Depression and Anxiety in Children

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Depression and Anxiety in Children

• Ruth E. Imershein, MD RMO/P
• US Embassy Bangkok

2
Depression - definition

• Depression is defined as the state of being
  depressed, dejected, downcast, sad or gloomy.

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Depression

• Depression is an illness when the feelings of
  depression are greater or more prolonged than
  warranted by any objective reason.
• Depression is an illness when the feelings of
  depression persist and interfere with an
  individual's ability to function.

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Depression - incidence

• About 5 percent of children and adolescents in
  the general population suffer from depression at
  any given point in time.
• Children under stress, who experience loss, or
  who have attentional, learning, conduct or
  anxiety disorders are at a higher risk for
  depression.
• Depression also tends to run in families.

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Depression - types

• Adjustment Disorders
• Dysthymia
• Major Depression
• Bipolar Disorder

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Adjustment Disorder with Depressed Mood

• The development of emotional or behavioral
  symptoms in response to an identifiable
  stressor(s) occurring within three months of the
  onset of the stressor(s).

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Adjustment Disorder with Depressed Mood

• The symptoms or behaviors are clinically
  significant as evidenced by either of the
  following
• Marked distress that is in excess of what would
  be expected from exposure to the stressor
• Significant impairment in social or occupational
  (academic) functioning

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Adjustment Disorder with Depressed Mood

• The stress related disturbance does NOT meet
  criteria for another specific mental health
  disorder and is NOT merely exacerbation of a
  preexisting mental health disorder
• The symptoms do NOT represent Bereavement.
• Once the stressor (or its consequences) has
  terminated, the symptoms do not persist for more
  than an additional 6 months.

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Dysthymic Disorder

• Depressed mood for most of the day, for more days
  than not, as indicated by either subjective
  account or observation by others, for at least
  two years.
• Note that in children and adolescents this has
  been modified so that the mood can be irritable
  and that the duration must be at least one year.

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Dysthmic Disorder

• The presence, while depressed, of two or more of
  the following symptoms
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

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Dysthymic Disorder

• The symptoms cause clinically significant
  distress or impairment in social, occupational or
  other important areas of functioning.

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Dythymic Disorder

• The disturbance is not a Major Depressive
  Episode, either chronic or in partial remission.
• There has never been a manic or hypomanic
  episode.
• There is no evidence of psychosis.
• The symptoms are not due to the effects of a
  substance, either drug abuse or prescribed
  medication or a general medical condition.

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Dysthymic Disorder - facts

• The onset of dysthymic disorder (also called
  dysthymia) is usually in childhood or
  adolescence.
• The child or adolescent is depressed for most of
  the day, on most days, and symptoms continue for
  several years.

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Dysthymic Disorder - facts

• The average duration of a dysthymic period in
  children and adolescents is about 4 years.
• Sometimes children are depressed for so long that
  they do not recognize their mood as out of the
  ordinary and thus may not complain of feeling
  depressed.

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Dysthymic Disorder - facts

• Seventy percent of children and adolescents with
  dysthymia eventually experience an episode of
  major depression.
• Because of its persistent nature, Dysthymic
  Disorder is especially likely to interfere with
  normal adjustment.

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Major Depressive Disorder

• Five or more of the following symptoms have been
  present during the same 2 week period and
  represent a change from previous functioning.
• At least one of the symptoms is either
• Depressed mood
• Loss of interest or pleasure

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Major Depression

• List of symptoms
• Depressed (or in children irritable) mood most of
  the day, nearly every day either by subjective
  report or observation by others.
• Markedly diminished interest or pleasure in all
  or almost all, activities most of the day, nearly
  every day. Change in participation of activities.
  Change in communication. Social isolation.

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Major Depression

• Significant weight loss when not dieting or
  weight gain (5 change in body weight) or failure
  to gain weight as expected or decrease or
  increase in appetite.
• Trouble falling asleep, staying asleep or waking
  up too early OR desiring to sleep or sleeping all
  the time.

