Treating Anxiety in Children and Teens Who Present Comorbidities

Susan Van Cleve, DNP, RN, CPNP-PC, PMHS, FAANP, FAAN, Clinical Professor and Primary Care Pediatric Nurse Practitioner Program Director, University of Iowa College of Nursing, discusses how to identify and treat anxiety in children and teens who present comorbidities in advance of her presentation on the subject at the 2020 Virtual Conference on Pediatric Health Care.

Alana Hippensteele:Hi, I'm Alana Hippensteele fromPharmacy Times.Before we get started, one of our top articles today discusses a new survey that shows that pharmacists believe COVID-19 will result in lasting changes in how local pharmacies do business across the country. There's more of that on pharmacytimes.com. Today, I’m speaking with Susan Van Cleve, Clinical Professor and Primary Care Pediatric Nurse Practitioner Program Director at the University of Iowa College of Nursing, on how to identify and treat anxiety in children and teens in advance of her presentation on the subject at the 2020 Virtual Conference on Pediatric Health Care.

So, what is your background in treating anxiety in children and teens?

Susan Van Cleeve: I've been a pediatric nurse practitioner for more than 30 years, and about 15 years ago I started working in a Child Development Center, and 10 years ago I started what's called an integrated practice. So that is a practice where there are 2 nurse practitioners and a nurse, and well I'm one of the nurse practitioners. We provide assessment diagnosis and treatment of children and teens with health disorders in our primary care practice. This is quite a large practice in Pittsburgh, Pennsylvania, and we have separated off and segmented off the behavioral health care, and we tried to do a really comprehensive evaluation as well as do a good job of providing high quality health care to this population.

Alana Hippensteele:Why is assessing, diagnosing, and treating anxiety in children and teens a complicated issue?

Susan Van Cleeve: Well, I think that there's so much comorbidity in terms of children and teens who have either depression with anxiety or ADHD, mostly inattentive ADHD, and anxiety, that it really requires that the clinician spend a large amount of time, I shouldn't make it a large amount of time, but is really comprehensive in terms of assessing and evaluating for all these different disorders, so that we don't miss a disorder. I think that the tendency for people who are in a hurry is that they will just look at maybe ADHD, or maybe just look at depression, or they'll look at, you know, other kinds of characteristics, but we really have to do a big picture before we can sort of settle in on anxiety as the diagnosis. So it requires a fair amount of time, it requires a lot of questions. We need to get information from teachers, parents, and kids themselves, as well as look at their symptoms and how much that's interfering with their functioning, and then come up with a proper diagnosis and treatment plan. So it takes a fair amount of time.

Alana Hippensteele:Why is the use of screening tools for assessments important?

Susan Van Cleeve:Screening tools provide us with so much objectivity, and it takes away the subjectivity from the clinician. It also provides us with an opportunity to hear from people that are not present during the visit, so that can be a teacher, that can be a daycare worker for younger children, that can be a counselor or a therapist who's working with a child or the teen, and including the parents as well as the teen or the child.

So there's self-reports that we also use that can really give us a window of understanding into how their feeling and how that child is, what the struggles are that the child's having or the teens having. So, the use of screening tools is invaluable, and I really think that we should recommend that for every practice in terms of screening for depression and anxiety, we screen for all kinds of behavioral issues with our patients; it's very important.

Alana Hippensteele:Does the presence of comorbidities in children and teens make the process of diagnosing anxiety more difficult?

Susan Van Cleeve:It does because we often have to really look at what diagnosis or what problem is interfering the most with the child's functioning. So if a child comes to us with a complaint of inattention in school and we go through our whole evaluation process and determine that the child may have a form of ADHD, it's called inattentive ADHD, but also have anxiety. We have to decide well what treatment is going to be appropriate because that diagnosis will affect the treatment, and so by doing a thorough evaluation and really looking at the symptoms that are interfering with that child's level of functioning, it enables us to choose the appropriate treatment plan.

So, it is really important to come up with the right diagnosis, and it sometimes it’s hard. It can be pretty challenging. Many times when I'm in practice, I'll really sit down with parents and children and say what seems to be causing the most harm in your life right now: is it the anxiety or is it the inattentive ADHD, and then that determines our plan.

Alana Hippensteele:What are some evidence-based treatment options available?

Susan Van Cleeve: So, if we do determine that a child has anxiety, we always refer them for therapy. So, in some practices, I'm actually learning to do this now, we can provide some cognitive behavioral therapy within the practice, or we refer out to people who are skilled in cognitive behavioral therapy. Working in a big city, there are lots of therapists available who have that skill. I think that that's a bigger challenge for people who work in rural areas where there's really very few mental health therapists in the county or the community, but I am very fortunate in that we have a huge list of people that are skilled in that area, so we’re able to refer kids for therapy.

You know, this includes very young children. I see children who are 4 years old, 5 years old who can exhibit anxiety symptoms, and they benefit from treatment as well. Obviously, you need a skilled counselor in order to work with them, but the basis of the therapies called cognitive behavioral therapy, and it's basically cognitive restructuring and helping that child to sort of change the way he or she thinks about their life, and how they think about it, how they believe it, and then they sort of behave, what their behavior is, and how they feel about it. It's very interesting. It does work and children's brains are very pliable, so it's a wonderful thing to see when children can learn these skills and really reframe how they think about things.

Alana Hippensteele:Yeah, absolutely. Thank you so much for taking the time to speak with me today. Now, let's hear from some of our other MJH Life Sciences brands on their latest headlines.

Susan Van Cleeve:Thank you.