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Jul.30.2020

Elsevier Clinical Skills

Anxiety: Anxiety Disorders in Children and Adolescents Assessment (Mental and Behavioral Health) - CE

ALERT

Anxiety can lead to challenging and dangerous behaviors (e.g., throwing objects, destroying property, self-injury, assault, suicide).4,18 Unresolved anxiety, as well as ineffective coping with anxiety, can lead to depression.9 Regularly occurring anxiety in a child or adolescent patient may be a sign of depression or another underlying mental health issue.9

OVERVIEW

Anxiety disorders are among the most prevalent mental health conditions in children and adolescents.22 In many cases, these conditions are precursors to psychiatric disorders in later adolescence and adulthood. These disorders may include additional subsequent anxiety disorders, major depression, substance abuse, self-injurious behaviors, and suicide attempts.22

Anxiety is different than fear. The two conditions share some similarities but have many differences. Fear is typically a healthy, natural emotional reaction to an impending threat; it has a direct cause and promotes safety. Fear is commonly combined with an acute arousal of the autonomic system needed for fight or flight and thoughts and behaviors associated with immediate danger and escape. Anxiety is the expectation of an imagined or potential threat; it tends to be vague and more unfocused. Anxiety can affect emotions, thought processes, bodily sensations, and behaviors. With anxiety, vigilance, preparation for future threats, caution, and avoidant behaviors are more common.2

A child or adolescent patient’s memories, experiences, and social situations play intricate roles in the experience of stress and the development of anxiety. The patient may experience vague anxiety stemming from past pain and suffering or fear. Because these experiences are unique to each person, understanding or relating to the patient’s stress and anxiety may be difficult.22

Anxiety is characterized by:2,8

  • Physical complaints (e.g., chest tightness, dizziness, nausea, headache)
  • Cognitive symptoms (e.g., impaired judgment, confusion, inability to make decisions)
  • Behavioral issues (e.g., avoidance, impulsiveness, isolation, arguing, refusal to cooperate, attempts to control others)
  • Emotional symptoms (e.g., worry, irritability, sense of dread, a feeling of being overwhelmed, frustration)

In many cases, an anxiety disorder occurs concomitantly with physical, emotional, or mental illnesses or substance abuse. These other issues can also hide or aggravate anxiety symptoms. Assessment for an anxiety disorder must be part of a comprehensive examination that includes a detailed history, physical assessment, a review of symptoms, and assessments of associated functional impairments, current psychosocial issues, and other contributing factors.17

Children and adolescent patients may experience anxiety differently than adult patients. Adolescents typically have more anxiety regarding social relationships and may avoid social activities, such as talking in groups or school.2,8 Children may worry about their competence in school.2 Children and adolescents with an anxiety disorder are more likely to demonstrate irritability and difficulty coping and functioning than adolescents who do not have an anxiety disorder.5 Agitation may develop more quickly and result in aberrant behaviors. Interactions that may increase the patient’s anxiety, such as confrontation, will increase agitation and aggression and, therefore, should be avoided.4

The types of anxiety disorders that can occur during childhood and adolescence include separation anxiety, social anxiety, generalized anxiety disorder, specific phobia, and panic disorder.9

Important goals for caring for children and adolescent patients who are experiencing anxiety include:2,8

  • Determining whether the patient is experiencing fear or a normal anxious response to a given situation, versus whether he or she has an anxiety disorder or another psychiatric or medical disorder
  • Intervening to help the patient relieve anxiety
  • Evaluating the effectiveness of interventions

Recent research, such as the Child/Adolescent Anxiety Multimodal Study (CAMS), and a review of evidence-based practices, have found that children and adolescents with anxiety who were treated with cognitive behavioral therapy or medication, such as a selective serotonin reuptake inhibitor (SSRI) (sertraline), experienced favorable outcomes.11

