Depression and anxiety in children

Question 1

Depression: Epidemiology

Answer 1

Prevalence:
0.2% 5 – 10 year olds (pre-pubertal children)
2% 11 –15 year olds (adolescents)

The rise in adolescence seems to be more closely linked to pubertal status than to chronological age.

Sex ratio: equal in pre-adolescent boys and girls, but twice as common in girls in later adolescence.

Question 2

Depression: Aetiology

Answer 2

Depression runs in families.

Depressed children are more likely than children with other psychiatric disorders to have parents or siblings who are themselves depressed.

Conversely, parents with depression are more likely to have depressed children.

Twin studies suggest moderate heritability, but this has not been replicated in adoption studies.

There is preliminary evidence that a genetic loading for depression may sometimes act by increasing a young person’s vulnerability to adverse life events ‘a gene–environment interaction’.

Question 3

Core symptoms of depression

Answer 3

Persistent and pervasive sadness or unhappiness.

Loss of enjoyment of everyday activities (Anhedonia)

Irritability

Question 4

Depression: Associated symptoms

Answer 4

Negative thinking and low self-esteem

Hopelessness

Unwarranted ideas of guilt, remorse or worthlessness

Suicidal thoughts or thoughts of death

Lack of energy, increased fatigability, diminished activity,

Difficulty concentrating, forgetfulness

Appetite disturbance (decrease or increase)

Sleep problems (insomnia or hypersomnia).

Question 5

Depression: Clinical presentation

Answer 5

Young people tend to present initially with behavioral or physical complaints which may obscure the typical depressive symptoms seen in adults.

Irritability or cranky mood

Chronic boredom or loss of interest in previously enjoyed leisure activities (for example, dropping out of sporting activities, or dance and music lessons)
Social withdrawal or no longer wanting to “hang out” with friends

Avoiding school

Decline in academic performance.

Change in sleep-wake pattern (for example, sleeping in and refusing to go to school).

Frequent unexplained complaints of feeling sick, headaches, stomach-aches.

Development of behavioral problems (such as becoming more defiant, running away from home, bullying others).

Abusing alcohol or other substances.

Question 6

Diagnosis: Major depressive episode

Answer 6

Core symptoms

Some associated symptoms (usually four should be present)

Pervasiveness (symptoms must be present every day, most of the day)

Duration (for at least two weeks)

Symptoms must cause impairment in functioning or significant subjective distress, and

Symptoms are not the manifestation of the effects of a substance or another medical condition.

Symptoms should not be due to another mental disorder.

Question 7

Depression: Classification

Answer 7

One major depressive episode with no manic, hypomanic or mixed episodes = major depressive disorder, single

Two or more major depressive episodes but no manic, hypomanic or mixed episodes = major depressive disorder, recurrent.

Question 8

Depression: Classification 2

Answer 8

Those with milder symptoms may meet the diagnostic criteria for dysthymia or adjustment disorder with depressed mood.

Dysthymia involves chronic mild symptoms for at least one year (as opposed to the two years stipulated for adults).

An adjustment disorder can be diagnosed if the symptoms occur shortly after an identifiable stressor (within three months according to DSM-V) and do not outlast the stressor by more than six months.

Question 9

Depression: Severity

Answer 9

Mild:
5 depressive symptoms (at least 1 core).
Mild impairment in functioning.

Moderate:
6-7 symptoms (at least 1 core).
Considerable difficulty in continuing with school work, social and family activities.

Severe:
More than 7 depressive symptoms.
Hallucinations or delusions (psychotic depression).
Severe impairment in most aspects of functioning.
Significant risk of suicide.

Question 10

Depression: Comorbidity

Answer 10

Over 50% of depressed children in epidemiological samples have at least one other psychiatric disorder as well
Anxiety disorder
Disruptive behavioural disorder
Learning disorder,

Rate of comorbidity is often even higher in clinic samples.

Question 11

Depression: Diff. Diagnosis

Answer 11

Normal sadness, including normal bereavement reactions.
Misery can occur as just one feature of another psychiatric disorder, without the additional affective, cognitive and behavioural features needed to diagnose a true depressive disorder.

