We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Hi. Nice to be here. My name is Dave Coghill. I'm the financial markets foundation chair of Developmental Mental Health at the University of Melbourne. And I'm here to talk part of our presentation to you, a guide to childhood anxiety. Evidence-based approaches. And my colleague Sydney Stevens, I think, has already talked through the development process of our clinical guideline. I'm going to talk about the clinical aspects and the guideline, as you know, evidence-based clinical practise guideline for anxiety in children and young people, developed by our colleagues at the Melbourne Children's Campus and reduced in-- released in 2024. I'm going to base my talk on the patient journey as designed and depicted within the evidence-based guideline. Starting with identification, assessment, and care planning, and then moving on to treatment and monitoring. But before I start, I just want to think about a couple of principles. Actually, I'll start with the second one here, that all of the information that I'm going to present to you is informed directly by the evidence-based clinical practise guideline. What we've done is we've included specific recommendation numbers. So if you watch this talk and also have a copy of the guideline, then the recommendation numbers are in brackets. So you can see up above, it says 1.1. That means recommendation 1.1 from the guideline. This presentation and the document that I'm presenting from is not intended to be used as sole guidance for decision making. You need to really bolster this by including the information from the guideline about clinical context, the implementation notes, the evidence reports, and for that, consult the full document. One of the things that we felt was really important when we started this process was that the guideline is really designed to take you on a patient journey, but actually we want to really emphasise that it's important that steps are taken to ensure that pathways are available within a broad range of settings. We're really here talking about health settings, but also these pathways need to be available for people in their communities, in schools, as well as within clinical settings for young people and their families. And also, just to mention that in this context, family is used to refer to the family unit, and that includes caregivers, but also support people and those who do not have a caring, direct caring relationship with the child, such as siblings. So we will use families as a shortcut. But actually, we're thinking about the broader context of caregiving and living circumstances. When is it appropriate to think about anxiety in a child or young person who's sitting before you within a clinical setting? Well, obviously, if there are any signs or symptoms presented to you or worries that include anxiety as part of the presentation, then, of course, you're going to be thinking about the need to explore that further. But I think we would go further than that. And indeed, the guideline recommendations, you'll see there, 1.2 and 1.3, specifically suggest that when high risk factors or high risk conditions are present, things like neurodevelopmental disorders, chronic medical conditions, school or social difficulties, a history of trauma or other mental health conditions, then you should be asking the question, does anxiety contribute, is anxiety contributing to the clinical presentation that I see before me? As we'll see later, we shouldn't reduce that to, is it anxiety? Yes or no? I think a much more appropriate question is, does or is anxiety contributing to the clinical presentation that I see? And we recommend that when any of these high risk factors or conditions are present, then you at least screen for anxiety. Our recommendation for screening is to use the questionnaire-- the questionnaire tool, the SCARED, the Screen for Child Anxiety Related Disorders. There are actually many other screening tools available, and you can find a list of those in the guideline. The reason we went for the Scared was one, it had good evidence of robust screening properties with a reasonable sensitivity and specificity. But more than that, it was available as a parent and child report, with the parent report being applicable from age 3 up to 18, and the child or young person report from 8 to 18. The SCARED includes its own outcome scores and gives guidance about what these scores mean in terms of the risk of there being an anxiety disorder present. And so it's really easy to administer, score, and interpret. Our recommendation is that if you're seeing a child between the ages of 3 and 7, then parent report will suffice. But if you're seeing a child from 8 to 18 years, child or young person from 8 to 18 years, then you ought to get both the parent and the child report. And this is because there are often differences between parents and children in their both awareness and therefore reporting of anxiety. Most commonly, we would say, that children and young people are better at understanding and recognising their own anxiety. Doesn't mean they're the only people that do, but they are considered to be better at recognising these. So including them from as young as possible, using the screeners would be appropriate. Of course, children younger than 8 can talk about their anxiety and can recognise their anxiety, but we don't have reliable screening tools, if that's what we're using, from below the age of-- the age of eight. So once you've done the screening, then if the screen is positive, we