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treated with medication – alone or in combination with CBT (multimodal treatment) – keep in mind that: − No medication is approved by the US Food and Drug Administration (FDA) for any anxiety disorder in patients younger than 6 years of age (see Table A.8.1). Overall, avoid medication in younger children (i.e., younger than 10 years of age). − While there is some evidence of effectiveness for some SSRIs for several anxiety disorders (e.g., OCD, social phobia, generalised anxiety) (see Table A.8.1), they are formally approved by the FDA in the US only for the treatment of OCD (that is, they are used “off label” for anxiety disorders other than OCD). This may not be the case in other countries. − Avoid using benzodiazepines. While benzodiazepines reduce anxiety in the short term, there is no evidence they are effective treating the disorder. They have more side effects in young people and potential for dependence. − Monitor side effects, particularly suicidality. − Review regularly, initially weekly, later on monthly. − Monitor response using an appropriate rating scale and switch to another SSRI if there is no improvement or, if not already tried, add CBT. Click on the picture to hear Professor Rapee talk about anxiety disorders (06:08) Anxiety disorders F.1 15 IACAPAP Textbook of Child and Adolescent Mental Health disorder as well as children with OCD; we rarely exclude children due to comorbidity. Our data indicate few differences in outcome aside from the usual poorer outcomes for young people with social anxiety disorder and those with comorbid depression (Hudson et al, 2015; Rapee et al, 2013). Therapists with training in clinical psychology, experience in working with young people, and skills in the delivery of cognitive behavioural treatments are able to run the program; training workshops are regularly conducted through our centre and over the internet, and we have a system of accreditation. The program is available in a number of languages and is used around the world. PREVENTION AND EARLY INTERVENTION Given the growing knowledge of risk factors for the development of child anxiety, there is rising interest into the possibility of very early intervention and prevention. Growing recognition of the public health implications of psychopathology has increased the realisation that a large proportion of children who are high in anxiousness but do not meet criteria for an actual disorder may nevertheless be suffering and endure restrictions on their lives. As a result, programs for prevention and early intervention of anxiety are now being evaluated (Lyneham et al, 2014). These programs have covered all levels of prevention: universal, selective and indicated. Several large trials have demonstrated the efficacy of anxiety management programs applied universally across sub-populations, most commonly delivered via schools. These programs typically cover similar skills to those found in clinical packages including education, relaxation, cognitive restructuring, and invivo exposure; often they include additional skills such as communication and problem-solving. Therefore, they may be better thought of as broad emotional health programs that aim to teach young people ways of managing distressing emotions. Results have mostly indicated reductions in anxiety, usually with small effect sizes (Werner-Seidler et al, 2017). Given that these are universal programs and are not targeting high risk groups, large effects are not expected but even small effects across an entire population are meaningful. Selective anxiety programs refer to those that target children who report moderate to high symptoms of anxiety but do not necessarily meet criteria for a disorder. The presumption is that these children are at increased risk to develop disorders in the future and hence teaching them anxiety management skills provides a clear method of prevention. However, even if they do not go on to develop anxiety disorders, the low to moderate distress and life interference experienced by these children makes them a valid target for skills training, especially given that very few seek professional help. As with universal programs, the majority of these interventions have used school-based populations. There are many methods of selecting children with high levels of anxiety but most trials so far have used a combination of student self-report and teacher report. Once again, the content of these programs is very similar (or identical) to that of clinical treatment programs. Results have mostly indicated significant reductions in anxiety following intervention, generally with small to moderate effect sizes (Werner-Seidler et al, 2017). Finally, a few studies have begun to investigate indicated programs for the prevention of anxiety – i.e., programs aimed at children scoring high on anxiety risk factors. Targeted children have most commonly been selected on the basis of high levels of temperamental inhibition, but high parent anxiety has also been used to identify relevant children. In the only longer-term study to date, we developed a modified version of Cool Kids called Cool Little Kids. The program is aimed at parents of inhibited preschool-aged children and comprises 6 group sessions. Components are mostly aimed at reducing parent overprotection and encouraging Anxiety disorders F.1 16 IACAPAP Textbook of Child and Adolescent Mental Health in-
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