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Initial Post: Created by Facilitating Group

This is a student-led discussion.

  • The facilitating group should choose one member from their group who will be responsible for the initial post.
  • On Day 1 of this week, the chosen group member will create an initial post that is to include the group’s discussion prompts, resources, and the instructions for what your classmates are to do with the resources.
  • During this week, each member of your group is to participate in the facilitation of the discussion. This means making certain that everyone is engaged, questions from students are being answered, and the discussion is expanding.
  • It is the expectation that the facilitating group will address all initial peer response posts by Day 6.

Reply Posts: Non-Facilitating Students

  • If you are not a member of the facilitating group, you are to post a discussion prompt response according to the facilitating group’s instructions by Day 4. Your reply posts should include substantive reflection directed to the presenters.
  • You are also expected to respond to at least two other peer’s initial discussion prompt posts.

Due: Facilitating group to post by Day 1; all other students post to discussion prompt by Day 4 and one other peer initial discussion prompt post by Day 6

Initial Post: Created by Facilitating Group ( I am not in the facilitating group)

This is a student-led discussion.

· The facilitating group should choose one member from their group who will be responsible for the initial post.

· On Day 1 of this week, the chosen group member will create an initial post that is to include the group’s discussion prompts, resources, and the instructions for what your classmates are to do with the resources.

· During this week, each member of your group is to participate in the facilitation of the discussion. This means making certain that everyone is engaged, questions from students are being answered, and the discussion is expanding.

· It is the expectation that the facilitating group will address all initial peer response posts by Day 7.

Reply Posts: Non-Facilitating Students

· If you are not a member of the facilitating group, you are to post a discussion prompt response according to the facilitating group’s instructions by Day 4. Your reply posts should include substantive reflection directed to the presenters.

· You are also expected to respond to at least two other peer’s initial discussion prompt posts.

Facilitating Group’s Post (to be replied)

Week 11 Discussion: Child and Adolescent Anxiety Disorders

Introduction:

Anxiety is an emotion that is present in all humans from the time of birth and is the brain’s response to “perceived or actual danger” (Yearwood et al., 2012).  An advanced practice registered nurse needs to be able to distinguish the anxiety related to fear and worry that many children experience as developmentally appropriate anxiety that occurs in childhood and that of anxiety disorders which interferes with a child’s functioning (Yearwood et al., 2012).  In this week’s discussion, we will take a closer look at diagnosis, treatment options, and education resources for families with children who are diagnosed with anxiety disorder.  

Types of Anxiety Disorders:

The most common types of anxiety disorder seen in children include generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, social phobia, separation anxiety disorder, selective mutism, and school refusal (Yearwood et al., 2012).   

· Generalized anxiety disorder involves chronic and excessive worries in several different areas of life, such as school, family, social interactions, world events, with at least one somatic symptom (Yearwood et al., 2012). 

· Panic disorder involves recurrent episodes of excessive fear (Yearwood et al., 2012). 

· Obsessive-compulsive disorder involves either obsession and worries or compulsions and rituals (Yearwood et al., 2012). 

· Social phobia involves feeling scared or uncomfortable in social settings.  Additional forms of social phobia include selective mutism and school refusal (Yearwood et al., 2012). 

· Separation anxiety involves a high level of stress, fear, and worry when separated from the home or primary caregiver (Yearwood et al., 2012). 

Required Reading:

· Boland, R., Verduin, M., & Ruiz, P. (2021). Kaplan & Sadock’s Synopsis of Psychiatry Twelfth Edition. Wolters Kluwer. ISBN-13: 978-1975145569

o    Chapter 8 Anxiety Disorders

·  Yearwood, E. L., Pearson, G. S., & Newland J. A. (2012). Child and adolescent behavioral health. Sussex, UK: Wiley-Blackwell

o    Chapter 8 Anxiety Disorders

· American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Washington, DC: APA Press. ISBN 978-0-89042-554-1

o    Pp. 189-285

Recommended Reading:

