All right. So now I'm going to provide just a brief introduction for our speakers today. Um First, we'll hear from Dr Alison Libby Arnold who is a clinical psychologist at U CS F, who provides individual group and family treatment for Children, adolescents and adults with anxiety, O CD spectrum disorders, depression and trauma disorders. She provides training and supervision to psych and psychiatry fellows and residents. She completed her undergraduate training at U C L A, followed by a master's and a Doctorate of Clinical Psychology at Stanford University where she defended her dissertation on perceived family environment and clinical correlates in adolescence with recent onset bipolar disorder. And then we will hear from Dr Jean Yun who is a child and adolescent psychiatrist here at U CS F be Children's Hospital Oakland. She serves as the site director for the U CS F Child and Adolescent Psychiatry Fellowship, as well as Associate director of resource development for the cat portal, the Child and Adolescent Psychiatry Portal. She completed her pediatrics residency at Cleveland Clinic, followed by fellowship at Children's Hospital of Philadelphia. Her interests include serving the community by integrating behavioral health into pediatric primary care all right. Without further ado, I will hand it off to uh Doctor Libby Arnold. Thank you. Great. Thank you so much. So, we're gonna be talking all about anxiety and youth today and uh no financial disclosures to report the learning objectives are to identify and diagnose anxiety disorders in youth. Explain cognitive and behavioral treatment strategies, otherwise known as C BT that we use to treat youth with anxiety disorders and to identify medication options for treating anxiety in youth. So it's always important to start off with what is anxiety. Um Anxiety is often confused with fear and there are obviously a lot of overlap here. So fear is a response to immediate threat. So in this little image, we have, we have a saber toothed tiger about to attack this cave person. That person is experiencing fear because there's a real life or death danger. Anxiety is more future oriented. It's all about a what if or what could happen in the future? Apprehensive uneasiness or nervousness usually over an impending or anticipated ill. So it's different in that fear is the immediate threat and anxiety is this kind of nebulous future or what if or what could happen? Anxiety serves a very important purpose. It prepares us for threats. So if we know to expect danger, then we can prepare and we can run away, we can uh you know, do something to keep ourselves safe. Our goal is not to get rid of all anxiety that would not be possible and it's not even helpful because anxiety is adaptive and effective up to a point. So whenever we treat Children with anxiety, the goal isn't to get rid of anxiety, it's to be able to do whatever we need and want to do regardless of the level of anxiety. So I always want Children to understand anxiety is not bad and it's not even really good, it's just neutral and what we do about it is what's important. So everybody has anxiety as you all know, and there's a difference between typical anxiety and clinical anxiety. So the dictionary definition of anxiety is an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, doubt concerning the reality and nature of the threat and self doubt with the ability to cope with it. So as the perception of threat increases and our perception of our, our ability to cope decreases, then we get anxiety. So if something is a little bit threatening, but we feel like we have a good ability to cope with it. We don't experience the anxiety versus as that threat seems more and more intense and our ability to cope with it seems less intense than we experience the anxiety. So the perception is what's really important here and not necessarily what's accurate. Um as we know you taking a math test isn't going to kill you. Um But kids who are quite anxious about math tests and think that something catastrophic will happen. If they fail the test, they will experience anxiety because they're perceiving that to be a significant threat. Any time we're looking at psychiatric disorders, we're always considering two things when thinking about is this clinical? One is excessive amounts of distress. So, is the anxiety excessive and persisting beyond what's typical? Is it causing a lot of distress? And the second is functional impairment. So how is this anxiety getting in the way of life areas that kids need to do? So, school, friends activities, home, relationships, self-care, et cetera. So we have uh typically about five types of anxiety disorders that we see in youth. So the first one is generalized anxiety disorder or G AD or Gad and this is excessive, worry about things that most people worry about. But in a way where the worry feels out of control and is taking up a lot of time and energy. So in Children and adolescents, this might be worries about grades and tests, worries about something catastrophic happening, like school shootings, earthquakes, car crashes, worries about having enough time to do things or being late to things. Worries about finances in the family, even if the fam family is financially secure. The second type of anxiety disorder is separation anxiety. And so this is anxiety um being away from caregivers and is usually accompanied by worries that something bad will happen to the child or the caregiver while they're away And this of course, is important to consider what is developmentally appropriate. It is very developmentally appropriate for a three year old to be concerned about being away from a caregiver, but definitely not so much for a 10 year old. The next type is social anxiety disorder also called social phobia. So this is anxiety in any social situation and it really boils down to a fear of negative judgment from others. So this could be a fear of talking in class, meeting new kids, talking to adults, performing, eating in front of others, really with a fear that other people are noticing them and thinking badly about them. Then we have specific phobias. So you're all familiar with erect phobia and claustrophobia in Children and teens. We tend to see fears of needles and injections and blood. Uh specific things like bridges, vomiting is a really common one and animals and insects are also really common. Panic disorder is when people have panic attacks out of the blue. So a panic attack itself when it's clearly triggered isn't a clinical disorder. Um but panic disorder is when panic attacks are happening with no identifiable trigger. So here we can see some prevalence rates across different uh you know, areas of Children and adolescents. Um it looks like anxiety is increasing. And so here we have a study that looked at kids ages 6-17, ever having