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Mood and Anxiety disorders in Children and Adolescents

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Title: Mood and Anxiety disorders in Children and Adolescents


1
Mood and Anxiety disorders in Children and
Adolescents
  • How can they be recognized and
  • What can be done?

2
Introduction
  • Mental Health problems are very common in
    children and adolescents. Studies suggest that
    110 children may suffer from serious mental
    issues.
  • Many psychiatric disorders have their onset in
    childhood, especially in adolescent years.
  • Many psychiatric disorders are more common or as
    common in boys and girls during childhood. Around
    puberty the rates of anxiety and depression
    sharply increase in females.

3
Some signs of trouble
  • Sadness, agitation, restlessness, anger, severe
    mood changes , especially when they persist.
  • Weight loss or gain
  • Fatigue and loss of energy
  • Sleep problems
  • Withdrawal and loss of interest
  • Drop in grades and academic performance
  • Legal problems

4
Anxiety Disorders
  • One of the most common psychopathology in
    children. They are often undetected and
    untreated.
  • They include disorders such as Separation Anxiety
    Disorder, Simple phobias, Generalized Anxiety
    Disorder, Social Anxiety Disorder, Panic
    Disorder, Post Traumatic Stress Disorder and
    Obsessive Compulsive Disorder. We will focus on
    GAD, Social phobia and Panic Disorder.

5
Anxiety Disorders
  • It is important to differentiate between normal
    fears, worries, and shyness and pathological
    anxiety. It is also important to have an
    understanding of normal developmental anxiety.
    For example older children and teens are often
    worried about social competence, health matters
    and school performance.
  • Consider Anxiety Disorder if symptoms do not
    subside, especially when they interfere with
    functioning and development.

6
Generalized Anxiety Disorder
  • GAD is characterized by chronic and excessive
    worries about multiple areas such as school,
    home, future, health, natural disasters.
  • Worries are accompanied by somatic complaints.
  • As those symptoms are internal, parents and
    teachers are often not aware of the magnitude.

7
Social Anxiety Disorder
  • Patients with Social phobia show severe
    discomfort in one or more social setting.
  • They are very self-conscious and are very afraid
    of being scrutinized and judged.
  • They may have a lot of avoidance. They may be
    afraid to answer questions, start conversations,
    eat in front of others, answer the phone, accept
    peer invitations
  • Social anxiety often peaks in teenage years

8
Panic Disorder
  • They are characterized by sudden recurrent panic
    attacks. Some symptoms include feeling very
    anxious, pounding heart, sweating, shortness of
    breath, dizziness, chest pain, tingling, feelings
    of unreality, fear of loss of control
  • Patients who have panic attacks often are afraid
    of having another attack and may avoid situations
    or setting where the attacks have occurred.

9
Prevalence Rates
  • It is not clear how common anxiety disorders are
    in children and adolescents. The estimates vary
    from 6 to 20 of children have at least one
    anxiety disorder.
  • Panic Disorder usually emerges late in the teen
    years.
  • Social Anxiety peaks in the teen years.
  • Several anxiety disorders are more common in
    girls especially after puberty

10
Prevalence Rates
  • Children who suffer from anxiety disorder appear
    to be 2 to 3 times more likely to develop another
    anxiety disorder or depression later on in life.

11
Risk Factors
  • Biological risk factors include genetics and
    temperaments.
  • Children who are very behaviorally inhibited in
    childhood are at higher risk of developing
    anxiety in middle childhood and social anxiety in
    adolescence.
  • Parents anxiety, through genetics and modeling

12
What to do ?
  • Talk to your PCP or possibly appropriate school
    staff
  • PCP will make sure there are no underlying
    medical condition or medication side effects that
    may be presenting as anxiety. Some examples may
    include thyroid problems, drug use including
    excess caffeine
  • If after screening it is felt that an anxiety
    disorder is likely then consider referral to a
    mental health specialist

13
Treatment
  • Cognitive Behavioral therapy (with exposure
    component) can be extremely useful for most
    anxiety disorders.
  • If the anxiety is very severe consider addition
    of a medication, in particular an SSRI type
    medication such as Prozac, Zoloft, Celexa or
    Lexapro.

14
Depressive Disorders
  • There are 2 major forms of depression Major
    Depressive Disorder and Dysthymic Disorder.
  • Other forms include Seasonal Affective Disorder,
    Depression, NOS and Premenstrual Dysphoric
    Disorder.
  • The risk of depression in girls increases 2 to 4
    folds after puberty.
  • A lot of adolescents may also have subclinical
    depression.

15
Major Depressive Disorder
  • At least 2 weeks of persistent depressed/irritable
    mood and loss of interest. At the same time
    other symptoms have to be present such as
    appetite and sleep changes, decreased energy and
    motivation, increased guilt feelings, decreased
    concentration and suicide thoughts.
  • Irritability, anger, tantrums, and physical
    symptoms can be more common in children and
    adolescents.

16
Major Depressive Disorder
  • It is believed that around 2 of children (11
    male to female) and 4-8 of adolescents (21
    female to male)
  • Recurrence of Major Depression is around 70
  • 60 of children who suffer from MDD experience
    suicidal thoughts and a lot of them have suicide
    attempts.

17
Major Depressive Disorder
  • The presence of disruptive disorders, a history
    of abuse and substance abuse, family history of
    suicide and availability of weapons increase the
    likelihood of suicide.

