Professor David Coghill Hi everyone, my  name’s Dave Coghill. I’m the Financial   Markets Foundation Chair of Developmental  Mental Health, at the University of Melbourne.   It’s my please to talk to you about  some of the clinical aspects of our new   "Evidence-based Clinical Practice Guideline  for Anxiety in Children and Young People.”   I’m going to base my talk on, really,  what I think of as the patient journey,   which will take us through identification,  assessment, care planning and then the delivery of   treatment and monitoring. And I’m going to break  this down as shown in this flowchart, actually. Just to get us started, though, I think one  of the really important things for us when we   were developing the guideline was thinking about  how it’s taken in context. And so, it’s really   important, anxiety is a very common presentation  in children and young people, and actually, many   of them are not picked up within clinical settings  nowadays, and they’re not picked up by Clinicians,   but also not picked up in the community. And so,  we think it’s really important that steps are   taken to ensure that the clinical pathways that  we talk about are available within communities,   within schools, as well as in clinical settings,  for young people and for their families,   so that we can recognise and raise concerns  about anxiety in children and young people. And just to note here that for the rest  of the talk I will talk about 'families',   but in this context, I’m thinking of families as  the family unit, and that can include caregivers,   support persons and those who do not have a  caring relationship within – with the child,   such as siblings, so taking an inclusive look  at what family is. It’s also important for   me to say that all information that I’m going  to present to you is informed directly by the   “Evidence-based Clinical Practice Guideline  for Anxiety in Children and Young People”,   published in 2024. We’ve included throughout  the talk specific recommendation numbers. You   can see one up above on that first paragraph,  1.1. That actually is referring to a specific   recommendation made within the guideline.  This talk, and the document that I’m going to   use to illustrate it is not intended to be  used as sole guidance for decision-making,   and so for more information, clinical context,  implementation notes, evidence reports,   etc., please consult the full  guideline, the full document. But let’s get started on that journey, and the  first thing that we consider is screening for   anxiety in children and young people. And the  guideline recommends, I think with good reason,   that we particularly look for anxiety,  not just in those with signs of anxiety,   who may be presenting with symptoms, but also, in  all of those who present with high risk factors   and conditions. Things like neurodevelopmental  disorders, other chronic medical conditions,   school or social difficulties, a history of  trauma, or other mental health conditions.   When you see a child or a young person with  one of these problems, then it’s important   to think about, could anxiety be playing a  part in the clinical presentation that I’m   seeing before me? It’s not just about, is it  anxiety or isn't it? It’s whether anxiety is   part of the picture and therefore, needs to be  part of the treatment, part of the solution. If you're going to screen, then the  best approaches that we have are with   questionnaires. We’ve actually  suggested using the SCARED,   which is short – the short title for the  Screen for Child Anxiety-Related Disorders.   We chose the SCARED because it’s available both  as a parent report from three years and older,   and from a parent and child, or a youth report,  from eight to 18 years. There are several others   that give just parent report or just child  and youth report, but we felt this was the   best balanced combination. So, if you're using  the SCARED, which comes with its own metrics,   with its own scoring and with guidance on how  to interpret that scoring, we would suggest if   you're seeing someone, or thinking about someone  between three and seven years, you just use the   parent report, but from eight years onward,  you use both the parent and the child report. Once you’ve screened, if someone screens positive  on the screener, then should think about moving   towards an assessment. What’s important about  assessment is that in order to do a clinical   assessment, you need to do an interview. You need  to do an interview with the child and the parent   together, not just using rating scales. I see many  people referred to me who’ve had what’s called   an “assessment for anxiety.” What that really  means is they’ve had a screening tool applied,   they’ve had a rating scale delivered. And so,  if there are signs and symptoms of anxiety,   you need to then be able to address,  are they appropriate, age-appropriate,   according to age and developmental  stage, or not? And do they meet the   diagnostic criteria? And we suggest using formal  diagnostic criteria, either DSM-5 or ICD-11. I often get asked the question, “Who  can conduct a diagnostic assessment?”   