move on to assessment. One of the questions that the guidelines address, and that's often asked is, who should be able, who should be allowed to conduct an assessment for anxiety? Well, I think there are some general rules there. It should be someone who is appropriately registered with an agency, such as AHPRA. It should be someone who has adequate training in diagnostic assessment using the DSM or ICD criteria. It should be someone who's experienced in conducting clinical interviews, as well as administering and interpreting standardised rating scales, and also someone who is experienced in assessing functional impairment. As with all mental health conditions, the symptoms of anxiety on their own are not enough to make a diagnosis. Those symptoms need to be impairing. And so it's important that the clinician making the assessment is experienced, and can, and does include functional impairment. The guideline also recommends that the clinician is experienced in the identification, not just of anxiety, but of other associated conditions or disorder that will require investigation, intervention, and support. But having experienced in anxiety itself is important, or to have good quality supervision with a clinician experienced in that field. And lastly, but no less important, is good quality experience and training in child and adolescent development. When you're doing the assessment, the guidelines are very clear that rating scales on their own are not sufficient to make a diagnosis of anxiety. You can use rating scales as part of the assessment, but you also need to do a clinical assessment that includes an interview with the child or young person and with the parent, and that you use that interview to assess if signs and symptoms of anxiety are present. You need to be able to judge whether these are appropriate or inappropriate according to age and developmental stage, and also that they formally meet the diagnostic criteria in DSM-5 or ICD-11. Once you've done your assessment, you will make a judgement about whether the young person, child, or young person does or do not-- does not meet the diagnostic criteria for anxiety. It's important that if they don't, you then go on to ask the question, are there any other mental or physical conditions that are causing the distress, the presenting symptoms, or complaints? And if there are, what are they, and how should they be managed? It's not, I don't think, sufficient, adequate, or appropriate if you don't meet the condition-- the diagnostic criteria for anxiety just to say, no anxiety. Bye, bye. You need to think about why someone has presented. But likewise, if someone does meet criteria for an anxiety disorder, then it's still important to screen for other medical, neurodevelopmental, and mental health conditions that commonly co-occur with anxiety. And there are a wide range of medical, neurodevelopmental, and mental health conditions that should be considered. Anxiety is often comorbid. It often presents with other problems, and understanding those other problems can sometimes be really key to how you manage the anxiety because it may well be appropriate, for example, to treat a neurodevelopmental condition like ADHD first, and then to reassess the anxiety. Similarly, if there are medical causes for the anxiety, we need to make sure that those are being adequately recognised and treated. When you've made a diagnosis of an anxiety disorder, you've also considered the other coexisting problems that may be there physical and mental health, it's time to start care planning. And care planning is a really important part of the process that is often rushed. Often, people will say, I didn't have time. At the end of the session, everyone was tired. We didn't have time. I needed to get on and do the treatment. I think if that's the situation you find yourself in, then think about whether it would be appropriate to say, we've made that diagnosis. We now need to do some treatment planning, but maybe we need to come back for another appointment. Because the treatment planning is really important for people buying in to the treatment process. The guidelines suggest that you cover things like family, not just family, but family child and young person attitudes towards mental health in general and towards its management. The likelihood of the child and the family adhering to the treatment plan, what other kinds of mental health support is there for the family, and then thinking about the options for an evidence-based, multimodal treatment and support for the anxiety. What do we mean by evidence-based? Well, that's what's included in this guideline. And you'll see what we think the evidence-based recommendations are. What do we mean by multimodal treatment and support? Well, as you'll see for anxiety, this should include at least a combination of high quality, in-depth psychoeducation alongside a psychological therapy like CBT with possible addition of medication. Now, language is important when you read an evidence-based guideline. There are two key words, should and could. Should means-- should is actually quite a strong recommendation within an evidence-based guideline, suggesting that unless there is a good reason not to, this is what you should be offering. One of the drivers for me for suggesting that we develop this guideline, was an observation that many children and young people in Australia, who had a diagnosis of anxiety, had never been offered good quality psychoeducation or psychological therapy, and had been started straight away on medication. I