Read the article and answer the question on the CADTH appraisal tool. No yes/no answers please, answer yes or no and support th
Read the article and answer the question on the CADTH appraisal tool. No yes/no answers please, answer yes or no and support the answer with 2-3 sentences with evidence from the article with the page number from the article for easy reference.
VERY VERY IMPORTANT. Give a summary of at least 2 strengths and 2 weaknesses of the guideline.
Guide to the Critical Appraisal of Clinical Practice Guidelines (CPG)
Student Name:
Faculty name:
Reference of CPG:
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1. WHAT QUESTION ARE YOU TRYING TO ANSWER? |
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Patients |
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Intervention |
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Comparison |
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Outcome(s) |
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2. ARE THE RESULTS OF THE GUIDELINES VALID? |
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Questions that need asking |
What is this, and where do I find this information? |
Details from Assigned CPG Include page number as applicable |
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Is the group, committee, or organization that developed the guidelines clearly identified? |
Yes / No Can’t tell |
This information is usually located either right at the front of the guidelines, or in the back of the document in an appendix. For some guideline groups, this information is located on their website at point of download of the guideline itself. |
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Did authors declare conflicts of interest among all parties involved in guideline preparation and consensus? |
Yes / No Can’t tell |
Conflict of interest is essential to locate within a clinical practice guideline (CPG) to ensure validity. Sometimes the writers of CPGs have financial or expert relationships with pharmaceutical companies or are extensively involved in other research studies that might negatively bias the development of objective CPGs. Conflict of interest should ideally be stated up front within the guideline, but may also be included in a paragraph at the very back of a document. |
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Is there proof of a systematic literature search and strategic selection of articles for review? (Was it a SYSTEMATIC PROCESS?) |
Yes / No Can’t tell |
All CPGs need to describe the literature review (and the timeline; example 2000-2009) whereby evidence was located. Specific databases where the search occurred should be cited (e.g., Medline, PubMed, Embase, Cochrane). Again, this should be noted within the first few pages of the CPG. |
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Have evidence ratings or indicators of value been indicated for each guideline? |
Yes / No Can’t tell |
CPGs should be developed by consensus. In doing so, there should be a specific scale to rate the quality and strength of evidence and also the consensus result. This might look like “Grade 1a,” which might suggest a highly rated recommendation and a highly rated consensus among the CPG committee. This should be noted for each and every guideline within the CPG and be noted throughout the document. |
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To what extent has expert opinion been identified for particular guidelines – is it extensive? |
Yes / No Can’t tell |
Sometimes, background research is just not available to help inform CPGs on particular topics. In these instances, guideline groups or committees sometimes choose to create a statement or guideline that is based solely on expert opinion or experience of experts. While a few statements of this nature are usually accepted within guidelines, a high percentage of statements within a CPG may be inappropriate. Further, clinicians using these guidelines must consider the risks and value of using expert opinion-based guidelines to make clinical decisions. |
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3. WHAT ARE THE RESULTS? |
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Questions that need asking |
What is this, and where do I find this information? |
Details from Assigned CPG Include page number as applicable |
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Is there a clear message on the clinical importance and practical value for use of these guidelines? |
Yes / No Can’t tell |
All CPGs must be written in practical and implementable statements. They must not be vague or generic; they are intended to be actionable and easy to understand without risk of misinterpretation. |
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Is there discussion of benefits, harm, risks, and cost impacts? |
Yes / No Can’t tell |
High-quality CPGs provide specific information within the guidelines about patient-specific benefits, harms/risks, and also cost of implementation of the guidelines in clinical settings. This is essential to note because it informs the prospective user of the CPG of what implementation aspects might warrant further review. |
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Are these guidelines of recent age? Do the results include reference to currently available treatments or interventions? |
Yes / No Can’t tell |
Most clinical practices note changes every 5 years or so. As such, a CPG that is older than this timeframe may not be appropriate, particularly if there is mention of older and less-used medications particular to your clinical practice setting. |
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4. WILL THE RESULTS HELP ME IN CARING FOR MY PATIENT? |
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Questions that need asking |
Response |
What is this? |
Details from Assigned CPG Include page number as applicable |
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Are the guidelines presented in a user-friendly and easy-to-follow format? |
Yes / No Can’t tell |
Guidelines that are difficult to understand or hard to follow can be prone to misinterpretation. There is also greater likelihood that the CPG will not be embraced and used consistently in clinical settings if it is hard to interpret. |
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Do the guidelines offer next steps for practical implementation; recognition of implementation barriers? |
Yes / No Can’t tell |
Most good CPGs include suggestions for next steps including a standardized documentation, standing-orders form, or audit assessment sheet, for example. This may also include a sample patient or family education pamphlet, posters for health care professionals, electronic flags for charts, or other resources. It is a good sign that some suggestions and tools are provided for implementation by guideline developers. |
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Is there discussion of clinical flexibility for application in multiple or diverse clinical settings? |
Yes / No Can’t tell |
Remember that CPGs created exclusively for implementation in large tertiary facilities may not be directly applicable in smaller or community-based health care settings. A strong CPG should identify some general recommendations of special implementation for different settings. As an example, a CPG intended for use in hospitals may not necessarily be effective for implementation in rural clinic settings. |
Overall Appraisal: In one succinct paragraph, give a narrative overall appraisal that includes a summary of the strengths and weaknesses of the guideline, as well as its use for the identified PICO question.
