Copyright © The REACH Institute. All rights reserved. Assessment of Anxiety Disorders.

Copyright © The REACH Institute. All rights reserved.

Assessment of Anxiety Disorders


Learning ObjectivesLearning Objectives• Review how to screen and assess for anxiety

disorders in children and adolescents in a primary care setting

• Analyze two clinical case vignettes on anxiety

• Score and interpret standardized anxiety questionnaires for use in assessment of anxiety.


Unit AgendaUnit Agenda

• Observe an interview

• Interview the Expert: Facts and clinical “pearls” on assessing anxiety in pediatric primary care

• Table activity with Mental Health card

• Review anxiety tools

• Evidence based treatment strategies for anxiety disorders in children and adolescents


For children under 11 y/o, meet with parent and child together to discuss chief concern. SOAPThen meet alone with child for at least five minutes.

For adolescents, consider meeting with adolescent first.

CHIEF CONCERNIf not specific, consider starting with school and social history

SYMPTOM-SPECIFIC HISTORY

Time Frame: Initial event? Persistent/intermittent? Duration? Cyclical? Prolonged hiatus?When: Global? Triggered? Persistent/intermittent? Cyclical? Prolonged hiatus? Setting: School? Home? Alone? With others? Who? Intensity?What makes it better? What makes it worse?

RESPONSE:How do you deal with it?Is there anything that YOU do that makes it better?

Adaptive skills?EtOH? Self-medicating?

Is there anything that YOU do that makes it worse?IMPAIRMENT:

Tell me how bad it gets/got…describe it to me (time, place, situation)What’s the worst it ever got?

Depression? Suicidal thoughts?Aggression?

What does it stop you from doing?

REVIEW OF SYSTEMS (e.g., Mood, Sleep, Appetite, Energy, Concentration, Anxiety, Aggression, etc)

BIRTH, DEVELOPMENTAL AND BEHAVIORAL HISTORY

RELEVANT MEDICAL HISTORY (include meds/otc)

SCHOOL HISTORYAcademics? Behavior? Extra services? Recent changes?May need to get parental permission to communicate with school

SOCIAL HISTORYLiving environmentTrauma History, including witnessed domestic violenceFriends (changes, new, withdrawal)Substance useFunctioning, strengths, interests

TARGETED FAMILY HISTORY

SAFETY--danger to self, danger to othersIs the home safe (no guns, access to Tylenol, etc)?Safety Plan/Contract: (What is the plan if thoughts of harming self or others emerge?)

LAB VALUES/TOOLS

ASSESSMENT/DIAGNOSIS

TREATMENT OPTIONS (consider guidelines or algorithm)

Mental Health Card

DESCRIPTION: (what it is…get concrete examples, including)


Case PresentationCase Presentation

Sue an eight year old girl in third gradeSue an eight year old girl in third grade During case, follow along with Mental During case, follow along with Mental

Health cardHealth card


For children under 11 y/o, meet with parent and child together to discuss chief concern. SOAPThen meet alone with child for at least five minutes.

For adolescents, consider meeting with adolescent first.

CHIEF CONCERNIf not specific, consider starting with school and social history

SYMPTOM-SPECIFIC HISTORY

Time Frame: Initial event? Persistent/intermittent? Duration? Cyclical? Prolonged hiatus?When: Global? Triggered? Persistent/intermittent? Cyclical? Prolonged hiatus? Setting: School? Home? Alone? With others? Who? Intensity?What makes it better? What makes it worse?

RESPONSE:How do you deal with it?Is there anything that YOU do that makes it better?

Adaptive skills?EtOH? Self-medicating?

Is there anything that YOU do that makes it worse?IMPAIRMENT:

Tell me how bad it gets/got…describe it to me (time, place, situation)What’s the worst it ever got?

Depression? Suicidal thoughts?Aggression?

What does it stop you from doing?

REVIEW OF SYSTEMS (e.g., Mood, Sleep, Appetite, Energy, Concentration, Anxiety, Aggression, etc)

BIRTH, DEVELOPMENTAL AND BEHAVIORAL HISTORY

RELEVANT MEDICAL HISTORY (include meds/otc)

SCHOOL HISTORYAcademics? Behavior? Extra services? Recent changes?May need to get parental permission to communicate with school

SOCIAL HISTORYLiving environmentTrauma History, including witnessed domestic violenceFriends (changes, new, withdrawal)Substance useFunctioning, strengths, interests

TARGETED FAMILY HISTORY

SAFETY--danger to self, danger to othersIs the home safe (no guns, access to Tylenol, etc)?Safety Plan/Contract: (What is the plan if thoughts of harming self or others emerge?)

LAB VALUES/TOOLS

ASSESSMENT/DIAGNOSIS

TREATMENT OPTIONS (consider guidelines or algorithm)

Mental Health Card

DESCRIPTION: (what it is…get concrete examples, including)


6 150 9

Father D 1.1

Workbook D 1.1

Copyright © 2014The REACH Institute. All rights reserved.