thought, and the guideline development process proved, that was a correct thought, that that wasn't the evidence-based approach. The evidence-based approach is that combination of psychoeducation and psychological therapy. And so that's something I think that's been very important for us in developing this guideline, is looking at the evidence to see whether that's right, and that is what we came up with. So the word here should include, is a strong wording, the possible is a could, and we'll think about when medication might be appropriate as we go on. I said it, psychoeducation really important. It forms the base on which all other treatments are built. It provides support through education for the child and young and family about anxiety, as well as other relevant mental health conditions, about the factors that cause, maintain, and improve anxiety, about the various treatment options, their purpose, and how they should be ordered, about the impacts of anxiety on the child and on the family. And this is something that everybody who makes a diagnosis of anxiety should be able to contribute to. In order to do good quality psychoeducation, you obviously need to have read in some depth. And we hope that the guideline can provide some of that information to support you in delivering psychoeducation, but also it will be important to look at broader-based education about anxiety, its causes, and the way in which we can-- we can reduce anxiety. All of these sections that we've gone through up until now could be delivered by a general or more general clinician, who's had some experience and training in anxiety. Obviously, as I said, the psychoeducation needs to be done well and needs a good base of information. When we get further down the treatment pathway, we're thinking about treatments that should be delivered or would be delivered by people with more specialist mental health skills. And so after this point, if you're thinking about further treatment for anxiety, and we think that you should, then consider referral to a mental health service or paediatric pathway for treatment for anxiety. If we move on to the treatment and management side, again, just really want to highlight. I know I'm over-- not overemphasising it, but I know I'm really banging on about this, psychoeducation should continue throughout the treatment and management process. It's something, again, that is not done well in general. Often, I see people who have been referred because of treatment resistance. And you often would assume they've seen several clinicians that their knowledge and understanding about anxiety and its treatments would be good, but that's often not the case. So psychoeducation key, not just at the beginning, but all the way through treatment and management. So we've said, psychological therapies should be the first specialist intervention for anxiety. When you're thinking about a psychological therapy, you need to be able to consider the individual needs of the child, including their age or developmental capacity, their ability to participate in therapy, and their desire to engage with a therapist, the availability of therapies and modalities, the caregivers who may inadvertently be maintaining anxiety. We know that part of treating anxiety is exposure. Good quality CBT will include exposure to the anxiety-provoking situations and thoughts, not necessarily as flooding, can be very gradual, but a lot of caregivers inadvertently and well-meaningly will avoid and help the child or young person avoid the anxiety-provoking situations and therefore be inadvertently maintaining the anxiety. That's something that will come up in your psychoeducation. And of course, there are also a wide range of environmental factors that contribute to anxiety. And these are important to think about and think about, how can we remove those from the path of someone with anxiety or how can we help the child or young person master the environment, master the situation that's contributing to their anxiety? Again, another part of exposure. I just want to jump up to the availability of therapies and modalities. This is something that has changed quite a lot over recent years. One of the things, and particularly post COVID, that we have access to is not just the traditional face to face CBT, psychological therapies, but also evidence-informed, internet-based CBT programmes. Things like the University of Queensland's Brave programme, both for the prevention and treatment of anxiety in young people, and Macquarie University's Cool Kids anxiety programme, aimed at teaching children and young people and their parents how to better manage a child or young person's anxiety. And these internet-based online therapies actually are. Australian government has been very helpful here in making them available, but they are widely available now in the community. And it's something that can be an alternative to face to face treatment, where it's appropriate or as an adjunct to working face to face. So I think that old adage of I couldn't give, I had to start medication because there's no psychologist available in my area, is one that's much harder to justify now because we do have these much more open access to online therapies. And the other bit that I wanted to emphasise here is that one of our real jobs in setting up for therapy, and part of that psychoeducation is to help people get to a position, where they're willing to and even to engage with a therapist and participate in therapy. This is something that we have a lot of control over. And