Anxiety & Traumatic Stress

What does it look like?

Traumatic stress and anxiety in adolescents can look similar to adult stress and anxiety. Teens sometimes share that they are experiencing fear or sadness related to events in their lives. However, at other times they retreat and do not share these feelings with those closest to them. This table (insert Ramsdell table) provides examples of common symptoms of PTSD in children and adolescents. It is important to ask teens directly about their experiences and to look for signs of changes in behavior

How do I screen for it?

Continue with regular screening using instruments such as the PHQ-9 and GAD-7 during well-child visits. Consider using these more frequently over the next couple years, perhaps even during sick visits.

1. Consider asking these questions:

  • This has been a difficult time for all of us. We aren’t sure yet what effect the pandemic will have on us, but we want to watch out for changes in mood and behavior that might be related to the pandemic or social distancing measures.
  • Have you noticed any of the following changes:
    • Change in sleep patterns (e.g. difficulty falling or staying asleep, increased nightmares, sleeping more than usual, significant changes in bedtime routines or sleep/wake cycle)
    • Change in eating patterns (e.g. increase or decrease in appetite or types of foods)
    • Increase in aches and pains
    • Changes in mood or behavior (e.g. not feeling good about yourself, difficulty getting along with family or friends, less interest in having fun, learning)
    • Withdrawal/isolation
    • Difficulty concentrating
    • Increased worry or difficulty focusing
    • Use of alcohol, marijuana, or other drugs
    • Engaging in risky behaviors

2. If you are concerned about the answers to these questions, or notice the above warning signs:

  • Consider the following screening instruments:
    • Psychiatric Impact of COVID-Child and Adolescent Outpatient Screener, which will be built into MiChart. We recommend using this screener as standard practice for all sick visits.
    • The Pediatric Symptom Checklist is a broad screening instrument that may also be a useful first step if you are concerned about general changes of behavior. It can help point you in the direction to question further for a specific disorder.
      1. Full PSC form: Total score of greater than 28, is considered High Risk.
      2. PSC-17: Total score of 15 or greater is considered High Risk.
    • Continue to use standard screening practices for anxiety and depression, such as the GAD-7 and PHQ. If you have questions about implementing evidence-based screening procedures in your clinic, MC3 (insert link) is a wonderful resource to consult about these procedures.
    • The UCLA Brief Screen for Child/Adolescent Trauma and PTSD-Reaction Index is not built into Mi-Chart but is a good, free option if you want to screen for broad traumatic symptoms in adolescents. It can be found at: https://www.reactionindex.com/
      1. Scoring: Add items for total score, score sheet is available for subdomains in measure
      2. Interpretation:
        • 0-10 Minimal PTSD Symptoms - Monitor, Psychoeducation and periodic re-screening
        • 11-20 Mild PTSD Symptoms - Consider further evaluation - Monitor, Psychoeducation and Suggest for PTSD-RI Assessment
        • 21+ Potential PTSD - Warrants full PTSD-RI Assessment and Triage
    • If you are concerned with overall exposure to Adverse Childhood Experiences consider the ACE: Adverse Childhood Experiences Teen version: self-report for age range of 13-17 (MiChart: Adverse Childhood Experiences - Teen Self-Report)
      - Scoring: sum score
      - Interpretation: Higher score indicates more issues
    • If you are concerned about Adolescent Substance Use consider using a measure such as the CRAFFT-2.
      1. Age range: 12-18 yo
      2. Interpretation:
        • If : total # of days of use = 0 AND CRAFFT score= 0 then:Low Risk of substance use and substance use related riding/driving
        • If : total # of days of use = 0 AND item # 4 = 'yes' then: 'Medium Risk of substance use and substance use related riding/driving'
        • If : total # of days of use > 0 AND CRAFFT score < 2 then: 'Medium Risk of substance use and substance use related riding/driving'
        • If total # of days of use > 0 AND CRAFFT score > 1 then: 'High Risk of substance use and substance use related riding/driving'
      3. Subscales:
        • Total # of days of use
        • CRAFFT score
      4. MiChart: UM AMB CRAFFT 2-SUBSTANCE ABUSE RISK SCREENING (ADOLESCENTS)

