Bns 3 Exam - Anxiety Disorders In Children And Adolescense

Front 1

Categories of anxiety disorders in children

Back 1

 Separation Anxiety Disorder (SAD)***
 School Refusal***
 Selective Mutism***
 Generalized Anxiety Disorder or GAD (Overanxious Disorder of Childhood)
 Social Phobia (SP) aka social anxiety disorder.
 Specific Phobia
 Panic Disorder
 Obsessive Compulsive Disorder (OCD)
 Post Traumatic Stress Disorder (PTSD)***

Front 2

 Normal Anxiety

Back 2

Physiological preparedness to potential threat

Front 3

 Pathological Anxiety

Back 3

: Impaired ability to respond to environmental threat (fear overwhelms

Front 4

 Normal fears in children
Preschool

Back 4

Safety, nightmares, monsters

Front 5

 Normal fears in children
School age

Back 5

School, the unknown

Front 6

_____ of children of parents with anxiety will have anxiety

Back 6

20-25%

Front 7

Psychological Etiology

Back 7

 Disordered Attachment
Insecure attachment at age 1 confers at 2x higher risk of anxiety as teen
 Temperament
Behavioral inhibition i.e., approach new or strange situations with restraint

Front 8

***Parental Behaviors that promote anxiety

Back 8

 Overprotection
 Intrusiveness
 Over-control
 Promoting avoidance
 Disordered attachment

Front 9

 Parental Behaviors that protect from anxiety:

Back 9

 Modeling
 Encouragement
 Acceptance
 Support
 Play, Challenge, Risk Taking,
 Encouraging independence

Front 10

Most common childhood psychiatric diagnoses

Back 10

Anxiety Disorders
 Specific Phobia

Front 11

Anxiety in Girls:Boys 2:1 through adolescence except ______ and _____where boys>girls

Back 11

OCD
Social Phobia

Front 12

Most prevalent anxiety per age group
1. Preschool:
2. School Age
3. Adolescence:

Back 12

1. Separation Anxiety Disorder
2. Specific Phobia, GAD, Selective Mutism, OCD.
3. Social Phobia, Panic Disorder

Front 13

Diagnosis

Back 13

 Interview
 Scales (MASC or SCARED)
 DSM IV TR Criteria application
 Note 82% of originally diagnosed anxiety disorders remit but there is a HIGH risk for new anxiety orders to emerge.

Front 14

Note __% of originally diagnosed anxiety disorders remit but there is a HIGH risk for new anxiety orders to emerge.

Back 14

82%

Front 15

Treatment for anxiety

Back 15

 First Line: Psychotherapy!=Anxiety. Mood Disorder is cognitive behavioral therapy.
 Biological: SSRIs
 Social: School/Community Interventions

Front 16

 Psychotherapy:

Back 16

 1. CBT – First line always.
 2. Behavioral therapy (graded exposure, response prevention, habit reversal training)
 3. Social Skills Therapy
 4. Relaxation Techniques
 5. Family Therapy (esp. if parent also has anxiety)
 6. Parent Training (how is parent maintaining/facilitating anxiety in child?)

Front 17

 CBT includes:

Back 17

 Psychoeducation
 Somatic management skills training
 Cognitive restructuring
 Exposure methods
 Relapse Prevention
 Most studied is the “Coping Cat” for school age and C.A.T. for adolescents – workbook guided, evidence supports use. These are different CBTs for different age group.

Front 18

CAMS Study and Outcomes

Back 18

 Child/ Adolescent Anxiety Multimodal Treatment Study
 488 children, ages 7-17, DX: SAD, SP,GAD
 4 treatment arms for 12 weeks
 CBT
 CBT + Sertraline
 Sertraline alone
 Placebo
 CBT + Sertraline: 80% response rate***
 CBT Alone: 60% response rate
 Sertraline alone: 55% response rate
 Placebo: 24% response rate

Front 19

Separation Anxiety Disorder

Back 19

 Prevalence: 4%
 Peak Onset: 7-9 yrs of age
 Excessive anxiety about separation from home or attachment figure
 Lasts at least 4 weeks
 Onset must be prior to age 18yo
 Causes impairment, distress
 Not due to another Axis I mental disorder
 Specifier: early onset if <6yo

Front 20

SAD treatment
•

Back 20

SSRIs have demonstrated short term efficacy
• Graded Exposure Therapy is recommended.
• Coping Cat CBT for school age kids
• Parent and Family Intervention
o Know that “high maternal emotional over involvement” is connected to SAD.

