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Fear and Trembling

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Peggy Greco

on 18 September 2018

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Transcript of Fear and Trembling

Midline Physical Complaints
Medication
Dosing for Anxiety
Clinical Presentation
Assess Symptoms and Severity
Treatment/ Management
Tools
A Closer Look at Anxiety
Fear and Trembling
: Identification and Treatment of Anxiety Disorders in Pediatric Primary Care
Elise Fallucco, M.D.
University of Florida - Jacksonville
and
Peggy Greco, Ph.D.
Nemours Children's Specialty Care
Utilize Technology
Anxiety-Related Apps:
Psychological Approaches
When to Refer for Collaborative Care
The distress or anxiety interferes significantly with the child's normal routine, school functioning, social activities or relationships, or if there is any negative impact on physical functioning.

The distress or anxiety is occurring more frequently or has persisted through the end of an anxiety-provoking event
Severity
Frequency or Duration
Cognitive Behavioral Therapy
Basic Cognitive and Relaxation Strategies
Treating/Referring for Emergent Care
Specific Phobia
i.e. fear of choking leading to avoidance of swallowing
R
E
M
A
P
Reassure
Explain
Make a plan
Arrange for help (if needed)
Predict positive outcome
MindShift
comprehensive tracker and tool kit
The Screen for Child Anxiety Related Disorders (SCARED)
41 items;
child and parent report for 8-18 yo
FREE:
http://partnershipforchildhealth.org/collaborative-care/
Workbooks
Anxiety by any other name...
Start low, aim HIGH
Caution!
Take-Home Message
Remain aware of clinical presentation..
Intervene using a
3-tier approach
Case Examples
Case 1: Stomach aches, Blisters
Case 2 : Nausea and Vomiting
Case 3 : Headaches, Fatigue
"Molly” 8 yo figure skater

CC: stomach aches, blisters
initial insomnia, clingy in past
CC: nausea, vomiting (weight loss)
insomnia

Worries: “What if ... What if...”

SCARED score =45
Alex : 16 yo M w/ ADHD

CC: headaches, fatigue

Not into sports, worries about what others think of him

SCARED = 35

2 TIERS:
Self-management (workbook)
Therapy (refer for CBT)
Treatment Plan
Treatment Plan
All THREE TIERS
Self-management (Workbook + app)
Therapy (CBT)
Medication
Treatment Plan
Started with TWO TIERS
Self-management (app)
Therapy (CBT)

Three-Tiered Approach
Self-Management Approaches
Psychological Therapy
Pharmacological
Treatment
Self-Management Approaches
AACAP Facts for Families
www.aacap.org

Nemours KidsHealth
www.Kidshealth.org
Resources for Families
Web-Based Education
Klonopin, Ativan, Valium

Limited RCT data for efficacy

Side effects: "cognitive blunting", drowsiness, irritability, physiologic dependence

Benzodiazepines
Fear
scared
Stress
Worries
Avoidance
Dread
shy
self-conscious

Anxiety is Common
Assessment
ABCs of CBT
What should you convey to parents and kids about CBT?
CBT refers to cognitive-behavioral therapy, a category of treatment that is based on the theory that we can change our feelings by changing our thoughts
"Therapy helps greatly to reduce anxiety and your child will gain tools to help reduce stress and anxiety throughout his/her life. Typically your child would see a therapist about once per week for a total of about 6-10 sessions. However, you’ll start to see improvements even before then."
most common childhood disorder

> 6 million US teens

onset 6-12 yo


Slide credit: John Walkup, MD
n=488 (7-17 yo)
Generalized Anxiety
Social Anxiety
Separation Anxiety

Is the anxiety severe enough to treat?
SCARED
score 25+

Anxiety
impacts functioning
(home, school, and/or social)

Anxiety causes significant
distress

Midline physical symptoms

Stressed, worried, afraid
Assess symptoms and severity...
Determine the total score as well as level of functioning
Intervention
Who Does CBT?
All psychologists (PhD) are trained in CBT

May need to determine if other therapists (master's level counselors, social workers, etc. ) have specialized experience in treatment of childhood anxiety
Provide handout/encourage further self-education and exploration of resources
"This is a summary sheet that gives you a few techniques you can start to use. I would encourage you to pick a few and try them so you can get a feel for what works for you ."
QUESTIONS?
Self-Management
Self-Management Approaches
Psychological Therapy
Medication
Approaches
Clinical Presentation

Assess Symptoms and Severity

Intervention: Three-tiered Approach
Everything You Need to Know
About Anxiety ...And More
American Psychological Association

www.APA.org


Anxiety Disorders Association of America
www.adaa.org

Anxiety Disorders Association of British Columbia
www.anxietybc.com
Referring for CBT
Diphenhydramine (Benadryl) Hydroxyzine (Atarax, Vistaril)
CNS depressant, antihistamine
Side effects: sedation, dizziness
Response Rate for Anxiety
* p< 0.05
*
*
*
event
thought
feeling
Stop, Breathe, and Think
anxiety tracking and toolkit
Pacifica
mood and thought tracker,
provides tools for handling
stress and anxiety
Handling Resistance
1) Agree that the child can have greater input after they attend a minimum of three sessions

2) Explain that it will take that long to get a
good feel for the connection with the
therapist and the effectiveness of
therapy(first session is primarily
information-gathering)


*Consider requiring a family commitment to therapeutic activities (workbooks, apps, and/or therapy) as a condition of prescribing.

