Treatment of
Anxiety Disorders in Children and Teens
James Wallace MD
Child and Adolescent Psychiatrist University of Rochester
Speaker:
James Wallace MD
Associate Clinical Professor
University of Rochester 585-273-2561
James_Wallace@urmc.rochester.edu
Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.
Disclosures
Managing Anxiety in Primary Care:
Learning Objectives
• Offer educational resources for anxiety – books and websites online
• Understand the role of (school) avoidance in anxiety disorders
• Review the (EB) psychotherapy for anxiety
• Review the (EB) medications for pediatric anxiety
disorders
Early Intervention
• Education about all forms of anxiety
• Prevention of Anxiety Disorders in children with an anxious temperament
• Parents reward and model curiosity, exploration and engagement
• Reduce (school/social) avoidance and overprotectiveness
• Prevent generational transmission of Anxiety symptoms and impairment
Books for Parents (and their doctors!)
Books for Kids and Teens
Psychoeducation
Management of Anxiety Disorders:
It Depends on Severity
- Mild Consider the 3 ‘Ps’:
Pervasive
- Moderate Persistent
imPairing - Severe
Mild: Treatment Planning
• Limited
symptoms with minimal impairment:
• SCARED score 20-30
• Educate/support/monitor/nudge
• Bibliotherapy
• e-programs
• 1. BRAVE for Children (can be purchased by parent)
• 2. Camp Cope-A-Lot (can be purchased by a “therapist”)
Somatic Management
• Breathing Retraining
• Progressive Muscle Relaxation
• Practice Controlled Relaxation Goals
• Develop tolerance of normal, expected levels of anxiety
• Learn & utilize strategies to calm self during stressful/ fear provoking situations or tasks
Slide courtesy of Drs. Albano and Rynn
Apps
• Headspace
• Calm
• Insight Timer
• Stop, Breathe and Think
Anxiety Fear Hierarchy
Situation SUDS
Spending night at friend’s house 10 Spending 2 hours at friend’s– w/o mom 8 Spending 30 mins at friend’s– w/o mom 7 Mom leaving home for 30 minutes 6 Mom leaving home for 15 minutes 5 Mom going out to get mail 3 Mom going in a different room–nighttime 2
Most Anxiety 1
0 9 8 7 6 5 4 3 2
Separation Anxiety Fear Hierarchy Fear Thermometer (SUDS)
Moderate/Severe Anxiety
Symptoms/impairment
SCARED score 30-40 and above
Cognitive Behavior Therapy Psychopharmacology
Collaborative team work
Goals of Cognitive Behavioral Therapy
• Educate the patient and family
• Teach self-soothing and somatic management
• Identify and change maladaptive thinking
• Introduce graduated EXPOSURE
• Extinguish avoidance behavior
• Increase healthy problem-solving
• Facilitate insight and self-efficacy
Pooled Analysis of CBT for Child Anxiety Disorders by Modality
0 10 20 30 40 50 60 70 80
Individual -CBT Group-CBT Family-CBT
% Remission Dx
N=170 N=162 N=121
Slide courtesy of Drs. Walkup and Rynn
Child Anxiety Multimodal Study - CAMS
• NIH funded, N= 488 Non-OCD Anxiety Do ages7-17
• 12-week trial: CBT, Sertraline, Combination, Placebo
• Randomized, blind Independent Evaluators
• Phase II: 6 month maintenance for treatment responders
Child Anxiety Multimodal Study CAMS: N=488, 7-17 Years Old for 12 Weeks
CGI-I 1 and 2 (ITT, LOCF)
Medications FDA approved for Non-OCD Pediatric Anxiety Disorders
• Duloxetine
SSRI Evidence of Efficacy for Non-OCD Anxiety Disorders
§ SAD, GAD and SoP
§ Fluvoxamine – RUPP, 2001
§ Fluoxetine – Birmaher et al, 2003
§ Sertraline (CAMS) – Walkup et al, 2009
§ SoP
§ Paroxetine - Wagner et al, 2004
§ Fluoxetine - Beidel et al 2007
§ Venlafaxine - March et al, 2007-
§ GAD
§ Sertraline - Rynn et al., 2001
§ Venlafaxine, Rynn et al., 2007
§ Duloxetine, Strawn et al 2015
§ Buspirone in GAD, unpublished negative trial
Slide courtesy of Dr. Walkup
When to Consider SSRI TREATMENT for Anxiety Disorders
• Patient has severe symptoms and impairment
• Patient and Parent have strong preference over CBT
• Patient is too anxious and impaired to start CBT
• Good CBT has failed or only partially resolved symptoms
Using SSRIs
• Discuss and use full dosage range (CAMS avg. dose 145 mg!!)
• Start low and educate due to hyper-vigilance for side effects
• Anxiety often needs higher doses in the end
• Younger kids respond but may have more side effects
• Monitor progress/side effect at 2-4 weeks,1-2 weeks with anxious parent (call, portal message, in-person)
• Maintain good response on meds for 6-12 months or longer before tapering
Side Effects
• Common Side effects of SSRI’s:
• Dry mouth
• GI: Constipation, Diarrhea
• Sweating
• Sleep disturbance
• Sexual dysfunction
• Irritability
• “Disinhibition” (risk-taking behaviors, increased impulsivity, or doing things that the youth might not otherwise do)
• Agitation or jitteriness
• Headache
• Appetite changes
• Rashes
• More serious side effects
• Serotonin syndrome (fever, hyperthermia, restlessness, confusion, etc)
• Akithisia
• Hypomania
Benzodiazepines
• Have NOT shown efficacy in controlled trials in childhood anxiety disorders
• Clinically, occasionally used as a short-term treatment with
SSRI’s to quickly address severe anxiety symptoms (give small supply)
• Contraindications: adolescents with substance abuse
• Possible side effects: sedation, disinhibition, cognitive impairment, difficulty with discontinuation
• Less incentive to work in CBT
Other Meds?
Careful use of prn or scheduled hydroxyzine
No evidence for Buspirone over placebo in anyone
No evidence of propanolol over placebo in children and teens
Summary
§ PCPs should identify anxiety early and educate the family against avoidance
§ Treatment for moderate to severe anxiety disorders includes education, medication and CBT
§ Can start with psychological approaches but
medication should not be considered “last resort”
§ Pediatrician’s enthusiastic support of firm parenting and treatment options liberates and empowers parents!
