Evidence-based treatments for Anxiety Disorders in

Children and Youth

Christopher Bellonci MDVice President of Policy and Practice Chief Medical Officer

Judge Baker Childrenrsquos Center

Overview of Anxiety disorders

bullMost common mental health disorder of childhood

bullChildren with anxiety disorders can be shy isolative and somatic or they can be agitated aggressive and unfocused

bullHow does one identify anxiety disorders in children and what is the evidence base for treatment

bullThis presentation will focus on Anxiety disorders look for OCD and PTSD to be addressed in separate presentations

2

DSM 5bullThe DSM-5 organizes anxiety disorders by typical age of onset

ndashseparation anxiety disorder ndashselective mutism ndashspecific phobia ndashsocial anxiety disorder (social phobia) ndashpanic disorder ndashgeneralized anxiety disorderndashsubstancemedication-induced anxiety disorder anxiety disorder due to another medical condition other specific anxiety disorder and unspecific anxiety disorder (APA 2013)

3

ndash 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 ndash 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)

ndash Moreover anxiety can be useful For example healthy anxiety can motivate children to study for tests and stay out of danger

ndash Itrsquos when these fears interfere with daily functioning over a period of time that a disorder develops

Differentiating from developmentallyappropriate fears and worries

4

Consequences of untreated childhood anxiety disorders are myriad

bull Increased risk for educational underachievement low-self esteem poor problem-solving and impaired social development (AACAP 2007)

bull Increased risk for adult anxiety disorders depression and substance use (AACAP 2007)

5

bull Broad range in presentations that can include both internalizing and externalizing symptoms

bull Internalizing symptoms include excessive worry and somatic or bodily complaints

bull Externalizing symptoms can include irritability and oppositional behaviors Children may go to great lengths to avoid the situation or object that triggers their anxiety When pushed to do something that makes them anxious they may become aggressive

Clinical presentation

6

Psycho-pathologicallyrelevant symptoms of fear and anxiety

Sleep disturbances nocturnal panic attacks oppositional 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

Normativefears

Separation

Shyness to strangers

Fear of loss

Deathdying

Thunder lightning fire animals water nightmares imaginary creatures

School anxietyperformance anxiety

Fear of specific objects germs natural disasters traumatic events

Fear of negative evaluation

Rejection from peers

Infancy and toddlerhood

Childhood School age Adolescence0 3 6 12

Age7

Anxietyrsquos Potential TrajectoriesProgressive

Persistent

Waxing and Waning

Remitting

0 3 6 12Infancy and toddlerhood

Childhood School age Adolescence

Psycho-pathologically relevant symptoms of fear and anxiety

Normativefears

8

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 17-18y12-MonthPrevalence

Agoraphobia 34 14 25 25 20 18

GeneralizedAnxiety DO

30 15 10 28 30 11

Social phobia 112 70 77 97 101 82

Specific phobia 221 167 216 183 177 158

Panic disorder 26 20 18 23 33 19

SeparationAnxiety DO

90 63 78 80 67 16

Any Anxiety Disorder

380 261 314 321 323 249

9

Prevalencebull CDC reports 3 of children ages 3-17 years old have a current diagnosis

of an anxiety disorder (httpwwwcdcgovchildrensmentalhealthdatahtml)

bull Lifetime prevalence rates for having at least one anxiety disorder range from 6 to 20 (Costello et al 2004)

bull All anxiety disorder subtypes were more frequent in females (MerikangasKR et al 2010)

bull Few raceethnic variations across anxiety disorders with the exception of increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (MerikangasKR et al 2010)10

Overview of Anxiety disorders

bullMost common mental health disorder of childhood

bullChildren with anxiety disorders can be shy isolative and somatic or they can be agitated aggressive and unfocused

bullHow does one identify anxiety disorders in children and what is the evidence base for treatment

bullThis presentation will focus on Anxiety disorders look for OCD and PTSD to be addressed in separate presentations

2

DSM 5bullThe DSM-5 organizes anxiety disorders by typical age of onset

ndashseparation anxiety disorder ndashselective mutism ndashspecific phobia ndashsocial anxiety disorder (social phobia) ndashpanic disorder ndashgeneralized anxiety disorderndashsubstancemedication-induced anxiety disorder anxiety disorder due to another medical condition other specific anxiety disorder and unspecific anxiety disorder (APA 2013)

3

ndash 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 ndash 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)

ndash Moreover anxiety can be useful For example healthy anxiety can motivate children to study for tests and stay out of danger

ndash Itrsquos when these fears interfere with daily functioning over a period of time that a disorder develops

Differentiating from developmentallyappropriate fears and worries

4

Consequences of untreated childhood anxiety disorders are myriad

bull Increased risk for educational underachievement low-self esteem poor problem-solving and impaired social development (AACAP 2007)

bull Increased risk for adult anxiety disorders depression and substance use (AACAP 2007)

5

bull Broad range in presentations that can include both internalizing and externalizing symptoms

bull Internalizing symptoms include excessive worry and somatic or bodily complaints

bull Externalizing symptoms can include irritability and oppositional behaviors Children may go to great lengths to avoid the situation or object that triggers their anxiety When pushed to do something that makes them anxious they may become aggressive

Clinical presentation

6

Psycho-pathologicallyrelevant symptoms of fear and anxiety

Sleep disturbances nocturnal panic attacks oppositional 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