Guide to the Critical Appraisal of Clinical Practice Guidelines Page 1 of 2
Guide to the Critical Appraisal of Clinical Practice Guidelines Page 2 of 2
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Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders Heather J. Walter, MD, MPH, Oscar G. Bukstein, MD, MPH, A. Reese Abright, MD, Helene Keable, MD, Ujjwal Ramtekkar, MD, MPE, MBA, Jane Ripperger-Suhler, MD, Carol Rockhill, MD, PhD, MPH
Anxiety disorders are among the most common psychiatric disorders in children and adolescents. As reviewed in this guideline, both cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication have considerable empirical support as safe and effective short-term treatments for anxiety in children and adolescents. Serotonin norepinephrine reuptake inhibitor (SNRI) medication has some empirical support as an additional treatment option. In the context of a protracted severe shortage of child and adolescent�trained behavioral health specialists, research demonstrating convenient, efficient, cost-effective, and user-friendly delivery mechanisms for safe and effective treatments for child and adolescent anxiety disorders is an urgent priority. The comparative effectiveness of anxiety treatments, delineation of mediators and moderators of effective anxiety treatments, long-term effects of SSRI and SNRI use in children and adolescents, and additional evaluation of the degree of suicide risk associated with SSRIs and SNRIs remain other key research needs.
Key Words: clinical practice guideline, anxiety, child psychiatry, assessment, treatment
J Am Acad Child Adolesc Psychiatry 2020;59(10):1107–1124.
T
Journal of t Volume 59
he objective of this Clinical Practice Guideline is to enhance the quality of care and clinical out- comes for children and adolescents with anxiety
disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders.1 The primary aim of the guideline is to summarize empirically based guidance about the psycho- social and psychopharmacologic treatment of anxiety. A secondary aim is to summarize expert-based guidance about the assessment of anxiety as an integral part of treatment and the implementation of empirically based treatments in clinical practice.
Anxiety disorders are among the most common psy- chiatric disorders in children and adolescents. At any given time, nearly 7% of youths worldwide have an anxiety dis- order2; estimated lifetime prevalence in the United States approximates 20% to 30%.3,4 For specific anxiety disorders among youths 13 to 18 years old, lifetime prevalence rates approximate 20% for specific phobia, 9% for social anxiety, 8% for separation anxiety, and 2% each for agoraphobia, panic, and generalized anxiety.3
The median age of onset of anxiety disorders approxi- mates 11 years5; however, each anxiety disorder often (but not always) onsets during a specific developmental phase:
he American Academy of Child & Adolescent Psychiatry / Number 10 / October 2020
separation anxiety during the preschool/early school-age years; specific phobias in the school-age years; social anxi- ety in the later school-age and early adolescent years; and generalized anxiety, panic, and agoraphobia in the later adolescent/young adult years.6 The development of an anxiety disorder may be foreshadowed by behavioral inhi- bition,7 autonomic hyperreactivity,8 or negative affectivity.9
Parent/parenting factors,10 stressful/traumatic exposures,11
and insecure attachment12 also may play important etio- logic roles. Anxiety disorders (especially generalized anxiety) are highly comorbid with each other and with other psy- chiatric disorders,13,14 particularly depression15 but also bipolar, attention-deficit/hyperactivity disorder (ADHD), learning/language, behavior, obsessive-compulsive, eating, and substance-related disorders. For comorbid occurrences, multifaceted treatment plans likely are necessary.16
Although onset can be acute, the course of anxiety tends to be chronic,17 often with waxing and waning, and exhibits both homotypic (prediction of a disorder by the same dis- order) and heterotypic (prediction of a disorder by a different disorder) continuity.18 Likely reflecting a common underlying vulnerability (eg, “negative valence systems”),19
examples of heterotypic continuity are the prediction of
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panic and depressive disorders in adolescence and adulthood by separation anxiety in childhood, and the prediction of social anxiety in adolescence and adulthood by selective mutism in childhood.
