Depression & anxiety in the lives of our kids & teens : what every parent needs to know

1. Depression & anxiety in the lives of our kids & teens : what every parent needs to know MedPsych Associates of New Jersey Mohab Hanna, M.D. Board Certified in Child & Adolescent Psychiatry 545 Island Road, Suite 2B Ramsey, NJ 07446 201-995-1004 www.medpsychhealth.com

2. Quotes • “I have a new philosophy. I only dread one day at a time.” Charlie Brown • “The odd thing is that fear and anxiety are running away from something, but they don’t know what to run to. They know danger, but they don’t know where to find peace and rest.” Ed Welch • “Anxiety does not empty tomorrow of its sorrows., but only empties today of its strength” Charles Spurgeon

3. Quotes • “Depression ... involves a complete absence: absence of affect, absence of feeling, absence of response, absence of interest. The pain you feel in the course of a major clinical depression is an attempt on nature’s part ... to fill up the empty space. But for all intents and purposes, the deeply depressed are just the walking, waking dead.”  Edward T. Welch • “Worriers act as if they might be able to control the unctrollable . Central to worry is the illusion that we can control things…The illusion of control lurks inside your anxiety. Anxiety and control are two sides of one coin. When we can’t control something, we worry about it.” David Powlison

4. Quotes • “Because here's something else that's weird but true: in the day-to day trenches of adult life, there is actually no such thing as atheism. There is no such thing as not worshipping. Everybody worships. The only choice we get is what to worship. And the compelling reason for maybe choosing some sort of god or spiritual-type thing to worship… or some inviolable set of ethical principles—is that pretty much anything else you worship will eat you alive. If you worship money and things, if they are where you tap real meaning in life, then you will never have enough, never feel you have enough. It's the truth. Worship your body and beauty and sexual allure and you will always feel ugly. And when time and age start showing, you will die a million deaths before they finally grieve you. On one level, we all know this stuff already. It's been codified as myths, proverbs, clichés, epigrams, parables; the skeleton of every great story. The whole trick is keeping the truth up front in daily consciousness.” David Foster Wallace

5. Quote • “Jesus is a teacher who doesn’t just inform our intellect but forms our very loves. He isn’t content to simply deposit new ideas into your mind; he is after nothing less than your wants, your loves, your longings.” ― James K.A. Smith, You Are What You Love: The Spiritual Power of Habit • “All human beings are alike in seeking happiness. Where they differ is in the objects from which they seek it and the strength they have to reach the objects they desire.” ― OsGuinness

6. Mental Health Crisis? • The National Survey on Drug use and Health administered by the U.S. Department of Health and Human  Services (surveyed over 600,000 Americans): • From 2009 to 2017, major depression among 20- to 21-year-olds more than doubled, rising from 7 percent to 15 percent. Depression surged 69 percent among 16- to 17-year-olds.  •  Twice as many 22- to 23-year-olds attempted suicide in 2017 compared with 2008, and 55 percent more had suicidal thoughts. The increases were more pronounced among girls and young women.  •  Serious psychological distress, which includes feelings of anxiety and hopelessness, jumped 71 percent among 18- to 25-year-olds from 2008 to 2017 • By 2017, one out of five 12- to 17-year-old girls had experienced major depression in the previous year. • the suicide rate among 18- to 19-year-olds climbed 56 percent from 2008 to 2017.

7. Preview • What is anxiety? • The nature of anxiety • How anxiety presents?- different types • Clinical Depression in kids & teens • Causes of Depression • Treatment • Why treat? What is the big deal? • Treatment approaches • Therapy • Parenting Tips • Medication Treatment • Medicines • Summary • Questions

8. What is Anxiety? • “Stressed out” = anxiety • Any fears - too much, too late • Any worries, concerns or apprehension including perfectionism • Physical complaints- headaches, stomach aches, dramatic presentations of pain • Neurologists, gastroenterologists, cardiologists • Problems with falling asleep and middle of the night awakening, repeated visits to parents room - • Eating problems

9. What is anxiety? II • Excessive need for reassurance- new situations, bedtime, school, storms, bad things happening • Controlling behaviors (manipulation) • Any impairment or significant accommodation by parents • AVOIDANCE of outside and interpersonal activities- school, parties, camp, sleepovers, safe strangers- makes their world very small • True anxiety is irrationalversus appropriate fears and concerns that lead to appropriate avoidance. • Not necessarily pervasive- some areas of function remain

10. The nature of Anxiety I • Very common up to 8-10% of kids • Under diagnosed • Under treated • Pattern • Anxiety versus ADHD • Easy to mix up in young kids • Can be both • Who gets anxiety? • Genetic • Learned behavior • Must have happen – disordered wants/loves/ longings