Normativefears

Separation

Shyness to strangers

Fear of loss

Deathdying

Thunder lightning fire animals water nightmares imaginary creatures

School anxietyperformance anxiety

Fear of specific objects germs natural disasters traumatic events

Fear of negative evaluation

Rejection from peers

Infancy and toddlerhood

Childhood School age Adolescence0 3 6 12

Age7

Anxietyrsquos Potential TrajectoriesProgressive

Persistent

Waxing and Waning

Remitting

0 3 6 12Infancy and toddlerhood

Childhood School age Adolescence

Psycho-pathologically relevant symptoms of fear and anxiety

Normativefears

8

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 17-18y12-MonthPrevalence

Agoraphobia 34 14 25 25 20 18

GeneralizedAnxiety DO

30 15 10 28 30 11

Social phobia 112 70 77 97 101 82

Specific phobia 221 167 216 183 177 158

Panic disorder 26 20 18 23 33 19

SeparationAnxiety DO

90 63 78 80 67 16

Any Anxiety Disorder

380 261 314 321 323 249

9

Prevalencebull CDC reports 3 of children ages 3-17 years old have a current diagnosis

of an anxiety disorder (httpwwwcdcgovchildrensmentalhealthdatahtml)

bull Lifetime prevalence rates for having at least one anxiety disorder range from 6 to 20 (Costello et al 2004)

bull All anxiety disorder subtypes were more frequent in females (MerikangasKR et al 2010)

bull Few raceethnic variations across anxiety disorders with the exception of increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (MerikangasKR et al 2010)10

DSM 5bullThe DSM-5 organizes anxiety disorders by typical age of onset

ndashseparation anxiety disorder ndashselective mutism ndashspecific phobia ndashsocial anxiety disorder (social phobia) ndashpanic disorder ndashgeneralized anxiety disorderndashsubstancemedication-induced anxiety disorder anxiety disorder due to another medical condition other specific anxiety disorder and unspecific anxiety disorder (APA 2013)

3

ndash 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 ndash 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)

ndash Moreover anxiety can be useful For example healthy anxiety can motivate children to study for tests and stay out of danger

ndash Itrsquos when these fears interfere with daily functioning over a period of time that a disorder develops

Differentiating from developmentallyappropriate fears and worries

4

Consequences of untreated childhood anxiety disorders are myriad

bull Increased risk for educational underachievement low-self esteem poor problem-solving and impaired social development (AACAP 2007)

bull Increased risk for adult anxiety disorders depression and substance use (AACAP 2007)

5

bull Broad range in presentations that can include both internalizing and externalizing symptoms

bull Internalizing symptoms include excessive worry and somatic or bodily complaints

bull Externalizing symptoms can include irritability and oppositional behaviors Children may go to great lengths to avoid the situation or object that triggers their anxiety When pushed to do something that makes them anxious they may become aggressive

Clinical presentation

6

Psycho-pathologicallyrelevant symptoms of fear and anxiety

Sleep disturbances nocturnal panic attacks oppositional 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

Normativefears

Separation

Shyness to strangers

Fear of loss

Deathdying

Thunder lightning fire animals water nightmares imaginary creatures

School anxietyperformance anxiety

Fear of specific objects germs natural disasters traumatic events

Fear of negative evaluation

Rejection from peers

Infancy and toddlerhood

Childhood School age Adolescence0 3 6 12

Age7

Anxietyrsquos Potential TrajectoriesProgressive

Persistent

Waxing and Waning

Remitting

0 3 6 12Infancy and toddlerhood

Childhood School age Adolescence

Psycho-pathologically relevant symptoms of fear and anxiety

Normativefears

8

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 17-18y12-MonthPrevalence

Agoraphobia 34 14 25 25 20 18

GeneralizedAnxiety DO

30 15 10 28 30 11

Social phobia 112 70 77 97 101 82

Specific phobia 221 167 216 183 177 158

Panic disorder 26 20 18 23 33 19

SeparationAnxiety DO

90 63 78 80 67 16

Any Anxiety Disorder

380 261 314 321 323 249

9

Prevalencebull CDC reports 3 of children ages 3-17 years old have a current diagnosis

of an anxiety disorder (httpwwwcdcgovchildrensmentalhealthdatahtml)

bull Lifetime prevalence rates for having at least one anxiety disorder range from 6 to 20 (Costello et al 2004)

bull All anxiety disorder subtypes were more frequent in females (MerikangasKR et al 2010)

bull Few raceethnic variations across anxiety disorders with the exception of increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (MerikangasKR et al 2010)10

ndash 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 ndash 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)

ndash Moreover anxiety can be useful For example healthy anxiety can motivate children to study for tests and stay out of danger

ndash Itrsquos when these fears interfere with daily functioning over a period of time that a disorder develops

Differentiating from developmentallyappropriate fears and worries

4

Consequences of untreated childhood anxiety disorders are myriad

bull Increased risk for educational underachievement low-self esteem poor problem-solving and impaired social development (AACAP 2007)

bull Increased risk for adult anxiety disorders depression and substance use (AACAP 2007)

5

bull Broad range in presentations that can include both internalizing and externalizing symptoms

bull Internalizing symptoms include excessive worry and somatic or bodily complaints

bull Externalizing symptoms can include irritability and oppositional behaviors Children may go to great lengths to avoid the situation or object that triggers their anxiety When pushed to do something that makes them anxious they may become aggressive

Clinical presentation

6

Psycho-pathologicallyrelevant symptoms of fear and anxiety

Sleep disturbances nocturnal panic attacks oppositional 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

Normativefears

Separation

Shyness to strangers

Fear of loss

Deathdying

Thunder lightning fire animals water nightmares imaginary creatures

School anxietyperformance anxiety

Fear of specific objects germs natural disasters traumatic events

Fear of negative evaluation

Rejection from peers

Infancy and toddlerhood

Childhood School age Adolescence0 3 6 12

Age7

Anxietyrsquos Potential TrajectoriesProgressive

Persistent

Waxing and Waning

Remitting

0 3 6 12Infancy and toddlerhood

Childhood School age Adolescence

Psycho-pathologically relevant symptoms of fear and anxiety

Normativefears

8

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 17-18y12-MonthPrevalence

Agoraphobia 34 14 25 25 20 18

GeneralizedAnxiety DO

30 15 10 28 30 11

Social phobia 112 70 77 97 101 82

Specific phobia 221 167 216 183 177 158

Panic disorder 26 20 18 23 33 19

SeparationAnxiety DO

90 63 78 80 67 16

Any Anxiety Disorder

380 261 314 321 323 249

9

Prevalencebull CDC reports 3 of children ages 3-17 years old have a current diagnosis

of an anxiety disorder (httpwwwcdcgovchildrensmentalhealthdatahtml)

bull Lifetime prevalence rates for having at least one anxiety disorder range from 6 to 20 (Costello et al 2004)

bull All anxiety disorder subtypes were more frequent in females (MerikangasKR et al 2010)

bull Few raceethnic variations across anxiety disorders with the exception of increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (MerikangasKR et al 2010)10

