Tools in the Treatment of Anxiety Disorders

Hanna Stevens, MD PhDIda P. Haller Chair of Child and Adolescent Psychiatry University of Iowa Carver College of Medicine

Acknowledgements and Disclosures

I have no commercial financial relationships to disclose

I will be discussing off label use of medications, given the limited FDA approved medications for anxiety in children

Objectives• To know tools that can be used for assessment of

children with anxiety• To be able to identify resources for families of children

with anxiety• To be able to know resources for prescribing

medication for children with anxiety disorders

• Caption

Why is this important to primary care providers of children?

Why is this important to primary care providers of children in Iowa?

Why is this important to primary care providers of children?

Child Development

Neuroscience

Psychological and

Behavioral Intervention

Psychophar-macology

Psychosocial stress

Background Information- Prevalence rates: 6-30% of Children in the US will have at least one anxiety

disorder during childhood- Separation anxiety (5-8%)- Social phobia (7-9% in general pop, 20-50% of clinical referrals)- Generalized anxiety disorder (2-5%)- Specific Phobia (15-20%)- Obsessive Compulsive Disorder (2-4% prevalence)- Selective Mutism (0.5-1% prevalence)- Panic Disorder (2-5% prevalence)- Post Traumatic Stress Disorder (3-5% in general pop; 15% of children who

experience traumatic events)

- From the National Comorbidity Survey- Kessler et al Arch Gen Psychiatry, 2012

Background Information- Risk factors: From Nat’l Comorbidity Study: anxiety is less common in

adolescents who were male and whose parents were married and graduated college

- Age of Onset: - Median Age of Onset: 11 years old

- The majority of anxiety disorders experienced across the lifespan emerge in childhood or adolescence

Developmental factors to consider in children with anxiety

• Infants – developmentally normal stages of anxiety related to strangers

• Toddlers – normal fears of imaginary creatures and separation anxiety

• School Age – bad things happening, performance, health

• Adolescence – fears of being accepted socially

• Some degree of anxiety is a normal, biologic and protective process

• Becomes problematic and meetings the criteria for a treatable condition when it causes impairment

Most children with an Anxiety Disorder will present to a pediatrician firstStomach aches, headaches, fatigue, insomnia, or chief complaint of anxiety

Sometimes the presentation is more complex– i.e. difficulty concentrating because of over-focus on worries, excessive tantrums because of efforts to avoid things that bring on anxiety

Factors to consider in children when trying to identify anxiety

• Children do not always have a good sense of time• Their history-reporting of emotions/symptoms may overly reflect what is

happening in the present or immediate past and reflecting over the past weeks or months may be difficult

• Young children (up to age 8, and some up to age 10) are not always good at identifying emotions• Children may not always be able to report worries/fears

• Anxiety disorders are highly heritable• understanding parental anxiety may aid in diagnosing child anxiety

• The natural response to anxiety in humans is to try to reduce the feeling and therefore to avoid things that induce anxiety. • Identifying patterns of avoidance can be very helpful in the diagnosis

Tools for Assessment

- GAD 7 (Generalized Anxiety Disorder Assessment with 7 questions) –general questions about impairment (treatment is more dependent on degree of impairment rather than number of symptoms)

- 10 or greater is concerning

Tools for Assessment

- Screen for Child Anxiety Related Disorders (SCARED) –available online

- Parent and child report forms (41 questions each)

- screens for Panic, GAD, Separation Anxiety, School Avoidance and Social anxiety

- *Not a validated instrument, but can be filled out and scored easily in clinics

Tools for Assessment

- Screen for Child Anxiety Related Disorders (SCARED) –available online

- Parent and child report forms (41 questions each)

- screens for Panic, GAD, Separation Anxiety, School Avoidance and Social anxiety

- *Not a validated instrument, but can be filled out and scored easily in clinics

Tools for AssessmentFamily Accommodation Scale

- Not a validated instrument- Scores above 10 are concerning- Can be helpful in demonstrating to parents how significant the problem is

Tools after Assessment

Describing the problem to families• American Academy

of Child and Adolescent Psychiatry

Facts for Families

Tools after AssessmentEli Lebowitz PhD, Expert in Childhood Anxiety• Yale Child Study Center Youtube Lecture Series

• These are appropriate for clinicians or families

• Introduction to Childhood Behavioral Disorders • https://www.youtube.com/watch?v=xLDieMMXF2Y

• Cognitive Behavioral Therapy for Childhood Anxiety• https://www.youtube.com/watch?v=8pyanIgSJuw&t=1s

• **Parenting Children with Anxiety Disorders**• https://www.youtube.com/watch?v=5nzetUfrWsg

Tools after Assessment

Child Mind Institute

Provides excellent basic information on a range of child mental health topics

Tools after Assessment

Tools for Treatment

https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/JAACAP_Anxiety_2007.pdf

Treatment

- First line treatment for all anxiety diagnoses (that are mild to moderate in terms of impairment) is individual psychotherapy.