3. If screening instrument scores are high:

  • Provide empathy around places of struggle and psychoeducation about the resiliency of children to overcome stressful situations with appropriate supports in place (this alone is an important intervention) (INSERT LINK TO BRIEF BEHAVIORAL MANAGEMENT FOR DISTRESSED PATIENTS)
  • Encourage self-care including:
    1. Maintaining routines where possible, while being flexible or establishing new routines
    2. Good sleep hygiene (Clearinghouse doc: http://www.med.umich.edu/1libr/Pediatrics/SleepHygiene.pdf)
    3. Healthy eating
    4. Exercise
    5. Engaging in fun activities (brainstorm what is allowable/safe and still fun)
    6. Engagement of natural support systems (e.g. spiritual, extended family and friends, and culturally relevant groups).
  • Consider consulting with MC3 and/or other resources.
    • Self-help resources are a first step in treatment.
    • Consider psychotherapy for more significant symptoms or if treatment response is not evident, following use of self-help resources. If you are a Michigan Medicine provider, and would like access to our lists of behavioral health resources, you may contact Michele Brown at resoho@med.umich.edu
    • Medications are also an option if mental health challenges are causing more significant impairment or distress (e.g. ongoing suicidal ideation or suicide attempt, significantly impacting ability to attend or perform at school) or if evidence-based therapy has not been effective on its own. The MC3 program provides information on medication dosing here: https://mc3.depressioncenter.org/wp-content/uploads/2020/03/pharmacards-online-11-19.pdf

4. If you are concerned with caregiver’s mental health please see these treatment resources:

Link to Adult subsection treatment referral pages for each condition. MC3 is also available for consult for pregnant and nursing mothers and provides psychopharmacologic recommendations here (insert link to MC3 for moms psychopharm cards
https://mc3.depressioncenter.org/wp-content/uploads/2020/03/pharmacards-MC3moms-online.pdf). Insert info about BHCC program too?

5. Provide all families anticipatory guidance.

These handouts are in the process of being added to the Michigan Medicine Patient Education Clearinghouse. When they are there, we will insert a dot phrase than can be used in After Visit Summaries.

    1. https://www.nctsn.org/sites/default/files/resources/fact-sheet/parent_caregiver_guide_to_helping_families_cope_with_the_coronavirus_disease_2019_covid-19.pdf
    2. https://medicine.umich.edu/dept/psychiatry/michigan-psychiatry-resources-covid-19/children-adolescents/helping-kids-cope-covid-19-crisis)
    3. Link to Section 5 resource page for parent and adolescent self-help resources

What are the treatment options

Self-Help Resources

Treatment Options:

Psychotherapy is the first-line treatment option for most anxiety disorders and for mild to moderate depression  in children and adolescents. The most widely accepted evidence-based intervention for anxiety is Cognitive-Behavioral Therapy. For traumatic stress, we generally recommend Trauma-Focused Cognitive Behavioral Therapy for school-aged children and adolescents and Child Parent Psychotherapy for younger children.

Medication is an option to treat anxiety in children. We typically recommend medications if a child has been enrolled in evidence-based therapy (typically Cognitive Behavioral Therapy) and still has residual symptoms. At times, the decision is made to start medication prior to, or in conjunction with, therapy if symptoms are severely impairing functioning (e.g. child is not able to attend school because of anxiety, school functioning is significantly impaired as a result of anxiety, child is having daily panic attacks etc.). You can find information on medication through the MC3 program here.

Additional resources

  1. 12 Core Concepts for Understanding Traumatic Stress Responses in Children and Families E-Learning: https://learn.nctsn.org/enrol/index.php?id=94

  2. Psychological First Aid E-Learning: https://learn.nctsn.org/course/view.php?id=38

  3. Skills for Psychological Recovery E-Learning: https://learn.nctsn.org/course/view.php?id=535

Select references

  1. Ramsdell KD, Smith AJ, Hildenbran, AK, & Marsac ML. Posttraumatic stress in school-age children and adolescents: Medical providers’ role from diagnosis to optimal management. Pediatric Health Med Ther. 2015 Oct 3; 6: 167-180. DOI: 10.2147/PHMT.S68984

  2. Cohen, JA, Kelleher, KJ, & Mannarino, AP. Identifying, treating, and referring traumatized children. Arch Pediatr Adolesc Med 2008; 162(5): 447-452.DOI: 10.1001/archpedi.162.5.447

  3. Dalton, L, Rapa, E, Stein, A. Protecting the Psychological Health of Children Through Effective Communication About COVID-19. Lancet Child Adolesc Health 2020 May;4(5):346-347. doi: 10.1016/S2352-4642(20)30097-3. Epub 2020 Mar 31.

  4. Flynn, AB, Fothergill, KE, Wilcox HC, Coleclough, E, Horwitz, R, Ruble, A, Burkey, MD, Wissow, LS. Primary Care Interventions to Prevent or Treat Traumatic Stress in Childhood: A Systematic Review. Acad Pediatr. Sep-Oct 2015;15(5):480-92. doi: 10.1016/j.acap.2015.06.012.

  5. Wilson, HW & Joshi, SV. Recognizing and Referring Children With Posttraumatic Stress Disorder: Guidelines for Pediatric Providers. Pediatr Rev. 2018 Feb;39(2):68-77. doi: 10.1542/pir.2017-0036.