· Bushnell, G. A., Compton, S. N., Dusetzina, S. B., Gaynes, B. N., Brookhart, M. A., Walkup, J. T., Rynn, M. A., & Stürmer, T. (2018). Treating pediatric anxiety: Initial use of SSRIs and other antianxiety prescription medications. The Journal of Clinical Psychiatry79(1), 16m11415. https://doi.org/10.4088/JCP.16m11415

· Carnes, A., Matthewson, M., & Boer, O. (2019). The contribution of parents in childhood anxiety treatment: A meta-analytic review. Clinical Psychologist23(3), 183. https://doi.org/10.1111/cp.12179

· Creswell, C., Waite, P., Cooper, P. J. Assessment and management of anxiety disorders in children and adolescents. (2014). Archives of Disease in Childhood, 99(1), 674-678. https://adc.bmj.com/content/99/7/674

· Nguyen, S.-A., & McAloon, J. (2018). A cross-cultural comparison of parental perceptions of childhood separation anxiety disorder symptoms and likelihood to seek help. Journal of Cross-Cultural Psychology49(3), 453–469. https://doi.org/10.1177/0022022118754722

· Vallance, A., & Fernandez, V. (2016). Anxiety disorders in children and adolescents: Aetiology, diagnosis and treatment. BJPsych Advances, 22(5), 335-344. https://doi.org/10.1192/apt.bp.114.014183

Videos:

· Anxiety Disorders in Children and Teens

https://youtu.be/OBbgw3mSwiU

· Anxiety and depression in kids: Healthy Head to Toe

https://youtu.be/dZgMvyRkaI4

Additional Resources: 

·  Anxiety Disorders in Children and Adolescents Flash Cards

https://quizlet.com/199295304/anxiety-disorders-in-children-and-adolescents-flash-cards/

Discussion Prompts:

1.     How do healthcare providers detect separation anxiety disorders in order to refer children and adolescents for mental health treatment? What evidence-based treatment modalities are available for the treatment of separation anxiety disorder?

2.      Discuss the role of psychotherapy and holistic treatment in children and adolescents diagnosed with anxiety disorders.

3.     Due to the stigma associated with mental health, African American and Asian parents are less likely to administer psychiatric medications to their children. What medications would you prescribe for anxiety disorders in children and adolescents? What education would you provide these parents to increase medication compliance?

Peer Post 1 (To be replied)

 Week 11 Discussion: Anxiety Disorders

Jeffrey Pham

November 9, 2021

Dear Group 2,

Thank you for an informative and creative presentation. It is essential to screen for and treat for separation anxiety disorder (SAD) because SAD in childhood is correlated to increased risk of developing depression, panic disorder and other various anxiety disorders in adulthood  (Cooper-Vince et al., 2014). To detect SAD requires first knowing what symptoms children with this disorder commonly display in order to know what  to watch for or assess for during psychiatric evaluation.  According to Cooper-Vince et al. (2014), a study conducted showed  children with SAD reported the following as their symptoms: Distress related to separation; worried about harm befalling attachment figure; worry that untoward will lead to separation; reluctance/refusal to go to places; fear of being alone or without attachment figure; reluctance from sleep away from attachment figure; repeat nightmares about separation; and physical symptoms (i.e. nausea, vomiting, headaches, or stomaches) about separation. While SAD also runs in family and there is an increased risk for the disorder if the first or 2nd generation relative has SAD, certain environmental factors are also risk factors, such as parental alcoholism, low birth rate, female sex, parental conflict, parental loss/absences, parent co-sleeping with child, foster care, etc. (Feriante, & Bernstein, 2021).

Given the genetic and environmental predisposition to SAD, a thorough family and birth history while thoroughly assessing  for common somatic complaints and fear surrounding separation from a significant figure, such as a parent or legal guardian, can help screen for SAD (Feriante, & Bernstein, 2021). As pertain to DSM 5, to exhibit SAD, at least 3 of the 8 symptoms must present that significant impact work, school and social aspects of functioning (Feriante, & Bernstein, 2021).

