Anxiety in Children

Dr. Shamanthakamani NarendranMD(Pead), PhD(Yoga Science)

Depressed Mood

Q: How do you know a child or adolescent has a depressed mood?

A: – Ask

Sadness is just one presentation Irritability is common Loss of pleasure

– Observe– Use multiple informants

The Informant Matters

Parents commonly under- and over-report child’s mood and anxiety feelings (internalizing symptoms)

Parents are typically good reporters of disruptive behaviors such as hyperactivity & aggression (externalizing symptoms)

Depressed vs Depressive Episode

Q: What is the difference between a depressed mood and a depressive episode?

A: – Mood is the subjective feeling state– An episode is a cluster of specific, associated

symptoms that occur over a defined period of time DSM-IV-TR definition

Major Depressive Episode

Criteria: 5+ during same 2 weeks– Depressed mood - most of the day, most days– Anhedonia– Appetite change, weight loss, FTT– Insomnia or hypersomnia– Psychomotor agitation or retardation– Fatigue or loss of energy– Feelings of worthlessness or inappropriate guilt– Poor concentration and/or indecisiveness– Recurrent thoughts of death or suicidal ideation

Major Depressive Disorder

Must have distress/impairment R/O causative medical and/or drug condition R/O Bereavement R/O mixed mood episode This is additionally rated

– Single vs. Recurrent– Mild, Moderate, Severe– With or Without Psychotic Features

Depressed Mood: Diagnostic Considerations?

Simple depressed mood (no diagnosis) Adjustment Disorder(s) Dysthymia Major Depressive Disorder Bipolar Disorder, Depressed Schizoaffective Disorder, Depressed Depressed mood associated with another diagnosis Substance Use/Substance Use Disorder Medical Condition

Irritable Mood:Diagnostic Considerations

Simple irritable mood (no diagnosis) Adjustment Disorder(s) Dysthymia Major Depressive Disorder Bipolar Disorder, Depressed or Hypomanic or Manic or

Mixed Episode (or “NOS”) Psychotic (Thought) Disorders

Irritable Mood:Diagnostic Considerations

Oppositional Defiant Disorder ADHD Anxiety Disorders, e.g. PTSD Sleep Disorder Substance Use/Substance Use Disorder Medical Condition Personality Disorder

Hypomanic & Manic Episodes

Distinct period of abnormal & persistent mood change - elevated, expansive, or irritable

3+ corresponding sx– Inflated self-esteem– Decreased need for sleep– More talkative; pressured talk– Flight of ideas or thought racing– Distractibility– Increase in goal-directed activity or agitation– Excessive involvement in risky pleasurable activities

Hypomanic & Manic Episodes

R/O Somatic causes, e.g. medical conditions, drug effect

Not a mixed mood episode Unequivocal change in function Hypomania vs mania

– Time– Degree of impairment– Presence/absence of psychotic symptoms

Anxiety

Q: What does this look like in children and adolescents?

A:

Anxiety vs Anxiety Disorder(s)

Important to determine– Impairment present?– Circumstances?– Associated symptoms?

Anxiety Disorders

Adjustment Disorder(s) PTSD Social Phobia Other Phobias Obsessive Compulsive Disorder Panic Disorder (panic attacks necessary but not

sufficient for diagnosis) Generalized Anxiety Disorder Separation Anxiety Disorder Substance Use/Substance Use Disorders Medical Condition

Diagnostic Precision

Q: Why is this important?

A: For prognosis & treatment

- Evidence-Based Medicine

Clinical Case

10 year old female Chief complaint of parents - she fights a lot and

is not compliant Has trouble falling asleep Poor concentration and falling grades in school Mopes around the house, doesn’t seem as

interested in doing things with her friends

Possibilities

Depressed mood– Adjustment Disorder– Major Depressive Disorder– Bipolar, Depressed

NB: ~ 30% of children with Major Depressive Episode are eventually diagnosed with Bipolar Disorder

Screening

What do you want to screen? Who do you want to screen? What will you do with positive screens?

Diagnostic Evaluation

Do it yourself Make a referral

– Type of provider– Insurance– Availability– Communication

Three Components of Anxiety

Physical symptoms Cognitive component Behavioral component

Physiology of Anxiety: Physical System

Perceived danger Brain sends message to autonomic nervous system Sympathetic nervous system is activated (all or none

phenomena) Sympathetic nervous system is the fight/flight system Sympathetic nervous system releases adrenaline and

noradrenalin (from adrenal glands on the kidneys). These chemicals are messengers to continue activity

Parasympathetic Nervous System

Built in counter-acting mechanism for the sympathetic nervous system

Restores a realized feeling Adrenalin and noradrenalin take time to

destroy

Cardiovasular Effects

Increase in heart rate and strength of heartbeat to speed up blood flow

Blood is redirected from places it is not needed (skin, fingers and toes) to places where it is more needed (large muscle groups like thighs and biceps)

Respiratory Effects-increase in speed and dept of breathing

Sweat Gland Effects-increased sweating

Behavioral System

Fight/flight response prepares the body for action-to attack or run

When not possible behaviors such as foot tapping, pacing, or snapping at people

Cognitive System

Shift in attention to search surroundings for potential threat

Can’t concentrate on daily tasks Anxious people complain that they are easily

distracted from daily chores, cannot concentrate, and have trouble with memory

“U” Shaped Function of Anxiety

Useful part of life Expressed differently at various age levels

Generalized Anxiety Disorder

Unfocused worry

Generalized Anxiety Disorder: Diagnostic Criteria

Excessive anxiety or worry occurring more days than not for at least 6 months about a number of events or activities

Difficulty controlling worry 3 of 6 symptoms are present for more days

than not:restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance

Generalized Anxiety Disorder (GAD): Prevalence

~ 4% of the population (range from 1.9% to 5.6%)

2/3 or those with GAD are female in developed countries

Prevalent in the elderly (about 7%)

Generalized Anxiety Disorder: Genetics

Familial studies support a genetic model (15% of the relatives of those with GAD display it themselves-base rate is 4% in general population)

Risk of GAD was greater for monozygotic female twin pairs than dizygotic twins.

