Anxiety in Youth: Identification, Management, & Referral

Martin E. Franklin, Ph.D.

Associate Professor of Psychiatry

University of Pennsylvania School of Medicine

Prelude to the Talk: Anxiety & Its Disorders

• What do the anxiety disorders have in common?

» Intense anxiety resulting in distress and/or functional impairment

» Avoidance, resulting in a “shrinking world”

• What are the different anxiety disorders?

• Why should I care?

• What if my child or student appears to be especially/painfully anxious?

• When is it time to do more than manage it at home & at school?

• What treatments are available?

• Are there self-help resources?

Anxiety: What Is It

& Why Should I Care?

• 3 months estimates: 2 - 8%

• 12 months estimates: 22%

• Lifetime estimates: 28%

I. Anxiety Disorders are Highly Prevalent

II. Childhood Anxiety Disorders Tend to Persist in Some Form

• Half of adults with anxiety or depressive disorder report a history of anxiety disorder in childhood

• Most childhood anxiety disorders remit by follow-up, but often replaced by other anxiety disorders or depression

• Significant, long-term impact

III. Anxiety Disorders are Highly Treatable

• Medication Classes:

» Benzodiazepines (e.g., Klonipin, Xanax)

» SSRI’s – most commonly used, best evidence base:

• Zoloft, Luvox, Prozac, Paxil, Lexapro…

» Tricyclic antidepressants (e.g., Anafranil)

» Other (e.g., Buspar)

• Psychotherapy:

» Cognitive-Behavior Therapy – usually involving some form of exposure and coping techniques

Why Pay So Much Attention to Anxiety?

• 10-20% of school age children have anxiety symptoms

• Negative impact in multiple domains

• May not get noticed by adults

Why OCD & Anxiety Symptoms Often Go Undetected in Youth

Normal Developmental Fears

• Transitory fears and anxieties are part of normal development:

• 1st years of life fears of loud noises, strangers, new places, heights

• preschool age fears of being alone, dark, animals, imaginary creatures

• school age fears of negative evaluation by others, illness/bodily injury, supernatural phenomena, natural disasters

Anxiety & Related Disorders

• What are the different anxiety disorders?

» Separation Anxiety Disorder

» Selective Mutism

» Specific (Simple) Phobia

» Social Anxiety Disorder (Social Phobia)

» Panic Disorder

» Agoraphobia

» Generalized Anxiety Disorder (GAD)

» Obsessive-Compulsive Disorder (OCD)

» Posttraumatic Stress Disorder (PTSD)

Separation Anxiety Disorder

Four Criteria

1. Developmentally inappropriate & excessive fear/anxiety concerning separation from attachment

figures • i.e. excessive distress anticipating separation [can include

physical symptoms], refusal to sleep away from home, nightmares with separation themes, kidnapping worries

2. Fear/anxiety is persistent • ≥ 4 weeks in children, ≥ 6 months in adults

3. Clinically significant distress/impairment socially, in school, at work

4. Disturbance not better explained by another mental disorder • i.e. autism, agoraphobia, GAD

Selective Mutism Five Criteria

1. Consistently not speaking in specific social situations

(i.e. school) despite speaking in other situations

2. Causes interference socially, at school, or at work

3. Duration ≥ 1 month • Not limited to first month of school

4. Not associated with lack of knowledge of, or comfort

with, the language required in the setting

5. Not better explained by communication disorder • i.e. autism, schizophrenia

Social Anxiety Disorder

Ten Criteria Total - Main Criteria Below

1. Fear/anxiety of ≥ 1 social situations w/ exposure to possible scrutiny by others » i.e. having conversations, being observed eating, performing

2. Fear of negative evaluation

3. Social situations avoided or endured with intense fear/anxiety

4. Fear/anxiety out of proportion to actual threat posed

5. Fear/anxiety lasts ≥ 6 months

6. Causes clinically significant distress/impairment socially, in school, or at work

7. Not attributable to drug/alcohol abuse, other medical condition, or other mental disorder

Generalized Anxiety Disorder

Six Criteria

1. Excessive anxiety/worry occurring more often than not for ≥ 6 months about several events/activities

2. Difficult to control worry

3. Associated with at least some symptoms below more often than not for past 6 months • Restlessness • Easily fatigued/sleep disturbance • Difficulty concentrating • Irritability • Muscle tension

4. Causes clinically significant impairment in social, occupational, or other important areas

5/6. Not better explained by drugs/alcohol, another medical condition, or other mental disorder

Obsessive Compulsive Disorder Four Criteria

1. Presence of obsessions or compulsions or both » Obsessions:

• Persistently recurring thoughts, impulses or urges that are intrusive, disturbing, and unwanted with anxiety/distress

• Attempts made to ignore/suppress/neutralize thoughts, urges, images with another thought/action (compulsion)

• Common obsessions in children and adolescents: contamination, safety of self/others, excessive doubt, scrupulosity

» Compulsions: • Repetitive behaviors or mental acts that a person feels driven

to perform in response to an obsession to reduce distress or prevent a dreaded outcome