The sequelae of untreated child and adolescent anxiety disorders are manifold, including impairments in social, educational, occupational, health, and mental health out- comes extending from childhood into adulthood.20-22
Among adolescents with anxiety, 9% were reported to have had suicidal ideation, and 6% made suicide attempts23; panic disorder24 and generalized anxiety dis- order with comorbid depression25 may convey the great- est risk.
Despite the availability of effective treatments for anx- iety,26 less than one-half of youths needing mental health treatment receive any care, and fewer still receive evidence- based care.27-30 Better identification, assessment, and treatment of anxiety disorders by clinicians from multiple disciplines could have a substantial impact on the individual and public health burden of mental illness in children and adolescents.
OVERVIEW OF THE GUIDELINE DEVELOPMENT PROCESS Authorship, Source, and Scientific Review The authors of this guideline (the Guideline Writing Group) are co-chairs and members of the AACAP Committee on Quality Issues (CQI) (https://www. aacap.org/AACAP/Resources_for_Primary_Care/Practice_ Parameters_and_Resource_Centers/Practice_Parameters. aspx).31 The CQI is charged by AACAP with the devel- opment of Clinical Practice Guidelines in accordance with standards promulgated by the Institute of Medicine (IOM)32 and the Appraisal of Guidelines Research & Evaluation (AGREE) Next Steps Consortium.33 Both standard sets emphasize rigor (critically appraised empirical evidence) and transparency (minimization of conflicts of interest and well-delineated guideline development process). CQI chairs are nominated by the AACAP president based upon their expertise and experience in the synthesis of psychiatric knowledge and their lack of relevant conflicts of interest. CQI members are nominated by CQI co-chairs to broadly represent AACAP members in geographic, gender, and professional practice type, duration and setting do- mains, and to have no relevant conflicts of interest. Pro- spective CQI members are reviewed and approved by the AACAP president.
In this guideline, statements about the treatment of anxiety disorders are based upon empirical evidence derived from a critical systematic review of the scientific literature
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conducted by the Mayo Clinic Evidence-based Practice Center under contract with the Agency for Healthcare Research and Quality (AHRQ).34-36 (Because selective mutism was not included as a primary disorder in studies included in the AHRQ/Mayo review, the treatment of this disorder is not addressed in this guideline). Insofar as available, evidence from meta-analyses published since the AHRQ/Mayo review are presented to support or refute the AHRQ/Mayo findings.37-43
Because of sparse or absent empirical evidence, clinical guidance about the assessment of anxiety disorders and about the implementation of empirically based treatments is based primarily upon expert opinion and consensus as presented in chapters in leading textbooks of child and adolescent psychiatry,44-61 the DSM-5,1 previously pub- lished clinical practice guidelines,62-65 and government- affiliated prescription drug information websites (https:// dailymed.nlm.nih.gov/dailymed/66; https://www.fda.gov/ Drugs67).
The peer review and approval process for the draft guideline spanned the period February 1, 2019, to March 11, 2020, and included reviewers representing the following stakeholder groups (see end of this document for complete list): 1) topic experts; 2) other members of the AACAP CQI; 3) other relevant AACAP committees; 4) the AACAP Assembly of Regional Organizations; 5) relevant external organizations; and 6) AACAP members. All suggested edits were considered; however, the CQI Guideline Writing Group exercised editorial authority as to whether the sug- gested edits were included in the final document. Final approval of the guideline as an AACAP Official Action rested with the AACAP Council.
ASSESSMENT OF ANXIETY Diagnostic evaluation is an essential prerequisite for the treatment of an anxiety disorder. Specialized clinical edu- cation, training, and experience are necessary to conduct a diagnostic evaluation of a child or adolescent in accordance with current psychiatric nomenclature (DSM-51). A diag- nostic evaluation identifies the following: symptoms; syn- dromal symptom combinations; symptom frequency, severity, onset, and duration; degree of associated distress and functional impairment; developmental deviations; and physical signs. Clinical expertise is required to differentiate anxiety disorders from normal psychological processes common to human experience.