it's something that you need confidence to do, but something that can be really important for many anxious people who are anxious about therapy, they may have had challenging experiences in the past. And so working with them to improve that relationship is going to be hugely important. When you come to choose the appropriate therapy, then cognitive behavioural therapy, CBT would usually be offered as the first choice and should be delivered using an evidence-based programme. There are many modalities of CBT but can be offered. I've already mentioned online. There are a range of different group-based, individual-based, parent and child, parent only, child only, packages of-- evidence-based packages for CBT. The one thing that unites all of those evidence-based programmes for CBT is that they include exposure. And this is actually something that we hadn't really picked up on the full importance of when we published the guideline. And certainly, when the guideline is updated, it will become more visible within the guideline that CBT programmes should include an element of exposure. As I said, that doesn't need to be flooding. It can be a gradated exposure, but it should be-- it should be there. Traditional CBT is face to face, and it's a talking therapy. There are times and there are packages or evidence-informed packages of play-based approaches that use CBT concepts. So I'm not talking here about psychodynamic play therapy. I'm talking about play-based approaches to CBT. And many of them will have a big B, a big behavioural part and maybe a smaller C, cognitive part. And these could be considered for younger children, eight years or younger, or for those who are struggling to engage in a more formal CBT approach. For example, those with neurodiversity, ADHD, autism, or those with intellectual disability. And so play-based approaches are something that one could very much consider there. The other therapy with an evidence-informed therapy would be acceptance and commitment therapy. And the guideline recommends that this could be considered. That could is not as strong as the CBT, but could be considered for those who are 12 years or older, or specifically those living with a chronic health condition, where act has been demonstrated to be particularly helpful. Now, we come to when we would consider medication. So the guidelines recommendation is that medication could be considered for use in conjunction with psychological therapy. So we're not talking about medication on its own in the ideal situation. Medication as an adjunct to psychological therapy. In situations where the anxiety is too severe to allow the child to engage at first in a psychological therapy, where the anxiety has led to significantly reduced participation in their community, and that includes the family, the school, social networks, and social events and sports. Where the anxiety is associated with a moderate or greater risk of deliberate self-harm or suicide attempts, and where the anxiety is affecting the being not just of the young person who's living with it, but also of a family member. And these were considerations. And also, psychological therapy has not been as effective as one hopes. One could then think about adding in medication. Before you're-- if you're considering a medication, before initiating, it's important to assess the history of medication, the history of other comorbid existing-- comorbid conditions, and also to discuss potential adverse effects. Some of the adverse effects obviously include things like nausea, diarrhoea, insomnia, daytime tiredness, headaches, restlessness, and dizziness. And so it's really important to think about those and to discuss those with people before they start. It's also important to have some caution when you're thinking about prescribing an SSRI or a medication to a child or young person because they are more prone to activation syndrome, where the medication will actually, as an adverse effect, have an activating rather than an anxiogenic effect. After you've done this and discussed this, then you should be getting informed consent. It's important to remember that the medications that we're using for anxiety are essentially being used off label. Working with children and young people, we're used to working with off label medications, but it is important to make sure that we get good quality, informed consent. And that means you need to have discussed these other issues. When you choose a medication, a selective serotonin reuptake inhibitor would be the first choice. These include fluoxetine, paroxetine, sertraline, citalopram, escitalopram, and fluvoxamine. There is no strong evidence to rank one as more effective in anxiety in children and young people than the other. Most people, though, to reduce the risk of sudden withdrawal-related adverse effect, would think about SSRIs with the longer half life. And for that reason, fluoxetine, which has the greatest evidence, would usually be people's number one choice. Once you've chosen your medication, it's important to think about what dose to start with. We need to use an age-appropriate dose. We should start low and go slow, then titrate the dose gradually. When you're thinking about an appropriate starting dose, then we have some recommendations in the guideline. Fluoxetine, 5 to 10 milligrammes. Sertraline, 12 to 25 miligrams. Escitalopram, 5 milligrammes. Fluvoxamine, 12.25. milligrammes. You would continue at that dose, probably for at least the first month, maybe for the first two months. And then depending on