The Separation Anxiety Avoidance Inventory (SAAI), an assessment tool used to screen specifically for SAD can be utilized to guide and evaluate treatment (Feriante, & Bernstein, 2021). Based on the results of the validated screening tool, treatment is implemented. In mild symptoms education and support may be sufficient, however, in moderate to severe symptoms, the standard first line therapy is CBT; if CBT is not effective, several randomized clinical trials have shown that augmenting SSRI antidepressant with CBT are the most effective in improving anxiety (Feriante, & Bernstein, 2021).

Stigma or fear of disclosing or being judged  can contribute to noncompliance (Naghavi et al., 2019).  To reduce stigma and promote treatment requires establishing good therapeutic alliance, gaining parents trust, answering any questions, including the parents and patients in decision-making and designing in treatment plan, and educating accurately about disease and treatment can increase compliance (Naghavi et al., 2019). 

 

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References

Cooper-Vince, C. E., Emmert-Aronson, B. O., Pincus, D. B., & Comer, J. S. (2014). The diagnostic utility of separation anxiety disorder symptoms: an item response theory analysis. Journal of abnormal child psychology, 42(3), 417–428. https://doi.org/10.1007/s10802-013-9788-

Feriante, J., & Bernstein, B., (2021). Separation Anxiety. StatPearls Publishing. Treasure Island (FL). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560793/#_NBK560793_pubdet_

Naghavi, S., Mehrolhassani, M.H., & Nakhaee, N. et al. (2019). Effective factors in non-compliance with therapeutic orders of specialists in outpatient clinics in Iran: a qualitative study. BMC Health Serv Res 19, 413. https://doi.org/10.1186/s12913-019-4229-4

Peer Post 2 (To be replied)

Deborah Penny

Child and Adolescent Anxiety Disorders

Thank you Group 2 (Julianne, Laura B, and Marie).  Your presentation about child and adolescent anxiety disorders is a subject of high prevalence due to the trajectory of undiagnosed and untreated disorders leading to self-harm and suicide.

How do healthcare providers detect separation anxiety disorders to refer children and adolescents for mental health treatment?

“Anxiety is perhaps the most common of DSM diagnosed mental health disorders, yet less than one-third of affected individuals ever seek treatment. Untreated, anxiety may easily worsen, leading to the devastating signs of depression such as hopelessness, exhaustion, frequent school absences, social isolation, and negative obsessive thinking, all of which may contribute to the feared possibility of suicide” (Kuzujanakis, 2021).

According to APA, (2013), Diagnostic and Statistical Manual of Mental Disorders (DSM-IV®) diagnostic criteria for Separation Anxiety Disorder (SAD) is when the anxiety a person experiences exceeds what may be expected given the person’s developmental level and the disturbance causes significant impairment in social, academic, and occupational areas.  To be diagnosed with SAD, individuals must meet at least three of the criteria on listed pages 190-191 of the DSM-IV.

The United States Preventative Task Force (USPSTF) is in the process of updating their recommendation on screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents.  The Draft Research Plan has proposed key questions for systematic review.  One of those questions asks; Do instruments to screen for depression, anxiety, or increased risk of suicide accurately identify children and adolescents with depression, anxiety, and increased risk of suicide in primary care or comparable settings? (USPSTF, 2020).  A few noteworthy screening tools for SAD are the Family Accommodation Scale (FAS), the Multidimensional Anxiety Scale for Children-Parent and Child Report (MASC-P/C) and the Revised Child Anxiety and Depression Scale (RCADS) are tools that measure anxiety on various subscales and can be completed by both parent and child.   The FASA is a modified version of the Family Accommodation Scale (FAS), with changes made to measure accommodation of anxiety symptoms, rather than solely OCD symptoms. The 13-item FASA measures the degree to which family members (i.e., parents) have accommodated a child’s anxiety symptoms. Four of the items assess distress related to accommodation and negative consequences of not accommodating. (Phillips, et al., 2020). The Multidimensional Anxiety Scale for Children–Parent and Child Report (MASCC/P) is a 39-item measure of child anxiety on four subscales; Social Anxiety, Separation/Panic, Harm Avoidance, and Physical Symptoms. The Revised Child Anxiety and Depression Scale (RCADS) is a 47-item measure of youth anxiety that corresponds with DSM-IV in five anxiety subscales; Generalized Anxiety disorder (GAD), obsessive-compulsive disorder (OCD), Specific Phobia (SP), Separation (Sep) and Social (Soc) Anxiety. 