Currently, certain SSRIs are approved by the U.S. Food and Drug Administration (FDA) only for obsessive-compulsive disorder or depression in children and adolescents. The risks and benefits of using medications to treat anxiety need to be considered, and informed consent must be obtained from parents or legal guardians and, if possible, the adolescent. SSRIs carry a black box warning for increased suicidality in children, adolescents, and young adults. If SSRIs are prescribed, the patient should be routinely assessed for suicidal thoughts and worsening of mood. The therapeutic effect of these medications may not be experienced immediately; however, studies indicate that the benefits of treatment outweigh the risks.10

The use of social media is prevalent among children and adolescents and represents an area that can have both positive and negative influences on mental health.12 There is evidence that for children and adolescents, digital media can increase anxiety and depression.12 Concerns include issues related to social isolation and cyberbullying.12 The positive aspects include use of internet-based prevention and treatment programs for anxiety and depression.6

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Establish a rapport with the patient and family that encourages questions. Answer them as they arise.
  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Consider the patient’s and family’s values and goals in the decision-making process.
  • Assist the patient and family with recognizing signs and symptoms of acute exacerbation of the illness.
  • Explain the manifestations of the illness and expected progression of symptoms if the patient experiences a relapse. Describe what the family is likely to see, hear, and experience (e.g., nausea, headache, confusion, impulsivity, irritability, worry, frustration). Advise the patient and family of steps to take if relapse occurs.
  • Explain to the patient and family that the main goal is to provide a safe, secure place to receive treatment.
  • Explain how the behavioral health unit may be different than other settings. Interaction is promoted between patients and staff, and group meetings are encouraged. To ensure patients’ safety, they are checked on frequently throughout the day.
  • Educate the family regarding the nature of the psychiatric illness and expected signs and symptoms (e.g., nausea, headache, confusion, impulsivity, irritability, worry, frustration).
  • Assist the patient and family with engaging and participating as drivers of the plan of care.
  • Explain the importance of following the medication regimen as ordered. The patient should not alter the dose or stop taking the medication even if symptoms have subsided and he or she is feeling better.
  • Inform the patient about his or her rights to privacy and confidentiality. Explain that in some instances (e.g., when abuse or harm to self or others is suspected), exceptions to confidentiality are made. Specific rules regarding confidentiality and adolescents can vary from state to state.
  • Encourage the family to collaborate with the patient and health care team members to support him or her in making healthy treatment decisions.
  • Educate the family about creating an environment that minimizes stress or aggravation.
  • Educate the patient and family about the differences between norms at home and those in the behavioral health setting and explain why differences are necessary. For example, the patient may play music before bed at home, but this may not be possible in the behavioral health setting. Look for ways to problem solve when a conflict arises (e.g., using headphones to listen to music).
  • Instruct the patient in deep breathing and other grounding techniques (e.g., distraction, journal writing, reframing, reflection, positive self-statements) to manage anxiety.
  • Advise the patient and family about the use and benefits of a sensory room if available.
  • Educate the patient and family about the effect of digital media on the mental health of children and adolescents.16