Consequences of untreated childhood anxiety disorders are myriad

bull Increased risk for educational underachievement low-self esteem poor problem-solving and impaired social development (AACAP 2007)

bull Increased risk for adult anxiety disorders depression and substance use (AACAP 2007)

5

bull Broad range in presentations that can include both internalizing and externalizing symptoms

bull Internalizing symptoms include excessive worry and somatic or bodily complaints

bull Externalizing symptoms can include irritability and oppositional behaviors Children may go to great lengths to avoid the situation or object that triggers their anxiety When pushed to do something that makes them anxious they may become aggressive

Clinical presentation

6

Psycho-pathologicallyrelevant symptoms of fear and anxiety

Sleep disturbances nocturnal panic attacks oppositional 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

Normativefears

Separation

Shyness to strangers

Fear of loss

Deathdying

Thunder lightning fire animals water nightmares imaginary creatures

School anxietyperformance anxiety

Fear of specific objects germs natural disasters traumatic events

Fear of negative evaluation

Rejection from peers

Infancy and toddlerhood

Childhood School age Adolescence0 3 6 12

Age7

Anxietyrsquos Potential TrajectoriesProgressive

Persistent

Waxing and Waning

Remitting

0 3 6 12Infancy and toddlerhood

Childhood School age Adolescence

Psycho-pathologically relevant symptoms of fear and anxiety

Normativefears

8

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 17-18y12-MonthPrevalence

Agoraphobia 34 14 25 25 20 18

GeneralizedAnxiety DO

30 15 10 28 30 11

Social phobia 112 70 77 97 101 82

Specific phobia 221 167 216 183 177 158

Panic disorder 26 20 18 23 33 19

SeparationAnxiety DO

90 63 78 80 67 16

Any Anxiety Disorder

380 261 314 321 323 249

9

Prevalencebull CDC reports 3 of children ages 3-17 years old have a current diagnosis

of an anxiety disorder (httpwwwcdcgovchildrensmentalhealthdatahtml)

bull Lifetime prevalence rates for having at least one anxiety disorder range from 6 to 20 (Costello et al 2004)

bull All anxiety disorder subtypes were more frequent in females (MerikangasKR et al 2010)

bull Few raceethnic variations across anxiety disorders with the exception of increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (MerikangasKR et al 2010)10

bull Broad range in presentations that can include both internalizing and externalizing symptoms

bull Internalizing symptoms include excessive worry and somatic or bodily complaints

bull Externalizing symptoms can include irritability and oppositional behaviors Children may go to great lengths to avoid the situation or object that triggers their anxiety When pushed to do something that makes them anxious they may become aggressive

Clinical presentation

6

Psycho-pathologicallyrelevant symptoms of fear and anxiety

Sleep disturbances nocturnal panic attacks oppositional 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

Normativefears

Separation

Shyness to strangers

Fear of loss

Deathdying

Thunder lightning fire animals water nightmares imaginary creatures

School anxietyperformance anxiety

Fear of specific objects germs natural disasters traumatic events

Fear of negative evaluation

Rejection from peers

Infancy and toddlerhood

Childhood School age Adolescence0 3 6 12

Age7

Anxietyrsquos Potential TrajectoriesProgressive

Persistent

Waxing and Waning

Remitting

0 3 6 12Infancy and toddlerhood

Childhood School age Adolescence

Psycho-pathologically relevant symptoms of fear and anxiety

Normativefears

8

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 17-18y12-MonthPrevalence

Agoraphobia 34 14 25 25 20 18

GeneralizedAnxiety DO

30 15 10 28 30 11

Social phobia 112 70 77 97 101 82

Specific phobia 221 167 216 183 177 158

Panic disorder 26 20 18 23 33 19

SeparationAnxiety DO

90 63 78 80 67 16

Any Anxiety Disorder

380 261 314 321 323 249

9

Prevalencebull CDC reports 3 of children ages 3-17 years old have a current diagnosis

of an anxiety disorder (httpwwwcdcgovchildrensmentalhealthdatahtml)

bull Lifetime prevalence rates for having at least one anxiety disorder range from 6 to 20 (Costello et al 2004)

bull All anxiety disorder subtypes were more frequent in females (MerikangasKR et al 2010)

bull Few raceethnic variations across anxiety disorders with the exception of increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (MerikangasKR et al 2010)10

Psycho-pathologicallyrelevant symptoms of fear and anxiety

Sleep disturbances nocturnal panic attacks oppositional 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