Parental accommodation is an important variable that may be associated with the onset and maintenance of anxiety disorders in youth. Accommodation describes ways in which family members, primarily parents, modify their behavior to diminish, alleviate or avoid distress caused by SAP.  These behaviors can include excessive reassurance about a child’s fears, modifying family routines and schedules.  A classic example of this is the parent or caregiver leaving their child at daycare and continuing to hang around, placating (accommodating) their child, to try an alleviate the anxiety of separation.  “Although many parents feel they are reacting to their child’s anxiety in a protective way, this protectiveness becomes maladaptive when these reactions allow the child to avoid anxiety-provoking situations in the future” (Phillips, et al., 2020).

What evidence-based treatment modalities are available for the treatment of separation anxiety disorder?

It is important for a practitioner to know the difference between SAD and “stranger anxiety” which is seen in children by twelve months of age, during periods of heightened separation anxiety from attachment figures.  This is part of normal early child development and will subside around the time of preschool.   “By the time children reach school age, they develop the cognitive ability to understand that what others think of them may be different from how they view themselves and this creates fear and uncertainty.  One of the hallmark features of anxiety are somatic complaints that include frequent recurrent abdominal pain, muscle aches and pains, chest pain, palpitations, sweating, dizziness, shortness of breath, and headaches.  It is important to follow through and assess these complaints for an actual physical condition but if no evidence is found to support a specific diagnosis, anxiety must be considered” (Yearwood, et al., 2012).    

Treatment for anxiety should take a multimodal approach that involves education about the disorder to parent and child.  Behavior therapy should be the first course of treatment and last about 6-8 weeks which should be enough time to start seeing some resolution of symptoms.  Cognitive Behavioral Therapy (CBT) is evidence-based therapy and is the treatment of choice. In addition, family therapy is an absolute, especially if the parents/family have maladaptive behaviors that fuel the patient’s anxiety disorder.  “If after 6 to 8-weeks of therapy with little to no resolution of symptoms across multiple areas such as home, school, interpersonal, and social, then a medication trial may be necessary, but therapy should be ongoing.     

Discuss the role of psychotherapy and holistic treatment in children and adolescents diagnosed with anxiety disorders.

Psychotherapy and holistic treatment examples could be mindfulness and meditation, which depending on a person’s preference could be advantageous in reducing anxiety, or at the very least, make the person aware of how their body is responding to stimuli.  However, not every person enjoys meditation and mindfulness.  Deep breathing and quiet spaces can make the symptoms worse by bringing the anxiety to the forefront. 

Due to the stigma associated with mental health, African American and Asian parents are less likely to administer psychiatric medications to their children. What education would you provide these parents to increase medication compliance?

Patients’ beliefs about psychotropic medications are important factors influencing medication adherence and can easily compromise treatment effectiveness and interfere with recovery.  This is not just a problem for psychotropic drugs, it is also a concern for medications prescribed for chronic medical diseases like hypertension and diabetes mellitus.  One facet of increasing medication compliance is to provide culturally-sensitive care. It isn’t uncommon for children and youth who have anxiety to refuse any form of treatment. Denial is sometimes a self-protective measure, meant to lessen the anxious person’s already overwhelming feelings of shame. Societal attitudes have also traditionally been a barrier to mental health treatment, with many believing that mental illness is a sign of personal weakness.  Educating a patient about the cause and effect of a medication may provide insight and understanding that allow for adherence.  Communication is always a good thing because it builds a dialogue, which in turn builds respect and trust. 

