Anxiety Disorders in Children and Youth: A Practical Approach

1. Anxiety Disorders in Children and Youth: A Practical Approach Katharina Manassis, MD, FRCPC Professor Emerita, University of Toronto

2. Disclaimer • Use of SSRIs in children <18 years is off-label Conflicts • I get book royalties from Routledge, Guilford, and Barron’s Educational Series • I have done unrestricted talks for Shire & Janssen

3. Objectives • Highlighting important aspects of assessing anxious children and youth • Learning how to talk to families about Selective Serotonin Reuptake Inhibitors (SSRIs) • Introducing brief CBT-based interventions that may be useful in the office

4. Case Example: Malcolm, age 8 • Teacher notices he is unfocused, distractible, and has trouble finishing work • Mother says he has stomachaches, worries, and is anxious • Father says he’s lazy • Family doctor refers to a specialized anxiety clinic, based on mother’s report • Resident sees child and does diagnostic assessment • Result: ADHD and Generalized Anxiety Disorder

5. Malcolm (continued) • Parents refuse medical treatment • Malcolm is referred to a CBT-based anxiety group • Group therapist reports that he is unfocused, distractible, and has difficulty finishing his CBT exercises; asks to meet with parents • Only mother attends, and she reiterates she will not consider medication • Mother reveals the parents are in the process of separating • Mother concludes “If you can’t teach him coping strategies for his anxiety so he can focus, I will move him to a private school. I just have to get his father pay child support” • Bitter custody battle ensues, Malcolm remains at the public school, and Malcolm’s school performance deteriorates

6. Community Practice • High comorbidity • High conflict families • Frequent disagreement about nature of problem • Low treatment motivation (medical, psychological, or both) • Frequent desire for “quick fix”

7. Separation Anxiety Disorder Specific Phobia Social Phobia Generalized Anxiety Disorder Panic Disorder (teens) Selective Mutism Note: School Phobia is not an official disorder, but is a very common anxiety-related condition resulting in psychiatric referral OCD and PTSD are now in separate categories DSM-5 Anxiety Disorders in Children

8. Becoming & Staying Anxious (Children)

9. Contextual/Developmental Factors Temperament Medical History Family History Developmental Probs. Recent or current stressful events Family/Other Supports Child Strength/Coping

10. Address the exacerbating factors (common ones below) • Assess & address learning problems, medical/psychiatric comorbidities • Address bullying and encourage hanging out with friends to reduce the risk • Increase healthy routines (sleep, meals, activity, homework, limited gaming) • Decrease family conflict & increase parental consistency • Help parents see the child’s strengths & manage their own anxiety • Decrease exposure to frightening shows or games • Make sure expectations are developmentally appropriate • For school avoiders: How to catch up on academics after absence • What to tell other kids when you return to school after absence

11. Why Didn’t Malcolm do Well in CBT Group? • His home life was making him anxious • His ADHD interfered with understanding CBT concepts, so he struggled along while everyone else in the group seemed to “get it” • The group reminded him too much of school (a risk with CBT programs), so he wasn’t motivated Options: • Individual CBT • Treating ADHD First (with stimulant or atomoxetine) • Postpone treatment until custody issues resolved • All of the above

12. Cognitive Limitations Behavioral, Parent focus, Use Imagery, Externalize Challenge evidence; Cognitive, Verbal, Individual Focus (Engagement) Level of Functioning Age or Cognitive Level

13. Objectives • Highlighting important aspects of assessing anxious children and youth • Learning how to talk to families about Selective Serotonin Reuptake Inhibitors (SSRIs) • Introducing brief CBT-based interventions that may be useful in the office

14. SSRI evidence in Child Anxiety Disorders • RUPP Anxiety Trial: Fluvoxamine > placebo for non-OCD anxiety (moderate to severe) • CAMS Trial: Sertraline + CBT > Sertraline OR CBT > Placebo for non-OCD anxiety (moderate to severe) • Multiple smaller trials for all the other SSRIs for non-OCD anxiety • Younger children and mildly affected children may respond to CBT/parent intervention alone • Introverts respond best!