been diagnosed with an anxiety disorder increased from 5.5% in 2007 to 6.4%, only a few years later. And as we know, things with the pandemic took a big hit on anxiety. Um So we have significantly elevated anxiety symptoms um that almost doubled during the first couple years of the pandemic. So, anxiety really is getting worse across this population. There are some important disparities among different groups. So females are more likely to be diagnosed than males. Um And the rates across uh different race and, and ethnic minorities varies depending on the study, what it looks like is um you know, if you just look at the, at the raw data, it looks like girls are more likely than boys to have anxiety disorders and that white people might be more likely than other races to have anxiety disorders. This isn't accurate. This is um a problem with the way that we uh treat people and see people and collect data um because it looks like actually all things being equal in terms of if we were to take away adverse life experiences and poverty rates of anxiety disorders would actually be the same across populations. The difference is whether or not it's actually like diagnosed. So we know that many minority populations are correlated with less, less access to care, higher poverty rates. And these things are certainly going to be linked to being more likely to have anxiety disorders. So we have increased rates of anxiety and trauma in populations that have poverty, food insecurity and exposure to racism. Um but the problem is that it's not often diagnosed. So this is something that's very important for doctors to keep in mind that uh you know, white girls are going to be more likely to receive that diagnosis even though that diagnosis would be appropriate, appropriate across genders and races. Something else to note is that during uh in post pandemic, la Latinx and Asian individuals had greater increases in symptoms of anxiety and depression than white individuals while also being less likely to receive mental health care. So there's a big gap here, not just with diagnosis disparity, but of course, also access to care. Uh Minorities represent the fastest growing segment of the US population and also suffer from anxiety disorders. And we do not have health care providers or researchers from these groups in representative numbers. And so we want to be aware of that. Um and also aware that self report questionnaires, which is usually how a lot of primary care doctors catch anxiety. It could be different for different groups. These questionnaires have been researched and normed oftentimes using a majority white population. And so it's not necessarily catching anxiety in some of these different groups that's important to keep in mind. So, um in some Japanese and Korean communities, they experience social anxiety as fear of embarrassing others, which is different from the Western concept of it. And so a lot of these questionnaires might talk about, do you have a fear of embarrassing yourself? And they might say no to that, even though they have significant anxiety, there was also a study that showed that self report skills didn't adequately capture symptoms of anxiety in black respondents versus white respondents. And there of course, are differences in how different cultural communities experience and show anxiety. So there's an example of Cambodian refugees that experience a lot of um neck pain. And it turns out that that neck pain is actually based on an anxiety disorder. So they have this, this somatic experience of anxiety that might not be captured from this Western white normed self report questioner that being said. So take that into account and caveats and we do have some screening tools that we like to use. These are all free. So the scared is a great one for kids, ages eight and up. And there is a parent and child version important for both parents and Children to complete it. And then the gad seven um ages 11 up the preschool anxiety scale and then the L SAS is the leap of it. Social anxiety scale. OK. So why diagnose an anxiety disorder? Of course, with anything, the sooner we treat it the better. And so when we can have early intervention for kids and teens with anxiety, they're going to have better prognosis in the end. So we wanna start CBT and or medication as well to help these kids um have kind of a head start with battling some of these things and we can also intervene with schools. So having a 504 or IEP plan different accommodations in schools that could potentially be helpful, putting the kids on um a good trajectory. Most important in my opinion, is validation for youth and their parents anxiety can look different in different kids and different families. And so when someone is saying, hey, there's a reason for this and it's not your fault and we have treatment for it that can be really relieving and validating. So we're gonna jump into some cognitive behavioral therapy strategies. So here are the components of C BT. The first thing is psychoeducation. So we always want to be teaching kids and families, what is anxiety? Why do we have it? What is the cycle of anxiety that's making the anxiety more likely to continue? And the ineffective coping strategies continue even though they, they aren't helpful in the end. And then we give them some skills and tools, cognitive strategies, changing physiology. So learning how to identify when our fight flight, freeze response is triggered and what to do to help calm it down. And then behavioral strategies, our goal is to shrink the risk and then approach. So the most effective way that we can treat anxiety hands down is exposure therapy, which I will be talking about. Exposure therapy is facing fears in a systematic and planned way and of course, that can feel really scary. And so being able to use some cognitive strategies, some relaxation strategies to feel like the risk shrinks then face the fear that's gonna be really meaningful. Cognitive behavioral therapy is an evidence-based treatment for anxiety disorders in all ages. It's not a magic bullet like any treatment that we have. Um so average response rate for youth is 60% across the randomized clinical trials. 