response, titrate the dose upwards, measuring both the effects and the adverse effects. Most people would aim for an effective dose that is well tolerated. If you're not getting an effective dose at the dose that's not tolerated well, then it may well be worth thinking about switching to another medication. And if you are going to change medication, the first change would almost always be to one of the other SSRIs. Good evidence for the fact that if you don't respond to one SSRI, there is a good chance that you will respond to the other. If SSRIs and more than one SSRIs are not tolerated, there's an inadequate response or there are any safety issues, then you can consider a specific noradrenaline reuptake inhibitor, like duloxetine, venlafaxine, or desvenlafaxine. However, the SNRIs come with some warning. Duloxetine may be associated with hepatic failure compared with the other SNRIs. Venlafaxine is also associated with an increase in suicidal thinking, and there really is inadequate safety data for desvenlafaxine in the child and young person population. One of the other things to think about with these medications and thinking about doses is that the pharmacokinetics of medication education in children and young people differ from those in adult. Liver enzymes, which are the enzymes that metabolise many of the antidepressant, the SSRI, and SNRI medications, liver enzymes peak during childhood, which typically means that children have a higher clearance rate than adults. This typically reduces in adolescence. But as some medications efficacy and side effects are actually attributed to their active metabolites, the higher rates of metabolism can result in increased effects and adverse effects. So it's actually a very complicated thing to be thinking about age and dose. And that's why we really should be thinking about start low, go slow, and titrate gradually. If it comes time to discontinue a medication, either because of an inadequate response or because someone's anxiety has been treated and has stayed, well, I would suggest you don't try reducing or discontinuing an effective medication for at least 12 months. I tend to go for two years as long as there aren't any negative effects. But if you are discontinuing medication, then the SSRIs are known to have discontinuation symptoms. And to minimise that, one, we tend to use those with a longer half life. But even for those, and certainly for those with shorter half life, these should be gradually reduced over a period of weeks and then discontinued. Once you've got an adequate response, then it's important not to just step away and say, there, we're finished. Actually, during that build up to good response, but also during that period of hopefully remission, it's important to have regular and frequent follow up monitoring visits, where you monitor both symptoms and adverse effects. And this should happen at all points of care at all stages. We recommend a measurement-based care approach, where you use a good quality, reliable outcome measure. Our suggestion would be the ACAS, which is a measure for anxiety and depression in children and young people. Use the ACAS to measure symptoms, ask about adverse effects, and adjust your treatment according to the outcomes. If you need to increase the dose, not just a medication but of your psychological therapies, it will become clear if you measure the response. It's something actually that within mental health is not done well, but has been shown to be very effective. None of us are as good as we think we are at judging two things actually. One, how well people are, but also whether they've actually slipped back somewhat in treatment. So measurement-based care, monitoring and adjusting on a regular basis is really important. I just want to go back and just qualify some of the recommendations that I've been giving to you. These are based, as I said, directly on the recommendations in the guideline. But they, themselves, the recommendation themselves, are not just pulled out of the air by the guidelines group. Each of those recommendations was informed by a systematic review. This is just telling us the systematic review, as you'll see in the middle there, for medication treatments. So they searched the databases. Just nearly 8,000 references found. 1,100 duplicates. They screened the title and abstract of almost $7,000, looked at the full text of 42, and included 14 RCTs and nine systematic reviews. And of those, three of the systematic reviews that included 13 RCTs and one additional RCT were considered to be of a high enough quality to be able to inform the review. Now, you can already see just from those numbers, this was a really big piece of work. It was a big piece of work that was carried out for each of the different steps. And so for example, this is the data. You can't read it, but it's just really to show that it's there, not just the studies that were included, the map of the studies included, the characteristics and risk of bias of the included studies, and then the grade table that looks at the quality of the evidence. So developing this guideline was a huge piece of work. That's me finish. I hope that that's been helpful to you. This is the QR code for the research resources. I think Sidney showed you that we have the actual guide. It's available free. We have the flowchart from the guide. We have the lived experience resources and the-- a range of different resources for you to look at. So I hope you enjoyed that. I hope it was helpful. And thank you very much for your attention. [AUDIO LOGO]