11. The Nature of Anxiety II • Not all anxiety is the same • Primary Genetic versus Secondary • Genetic predisposition in context of stressors • Could be secondary to many things • Parental expectations • Peer Group Expectations • Cultural expectations • Substances/ tech ( social media, video games) • Family dynamic & health of marriage • Liturgy of life-: how life is done; routines, schedules, habits, etc.…

12. Types of Anxiety • Separation Anxiety Disorder • Generalized Anxiety Disorder • Physical symptoms • Performance anxiety symptoms • Phobias (Animals, insects, weather, blood, etc…) • 70% have another anxiety disorder • Social Anxiety Disorder & Selective Mutism • Acute Stress Disorder • Panic Disorder • Obsessive Compulsive Disorder • Post Traumatic Stress Disorder (PTSD) • Anxiety Disorder NOS (non-specific)

13. Separation Anxiety Disorder • Excessive concern regarding separation from home or from attachment figures • Bad things happening to parent and or child • Cannot be alone • Avoidance (mild to severe) • Difficulty falling asleep or sleeping with loved ones • Physical aches and pains • Accommodation by adults (can mask symptoms) • Impairment or distress.

14. Generalized Anxiety Disorder • Excessive worry and apprehensiveness • Restless, keyed-up or on edge. • Fatigued at end of school day • Concentration problems “choking on tests” • Sleep problems (falling asleep) • Tense and irritable • Unable to control the worry • Impairment or distress

15. Social Phobia & Selective Mutism • Social Phobia • Excessive Fear of social or performance situations • Selective Mutism • Ability to speak • Not speaking in certain social situations

16. Obsessive Compulsive Disorder • Prominent obsessions or compulsions • Dirt, germs, or other contamination • Ordering and arranging/symmetry • Checking • Repetitive acts • Hoarding- difficult to treat • Impairing or time consuming

17. Panic Disorder • Attacks of anxiety (Physical Symptoms) • Heart rate, pounding heart, palpitations • Hyperventilation, shortness of breath • Choking sensation • Chest discomfort or pain • Abdominal pain • Some psychological symptoms • Worry about the next one • Avoidance behavior related to the attacks

18. Post-traumatic Stress Disorder • True stressful event – life threatening • Re-experiencing the event • Avoidance and numbing • Increased arousal

19. Bottom Line • Any fears - too much, too late (developmentally inappropriate) • Any worries, concerns or apprehension including perfectionism • Controlling and demanding behaviors • Any impairment or significant parental accommodation • AVOIDANCE

20. Clinical Depression: kids and teens • sadness without a reason • Frequency, intensity, duration • Pattern of negativity • Self • Others • Life • Irritability • Low frustration tolerance • Excessive power struggles • Oppositional Defiance

21. Clinical Depression: kids & Teens II • Fatigue, low energy, lethargy • Decreased or increased appetite • Excessive Sleep or difficulties with falling or staying asleep • Lack of motivation • Anhedonia- inability to enjoy things that are typically enjoyable; nothing fun; frequent boredom

22. Clinical Depression: kids & Teens • Cyclical - comes and goes • Good weeks / bad weeks • Good months/ bad months • Hopelessness • Passive death wishes • Active death wishes • Suicidal thoughts • Suicidal plans • Suicide/ self-harm attempts • Interferes with function

23. Causes of Depression: Kids & Teens • Life Story/ environment • Home/ family • School ( academic struggles due to Learning disabilities/ ADHD/ Language delays/ developmental delays, unrealistic expectations from parents or self ) • Peers – conflicts, dating, social media • Trauma- personal or family • Biological/ genetic • Anxiety • Substances ( alcohol & drugs) • Technology addiction/ video games

24. Treatment • Why Treat? What is the big deal? • Anxiety/ depression interfere with function and development versus developmentally appropriate worries moods • Anxiety/ depression shape the development of personality • Anxiety is a very common cause of depression in kids and teens • Treatment Approaches – not everyone needs professional treatment- depends on severity • Frequency, Intensity, Duration, degree of interference with function • What is the cause? • Environment versus biological or both – guides if need for treatment and what kind of treatment • Therapy ? – Parents have a large role to play • Medications

25. Therapy for Anxiety & Depression • Helpful for mild to moderate anxiety • Cognitive Behavioral Therapy • Needs to focus on anxiety or depression or both • Benefit versus risk • Cognitive distortions • Behavioral avoidance • Relaxation training • Helpful for treating symptoms but doesn’t address the heart/desire/worship • Not every child or teen is a good candidate

26. Parenting Tips • As a parent, you spend much more time with your kids and teens than any therapist or psychiatrist ever will • You have a large role to play in how your kids and teens process the anxiety/ depression ; your reaction to it matters huge • Need to teach our kids and teens who struggle in this manner to learn to apply the Gospel to their struggle. “I am weak and broken ( reality of all of us in some way) so I am in desperate need for Jesus and my identity and security is based knowing that I am loved despite my sin and brokenness, etc.. “ • Be honest with yourself about your own anxiety/moods – be open with your kids about your struggle ( based on their level of maturity of course) • Do you need to get help for your anxiety/ depression? • Your kids will do as well as you do – How are you applying the Gospel to your own struggles ?