And the Guideline Development Group  thought carefully about this. They   decided that it should be someone who  was appropriately registered, such as,   with Ahpra, who was adequately trained  and so had experience and training in   diagnostic assessment using the DSM or ICD. Who’s  experienced in conducting clinical interviews,   administering and interpreting standardised  rating scale and assessing functional impairment.   Also, should be experienced in the identification  of any associated conditions or disorders that   may require – and you’ll see why I  emphasise this as we go on. Also,   who’s got access to supervision with  a Clinician experienced in the field,   if they’re not experienced in the assessment  themselves, and who’s understanding,   experienced and trained in child and adolescent  development. So, it’s not really about who the   professional is, more about whether they’ve  actually had the experience and training. If, when you’ve done your assessment,  someone – well, you’ll identify whether   someone does or doesn’t meet criteria for an  anxiety disorder. For those situations where   you’ve assessed someone and decided they do not  meet the criteria for an anxiety disorder, then   it’s really important to consider other mental  or physical causes for their presentation. Again,   it’s not appropriate just to say, “No anxiety, we  will discharge you, we’ll finish there.” They’ve   presented for a particular reason, and if it’s  not anxiety, then it may well be other mental or   physical causes. And in a similar vein, even if  someone meets criteria for an anxiety disorder,   it’s still important to screen for  other medical, neurodevelopmental   and mental health conditions, because these  can commonly co-occur with anxiety [pause]. Once you’ve made the diagnosis for those  who have anxiety – excuse me, it’s beginning   to – it’s important to then think about your care  planning. You begin the care planning by entering   into a discussion about that child’s mental  health needs, not just their anxiety needs,   but their broader mental health and  physical health needs and treatments.   It’s important to assess the family’s attitudes  towards mental health and towards the management   of mental health problems. It’s important  to explore that with them, and, also, have a   discussion, reflect your experience and knowledge  about effective mental health management and their   own particular feeling. Thinking also about the  likelihood of the child, young person or family,   adhering to a treatment plan. Thinking  about broader mental health support,   not just for the family, as it says here, but  also for the child or young person. And then   thinking specifically about anxiety and about the  options for evidence-based multimodal treatment   and support. And we’ll come to the 'multimodal'  aspect of this in a bit more detail very shortly,   but, at the very least, that multimodal  support should include a combination of   psychoeducation with psychological therapy,  and it may include possible medication. Now, I should have mentioned earlier, maybe,  the importance of the language in evidence-based   guidelines. When an evidence-based guideline  says 'should' it means should. It’s a really   quite strong suggestion that that should  be part of what you do. For those where   there’s an option, one would say 'could', or  a guideline will say 'could'. There’s also   a stronger way of putting an evidence-based  recommendation, where it says 'must',   but actually in our guidelines, it’s  really a mixture of shoulds and coulds.   This comment that the treatment  should be “evidence-based, multimodal   and supportive" in – and that it “should include a  combination of psychoeducation with psychological   therapy” is really quite a strong wording.  The “possible medication” is like a could. We also emphasise and stress that psychoeducation  forms the base on which other treatment builds.   With good quality psychoeducation, you should be  able to provide support through that education   for the child and family about anxiety and  other relevant mental health conditions   that are present, the factors that can cause,  maintain and improve anxiety, treatment options   for anxiety and their purpose and the impacts of  anxiety, not just on the child and young person,   but also on the family. And we don’t have time  to go into how you do this in this presentation,   but what you can already see is that in order to  give good quality psychoeducation, you, yourself,   needs to be - need to be well educated and have a  really deep understanding. Because after providing   your information, you need to really look  for responses, “Do you have any questions   about that?” And then be able to answer those  questions in some detail and with confidence. You’ll see that the next stage suggests  "Consider referral to a mental health   service or care pathway for treatment."  Now, all of what we’ve already talked   about could've been delivered, and often will  be delivered, within a mental health service.   