Questionnaires are a good way to start dialogue and one specific to medication adherence is the “Beliefs about Medicines Questionnaire Specific Scale (BMQ).  It is a tool that has two sections; BMQ-Specific (Specific-Necessity and Specific-Concerns; 10 items), which assesses beliefs about the medication prescribed for personal use, and the BMQ-General (General-Harm and General-Overuse; eight items), which assesses beliefs about medication in general. The two sections of the BMQ can be used in combination or separately” (Verhagen, 2017).  Having the patient fill out the BMQ is a good starting point, and the questionnaire can be completed either before or during the visit. 

What medications would you prescribe for anxiety disorders in children and adolescents?

For a patient with a pediatric anxiety disorder that does not respond to an adequate trial of Cognitive Behavioral Treatment (CBT), treatment with a selective serotonin reuptake inhibitor (SSRI) is recommended.  SSRIs have been found to be efficacious in clinical trials of pediatric anxiety disorders. SSRIs are most extensively studied class and are generally better tolerated than the other antidepressants. Selection between modalities should be guided by child/parent preferences.  “Sertraline, a selective serotonin reuptake inhibitor (SSRI) can be started at an initial dose of 12.5 to 25 mg/day for a minimum of seven days and titrated up to 50 mg/day in increments of 12.5 mg (child) or 25 to 50 mg (adolescent) per week. If an adequate clinical response is not seen after six to eight weeks of treatment, subsequent trials should be tried following dose increases of 12.5 mg/day for children and 25 to 50 mg/day for adolescents to a maximum of 200 mg/day” (Glazier-Leonte, et al., 2019).  Patient education about the US Food and Drug Administration “black box” warning is mandatory and part of disclosure.  The warning states that children and adolescents taking antidepressant medication, are at increased risk for suicidal thinking or behavior and recommends close monitoring of patient’s clinical status during the early weeks of antidepressant treatment and limiting the duration of their use.

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References

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM- 5®). American Psychiatric Publishers. https://www.psychiatry.org/psychiatrists/practice/dsm

De las Cuevas, C., Motuca, M., Baptista, T., Villasante-Tezanos, A. G., & Leon, J. (2019).                       Ethnopsychopharmacology study of patients’ beliefs regarding concerns about and necessity of taking psychiatric medications. Human Psychopharmacology: Clinical and Experimental, 34(2). https://doi.org/10.1002/hup.2688       

Glazier-Leonte, K., Puliafico, A., Na, P. J., & Rynn, M. A., (2019). Pharmacotherapy for anxiety disorders in children and adolescents.  UpToDate.    https://www.uptodate.com/contents/pharmacotherapy-for-anxiety-disorders-in-children-       and-adolescents?search=anxiety%20disorder%20treatment%20for%20children%20and%20ad            olescents&source=search_result&selectedTitle=1~150&usage_type=default&display_ran            k=1#H876805                                                            

Kuzujanakis M. (2021). Anxiety in today’s children and young adults. Gifted Education International 37(1):54-66. doi:10.1177/0261429420934445

Phillips, K. E., Norris, L. A., & Kendall, P. C. (2020). Separation Anxiety Symptom Profiles and Parental Accommodation Across Pediatric Anxiety Disorders. Child Psychiatry and Human Development, 51(3), 377–389. https://doi.org/10.1007/s10578-019-00949-7

USPSTF (2020). United States Preventive Services Task Force.  Screening for Depression,  Anxiety, and Suicide Risk in Children and Adolescents. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/document/draft-research-    plan/screening-depression-anxiety-suicide-risk-children-adolescents            

Verhagen, A. P. (2017). Beliefs about Medicine Questionnaire. Journal of Physiotherapy, 64(1)             http://dx.doi.org/10.1016/j.jphys.2017.04.006

Yearwood, E. L., Pearson, G. S., & Newland J. A. (2012). Child and adolescent behavioral health. Wiley-Blackwell.