DSM 5 Criteria for Anxiety Disorders

DSM 5 Criteria for Anxiety Disorders

The Screen for Child & Adolescent The Screen for Child & Adolescent Anxiety-Related Disorders Anxiety-Related Disorders (SCARED)(SCARED)


Sue (D1.2&3)


Total Score = 34


AssessmentAssessment Review relevant history (past medical history,

medications, psychiatric family history) Assess function through symptoms & screeners Assess safety—May need to address this before

going further in the evaluation

Consider other rating scales besides SCARED and PSC, such as the SCAS (Spence Children's Anxiety Scale)

Explore trauma, neglect/abuse. If appropriate, ask suicidality questions

Consider any needed medical and additional mental health assessments


PTSD (or Traumatic Stress)(no longer listed as an “Anxiety Disorder in

DSM-5)

PTSD (or Traumatic Stress)(no longer listed as an “Anxiety Disorder in

DSM-5)

> 1 in 4 American children have had a > 1 in 4 American children have had a traumatic event before age 16 traumatic event before age 16

Look for Look for ExposureExposure plus plus Symptoms:Symptoms:– Exposure: “Exposure: “Has anything frightening or Has anything frightening or

dangerous, either recently or EVER dangerous, either recently or EVER happened to you or your child?happened to you or your child?””

ANDAND– Symptoms (changes in behavior/mood to Symptoms (changes in behavior/mood to

suggest more anxious or distracted)suggest more anxious or distracted)


Traumatic Stress Symptoms in Children and Youth

Traumatic Stress Symptoms in Children and Youth

1. Re-experiencing:Imagery Misperceiving dangerNightmares Distress when cuedBody memories

2. Avoidance:Numbing out Numbing out Diminished InterestDiminished InterestDissociationDissociation Self IsolationSelf IsolationDetachmentDetachment

3.3. Hyperarousal: AnxietyAnxiety Sleep Disturbance Sleep Disturbance HypervigilanceHypervigilance Irritability or quick to Irritability or quick to

angeranger Startle responseStartle response Physical ComplaintsPhysical Complaints


Trauma creates toxic stress which is linked to:

Disrupted autoimmune system dev & function More/earlier smoking, alcohol & drug use Increased violent behavior Increased JJ involvement Chronic health & MH problems1-3

– ACE Study: Adverse Childhood Experiences

Trauma-Informed Care: Why It Matters

Trauma-Informed Care: Why It Matters

1 Felitti VJ, Anda RF, et al.. The relationship of adult health status to childhood abuse and household dysfunction. Am J Prev Med 1998; 14: 245-258

2 Dube SR,, et al. Childhood abuse, household dysfunction and the risk of attempted suicide throughout the life span. JAMA 2001; 286: 3089-3096

3 Heckman J, et al. Economic, Neurobiological, and Behavioral Perspectives on Building America’s Future Workforce. PNAS 2006; 103:10155-10162


The Facts and Clinical Pearls on Assessing for Anxiety in

Children and Adolescents

The Facts and Clinical Pearls on Assessing for Anxiety in

Children and Adolescents

Interview the Expert with Audience Q&A

Copyright © 2014The REACH Institute. All rights reserved.


Anxiety in Children and Adolescents

Anxiety in Children and Adolescents

• Presentation

• Differential

– Medical

– Psychiatric

– Substance-induced

• Sorting out which anxiety disorder

• Developmental considerations


Anxiety DisordersAnxiety Disorders• Prevalence: up to 8% of all children and adolescents• Symptoms:

– Recurring and/or increasing fears and worries about routine parts of everyday life

– Physical complaints, like stomachache or headache

– Trouble concentrating

– Trouble sleeping

– Fear of social situations

– Fear of leaving home

– Fear of separation from a loved one

– Refusing to go to school

• Developmental Considerations– Separation from primary caregiver

– Situational anxieties which are developmentally appropriate

D 1.0


Developmental ConsiderationsDevelopmental Considerations

Infancy PreschoolMiddle

ChildhoodAdolescence Young Adulthood

Inciting Situation Parent leavingSocial interaction

Performance anxiety

Social Performance

Post-high school moratorium

Developmental Skill

Object Permanence

Emerging executive functions

Transitioning from home to larger community

Individuation/ separation

Executive functions

Other FactorsLanguage understanding, expression

Expressive language; temperament

Cognitive skills: language, memory

Body image,adult modeling, group normative expectations

Cognitive ability, developmental strengths profile; familial expectations

Developmentally “normal” ?