60% is pretty good. I think in my experience, it's even higher if uh the kids and teens are willing to do their homework. So any time we do cognitive behavioral therapy, we're always assigning homework. And so if the kids are doing the homework, we have a really good response rate. And so it's really kind of all about motivation and the buy in um between the child and the therapist. C BT is goal focused and skill based treatment, which means that we are looking at specific goals. So it's not just hey, come to therapy and our goal is to reduce anxiety, but it's something more specific. Like I would like to be able to raise my hand and answer questions in class or I would like to be able to go to a sleepover or I would like to be able to um go to the park when there's dogs running around and not feel like I need to hide and run away because I'm afraid of the dogs. CBT is time limited. So this really varies based on the child and the complexity of the anxiety and whether you're working on one or two or three different anxiety disorders. Um but typically, we might expect about 12-20 weekly sessions and we have both individual and group CBT. So the key components of treatment, there's two main areas that we're looking at here. Cognitive. So our thinking strategies in younger Children, we'd call this detective thinking and in teens, we'd call it cognitive restructuring. How can we take a look at our anxious thoughts which are inaccurate and not helpful and break them down into something that's more fact based and much more helpful. And then I mentioned before that behavioral strategies are exposure therapy, facing fears in a way that feels challenging but manageable. And the key to exposure therapy is really two things. One is distress, tolerance. How can I learn to manage my anxiety and feel uncomfortable and be ok. And the second thing is expectancy, violation, anxiety expects something terrible to happen. So can I face my fear? Have nothing terrible happen and have that be a learning experience that I can remember? Ok, I did this thing that seemed really scary and it was ok. And I was ok, It's also really important for parents to be heavily involved in treatment. Um of course, this might change for a six year old versus a 17 year old um but we want parents to be involved so that they can learn how to support the child and also how to pull back on accommodations. So we don't want parents to be rescuing or uh you know, putting things in place to make uh life easier and help the child avoid the anxiety. And so having parents involved is going to be really important. Ok, a short caveat anxiety comes from disorder interpretation. So what if thoughts or possible future worries, anxiety, clinical anxiety, the way that I think of it isn't about a real life problem. So let's say a child is really being bullied, of course, they're going to be anxious about going to school. So I like to think about the difference between stress versus anxiety. Stress is an anxiety response based on a real problem. Like a child being bullied. Anxiety is a what if response or future oriented worry? So what if kids don't like me? What if I'll be bullied or what if I won't know what to say? And it will be awkward if it's a stress response. Like a child's being bullied, we don't treat it the same way and instead we problem solve versus if it's this anxiety, like what if someone doesn't like me, but they're actually doing fine socially, then we use C BT. So CV T is made up of a triangle. So here are the three points of the triangle are our, our thinking, our cognition the perception of the threat and our perception of ability to cope the behavior, what we're actually doing and our physical experience. So let's take a look at some of the cycles of anxiety. So the cycle starts with an event. So in this case, so I'm just gonna move my toolbar so I can see my screen. But um in this case, the event might be answering or speaking in class. So then we move on to the interpret interpretation. This is the distorted thinking. What if I say something dumb, everyone will laugh at me and then physical sensations that accompany anxiety. So our heart starts to beat faster, we start to breathe more rapidly and more shallowly. We might get dizzy, we might get sweaty, we might feel nauseous. Then we experience the emotion of anxiety. There are two types of ineffective coping strategies that we use with anxiety. The main categories of these ineffective coping strategies are avoidance or escape or reassurance seeking. So these are two sides of the same coin in that they might temporarily work a little bit, but ultimately, they are only serving to reinforce the cycle of anxiety. So in the case of speaking in class, I might want to avoid participating, say nothing, maybe try to shrink down in my seat a little bit or I might do some reassurance seeking. I might um kind of rehearse in my head. What the possible answers might be or what would I say, um, I might check my answer many times to make sure that I have the right answer. So we might immediately feel some short term relief. So if I hide in my seat and the teacher doesn't call on me, I might feel ok. So I have, you know, dodged that bullet or if I check the answer many, many times and I rehearse it in my head and I get it right. Ok. No one's gonna think that I'm done. But what happens is that we're reinforcing the cycle, making the anxiety worse in the long term and reinforcing these action urges, reinforcing the avoidance, reinforcing the reassurance seeking. The problem here is that, that, that interpretation wasn't actually true. So if I had participated in whether or not I got the answer right or wrong, it probably would have been fine and kids in class probably wouldn't have laughed at me. And even in the small chance that they would have life would go on, I would be ok. So by avoiding or by seeking reassurance, ultimately, we're kind of accommodating the anxiety in a way that's making the anxiety more likely to happen again. Ok. Let's use one other example. Um Let's say I am the type of kid with uh G ad and I'm anxious about grades and I have a math test coming up, the interpretation might be, I'm going to fail. I'm so bad at math and then all of a sudden my heart starts beating fast. I have butterflies in my tummy. I am anxious. So I'm going to be having the urge either to avoid or to seek reassurance. So with avoidance, I might procrastinate or I might for the reassurance again, I over study, I might way overdo it. Maybe I could reasonably study for 30 minutes for this test. But instead I study for two hours with either of these action strategies, we have short term relief only to make anxiety worse in the long run, increase school problems, increase self esteem problems because I continue to um kind of let my anxiety rule my decision making strategies. So with cognitive strategies, we check the facts, we identify um what is the facts that support this thought? What are the facts that say this thought is untrue? And we learn that just because I'm having a thought does not mean that it is true. In fact, it is a hypothesis, right? Anxiety is saying this is the hypothesis of the scary thing that could happen. Let's check the facts, let's test it out and let's actually see what happens. So we have some different uh categories of, of labeling, you know, our worry brain or emotion mind, we identify when our anxiety brain is kicking in and then we use our fact checker or detective