Mental disorder due other medical conditions e.g., hypothyroidism

Substance or medication induced depressive disorders
Disruptive mood dysregulation Disorder

Question 12

Mx: Psychosocial (CBT and IPT)

Answer 12

CBT:
The cognitive restructuring component of CBT is designed to alter negative cognitions, improve self-esteem and enhance coping skills.
behavioural activation component is designed to increase involvement in normal and rewarding activities.

Social skills training, problem solving treatment and remedial help with specific learning problems may also be offered.

Stress reduction interventions - school liaison, supportive individual therapy and family interventions.
E.g , if a bullied child becomes depressed, then tackling the bullying may be enough to cure the depression as well.
In more severe cases, however, it is necessary to treat the depression itself,

Question 13

Mx: medication

Answer 13

Meta-analyses – tricyclic antidepressants are little or no better than placebos for children and adolescents.

Serotonin reuptake inhibitors (SSRIs), particularly fluoxetine, are better than placebos at treating child and adolescent depression (especially severe depression).

Question 14

Mx: Fluoxetine

Answer 14

Fluoxetine is the only antidepressant approved by the US Food and Drug Administration (FDA) for the treatment of depression in children.
However, there are also concerns that SSRIs increase the risk of self-harm or suicide.

Analyses of reported adverse effects do suggest an increase in suicidal ideation and threats, with few attempts and no completed suicides.

In the light of reported levels of adverse effects with different SSRIs, the British Government guidelines do not support the use of SSRIs other than fluoxetine for depressed children or adolescents.

Question 15

Tx approach: Mid

Answer 15

support and stress reduction are often sufficient.

Question 16

TX approach: Moderate

Answer 16

Step 1: Support and stress reduction
Step 2: if fail- CBT or IPT ( If fail)
Step 3: if fail: Trail of SSRI- Fluoxetine

Question 18

Tx approach: Severe

Answer 18

Combination – combined pharmacological and psychological treatment.

Admission to an in-patient unit is indicated when there is severe suicidality, psychotic symptoms, or refusal to eat and drink.

Single episode - Continue successful therapy for about six months after
symptomatic remission in order to prevent early relapse

Question 19

Prognosis

Answer 19

An adjustment disorder with depressed mood usually lasts a few months and does not typically recur after the stressor is resolved.

Major depressive episodes often last six to nine months and commonly recur.

Dysthymia typically persists for several years; dysthymic individuals are at a high risk of major depressive episodes.

Someone with ‘double depression’ (that is, major depressive episodes superimposed on dysthymia) is particularly likely to experience recurrent major depressive episodes

Question 20

Prognosis: Adult outcome

Answer 20

Depression occurring in adolescence is often followed by depression in adult life,
Also predicts a roughly six-fold increase in adult suicide rates.

Depression occurring before puberty is less likely to lead to adult depression.

Question 21

Anxiety Dos in children

Answer 21

Separation anxiety Disorder ( SAD)
Generalised Anxiety Do ( GAD)
Social phobia
Specific phobia
Panic Do
Agoraphobia

Question 22

Common features

Answer 22

Core feature- avoidance- overt:specific situations, places, or stimuli. Subtle: hesitancy, uncertainty, withdrawal. Difference is the trigger

accompanied by affective components of fearfulness, distress or shyness.

Expectation of a threat- something bad is going to happen

All anxiety involve -anticipation of threat, in the form of worry, rumination, anxious anticipation, or negative thoughts

physical complaints -reflecting heightened arousal- headaches, stomach aches, nausea, vomiting, diarrhoea, and muscle tension.

Question 23

Epidemiology

Answer 23

Prevalence: around 5% of children and adolescents meet criteria for an anxiety disorder during a given period in Western populations (Rapee et al, 2009).

Gender: often F>M

Age of onset:
Animal phobias – early childhood -6-7 years
Separation anxiety Do – early to mid-childhood- 7-8 years
GAD– late childhood- 10-12 years
Social anxiety disorder – early adolescence -11-13
Panic disorder – early adulthood (around 22-24 years)

Question 24

Risk factors

Answer 24

Anxiety runs in families.-
Anxious children are more likely to have parents with anxiety disorders and
adults with anxiety disorders are more likely to have anxious children.

