Title: Depression and Anxiety in Children
1Depression and Anxiety in Children
- Ruth E. Imershein, MD RMO/P
- US Embassy Bangkok
2Depression - definition
- Depression is defined as the state of being
depressed, dejected, downcast, sad or gloomy.
3Depression
- 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.
4 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.
5Depression - types
- Adjustment Disorders
- Dysthymia
- Major Depression
- Bipolar Disorder
6Adjustment 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).
7Adjustment 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
8Adjustment 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.
9Dysthymic 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.
10Dysthmic 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
11Dysthymic Disorder
- The symptoms cause clinically significant
distress or impairment in social, occupational or
other important areas of functioning.
12Dythymic 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.
13Dysthymic 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.
14Dysthymic 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.
15Dysthymic 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.
16Major 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
17Major 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.
18Major 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.
19Major 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.
20Major 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.
21Associated 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
22Associated 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.
23Major 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.
24Major 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.
25Anxiety 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)
26Anxiety 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.
27Anxiety 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
28Separation 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
29Separation 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
30Separation 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
31Separation 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.
32Separation 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
33Separation 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.
34Separation 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.
35Social 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.
36Social 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.
37Social 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.
38Social 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.
39Social 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.
40Obsessive 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.
41Obsession - 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
42Common 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
43Compulsions - 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.
44Common 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
45OCD - 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.
46OCD - 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
47Treatment 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)
48Selective Serotonin Reuptake Inhibitors
- Prozac (Fluoxetine)
- Zoloft (Sertraline)
- Paxil (Paroxitine)
- Luvox (Fluvoxamine)
- Celexa (Citalopram)
- Lexapro (Escitalopram)
49SSRIs
- 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
50SSRIs 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
51SSRIs 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
52Anafranil
- 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.
53Resources 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
54More 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.
55Resources 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
56More 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
57Books 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