thinking to be able to say, well, hold on pause. Let me come up with a more reasonable fact based thought. Um So there are some different categories of thinking that, um, we teach the kids to be able to identify. So, just a couple of examples here, one would be all or nothing thinking. So, if I, you know, am working on my spelling test and I get two things wrong, do I think? Well, it's a disaster I have failed. Or can I see that maybe there's a middle path there? Another would be emotional reasoning. I have this really strong feeling that when I go on this airplane, it's gonna crash just because we have a feeling doesn't mean that anything bad's gonna happen. In terms of changing physiology. We wanna be teaching how to identify our fight flight, freeze response and to know this is a false alarm. I'm not actually in danger. This math test is not going to kill me and then how to activate our parasympathetic limbic system with our relaxation strategies. So belly breathing, there's actually a very cute Sesame Street video bubble breathing box breathing where we um inhale, hold, exhale, hold for four seconds or six counts or however, the kids want to do it. Um progressive muscle, relaxation, squeezing and releasing muscles. And at the, at the end of today, we'll talk about a few more ways to find resources about these things. Um ice diving, changing the temperature. So sucking on a piece of ice, holding ice in your hand. Uh if you live in San Francisco, stepping outside in the cold and fog um and getting active, doing some exercise. OK. So exposure is the most important way that we can fight anxiety. We wanna do opposite action. So our anxiety is telling us to avoid or to seek reassurance. We are going to do the opposite of those things. We're gonna do worry, workouts or, or building our muscles for our worry. And what we do is we develop a ladder or a hierarchy. And we ask kids to identify how hard would something be from a 0 to 10 scale. So if a kid has a fear of dogs, how hard would it be from 1 to 10 to watch a video of dogs or to go to a park and stand on the side while dogs are playing. And then we build this ladder based on what's easy all the way up to what's hard. And then we challenge kids by facing fears in a medium hard way. So I would say, OK, what if we do this thing that feels a four out of 10? What does your anxiety say will happen? Let's do it and be brave. And then afterwards, let's check in and see what actually happened. So here's an example of an exposure hierarchy for someone who is anxious about separating from their parents. So as an example, a medium hard one might be staying inside while parents are out in the yard or staying at home while dad and mom go out or staying home with dad while mom goes out. Ok. So this is really, really important but also can be very hard for parents to do. One thing. I want parent. I'm gonna skip ahead here because I uh I wanna make sure that we have time to cover everything. So I'm gonna hit the things I think are most important. We want to be thinking about what is shaping behaviors and what is reinforcing. So providing rewards when kids are doing something really good and this could be an actual reward, something tangible like a sticker from a sticker chart um or extra screen time or could just be praise. Praise is very shaping. Negative reinforcement is avoiding something stressful that ultimately decreases the anxiety, negative reinforcement is what the anxiety cycle is. When we decrease the anxiety by avoiding, we reinforce that avoidance. So we have to be very careful not to reinforce avoidance. Parents are important here. And so the idea is that kids need to experience anxiety and face fears in order to manage their anxiety more effectively. So parents also need to be able to handle their child's distress, which is hard. Kids need to build distress, tolerance. Parents need to build distress, tolerance of their kids' distress. So there's a free article in the Atlantic called How to Land Your kid in therapy. That is, that covers this concept. How can parents be able to tolerate, how to handle their kids discomfort, knowing that it's actually best for them to feel anxious and learn how to adapt. So we want a nice balance between being frustrated when we have anxiety versus overly accommodating and rescuing. We gonna be in the middle, being firm setting limits, pushing, facing fears while also being warm, encouraging and validating. Um So C BT is often the first recommended line of treatment and um we have some different ways to find therapists. Uh So we do have a group therapy that we're gonna be talking about at the end of today. Um that is available in our department. We have individual therapy. Of course, there's a very long wait list which is complicated. Um And there are some really excellent telehealth services that came about as a result of the pandemic. So, um that's, that's a nice silver lining of the pandemic and when therapy is not available or not sufficient, that's when we want to consider medication. Um So I am going to stop sharing and turn it over to my colleague, Dr Y. Thank you Alison. So I'm gonna take over the medication management piece today here. So when do we consider medication management? Um just as um Alison mentioned when a child or youth is already in therapy and they're not seeing much improvement despite adequate trial of therapy, we usually get referred like um this child might need a little bit more help. Um Not all patients actually are in therapy, they don't have the luxury to be in the therapy with the access issues. In those cases, we do have to screen for the severity of anxiety through screening tools or clinical interviews. And if it seems to be that um anxiety actually interferes with their ability to engage in daily life tasks or they can't even engage in the appropriate therapy exposures, that would be an indication to actually consider therapy as well. Um A lot of times these kids do actually have comorbid disorders such as depression. And if it's severe enough, we would have to think about treating with medication as well. So I'm gonna back up a little bit before we go into medication management and wanna give you the concept of chairs of treatment, um anxiety. Usually it, it is childhood onset, it's usually silent, quiet kids keep to themselves. So they're not as recognizable to the parents or teachers or schools initially. Um And it does prove for quite some time until it is um perceived as a problem or debilitating. Um as they reach their teenage years, some kids who have um just pervasive anxiety throughout their life will um have more accumulated disabilities. They will start having poor adaptation, poor coping strategies that have kind of really formed hard and it's gonna show up in their school life, they every day life with relationships