Normativefears

Separation

Shyness to strangers

Fear of loss

Deathdying

Thunder lightning fire animals water nightmares imaginary creatures

School anxietyperformance anxiety

Fear of specific objects germs natural disasters traumatic events

Fear of negative evaluation

Rejection from peers

Infancy and toddlerhood

Childhood School age Adolescence0 3 6 12

Age7

Anxietyrsquos Potential TrajectoriesProgressive

Persistent

Waxing and Waning

Remitting

0 3 6 12Infancy and toddlerhood

Childhood School age Adolescence

Psycho-pathologically relevant symptoms of fear and anxiety

Normativefears

8

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 17-18y12-MonthPrevalence

Agoraphobia 34 14 25 25 20 18

GeneralizedAnxiety DO

30 15 10 28 30 11

Social phobia 112 70 77 97 101 82

Specific phobia 221 167 216 183 177 158

Panic disorder 26 20 18 23 33 19

SeparationAnxiety DO

90 63 78 80 67 16

Any Anxiety Disorder

380 261 314 321 323 249

9

Prevalencebull CDC reports 3 of children ages 3-17 years old have a current diagnosis

of an anxiety disorder (httpwwwcdcgovchildrensmentalhealthdatahtml)

bull Lifetime prevalence rates for having at least one anxiety disorder range from 6 to 20 (Costello et al 2004)

bull All anxiety disorder subtypes were more frequent in females (MerikangasKR et al 2010)

bull Few raceethnic variations across anxiety disorders with the exception of increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (MerikangasKR et al 2010)10

Anxietyrsquos Potential TrajectoriesProgressive

Persistent

Waxing and Waning

Remitting

0 3 6 12Infancy and toddlerhood

Childhood School age Adolescence

Psycho-pathologically relevant symptoms of fear and anxiety

Normativefears

8

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 17-18y12-MonthPrevalence

Agoraphobia 34 14 25 25 20 18

GeneralizedAnxiety DO

30 15 10 28 30 11

Social phobia 112 70 77 97 101 82

Specific phobia 221 167 216 183 177 158

Panic disorder 26 20 18 23 33 19

SeparationAnxiety DO

90 63 78 80 67 16

Any Anxiety Disorder

380 261 314 321 323 249

9

Prevalencebull CDC reports 3 of children ages 3-17 years old have a current diagnosis

of an anxiety disorder (httpwwwcdcgovchildrensmentalhealthdatahtml)

bull Lifetime prevalence rates for having at least one anxiety disorder range from 6 to 20 (Costello et al 2004)

bull All anxiety disorder subtypes were more frequent in females (MerikangasKR et al 2010)

bull Few raceethnic variations across anxiety disorders with the exception of increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (MerikangasKR et al 2010)10

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 17-18y12-MonthPrevalence

Agoraphobia 34 14 25 25 20 18

GeneralizedAnxiety DO

30 15 10 28 30 11

Social phobia 112 70 77 97 101 82

Specific phobia 221 167 216 183 177 158

Panic disorder 26 20 18 23 33 19

SeparationAnxiety DO

90 63 78 80 67 16

Any Anxiety Disorder

380 261 314 321 323 249

9

Prevalencebull CDC reports 3 of children ages 3-17 years old have a current diagnosis

of an anxiety disorder (httpwwwcdcgovchildrensmentalhealthdatahtml)

bull Lifetime prevalence rates for having at least one anxiety disorder range from 6 to 20 (Costello et al 2004)

bull All anxiety disorder subtypes were more frequent in females (MerikangasKR et al 2010)

bull Few raceethnic variations across anxiety disorders with the exception of increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (MerikangasKR et al 2010)10

Prevalencebull CDC reports 3 of children ages 3-17 years old have a current diagnosis

of an anxiety disorder (httpwwwcdcgovchildrensmentalhealthdatahtml)

bull Lifetime prevalence rates for having at least one anxiety disorder range from 6 to 20 (Costello et al 2004)

bull All anxiety disorder subtypes were more frequent in females (MerikangasKR et al 2010)

bull Few raceethnic variations across anxiety disorders with the exception of increased rates of anxiety disorders among non-Hispanic Black adolescents compared to non-Hispanic White adolescents (MerikangasKR et al 2010)10

Additional Variablesbull 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)

bull 50 of adolescents with anxiety disorders in NCS-A had the onset of their disorder by age 6 years (Merikangas KR et al 2010)

bull 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 amp Kazdin AE 1996)

11

Geneticsbull Twin studies suggest there is a strong genetic component to

anxiety disorders (Eley 2001 in AACAP PP 2007)

bull ldquoChildren of parents with an anxiety disorder have a substantially increased risk to also develop an anxiety disorder rdquo (Beesdo-Braum K Knappe S 2012)

bull 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)

12

Environmentbull Parents with anxiety disorders may model anxious approaches

to their children

bull Overprotective controlling and critical parenting styles can interrupt normal development of autonomy and mastery and lead to anxiety disorders (AACAP 2007)

bull Parental unemployment is associated with anxiety disorders in children (Beesdo-Braum K Knappe S 2012)

bull Protective factor Coping skills (AACAP 2007) which form the basis for many of the evidence-based psychosocial interventions

13

Treatment starts with assessmentbull AACAP recommends obtaining data from multiple informants

including the youth and adults (parentsteachers) because children may be more aware of internal distress than adults but adults are often more aware of the functional impact of a childrsquos anxiety disorder (AACAP 2007)

bull 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 Childrenrsquos Anxiety Scale (SCAS) (Holly LE Little M Pina AA Caterino LC 2015)

14

SCAREDChild version httppsychiatrypittedusitesdefaultfilesDocumentsassessmentsSCARED20Childpdf

Parent Version httpwwwpsychiatrypittedusitesdefaultfilesDocumentsassessmentsSCARED20Parentpdf

SCARED is also available in numerous translations including Arabic Chinese French German Italian Thai Spanish and Tamil (Sri Lanka) httpwwwpediatricbipolarpitteducontentaspid=2333

There is also a five-item brief version 15

Geneticsbull Twin studies suggest there is a strong genetic component to

anxiety disorders (Eley 2001 in AACAP PP 2007)

bull ldquoChildren of parents with an anxiety disorder have a substantially increased risk to also develop an anxiety disorder rdquo (Beesdo-Braum K Knappe S 2012)

bull 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)