ASSESSMENT

  1. Perform hand hygiene.
  2. Introduce yourself to the patient and family.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient’s mental status and ability to understand information and participate in decisions. Include the patient as much as possible in all decisions.
  5. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.13
  6. Evaluate the patient’s and family’s understanding of the patient’s illness.
  7. Assess and discuss the patient’s goal for treatment.
  8. Collaborate with the patient and family to develop a plan of care.
  9. Identify the patient’s psychiatric advance directives, if available.
  10. Determine the patient’s desire for the family to be kept informed and involved in treatment.
  11. Determine the family’s ability to support the patient during treatment.
  12. Assess the patient’s communication needs.
    1. How does the patient communicate best—for example, by speaking or writing?
    2. Does the patient speak a language other than English?
    3. Which barriers to effective communication exist (e.g., emotional barriers, thinking distortions, misperceptions)?
  13. Determine the level of stimulation in the patient’s current environment.
  14. Assess the patient’s physical well-being, including current medical complaints, associated symptoms, and vital signs.
  15. Assess the patient for the presence of anxiety. Consider using a standardized tool such as The Revised Child Anxiety and Depression Scale.19
  16. Assess the patient’s current level of anxiety and determine the source, if possible.
  17. Assess the patient’s current coping skills and ability to use them while in the behavioral health setting.
  18. Ask the patient which intervention is most helpful immediately during times of anxiety or distress.
  19. Assess the patient for recent ingestion of toxins and for a history of substance use or abuse.
  20. Determine the medications and doses the patient currently takes.
  21. Obtain information from the family to assess the patient’s typical responses, characteristics, and common coping mechanisms.
  22. Assess the patient’s family, academic, and social and sexual history, including sexual preferences and gender identification.
  23. Assess the patient for sexual, physical, or emotional abuse or a history of abuse, understanding that a history of adverse childhood events increases the risk of anxiety disorders.21
  24. Assess the patient for exposure to peer-related bullying, understanding that victimization increases the risk of anxiety disorders.20
  25. Assess the patient’s habits, such as gambling, sexual activities, substance use, and eating patterns.
  26. Assess the use of digital media and its impact on the patient.1
  27. Assess the family for current issues related to marital conflict, substance use or abuse, and underlying psychiatric disorders. The family may have difficulty caring for an ill child or adolescent in the event of severe family dysfunction.
  28. Assess the patient for the presence of an underlying or comorbid psychiatric disorder.

STRATEGIES

  1. Perform hand hygiene.
  2. Verify the correct patient using two identifiers.
  3. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.13 If homicidal or suicidal ideation is present, implement appropriate precautions based on the patient's status.
  4. Explain the strategies to the patient and family and ensure that they agree to treatment.
  5. Establish a rapport with the patient.
    Rationale: Establishing a rapport is a priority when working with children and adolescent patients. It facilitates assessment of the anxiety level, provides the patient with reassurance, engages the patient in a cooperative manner, and facilitates anxiety reduction.
  6. Maintain a calm, collaborative communication approach, avoiding the use of coercion.
  7. Create an environment of trust that allows the development of a therapeutic relationship.
  8. Orient the patient to the unit. Include discussion of unit routines, guidelines, patients’ rights and expectations, and schedules. Inform the patient that he or she will be checked on frequently throughout the stay.
  9. Create an environment that advocates for the patient’s needs using an interdisciplinary team. Engage the team in collaborative assessment and treatment planning with the patient.
  10. Engage the patient in treatment, including participation in therapeutic groups and individual sessions.
  11. Administer psychiatric medications as ordered and monitor the patient’s response to the medications.
  12. Monitor the patient’s responses and social interactions in the milieu; reinforce appropriate social skills.
  13. Implement appropriate precautions based on the patient’s status.