This is really just a reminder that actually, up  until now, there will be many non-specialists,   such as yourself, that are listening to this talk,  who will be able to conduct the initial stages of   identification, assessment and  hopefully, some psychoeducation. When we move down through the treatment  pathways, more specialist skills are needed,   but I would implore you, even if you feel that  this is as far as you would be able to go with   managing the AD – the anxiety, then keep watching,  because part of the psychoeducation, part of you   being able to prepare people for that next stage  of their journey, receiving treatment and support,   really means understanding what that treatment  and support is. And so, treatment and management,   again, highlighting that psychoeducation should  continue throughout the treatment and management   process. It’s really important not just to stop,  think that everybody knows everything. You need   to go back, you need to back and reiterate, and  build on their education throughout the treatment. In our guideline, we stress that after  psychoeducation, if you are going to give   a specific therapeutic input for anxiety, then you  need to think about using a psychological therapy.   One of the drivers that really made me  interested in developing this guideline   was the fact that I saw a lot of children  and young people diagnosed with anxiety and   then started straightaway on medication,  without any psychological therapy and   support. That’s not what the evidence says,  the evidence says that first-line treatment   after psychoeducation should almost  always be psychological therapies. When you're thinking about psychological  therapies, it’s important to think about   the individual needs of the child, their age,  developmental capacity and developmental level,   their ability to participate in therapy and  their desire, or otherwise, to engage with   a Therapist. Often one needs to do quite a  lot of work to prepare someone for taking on   that next step of engaging with a Psychological  Therapist. Thinking about the availability of   therapies and modalities, that has become  a lot easier. A lot of people say, “Oh,   I couldn’t offer psychological therapy because  I couldn’t find a Therapist to do it.” Well,   we now have some very good and well-evidenced  psychological therapies available online,   and in fact, in Australia, the Australian  Government has really facilitated access to   online psychological therapies, and we’ll  talk a little bit about that in a minute. It’s also important to think about the role that  caregivers can play in inadvertently maintaining   anxiety. One of the factors that we know about  managing anxiety and CBT for anxiety is that   exposure is a big part of managing anxiety. You  need to be exposed to the anxiety in order to   manage it. That’s not always about flooding. It  can be a very gentle exposure. But quite often,   one will come up against caregivers who  inadvertently are protecting their child   from the anxiety and then, again inadvertently,  maintaining that anxiety. Also important to think   about real-world environmental factors that  contribute to the anxiety and think about how   we can manage the environment in order  to reduce the impact that it’s having. You then need to choose the appropriate therapy,  and cognitive behavioural therapy, CBT, should   usually be offered as the first choice therapy  and delivered using an evidence-based programme.   There are many modalities of CBT that can be  offered, and it wouldn’t be, again, appropriate   for us to take a deep-dive into those, but  thinking about how they can be offered according   to suitability and availability is important.  CBT would normally be offered as a face-to-face   therapy, with a talking therapy. For those who  are a bit younger, eight years and younger,   the guideline recommends then "Play-based  approaches using CBT concepts could be   considered." That’s quite carefully worded, again,  the 'could' is not saying it 'should' be offered,   but also, it’s not about just play therapy, it’s  play-based approaches that use CBT concepts. That would be, as I said, for the younger child,  and those who are struggling to engage in a more   formal talking CBT, those with neurodiversity,  those with intellectual disability. And again,   thinking about how we can be inclusive  in offering therapy. I’ve often heard   that – people will say, “Well, this young  person isn't able to engage in therapy.”   Well, they may not be able to engage in a  talking therapy, but they may well be able   to engage in a play-based approach to CBT.  Acceptance and commitment therapy is another   evidence-based approach to anxiety. Could  be considered, not considered as strong,   not considered as high up the hierarchy as CBT,  but could be offered to the young person if   they’re 12 years and older, and particularly those  who are living with a chronic health condition. Medication could be considered, again, it’s a  'could', not a should, for use in conjunction   with psychological therapy, if the child’s  anxiety is too severe to allow them to engage in   psychological therapy, has led to significantly  reduced participation in their community,   you know, for example, the family, school,  social events and sports, or is associated with   a moderate or greater risk of deliberate self-harm  or suicide attempt. And lastly, is affecting the   wellbeing of a family member. And these are  times when you might consider psychological   – pharmacological therapy, medication,  in conjunction with the child’s anxiety. If you're considering medication, before  initiating, it’s really important to assess   the child’s history, other medications they may be  taking, and comorbidities, co-existing conditions.   