12

Environmentbull Parents with anxiety disorders may model anxious approaches

to their children

bull Overprotective controlling and critical parenting styles can interrupt normal development of autonomy and mastery and lead to anxiety disorders (AACAP 2007)

bull Parental unemployment is associated with anxiety disorders in children (Beesdo-Braum K Knappe S 2012)

bull Protective factor Coping skills (AACAP 2007) which form the basis for many of the evidence-based psychosocial interventions

13

Treatment starts with assessmentbull AACAP recommends obtaining data from multiple informants

including the youth and adults (parentsteachers) because children may be more aware of internal distress than adults but adults are often more aware of the functional impact of a childrsquos anxiety disorder (AACAP 2007)

bull 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 Childrenrsquos Anxiety Scale (SCAS) (Holly LE Little M Pina AA Caterino LC 2015)

14

SCAREDChild version httppsychiatrypittedusitesdefaultfilesDocumentsassessmentsSCARED20Childpdf

Parent Version httpwwwpsychiatrypittedusitesdefaultfilesDocumentsassessmentsSCARED20Parentpdf

SCARED is also available in numerous translations including Arabic Chinese French German Italian Thai Spanish and Tamil (Sri Lanka) httpwwwpediatricbipolarpitteducontentaspid=2333

There is also a five-item brief version 15

Environmentbull Parents with anxiety disorders may model anxious approaches

to their children

bull Overprotective controlling and critical parenting styles can interrupt normal development of autonomy and mastery and lead to anxiety disorders (AACAP 2007)

bull Parental unemployment is associated with anxiety disorders in children (Beesdo-Braum K Knappe S 2012)

bull Protective factor Coping skills (AACAP 2007) which form the basis for many of the evidence-based psychosocial interventions

13

Treatment starts with assessmentbull AACAP recommends obtaining data from multiple informants

including the youth and adults (parentsteachers) because children may be more aware of internal distress than adults but adults are often more aware of the functional impact of a childrsquos anxiety disorder (AACAP 2007)

bull 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 Childrenrsquos Anxiety Scale (SCAS) (Holly LE Little M Pina AA Caterino LC 2015)

14

SCAREDChild version httppsychiatrypittedusitesdefaultfilesDocumentsassessmentsSCARED20Childpdf

Parent Version httpwwwpsychiatrypittedusitesdefaultfilesDocumentsassessmentsSCARED20Parentpdf

SCARED is also available in numerous translations including Arabic Chinese French German Italian Thai Spanish and Tamil (Sri Lanka) httpwwwpediatricbipolarpitteducontentaspid=2333

There is also a five-item brief version 15

Treatment starts with assessmentbull AACAP recommends obtaining data from multiple informants

including the youth and adults (parentsteachers) because children may be more aware of internal distress than adults but adults are often more aware of the functional impact of a childrsquos anxiety disorder (AACAP 2007)

bull 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 Childrenrsquos Anxiety Scale (SCAS) (Holly LE Little M Pina AA Caterino LC 2015)

14

SCAREDChild version httppsychiatrypittedusitesdefaultfilesDocumentsassessmentsSCARED20Childpdf

Parent Version httpwwwpsychiatrypittedusitesdefaultfilesDocumentsassessmentsSCARED20Parentpdf

SCARED is also available in numerous translations including Arabic Chinese French German Italian Thai Spanish and Tamil (Sri Lanka) httpwwwpediatricbipolarpitteducontentaspid=2333

There is also a five-item brief version 15

SCAREDChild version httppsychiatrypittedusitesdefaultfilesDocumentsassessmentsSCARED20Childpdf

Parent Version httpwwwpsychiatrypittedusitesdefaultfilesDocumentsassessmentsSCARED20Parentpdf

SCARED is also available in numerous translations including Arabic Chinese French German Italian Thai Spanish and Tamil (Sri Lanka) httpwwwpediatricbipolarpitteducontentaspid=2333

There is also a five-item brief version 15

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

scale that is available in 28 languages (httpwwwscaswebsitecom)

bull Recent research ldquoindicated that the SCAS is a fairly robust measure across ethnicity (ie HispanicLatino NHW) and sex with more variations for the latterrdquo ndash 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)

bull What sets SCAS scales specific to preschoolers httpwwwscaswebsitecom

16

Differential Diagnosisbull Other psychiatric disorders

ndash ADHD (restlessness inattention)

ndash Psychotic disorders (restlessness social withdrawal)

ndash Autism Spectrum Disorders (social awkwardness and withdrawal social skills deficits communication deficits adherence to routines repetitive behaviors)

ndash Learning disabilities (concerns about school performance)

ndash Bipolar disorder (restlessness irritability insomnia)

ndash Depression (poor concentration difficulty sleeping somatic complaints)

17

Medical Conditions and Substances that can cause Anxiety Symptoms

bull Side effects of medications including SSRIs steroids antipsychotics

antihistamines diet pills other cold medications

bull Medical disorders

ndash Hyperthyroidism

ndash Migraine

ndash Asthma

ndash Seizure disorders

bull Substances

ndash Lead intoxication

ndash Caffeine 18

Treatment choice bull Based on symptom severity functional impairment and a childrsquos

developmental capacity to access different therapeutic or coping tools

bull AACAP recommends a multimodal treatment approach for all levels of anxiety disorder

bull AACAP recommends mild anxieties be treated with psychotherapy

ndash Patient and parent education support and encouragement to resume normal activities gradually

ndash Family encouragement to maintain routines (Ramsawh H Chavira DA and Stein MB 2010)

bull Exposure-based CBT has the most evidence behind it (AACAP 2007)19

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) 20

Psychoeducation

bull Teach the family about the disorder

bull Teach parents skills to manage anxiety symptoms so they can provide support to the child (or themselves) at home

bull Additional points positive incentives to practice skills are okay parents are seen as CBT coaches (AACAP 2007)

bull Education about parental accommodation 21

Somatic management skills trainingbull These skills address the autonomic arousal and related

psychological responses children have to their feared stimuli bull Relaxation training is used to teach children awareness and

control over their physiological reactions bull 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

bull Ultimately the goal is to help children be aware of and tolerate arousal resulting from anxiety