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Major Depression

• Feelings of restlessness or agitation OR being
  slowed down by self report AND observation of
  others
• Fatigue or loss of energy nearly every day.
  Complaints of boredom.
• Feelings of worthlessness, or excessive or
  inappropriate guilt nearly every day. Low self
  esteem. Hopelessness.

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Major Depression

• Diminished ability to think or concentrate or
  indecisiveness, nearly every day. Trouble making
  decisions.
• Recurrent thoughts of death (not just a fear of
  death), recurrent suicidal ideation without
  specific plan, or a suicide attempt or specific
  plan for committing suicide. A desire to get
  away. Talk of or efforts towards running away.

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Associated Features

• Crying spells or tearfulness
• Frequent absences from school or poor performance
  in school
• Frequent complaints of physical illnesses such as
  headaches and stomachaches
• Frequent bouts of illnesses that don't get better
  with treatment
• Extreme sensitivity to rejection or failure

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Associated features

• Emotional outbursts
• Poor social relationships
• Alcohol or Substance abuse
• Reckless behavior
• Reluctance to meet new people or try new things
• Fears of separation
• Psychotic features can occur but are more likely
  to be auditory hallucinations than delusions.

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Major Depression - facts

• Population studies show that at any point in time
  10 to 15 percent of children and adolescents have
  some symptoms of depression.
• In children and adolescents, an episode lasts on
  average from 7 to 9 months.
• It has many clinical features similar to those in
  adults.

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Major Depression - facts

• Once a young person has experienced a major
  depression, he or she is at risk of developing
  another depression within the next 5 years.
• There is also an increased risk for other mental
  health problems.
• Having a family history of depression,
  particularly a parent who had depression at an
  early age, also increases the chances that a
  child or adolescent may develop depression.

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Anxiety Disorders - definition

• Distress or uneasiness caused by danger or
  misfortune. (everyday)
• A state of apprehension or psychic tension that
  can be found in most mental health disorders.
  (psychiatric)

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Anxiety Disorders

• Anxiety disorders are more common in children and
  adolescence than all other mental disorders in
  this age group.
• The 1-year prevalence in children ages 9 to 17 is
  13 percent.
• Anxiety disorders occur in younger children as
  well.

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Anxiety Disorders - types

• Adjustment disorder with anxious mood or with
  mixed emotional features
• Separation anxiety disorder
• Generalized anxiety disorder
• Social phobia
• Obsessive-compulsive disorder
• Panic Disorder with or without agoraphobia
• Acute Stress Disorder
• Post Traumatic Stress Disorder

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Separation Anxiety Disorder

• Developmentally inappropriate and excessive
  anxiety concerning separation from home or from
  those to whom the individual is attached as
  evidenced by three or more of the following

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Separation Anxiety Disorder

• Recurrent excessive distress when separation from
  home or major attachment figures occurs or is
  planned
• Persistent or excessive worry about losing or
  about possible harm befalling major attachment
  figures
• Persistent or excessive worry that an untoward
  event will lead to separation from a major
  attachment figure

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Separation Anxiety Disorder

• Persistent reluctance or refusal to go to school
  or elsewhere because of fear of separation
• Persistently and excessively fearful or reluctant
  to be alone without major attachment figures at
  home or without significant adults in other
  settings
• Persistent reluctance or refusal to go to sleep
  without being near a major attachment figure or
  to sleep away from home

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Separation Anxiety Disorder

• Repeated nightmares involving the theme of
  separation
• Repeated complaints of physical symptoms such as
  headaches, stomachaches, nausea, vomiting when
  separation from major attachment figures occurs
  or is anticipated.

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Separation Anxiety Disorder

• The duration of the disturbance is at least 4
  weeks
• The onset is before 18 years of age
• The disturbance causes clinically significant
  distress or impairment in social, academic or
  other important areas of functioning

33
Separation Anxiety Disorder

• Separation anxiety is often associated with
  symptoms of depression, such as sadness,
  withdrawal, apathy, or difficulty in
  concentrating, and such children often fear that
  they or a family member might die.
• Young children experience nightmares or fears at
  bedtime.

