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Fear and Trembling

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Peggy Greco

on 5 September 2017

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Transcript of Fear and Trembling

Midline Physical Complaints
Dosing for Anxiety
Clinical Presentation
Assess Symptoms and Severity
Treatment/ Management
A Closer Look at Anxiety
Fear and Trembling
: Identification and Treatment of Anxiety Disorders in Pediatric Primary Care
Elise Fallucco, M.D. and Peggy Greco, Ph.D.
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
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
Make a plan
Arrange for help (if needed)
Predict positive outcome
comprehensive tracker and tool kit
The Screen for Child Anxiety Related Disorders (SCARED)
41 items;
child and parent report for 8-18 yo
Available in Spanish

validated in diverse populations
FREE: http://www.psychiatry.pitt.edu/research/tools-research/assessment-instruments
Anxiety by any other name...
Start low, aim HIGH
2nd/3rd line medications
Take-Home Message
Remain aware of clinical presentation..
Intervene using a
3-tier approach
Case Examples
Case 1: Stomachaches, Blisters
Case 2 : Nausea and Vomiting
Case 3 : Headaches, Fatigue
"Molly” 7 yo figure skater

CC: stomach aches, ?? blisters
Initial insomnia

Afraid to leave mom

SCARED score = 30

CC: nausea, vomiting (weight loss)

Worries: “What if ... What if...”

SCARED score =45

“Haley”: 16 yo F w/ ADHD

CC: headaches, fatigue

Worries about what others think


2 tiers:
- Self-management (workbook)
- Refer for CBT

Outcome =
“best skate competition ever”
“double jumps and spins"

Treatment Plan
Treatment Plan
All three tiers
- self-management
- medication

Which medication/dose?

Treatment Plan
Started with self-management + CBT --> mild improvement

Now what??

Three-Tiered Approach
Self-Management Approaches
Psychological Therapy
Self-Management Approaches
AACAP Facts for Families

Nemours KidsHealth
Resources for Families
Web-Based Education
Klonopin, Ativan, Valium

Limited RCT data for efficacy

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

5-HT 1A agonist

Buspirone (Buspar)

Atomoxetine (Strattera)
good for ADHD + ??? Anxiety
Feeling shy, self-conscious
Anxiety is Common
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 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 between once a week to once a month for a total of about 6-10 sessions. However, you’ll start to see improvements even before then."
"most common childhood disorder"

onset 6-12 yo
-->6 million US teens

increased risk of depression, drug use, academic problems

Undertreated... limited resources
Slide credit: John Walkup, MD
n=488 kids
7-17 yo
Generalized Anxiety
Social Anxiety
Separation Anxiety

4-arm RCT
Sertraline + CBT
12 week trial
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
Behavioral Strategies
Example: goal setting with consequences and rewards
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 ."
Self-Management Approaches
Psychological Therapy
Clinical Presentation

Assess Symptoms and Severity

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


Anxiety Disorders Association of America

Anxiety Disorders Association of British Columbia
Referring for CBT
Diphenhydramine (Benadryl) Hydroxyzine (Atarax, Vistaril)
CNS depressant, antihistamine

Side effects: sedation, dizziness
Response Rate for Anxiety
* p< 0.05
Stop, Breathe, and Think
anxiety tracking and toolkit
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

*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
Used within the CBT framework
Behavioral strategies emphasized with younger kids
Scoring of the SCARED
Likert scale: 0=rarely, 1 = sometimes, 2=often true
Total score 25+ is indicative of possible anxiety disorder
Characteristics of the SCARED
0 5 10 15 20 25 30 35 40+
Easily scored at the bottom of the measure
Common side effects: sedation, insomnia, activation

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

Options to Help with Sleep
sleep hygiene

melatonin 1,2,3

clonidine 0.05-0.1 mg

trazadone 25-50 mg

“Katie”, 14 yo cheerleader
Use a screening tool
psychological therapy
Remember the superiority of combination therapy!
Step 1: Give SCARED to child and/or parent prior to the visit

Step 2: MA/nurse scores SCARED

Step 3: PCP reviews SCARED with family

Screening in Practice
The Collaborative Care Initiative: A Partnership between Pediatrics and Psychiatry
The Collaborative Care Initiative:
A Partnership between
Pediatrics and Psychiatry
"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"

Medication is one part of the treatment to lower your anxiety. 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. Compared with placebo, around 1-2% of people who take this medication may feel worse (more irritable, agitated).

Most people feel much better after a few weeks on medication. You should see a big difference
after 4-6 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:
1) self management
2) therapy and/or
3) medication
How do you explain physical symptoms as a manifestation of anxiety?
-brief summary
-give handout
Behind the Black Box (2004)
Valentina Bolanos, MPH
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

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

How long to keep her on this medication?
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 her on medication?
Full transcript