15. Evidence in other conditions • Black & Uhde (smallish trial): Prozac > placebo for Selective Mutism • Oerbeck et al.: Younger children with selective mutism (<7) often respond to CBT alone; only 33% do once they are 7+ • Anxiety in ASD: small, open trials for citalopram & buspirone (anecdotally, I’ve had several young ones with ‘transition tantrums’ on fluoxetine) • School avoidance: small trials suggest that combining medication and behavioral/cognitive behavioral treatment is best • Better evidence for stimulants in ADHD + Anxiety (high risk activation with SSRIs)

16. Development and SSRIs • Start low, go slow with dosage • Final dose may be in the adult range due to metabolism & other pharmacokinetic differences between children & adults • Swallowing is a consideration in younger children (liquid Prozac, opening Zoloft capsules onto pudding) • Higher risk of behavioral activation than adults, especially early in treatment and if comorbid externalizing problems • Activation may be associated with reports of suicidal ideation (4% if child medicated; 2% baseline) • Favorable risk-benefit analysis for non-OCD anxiety disorders

17. Overall • Combination treatments seem to work best • CBT reduces relapse risk when medication stopped, and may be sufficient in some mildly affected or young children • When increasing dose, anxiety typically responds first, then depression, and OCD last & partial response (so sometimes augment with atypicals in OCD) • Behavioral activation is more common in children than adults across disorders and across specific medications (theoretically highest for fluoxetine & paroxetine; least for fluvoxamine but every child is different)

18. Talking to families • What the medication does • Why it is needed • Why this particular medication • What to expect (risks & benefits) • How we will monitor • What are the alternatives

19. What the medication does • It increases the level of a brain chemical called serotonin that is important for regulating mood and controlling anxiety • Nature recycles serotonin quite quickly • The medication interferes with the recycling process, so that the person’s serotonin stays active in the brain longer • As the serotonin stays active longer, the person becomes less anxious and less depressed • This process takes time, so the medication does not work right away • It needs to be taken daily for several weeks (2 – 6 weeks) to get the benefit, once the dosage is right • Curious adolescents sometimes like a more detailed drawing of synapse etc.

20. Why it is needed • We only give these medications to people whose anxiety problems, mood problems, or OCD are interfering regularly in their lives • For children, this usually means daily or almost daily impairment in school, at home (including sleep/eating problems), or socially • Children can also fall behind their peers in development if they are impaired in one of these areas for a long time, which can leave them vulnerable to other mental health problems later (e.g., depression) • We always look at a balance of possible risks versus possible benefits, both for medication and also for not medicating • In my judgment, the possible benefits of medication outweigh the possible risks at this point in your child’s life • You will probably be told at the pharmacy that this is “off label” in children

21. Why this particular medication • Fluoxetine: Best evidence for depression and also selective mutism; comes in a minty sweet liquid for kids who can’t swallow pills; long half-life means you can create intermediate doses easily by adjusting how much is taken per week; no withdrawal reaction if you miss a dose so be careful • Fluvoxamine: Least activating of the SSRIs, good evidence for anxiety • Sertraline: Best evidence for OCD & good evidence for anxiety, not very activating, can tell if dose gets too high (loose stools) • Citalopram: Some evidence for depression, most weight-neutral, least effect on glycemic index, fewest interactions with other medications, arrhythmia risk at doses >40mg (which are sometimes needed in OCD) • Escitalopram: teens like it, but difficult to finely titrate dose in kids • Paroxetine: short half-life (bid dose & withdrawal risk) so I avoid it • “Family history of response”: no real evidence for this, but it may augment placebo effect

22. The SSRI ‘Spectra’ Activation Paroxetine > Fluoxetine > Citalopram > Sertraline > Fluvoxamine Half-Life Fluoxetine > Citalopram & Sertraline & Fluvoxamine > Paroxetine (5 days) (about 24 hours) (< 24 hours; CR longer)

23. What to expect (for child) • You will take it daily with food, either at breakfast or dinner time • It may upset your stomach the first few days, but that goes away • Tell your parents if you feel unusually restless, can’t sleep, or have any unusual thoughts • The medication will take a few weeks to work, so be patient • We’ll start with a little bit, and I will see you every few weeks until we get the dose right

24. What to expect (parents) • I give the same explanation as for the child, but also indicate: • Need to call/email if insomnia, extreme restlessness, or suicidal thoughts (emphasizing that 96% of the time it’s not an issue); • Use ER if any safety concerns • Headaches, rashes, weight gain (usually modest) are less common but possible • In teens, there may be effects on sexual function Feel free to call or email if you observe any changes you’re not sure about. Anxious kids are often suggestible, which is why I don’t always mention all the side effects to the child.