Really important to discuss potential adverse  effects, things like nausea, diarrhoea, insomnia,   daytime tiredness, headaches, restlessness  and dizziness. And again, really important to   obtain informed consent to starting medication.  Once you’ve done that and it comes to choose   a medication, then the first choice should be a  serotonin – specific serotonin reuptake inhibitor,   an SSRI. And that includes those who have comorbid  conditions, such as OCD or ADHD, depression,   and other co-existing problem. In order to  reduce the risk of a sudden withdrawal-related   adverse effect, then one would think more  about the SSRIs with a longer half-life.   For – the most common one to present there would  be fluoxetine, and fluoxetine’s actually the   medication with the best evidence that  we have for treating this age group. As well as which medication, you need to think  about dosage considerations. I’m not going to   go into those in detail at the moment, but you  will find them in the – some recommendations for   starting doses in the guideline. Age-appropriate  dose, start low and go slow, and then titrate the   dose up gradually, as required. The starting  doses for children and young people are around   half of those that are typically used to  start in adults. I tend, particularly for   adolescents, if there’s not adverse effect,  to titrate up over a period of a few weeks,   or maybe a couple of months, at least to the  maintenance dose, the regular maintenance dose. If the medication doesn’t work  – and you need to give it a good   at least two to three months at a right  dose before you decide it’s not working,   these are medications that take some time to  kick in, if you are considering to change to   another medication, either because a lack  of effect or because of an adverse effect,   then the first change usually would be to the  – another SSRI. That would be the first option.   If at least two SSRIs were not tolerated, or there  was inadequate response, then you could consider   a specific noradrenaline reuptake inhibitor,  like duloxetine, venlafaxine and desvenlafaxine.   But those medications have increased risk of  adverse effects, they’ve not been demonstrated   to be as effective in anxiety in children and  young people, and also, have less in the way of   safety data. When it comes time to discontinue the  SSRI, or SNRI, then it’s important to recognise,   and you probably will have seen this in the  popular press, in the media recently, that   SSRIs are known to have discontinuation symptoms,  people do get withdrawal symptoms. To minimise   these, then really, they should be gradually  reduced over time, before being discontinued. Once you’ve got a treatment that’s effective,  it’s really important to continue regular and   frequent follow-up for monitoring of symptoms  and adverse effects, across all points of care.   The treatment should be adjusted according  to outcomes, but also, that implies that you   need to measure outcomes. Not on this slide,  but we recommend the RCADS, the Revised Child   Anxiety and Depression Scale, which is a good  quality reliable outcome measure that has been   recommended by international guidelines as a  good outcome to measure for anxiety. And so,   you do need to measure outcomes and I suggest,  and the guidelines suggest, that that’s done   systematically over time. And my advice would be  to follow the measurement-based care principles,   measure outcome each time you see someone,  and then adjust the treatment in dose,   or considering stopping treatment after  you’ve seen remission for a period of time.   Usually we would continue medications for  at least a year after we’ve seen remission,   but that should be done and then continued  measuring to check if there’s any relapse. I just want to highlight one last thing  on the evidence. I’ve talked a lot about   'recommendations', and they’re written here in  real shorthand. Each of these recommendations   came after a systemic search, a systemic review.  This is the PRISMA flowchart for medication   treatments. So, you’ll see here that when we were  looking at medication, we included 14 randomised   controlled trial and nine systemic reviews. All  of these were looked at for quality and outcomes,   and we included three systematic reviews that  included RCTs, and one additional RCT when we   checked quality. And so, you're not going to be  able to read this, but just to show, this is the   evidence that backs the recommendations about the  use of medication in treating anxiety. And you can   see an awful lot of work went in at the backend in  order to come up with those recommendations that   you see here. And so, all of that 4.3 and 4.4  were supported by that big amount of evidence. That’s all I want to say to you. You  can access the full guideline here,   it’s free. Sydney, I think, has also shown  you some of the other resources that we have,   they’re available from this website.  Thank you very much for your attention.