22

Cognitive restructuring

bull Challenge negative thoughts and expectations

bull Identify and correct negative self-talk ndash teach positive self-talk

Exposure methods

bull Gradual desensitization based on a fear hierarchy

bull Teach how to couple relaxation techniques with fear stimuli

bull One might start treating a specific phobia by reading

a book about or drawing pictures of the feared stimuli

24

Relapse prevention

bull Homework is used to practice skills outside of therapy sessions

bull Booster sessions are scheduled as needed

25

Medicationsbull AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when

ndash Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy

ndash There is a comorbid disorder that requires treatment with medication

bull Of note the AACAP Anxiety practice parameter was written before the ChildAdolescent Anxiety Multimodal Study (CAMS) was published CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP 2007)

26

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Medical Conditions and Substances that can cause Anxiety Symptoms

bull Side effects of medications including SSRIs steroids antipsychotics

antihistamines diet pills other cold medications

bull Medical disorders

ndash Hyperthyroidism

ndash Migraine

ndash Asthma

ndash Seizure disorders

bull Substances

ndash Lead intoxication

ndash Caffeine 18

Treatment choice bull Based on symptom severity functional impairment and a childrsquos

developmental capacity to access different therapeutic or coping tools

bull AACAP recommends a multimodal treatment approach for all levels of anxiety disorder

bull AACAP recommends mild anxieties be treated with psychotherapy

ndash Patient and parent education support and encouragement to resume normal activities gradually

ndash Family encouragement to maintain routines (Ramsawh H Chavira DA and Stein MB 2010)

bull Exposure-based CBT has the most evidence behind it (AACAP 2007)19

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) 20

Psychoeducation

bull Teach the family about the disorder

bull Teach parents skills to manage anxiety symptoms so they can provide support to the child (or themselves) at home

bull Additional points positive incentives to practice skills are okay parents are seen as CBT coaches (AACAP 2007)

bull Education about parental accommodation 21

Somatic management skills trainingbull These skills address the autonomic arousal and related

psychological responses children have to their feared stimuli bull Relaxation training is used to teach children awareness and

control over their physiological reactions bull 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

bull Ultimately the goal is to help children be aware of and tolerate arousal resulting from anxiety

22

Cognitive restructuring

bull Challenge negative thoughts and expectations

bull Identify and correct negative self-talk ndash teach positive self-talk

Exposure methods

bull Gradual desensitization based on a fear hierarchy

bull Teach how to couple relaxation techniques with fear stimuli

bull One might start treating a specific phobia by reading

a book about or drawing pictures of the feared stimuli

24

Relapse prevention

bull Homework is used to practice skills outside of therapy sessions

bull Booster sessions are scheduled as needed

25

Medicationsbull AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when

ndash Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy

ndash There is a comorbid disorder that requires treatment with medication

bull Of note the AACAP Anxiety practice parameter was written before the ChildAdolescent Anxiety Multimodal Study (CAMS) was published CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP 2007)

26

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Treatment choice bull Based on symptom severity functional impairment and a childrsquos

developmental capacity to access different therapeutic or coping tools

bull AACAP recommends a multimodal treatment approach for all levels of anxiety disorder

bull AACAP recommends mild anxieties be treated with psychotherapy

ndash Patient and parent education support and encouragement to resume normal activities gradually

ndash Family encouragement to maintain routines (Ramsawh H Chavira DA and Stein MB 2010)

bull Exposure-based CBT has the most evidence behind it (AACAP 2007)19

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) 20

Psychoeducation

bull Teach the family about the disorder

bull Teach parents skills to manage anxiety symptoms so they can provide support to the child (or themselves) at home

bull Additional points positive incentives to practice skills are okay parents are seen as CBT coaches (AACAP 2007)

bull Education about parental accommodation 21

Somatic management skills trainingbull These skills address the autonomic arousal and related

psychological responses children have to their feared stimuli bull Relaxation training is used to teach children awareness and

control over their physiological reactions bull 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

bull Ultimately the goal is to help children be aware of and tolerate arousal resulting from anxiety

22

Cognitive restructuring

bull Challenge negative thoughts and expectations

bull Identify and correct negative self-talk ndash teach positive self-talk

Exposure methods

bull Gradual desensitization based on a fear hierarchy

bull Teach how to couple relaxation techniques with fear stimuli

bull One might start treating a specific phobia by reading

a book about or drawing pictures of the feared stimuli

24

Relapse prevention

bull Homework is used to practice skills outside of therapy sessions

bull Booster sessions are scheduled as needed

25

Medicationsbull AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when

ndash Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy

ndash There is a comorbid disorder that requires treatment with medication

bull Of note the AACAP Anxiety practice parameter was written before the ChildAdolescent Anxiety Multimodal Study (CAMS) was published CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP 2007)

26

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

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) 20

Psychoeducation

bull Teach the family about the disorder

bull Teach parents skills to manage anxiety symptoms so they can provide support to the child (or themselves) at home

bull Additional points positive incentives to practice skills are okay parents are seen as CBT coaches (AACAP 2007)

bull Education about parental accommodation 21

Somatic management skills trainingbull These skills address the autonomic arousal and related

psychological responses children have to their feared stimuli bull Relaxation training is used to teach children awareness and

control over their physiological reactions bull 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

bull Ultimately the goal is to help children be aware of and tolerate arousal resulting from anxiety

22

Cognitive restructuring

bull Challenge negative thoughts and expectations

bull Identify and correct negative self-talk ndash teach positive self-talk

Exposure methods

bull Gradual desensitization based on a fear hierarchy

bull Teach how to couple relaxation techniques with fear stimuli

bull One might start treating a specific phobia by reading

a book about or drawing pictures of the feared stimuli

24

Relapse prevention

bull Homework is used to practice skills outside of therapy sessions

bull Booster sessions are scheduled as needed

25

Medicationsbull AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when

ndash Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy

ndash There is a comorbid disorder that requires treatment with medication

bull Of note the AACAP Anxiety practice parameter was written before the ChildAdolescent Anxiety Multimodal Study (CAMS) was published CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP 2007)