YesYes –within limits

Yes – within limits

Yes Yes

ExampleSeparation anxiety

Biting Test anxiety “Pack identification” in clothing

The 6 year bachelor’s degree


EvaluationEvaluation• Consider differential diagnosis of physical

conditions that may mimic anxiety symptoms:– Hyperthyroidism

– Caffeinism (including from carbonated beverages)

– Migraine

– Asthma

– Seizure disorders

– PANDAS–Pediatric autoimmune neuropsychiatric disorders associated with strep infections

– Lead intoxication

– Less Common:• Hypoglycemia• Pheochromocytoma• CNS disorder (delirium or brain tumor)• Cardiac arrhythmias


EvaluationEvaluation• Consider differential diagnosis of other psychiatric

disorders that may mimic anxiety symptoms:

– ADHD (restlessness, inattention)

– Psychotic disorders (restlessness and/or social withdrawal)

– PDD, esp Asperger’s (social awkwardness and withdrawal, social skills deficits, communication deficits, repetitive behaviors, adherence to routines)

– LD (generate persistent worries about school performance)

– Bipolar (restlessness, irritability, insomnia)

– Depression (poor concentration, sleep difficulty, somatic complaints)


Other ConsiderationsOther Considerations• Substance use*

• Adjustment disorder

• Abuse

• Bullying

• Threatening environment

• Pregnancy• Drug Side Effects

• Prescription: Antiasthmatics, sympathomimetics, steroids, SSRIs, antipsychotics (akathisia)

• Nonprescription: Diet pills, antihistamines, and cold medications

* Tools - CRAFFT


EvaluationEvaluation

• If impression/screening suggests possible anxiety, the clinician should conduct a formal evaluation to determine:

– Which anxiety disorder may be present

– The severity of anxiety symptoms

– Functional impairment


Other Anxiety DisordersOther Anxiety Disorders

Post-traumatic Stress DisorderPost-traumatic Stress Disorder– PTSD is no longer under Anxiety

Disorders in the DSM-5. – Post-Traumatic Stress Reaction Index

(PTSRI)

Obsessive Compulsive DisorderObsessive Compulsive Disorder– DSM Criteria– Yale-Brown Obsessive Compulsive Scale

(Y-BOCS)

Copyright © The REACH Institute. All rights reserved.Copyright © 2014The REACH Institute. All rights reserved.

Audience Q&A


Assessment Key PointsAssessment Key Points

• Watch for co-existing disorders, in particular ADHD and depression, which are not uncommon

• Use standardized anxiety tools (SCARED) to aid in the assessment but also listen to parent concern and your own concern from interviewing the child

• Remember the importance of reading non-verbal information with Anxiety disorders


Reading Non-Verbal InformationReading Non-Verbal Information• Real messages often hidden by words

• A person may or may not use the right words to describe their real needs

• What is the person’s inner needs?

• Example:

• Doctor: How can I help you?

• Parent: I don’t think you can help me…

A. To Antagonize

B. To Get Help

C. To Get Respect


Table Activity (in pairs)Table Activity (in pairs)

Applying it to Anxiety: Two role plays with cases - Chad/Charlotte (D 1.4) and Michelle/Michael (D1.5)

• Go slow, pause, see what you get back, adjust your response to what you feel from the patient, ask best-fitting questions from MH card

• Do not “read” lines – “speak from the heart” to Chad/Michelle only after making eye contact

• Change roles and scripts


COLDER:Your Mental Health Interview

COLDER:Your Mental Health Interview

CCharacteristicsharacteristics OOnsetnset LLocationocation DDurationuration EExacerbationxacerbation RReliefelief

* Also found on MH card


SummarySummary

Role of rating scales Stop, Look, and Listen for

underlying needs and emotions Mental Health Card and COLDER


REMINDER: REMINDER: Please fill out Unit D Please fill out Unit D

evaluationevaluation


Getting it Paid For: Self-Study

Do you know how to code these cases so you will get paid?

Do you know when to use these coding variations?

Getting it Paid For: Self-Study

Do you know how to code these cases so you will get paid?

Do you know when to use these coding variations?


Sue’s Diagnostic Code Sue’s Diagnostic Code

ICD-9-CM/DSM-IV: 290-319 codes Despite all the commotion about ‘mental

health parity’ –may be ‘carved out’ by insurers as “mental health”– Only “approved” mental health specialists may

be paid for services provided for these conditions (this is an insurer’s decision)

We don’t want fraud –but we DO want fair payment for rendered services


ICD-9-CM Options for SueICD-9-CM Options for Sue

799.2 Signs and symptoms involving emotional state (excl. anxiety and depression)

789.05 Abdominal pain, periumbilic

Try to stay out of v-code land for primary dx.! Secondary dx –ok


Sue’s ProceduresSue’s Procedures

96110: Developmental Screening (Developmental Testing, limited until 2013) per standardized form, w/ interpretation and report

May be used for standardized developmental rating scales –including behavioral rating scales


Rating ScalesRating Scales

Must be standardized Informal checklists don’t qualify Ex: ASQ-SE, PEDS, M-CHAT, Vanderbilt

ADHD, SCARED, PSC, PHQ-9, Connor’s ADHD, CBCL, BASC-2, BRIEF, CDS

May assign one unit of 96110 for each form completed, scored, interpreted and noted in the medical record


Sue’s Visit: Option 1Sue’s Visit: Option 1

99383 99214-25 (2) 96110 (PSC, SCARED)

This is for insurers who allow -25 and multiple units of a procedure



99383 99214-25 96110 96110-76

This is for insurers who permit -25, but want each procedure on a separate line AND who do not adhere to CMS guidelines



99383 99214 96110-59 96110-59

This could be used for payers who do not permit -25 use and who also follow CMS guidelines regarding -76.

Copyright © The REACH Institute. All rights reserved. Assessment of Anxiety Disorders.

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