Ado anxiety & PTSD Flashcards
What is the most prevalent and most treatable psychiatric condition, according to the lecture?
anxiety
Where do people with anxiety usually go to get help and why?
-
3-5x more likely to go to a primary care provider because of the physiological symptoms associated with anxiety
- Sympathetic Dominance
- “Fight or Flight”
Characteristics of day to day anxiety
- Worry about paying bills, landing a job and other important life events
- Embarrassment in awkward situations
- A case of nerves or sweating before a presentation, test or stage performance
- Realistic fear of a dangerous object, place or situation
- Assurance that you are living in a safe, healthy environment
- Anxiety, sadness or difficulty sleeping immediately after a traumatic event
Characteristics of anxiety DO
- Constant, unsubstantiated worry that causes significant distress and impairs functioning
- Avoidance of social situations for fear of being judged, humiliated or embarrassed
- Out of the blue panic attacks
- Irrational fear or avoidance of object, place or situation that poses little or no threat
- Performing uncontrollable and repetitive actions such as checking, touching, arranging or excessive cleaning
- Recurring nightmares, flashbacks or emotional numbing for several months or years after a traumatic event
What happens during a fight or flight response?
- Heart
- Racing heart
- Pounding in ears
- Stomach
- Stomachache, cramping
- Nausea/vomiting
- Diarrhea
- Brain
- Headache
- Inability to concentrate
- Inability to “think” and “learn”
- Lungs
- Hyperventilation
- Dizziness or “spaciness”
- Fainting
- Eyes
- Blurry vision
- Spots
- Skin
- Sweating
- Vascular System
- Cold hands and feet
- Flushed face and chest
How could you describe the F or F response to an adolescent?
Heart: “pretend a saber toothed tiger comes into the room. Your heart beats fast – you need to get oxygen to muscles to run away.”
Stomachache: body shuts off unnecessary functions. Digestion shuts off may feel sick. Diarrhea – get rid of everything – pee & BMs to make yourself lighter to run
Brain: worried and smart brain can’t operate at same time - can’t remember things. ADHD Dx, but actually anxiety
Lungs: hyperventilation – you need O2 to run (from tiger) (but can cause the dizziness, etc)
Eyes: pupils dilate to let more light in - floaters – anxious you are always in peripheral vision. (let more light in)
Skin: sweating – body knows you’ll be hot from running - keeps you cool
Vascular system: hands cold and clammy, face and chest flushed - body is sending blood where it’s needed most.
Risk factors for an anxiety DO
Genetics, temperament, environment
What genetic factors put a teen at risk for an anxiety DO?
1st or 2nd degree relative w/anxiety DO
What temperaments put a teen at risk for an anxiety DO?
Difficult
Slow to warm up/cautious
What environmental factors put a teen at risk for an anxiety DO?
- Parent-child interaction
- Parenting style
- Overprotective
- Over controlling
- Overly critical
- Insecure attachments
- Physical, academic and social environments
Lot of anxiety created by social media
How does anxiety present in adolescents?
- Physiological signs and symptoms of sympathetic dominance
-
Sleep Disturbances
- Difficulty falling asleep
- Frequent awakening
- Early morning awakening
- stomacheache, HA
- Shy
- Excessive distress out of proportion to the situation evidenced by:
- sadness
- anger/explosiveness
- hopelessness
- embarrassment
- Anticipatory worrying (hours, days or weeks ahead)
- Repetitive reassurances
“What if” *****
“Are you mad at me?” *****
- Nail biting, hair pulling, motor tics (not trichotillomania, but tics)
- Unable to respond to logic
- Overly responsible people pleasers / overly compliant
- Excessive apologizing
- Perfectionistic and highly self-critical / self-depricating
- Sets unrealistic standards
- Excessive avoidance and refusal to participate in expected events
- School
- Family functions
- Social events with peers
- overwhelmed
What are some anxiety DOs?
- Separation Anxiety Disorder (SAD)
- Selective Mutism
- Specific Phobia
- Generalized Anxiety Disorder (GAD)
- Social Anxiety Disorder (Social Phobia)
- Panic Disorder
- Agoraphobia
What are some Closely Related Disorders - to anxiety?
