Anxiety & Traumatic Stress

What does it look like?

Traumatic stress and anxiety in children can look similar to adult stress and anxiety. Children sometimes share that they are experiencing fear or sadness related to events in their lives. However, often, they show their feelings through their behavior. Examples of this are available in the tables below, and in the following vignette:

Tables

Normal vs Pathological Response  Ramsdell et al.,2015  \

Child Trauma Vignette

Jacob is a 7-year-old first grader with no previous medical conditions who presents to the pediatrician for persistent abdominal pain. His mother reports that over the last three weeks, Jacob has been complaining of stomach aches with increasing frequency, now occurring almost daily. He has been eating less at each meal and his mother notes that his pants have looked baggy on him lately. He has not had any nausea, vomiting, diarrhea, constipation, fever, headaches, body aches, rashes, or cold symptoms. No one in the family has been ill.

When asked to describe the pain, Jacob replies: “It feels like someone is standing on my belly all the time.” He points to the right and left upper quadrants when asked to locate the pain. The only thing that will sometimes relieve the pain is taking a nap. Jacob’s mother reports that the abdominal pain is interfering with Jacob’s focus when trying to complete his school work, and that he is now behind on several of the worksheets that have been assigned for the week. He has been less interested in playing his favorite video game during free time at home and he has been more irritable with his younger sister. Jacob’s mother also reports that he has been doing something odd when going to the bathroom lately, wanting to keep the door slightly ajar and sometimes calling out to his mother to check that she is still in the other room.He has been more tired in the mornings, and on two occasions over the last few weeks, Jacob wet the bed overnight, which he hadn’t done in over two years.

Jacob lives with his mother, who is a music teacher at the local high school and has been holding virtual classes since the stay-at-home order went into effect; his father, who is a firefighter and has been working extra shifts because several of his colleagues have been ill with COVID-19; and his 4-year-old sister, who used to attend a preschool program before her daycare center shut down. His mother notes that the family is “coping okay” with the COVID-19 pandemic, but that the isolation has been hard on everyone and she acknowledges that both she and her husband have been more short-tempered lately. She is also concerned that Jacob is distancing himself from his father, noting that Jacob will retreat to his room as soon as he hears his dad’s car pull into the driveway. This behavior started when his dad began coming home wearing a face mask, waving hello to the family from the entryway, and then immediately going to take a shower before interacting with anyone further. When asked directly what he thinks about the pandemic and having to stay at home all the time, Jacob replies: “I miss my friends at school.”

In addition to performing a physical exam and completing any additional workup indicated for the abdominal pain, what other conditions should be included in your differential? What screening tools might help you in further delineating what is going on with Jacob and how you might be able to help?

Possible psychiatric diagnoses

  • Adjustment Disorder
  • Acute Stress Disorder
  • Posttraumatic Stress Disorder (if symptoms have lasted for more than 1 month)
  • Anxiety
  • Depression

Additional screening tools

How do I screen for anxiety & traumatic stress in youth?

Children 6 and under

Consider asking parents the following questions:

  • What are your sources of support? Who helps you as a parent? (look for sources of resilience/support)
  • What are the challenges you’re facing as a parent right now?
  • Have you noticed any changes in your child’s behavior since [school/daycare closed, COVID, other recent stressors, etc.]?
  • Do you have a routine at home and how is that working? Is your child attending school/preschool (virtually)? If so, how is that going?
  • How is your child using media? What shows/games/activities does s/he use most?
  • Introduce high quality media resources:

One of the challenges many people are describing is living and being home more in the same space. How is that for your child? How is that for you? Do you ever feel that you or your child might be unsafe in your current living situation?Please see this section for further information and suggested questions on Intimate Partner Violence and Child Abuse and Neglect.

Look for these warning signs:

  • Regression in milestones, failure to meet milestones
  • Changes in behavior and emotion (e.g., irritability, difficulty following directions, tantrums, problem behaviors, etc.)
  • Regulatory difficulties (crying, feeding, sleeping problems)
  • High parent distress; parental withdrawal or apathy; or notable anger, frustration, perceived helplessness with regard to the child

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

See MC3 Screening Guide for an overview of screening options. We recommend using the Psychiatric Impact of COVID-Child and Adolescent Outpatient Screener for all sick visits. For children 4 and older we recommend the Pediatric Symptom Checklist (PSC) for screening of general distress because it is brief and captures several domains. It will point in the direction to question further for a specific diagnosis.

  • Full PSC form: Total score of greater than 24 in children ages 4-5, is considered High Risk.
  • PSC-17: Total score of 15 or greater is considered High Risk.

