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Jul.30.2020

Elsevier Clinical Skills

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

ALERT

Anxiety can trigger agitation and aggression in children and adolescents.11 Unresolved anxiety, as well as ineffective coping with anxiety, can lead to depression.16 Regularly occurring anxiety in a child or adolescent may be a sign of depression or another underlying mental health issue.16

OVERVIEW

Anxiety disorders are among the most prevalent mental health conditions in children and adolescents.9 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.16

Anxiety can affect emotions, thought processes, bodily sensations, and behaviors. For patients with anxiety, vigilance, preparation for future threats, caution, and avoidant behaviors are common.2

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)

Children and adolescents may experience anxiety differently than adult patients. Children and adolescents typically have more anxiety regarding social relationships and may avoid social activities, such as talking in groups or school.2,8 Children and adolescents with an anxiety disorder are more likely to demonstrate irritability and difficulty coping and functioning than those who do not have an anxiety disorder.5 Agitation may develop more quickly and result in aberrant behaviors.

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.2

Important goals for caring for children and adolescent patients who are experiencing anxiety include intervening to help the patient relieve anxiety and evaluating the effectiveness of interventions.2,8

Since anxiety symptoms can have a negative impact on the child’s and adolescent’s school performance, family life, and leisure activities, it is important to provide treatment to ameliorate the symptoms.21 The psychotherapeutic intervention that has demonstrated effectiveness in the treatment of anxiety disorders is cognitive behavioral therapy (CBT).21 Additionally, for social anxiety disorder, supplementing CBT treatment with social skills training enhances the impact of the success of CBT.17 In addition to psychotherapeutic interventions, psychopharmacologic interventions are also used in the treatment of child and adolescent anxiety disorders.19 The medications most often used are selective serotonin reuptake inhibitors (SSRIs) or selective serotonin norepinephrine reuptake inhibitors (SNRIs). Even though there are risks related to increased suicide ideation, for most children and adolescents, the benefits outweigh the risk of treatment.10 For children and adolescents with generalized anxiety disorder, separation anxiety or social anxiety disorder, SSRIs have demonstrated superior effectiveness to SNRIs.19

For children and adolescents with specific phobias, one-session treatment (OST), which incorporates CBT techniques with modeling, psychoeducation, skills training, and graduated exposure into a single, extended session has demonstrated effectiveness.7

For many patients, the combination of CBT and SSRIs may provide greater symptom relief than either modality alone.10

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.
  • 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, and frustration).
  • Assist the patient and family with engaging and participating as drivers of the plan of care.
  • Educate the patient and family about the potential risks of media use.1
  • 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.

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 use of positive versus maladaptive coping skills in response to anxiety symptoms.3 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
  13. Assess the use of digital media and its impact on the patient.1
  14. Assess the patient’s response to past treatment if applicable, including his or her response to medications.

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. Maintain a calm, collaborative communication approach, avoiding the use of coercion.
  6. Explore with the patient any issues that may be increasing the experience of stress. Explore methods that have been successful in the past for reducing anxiety.11
  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 that have demonstrated effectiveness in the treatment of anxiety disorders, such as CBT and social skills training.
    Rationale: Group CBT is a treatment of choice for children and adolescents with anxiety disorders. 21 Individual treatment using CBT is preferred for children and adolescents with anxiety disorder and autism spectrum disorder. 14 For children and adolescents with social anxiety disorder, the addition of social skills training to CBT improves outcomes of treatment. 17
  11. Administer psychiatric medications as ordered and monitor the patient’s response to the medications. Be aware that antidepressant medications may increase the risk of suicidal ideation in children and adolescents.18
  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. Engage the patient’s parents in treatment as much as possible.
    Rationale: Increased parental involvement and participation in the patient’s treatment improves the outcomes of treatment. 15
  16. Consider using alternative approaches to help the patient develop coping skills to manage his or her anxiety effectively.
    Rationale: Yoga has been an effective method of reducing symptoms of anxiety in children and adolescents. 20
  17. Assist the patient in identifying and developing positive coping skills that will be effective (e.g., reaching out to friends or parents, using relaxation techniques).
  18. Work with the patient and family to develop a plan for media use after discharge to determine appropriate parameters for its use.1
    Rationale: Developing personalized media plan based on a child’s age, physical and mental health, personality, and developmental stage can help establish the necessary limits to promote adequate sleep, activity, and social interactions and avoid excessive and inappropriate media use. 1
  19. Collaborate with the patient, family, and team in planning for patient discharge and follow-up care.
  20. Provide the appropriate education related to medications, crisis management, and follow-up care to the patient and family at the time of discharge. Explain the potential risks associated with some of the medications used to treat anxiety disorders in children and adolescents.
    Rationale: Certain medications used in the treatment of anxiety disorders (e.g., SSRIs and SNRIs) may lead to increased risk of suicidal ideation in children and adolescents. 18
  21. Explain to the patient and family that ongoing treatment is vital to continuing recovery. Making and keeping follow-up appointments is critical.
  22. Perform hand hygiene.
  23. 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. Assess whether the patient’s anxiety has been reduced.
  3. Assess whether the patient is better able to manage his or her own anxiety.
  4. Assess the patient’s level of participation in his or her own care.
  5. Assess the success of treatment strategies and the patient’s coping skills.