-
Obsessive-Compulsive and Related Disorders
- Obsessive-Compulsive Disorder
-
Trauma and Stress Related Disorders
- Post Traumatic Stress Disorder
- Depression
OCD used to be under anxiety, now w/DSMV is related
Developmentally appropriate fears at birth to 6mths
Loss of physical support
Loud noises
Developmentally appropriate fears at 7-12 mths
strangers
Developmentally appropriate fears at 1-5years
- Separation from parents
- Storms
- Animals
- The dark
Developmentally appropriate fears at 6-12 years
- Bodily Injury
- Burglars
- Principal’s Office
- Punishment
- Failure/School Performance
Developmentally appropriate fears at 12-18 years****
- Tests/School Performance
- Social Embarrassment
- Health Issues
- Relationships
- The Abstract/Future
Prevalence of separation anxiety DO
4%
separation anxiety DO: male vs female
equal
onset of separation anxiety DO
- 7-9 years of age
- Start of school, after vacations, recent death, divorce
- One of the earliest occurring disorders
- ? “Gateway Disorder”
Characteristics of separation anxiety DO
- Anxiety when away from or anticipating separation from home, parents or caregivers
- Excessive and extreme homesickness and feelings of misery
- Crying
- Tantrums
- Vomiting
- Commonly have fears regarding the health and safety of their parents/caregivers.
- Try to avoid going places by themselves
- Refuse to go to school or camp
- Reluctance or refusal to participate in sleepovers
- Follow a parent around
- Demand that someone stay with them at bedtime, or “appear” in their parent’s bedroom during the night
- Awake from nightmares about being separated from loved ones.
Prevalence of selective mutism
fever than 1%
Gender ratio of selective mutism
female > male 2:1
Onset of selective mutism
4-8 years
Characteristics of selective mutism
- Refusal to speak in situations where speech is expected or necessary
- Interferes with school and relationships
- Symptoms last at least 1 month
Which anxiety DO is called “a sever form of social phobia”? *****
selective mutism
Behavior of an adolescent with selective mutism***
- Stand motionless and expressionless, turn his/her head away, chew or twirl hair, avoid eye contact or withdraw into a corner.
- These children are talkative and even boisterous when around family or in a place they feel comfortable****Important to know this distinction
What kind of signs and symptoms might an ado with selective mutism experience?
- Symptoms of anxiety present before social events include: stomach aches, headaches, and other physical symptoms.
- Additional signs of severe anxiety: separation anxiety, frequent tantrums and crying, moodiness, inflexibility, sleep problems and extreme shyness.
Prevalence of specific phobia
5%
Onset of specific phobia
6-9yo
Definition of specific phobia
- Intense, irrational fear of a specific object or situation that persists for at least 6 months and interferes with daily routine
- children do not usually recognize that their fear is irrational or out of proportion to the situation
- they may not articulate their fears
- avoidance of fearful situations or things or endure them with anxious symptoms
if once bitten attacked by dog = trauma; if never = irrational/sp ph
Anxious symptoms associated with specific phobia
- Crying
- Tantrums
- Freezing
- Clinging
- Headache
- Stomachache
Common phobias
- Animals
- Storms
- Heights
- Water
- Blood
- The dark
- Medical procedures
OCD prevalence
1-4%
Gender ratio of specific phobia
female = male
Gender ratio of OCD
females = males
Onset of OCD
10 years of age
Males tend to have an earlier age of onset
Definition of OCD
- Recurrent, persistent and distressing thoughts (obsessions) and behaviors (compulsions) that are usually recognized as excessive (not always present in children)
- Time consuming (>1 hr/day) and interfere with daily living
OCD: common obsessions
- Worry about dirt, germs or contamination
- Nagging feelings that something bad will happen if certain items are not in an exact place, position or order
- Fear that one’s negative or blasphemous thoughts or images will cause personal harm or harm to a loved one
- Rumination about accidentally or purposefully injuring another person
OCD: common compulsions
- Cleaning - Repeatedly washing one’s hands, bathing or cleaning household items
- Checking - Checking and re-checking, that the doors are locked, stove is turned off, hairdryer is unplugged, etc.
- Repeating - Unable to stop repeating a name, phrase or song
- Touching and arranging
- Mental rituals-good thoughts neutralize bad thoughts, praying, special words/phrases
OCD: related DOs
- Body Dysmorphic Disorder
- Hoarding Disorder
- Trichotillomania (Hair Pulling)
- Excoriation (Skin Picking) Disorder – careful w/acne. Can go way overboard.