18
Dysthymic Disorder
  • Less intense but more chronic symptoms of
    depression
  • In children symptoms have been present for at
    least one year.
  • Impairment at times can be more severe then in
    MDD
  • Rates are 0.6 -1.7 in children and 1.6-8 in
    adolescents

19
Risk Factors
  • Interaction of genetics and environmental factors
    are thought to be important
  • High family loading of depression, loss, abuse
    and neglect
  • Other Co morbid condition can predispose to
    depression such as Anxiety Disorders, ADHD,
    Substance Abuse, Medical illness such as diabetes

20
What to do?
  • Screening by PCP and or school psychologist for
    example
  • PCP will exclude medical conditions that may
    present with depression
  • Refer when appropriate to mental health provider
  • Keep in mind importance of rapport and
    confidentiality

21
Treatment
  • In mild cases of depression there is some
    evidence that supportive therapy can be helpful.
  • In more moderate to severe cases consider two
    particular therapies Cognitive behavioral
    therapy and Interpersonal therapy.
  • In severe cases or when there is no response to
    therapy consider medication treatment.

22
Treatment
  • SSRIs have been shown to be effective. Currently
    Prozac is the only FDA medication indicated for
    depression on children.
  • Monitor for emergence of suicidal thoughts and
    behaviors.
  • Monitor for emergence of manic symptoms.
  • 20 to 30 of children who present with an
    episode of depression will end up developing
    Bipolar Disorder.

23
Prevention
  • Treatment of maternal (and paternal) depression.
  • Treatment of anxiety disorder that often precedes
    depression
  • Improve life style by adding exercise,
    involvement in social activities, hobbies, good
    diet

24
Bipolar Disorder
  • There is considerable debate still on how to best
    define Bipolar Disorder in children and
    adolescents. There is consensus however that
    Bipolar Disorder can first present in childhood.
  • Children who have mood lability, reckless
    behaviors and aggression are often labeled
    Bipolar. This is still controversial.
  • You will hear terms such as Ultra rapid cycling
    and Ultradian cycling used to refer to Bipolar in
    children.

25
Bipolar Disorder
  • The different types of Bipolar Disorder include
    Bipolar I, Bipolar II and Bipolar, NOS.
  • To be diagnosed with Bipolar I a patient must
    have history of a manic episode that lasts 7 or
    more days unless hospitalized. Manic symptoms
    include euphoria (or extreme irritability),
    decreased need for sleep, grandiosity,
    hypersexualty, increased activity level, racing
    thoughts

26
Bipolar Disorder
  • When asking questions keep in mind the childs
    developmental level.
  • Patient who have Bipolar I can be in a manic,
    depressive, hypomanic, or mixed episode.
  • Patients who have Bipolar II have episodes of
    major depression and hypomanic episodes.
    Hypomanic episodes are less severe then manic
    episodes and last at least 4 days.

27
Bipolar Disorder
  • Rapid cycling means having 4 or more mood
    episodes a year.
  • Mixed episodes are when depressive and manic
    symptoms occur together.
  • In children and adolescents the illness is more
    chronic (less episodic) and usually harder to
    treat.

28
Prevalence
  • Bipolar I rates in adults are from 0.4-1.6.
    Bipolar I and II in adults are around 2.6. The
    rate increases to around 6 if subthreshold cases
    are included.
  • Recent surveys of adults show that for many
    symptoms have started in childhood or
    adolescence.
  • Around 1 of youths may have Bipolar Disorder

29
Risk Factors
  • The risk of Bipolar Disorder increase 4-6 folds
    if a first degree relative suffers from Bipolar.
    In cases of prepubertal onset the genetic loading
    is even more significant. In those patients it is
    often very common to have maternal and paternal
    first degree relatives with severe mood disorder.
  • Most children who have Bipolar have had
    disruptive behaviors and hyperactivity. The
    majority of ADHD patients do not have Bipolar.

30
Risk Factors
  • Children with depression, especially psychotic
    depression have a higher risk of developing
    Bipolar.

31
What to do?
  • Screening through a PCP, school psychologist
  • PCP to make sure there are no underlying medical
    conditions.
  • Referral to a mental health provider

32
Treatment
  • Medication treatment is usually essential if the
    diagnosis is confirmed.
  • Options include Lithium, Atypical antipsychotic
    medications such as Abilify, Seroquel, Risperdal
    and Geodon and Zyprexa, Anticonvulsants such as
    Lamictal, Tegretol and Depakote. Different types
    of monitoring and blood work for different
    medications.
  • Psychoeducation and Relapse prevention are
    important.

33
Advice for Parenting
  • Provide a safe and loving environment.
  • Develop a relationship of mutual trust, honesty
    and respect.
  • From early on develop a relation that invites
    your child to talk to you. OPEN COMMUNICATION is
    vital. Do not hesitate to talk and ask questions.
    Always makes sure your child knows you are
    available and willing to listen

34
Advice
  • Positive feedback is always more helpful than
    negative feedback.
  • Allow age appropriate independence and
    assertiveness.

35
Resources
  • Primary care physician
  • School
  • Nationwidechildrens.org (behavioral health link)
  • Aacap.org (especially family facts)
  • Nami.org

36
Resources
  • Nih.gov
  • Netcare or local ED if safety concern.
  • Insurance company
  • Suicide hotline (614-2215445)
  • Clinicaltrials.gov
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