Tools in the Treatment of Disorders

Hanna Stevens, MD PhD Ida P. Haller Chair of Child and Adolescent University of Iowa Carver College of Medicine Acknowledgements and Disclosures

I have no commercial financial relationships to disclose

I will be discussing off label use of medications, given the limited FDA approved medications for anxiety in children Objectives

• To know tools that can be used for assessment of children with anxiety • To be able to identify resources for families of children with anxiety • To be able to know resources for prescribing medication for children with anxiety disorders

• Caption Why is this important to primary care providers of children? Why is this important to primary care providers of children in Iowa? Why is this important to primary care providers of children?

Psychosocial Child stress Development

Psychophar- Neuroscience macology

Psychological and Behavioral Intervention Background Information - Prevalence rates: 6-30% of Children in the US will have at least one during childhood - Separation anxiety (5-8%) - Social (7-9% in general pop, 20-50% of clinical referrals) - Generalized anxiety disorder (2-5%) - (15-20%) - Obsessive Compulsive Disorder (2-4% prevalence) - Selective Mutism (0.5-1% prevalence) - (2-5% prevalence) - Post Traumatic Stress Disorder (3-5% in general pop; 15% of children who experience traumatic events)

- From the National Comorbidity Survey- Kessler et al Arch Gen Psychiatry, 2012 Background Information - Risk factors: From Nat’l Comorbidity Study: anxiety is less common in adolescents who were male and whose parents were married and graduated college - Age of Onset: - Median Age of Onset: 11 years old - The majority of anxiety disorders experienced across the lifespan emerge in childhood or adolescence Developmental factors to consider in children with anxiety

• Infants – developmentally normal • Some degree of anxiety is a stages of anxiety related to normal, biologic and protective strangers process • Toddlers – normal fears of • Becomes problematic and imaginary creatures and meetings the criteria for a separation anxiety treatable condition when it causes impairment • School Age – bad things happening, performance, health • Adolescence – fears of being accepted socially Most children with an Anxiety Disorder will present to a pediatrician first Stomach aches, headaches, fatigue, insomnia, or chief complaint of anxiety Sometimes the presentation is more complex– i.e. difficulty concentrating because of over-focus on worries, excessive tantrums because of efforts to avoid things that bring on anxiety Factors to consider in children when trying to identify anxiety • Children do not always have a good sense of time • Their history-reporting of emotions/symptoms may overly reflect what is happening in the present or immediate past and reflecting over the past weeks or months may be difficult • Young children (up to age 8, and some up to age 10) are not always good at identifying emotions • Children may not always be able to report worries/fears • Anxiety disorders are highly heritable • understanding parental anxiety may aid in diagnosing child anxiety • The natural response to anxiety in humans is to try to reduce the feeling and therefore to avoid things that induce anxiety. • Identifying patterns of avoidance can be very helpful in the diagnosis Tools for Assessment - GAD 7 (Generalized Anxiety Disorder Assessment with 7 questions) – general questions about impairment (treatment is more dependent on degree of impairment rather than number of symptoms) - 10 or greater is concerning Tools for Assessment

- Screen for Child Anxiety Related Disorders (SCARED) – available online - Parent and child report forms (41 questions each) - screens for Panic, GAD, Separation Anxiety, School Avoidance and - *Not a validated instrument, but can be filled out and scored easily in clinics Tools for Assessment

- Screen for Child Anxiety Related Disorders (SCARED) – available online - Parent and child report forms (41 questions each) - screens for Panic, GAD, Separation Anxiety, School Avoidance and Social anxiety - *Not a validated instrument, but can be filled out and scored easily in clinics Family Accommodation Scale Tools for Assessment

- Not a validated instrument - Scores above 10 are concerning - Can be helpful in demonstrating to parents how significant the problem is Tools after Assessment

Describing the problem to families • American Academy of Child and Adolescent Psychiatry Facts for Families Tools after Assessment

Eli Lebowitz PhD, Expert in Childhood Anxiety • Yale Child Study Center Youtube Lecture Series

• These are appropriate for clinicians or families

• Introduction to Childhood Behavioral Disorders • https://www.youtube.com/watch?v=xLDieMMXF2Y

• Cognitive Behavioral Therapy for Childhood Anxiety • https://www.youtube.com/watch?v=8pyanIgSJuw&t=1s

• **Parenting Children with Anxiety Disorders** • https://www.youtube.com/watch?v=5nzetUfrWsg Tools after Assessment Child Mind Institute

Provides excellent basic information on a range of child topics Tools after Assessment Tools for Treatment https://www.aacap.org/App_Themes/ AACAP/docs/practice_parameters/JA ACAP_Anxiety_2007.pdf Treatment