- Body Focused Repetitive Disorder
- Nail or lip biting, cheek chewing
- Olfactory reference Syndrome – new dsm V. So intolerant of odors that can’t be in room. Not important.
GAD: prevalence
4.6% (1%-14%)
GAD: gender ratio
2 females: 1 male
GAD: common worries
Grades Performance in sports
Punctuality Family Issues
Natural Disasters Health
GAD: definition
- Excessive worry
- Difficult to control
- At least one of the following symptoms for a 6 month duration:
restlessness muscle tension
fatigue concentration problems
irritability sleep disturbance
how to distinguish from adolescence. Probe.
GAD: describe the person with GAD - presenting symptoms, personality, etc
- Usually come in with c/o stomachache, headache and fatigue*** (also test for thyroid, lyme)
- Often are nail biters, hair pullers, thumb suckers
- Shy, self-deprecating and pessimistic
- Overly serious, perfectionistic and excessively compliant with authority
- At risk for somatization disorders
Social Anxiety DO: prevalence
2-5%
Social Anxiety DO: gender ratio
female>male; 2.5:1
Social Anxiety DO: onset
12-15 years of age****
Social anxiety DO: definition
Pervasive fear of social encounters and public performance where there is a possibility of negative evaluation by others
Characteristics of an ado w/Social Anxiety DO
- Hesitance, passivity and discomfort when in the spotlight
- Avoidance or refusal to initiate conversations, perform in front of others, invite friends to get together, call others on the telephone for homework or other information, or order food in restaurants
- Avoidance of eye contact and speaks very softly or mumbles
- Minimal interaction and conversation with peers
- Appearing isolated and on the fringes of the group
- Sitting alone in the library or cafeteria, or hanging back from the group at team meetings
- Overly concerned with negative evaluation, humiliation or embarrassment
- Difficulty with public speaking, reading aloud, or being called on in class
** “fear of being negatively judged”. Not about how social they are, how many friends have, etc
Importance of timely treatment of social anxiety DO
- Age of onset is a critical time in normal social development
- Avoidance interferes w/QoL, can impair school performance, attendance, the ability to develop and maintain relationships
- If untreated, can increase risk for adult depression or alcohol abuse.
Ask who sit w/at lunch – good indicator
Why may social anxiety d/o go unrecognized?
Parents and teachers may not consider “extreme shyness” as a problem that warrants professional attention.
Prevalence of panic d/o
11%
Gender ratio of panic d/o
female>male 3:1
Panic DO: age of onset
16-18******
Definition of panic d/o (what happens, how long last)
- Abrupt onset of an episode of intense fear or discomfort that comes “out of the blue”
- Peaks in approximately 10 minutes
- Subsequent fear of having another “panic attack” is Panic Disorder
A panic attach must include 4 of the following symptoms
- a feeling of imminent danger or doom
- the need to escape
- palpitations
- sweating
- trembling
- shortness of breath or a smothering feeling
- a feeling of choking
- chest pain or discomfort
- nausea or abdominal discomfort
- dizziness or lightheadedness
- a sense of things being unreal, depersonalization
- a fear of losing control or “going crazy”
- a fear of dying
- tingling sensations
- chills or hot flushes
Given the symptoms of panic attacks, what are they sometimes misperceived as being? What is the consequence?
asthma, panic attack perceived as asthma, inhaler makes it worse
What is agoraphobia?
- Anxiety about being in places or situations from which “escape” might be difficult, embarrassing or in which help might not be available. Missing school? May not just be tests, transportation probs.
What situations are typically avoided in agoraphobia?