Front 21

School Refusal

Back 21

• Not a DSM criteria disorder – but commonly comorbid
• Prevalence 5%
• Most common in 5-11yo
• Common around academic transition (pre to grade school or grade school to middle school)
• Easily reinforced by parents who take kids out, home school, “can’t stand to see him cry like that”.
• Longer out of school = harder to return

Front 22

School Refusal Treatment

Back 22

 Multimodal
 Meds (SSRIs) – note TCAs and benzos no better than placebo
 CBT
 School Support
 Get as many teachers, counselors, providers, and parents in same room and strategize how to get this kid back in school. Unless they are physically unable to walk and sit at a desk – and even then I think they should be in school. Socially stigmatizing and retarding to be school age but not in school.

Front 23

Selective Mutism

Back 23

 <1:1000
 Mostly Girls
 Most common age 3-6y
 Criteria:
 A. Consistent failure to speak in specific social situations despite speaking in other situations
 B. Interferes with education/occupation/academics.
 C. >1 month and not limited to first month of school
 Do not due to lack of knowledge or comfort speaking
 E. R/o Communication Dos, PDD, Psychotic Dos.

Front 24

Selective Mutism Treatment

Back 24

 Team approach, both home and school on board.
 Positive reinforcement for any attempts at communication
 Gradual exposure technique: mouth words, then gesture, then speak.
 Adults and other kids are NOT allowed to speak for the patient (so school, peers, teachers, family must all be aware).

Front 25

PTSD in Children/Adolescents

Back 25

 Criteria same as adult PTSD except:
 Response to trauma may involve disorganized or agitated behavior
 Reexperiencing symptoms in kids may include:
 repetetive play in which trauma is reenacted as opposed to intrusive images/recollections of trauma
 frightening dreams without recognizable content as opposed to nightmares
 trauma specific reenactment as opposed to flashbacks

Front 26

PTSD Epidemiology

Back 26

 1-14% lifetime prevalence
 24-35% occurrence if exposed to community violence
 Up to 100% occurrence if exposed to direct interpersonal violence, war

Front 27

Clinical Picture of PTSD
Preschool/Toddler:

Back 27

 Can’t meet full criteria due to limited cognitive/language skills
 Presents like GAD
 Sleep disturbance is common
 Loss of developmental skills (regression)
 Social withdrawal

Front 28

Clinical Picture of PTSD
School age

Back 28

May remember event well
 Avoidant/numbing symptoms unlikely
 Sleep disturbance common
 Reenactment of trauma in play, drawings, or conversation is common.

Front 29

Clinical Picture
Adolescents

Back 29

 Chronic PTSD (Sexual abuse current or in past) common
 Dissociative features more common
 Self injurious behavior common
 Intermittent anger/explosive outbursts
 Substance abuse very common

Front 30

Treatment for PTSD

Back 30

 CBT is first line treatment.
 Trauma Focused CBT = specific to PTSD
 Stress management/relaxation techniques
 Include parents when appropriate
Meds

Front 31

 CBT is first line treatment

Back 31

 Stress management
 Direct exploration of trauma
 Include parents
 Exposure to feared cues

Front 32

 Trauma Focused CBT = specific to PTSD

Back 32

 “PRACTICE”
 Psychoeducation and parenting skills
 Relaxation and stress management skills
 Affective expression modulation
 Cognitive coping style and processing (triad)
 Trauma Narrative
 In vivo mastery of trauma reminders to decrease avoidance
 Conjoint parent-child sessions
 Enhancement of future safety and developmental trajectory

Front 33

 Stress management/relaxation techniques

Back 33

 Progressive muscle relaxation
 Thought stopping
 Positive imagery
 Deep Breathing Techniques

Front 34

 Include parents when appropriate

Back 34

 Educate
 Help parents manage their distress because their stress will impact child

Front 35

What is PRACTICE stands for and what is it used for?

Back 35

Trauma Focused treatment
 Psychoeducation and parenting skills
 Relaxation and stress management skills
 Affective expression modulation
 Cognitive coping style and processing (triad)
 Trauma Narrative
 In vivo mastery of trauma reminders to decrease avoidance
 Conjoint parent-child sessions
 Enhancement of future safety and developmental trajectory