25. How we will monitor • We will do a baseline of your child’s most distressing/impairing symptoms (frequency, intensity, duration, ability to manage/carry on—let’s quantify!) • We will get baseline from both child and parent, and teacher too if symptoms occur at school • Some children report more verbally; others on questionnaire (MASC, CDI, YBOCS) • Change is often gradual (like watching grass grow) and the people around the child may notice it first; good days & bad days are the norm, with good ones becoming more frequent over time • We “start low and go slow” with dosage to minimize the risk of side effects • Because 6 weeks is a long time to wait, I often adjust dose every 3 weeks (might go slightly high, but at least the child doesn’t suffer for months)

26. Dosages • Fluoxetine, citalopram, and paroxetine all go in 5-10mg increments; fluvoxamine and sertraline go in 25mg increments; escitalopram in 5mg; can reduce the size of the increment if history of adverse reactions (e.g., alternating 10mg/20mg fluoxetine capsules to create 15mg) • Beware of accidental liquid Prozac overdose (4mg/mL, so 10mL=40mg) • Starting dose is lower the smaller the child, but the final dose may be in the adult range (rapid metabolism, high volume of distribution) and there is no exact formula by body weight • Some slow metabolizers respond at low doses; more common in Asians • Preschoolers: 6mg of liquid fluoxetine, increase in 2mg increments • School age: 10mg of fluoxetine or 25mg of sertraline to start • Adolescents: 20mg fluoxetine or 50mg sertraline to start

27. NO thanks! • What are you most concerned about? (explore & discuss: e.g., deciding based on one negative reaction in a close friend/relative vs. a large trial) • Would you like to talk to your spouse about this (or come back with your spouse)? • Would you like some more information? • Let’s think about the long term with/without using medication • I don’t have to write a prescription today—take some time to think about it and let’s follow up in a few weeks • We could try other interventions for a month or so, and then revisit the question of medication • Take my card—you can always call back if things change

28. Will my child be on this forever, and what will that do to him/her? • We never say ‘forever’ because there are new treatments being developed all the time, and some children do get better at using coping strategies with CBT and/or maturation • Evidence suggests that depressed teens need to be on at least a year, and usually anxious kids do better with this too as it allows time to build confidence; OCD treatment is often longer term but up to 50% do come off medication eventually • We will monitor at least every 6 months and determine if a dosage increase is needed (usually for growth) or if your child is doing well enough to decrease the dose and see how he/she handles this; gradual decreases (e.g. monthly) will ensure that the child is on the minimum needed • I rarely taper children in the summer, as September is usually stressful • Amotivation is the only long-term side effect documented, and it responds to dosage reduction or discontinuing medication

29. What are the alternatives? • The best evidence is for CBT, although the benefits are limited in depression if medication is not also used • There is some evidence for regular aerobic activity in preventing depression and regulating mood & anxiety symptoms (endorphin effect; 4x/week) • Regular sleep patterns are helpful (review good sleep hygiene), and some also benefit from melatonin for this • Avoiding caffeine (to reduce anxiety) and avoiding alcohol & street drugs helps • There is no special diet that has been proven to work in any of these conditions • When it comes to natural supplements: caveat emptor • Do not mix St. John’s Wort with SSRIs as the interaction can be dangerous (serotonin syndrome)

30. Objectives • Highlighting important aspects of assessing anxious children and youth • Learning how to talk to families about Selective Serotonin Reuptake Inhibitors (SSRIs) • Introducing brief CBT-based interventions that may be useful in the office

31. Is there evidence for brief CBT-based interventions? • Not specifically • However…’state of the art’ CBT for children with complex presentations is now emphasizing the use of several brief modules focused on specific skill-sets, rather than disorder-focused manuals • See: ‘Modular Cognitive Behavioral Therapy for Childhood Anxiety Disorders’, Bruce F. Chorpita, Guilford, 2006 • Most of the children you see in the community will have complex presentations • While awaiting formal CBT, alone or in combination with medication • Follow up to make sure children (and parents) are using what you teach

32. Component Processes in Anxiety • Feeling Awareness • Physiological Arousal • Catastrophic Thinking • Behavioral Avoidance • Poor Problem-Solving

33. An ‘early warning system’ for anxiety • Anxiety strategies don’t work once anxiety is extreme, so kids need to attend to the early signs of anxiety • Briefly explain the ‘fight or flight’ response and some anxiety symptoms that can relate to it (e.g., tummy-ache from blood rushing away to big muscles) • Use a body drawing to have the child point to places where he/she notices anxiety symptoms • Ask which symptoms are the earliest • Ask if there are thoughts/feelings that come up even earlier • Include the earliest signal on a coping card (see below), so the child knows when to use strategies

34. “Panic” in anxious situations (i.e., hyperventilation) • Box breathing: 4 in, 4 hold, 4 out, 4 wait & repeat • Focus is on counting rather than anxiety; breathing is slowed; no regular practice needed • If at school, have a quiet room for the child to calm down & then return to class when calm (usually a few minutes; half hour at most) • Discourage calls home/parents picking up unless fever or vomiting • Discourage the adults from talking/reassuring too much (adrenaline will subside with time if you don’t fuel it further) • What if they prefer to do yoga, mindfulness, Eli Bay, or some other version of relaxation? If they’re willing to practice daily, tell them to go for it!