with avoidant symptoms, starting to avoid school, um avoid certain activities and that can perpetuate into their adult life as well with holding a job dropping out of school um affects relationships as well. Sometimes these um further progress to maladaptive behaviors such as developing suicidal ideation or self-harm. Not all of self-harm is um with suicidal in intent. Um they can be from distress, tolerance from anxiety as well. And some of our kids, um teenage teenagers or young adults also engage in substance use as well. So when it reaches uh accumulated disability stage or maladaptive behaviors, we also have to address those psychosocial environments and specific um treatment modalities for addressing high risk behaviors. So I just wanted to make that point clear before we went into medication management strategies. So this is a big landmark study in child and adolescent psychiatry. It's called the CAM study. Um Child and adolescent anxiety multimodal study. This was an N I MH funded randomized control trial that enrolled um 488 participants ages between 7 to 17 with uh admission criteria with meeting the diagnosis criteria for general anxiety disorder or separation anxiety disorder or social anxiety disorder. They were randomized into four different treatment groups. Um One was a placebo group. The second group was a cognitive behavioral therapy only group receiving 14 sessions of C BT during a 12 week period. Um The third group was a medication only group um that received zole and the last group was a combination treatment group who received both medication and C BT. So the next slide we look at the cams remission status and the results. So here in this graph on the left, we can see the purple graph that has the biggest greatest response um at 12 weeks, that's the combination group followed by the red graph. That is the medication only group. And at the top, um we're seeing the green line, which is the C BT only group. As you can see, the combination group did far better than the placebo group. Of course, it was still superior to the medication only group and also, um did come out superior than the C BT only group. So in essence, at the 12 week short, um follow up trial period, um any therapy that a patient received was superior to placebo. Now, the authors and, and the child and adult and psychiatrists wondered what happens long term with these patients. So they did a follow up long term follow up studies from, from the initial cams. Um, they reenrolled about 319 youth from the initial cam study. And at that time point, this was held between 2011 to 2015. So the initial CAMS candidates, um about 5 to 10 years has had passed from their initial enrollment and their Ranged from about 10 years to 25 years of age. Um, the admission criteria was the same because we used the same group from the initial cam study and they were looking at specifically which participants were gonna be in remission with better outcomes and what are the predictors for remission? So, for the camel study results, um we're gonna look at the figure on the right hand side. First, this figure actually looks at each individual over a four year follow up period between 2011 to 2015. And how many of those actually remained in remission during those four years versus relapse versus were chronically ill, meaning that they were diagnosed or met the threshold for G S M five, Um diagnosis of the anxiety disorders that we were looking at. And it really depicted that about 22% of these participants were in stable remission between 2011-2015, the four years that they were followed up, About 30% remained chronically ill, meaning they met still met criteria for an anxiety disorder and about half 48% were relapsers during that time period. So that might indicate or just give you an idea of how pediatric anxiety is um does have a chronic pattern of illness and relapse. Um just more than 50% are gonna be in the relapse group or the chronically ill group. Now, on the left hand side, we'll look at um remission by their initial treatment assignment group and we followed up from 2011 to 2015 to see. OK, who was assigned to the C BT group in 22, 2002 to 2005. Did they do better? Did the monotherapy with um an S S R I group do better, did the combination group do better. But like, as you can see, the numbers don't really pop up, it didn't really differentiate. So the initial cams treatment modality didn't really seem to be a predictor for remission 10 years down the road. Um and they looked at other factors such as what are the positive predictors for someone to be in the remission group? And what really stood out was that regardless of which group they were assigned to at the initial cams trial. Um those who had early treatment response, whether they were on the CBT only group, the medication only group or combination group, those kids who had some kind of an early response were more likely to be in the remission group 10 years down the road. Um also being of male gender and not having a social anxiety diagnosis at entry point. Um also seem seem to be a positive predictor of staying in remission group and better family functioning and fewer negative life events seem to be a positive predictor for remission. Now, I'm going to review a 2018 meta analysis study that compared the antidepressant class uh treatment response in in treating pediatric anxiety disorders. So this study actually looked at a couple of S S R I S and a couple of S MRI s and the treatment response um when you're treating anxiety in the pediatric population, as you can see that the dark blue graph or purple graph is the S S R I curve and the green graph is the S MRI group. Um Both S S R I and S MRI s did have a positive response statistically by week two of treatment. That doesn't mean the patients noticed that there, there was clinical improvement, but there was a statistical improvement and both medication groups at week 12 had a clinically significant improvement that was noticeable. Um However, as you can see the purple graph, the S S R I class medication group does have uh a more bigger impact in terms of clinical improvement and earlier response, so to speak. Um If, if you follow the, the graph here at week 12 50% of the improvement you would have achieved by week 12 has happened by week four for the S S R I group versus um less than 50% of the response happens by week eight for the S MRI group. So you can see that the S S R I has a more greater magnitude of response and quicker response, so to speak. So this next study um for the 2022 study that I'm gonna review is looking at improvement trajectories and he treated with both um the S S R I and C BT combination treatment. Um The red graphs both depict the S S R I plus C BT combination treatment group. And the blue graphs are just a comparison graph for S S R I