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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