- Being outside alone
- Being in a crowd or standing in line
- Being on a bridge
- Traveling in a bus, train or automobile
Common medical disorders/problems that should be ruled out when a teen presents with symptoms of anxiety
- GI disorders
- organic causes of headaches
- migraines
- partial seizure disorder
- Asthma
- Hyperthyroidism
- Hypoglycemia
- Cardiac disorders
- MVP
- paroxysmal supraventricular tachycardia
- MI
Other underlying psychiatric d/os that need to be considered when an ado presents with anxiety
- ADHD****
- Psychotic Disorders
- PDD/Asperger’s
- Learning Disorders****
- Bipolar Disorder
- Depression
important b/c if take away Sx of these, anxiety will decrease
Anxiety: important aspects to focus on in the MSE
- Physical appearance and grooming
- Interaction with clinician
- Motor activity and coordination
- Mood and affect
- Attention, frustration tolerance
- Impulsivity/oppositional behavior
- Speech (rate and content)
- Judgment and insight
Fight or flight: fight – anger, aggression. Dxed w/ODD but anxious
Anxiety: important aspects to focus on in the Hx
- Presenting problem
- Symptoms
- Family History
- The anxious apple doesn’t fall far from the tree
- Social history
- academic
- recent stressors
- Medication history
- Substance use
Kids don’t know. Explain will not ask about them if you need to call family for Hx
Medications that may be involved in ado’s anxiety
- Steroids
- Anabolic and corticosteroids: aggravates
- Stimulants
- methylphenidate
- amphetamines
- Caffeine (caffeinism)
- cocaine
just decreasing caffeine may help those w/astronomical intake
- Alcohol (withdrawal)
- OTC medications
- Diet pills
- Antihistamines
- Cold medications- transient, but may c/o
- Psychotropic Medications
- SSRIs
- antipsychotics
- Street Drugs
Tools for screening an ado for anxiety DO
- Pediatric Symptom Checklist-Youth Report (11+)
- Self-Report for Childhood Related Anxiety Disorders (SCARED)
- Hamilton Anxiety Rating Scale (HAM-A)
- Online at Anxiety and Depression Association of America
http://www.adaa.org/living-with-anxiety/ask-and-learn/screenings
What are some options for treating an ado w/an anxiety DO?
- Cognitive Behavioral Therapy
- Other Forms of Therapy
- Dialectical Behavioral Therapy (DBT)
- Conflict resolution and distress tolerance
- Acceptance and Commitment Therapy (ACT)
- Acceptance and mindfulness
- Dialectical Behavioral Therapy (DBT)
- Pharmacology
How long does CBT usually last?
8-16 weeks
Is CBT individualized or group?
either
What is the overall goal of CBT?
- Manualized Treatment
- Changes behaviors by challenging maladaptive, distorted, “worried” thoughts or statements
- Replaces with more adaptive, positive thoughts or statements
What are the components of CBT?
- Psychoeducation: fight or flight
- Relaxation
- Breathing
- PMR
- Visualization
- Problem Solving: Anxiety à regression to concreteness. See abstract
- Cognitive Restructuring
- “proof”, “facts”, “what’s the worst thing that could happen”
- Exposure/Response(Ritual) Prevention
What are some options for pharm therapy of anxiety DOs?
- SSRIs
- Buspirone (Buspar)
- Benzodiazepines
- Clomipramine (Anafranil)
- Antipsychotics
- Augmentation agent in OCD and PTSD
- Other
- Gabapentin and pregabalin
- Diphenhydramine and hydroxyzine
SSRIs that are approved for pediatric OCD - and what ages?
Sertraline (Zoloft) > 6yo
Fluoxetine (Prozac) - > 7yo
Fluvoxamine (Luvox) > 8yo
also escitalopram (Lexapro) and Climipramine (Anafranil) but not in chart for ages
SSRIs given for GAD
Fluoxetine (Prozac), Fluvoxamine (Luvox), Sertraline (Zoloft)
SSRIs given for SoAD
Fluoxetine (Prozac)
Common SEs of SSRIs
- Anorexia
- Weight loss
- Headaches
- Nausea/Vomiting
- Tremor
- Drowsiness
- *ACTIVATION
- Insomnia, social disinhibition and agitation
Worried about SI. Will start w/slow dose. SI was d/t undxed bipolar. Adults usually start in mania, teens in depression – get pushed into manic state
When would withdrawal happen with SSRIs and which agents are the main culprits?
Usually occurs with a sudden discontinuation (paroxetine and fluvoxamine are the culprits)
Which SSRI is self-taper?
fluoxetine
S/Sx of withdrawal from SSRIs
- Dizziness
- HA
- N/V and diarrhea
- Insomnia
- Irritability
- lethargy
Safety with SSRIs: dosing *****
Start low, go slow
Be vigilant for activation with dosage increases (will usually happen in the week following a change)
Safety with SSRIs: Monitoring*****
Once on a stable dose, monitor:
- once a week for the first month
- Bi-weekly for the next 2 months
- Monthly there after
Safety with SSRIs: education*****
- Extensive education regarding side effects, particularly activation
- Careful instruction to patient, family and therapist to report ANY side effects
- Tell patients to avoid caffeine (SSRIs are powerful CP450 inhibitors) – cup of coffee that lasts a week
Buspirone (Buspar) for anxiety - type of drug and dosing schedule
anxiolytic, BID or TID
good for “anxious ADHD”
What is important to tell adolescents if you’re starting them on buspar***
no grapefruit juice!