monotherapy. Um They also kind of delineated between Caucasian um study population and a non Caucasian study population. And it, it, as you can see for both um demographics, the combination group had robust outcomes for both anxiety and depression treatment. But uh the clinically significant uh benefit of adding C BT to S S R I didn't really show up until week 12 and they also looked at what are the factors for lower response and combination treatment. Um We're not looking, we're not talking about the S S R I monotherapy for that for the combination treatment. It turned out that the non Caucasian minority youth had lower response if they were of older age or they had um comorbid Externalizing disorders, these also affected a poor response. So I did want to point that out and this kind of brings up uh some, some points to think about. Why is that, that the minority youth didn't respond as well um to their counterparts of Caucasian white youth um with combination treatment, we might have to test out. Do we have to uh come up with more culturally tailored C BT strategies? Think about the alliance and family involvement. Because if we extrapolate from other studies such as O CD studies, they do find that um when you do involve closer family involvement, they do have robust response and therapy. And we have to think about the different cultural aspects within family dina dynamics that may be in, like in playing out these results. Ok. So this next slide looks at some of our antidepressant class medications for um, each diagnoses and which ones have FDA approvals actually in our youth. For O CD, we have quite a couple S S R I um class medications that have FDA approval. So the surge, the glute, the glutamine, they are pretty much approved for O CD treatment from age 67 and eight respectively. The Clini Perin is actually gonna be a T C A class medication, but I just listed it there too for comparison. Um for depression, our FLUoxetine is Aram or the two FDA approved medications um to treat for depression. But uh if you actually look at anxiety disorders, there is no S S R I that actually has an FDA approval. The DULoxetine is actually an S N R I category of medication that has approval. But as you can see from the previous studies that we did review, there is an that empirical evidence to support use of S S R I S and, and currently it is off label use strictly speaking if you buy the FDA approval status, but that is um what we use. And that would be our first line recommendation is to pick an S S R I to treat anxiety if vindicated. So some of the S S R I side effects, I'm gonna briefly review um I just kind of listed it in three tiers of what is the relatively more common and mild symptom ones that we encounter versus the less common ones and the rare ones. Um, I think the, the mild and relatively more common ones we hear about are the G I symptoms with nausea, abdominal pain, sometimes diarrhea, headaches, uh, sedation and low energy. Um, sometimes insomnia, too, less common ones would be like activation symptoms with disinhibition. Um, kids can kind of act out like drugs. Um, they'll lose their filter, they'll be really extremely agitated or irritable. Um just lashing out and having difficulty sleeping. Um Sometimes we have sexual dysfunction, dry mouth tremors and then the rare side effects. But the ones that are notable that we want to discuss with our families are going to be the black box warning with increased thoughts of suicide or self harm. Um And Serotonin syndrome is another one as well. So what do we do if we see, we don't see enough treatment response, we have to sit down and think about is the the patient ready for change? Are they actually engaged in treatment? Whether that is therapy or medication we wanna screen for medication adherence? What is actually happening? Um Did we do an adequate trial of medication, whether that be in terms of duration? Um Did we trade up to an adequate dose? Um Same with C BT. Did we do an adequate um length of treatment or do we need a, a booster session? Um Did the the family or the patient give up too soon? Too early? Um The third pillar of thinking should be, did we really support the tier two and tier three of treatments in terms of addressing coping skills, um maladaptive behaviors. Um If there are more high, higher acuity issues such as substance use or suicidality, are we addressing those behaviors? So specifically, and then if all of the above has, has been checked off and we're still like kind of puzzled, we're gonna have to come back to the drawing board and think about is our diagnosis correct? Um We might have to rethink, did we get the right diagnosis or are there other comorbidities that we are not addressing? So some key take home points. Um I think identifying anxiety is half the battle or 51%. And I really stress the importance of psychoeducation um setting expectations for what the treatment course will be. The trajectory prognosis is. I I do spend a lot of time just screening and doing a clinical interview of how the anxiety symptoms are really affecting their day to day lives. Um C BT is your first line choice for anxiety treatment in youth. And if medication is indicated, um S S R I S would be our first line choice as well. And don't forget about the comprehensive approach to make sure that we are supporting the psychosocial environment in any higher acuity need. So I am going to hand it back to Doctor Libby for resources. Great. So I have asked that these slides be made available to you because some of them are, I just want to cover these things that then you can then pass on to your, your families. Here are some uh books that I really like for kids and teens. So for Children, um what to do when you worry too much and, and when Harley has anxiety, they're very cute workbooks that are appropriate for ages, I would say 5-10. Um and then for the preteen and teenagers, the preteens might need a little bit of help from the, from the parents, but certainly from age 11 and up, I think that these books would be good. Um they're uh the anxiety survival guide and anxiety sucks. And both of these are some nice CBT workbooks, advanced plates. Great. Ok. Here are some books for, for the parents. Um In particular. My favorite is the Tamar Chay one in the middle. Um But the um Ronald Rapey one is also really good. That's the picture that we have up here. And we've actually adapted this book to become um a parent anxiety long form group that we have for 9 to 12 year olds. Ok. Thank you. All right. So let me highlight the groups for a moment. So these groups are, you can make referrals to these groups. I know part of the issue that we have is that we have such extensive waitlist and it's very hard to find therapists. We do currently have waitlist open for these groups, um that could change. But as