ANXIOUS KIDS OBJECTIVES. Measuring Outcomes Question: 9/16/2015 A PRIMARY CARE APPROACH MEDS AND MORE
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1 ANXIOUS KIDS A PRIMARY CARE APPROACH MEDS AND MORE Treating Childhood Anxiety Disorders C. Allen Musil Jr MD OBJECTIVES 1. List 3 classes of medication commonly prescribed to treat childhood anxiety. 2. List 2 appropriate reasons to initiate medication 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 interacting with school systems, when treating a child/adolescent with school refusal 2 nd to anxiety. Measuring Outcomes Question: True Or False? You are treating a 10 year old child who refuses to attend school because of anxiety, has truancy charges filed, and is at risk of removal from parents and placement in a residential group home. Individual and family therapy is in place for the last 6 months but there is little progress. Starting medication for anxiety is appropriate. 1
2 Disclosure I am on the speaker panel for the drug company Novartis. I will not be mentioning the Novartis schizophrenia medication during this presentation. Outline Definitions (DSM V) Approach Treatments DEFINITIONS (adult) Anxiety is an unpleasant state of inner turmoil, often accompanied by nervous behavior, such as pacing back and forth, somatic complaints and rumination. It is the subjective unpleasant feelings of dread over something unlikely to happen, such as the feeling of imminent death 2
3 DEFINITION Anxiety is not the same as fear, which is a response to a real or perceived immediate threat; whereas anxiety is the expectation of future threat Anxiety can be appropriate, but when it is too much and continues too long, the individual may suffer from an anxiety disorder. DEFINITIONS Fear and anxiety can be differentiated in four domains: (1) duration of emotional experience, (2) temporal focus, (3) specificity of the threat, and (4) motivated direction. Fear is defined as short lived, present focused, geared towards a specific threat, and facilitating escape from threat; while anxiety is defined as long acting, future focused, broadly focused towards a diffuse threat, and promoting excessive caution while approaching a potential threat and interferes with constructive coping. Sylvers, et all, (2011) Differences between trait fear and trait anxiety, Clinical Psychology Review 31 (1): Working towards a DEFINITION of: Anxiety Disorders Most cases of anxiety are common, predictable, normal, a basic emotion Ongoing excessive worry, nervousness, and anxiety felt intensely and interfering could be a disorder Exaggerated and not appropriate for developmental age, pervasive, out of proportion to the situation at hand could be a disorder 3
4 Working towards a DEFINITION of: ANXIETY DISORDERS DSM IV & V Core Anxiety Criteria Persistent worry or fear (a required time period) Significant distress with/without avoidance Interferes with and results in daily dysfunction in school, play, home, work, social, developmental milestones Symptoms are time consuming Exclusion criteria (meds/substance, psychological effects, medical condition) Epidemiology/ Prevalence (HISTORICAL) General Infant/toddler 100% Children 10% Adolescence 15% Adults 20% Females> Males (2:1) Genetic component Rynn et al (6 18%) Laughing Tiger The Magic Years Understanding and Handling the Problems of Early Childhood Selma Fraiberg, SCRIBNER, 1957 (2008 edition with introduction by T. Berry Brazelton MD) Jan a 2 year and 8 month old female who reforms laughing tiger He doesn t roar. He never scares children. He doesn t bite. He just laughs. He has to learn to mind. 4
5 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 time stories and policed his daily life for every conceivable source of danger, he would still succeed in constructing 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 Protection moves from parent over time to child. Each child s reaction and defenses to anxiety and fear are specific to them. The more a parent understands and fosters these specific abilities, the more a parent helps their child deal with the fear/anxiety process. Imagination! Now there is one place where one can meet a ferocious beast on you own terms and leave victorious. That place is the imagination. It is a matter 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 imagination offers such solutions. (p. 17) 5