*Ask the child/teen to bring their workbook or show you their progress with the app they have chosen when they come for follow-up
appointments
Scoring of the SCARED
Characteristics of the SCARED
Common side effects: sedation, insomnia, activation

Serious, rare side effects:
- Serotonin syndrome (HTN, sweating,
hyperreflexia, myoclonus, mental state
changes)
- Mania (by week 4)

Options to Help with Sleep
sleep hygiene

melatonin 1,2,3

refer to therapy

Blake , 14 yo in theatre
Use a screening tool
Psychological Therapy
Pharmacotherapy
Remember the superiority of combination therapy!
Screening in Practice
The Collaborative Care Initiative: A Partnership between Pediatrics and Psychiatry
The Collaborative Care Initiative:
A Partnership between
Pediatrics and Psychiatry
Script
"Now that we have identified some concerns about anxiety, let’s focus on how we can help you. We’re going to talk about:
1) ways you can to work on this at home,
2) treatment with cognitive behavioral therapy and/or
3) treatment with anti-anxiety medication"

Self-Management: " I am going to give you some resources on ways you can start decreasing your anxiety right away.These resources will include handouts on strategies you can try, information on workbooks you can order, and apps that you can download and try."
"
Cognitive Behavioral Therapy: "Therapy is also very effective at reducing anxiety, particularly a type of therapy called cognitive-behavioral therapy. Not only will it help decrease anxiety now, but your child will gain tools to help reduce stress and anxiety throughout his/her life. Typically your child would see a therapist at a frequency between once a week to once a month to complete approximately 6-10 sessions. You’ll start to see improvements though even before that time."

Anti-anxiety Medication: “Many children and adolescents with anxiety also benefit from treatment with medication, particularly when it is coupled together with therapy. We are going to talk about a medication option that I believe would be a good match for your child. I am recommending __________ for your child"



It is important to take your medication every day.

As your body adjusts to the new medication, you may feel too sleepy, have trouble sleeping, or have an upset stomach. These side effects should go away in a few days. Very few people who take this medication may feel worse (more irritable, agitated).

Most people feel much better after a few weeks. If you have any concerns, call our office and we will talk about what to do.


Increased suicidal thoughts/behavior*

2% placebo 4% antidepressant


6 x more teens benefit from tx > harm^

*Newman TB, NEJM 2004 ^Bridge JA et al, JAMA 2007

Disclosure: No Conflicts of Interest
Let's talk about how to help you with anxiety.

We'll go through 3 different approaches to treatment:
How do you explain physical symptoms as a manifestation of anxiety?
Behind the Black Box (2004)
Lauren James, MA
Kitty Leung, MD
Birmaher B et al, JAACAP 1999
Sertraline 12.5->25mg-> 50mg

SCARED = 37 (was 45)

What to do next???



Sertraline 50mg --> 100mg

Titrate to An Effective DOSE
What if the first SSRI doesn't work??
Add Fluoxetine 5-> 10-> --> 40mg


Outcome:
"I used to not talk to people, and now I’m friendlier – I wish that I felt like this when I started high school.”

How long to keep him on medication?
SCARED score = 30
We are wired so that stress and anxiety can cause physical symptoms in our body. We will still make sure that we rule out other causes of Molly's stomachaches but in the meanwhile we will also start working on decreasing the anxiety she is feeling.
0 5 10 15 20 25 30 35 40+
Total score 25+ is indicative of possible anxiety disorder
Does your patient have trouble
FALLING ASLEEP?
YES
Sertraline
(Zoloft)
NO
Does your patient have trouble
STAYING AWAKE?
NO
YES
Is your patient on
MULTIPLE MEDICATIONS?
Fluoxetine
(Prozac)
YES
Citalopram
(Celexa)
Escitalopram
(Lexapro)
NO
Is your patient unable to tolerate
OTHER SSRIs?
YES
Outcome:
“best skate competition ever”
“double jumps and spins"
Which medication/dose?
Outcome:
only mild improvement


Now what??
Outcome:
“I used to care way too much - now it has dropped to a normal level”


How long to keep her on this medication?
Table Discussion
Table Discussion
Table Discussion
And most importantly...
Modify your practice!
Table Discussion: What will you do differently in your practice after this seminar?
2) therapy and/or
3) medication
1) self management
Placebo
CBT
Sertraline
Combination:
CBT + SERT
Step 1: Choose another SSRI
Step 2: STOP old SSRI
Step 3: START new SSRI at slightly below
dose-equivalent
Full transcript