27. Quotes • “Discipleship, we might say, is a way to curate your heart, to be attentive to and intentional about what you love.” ― James K.A. Smith • “Our wants and longings and desires are at the core of our identity, the wellspring from which our actions and behavior flow.” ― James K.A. Smith, You Are What You Love: The Spiritual Power of Habit

28. Parenting Tips II • The adults in the home set the emotional tone- individually and marriage • It is difficult to have emotionally healthy kids and teens if the adults are not addressing their own anxiety/ depression/struggles • The health of a marriage has a huge impact on stress and anxiety in kids and teens.

29. Quote • “Here is the sweet paradox in how God works. He blesses those who admit that they need help: The poor in spirit are blessed (Matthew 5: 3). Sanity has a deep awareness, I need help. I can’t do life right on my own. Someone outside me must intervene. The sanity of honest humility finds mercy, life, peace, and strength. By contrast, saying we don’t need help keeps us stuck on that hamster wheel of making excuses and blaming others. The end result isn’t life and peace; it’s self-righteousness, self-justification, alienation, and bitterness.” ― David A. Powlison, Good and Angry: Redeeming Anger, Irritation, Complaining, and Bitterness

30. Parenting Tips III • Say no to Avoidance both for anxiety and depression • Beware of the curse of accommodation • Nothing bad happens if your kids experience symptoms of anxiety. • Anxiety Goal is to learn to tolerate distress; not to feel better? Learning to tolerate distress can lead to improvement.

31. Basics that help • Good sleep hygiene • Limits on technology • Physical activity • Protein based diets • Omega-3 FA for mood • Bright light therapy for depression • Check Thyroid, Vitamin D, B12 and other blood work

32. Medication Treatment • Moderate to severe anxiety • Benefit versus risk • Risk of not treating with medications • Medication Trial • 7-10 days to kick in • 4-6 weeks to see full benefit • 9-12 months then consider getting off • Risk of return of symptoms • Need to do an adequate trial • Duration • Dosage • Take daily • Need to be patient

33. Medicines • SSRIS (Selective Serotonin Reuptake Inhibitors) • Same exact medications used for depression • No concern about suicidalityin published data in the treatment of anxiety • Standard first line medications used • FDA approved in kids and teens • Fluoxetine, Sertraline, and Fluvoxamine • Clomipramine (OCD) • SNRIS (serotonin norepinephrine reuptake inhibitors)

34. SSRIS/ SNRIS • SSRIS • Fluoxetine (Prozac) • Sertraline (Zoloft) • Fluvoxamine (Luvox) • Citalopram (Celexa) • Escitalopram (Lexapro) • Paroxetine (Paxil) • SNRIS • Venlafaxine (Effexor) • Duloxetine (Cymbalta) • Desvenlafaxine (Pristiq)

35. Potential Side Effects • All medications have the same potential benefits and side effects, but each child will have a unique response to a given medication. • Every medication has potential side effects • Common- nuisance- tend to go away • Stomach aches • Headaches • Dizziness • Dry mouth • Activation • Hyperactivity, impulsivity and disinhibition • Need to start low and go slow- micro-dosing for young children • Sleepiness or sleep disruption • Increased appetite- rarely an issue in kids, but can be in teens • Celebration versus Bipolar Switch • Long term side effect- apathy and lack of motivation

36. Benzodiazepines • Not first line • Only use in very specific circumstances • Rarely with pre-pubertal kids • Agitation • Risk of dependence and abuse • Tolerance • Be careful with adolescents who drink alcohol • Worsens depression • Sedation/ cognitive slowing

37. Summary • Anxiety disorders are perhaps the most common psychiatric disorders among children. • Less often recognized and treated than any other disorder?!?!?! • Look for depression • Depression is much more common in kids and teens than most people realize • Internal experiences present as behaviors • Avoidance is the big issue • Subthreshold problems may need intervention • Treatment is unbelievably helpful

38. Resources • CCEF- Christian Counseling & Educational Foundation – www.ccef.org • Ed Welch: Running scared & Depression: looking up from the stubborn darkness • Mike Emlet: Descriptions and prescriptions • David Powlison: Seeing with new eyes • Paul Tripp: Instruments in the hands of the redeemer • James K A Smith: You are what you love • OsGuiness: The call

39. Questions • ? • ?? • ???