- Best evidence support for Cognitive Behavioral Therapy (or CBT)

- For children, success from individual psychotherapy depends on

- Psychoeducation on the problem for the Child and Parent(s) (what is anxiety, how does it make you feel, what kinds of problems can you have due to anxiety)

- Learning to identify emotions (cognitively and physically)

- Learning how to relax

- Reducing avoidance/gradually facing fears

Treatment• Avoid reinforcing avoidance!

• Reducing avoidance is best done in a gradual way• Parents often have a difficult time reducing avoidance, as the natural parent

tendency is to try to reduce our children’s fears

• For School Avoidance – primary component of treatment is going to school

• For Obsessive Compulsive Disorder – mainstay of treatment is exposure and response prevention

• All Anxiety therapies revolve around learning coping skills to build confidence to engage the things that make you anxious head on, and decrease distress.

Pharmacologic Interventions

***No Benzodiazepines

• Benzodiazepines have not shown efficacy in controlled trials in childhood anxiety disorders despite established benefit in adults.

• Reasons to avoid their use in children• They can cause sedation

• In children, disinhibition is quite common (the opposite of what is helpful)

• Cognitive impairment is a real problem in anyone who uses benzodiazepines for longer than a few weeks or months (this is often the most compelling reason for patients)

• Possibility of developing dependency

Pharmacologic InterventionsFDA approved Treatments for anxiety disorders in children

- Fluoxetine (Prozac) –indicated for OCD in ages 7+ - recommended dose 10-60 mg

- Sertraline (Zoloft) indicated for OCD in ages 6+ and GAD in ages 7+ - dose 25-200 in age 6-12 y/o and 50-200 mg in 13-17 y/o

- Fluvoxamine (Luvox) – indicated for OCD in ages 8+ - dose 50-200 mg in age 8-12; 50-300 mg in ages 13-17

- Clomipramine has indication for OCD in age 10+ - recommended dose 25-100 mg daily

- Venlafaxine - FDA indication for GAD in adolescents – recommended starting dose of 37.5 mg daily

- Paroxetine – indicated for OCD in ages 7+ and Social phobia in ages 8+ (not recommended) – 10-50 mg daily

Non FDA-approved but evidence based

- Sertraline – Randomized Control Trial for Social phobia and GAD; open label for Panic

- Fluoxetine – Randomized Control Trial for GAD and Social phobia; Open label for Panic

- Venlafaxine- Randomized Control Trial for Social phobia

- Mirtazapine – Open label studies for social anxiety and PTSD

Name Starting Dose Titration FDA Tested Range Reality (Clinical) Dosing

Citalopram(Celexa)

10 mg daily(5 mg young or sensitive)

10 mg x 1 week then 20 mg

n/a 10-40 mg daily

Escitalopram(Lexapro)

5 mg daily 5 mg x 1 week then 10 mg daily

10-20 mg daily 10-20 mg daily

Fluoxetine(Prozac)

10 mg daily(5 mg young or sensitive)

10 mg x 1 week then 20 mg

10-20 mg for MDD20-60 mg for OCD

10-80 mg daily

Fluvoxamine(Luvox)

25 mg daily 25 mg x 1 week then 50 mg daily

50-200 mg for kids50-300 mg for adol

50-300 mg daily

Sertraline(Zoloft)

25 mg daily(12.5 mg young or sensitive)

25 mg x 1 week then 50 mg daily

25-200 mg daily 25-200 mg daily

Paroxetine 10 mg daily 10-50 mg daily(mean dose 26.5 mg)

Mirtazapine(Remeron)

7.5-15 mg QHS 15-45 mg QHS

Venlafaxine(Effexor)

37.5 mg daily 75-225 mg daily

Medication Pointers

- Start low and go slow – initial dose then titrate after 1 week if tolerated; then if limited improvement after 4-6 weeks, dose can be further increased.

- Common side effects: GI (nausea, vomiting, diarrhea); headache; sleep changes, activation (restless or anxious feeling); sweating, dry mouth, sexual dysfunction

- Rare Side effects: Serotonin Syndrome, hypomania, or suicidal ideation- Slight increased risk of Suicidal ideation from ~2% to about 4% (in thoughts, no

attempts or completions); in the mid 2000s when black box warning came out and prescriptions dropped – it was then that youth suicide rates went up.

Questions?

Email: hanna-stevens@uiowa.edu

University of Iowa Hospitals and Clinics provides Consultation via a toll-free (800-322-8442) service 24 hours a day

Tools after Assessment

Worry Wise Kids Website run by The Children's and Adult Center for OCD and Anxiety