeling
Parent, sibling, peer and health professional
modeling
Relaxation Exercises
Progressive Muscle Relaxation
Relaxed BreathingMindfulness
Graduated Mastery
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CN Tower Toronto533 meters
32
““Look what I just Look what I just did!”did!”
MORE MORE IMPORTANTLY:IMPORTANTLY:
““look at who I am…”look at who I am…”BraveBrave
AdventuresomeAdventuresomeCapableCapable
IndependentIndependentStrongStrong
MORE MORE IMPORTANTLY:IMPORTANTLY:
““look at who I am…”look at who I am…”BraveBrave
AdventuresomeAdventuresomeCapableCapable
IndependentIndependentStrongStrong
Structure andPredictability
Gentle Logic
Mood and Activity Tracking
Optimism Online iPhone App
Optimism Online Emailed to Health Care Provider (M.D.,
Counselor, Psychologist)
Behavioral Strategies
Sleep hygieneExerciseHealthy EatingSocial activities: drama, sports, art, musicInformationResolve real issuesReferral for support
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6 Key Steps
1.Identification of children at risk2.Useful methods for screening and diagnosis3.Treatment template4.Suicide assessment5.Safety/contingency planning6.Referral flags
Delivery of Effective Treatment for Anxiety Disorders
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Ideal position of first contact health providers
Screen usual-risk youth at routine vaccination and start of school visits
I. Identification of Children & Youth At Risk
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Anxiety Disorder Identification Table
43
Educate about risk Obtain family history “Clinical review” threshold Standing “mental health check-up” Confidentiality, understanding & informed consent
A Child is Identified At Risk
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Screen at-risk youth every 6 months
15 minute office/clinical visits every 6 months
Standing “Mental Health Check-up”
Anxiety symptoms worsen:- During school year-Before first weeks of school-Should not cause severe distress or dysfunction
Anxiety symptoms decrease:- In summer months- After first few weeks of school
47
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 months)
› Significantly interferes with functioning
› Is often out of sync with magnitude of stressor
› Usually require health provider intervention
› Diagnosis made using DSM IV-TR criteria
Differentiating Distress from Disorder
49
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 School Home Work Friends
Tool for Assessment of Suicide Risk (TASR-A)
Useful Methods for Screening & Diagnosis
Use of SCARED in Assessment
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Anxiety disorder is suspected:if score of 25 or higher
50
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Clinical Approach to Possible Child / Adolescent Anxiety Disorder
Visit 1: SCARED FunctionUse PST & MEP 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 concerns.
Visit 3: SCARED, Function. Use PST & MEP
If SCARED remains > 25 or shows decrease in function, proceed to diagnosis (DSM-IVTR 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.
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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
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If Panic Disorder:
› Complete Panic Attack Diary
› Complete DPG:TD Diary
If Social Anxiety Disorder
› Complete K-GSADS-A
Teen Anxiety Disorder is Suspected
56
Don’t Get Overwhelmed
Onset of anxiety
disorder
is not an
emergency
Onset of anxiety
disorder
is not an
emergency
57
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
III. Childhood Anxiety Treatment Template
Enroll the Help of Others
Who does the child want to help them?
Family Teacher
School Counselor Coach
Neighbor
Babysitter
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Psychotherapy
1. Anxious Teen by Holly2. Learning by woodleywonderworks3. Social Competence by Purhoor Photograpy4. Lifelong Success by Jorge Franganillo 5. Amygdala - unknown6. Spider by Dincordero7. Spider on eye blog.ericlamb.net8. Beach by Zanzibar9. Yerkes Dodson – secretgeek.net10.Scared Child by Espon Faugstad11.Distressed Teen in Car by PLCjr12.Peers by teapics13.Parents by phub.com.au14.Educators – apa.org15.Classroom by horizontal.ingegration16.Counselor in chair by Parker Knight17.Staircase by Gwenael Piaser
Photos credits (mostly from Flickr)
Resources
Anxiety BC Main Website - FANTASTIC!
Guides for relaxed breathing, muscle relaxation, shyness, test anxiety
Quick Screening Questionnaires
Tools for teaching students with mental health issues