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Separation Anxiety Disorder

• About 4 percent of children and young adolescents
  suffer from separation anxiety disorder.
• Among those who seek treatment, separation
  anxiety disorder is equally distributed between
  boys and girls. In survey samples, the disorder
  is more common in girls.
• The disorder may be over diagnosed in children
  and teenagers who live in dangerous neighborhoods
  and have reasonable fears of leaving home.

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Social Phobia

• A marked and persistent fear of one or more
  social or performance situations in which the
  person is exposed to unfamiliar people or to
  possible scrutiny by others. The individual fears
  that he or she will act in a way (or show anxiety
  symptoms) that will be humiliating or
  embarrassing.

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Social Phobia

• Exposure to the feared social situation almost
  invariably provokes anxiety. In children the
  anxiety may be expressed by crying, tantrums,
  freezing or shrinking from social situations with
  unfamiliar people.
• The person recognizes that the fear is excessive
  and unreasonable. (This may be absent in
  children.)
• The feared social or performance situations are
  avoided or else is endured with intense anxiety
  or distress.

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Social Anxiety

• The avoidance, anxious participation or distress
  in the feared social or performance situation(s)
  interferes significantly with the person's normal
  routine, occupation or academic functioning, or
  social activities or there is marked distress
  about having the phobia.
• The duration is at least 6 months in children
  under 18 years of age.

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Social Anxiety - facts

• Social phobia is common, the lifetime prevalence
  ranging from 3 to 13 percent, depending on how
  great the fear is and on how many different
  situations induce the anxiety (DSM-IV Black et
  al., 1997).
• In survey studies, the majority of those with the
  disorder were found to be female (DSM-IV).
• Often the illness is lifelong, although it may
  become less severe or completely remit.
• Life events may reassure the individual or
  exacerbate the anxiety and disorder.

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Social Anxiety - facts

• Young children may not articulate their fears,
  but may cry, have tantrums, freeze, cling, appear
  extremely timid in strange social settings.
• They may fall behind in school, avoid school
  completely, or avoid social activities among
  children their age.
• The avoidance of the fearful situations or worry
  preceding the feared event may last for weeks and
  interferes with the individuals daily routine,
  social life, job, or school.
• They may find it impossible to speak in social
  situations or in the presence of unfamiliar
  people.

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Obsessive Compulsive disorder

• There are either obsessions or compulsions AND
• At some point during the course of the disorder,
  the person has recognized that the obsessions or
  compulsions are excessive and unreasonable. (this
  may not apply in children.)
• The obsessions or compulsions cause marked
  distress, are time consuming (take more than 1
  hour per day) or significantly interfere with the
  person's normal routine, functioning, or usual
  social activities or relationships.

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Obsession - definition

• Recurrent and persistent thoughts, impulses or
  images that are experienced, at some time during
  the disturbance, as intrusive and inappropriate
  and that cause marked anxiety or distress
• The thoughts, impulses or images are not simply
  excessive worries about real life problems
• The person attempts to ignore or suppress such
  thoughts, images or impulses or to neutralize
  them with some other thought or action
• The person recognizes that the obsessional
  thoughts, impulses or images are a product of
  his/her own mind

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Common Obsessions

• Excessive guilt
• Forbidden thoughts sexual or aggressive
• Needing to seek reassurance asking for or
  confessing to others
• Needing answers
• Fears about contamination
• Fears about illness in self or others
• Need for symmetry
• Worries about harm to self or others
• Concerns about exactness or the order of things

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Compulsions - definition

• Repetitive behaviors or mental acts that the
  person feels driven to perform in response to an
  obsession or according to rules that must be
  applied rigidly.
• The behaviors or mental acts are aimed at
  preventing or reducing distress or preventing
  some dreaded event or situation, however, these
  behaviors or mental acts either are not connected
  in a realistic way with that they are designed to
  neutralize or prevent or are clearly excessive.

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Common Compulsions

• Hand washing, cleaning, decontamination rituals
• Repeating behaviors
• Rearranging, straightening or ordering things by
  size, shape, color, etc.
• Counting
• Touching, tapping, rubbing
• Checking
• Seeking reassurance, praying, confessing

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OCD - facts

• Estimates of prevalence range from 0.2 to 0.8
  percent in children, and up to 2 of adolescents
• There is a strong familial component to OCD, and
  there is evidence from twin studies of both
  genetic susceptibility and environmental
  influences.