of right now, they're open and we are accepting referrals from our, from our, our pediatricians and other doctors. So we have our worry warriors. It's for ages 9-12 and there's also a parent group that happens at the same time, that's based on that book that we just saw and it's for trans diagnostic anxiety. So any type of anxiety disorder in this, in this population, we've got our teen social anxiety group ages 13-18. Um and one thing to note for all of these, when there's, when it says 18, it the child must be in high school. So we don't accept um 18 year olds that are already graduated or in college. So we've got our teen social anxiety group, our gender expansive social anxiety group. And so this group is appropriate for transgender teens or uh you know, not like any kind of non binary, gender fluid uh teen with social anxiety. We have a unified protocol group um which is trans diagnostic anxiety and or depression. And so this group is great if somebody has G ad or G ad and depression or um a a few different kinds of anxiety disorders, and then we have our teen depression group as well. So all groups are currently in person um at the Pritzker building. So I listed a bunch of different websites here. And again, I, my intention was to have these be available to you so that you could kind of click through in your own time. Um But here are some um some helpful uh websites that give a bunch more information on um resources and uh and they have uh different ideas of where to find uh providers. Ok. So I'm not gonna be playing any of these videos. Um But I wanted to have a, a quick compilation of videos that you could look at on your own time or to send off to parents and kids when appropriate. Um I think some of the, the, you know, you, you have very limited time with these families and so being able to like include a smart phrase with a video in their aftercare summary sometimes is the best that we can do. Um So uh we have our own youtube channel for U CS F which a bunch with has some different things and there are some different links here for um relaxation exercises and different skills for, for what to do. And I've divided it between kids and teens and parents. Um And so act is acceptance and commitment therapy. And we call it a third way of C BT, which basically means it's kind of a, the in some people think of it as the C BT of the future, but it's just a different way that we can look at some of these skills. Um And there are some um some nice videos here. Uh And then I just wanted to highlight there's an Australian uh resource called the Center for Clinical Intervention. So just take note of how they spell centers since it's Australian. Um And they have some incredible free resources. So if you were to Google, you know, Center for clinical interventions, anxiety or depression or perfectionism or whatever it is, they have some really amazing free worksheets, uh information sheets and manuals. Awesome, great. Thank you both so much. Uh We have several questions uh speaking to the resources specifically. Uh Could you let us know what the in person resources are, for example, for groups in the East Bay area, for local patients? Very good question. Um I don't, I don't have a good answer for that. Um I think that a lot of the options are private pay. Uh And so for those looking for uh groups covered by insurance, I'm not actually very familiar with what's available um in the East Bay. Um So I know that's, that's difficult. So send them our way to Mission Bay if they're able to travel. And um there was a question about uh how did you know if, if you each have experience with this, how can you treat anxiety and or depression in a war zone specifically where you know, the safety of a child or a family cannot be assured or guaranteed. Yeah, that's such a tough one. So first of all, we would not be, expect someone to be able to just use traditional C BT if they're like currently in the middle of a safety situation. And so I would want a provider who is trauma informed to be able to work with that family where obviously they really are in danger and things really are very scary. And so, rather than using traditional, you know, cognitive restructuring of like, well, how is this thought? Not true. Instead, we'd focus more on, you know, building coping resources and behavioral strategies. So what activities can I do that help me to feel good? And how can I think in ways that um you know, I, I can't guarantee my safety, but maybe I could kind of shift my thinking to seeing both sides and looking at um look at all these people trying to help and look at all these people showing love. Um So it's, it is complicated and being able to kind of combine some of these C BT strategies with also some, some trauma work would be ideal. Thank you. And uh doctor E and did you want to answer the question at the bottom about um uh the insurance options for the open groups? Um The Oakland groups currently, I think we have really limited capacity with our psychology department. Um But we do take Medic or Medicaid um with the U CS F Mission Bay Side, I believe currently we're only taking commercial insurances. Thank you. Uh Doctor Spi had a question about, you know, how do we, what are some strategies you advise for how to fit all of this in, in our 15 to 20 minute short appointments in primary care, especially given um mental health provider crisis. And what are some strategies there? I, I think that's a really tough one. I would just break it down in terms of um using the time you have to get a really good history and, and I usually spend time on psycho education a lot to make sure that the family understands where, where things are and get the validation and see their openness and readiness for change before I jump To medication treatment if that's where I'm going with this. But also at the same time for, for CBT or therapy, I, I believe that that's probably the same. We need the buy in from the patient and the parent. So psycho education is key and sometimes that takes months and broken down into 15 minute appointments that that might take longer. But I think psychoeducation is really key. I definitely agree with that and having like one or two things that I can send home with the family is really helpful. So not to overwhelm them. But if there's like a particular video that I like or like a one or two page information sheet that's online. Then I can at least say like here, you know, here's the information that I have and let's keep talking about it, but here's something to take home and review so that you can process it on your own time. Thank you. Could you speak to the use of the P HQ four uh combined depression anxiety tool in teenagers and, and what your experience has been with that, we don't personally use the P HQ four. We have, you know, usually when they're