Identification At present, there is no empirically based (eg, U.S. Preventive Services Task Force) recommendation for universal
Journal of the American Academy of Child & Adolescent Psychiatry Volume 59 / Number 10 / October 2020
aDSM-5 Anxiety Disorders with International Classification of Diseases– 10 code: Separation Anxiety Disorder (ICD F93.0); Selective Mutism (ICD F94.0); Specific Phobia (Animal: ICD F40.218, Natural environment: ICD F40.228, Fear of blood: ICD F40.230, Fear of injections and transfusions: F40.231, Fear of other medical care: F40.232, Fear of injury: F40.233, Situational: F40.248, Other: F40.298); Social Anxiety Disorder (F40.10); Panic Disorder (F41.0); Agoraphobia (F40.00); Generalized Anxiety Dis- order (F41.1); Substance/Medication-Induced Anxiety Disorder (see substance-specific codes), Anxiety Disorder Due to Another Medical Condition (F06.4); Other Specified Anxiety Disorder (F41.8); and Un- specified Anxiety Disorder (F41.9).
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screening for anxiety disorders in children and adolescents. However, in primary care, school, or other child-serving settings, freely available general social�emotional screening instruments (eg, Pediatric Symptom Checklist [https://www.massgeneral.org/psychiatry/treatments-and- services/pediatric-symptom-checklist/68]; Strengths and Difficulties Questionnaire [http://www.sdqinfo.com69]) can be deployed systematically to standardize identification of anxiety concerns. Early identification of an anxiety concern, if confirmed as a problem upon follow-up assessment, can facilitate early intervention, including guided self- management and focused intervention for subclinical and mild presentations.
In the context of a psychiatric evaluation, symptoms of anxiety typically are identified through spontaneous youth or parent report (the presenting problem or chief complaint), during the clinician’s review of psychiatric symptoms, the conduct of the mental status examination, or through input from referral sources. However, because of the variability inherent in nonsystematic methods of identification, a more standardized approach may be useful. As one option, the American Psychiatric Association (APA) developed the freely available parent- and self-rated Level 1 Cross-Cutting Symptom Measures (https://www. psychiatry.org/psychiatrists/practice/dsm/educational-resources/ assessment-measures70) to screen for multiple psychiatric disorders including anxiety. These instruments could be included in intake packets to systematically and efficiently gather information about presenting problems prior to the evaluation. The parent and self-rated versions of the Level 1 Cross-Cutting measure have demonstrated good reliability in the DSM-5 field trials conducted in pediatric clinical samples across the United States.71
Evaluation Clinically significant anxiety (ie, an anxiety disorder) must be distinguished from everyday worries and fears, which are common to the human experience and normative (even when exaggerated) in specific developmental stages (eg, being startled and exposure to strangers in infants, separa- tion from caregiver in toddlers, supernatural creatures in preschoolers, physical well-being and natural disasters in school-aged children, and social and existential concerns in adolescents). In DSM-5,1 mental disorders are defined as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.” By DSM convention, a mental disorder is diagnosed if all or a threshold of diagnostic criteria for the given disorder are met. Included in most diagnostic criteria
Journal of the American Academy of Child & Adolescent Psychiatry Volume 59 / Number 10 / October 2020
sets is the requirement for a specific frequency and duration of symptoms as well as clinically significant distress and functional impairment, along with the caveat that alterna- tive mental, medical, and substance-related explanations for the symptom presentation must have been ruled out before the diagnosis is applied.
In DSM-5,1 diagnostic criteria are provided for 11 anxiety disorders (one with 8 subcategories).a Although the boundaries between psychiatric disorders are now recog- nized as porous, such that different disorders within and across categories may share similar symptoms, risk factors, and neural substrates, diagnostic precision nonetheless is key for understanding disorder course and prognosis and for guiding empirically based treatment recommendations.
According to DSM-5,1 separation anxiety is character- ized by developmentally inappropriate, excessive worry or distress associated with separation from a primary caregiver or major attachment figure. Selective mutism is character- ized by absence of speech in certain social situations despite the presence of speech in other situations (usually at home). Specific phobia is characterized by excessive fear or worry about a specific object or situation. Social anxiety is char- acterized by excessive fear or worry about being negatively evaluated by others in social situations. Panic (ie, abrupt surge of intense fear or discomfort) is characterized by recurrent unexpected panic attacks with physical and cognitive manifestations. Agoraphobia is characterized by excessive fear or worry about being in situations (eg, crowds, enclosed spaces) in which the individual may be unable to escape or get help should panic-like or other overwhelming or embarrassing symptoms occur. Generalized anxiety is characterized by excessive, uncontrollable worries regarding numerous everyday situations or activities. Substance/ medication-induced anxiety and anxiety due to another medical condition are characterized by anxiety occurring in the context of substance/medication use or a physical illness. When diagnostic criteria are not fully met for a given anxiety disorder or if a precise diagnosis is not possible due to limited information or other factors, DSM-5 includes “other specified” and “unspecified” diagnoses to be applied in these circumstances. The “unspecified” diagnosis may be the best diagnostic choice for nonbehavioral health
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clinicians, who may not possess detailed knowledge of DSM-5 criteria for specific anxiety disorders.