35. Rationale for Coping Thoughts • The class is told there’s a big test coming up next week • Ben says to himself “That’s awful. I’m going to spend the whole weekend studying, and then I’ll freak out when I see it. What if I fail? My parents will be so disappointed. I wish I didn’t have to go to school.” • Charlie says to himself “Oh good. I’m not doing great in this course, but if the test is worth a lot of marks and I do well, I could really pull up my grade.” • How does Ben feel? • How does Charlie feel? • Which attitude is more helpful?

36. Generic self-talk for anxiety • I’ve done this (or something similar) before, so I can do it now • I can’t predict the future, so I might as well hope for the best • It’s my worried mind talking • I know I will be OK • I know I can deal with this when the time comes • Things are often not as dangerous as they seem to me • I can focus on something else • I can ask for help if needed • There are many explanations that have nothing to do with what I fear • What’s the worst that could happen? (if the feared outcome is non-lethal)

37. Using self-talk for anxiety: the coping card • Pick favorites and put on a card or slip of paper to be kept in the backpack (or wherever child gets anxious), encourage decorating it/personalizing it • People do not think on the spot when anxious, so need concrete reminders • Including a favorite picture or other reminder of home is helpful for some • Serves as a transitional object as well as a reminder • The more realistic the fear, the more the emphasis needs to be on personal strength rather than probabilities • It doesn’t have to be fancy, it just has to facilitate exposure • Emphasize personal competence rather than probabilities in children facing realistic threats

38. Problem-Solving • Pick ONE problem or situation • Brainstorm possible alternative solutions/actions for that situation • Evaluate the alternatives from 1 to 10 (terrible idea versus terrific idea), remembering that some things are very helpful for symptoms in the short term but unhelpful in the long term (e.g., smoking pot); other things are the opposite (e.g., doing homework) • Choose an action(s) that is/are likely to be helpful • Try it in the situation & see what happens • Report back and problem-solve again if needed • “Problem Solving in Child & Adolescent Psychotherapy” Manassis, 2012

39. Exposure • The only aspect of CBT that has been consistently associated with improvement in all age groups • Gradual versus immediate: gradual is tolerated better, but immediate may be needed if there is urgency (e.g., school avoidance, severe family conflict around co-sleeping or other anxiety issues) • Immediate: 1. Co-sleeping changes when parents are in agreement on what needs to happen and do it consistently; a bit of positive reinforcement for the child for ‘good nights’ is nice, and setbacks must be ignored • 2. School avoidance is easy in 5-year-olds (take them in their pj’s) and gets more difficult with age & longer time away; use non-family escorts and interception by teacher in the school yard whenever possible; medication helps but doesn’t cure; calm perseverance by everyone is needed

40. Exposure (2) • Gradual exposure is doable for almost all anxieties if you can find a small step to start with, and positively reinforce ignoring setbacks • Many kids can do anxious situations with parent present initially, and then you can gradually decrease parental support • Parental involvement is key: have them read Manassis’ “Keys to Parenting Your Anxious Child” or similar book by Ron Rapee • Social anxiety may need some training/rehearsal beforehand as kids lose social skills year by year through avoidance; • Try some conversation starters: comment on shared sensory experiences; ask the person what they are doing/just did/are about to do • Inhibited kids will never be naturally outgoing, but often do well with scripts and practice (try drama); large, unstructured social groups usually remain difficult

41. Exposure (3) • Unassertiveness is a common parental concern: • Have them keep a stiff upper lip (vs. weepy/angry reaction) & hang around with friends to minimize bullying; distinguish telling & tattling • Fake it till you make it—encourage walking tall, looking in the eye, firm handshake with adults, ending statements firmly vs. upward voice inflection, for teasing state the facts (e.g., “that is a rude thing to say”) & walk away, asking with “I need” statements, when in doubt say “I’ll think about it” • There is no exposure for GAD, right?—in younger kids no, in teens they can recognize the need to tolerate uncertainty & that’s their exposure (e.g., not checking their Facebook multiple times during the night) • Many anxious youth find the AA motto helpful: Each day, change what you can, accept (with reassuring self-talk) what you cannot change, and know the difference—the rest will have to wait till tomorrow

42. Parental Pearls • Don’t sweat the small stuff • Work on one or two situations at a time consistently, with empathic encouragement (“I know this seems hard, but you can do it!”) • Use charting so you don’t forget & to show the child he/she is making progress; attach a small reward to it if needed • Expect ‘2 steps forward 1 step back’ and focus on the ‘forward’ • Less talk, less negative emotion • It doesn’t matter if it’s anxiety or behavior: if you want to encourage it, praise it; if you want to discourage it, ignore it (unless severe--and then use time out, privilege withdrawal, natural consequence, etc.) • When in doubt, just breathe (kids can’t think when highly anxious so talking just makes it worse)

43. Thank you for your attention!Questions?