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OCD - facts

• Recent research suggests that some children with
  OCD develop the condition after experiencing one
  type of streptococcal infection.
• This condition is referred to by the acronym
  PANDAS, which stands for Pediatric Autoimmune
  Neuropsychiatric Disorders Associated with
  Streptococcal infections.
• Treatment includes antibiotics and standard OCD
  treatments

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Treatment Options

• Talk therapies
• Cognitive Behavioral Therapy
• Family psychoeducation
• Contextual Emotion Regulation Therapy learning
  self regulation of distress and dysophoria
• Medications Selective Serotonin Reuptake
  Inhibitors and Anafranil (Clomipramine)

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Selective Serotonin Reuptake Inhibitors

• Prozac (Fluoxetine)
• Zoloft (Sertraline)
• Paxil (Paroxitine)
• Luvox (Fluvoxamine)
• Celexa (Citalopram)
• Lexapro (Escitalopram)

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SSRIs

• They are very effective when properly prescribed
  and monitored
• They dont work instantly
• They all take anywhere from 2 weeks to 3 months
  to be effective
• They are generally well tolerated

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SSRIs continued

• These drugs all have the same potential for side
  effects
• They have similar side effects, but the half life
  of the drugs is different and the occurrence of a
  specific side effect may be different
• Each individual responds differently to each drug
• If one doesnt work, another should be tried

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SSRIs continued

• They are very safe - the only reports of death
  associated with overdose are in association with
  other medications or excessive alcohol with
  complications
• All antidepressants have been associated with
  suicidal thinking
• Recent studies suggest that failure to prescribe
  antidepressants may be resulting in an increase
  in suicide attempts and completed suicides

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Anafranil

• This is an older medication, a tricyclic
  antidepressant
• It is VERY effective particularly for individuals
  with OCD, however, it is not commonly prescribed
  because the side effects are considered less
  desirable and because it is dangerous is
  overdosage.

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Resources for Professionals

• Madison Institute of Medicine, Inc.
  http//www.miminc.org
• Books, games and other materials for
  professionals and some for parents
• Childswork/Childsplay http//www.childswork.com
• Creative Therapy Store http//www.creativetherapys
  tore.com

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More Resources for Professionals

• Psychiatric Annals Volume 35 Number 9 September
  2005, Childhood Anxiety Disorders Guidelines for
  diagnosis and treatment in general psychiatric
  practice
• Mental Health a Report by the Surgeon General
  Overview of Mental Disorders is Children
  http//www.surgeongeneral.gov/library/mentalhealth
  /chapter3/sec3.html
• Journal of the American Academy of Child
  Adolescent Psychiatry. 36(9)1305, September
  1997, Growing Up Sad Childhood Depression and
  Its Treatment by Nguyen, Nga M.D.

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Resources for parents

• For parents Is it Just a phase? by Susan Swedo
  and Henrietta Leonard
• Don't Be Afraid To Discipline The Commonsense
  Program for Low-Stress Parenting... by Ruth
  Peteres
• Hearing is Believing How Words Can Make or Break
  Our Kids by Elisa Medhus
• Its Not Fair, Jeremy Spencers parents let him
  stay up all night! by Anthony Wolf

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More resources for parents

• John Rosemonds New parent Power! by John
  Rosemond
• Parent Talk How to Talk to Your Children in
  Language that Builds Self Esteem and Encourages
  Responsibility by Chick Moorman
• Pick up Your Socks and other skills Growing
  Children Need by Elizabeth Crary
• The Pocket Parent by Gail Reichlin
• 1-2-3- Magic Effective Discipline for Children
  2-12 by Thomas Phelan

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Books for children

• Dont Feed the Monster on Tuesdays! The
  Childrens Self Esteem Book by Adolph Moser
• Tales of a Fourth Grade Nothing by Judy Blume
• Beezus and Ramona by Beverly Cleary