For children under 3, we recommend the Ages and Stages Social-Emotional Questionnaire Consider further assessment and referral if score is above the cut-off score for the child’s age group:

  • Ages 3-8 months cut-off score is 45
  • Ages 9 to 14 months cut-off score is 48
  • Ages 15 to 26 months cut-off score is 50
  • Ages 27 to 32 months cut-off score is 57
  • Ages 33 to 41 months cut-off score is 59
  • Ages 42 to 65 months cut-off score is 70

If you are more concerned with parental functioning, consider:

The Parenting Stress Index, 4th Edition Short Form is a 36-item inventory that focuses on three major domains of stress: child characteristics, parent characteristics, and situational/demographic life stress. It takes approximately 10 minutes for parents to complete. Primary Care offices may also wish to consider adoption of theSEEK (Safe substanceEnvironment for Every Kid) Model. This model screens for parental factors often associated with child abuse and neglect including parental depression, major stress, substance use, intimate partner violence, harsh punishment and food insecurity. It provides clear guidance on how to follow-up if these risk factors are uncovered. Training is free (CEs can be purchased) and available online.

Other options built into MiChart

Young Child PTSD Index (ages 1-6) Scoring:for PTSD, sum of items 14-36 - For functional impairment sum items (37-42) - Traumatic events (items 1-13) are list of traumatic experiences that may be linked to symptoms Interpretation:Count of number of traumatic events - PTSD Symptom Score (26+: probable diagnosis cutoff) - Functional Impairment Score (4+: probable diagnosis cutoff) ACE (Adverse Childhood Experiences)Child version: caregiver completed for age range of 0-12 (MiChart: PARENT:Adverse Childhood Experiences - Child). This tool is useful for screening for Adverse Childhood Experiences more broadly. Scoring:sum score Interpretation:Higher score indicates more issues

If screening instrument scores are high, or you are generally concerned:

  • 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). Consider asking, “How have you successfully coped with similar challenges in the past?”
  • Encourage self-care including:
    • Maintaining routines where possible, while being flexible and/or establishing new routines
    • Good sleep hygiene
    • Healthy eating
    • Exercise
    • Engaging in fun activities (brainstorm what is allowable/safe and still fun)
    • Engagement of natural support systems (e.g. spiritual, extended family and friends, and culturally relevant groups). “Who do you have in your life to support you in dealing with [fill in the issue]?”
    • Help them to focus on gratitude. “What are you grateful for?” “What positive things have happened for you lately?” For younger children, encourage parents to do this activity and regularly share what they are grateful for with their children.
      • Could be past day, past week, past year. Big or small.
      • Ask them to keep a daily/weekly list of positive events (gratitude journaling)
  • Teach them a breathing or mindfulness exercise, such as 4-square breathing: Breath in for 4 counts, blow out gently for 4 counts, hold the empty breath for 4 counts. Do this sequence 4 times. See links in the Self-Help Resources, under treatment options for further simple breathing and mindfulness exercises.
  • Consider consulting with MC3 and/or other consultation resources.
  • Self-help resources are a first step in treatment. See below under treatment options for a list of self-help resources.
  • 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.
  • Although medications are also an option, we typically recommend a consult with mental health providers prior to starting medication in this young age group.

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.

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.

Children 7-11

Consider asking these questions:

  • Lots of kids struggle with anxiety or mood problems, even from very young ages. We are not yet sure if the COVID pandemic will intensify these problems, but want to be on the look-out for this possibility.
  • Does your child have any fears, worries, moods or behaviors that seem to get in the way of doing things that they need (e.g., school, eating, sleeping) or want (getting along with family, friendships, having fun or playing, learning new things) to do? If yes, do you think these struggles first started or changed during the pandemic?
  • Have you noticed any of the following changes in your child:
    1. Change in sleep patterns (e.g. difficulty falling or staying asleep, increased nightmares, sleeping more than usual, bedwetting)
    2. Change in eating patterns (e.g. increase or decrease in appetite or types of foods)
    3. Increase in aches and pains
    4. Increase focus on the body
    5. Changes in mood or behavior (e.g. difficulty getting along with family or friends, less interest in having fun, playing, learning)
    6. Increased clinginess or difficulty with separation

If you are concerned about the answers to these questions, or notice the above warning signs: See MC3 Screening Guide for an overview of screening options. We recommend using the Psychiatric Impact of COVID-Child and Adolescent Outpatient Screenerfor all sick visits. The Pediatric Symptom Checklist is a good tool for screening of general distress. It is brief and captures several domains. It will point in the direction to question further for a specific diagnosis.

  • Full PSC form: Total score of greater than 28, is considered High Risk.
  • PSC-17: Total score of 15 or greater is considered High Risk.