Buspirone (Buspar) - what should you monitor for?
onitor for sedation, dizziness, stomachache, headache, fatigue and nervousness
When would you use benzos in an ado?
-
Short-term use ONLY
- School refusal
- Flying
- Dental/medical procedures
- Public speaking
- Panic attacks
Not ideal!
Important considerations when prescribing a benzo?
Discontinuation requires tapering
Potential for dependence; occurs after about 3 days
Benzos: monitor for
Close monitoring for behavioral disinhibition, drowsiness, dizziness, sedation and cognitive blunting
3 important aspects of managing anxiety in primary care***
- Validation
-
Education
- “Fight or Flight”
-
Relaxation
- Breathing
- PMR
- Visualization
Anxiety in PC: example of validating an ado’s concern
- “I believe that you are experiencing (insert somatic complaint)
- “I hear you are concerned about…”
- “It sounds like you are worried about …”
Anxiety in PC: when explaining fight or flight changes, what systems will you discuss?
Heart
Stomach
Brain
Skin
Vascular System
Eyes
Anxiety in PC: how will you teach relaxation?
- Breathing
- Diaphragmatic breathing
- Pursed lip breathing
- “sniff the flower; blow out the candle”
- maintain even O2, CO2 levels. Don’t take deep breaths – body will want to use it to run of fight
- Progressive Muscle Relaxation (PMR) – you tube, w/ear phones
- Visualization: iTunes, YouTube
Prevalence of PTSD
- *1%-30%
- higher in post-disaster or trauma exposed areas
- Up to 90% among witnesses of domestic violence and rape survivors
Gender ratio of PTSD
Females>Males
Onset of PTSD
variable
What percentage of youth experience a traumatic event by 16yo?*****
25%
What factors influence stress reactions (PTSD)
- Intensity and duration of stressor
- Age
- Coping ability
- Underlying mental health issues
- Support system
DSM-5 Criteria for PTSD
- A: 1 stressor
- B: 1 intrusion symptom
- C: 1 sx of avoidance
- D: 2 negative alterations in cognitions and mood
- E: 2 alterations in arousal
- F: Duration or B, C, D, E >1mth
- G: Functional significance
- H: Exculsion
DSM-5 Criteria for PTSD - Criterion A- examples of stressors
- Direct exposure
- Witnessing, in person
- Indirectly
- Close relative/friend
- Death (actual or threatened) must be violent or accidental
- Repeated or extreme indirect exposure to aversive details
- Does not include non-professionals through media, TV, movies or pictures
1 required
DSM-5 Criteria for PTSD - Criterion B- examples of Intrusion Sx
- Recurrent, involuntary and intrusive memories
- Children > can be repetitive play
- Traumatic nightmares (children no content)
- Dissociative reactions
- Distress after exposure to traumatic reminder
- Physiological reactivity after exposure to trauma-related stimuli
1 required
DSM-5 Criteria for PTSD - Criterion C- examples of avoidance
- Trauma related thoughts/feelings
- Trauma related external reminders
- People
- Places
- Conversations
- Activities
- Objects
- Situations
1 required
DSM-5 Criteria for PTSD - Criterion D- examples of negative alterations in emotions and mood
- Amnesia for key features
- Persistent negative beliefs/expectations
- Distorted blame of self or others
- Negative trauma related emotions
- Diminished interest in pre-traumatic significant activities
- Feelings of detachment or estrangement
- Constricted affect: inability for positive emotions
2 required
DSM-5 Criteria for PTSD - Criterion E- examples of alterations in arousal
- Irritability
- Self-destructive or reckless behavior
- Hypervigilence
- Exaggerated startle response
- Problems concentrating
- Sleep disturbance
2 required
DSM-5 Criteria for PTSD - Criterion F- Duration requirements
Persistence of B (intrusion sx), C (avoidance), D (negative alterations in cognition and mood), E (alterations in arousal) >1 mth
DSM-5 Criteria for PTSD - Criterion G - meaning of functional significance
Must impair social, occupational, scholastic, relationships, etc.
DSM-5 Criteria for PTSD - Criterion H - meaning of exclusion
- Not due to medication, substance use or other illness
- SPECIFY IF : with dissociative symptoms
- Depersonalization
- Derealization
- SPECIFY IF: With delayed expression
- Full diagnostic criteria not met until at least 6 months after trauma although sypmtoms occur immediately
Traumatic Events Associated with PTSD in Adolescents
- Sexual or physical abuse
- Violence (victim/**witness)
- Kidnapping
- Life threatening illnesses/procedures
- Injuries: animal bites, burns
- Accidents: motor vehicle, train
- Natural disasters
What did Lipschitz et al (2000) find in their community based study?
- 92% of the urban ado girls they studied had experienced at least one trauma.
- 14.4% met criteria for PTSD; 11.6% met criteria for partial PTSD
- Girls with PTSD vs. no PTSD were:
- Significantly more depressed
- Used more cigarettes and marijuana (substance use)
- More likely to have failed a grade in school
- More likely to be suspended from school
How does pediatric PTSD present in the office?
- Regression
- Sleep disturbances
- Irritability
- Poor concentration
- Depression/symptoms of depression
- Sexual promiscuity
- Violence toward self and others
- Substance use
- School failure
- School suspension
Some types of assessments that can be done for PTSD in ados
- Clinician-Administered PTSD Scale for Children and Adolescents for DSM-IV (CAPS-CA)
- Life Events Checklist-Child Version
- Both can be found at https://downloads.va.gov
What should you focus on in the office (in addition to scales/checklists for trauma/PTSD)
- Rule out medical diagnoses (as always)
- Parent interview (without patient)
- Symptom severity, intensity and duration
- Open ended questions about event if receptive
- Medication History
- Prescription
- Other
- Mental Status Exam
How should you interview an ado with suspected PTSD? Why?
- Ask direct yet open-ended questions related to the stressor
- They are reexperiencing, avoiding, have increased arousal (fight or flight)
- DO NOT ASK THEM TO RE-TELL IN DETAIL - educate that their feelings / sx are normal
Overview of mgmt in PC for PTSD
- Symptomatic patients should be referred to a mental health care provider
- Coordination of care
- Therapy
- Pharmacological (if appropriate)
- Stress management
- muscle relaxation
- positive imagery
- pursed-lipped breathing
Non-pharm treatment options for pediatric PTSD
- Trauma Focused CBT (TF-CBT)
- Trauma Releasing Exercises
- David Berceli, Ph.D.
- Hypnotherapy
- Neuro-linguistic programming (NLP)
- Eye Movement Desensitization and Reprogramming (EMDR)
- Trauma Incident Reduction (TIR)
- Somatic Experiencing (SE)
- Trauma Memory Processing
- Thought Field Therapy (TFT)
- Bio/neurofeedback
- Psychodynamic
How does Trauma focused CBT work?
- Integrates CBT with traditional child abuse therapies (ages 3-18 and parents)
- coping skills for grief
- stress management
- muscle relaxation
- positive imagery
- deep breathing
- thought stopping
- trauma exploration
Cohen and Mannarino, University of Pittsburgh
Pharm choices for pediatric PTSD
amitriptyline, SSRIs, Antipsychotics, Alpha-2s, BBs
SSRIs used for PTSD
paroxetine, sertraline and fluoxetine
Antipsychotics and PTSD
- used as augmentation agents
- risperidone
- aripiprazole
Alpha-2s and PTSD
- Clonidine (Kapvay FDA approved ADHD)
- Guanfacine
BBs and PTSD
- Atenolol
- Propranolol
- Performance anxiety
- 10-20 mg
- All B-blockers are banned in Olympics
Why use pharm therapy in PTSD
- Treat “core symptoms”
- Intrusion, re-experiencing and avoidant/numbing symptoms
- Consider with
- Moderate to severe symptoms
- significantly impaired functioning
- co-morbid mood/anxiety symptoms
- CBT/TF-CBT has low or no effectiveness
Benzos and PTSD
don’t work
What percent of children presenting to PC require mental health services?
33%