Evaluation Structure. A diagnostic interview for anxiety includes the parent/guardian and patient, either separately or together or both as developmentally and clinically indi- cated. Interview of the patient requires a developmentally sensitive approach that may use multiple age-appropriate assessment techniques (eg, direct and indirect questioning, interactive and projective techniques, symptom rating scales, behavioral approach tests). Family assessment can reveal environmental reinforcements for anxiety, and ob- servations of parenting styles and behaviors can identify those that are potentially anxiogenic. Input from collateral sources (records, interviews, rating scales), including (as applicable and with parent/guardian�patient consent) other family members, teachers, primary care and behavioral health clinicians, and/or child agency workers, can add depth and breadth to diagnostic information. Because of the multiple sources of information, a diagnostic evaluation of a child or adolescent may involve more than one session as allowed by current diagnostic billing code (Current Proce- dural Codes [CPT] 90791, 90792) specifications.
As lack of appropriate linguistic ability or interpreter support has been associated with misdiagnosis as well as adverse clinical outcomes,72 it is optimal to conduct the diagnostic evaluation in the language in which the child and parents/guardians are proficient. If live interpreter services are not available, telephonic or televideo interpreter services may be an alternative.
Differential Diagnosis. The primary goal of the history of present illness is to determine whether DSM-51 diagnostic criteria for a specific anxiety disorder are met, and to rule out alternative explanations (“masqueraders”) for the symptom presentation. In addition, characterization of previous anxiety presentations and response to previous treatments will inform current treatment choice.
Medical conditions associated with anxiety include (but are not limited to) hyperthyroidism, caffeinism, migraine, asthma, diabetes, chronic pain/illness, lead intoxication, hypoglycemic episodes, hypoxia, pheochromocytoma, cen- tral nervous system disorders, cardiac arrhythmias, cardiac valvular disease, systemic lupus erythematosus, allergic re- actions, and dysmenorrhea. Although laboratory testing is not routine in the evaluation of a suspected anxiety disorder, in collaboration with the child’s primary care practitioner, testing (eg, glucose, thyroid function) can be completed if suggested by signs and symptoms of a medical condition. For anxious youths presenting with somatic symptoms, the nature and severity of those symptoms are noted at baseline
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so that the somatic symptoms are not falsely attributed to adverse effects of medication treatment.
Medications that can cause anxiety include (but are not limited to) bronchodilators, nasal decongestants and other sympathomimetics, antihistamines, steroids, dietary sup- plements, stimulants, antidepressants, antipsychotics, and withdrawal from benzodiazepines (particularly short-acting). Medication reconciliation is a routine part of an evaluation for a suspected anxiety disorder.
A wide array of licit and illicit substances can cause anxiety, including (but not limited to) marijuana, cocaine, anabolic steroids, hallucinogens, phencyclidine, and with- drawal from nicotine, alcohol, and caffeine. Environmental etiologies such as exposure to organophosphates and ingestion of metals (eg, lead, arsenic) can also be considered. Although drug and toxin testing are not routine in the evaluation of a suspected anxiety disorder, testing can be considered if exposure is reported.
Mental conditions that may include symptoms that are similar to those of anxiety disorders are ADHD (distracti- bility, restlessness), depression (distractibility, insomnia, somatic complaints), bipolar disorder (distractibility, rest- lessness, irritability, insomnia), obsessive-compulsive disor- der (intrusive thoughts, avoidance, reassurance seeking), psychotic disorders (restlessness, agitation, social with- drawal, distractibility), autism spectrum disorder (social withdrawal, social skills deficits, distractibility), and learning disorders (worries about school performance).
Psychiatric Comorbidities. Anxiety disorders commonly co-occur with each other; other common comorbidities include (but are not limited to) depression, ADHD, and behavior, bipolar, obsessive-compulsive, eating, learning, language, and substance-related disorders. With selective mutism, developmental and communication disorders frequently co-occur. Comorbidities may heighten distress and functional impairment and may worsen
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