If after screening for general distress you are more concerned about anxiety, consider the Screen for Child Anxiety Related Emotional Disorders (SCARED). Both the parent and child report forms are built into MiChart for ages 8-17. (MiChart Name: UM AMB SCARED-CHILD [2100480011] & UM AMB SCARED-PARENT [2100480012])

  • A score above 25 is suggestive of an Anxiety Disorder
  • For Panic Disorder/Somatic Symptoms subscale: 7+ suggests panic disorder/somatic symptoms
  • For GAD subscale: 9+ suggests GAD
  • For Separation Anxiety Disorder subscale: 5+ suggests separation anxiety disorder
  • For Social Phobic subscale: 8+ suggests social phobic disorder
  • For School Avoidance subscale: 3+ may indicate significant school avoidance

If after screening for general distress, you are more concerned about depression, consider the Children’s Depression Inventory-Short. It is a 10-item self-report measure built into MiChart for children ages 7-18. (MiChart Name: UM AMB CHILDREN'S DEPRESSION INVENTORY-SHORT (CDI)

The measure is scored and then an age and gender normed T-score is established. Generally, raw scores above 8 should lead to further assessment and management.

    • T-scores below 45 are below Average
    • T-scores between 45 and 55 are Average
    • T-scores between 56 and 60 are Slightly Above Average
    • T-scores between 61 and 65 are Above Average - provide self-help resources and continue to monitor
    • T-scores between 66 and 70 are Much Above Average - provide self-help resources, assess further and consider referral
    • T-scores above 70 are Very Much Above Average - assess further, including assessment of safety, and consider referral

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 children.

Scoring: Add items for total score, score sheet is available for subdomains in measure

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

ACE (Adverse Childhood Experiences) Child version: caregiver completed for age range of 0-12 (MiChart: PARENT: Adverse Childhood Experiences - Child). This tool is useful for screening for Adverse Childhood Experiences more broadly.

  • Scoring: sum score
  • Interpretation: Higher score indicates more issues

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). Consider asking, “How have you successfully coped with similar challenges in the past?”
  • Encourage self-care including:
    • Maintaining routines where possible, while being flexible and/or establishing new routines
    • Good sleep hygiene
    • Healthy eating
    • Exercise
    • Engaging in fun activities (brainstorm what is allowable/safe and still fun)
    • Engagement of natural support systems (e.g. spiritual, extended family and friends, and culturally relevant groups). “Who do you have in your life to support you in dealing with [fill in the issue]?”
    • Help them to focus on gratitude. “What are you grateful for?” “What positive things have happened for you lately?” For younger children, encourage parents to do this activity and regularly share what they are grateful for with their children.
      • Could be past day, past week, past year. Big or small.
      • Ask them to keep a daily/weekly list of positive events (gratitude journaling)
  • Teach them a breathing or mindfulness exercise, such as 4-square breathing: Breath in for 4 counts, blow out gently for 4 counts, hold the empty breath for 4 counts. Do this sequence 4 times. See links in the Self-Help Resources, under treatment options for further simple breathing and mindfulness exercises.
  • Consider consulting with MC3 and/or other consultation resources.
  • Self-help resources are a first step in treatment. See below under treatment options for a list of self-help resources.
  • 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.

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.

Provide all families anticipatory guidance. These handouts are in the process of being added to the Michigan Medicine Patient Education Clearinghouse.

What are the treatment options?

Self-Help Resources

Further Provider Education

Helpful websites

  • COVID-19 Resources for Managing Stress For: Adults and families Cost: Free The coronavirus (COVID-19) pandemic can take an emotional as well as a physical toll. There are strategies that can help with the stress, grief, and anxiety that many people are feeling. This webpage, from the US Department of Veteran’s Affairs, links to information and resources to support self-care, the work of providers, and community efforts.
  • Virtual Cognitive Behavioral Therapy Skills Group for COVID-1 For: This is a group curriculum and training, developed by for school counselors, social workers, or other providers to offer for 9th-12th graders. Parents can share with school personnel to encourage them to offer the group, or primary care offices with behavioral health staff could use this curriculum to offer the group.
  • National Alliance on Mental Illness (NAMI) For: Adults and families Cost: Free The nation's largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness
  • TRAILStowellness.org Helpful handouts, worksheets, and videos for youth anxiety and depression
  • Anxiety and Depression Association of Americalearn more about anxiety in youth, and what to ask a potential therapist
  • Effective Child Therapy:Learn about evidenced based mental health services for youth
  • Find a CBT Therapist:Find a provider trained in Cognitive Behavioral Therapy, the evidence based therapy for youth anxiety.

Treatment Options

Psychotherapy is the first-line treatment option for most anxiety disorders in children. 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

Self-Help Resources

Handouts

Select references

  1. Eismann, E. A., Theuerling, J., Maguire, S., Hente, E. A., & Shapiro, R. A. (2018). Integration of the Safe Environment for Every Kid (SEEK) Model Across Primary Care Settings. Clinical Pediatrics, 58(2), 166–176.[SagePub]

  2. 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

  3. 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

  4. 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.

  5. 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.

  6. 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.