- First line treatment for all anxiety diagnoses (that are mild to moderate in terms of impairment) is individual psychotherapy. - Best evidence support for Cognitive Behavioral Therapy (or CBT) - For children, success from individual psychotherapy depends on - Psychoeducation on the problem for the Child and Parent(s) (what is anxiety, how does it make you feel, what kinds of problems can you have due to anxiety) - Learning to identify emotions (cognitively and physically) - Learning how to relax - Reducing avoidance/gradually facing fears Treatment • Avoid reinforcing avoidance! • Reducing avoidance is best done in a gradual way • Parents often have a difficult time reducing avoidance, as the natural parent tendency is to try to reduce our children’s fears • For School Avoidance – primary component of treatment is going to school • For Obsessive Compulsive Disorder – mainstay of treatment is exposure and response prevention • All Anxiety therapies revolve around learning coping skills to build confidence to engage the things that make you anxious head on, and decrease distress. Pharmacologic Interventions

***No Benzodiazepines

• Benzodiazepines have not shown efficacy in controlled trials in childhood anxiety disorders despite established benefit in adults.

• Reasons to avoid their use in children • They can cause sedation

• In children, disinhibition is quite common (the opposite of what is helpful)

• Cognitive impairment is a real problem in anyone who uses benzodiazepines for longer than a few weeks or months (this is often the most compelling reason for patients)

• Possibility of developing dependency Pharmacologic Interventions FDA approved Treatments for anxiety disorders in children - (Prozac) –indicated for OCD in ages 7+ - recommended dose 10-60 mg - Sertraline (Zoloft) indicated for OCD in ages 6+ and GAD in ages 7+ - dose 25-200 in age 6-12 y/o and 50-200 mg in 13-17 y/o - Fluvoxamine (Luvox) – indicated for OCD in ages 8+ - dose 50-200 mg in age 8-12; 50-300 mg in ages 13-17 - Clomipramine has indication for OCD in age 10+ - recommended dose 25-100 mg daily - Venlafaxine - FDA indication for GAD in adolescents – recommended starting dose of 37.5 mg daily - Paroxetine – indicated for OCD in ages 7+ and Social phobia in ages 8+ (not recommended) – 10-50 mg daily

Non FDA-approved but evidence based - Sertraline – Randomized Control Trial for Social phobia and GAD; open label for Panic - Fluoxetine – Randomized Control Trial for GAD and Social phobia; Open label for Panic - Venlafaxine- Randomized Control Trial for Social phobia - Mirtazapine – Open label studies for social anxiety and PTSD Name Starting Dose Titration FDA Tested Range Reality (Clinical) Dosing Citalopram 10 mg daily 10 mg x 1 week n/a 10-40 mg daily (Celexa) (5 mg young or sensitive) then 20 mg Escitalopram 5 mg daily 5 mg x 1 week then 10-20 mg daily 10-20 mg daily (Lexapro) 10 mg daily Fluoxetine 10 mg daily 10 mg x 1 week 10-20 mg for MDD 10-80 mg daily (Prozac) (5 mg young or sensitive) then 20 mg 20-60 mg for OCD

Fluvoxamine 25 mg daily 25 mg x 1 week 50-200 mg for kids 50-300 mg daily (Luvox) then 50 mg daily 50-300 mg for adol Sertraline 25 mg daily 25 mg x 1 week 25-200 mg daily 25-200 mg daily (Zoloft) (12.5 mg young or sensitive) then 50 mg daily Paroxetine 10 mg daily 10-50 mg daily (mean dose 26.5 mg) Mirtazapine 7.5-15 mg QHS 15-45 mg QHS (Remeron) Venlafaxine 37.5 mg daily 75-225 mg daily (Effexor) Medication Pointers

- Start low and go slow – initial dose then titrate after 1 week if tolerated; then if limited improvement after 4-6 weeks, dose can be further increased. - Common side effects: GI (nausea, vomiting, diarrhea); headache; sleep changes, activation (restless or anxious feeling); sweating, dry mouth, - Rare Side effects: Serotonin Syndrome, hypomania, or suicidal ideation - Slight increased risk of Suicidal ideation from ~2% to about 4% (in thoughts, no attempts or completions); in the mid 2000s when black box warning came out and prescriptions dropped – it was then that youth suicide rates went up. Questions?

Email: [email protected]

University of Iowa Hospitals and Clinics provides Consultation via a toll-free (800-322- 8442) service 24 hours a day

Tools after Assessment

Worry Wise Kids Website run by The Children's and Adult Center for OCD and Anxiety