26

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Psychoeducation

bull Teach the family about the disorder

bull Teach parents skills to manage anxiety symptoms so they can provide support to the child (or themselves) at home

bull Additional points positive incentives to practice skills are okay parents are seen as CBT coaches (AACAP 2007)

bull Education about parental accommodation 21

Somatic management skills trainingbull These skills address the autonomic arousal and related

psychological responses children have to their feared stimuli bull Relaxation training is used to teach children awareness and

control over their physiological reactions bull 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

bull Ultimately the goal is to help children be aware of and tolerate arousal resulting from anxiety

22

Cognitive restructuring

bull Challenge negative thoughts and expectations

bull Identify and correct negative self-talk ndash teach positive self-talk

Exposure methods

bull Gradual desensitization based on a fear hierarchy

bull Teach how to couple relaxation techniques with fear stimuli

bull One might start treating a specific phobia by reading

a book about or drawing pictures of the feared stimuli

24

Relapse prevention

bull Homework is used to practice skills outside of therapy sessions

bull Booster sessions are scheduled as needed

25

Medicationsbull AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when

ndash Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy

ndash There is a comorbid disorder that requires treatment with medication

bull Of note the AACAP Anxiety practice parameter was written before the ChildAdolescent Anxiety Multimodal Study (CAMS) was published CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP 2007)

26

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Somatic management skills trainingbull These skills address the autonomic arousal and related

psychological responses children have to their feared stimuli bull Relaxation training is used to teach children awareness and

control over their physiological reactions bull 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

bull Ultimately the goal is to help children be aware of and tolerate arousal resulting from anxiety

22

Cognitive restructuring

bull Challenge negative thoughts and expectations

bull Identify and correct negative self-talk ndash teach positive self-talk

Exposure methods

bull Gradual desensitization based on a fear hierarchy

bull Teach how to couple relaxation techniques with fear stimuli

bull One might start treating a specific phobia by reading

a book about or drawing pictures of the feared stimuli

24

Relapse prevention

bull Homework is used to practice skills outside of therapy sessions

bull Booster sessions are scheduled as needed

25

Medicationsbull AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when

ndash Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy

ndash There is a comorbid disorder that requires treatment with medication

bull Of note the AACAP Anxiety practice parameter was written before the ChildAdolescent Anxiety Multimodal Study (CAMS) was published CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP 2007)

26

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Cognitive restructuring

bull Challenge negative thoughts and expectations

bull Identify and correct negative self-talk ndash teach positive self-talk

Exposure methods

bull Gradual desensitization based on a fear hierarchy

bull Teach how to couple relaxation techniques with fear stimuli

bull One might start treating a specific phobia by reading

a book about or drawing pictures of the feared stimuli

24

Relapse prevention

bull Homework is used to practice skills outside of therapy sessions

bull Booster sessions are scheduled as needed

25

Medicationsbull AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when

ndash Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy

ndash There is a comorbid disorder that requires treatment with medication

bull Of note the AACAP Anxiety practice parameter was written before the ChildAdolescent Anxiety Multimodal Study (CAMS) was published CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP 2007)

26

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Exposure methods

bull Gradual desensitization based on a fear hierarchy

bull Teach how to couple relaxation techniques with fear stimuli

bull One might start treating a specific phobia by reading

a book about or drawing pictures of the feared stimuli

24

Relapse prevention

bull Homework is used to practice skills outside of therapy sessions

bull Booster sessions are scheduled as needed

25

Medicationsbull AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when

ndash Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy

ndash There is a comorbid disorder that requires treatment with medication

bull Of note the AACAP Anxiety practice parameter was written before the ChildAdolescent Anxiety Multimodal Study (CAMS) was published CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP 2007)

26

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Relapse prevention

bull Homework is used to practice skills outside of therapy sessions

bull Booster sessions are scheduled as needed

25

Medicationsbull AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when

ndash Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy

ndash There is a comorbid disorder that requires treatment with medication

bull Of note the AACAP Anxiety practice parameter was written before the ChildAdolescent Anxiety Multimodal Study (CAMS) was published CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP 2007)

26

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Medicationsbull AACAP recommends consideration of adding medication

treatment to psychotherapy in moderate to severely anxious children when

ndash Psychotherapy has produced only a partial response and there is the potential for improved outcomes with combination therapy

ndash There is a comorbid disorder that requires treatment with medication

bull Of note the AACAP Anxiety practice parameter was written before the ChildAdolescent Anxiety Multimodal Study (CAMS) was published CAMS provides strong evidence for the benefit of combination treatment for children with anxiety disorders (AACAP 2007)

26

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Anti-anxiety Medications

bull Also used to treat depressive disorders

bull Pooled response rate for active treatment was 69 for non-OCD anxiety disorders (95CI 65 to73) and 39 (95 CI 35 to 43) for placebo (Bridge JA et al 2007)

bull 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)

27

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

SSRIsSSNRIsbull Fluoxetine Fluvoxamine Sertraline and Paroxetine and Venlafaxine ER

outperformed placebo in studies of children and adolescents although some of these studies were quite small (Peters TE and Connolly S 2012)

bull Adolescents responded better than children but both groups showed significant and positive effects (Bridge JA et al 2007)

bull Side effects are possible

ndash 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)

ndash Unlike in adults SSRIsSSNRIs donrsquot statistically increase risk for GI symptoms (Strawn et al 2015)