• Common compulsions in children and adolescents: washing, touching, checking, mental rituals, repeating, arranging

2. Obsessions/Compulsions take > 1 hour per day or cause significant distress in social, occupational, or other settings

3/4. Not caused by another medical condition or mental disorder

Anxiety: Prevalence in Kids • Many anxiety disorders develop in childhood and

persist if not treated

• Group of disorders among the most common psychiatric diagnoses in children and adolescents

• 5-18% of children in community samples

• 12 month prevalence rates in US: • Specific phobia: 5% children, 16% 13-17yo • SAD: 7% children & adolescents (same as adults) • GAD: 2.2% 13-18yo (2.9% adults)

• Prevalence tends to rise with age

• Affects females more frequently than males (2:1)

Comorbidity

• Most common comorbidity is another anxiety disorder

• Second most common comorbidity is depression

• Frequently seen with externalizing disorders & subsequent substance abuse as well

Course/Continuity

• Half of adults with anxiety or depressive disorder report a history of anxiety disorder in childhood

• Most childhood anxiety disorders remit by follow-up, but often replaced by other anxiety disorders or depression

• Significant, long-term impact

Identifying & Managing Anxiety

Identifying Children with Anxiety Disorders in Schools

• Symptoms to look for:

• pattern of school refusal

• other avoidance

• frequent visit to nurse/somatic complaints

• shyness with peers

• Questions to ask:

• distressing for child? others?

• how is problem getting in the way?

• how long has problem been present?

Exposure to Fear Cues: A Fundamental Truth in

Managing Anxiety in Kids

• Should be voluntary

• Should be collaborative

• Should be hierarchy-driven

• Should focus on accomplishments rather than failures

• Should be designed to promote mastery of anxiety

• Should include some comment about managing anxiety rather than trying to run away from it

Working with Exposure Practices: Developmental Considerations

Younger children:

• More directive approach

• Use age-appropriate language and metaphors

• Greater use of goal-setting and reinforcement

• Greater family involvement

Adolescents:

• More collaboration in exposure selection

• More realistic discussion of risk

• More identification of feared consequence, and greater use of disconfirmatory evidence

LESSONS TO BE LEARNED

• Anxiety is transient

• Avoidance strengthens fear; exposure weakens it

• Exposure is necessary for habituation

• Anxiety in anticipation of exposure may be higher than

anxiety during actual exposure

• Feared consequences do not materialize

• “Ceiling Fan” Analogy – letting your anxiety make noise

while you go about your business

Rewarding Efforts: Key Element to Any Program

“Blah, blah, blah, do the thing you’re afraid of,

Blah, blah, blah, the more you do it, the easier it gets.”

Gwen Franklin, age 6, to her father, 2001

A Simplified Theoretical Approach

Working with Anxious Children in School Settings

• Some anxiety problems can be managed successfully in the school environment without referral for specific outpatient treatment

• Other anxiety problems require referral but the school staff can still play an important role

• In either case, the goals in school are to reduce avoidance and facilitate use of more adaptive coping strategies

When Is It Time to Do More?

When Is It Time To Do More?

• To refer or not to refer?

» If distressing or interfering and cannot be managed at school or home

• When to refer?

» The longer a problem goes on the harder it may be to treat

• Where to refer?

Seeking Treatment

Summary: Treatment of Pediatric Anxiety Disorders

• Plausible justification for initial treatment with either CBT or

pharmacotherapy

• CBT may be the best choice for the mildly ill child

• Treatment with an SSRI is the current drug standard, although

the FDA Black Box warning about suicidal ideation requires

careful and ongoing monitoring

• In CBT, therapist experience matters: Ask about the role that

exposure will play in the treatment…

Treatment Characteristics

Grounded in developmental psychopathology

Stages of treatment model, e.g. where we need initial

tx studies, beginning with monotherapies:

Dose-response and time-response parameters

Combined treatment (multicomponent CBT or

CBT + meds) for what population?

Treatment to criterion designs (remission)

Resources

• Penn’s Child/Adolescent OCD, Tics, Trichotillomania, & Anxiety Group (COTTAGe); 215-746-1230

• Child and Adolescent Anxiety Disorders Clinic (CAADC), Temple University (Dr. Philip Kendall), 215-204-7165

• Anxiety Disorders Association of America (www.adaa.org)

• Obsessive Compulsive Foundation (www.ocf.org)

Books for Parents & Teachers

• K. Manassis. Keys to Parenting Your Anxious Child.

• R. Rapee, S. Spence, V. Cobham, & A. Wignall. Helping Your Anxious Child.

• J. Dacey & L. Fiore. Your Anxious Child: How Parents and Teachers Can Relieve Anxiety in Children.

• E. Foa & L. Andrews. If Your Adolescent Has an Anxiety Disorder.

Books on OCD for Parents & Teachers

• T. Chansky. Freeing Your Child From Obsessive Compulsive Disorder.

• J. March and K. Mulle. OCD in Children and Adolescents.

• A. Wagner. Up and Down the Worry Hill.

Thank You for Your Patience…