6 J. AACAP (49):10 Oct 2010 Great Smoky Mountain Anxiety Study 1,420 participants from 11 counties 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) 6
7 Meta analysis Anxiety Review 2011 Costello EJ, et all. The developmental epidemiology of anxiety disorders: phenomenology, prevalence, and comorbidity. Anxiety Disorders Children Adolescent 2011: Risk Factors for Anxiety Disorders Shyness temperament trait Early age significant medical disorder Family history Chaos Overprotection Connolly & Bernstein
8 What to look for: Repeated physical complaints headaches, stomachaches, dramatic presentations of pain Problems falling asleep and multiple awakenings Eating problems too much or too little Avoidance Excessive need for reassurance Inattention/poor performance Outburst Dysfunction or lack of appropriate developmental steps Anxious parents ANXIETY DISORDERS (FLAVORS) DSM IV and V Separation anxiety disorder Selective mutism Specific phobia Social anxiety disorder (Social Phobia) Panic Disorder Agoraphobia Generalized anxiety disorder Below got their own Chapter in DSM V Obsessive compulsive disorder Body Dysmorphic Disorder, Hoarding, Trichotillomania, Excoriating Disorder, OCD, others Posttraumatic stress disorder Reactive Attachment, Disinhibited social engagement, PTSD, Acute Stress, Adjustment, others Separation 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 separation from those to whom the individual is attached, as evidenced by at least 3 of the following: 1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures 2. Persistent and excessive worry about losing major attachment 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 separation from a major attachment figure 4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation 5. Persistent and excessive fear of/or reluctance about being alone or without major attachment figures at home or in other settings 6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure 7. Repeated nightmares involving the theme of separation 8. Repeated complaints of physical symptoms (i.e.. headaches, stomachaches, etc.) when separation for major attachment figures occurs or is anticipated 8
9 Separation Anxiety Disorder Criteria: A,B,C,D(MUST HAVE ALL 4 CRITERIA TO GIVE DIAGNOSIS) (DSM V) B. Fear, anxiety, or avoidance is persistent, lasting 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, occupational, or other important areas of functioning D. The disturbance is not better explained by another mental disorder.(psychosis, autism, delusional disorder, etc...) Separation Anxiety Disorder Risk factors Precursor panic disorder, Social Phobia School refusal Often come from close knit protective families Parental factor Selective Mutism Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e. g., at school) despite speaking in other situations. The disturbance interferes with educational or occupational achievement or with social communication. The duration 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 situation. The disturbance is not better accounted for by a Communication Disorder (e. g., Stuttering) and does not occur exclusively in the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. 9
10 Specific Phobia Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. 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. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. In individuals under age 18 years, the duration 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 attacks 10
11 Generalized Anxiety Disorder Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (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). Note: Only one item is required in children. 1. restlessness or feeling keyed up or on edge. 2. being easily fatigued. 3. difficulty concentrating 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, occupational, or other important areas of functioning. Obsessive compulsive disorder Obsessions Compulsions Bimodal presentation in children/adolescence Very common diagnosis PTSD Post Traumatic Stress Disorder Acronym A anxiety R re experience E experience A avoidance Good prognosis 11