coming to us, they already have been kind of screened uh to the point where they're, we're pretty confident that there's something else going on. I think the tricky thing with any of these questionnaires is that you're looking for something that's really brief that you can just like get the, get the answers, get the scores right away, but also something that's gonna capture a lot. So I think with the P HQ four, it, it's gonna capture some of it, right? But it's not, it's nothing specific. And so it might give you a jumping off point. Yeah, I agree. Um I think we miss a lot if we just do a screening sometimes even because of our, just depending on the age group, some of these anxiety symptoms are not always generalized, they might be specific obvious or social anxiety. So I do recommend if there is a higher suspicion, I would um send out an extra scared screener or do a more in depth clinical interview. Thank you. We do have a few questions that just came up about medication management specifically um with comorbidities and the current difficulty with accessing at, at all. What prescription is recommended for patients with anxiety and a DH D. So when we start getting into the comorbidity diagnosis, I think it's really gonna be important to understand what we're dealing with and what is the primary symptom. And I usually tackle one at a time. If we're doing, we're treating more than once. Um That being said, it's gonna be really important to see what's the most impairing. And also I try to assess what the patient and family perceives as most impairing and kind of compare, compare my clinical impression of it. Um That I think there's specific questions that come up when we're doing primary care consults about a amoxin or stria, there's just mixed evidence and not great evidence to support that, that treats anxiety any better than the S S R I class medication. So, um I'm giving you a very specific example here, but if I feel like they legitimately have pretty bad A DH D and anxiety, whether that anxiety is secondary to a DH D symptoms or separate, um I would probably address them with an S S R I and A A stimulant category medication if need be if that is indicated, not always. Um But that's how I think about it or approach it. And there was a question about, you know, which S S R I is recommended first, you know, morning time bedtime recommendation. Um If the patient has no access to C B TT based on insurance or lack of access, um it sounds like we would go straight to an S S R I and try that first based on the evidence. Is that right? So that's the gist of it. We always recommend therapy first sign because that's really going to equip them with the skill set and the tools going forward, medication is not going to fix that problem. Um but that being said, if the anxiety is severe enough meeting the threshold for medication treatment, I guess I wouldn't wait until they find a therapist which may be 6 to 12 months out. Um So medication monotherapy can be a reasonable choice and S S R I S would be first line. Now, which S S R I, are you going to choose first is a bigger question, I think. Um like we kind of reviewed a lot of the literature suggests cline. Um We're extrapolating from a lot of data from the O CD studies that is, it is safe enough as young as age six and up. So that is one of the most common ones. We use PROzac two as you can see is approved for age eight and up for depression. So it's safe to use. We just have to think about the side effect profiles of activation that may be a little bit more prominent in the preteen age group of youth and especially with kids who have underlying anxiety. So I do take that into consideration also for a certain, um, like the half life of medications are different for versus um si S Iram versus the FLUoxetine. So, if I have concerns for teen medication deterrence, they're like forgetful or they're not really taking it consistently. I might choose the FLUoxetine which has a longer half life of about a week um over the search lane, which would be a shorter half life of a day or two. So those are things that you have to kind of weigh the pros and cons about and what the family sometimes feel com feels comfortable with because um a family member specifically had a bad experience or a good experience, but for one or the other, thank you. Um Considering the general trend in medicine and overtreatment um broadly, you know, have you seen this being a problem in this um in this area specifically and what's being done about that if at all? Um I want to say that I, I feel most primary care providers are a little bit more conservative um about S S R I management and prescriptions um than the stimulants per se. But that being said, I would really consider like just assessing for how impairing is this for they use in their day, day to day life. Um I'm talking about thresholds of it, impairing their social life, school life, family relationships, they're really actively avoiding things that they are developmentally expected to be engaging in. And um even then we would recommend looking for therapy first, but if it's really impairing medication would be helpful. So I'd, I'd really use your judgment, clinical judgment and threshold for like severe anxiety. Do you think the kind of conservative, conservative um management with kind of holding back on S S R I S at times in the younger age groups is due to the warning about suicidality. Do you, do you feel like that's the main driver? And there's another question if, if you've seen that um play out the increased suicidal behavior. So that's a, a excellent question. Um I think it's just more my understanding of it is most non psychiatrists don't feel comfortable prescribing for younger age groups, especially with an SSRI. Um the suicidal behavior in kids. I mean, there's definitely a black box warning for all um antidepressant class medication in um youth under the age of 24. So that's kind of across the board. It's a legal issue. So we do recommend you discuss this with your families. However, uh there's a 2020 recent study that came out looking at um antidepressant class medication, treatment related suicidality or treatment, emergent suicidality. And what that that kind of showed is when you're treating for anxiety disorders. It didn't really come out as having a statistically significant um correlation to um si or suicidal behavior when you're strictly um treating for anxiety diagnoses. But that being said, a lot of our youth who have an anxiety disorder may have morbid depression. So you wanna be careful about that piece. Thank you all so much that brings us to 9:00. That was all we had time for and we had a comment in the chat that that was excellent comprehensive and very specific. So, thank you again so much and uh we'll look forward to seeing you all back next week.