EXPECTED OUTCOMES

  • Identification of anxiety-related 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 the patient’s behaviors
  • Safety maintained
  • No attempted self-harm or aggressive behavior

UNEXPECTED OUTCOMES

  • Expectations not understood
  • Unmanaged anxiety, escalating to agitation
  • Violence and threats to harm self or others
  • Ineffective communication
  • Failure to establish trusting relationships
  • Failure of efforts to collaborate
  • Exacerbation of anxieties leading to diminished functioning and panic

DOCUMENTATION

  • Education
  • Patient’s behaviors and response to interventions
  • Patient’s progress toward goals
  • Assessment of pain, treatment if necessary, and reassessment
  • Interventions used to manage uncooperative behaviors
  • All persons 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
  • Vital signs
  • Unexpected outcomes and related interventions

SPECIAL CONSIDERATIONS

  • Children and adolescents with chronic medical conditions, such as asthma or inflammatory bowel disease, are at increased risk of experiencing anxiety disorders.4 In addition, anxiety disorders can have a negative impact on health outcomes for children and adolescents with chronic medical conditions; therefore, treatment should be initiated as soon as possible.4
  • Children and adolescents with social anxiety disorder are at higher risk of suicidal ideation and suicide.12
  • Children and adolescents with attention deficit hyperactivity disorder who are treated with psychostimulants are at reduced risk of experiencing anxiety disorders.6

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. Cobham, V.E. and others. (2020). Systematic review: Anxiety in children and adolescents with chronic medical conditions. Journal of the American Academy of Child and Adolescent Psychiatry, 59(5), 595-618. doi:10.1016/j.jaac.2019.10.010 (Level I)
  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. Coughlin, C.G. and others. (2015). Meta-analysis: Reduced risk of anxiety with psychostimulant treatment in children with attention-deficit/hyperactivity disorder. Journal of Child and Adolescent Psychopharmacology, 25(8), 611-617. doi:10.1089/cap.2015.0075 (Level I)
  7. Davis, T.E., III, Ollendick, T.H., Öst, L.G. (2019). One-session treatment of specific phobias in children: Recent developments and a systematic review. Annual Review of Clinical Psychology, 15, 233-256. doi:10.1146/annurev-clinpsy-050718-095608 (Level I)
  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. Ewing, D.L. and others. (2015). A meta-analysis of transdiagnostic cognitive behavioural therapy in the treatment of child and young person anxiety disorders. Behavioural and Cognitive Psychotherapy, 43(5), 562-577. doi:10.1017/S1352465813001094 (Level I)
  10. 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
  11. Gerson, R. and others. (2019). Best practices for evaluation and treatment of agitated children and adolescents (BETA) in the emergency department: Consensus statement of the American Association for Emergency Psychiatry. Western Journal of Emergency Medicine, 20(2), 409-418. doi:10.5811/westjem.2019.1.41344 (Level VII)
  12. Herres, J. and others. (2019). Differences in suicide risk severity among suicidal youth with anxiety disorders. Crisis, 40(5), 333–339. doi:10.1027/0227-5910/a000571 (Level VI)
  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/2020/npsg_chapter_bhc_jul2020.pdf (Level VII)
  14. Kreslins, A., Robertson, A.E., Melville, C. (2015). The effectiveness of psychosocial interventions for anxiety in children and adolescents with autism spectrum disorder: A systematic review and meta-analysis. Child and Adolescent Psychiatry and Mental Health, 9, 22. doi:10.1186/s13034-015-0054-7 (Level I)
  15. Kreuze, L.J. and others. (2018). Cognitive-behavior therapy for children and adolescents with anxiety disorders: A meta-analysis of secondary outcomes. Journal of Anxiety Disorders, 60, 43-57. doi:10.1016/j.janxdis.2018.10.005 (Level I)
  16. Melton, T.H. and others. (2016). Comorbid anxiety and depressive symptoms in children and adolescents: A systematic review and analysis. Journal of Psychiatric Practice, 22(2), 84-98. doi:10.1097/PRA.0000000000000132 (Level I)
  17. Scaini, S. and others. (2016). A comprehensive meta-analysis of cognitive-behavioral interventions for social anxiety disorder in children and adolescents. Journal of Anxiety Disorders, 42, 105-112. doi:10.1016/j.janxdis.2016.05.008 (Level I)
  18. Sharma, T. and others. (2016). Suicidality and aggression during antidepressant treatment: Systematic review and meta-analyses based on clinical study reports. BMJ, 352, i65. doi:10.1136/bmj.i65 (Level I)
  19. Strawn, J.R. and others. (2018). The impact of antidepressant dose and class on treatment response in pediatric anxiety disorders: A meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 57(4), 235-244.e2. doi:10.1016/j.jaac.2018.01.015 (Level I)
  20. Weaver, L.L., Darragh, A.R. (2015). Systematic review of yoga interventions for anxiety reduction among children and adolescents. American Journal of Occupational Therapy, 69(6), 6906180070p1-9. doi:10.5014/ajot.2015.020115 (Level I)
  21. Zhou, X. and others. (2019). Different types and acceptability of psychotherapies for acute anxiety disorders in children and adolescents: A network meta-analysis. JAMA Psychiatry, 76(1), 41-50. doi:10.1001/jamapsychiatry.2018.3070 (Level I)

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

Hoge, E., Brickham, D., Cantor, J. (2017). Digital media, anxiety, and depression in children. Pediatrics, 140(Suppl. 2), S76-S80. doi:10.1542/peds.2016-1758G

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.

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

*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