12 Treatment Approach 1. Practice Parameters American Acad. of Child/Adol.Psychiatrist ( OCD 2012 PTSD 2010 Anxiety Disorders 2007 Tennessee Behavioral Health Guidelines for Children and Adolescents from Birth to 17 years of age ( pract children.shtml) 2. Evidence based treatment/research, algorithms 3. FDA approval 4. Worst approach 5. Worstest! AACAP Treatment Guidelines for Anxiety Disorders 1. Journal of the American Academy of Child and Adolescent Psychiatry 46:2 February 2007 Routinely screen 2. Formal evaluation 3. Differential diagnosis 4. Treatment planning include multimodal treatment approach 5. Treatment planning consider severity and impairment 6. Psychotherapy (CBT) 7. SSRIs first line treatment (no specific suggestion of SSRI) 8. Medications other than SSRIs 9. Consider classroom based accommodations 10. Evaluate for comorbid conditions 11. Consider prevention DIFFERENTIAL DIAGNOSIS General Medical Medication 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 infection (PANDAS)» No good resource 12
13 DIFFENTIAL DIAGNOSIS Psychiatric/Environmental Mood disorders Pervasive developmental disorders ADHD Substance abuse (including caffeine) Eating disorders Schizophrenia Personality disorders Normal reaction to severe environmental stressors or dangers (e.g., ongoing victim abuse, divorce) Anxiety Comorbidity 20% to 40% of youth with anxiety disorders have comorbid attention disorders (Faraone & Kunwar, 2007) 11% to 69% of anxious youth suffer from a depressive disorder (Rosenbaum & Covino, 2005) Treatment Approach Nonmedical CBT (Cognitive Behavioral Therapy) Psychodynamic Parent child and family interventions Medical SSRI Others 13
14 Cognitive Behavioral Therapy for Anxiety Children and adolescents learn to stop associating stimulus with anxiety response as well as learning coping mechanism Motivation required Attendance required Family support Money Cognitive Behavioral Therapy for Anxiety Exposure based cognitive behavioral therapy has the most empirical support Most CBT incorporates Psych education Somatic management skills training Cognitive restructuring Exposure methods ( with desensitization) Relapse prevention plans Compton,Kratochvil & March 2007 Barrett et al Galla et al Interventions at School for Anxiety Disorders Establish check ins on arrival Accommodate late arrival Allow extra time for moving to another activity/class Identify a safe place Develop relaxation techniques/strategies Encourage small group interactions Reward a child s efforts DON T USE HOMEBOUND 14
15 Specific Anxiety Disorder Treatment Nonmedical treatment matters a little i.e. Trauma focused therapy for PTSD i.e. DO NOT USE HOMEBOUND with social phobia Medical treatment (choice does not matter when it comes to efficacy it is ok to choose any SSRI) (another words, the medication is not diagnosis specific it is symptom specific) When to use medication? In the END, it comes down to the degree/severity of symptoms and When to choose medical approach No medication Younger Less severe impairment No CBT trial in the past Few comorbidities No family history Medication Older More severe impairment Poor response to CBT Many comorbidities Family history 15
16 Combination Treatment CBT only mild anxiety/dysfunction CBT with/without medication moderate anxiety and dysfunction CBT with medication severe anxiety and dysfunction Who defines severity and dysfunction?? Medication Treatment SSRI s are considered first line medication treatment AACAP guideline #7 Most Often Used SSRI s for Childhood Anxiety Disorders Clomipramine (Anafranil)(TCA don t use 1st) (historical) Fluoxetine (Prozac) Sertraline (Zoloft) Fluvoxamine (Luvox) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) 16
17 FDA Approved Medication for Childhood Anxiety Disorders Clomipramine (Anafranil) OCD age 10 Fluoxetine (Prozac) OCD age 7 Sertraline (Zoloft) OCD age 6 Fluvoxamine (Luvox) OCD age 8 Paroxetine (Paxil) none Citalopram (Celexa) none Escitalopram (Lexapro) none FDA Approved Medication for Any Childhood Mood Disorders (except Bipolar ) Clomipramine (Anafranil) OCD age 10 Fluoxetine (Prozac) MDD age 7 OCD 7 Sertraline (Zoloft) OCD age 6 Fluvoxamine (Luvox) OCD age 8 Paroxetine (Paxil) none Citalopram (Celexa) none Escitalopram (Lexapro) MDD age 12 17
18 Do not use: Wellbutrin (bupropion) for anxiety disorders. It is NOT a SSRI and will usually make anxiety WORSE! How to Pick an SSRI FDA What you are familiar with Musil s approach No treatment parameter suggestions available Musil s Approach to Picking SSRI Choose the SSRI by the side effect you want! Requires knowing the differences in the common side effects among the SSRI s Learn Three: sedating/ neutral /activating Fingers Paxil, Celexa,( Lexapro, Luvox), Zoloft, Prozac Sedating/wt gain activating/wt neutral 18