  14. Respond to crisis in a calm, therapeutic, and nonthreatening manner. Use the least restrictive interventions to prevent harm to patients or staff.
  15. Monitor the patient’s level of anxiety and note changes that may indicate increasing agitation. Use the least restrictive means necessary to establish reasonable and enforceable limits.
    Rationale: Anxiety levels can change quickly, which may put the patient at risk for aberrant behaviors. The use of force or unreasonable consequences may be viewed as punitive or vindictive and can lead to increased agitation or aggression.
  16. Reduce environmental stimuli that may increase the patient’s anxiety level (e.g., a loud or chaotic environment). If possible, find a quiet room in which to meet with the patient.
    Rationale: Moving to a quiet or private area provides increased confidentiality, removes observers, reduces the likelihood of shame or embarrassment for the adolescent, and decreases environmental stimulation.
  17. Make inquiries into the patient’s current perceived distress to determine the source. Use observational statements such as, “You seem worried,” “It sounds like you’re afraid,” or “You look upset about something.”
    Rationale: The use of observational statements is less judgmental and more likely to be perceived as an attempt to understand the patient rather than as a negative view of the patient or an accusation. Identifying the source of distress allows statements of validation and empathy.
  18. Use open-ended questions to elicit information about the source of anxiety.
    1. Clarify statements that are ambiguous or superficial.
    2. Pay attention to statements that indicate an increased risk of harm to self or others.
    3. Express interest in the patient and allow him or her to have some control over the conversation.
    4. Actively listen to the patient without interrupting or correcting.
    5. Avoid statements that may appear judgmental, condescending, or dismissive.
      Rationale: Techniques that encourage the patient to demonstrate self-expression without fear of reprisals, consequences, or judgments should be used. A nonjudgmental attitude encourages the patient to share personal information that may be the cause of the increasing anxiety.
  19. Investigate medical complaints associated with anxiety as well as possible medical causes for increasing anxiety (e.g., drug overdose, intoxication, cardiac issues, hypoglycemia, hypoxia). Ask direct questions about potential medical issues.2
    Rationale: Medical complaints should never be assumed to be solely related to anxiety without proper investigation. Anxiety can be a symptom of some medical conditions (e.g., arrhythmias, low blood sugar, thyroid disorders). Anxiety can also produce physical symptoms (e.g., nausea, shaking, sweating). 2,8
  20. Encourage the patient to identify which behaviors or thoughts increase anxiety (e.g., “Things will never get better” or “This is really going to be painful”) or are triggers for anxiety (e.g., blood draws, family meetings).
    Rationale: Involving patients in their own care empowers them and helps them gain knowledge and insight when they make healthy, successful decisions.
  21. Use incidents of stress as teaching moments. Explore available resources in the current environment and at home and teach positive coping skills the patient can use to reduce anxiety.
    1. Taking slow, deep breaths
    2. Talking with someone
    3. Listening to soothing music
    4. Taking a walk or engaging in other exercise
    5. Meditating or praying
    6. Writing in a journal
    7. Using guided imagery
      Rationale: Identifying positive coping skills and encouraging their use empowers patients to regain control over their anxiety. Positive coping strategies include using social supports, engaging in productive activities, and working to solve problems versus maladaptive coping, which includes ruminating about concerns or problems, externalizing worries, and avoiding issues. 3
  22. Be aware of developmental needs specific to children and adolescent patients, such as the need for privacy, the need to preserve dignity, and the need to have access to peers.
    Rationale: Acknowledging the patient’s developmental needs shows respect and understanding.
  23. Collaborate with the patient, family, and team in planning for patient discharge and follow-up care.
  24. Provide the appropriate education related to medications, crisis management, and follow-up care to the patient and family at the time of discharge.
  25. Explain to the patient and family that ongoing treatment is vital to continuing recovery. Making and keeping follow-up appointments is critical.
  26. Perform hand hygiene.
  27. Document the strategies in the patient’s record.