The tendency to be anxious tends to be inherited rather than GAD specifically

Heritability estimate of about 30%

Generalized Anxiety Disorder: Neurotransmitters

Finding that benzodiazepines provide relief from anxiety (e.g. valium)

Benzodiazepine receptors ordinarily receive GABA (gamma-aminobutyric acid)

GABA causes neuron to stop firing (calms things down)

Generalized Anxiety Disorder: Neurotransmitters

Getting Anxious

Hypothesized Mechanism:

Normal fear reactions

Key neurons fire more rapidly

Create a state of excitability throughout the brain and body –perspiration, muscle tension etc.

Excited state is experiences as anxiety

Calming Down

Feedback system is triggered

Neurons release GABA

Binds to GABA receptors on certain neurons and “orders” neurons to stop firing

State of calm returns

GAD: problem in this feedback system

GABA Problems?

Low supplies of GABA Too few GABA receptors GABA receptors are faulty and do not capture

the neurotransmitter

Generalized Anxiety Disorder: Cognitions

Intense EEG activity in GAD patients reflecting intense cognitive processing: low levels of imagery

Worrying is a form of avoidance They restrict their thinking to thoughts but do not

process the negative affect Worry hinders complete processing of more disturbing

thoughts or images Content of worry often jumps from one topic to another

without resolving any particular concern

Generalized Anxiety Disorder: Treatment

Short term-benzodiazepine (valium) Cognitive Therapy (focus on problem)

Phobia: Diagnostic Criteria

Marked & persistent unreasonable fear of object or situation

Anxiety response Unreasonable Object or situation avoided or endured with

distress

Differential Diagnosis of Specific Phobia

Vs. SAD: not related to fear of separation Vs. Social Phobia: not related to fear of a

social situation or fear of humiliation Vs. Agoraphobia: fear not related to closed

places Vs. PTSD: fear not related to a specific past

traumatic event

Phobias: Types

Specific phobias Blood-Injection Injury phobias Situational phobia Natural environment phobia Animal phobia Pa-leng (Chinese) colpa d’aria (Italian) Germs Choking phobia…..

What are your fears???

Developmentally Normal Fears

Age Normal Fear

Birth- 6 Months Loud noises, loss of physical support, rapid position changes, rapidly approaching other objects

7-12 Months Strangers, looming objects, unexpected objects or unfamiliar people

1-5 Year Strangers, storms, animals, dark, separation from parents, objects, machines loud noises, the toilet

6-12 Year Supernatural, bodily injury, disease, burglars, failure, criticism, punishment

12-18 Performance in school, peer scrutiny, appearance, performance

Normal Rituals and Behaviors

Even some ritualistic behaviors are normal Any rituals?

Phobias: Prevalence

Fears are very prevalent Phobias occur in about 11% of the population More common among women Tends to be chronic

Etiology of Phobias: Genetics

31% of first degree relatives of phobics also had a phobia (compared to 11% in the general population)

Relatives tended to have the same type of phobia

Not clear if transmission is environmental or genetic

Specific Phobia: Behavioral Perspective

Case of Little Albert

Two-factor model: Acquisition-classical

conditioning Maintenance-operant

conditioning

Specific Phobia: Behavioral Perspective

Classical conditioning Modeling Stimulus generalization

Specific Phobia: Behavioral-Evolution Perspective (Preparedness)

Discussion Section Topic

Specific Phobia: Cognitive Perspective

Specific Phobia: Social and Cultural Factors

Predominantly female Unacceptable in cultures around the world for

men to express fears

Specific Phobia: Treatment

Systematic Desensitization

Social Phobia

Fearful apprehension Social situations

Social Phobia: Diagnostic Criteria

Marked or persistent fear in one or more social or performance situations

Exposure to fear situation is associated with extreme anxiety

Person recognizes that fear is excessive or unreasonable

Feared social and performance situations are avoided or endured with intense anxiety

Social Phobia: Prevalence

13% of the general population About equally distributed in males and females,

however, males more often seek treatment Usually begins around age 15 Equally distributed among ethnic groups

Etiology Social Phobia: Emotions

Temperament and Biological Theories (Kagan) Behaviorally inhibited children 2 remained inhibited at

age 7 and 12 (see video)

Biological preparedness We are prepared to fear rejecting people Social phobics more likely to foucs on critical facial

experessions

Biological Basis of Temperament

Kagan proposed temperamental differences related to inborn differences in brain structure and chemistry:

He found inhibited children have: Higher resting heart rates Greater increase in pupil size in response to

unfamiliar Higher levels of cortisol (released with stress)

Temperament and Anxiety Disorders

Inhibited temperament: risk factor in social phobia

Kagan’s Temperamental/Biological Theory and Prevention

Early identification of at risk children Parental training Avoid overprotecting Encourage children to enter new situations Help kids to develop coping skills Avoid forcing the child

Encouraging Shy Children: helpful hints

Use rewards Arrange don’t push No nagging

Social Phobia: Treatment

Cognitive-Behavioral Therapy Assess which social

situations are problematic Assess their behavior in

these situations Assess their thoughts in

these situations Teaches more effective

strategies Rehearse or role play

feared social situations in a group setting

Medication Tricyclic antidepressants Monoamine oxidase inhibitors SSRI (Paxil) approved for

treatment Relapse is common with

medications are discontinued