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Fear and Trembling
Transcript of Fear and Trembling
Dosing for Anxiety
Assess Symptoms and Severity
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.
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
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)
child and parent report for 8-18 yo
Available in Spanish
validated in diverse populations
Anxiety by any other name...
Start low, aim HIGH
2nd/3rd line medications
Remain aware of clinical presentation..
Intervene using a
Case 1: Stomachaches, Blisters
Case 2 : Nausea and Vomiting
Case 3 : Headaches, Fatigue
"Molly” 7 yo figure skater
CC: stomach aches, ?? blisters
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
SCARED = 35
- Self-management (workbook)
- Refer for CBT
“best skate competition ever”
“double jumps and spins"
All three tiers
Started with self-management + CBT --> mild improvement
AACAP Facts for Families
Resources for Families
Klonopin, Ativan, Valium
Limited RCT data for efficacy
Side effects: "cognitive blunting", drowsiness, irritability, physiologic dependence
5-HT 1A agonist
good for ADHD + ??? Anxiety
Feeling shy, self-conscious
Anxiety is Common
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 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
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
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 ."
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
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
clonidine 0.05-0.1 mg
trazadone 25-50 mg
“Katie”, 14 yo cheerleader
Use a screening tool
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
How do you explain physical symptoms as a manifestation of anxiety?
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?