28

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

ChildAdolescent Anxiety Multimodal Study (CAMS)

bull Established the standard of care

bull 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

29

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

CAMS Outcomes

bull Percentage of those who measured very much or much improved on Clinician Global Impression-Improvement scale

ndash 807 for combination therapy (Plt0001)

ndash 597 for cognitive behavioral therapy alone (Plt0001)

ndash 549 for sertraline alone (Plt0001)

ndash All therapies were superior to placebo (237)

30

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

CAMS Conclusions

bull CBT sertraline and their combination are all effective treatments for anxiety disorders in children and adolescents

bull Combination treatment with sertraline and CBT was the most effective

bull Placebo alone was not effective treatment (Walkup et al 2008)

31

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

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

bull FDA issued its warning based on 24 placebo-controlled trials (assessing more than 4400 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)

32

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Other considerations

bull Ensuring these evidence based interventions are available in the service array and accessible

bull Workforce development (training coaching supervision certificate programs)

bull Fiscal issues (eg incentives for implementing EBPs $ for training and ongoing 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 disordershellip esp in light of the 10-15 prevalence rate in adolescents

33

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

Other considerations (contrsquod)

bull 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 youthfamilyteam and know who provide such treatments

bull 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

34

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

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

Washington DC American Psychiatric Publishingbull 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 Psychopharmacology 19(6) 567-596

bull Beesdo-Baum K amp Knappe S (2012) Developmental epidemiology of anxiety disorders Child AdolescPsychiatr Clin N Am 21(3) 457-78 doi 101016jchc201205001

bull Bridge JA Iyengar S Salary CB Barbe RP Birmaher B Pincus HA Ren L amp 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

bull Carter R Silverman WK amp Jaccard J (2011) Sex variations in youth anxiety symptoms Effects of pubertal development and gender role orientation Journal of Clinical Child amp Adolescent Psychology (40) 730ndash741

bull Connolly SD and Bernstein GA Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders JAACAP 46(2) 267-283

bull Friedman RA (2014) Antidepressants Black-Box Warning mdash 10 Years Later NEJM 371(18) 1666-1668 httpwwwnejmorgdoifull101056NEJMp1408480t=article

bull Hammad TA (2004) Relationship between psychotropic drugs and pediatric suicidality US FDA Retrieved from httpwwwfdagovohrmsdocketsac04briefing2004-4065b1-10-TAB08-Hammads-Reviewpdf

35

References (contrsquod)bull Hammad TA Laughren T amp Racoosin J (2006) Suicidality in pediatric patients treated with antidepressant

drugs Arch Gen Psychiatry 63(3) 32-339bull Holly LE Little M Pina AA amp Caterino LC (2015) Assessment of Anxiety Symptoms in School Children A

Cross-Sex and Ethnic Examination J Abnorm Child Psychology 43(2) 297-309 doi 101007s10802-014-9907-4

bull Kessler RC Avenevoli S Costello EJ Georgiades K Green JG Gruber MJ He JP Koretz D McLaughlin KA Petukhova M Sampson NA Zaslavsky AM amp Merikangas KR (2012) Prevalence persistence and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication-Adolescent Supplement Arch Gen Psychiatry 69(4) 372ndash80

bull Last CG Perrin S Hersen M amp Kazdin AE (1996) A prospective study of childhood anxiety disorders J Am Acad Child Adolesc Psychiatry 35(11) 1502ndash10

bull Merikangas KR He J Burstein M Swanson SA Avenevoli S Cui L Benjet C Georgiades K Swendsen J (2010) Lifetime Prevalence of Mental Disorders in US Adolescents Results from the National Comorbidity Study-Adolescent Supplement (NCS-A) Journal of the American Academy of Child and Adolescent Psychiatry 49(10) 980-989

bull Ollendick TH Halldorsdottir T Fraire MG Austin KE Noguchi RJP Lewis KM Jarrett MA Cunningham NR Canavera K Allen KB amp Whitmore M (2015) Specific Phobias in Youth A Randomized Controlled Trial Comparing One-Session Treatment to a Parent-Augmented One-Session Treatment Behav Ther46(2) 141-155 doi 101016jbeth201409004

bull Peters TE and Connolly S (2012) Psychopharmacologic treatment for pediatric anxiety disorders Child Adolesc Psychiatr Clin N Am 21(4) 789-806 doi 101016jchc20120700736

References (contrsquod)bull Ramsawh H Chavira DA and Stein MB (2010) The burden of anxiety disorders in pediatric medical settings

prevalence phenomenology and a research agenda Arch Pediatr Adolsc Med 164(10) 965-972bull Reichenberg LW (2014) DSM-5 Essentials The Savvy Clinicianrsquos Guide to the Changes in the Criteria New

Jersey Wileybull Roberts RE Roberts C Xing Y (2006) Prevalence of youth-reported DSM-IV psychiatric disorders among

African American European and Mexican American adolescents Journal of the American Academy of Child and Adolescent Psychiatry 45(11) 1329ndash1337

bull Sanchez-Meca J Rosa-Alcazar AI Marin-Martinez F amp Gomez-Conesa A (2010) Psychological treatment of panic disorder with or without agoraphobia A meta-analysis Clinical Psychology Review 30(1) 37-50 doi 101016jcpr200908011

bull Strawn JR Welge JA Wehry AM Keeshin B amp Rynn MA (2015) Efficacy and tolerability of antidepressants in pediatric anxiety disorders a systematic review and meta-analysis Depression and Anxiety 32(3)149-57

bull Walkup JT Albano AM Piacentini J Birmaher B Compton SN Sherrill JT Ginsburg GS Rynn MA McCracken J Waslick B Iyengar S March JS Kendall PC (2008) Cognitive behavioral therapy sertraline or a combination in childhood anxiety New England Journal of Medicine 359(26) 2753ndash2766 DOI 101056NEJMoa0804633

bull Wittchen HU Lieb R Pfister H amp Schuster P (2000) The waxing and waning of mental disorders evaluating the stability of syndromes of mental disorders in the population Compr Psychiatry 41(2 Suppl 1) 122ndash32

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