REASSESSMENT

  1. Reassess the patient’s pain status and provide appropriate pain management (e.g., medication, relaxation, mindfulness skills).
  2. Reassess the patient’s anxiety. Ask these questions when reassessing the patient:
    1. Has the patient’s anxiety been reduced?
    2. Is the patient better able to manage his or her own anxiety?
    3. Are identifiable triggers communicated to all members of the health care team (e.g., in hand-off communication)?
    4. Is the patient participating in his or her care?
    5. Does the patient have a clear understanding of expected behaviors and treatment goals?
    6. Does the patient indicate a comprehension of expectations and limits?
    7. Is the patient cooperating with expectations and limits?
    8. Have the patient needs or concerns been addressed?
    9. Has an underlying medical condition been ruled out as the cause of the anxiety?
  3. If the patient has a history of anxiety reactions that involve agitation or aggression, conduct ongoing assessments to monitor the effectiveness of interventions.
  4. Ensure that all health care team members are aware of the patient who is at risk for self-harm or aggression.
  5. Communicate strategies that help establish a therapeutic relationship with the patient to all health care team members to encourage consistency of care.

EXPECTED OUTCOMES

  • Early identification of anxiety-related issues
  • Safe and timely response to acute psychiatric issues
  • Collaborative alliance with the patient
  • Demonstrated expectations
  • Reduced or eliminated episodes of anxiety
  • Self-care for managing anxiety
  • Parental involvement in treatment and management of patient’s behaviors
  • Safety maintained
  • No attempted self-harm or aggressive behavior

UNEXPECTED OUTCOMES

  • Expectations not understood
  • Unrecognized or unmanaged anxiety, escalating to agitation
  • Continued escalation of behavioral issues
  • Violence and threats to harm self, staff, other patients, or visitors
  • Ineffective communication
  • Failure to establish trusting relationship with the patient
  • Lack of collaboration with the patient
  • Lack of understanding of the patient’s concerns regarding unmet expectations
  • Unsuccessful collaboration between parents and the patient
  • Exacerbation of behavioral issues
  • No learning by the patient

DOCUMENTATION

  • Education
  • Patient’s behaviors and response to interventions
  • Patient’s progress toward goals
  • Assessment of pain, treatment if necessary, and reassessment
  • Mental status assessment (e.g., mood, affect, orientation, speech, behaviors, socialization) including behavioral risk assessment
  • Assessment findings of irritability, aggressive behavior, threats, and assaultive behaviors or self-harm
  • History of legal problems
  • Inappropriate sexual behaviors
  • Uncooperative behaviors, including verbal and nonverbal threats
  • Interventions used to manage uncooperative behaviors
  • All health care team members involved in interventions
  • Status change (e.g., one-to-one, change in the level of care)
  • Medical issues and resulting consults and treatment
  • Notification of family, practitioner, mental health services, police, or other emergency services, if indicated
  • Successful interventions for managing anxiety
  • Substances and quantity of drugs, medications, or alcohol used, if indicated; length of time of drug, medication, or alcohol use; pattern of usage and previous withdrawal and severity
  • Vital signs
  • Signs and symptoms of withdrawal
  • Consequences of substance use
  • Unexpected outcomes and related interventions

SPECIAL CONSIDERATIONS

  • Obesity in childhood and adolescence is associated with both anxiety and depression.15
  • It is important to consider the increased risk of comorbid anxiety and depression among patients with attention deficit hyperactivity disorder or autism spectrum disorder.7
  • Patients with anxiety disorders are more likely to experience intermittent exposure disorder than those without anxiety disorders.14