Temperament - inhibition, shyness (mostly seen 2-5yrs of age)

Common features of inhibition include:
Withdrawal in the face of novelty.
Slowness to warm up to strangers or peers.
Lack of smiling.
Close proximity to an attachment figure.
Lack of talk.
Limited eye contact or “coy” eye gaze.

Unwillingness to explore new situations.

Genetic – 30-40% heritable
-serotonin transporter gene (5HTTLPR) explored

Environmental stressors (home, school, environment)

Parenting and family factors- anxious parents.
- overprotection, intrusiveness and, negativity

Negative consequences
Academic
Social

Question 25

Differential Diagnosis

Answer 25

Normal / situational separation anxiety.
Generalized anxiety disorder.
Specific phobia / other anxiety disorders.
Mood disorders.

Conduct disorder.
Specific school problems.
Child abuse / PTSD.
GMC.

Question 26

Separation Anxiety Do

Answer 26

Separation anxiety is a normal phenomenon
Toddlers (6-18 months)
1st day of school/ crèche

Excessive anxiety with impairment = disorder

Most common anxiety disorder in children

Boys = girls

Onset usually 7-8 years old

Estimate 3-4% in primary school; 1% in high school

Fear or concern that something bad will happen to the child or attachment figure (commonly a parent) when they are separated.

As a result of this belief, the child avoids separation from the attachment figure

Question 27

SAD: Clinical features

Answer 27

Developmentally inappropriate and excessive anxiety

At least 3 of the following:
Distress on separation or anticipation thereof.
Worry about harm to parents / being lost.
Refusal to separate / go to school.
Refusal to be left alone or without close family member / Refusal to sleep alone.
Nightmares about separation / loss of parents.
Recurrent “non-organic” physical symptoms .

Symptoms: at least 4 weeks
Not caused by another psychiatric / physical disorder
Significant impairment in functioning

Question 28

SAD: Course and prognosis

Answer 28

Variable, related to age of onset / duration / comorbidity
Poor outcome is associated with
Older onset
Long duration of symptoms, missing >1 year of school
Underlying psychiatric disorders
Family psychopathology
May be at increased risk for anxiety disorders in adulthood

Question 29

Generalised Anxiety Do

Answer 29

Excessive worry about a wide range of negative possibilities
finances, friendships, schoolwork, sports performance, self and family health, and minor, daily issues

repeatedly seek reassurance about fears.

Avoidance- of novelty, negative news, uncertain situations, and making mistakes.

Physical symptoms, irritability, poor sleep

Question 30

Social phobia

Answer 30

Fear and avoidance of social interactions or social performance

belief that others will negatively evaluate the child

Avoided situations e.g:
speaking or performing in front of others,
meeting new children
talking to authority figures, eg. teachers,
being the centre of attention in any way,
teenagers- fears of dating

worries about negative evaluation include: unattractive, stupid, unpleasant, overly confident, or odd

Self conscious

Few friends

Question 31

Panic Disorder And Agoraphobia

Answer 31

Features- worries and fear of unexpected panic attacks,
involving several somatic symptoms and
Fears of dying or going crazy

Some somatic complaints: palpitations, breathlessness,dizziness, trembling, and chest pain

some attacks occur unexpectedly or “out of the blue“

Agoraphobia- avoidance of places for fear of getting a panic attack at those situations, eg, malls
Avoids places where quick escape is not available, eg bus

Question 32

Specific Phobias

Answer 32

Core avoidance of specific objects of situation

Main belief that object or situation will bring harm

Specific fears in children:
Animals such as dogs or birds
Insects or spiders
The dark
Loud noises and especially storms
Clowns, masks, or unusual looking people
Blood, illness, injections

Question 33

Interventions for children with anxiety disorders

Answer 33

Targeted as per diagnsosis, and severity

In-patient vs out-patient?

Multimodal/Multidisciplinary

Psychologist: Individual CBT/counselling/group?

OT: breathing, relaxation exercises, creative (arts and crafts)

Creative arts (drama, art, music therapy, storytelling)

Biological: medication (Ssri’s) if poor response to psychological therapy

Family work (social worker, psychologist)

Non-clinical (sport, art, music, yoga, play dates)

Biological: medication (Ssri’s) if poor response to psychological therapy