19 Black Box Warning Antidepressants may increase suicidal thoughts or behaviors in some children, teenagers, and young adults, especially within the first few months of treatment or when the dose is changed. Depression and other serious mental illnesses are themselves associated with an increase in the risk of suicide. Patients on antidepressants and their families or caregivers should watch for new or worsening depression symptoms, unusual changes in behavior, or thoughts of suicide. Such symptoms should be reported to the patient's healthcare provider right away, especially if they are severe or occur suddenly. Watts, Vabren. July 2014 Vol. XXXI No. 7 19
20 I will pick three SSRI s and discuss, they are the ones I use the most for childhood anxiety disorders: Celexa (citalopram) Lexapro (escitalopram) Zoloft (sertraline) I will pick three SSRI s and discuss, they are the ones I use the most for childhood anxiety disorders: Celexa (citalopram) Lexapro (escitalopram) Zoloft (sertraline) Celexa (citalopram) Europe s Prozac Dosage range10 40mg (60mg) Available in 10, 20, 40mg, Liquid available (10mg/5) Start 10mg but start ½ tablet (5mg) and suggest they increase whole tablet week later Dose night bc of sedation Cardiac (QTc) worry over 40mg No FDA approval under age 18 20
21 Lexapro (escitalopram) Isomer of Celexa FDA approval down to age 12 for MDD Dosage range 5 20mg, Available in 10mg, 20mg, liquid (5mg/5ml) Timing of dosage doesn t matter Start 10mg but start ½ tablet (5mg) and suggest they increase whole tablet week later FDA approved age 12 for MDD ONLY Zoloft (sertraline) FDA approved down to age 6 for OCD Dosage range: mg Doses 25, 50, 100mg, Liquid (20mg/1ml) Dose in am Watch out for stomach ache Has some ADHD effect at higher doses (dopamine)(>100mg) Start 25mg but start ½ tablet (12.5mg) and suggest they increase whole tablet week later Cook et al POTS study, 2004 Side Effects of SSRI s Nausea Nervousness, agitation or restlessness Dizziness Reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection (erectile dysfunction) Drowsiness Insomnia Weight gain or loss Headache Dry mouth Vomiting Diarrhea 21
22 Sienaert, Pascal PHD, July 2014 Vol XXXI No. 7 Short and Long Term results of Anxiety Study 12 weeks Comb = 80.7% CBT = 59.7% Sert = 54.9% Plac = 23.7% 24 weeks and 36 weeks (78% continued in study) Comb = 80% CBT = 70% Sert = 70% 22
23 9/16/
24 Think Pregnancy Discontinuation syndrome Disinhibiting effect Suicide Anxious kids already have somatic symptoms Anxious kids have anxious parents Expectations, wrestle with 50% improvement early What is the biggest reason SSRI s do not work? Compliance Wrong target symptoms identified With good compliance you can expect a 70% chance of response (40 50% improvement in certain symptoms) Effect size (strength of a phenomenon) medium (.50) How Long to Medicate Children? Depression: 6 9 months Anxiety disorder: one year Never for the rest of their life CBT or other supportive modality available Slow tapper (understand half life issues and SSRI Discontinuation Syndrome ) Pick right time for relapse Watch closely 24
25 What is the only CURE for Anxiety? Other Medications for Childhood Anxiety:(often prn use) Sedating antihistamine (Benadryl, Vistaril, etc..) Alpha 2 s (tenex, clonidine, Kapvay, Intuniv) Buspar (buspirone) Benzodiazepine (Valium, Ativan, Klonopin, etc..) Beta blockers SNRI s (Effexor, Pristiq, etc..) Seizure medications (Depakote and Neurontin, etc..) Antipsychotics (Seroquel, Zyprexa, etc..) (literature often suggest adding on Seroquel for partially treated OCD) Summary for treating Anxious Kids 1. Consider medicating childhood anxiety disorders depending on severity symptoms and dysfunction 2. Know three SSRI s 3. SSRI s do not treat a specific diagnosis, they treat a certain target symptom(s) 4. School interventions 5. Have a referral base 25
26 School Refusal Fremont, School Refusal in Children and Adolescents ; (2003) Measuring Outcomes Question: True Or False? You are treating a 10 year old child who refuses to attend school because of anxiety, has truancy charges filed, and is at risk of removal from parents and placement in a residential group home. Individual and family therapy is in place for the last 6 months but there is little progress. Starting medication for anxiety is appropriate. 26
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