REFERENCES

  1. American Academy of Pediatrics (AAP) Council on Communication and Media. (2016). Media use in school-aged children and adolescents. Pediatrics, 138(5), e20162592. doi:10.1542/peds.2016-2592 (Level VII)
  2. American Psychiatric Association (APA). (2013). Anxiety disorders. In DSM-5: Diagnostic and statistical manual of mental disorders (5th ed., pp. 189-233). Washington, DC: Author. (classic reference)* (Level VII)
  3. Chua, L.W., Milfont, T.L., Jose, P.E. (2015). Coping skills help explain how future-oriented adolescents accrue greater well-being over time. Journal of Youth & Adolescence, 44(11), 2028-2041. doi:10.1007/s10964-014-0230-8 (Level VI)
  4. Chung, J.E. and others. (2019). Association between anxiety and aggression in adolescents: A cross-sectional study. BMC Pediatrics, 19(1), 115. doi:10.1186/s12887-019-1479-6 (Level VI)
  5. Cornacchio, D. and others. (2016). Irritability and severity of anxious symptomatology among youth with anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 55(1), 54–61. doi:10.1016/j.jaac.2015.10.007 (Level VI)
  6. Das, J.K. and others. (2016). Interventions for adolescent mental health: An overview of systematic reviews. Journal of Adolescent Health, 59(Suppl. 4), S49-S60. doi:10.1016/j.jadohealth.2016.06.020 (Level I)
  7. Davidsson, M. and others. (2017). Anxiety and depression in adolescents with ADHD and autism spectrum disorders; Correlation between parent- and self-reports and with attention and adaptive functioning. Nordic Journal of Psychiatry, 71(8), 614-620. doi:10.1080/08039488.2017.1367840
  8. de Lijster, J.M. and others. (2018). Social and academic functioning in adolescents with anxiety disorders: A systematic review. Journal of Affective Disorders, 230, 108-117. doi:10.1016/j.jad.2018.01.008 (Level I)
  9. Freidl, E.K. and others. (2017). Assessment and treatment of anxiety among children and adolescents. Focus, 15(2), 144-156. doi:10.1176/appi.focus.20160047
  10. Garland, E.J. and others. (2016). Update on the use of SSRls and SNRIs with children and adolescents in clinical practice. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25(1), 4-10. Retrieved July 6, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4791100/
  11. Higa-McMillan, C.K. and others. (2016). Evidence base update: 50 years of research on treatment for child and adolescent anxiety. Journal of Clinical Child & Adolescent Psychology, 45(2), 91-113. doi:10.1080/15374416.2015.1046177 (Level V)
  12. Hoge, E., Bickham, D., Cantor, J. (2017). Digital media, anxiety, and depression in children. Pediatrics, 140(Suppl. 2), S76-S80. doi:10.1542/peds.2016-1758G
  13. Joint Commission, The. (2020). National patient safety goals. Behavioral health care accreditation program. Retrieved July 6, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_bhc_jan2020.pdf (Level VII)
  14. Keyes, K.M. and others. (2016). Anxious and aggressive: The co-occurrence of IED with anxiety disorders. Depression and Anxiety, 33(2), 101-111. doi:10.1002/da.22428 (Level VI)
  15. Lindberg, L. and others. (2020). Anxiety and depression in children and adolescents with obesity: a nationwide study in Sweden. BMC Medicine, 18(1), 30. doi:10.1186/s12916-020-1498-z (Level VI)
  16. Muzaffar, N. and others. (2018). The association of adolescent Facebook behaviours with symptoms of social anxiety, generalized anxiety, and depression. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 27(4), 252-260. (Level VI)
  17. National Institute for Health and Care Excellence (NICE). (n.d.). Generalised anxiety disorder overview. Retrieved July 6, 2020, from https://pathways.nice.org.uk/pathways/generalised-anxiety-disorder (Level VII)
  18. Pettit, J.W., Buitron, V., Green, K.L. (2018). Assessment and management of suicide risk in children and adolescents. Cognitive and Behavioral Practice, 25(4), 460-472. doi:10.1016/j.cbpra.2018.04.001
  19. Piqueras, J.A. and others. (2017). The revised child anxiety and depression scale: A systematic review and reliability generalization meta-analysis. Journal of Affective Disorders, 218, 153-169. doi:10.1016/j.jad.2017.04.022 (Level I)
  20. Pontillo, M. and others. (2019). Peer victimization and onset of social anxiety disorder in children and adolescents. Brain Science, 9(6), 132. doi:10.3390/brainsci9060132
  21. Sachs-Ericsson, N.J. and others. (2017). When emotional pain becomes physical: Adverse childhood experiences, pain, and the role of mood and anxiety disorders. Journal of Clinical Psychology, 73(10), 1403-1428. doi:10.1002/jclp.22444 (Level VI)
  22. Wehry, A.M. and others. (2015). Assessment and treatment of anxiety disorders in children and adolescents. Current Psychiatry Reports, 17(7), 52. doi:10.1007/s11920-015-0591-z

ADDITIONAL READINGS

Domingues-Montanari, S. (2017). Clinical and psychological effects of excessive screen time on children. Journal of Paediatrics and Child Health, 53(4), 333-338. doi:10.1111/jpc.13462

Odgers, C.L., Jensen, M.R. (2020). Annual research review: Adolescent mental health in the digital age: Facts, fears, and future directions. Journal of Child Psychology and Psychiatry, 61(3), 336-648. doi:10.1111/jcpp.13190

Vanucci, A., Flannery, K.M., Ohannessian, C.M. (2017). Social media use and anxiety in emerging adults. Journal of Affective Disorders, 207, 163-166. doi:10.1016/j.jad.2016.08.040

Woods, H.C., Scott, H. (2016). #Sleepyteens: Social media use in adolescence is associated with poor sleep quality, anxiety, depression and low self-esteem. Journal of Adolescence, 51, 41-49. doi:10.1016/j.adolescence.2016.05.008

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports