Anxiety and depression

 DO

• Rule out physical causes and delirium and treat these whenever possible. In doing so, be especially the possibility of pain.
• In case of acutely severe and/or persistent concerns around anxiety and/or mood, involve registered psychosocial care provider with experience in palliative care.

• Consider consulting experts with knowledge and experience in palliative care. 

 DO

• Discuss with child and family all factors that may influence anxiety and depression in the child (including siblings).
• Inform child and family about (counter-)transmission and reinforcement of emotions among themselves.
• Discuss the management of emotions for all members of the family.
• Fill in gaps in knowledge with child and family, while guarding against providing too much information.
• Connect in contact and conversations to the developmental level (cognitive and emotional) of the child and be alert to the existence of discrepancies in development.
• Draw up a (psychosocial) care plan together with the child and family, using Advance Care Planning. Support parents in prioritising care.
• Organise a day/week structure with attention to rituals, emotion-oriented activities and activities that are "as normal as possible" (recovery-oriented).

• Consider exploring their understanding of the child's death.
• Consider distinguishing between existential themes, normal appropriate reactions (requiring help) and the possible existence of psychiatric disorders.

 DO

• Treat physical causes whenever possible:
  • Treat pain that is inadequately controlled.
  • Discontinue or modify medications that cause or worsen anxiety and/or depression.

 DO

• Provide psychoeducation about the symptoms.
• Organise a day/week structure with attention to rituals, emotion-focused activities and activities that are "as normal as possible" (recovery-oriented).
• Involve a registered psychosocial counsellor with experience in palliative care when deploying counselling or treatment.

• For anxiety, consider engaging experts in self-management in the form of mindfulness, relaxation, self-hypnosis or guided fantasy.

 DO

• Discuss the use and initiation of medication with a child psychiatrist experienced in palliative care or a paediatrician.
• When initiating medication, consider whether supporting psychotherapy is appropriate and feasible.

• For anxiety reduction in dying children, consider intranasal midazolam.
• For acute anxiety, consider intranasal midazolam or oral lorazepam.
• For acute anxiety in paediatric delirium or psychotic dysregulation, consider antipsychotics (risperidone, haloperidol).

• Use of medication in consultation with a child psychiatrist experienced in palliative care or a paediatrician.
• When using medication, consider whether supportive psychological therapy is appropriate and feasible.
• For moderate to severe depression in children 8 years and older, consider fluoxetine. 
• Consider SSRIs especially for children with cancer.
• Consider methylphenidate.

• Administer TCAs because of the potential for serious adverse effects and the need for determinations of blood levels.

 DO

• Evaluate the effect and side effects of treatment instituted at the appropriate time, and adjust treatment as needed. Involve child and family in this process.