Felissa P. Goldstein, M.D. Child and Adolescent Psychiatrist December 14, 2006

1. MOOD AND ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS Felissa P. Goldstein, M.D. Child and Adolescent Psychiatrist December 14, 2006

2. Objectives • Describe the Diagnostic Criteria for the most common mood and anxiety disorders • Discuss the etiology and epidemiology for the most common mood and anxiety disorders • Describe the treatments available for mood and anxiety disorders. • Highlight the differences between children and adults with mood and anxiety disorders.

3. Mood Disorders

4. Major Depressive Episode • Depressed mood (In children can be irritable mood which can also lead to aggressive behavior) and / or • Markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day • Impairment in Functioning • Must be present for two weeks

5. Significant weight loss or weight gain (or failure to make expected weight gains) Insomnia or hypersomnia nearly Psychomotor agitation or retardation Fatigue or loss of energy Diminished ability to think or concentrate Recurrent thoughts of death or suicidal ideation (with or without a plan) Major Depressive Episode

6. Major Depressive Disorder • One or more Major Depressive Episodes • Occurs one time or recurrent

7. Dysthymia • Symptoms similar to Major Depressive Disorder but less severe and more chronic • Must be present for at least a year. • Prevalence: 0.6% to 1.7% in children and 1.6 to 8.0 % in adolescents.

8. Epidemiology of Major Depressive Disorder • Children: 0.3 % of preschoolers, 1-2% school-age • Adolescents: 5-6% 2:1 female to male ratio • Prevalence Rates by Age 19: 28% (35% in females and 19% in males) • Each generation since 1940 has been at greater risk for developing depressive disorder and disorder is being recognized earlier

9. Suicide • Threefold increase in suicide rate over past four decades • Incidence of suicide peaks at late adolescence. • Adolescent Boys twice as likely as girls to complete suicide • Adolescent girls attempt 2-3 times more than boys. • In 15-24 year olds suicide is 3rd leading cause of death after accidents and homicide • In 5-14 year olds, 5th leading cause of death after accidents, malignancies, congenital anomalies and homicides

10. Etiology • Multiple theories • Changes in growth hormone secretion • Dysregulation of cortisol secretion may lead to genetic vulnerability to depression • Levels of thyroid hormones may contribute to development of mood disorders • Abnormal melatonin secretion • Abnormalities in norepinephrine and serotonin secretion

11. Etiology • 2-3 fold increase in lifetime rates of depressive disorders in the relatives of depressed subjects • Early onset depression (age 20 or before) poses highest risk for family members. • Children of depressed parents have a 15% to 45% risk over their lifetime of developing depression. Early onset and recurrent episodes worsen the risk.

12. Etiology • Stressful life events and family interactions will also contribute to the development of depression. • Abnormal early interactions between mother and child may contribute to the child developing abnormal habits for handling stress. • Vulnerability to depression in the child increases when the parent has lack of affect, irritability towards the child, and abuse.

13. Treatment • Pharmacologic • Antidepressants • Selective Serotonin Reuptake Inhibitors • Miscellaneous Antidepressants: Buproprion, Venlafaxine, Trazodone, and Nefazodone • Tricyclic Antidepressants • Monoamine Oxidase Inhibitors

14. Psychosocial Interventions • Cognitive Behavioral Therapy • examines confused or distorted patterns of thinking.  • child learns that thoughts cause feelings and moods which can influence behavior.  • For example, if a child is experiencing unwanted feelings or has problematic behaviors, the therapist works to identify the underlying thinking that is causing them. The therapist then helps the child replace this thinking with thoughts that result in more appropriate feelings and behaviors. • effective in treating depression and anxiety.

15. Psychosocial Interventions • Family Therapy • Focuses on helping the family function in more positive and constructive ways by exploring patterns of communication and providing support and education.  • Includes the child or adolescent along with parents, siblings, and grandparents.  • Couples therapy is a specific type of family therapy that focuses on a couple's communication and interactions (e.g. parents having marital problems).

16. Psychosocial Interventions • Group Therapy • Uses the power of group dynamics and peer interactions to increase understanding and improve social skills • Many different types of group therapy (e.g. psychodynamic, social skills, substance abuse, multi-family, parent support, etc.)

17. Psychosocial Interventions • Interpersonal Therapy (IPT) • Brief treatment specifically developed and tested for depression.  • Goals of IPT are to improve interpersonal functioning by decreasing the symptoms of depression. • Effective in adolescents with depression.

18. Psychosocial Interventions • Play Therapy • Involves the use of toys, blocks, dolls, puppets, drawings and games to help the child recognize, identify, and verbalize feelings.  • Therapist observes how the child uses play materials and identifies themes or patterns to understand the child's problems.  • Through a combination of talk and play the child has an opportunity to better understand and manage their conflicts, feelings, and behavior.

19. Psychosocial Interventions • Psychodynamic Psychotherapy • Emphasizes understanding the issues that motivate and influence a child's behavior, thoughts, and feelings. • Identifies a child's typical behavior patterns, defenses, and responses to inner conflicts and struggles.  • Based on the assumption that a child's behavior and feelings will improve once the inner struggles are brought to light. • Psychoanalysis is a specialized, more intensive form of psychodynamic psychotherapy which usually involved several sessions per week. 

20. Bipolar Disorder

21. Manic Episodes • A distinct period of abnormally and persistently elevated, expansive or irritable mood ( lasting at least 1 week ) (or any duration if hospitalization is necessary). • Severe enough to caused marked impairment in occupational functioning or in usual social activities or relationships with others. May require hospitalization to prevent harm to self or others, or if there are psychotic features.

22. Manic Episodes • During the period of mood disturbance the following symptoms are present in some combination • Inflated self-esteem or grandiosity • Decreased need for sleep • More talkative than usual or pressure to keep talking • Flight of ideas or subjective experience that thoughts are racing • Distractibility • Increase in goal directed activity • Excessive involvement in pleasurable activities that have a high potential for painful consequences

23. Hypomanic Episode • Distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood. • There is a definite change in the person’s level of functioning but it is not so severe to cause marked impairment or to necessitate hospitalization. There are no psychotic features.

24. Hypomanic Episode • During mood disturbance some combination of the following symptoms have persisted • Inflated self-esteem or grandiosity • Decreased need for sleep • More talkative than usual or pressure to keep talking • Flight of ideas or subjective experience that thoughts are racing • Distractibility • Increase in goal directed activity • Excessive involvement in pleasurable activities that have a high potential for painful consequences

25. Mixed Episode • During a one week period patient meets criteria for a Major Depressive Episode and also a Manic Episode • Severe enough to caused marked impairment in occupational functioning or in usual social activities or relationships with others. May require hospitalization to prevent harm to self or others, or if there are psychotic features.

26. Bipolar I Disorder • Presence of at least one manic or mixed episode with or without depressive episodes • Symptoms significantly interfere with psychosocial functioning and must last at least a week or require hospitalization.

27. Bipolar II Disorder • Presence of one or more Major Depressive Episodes • Presence or history of at least one Hypomanic episode • There has never been a manic or mixed episode • Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

28. Epidemiology • Adults • 40-60 % of adults developed symptoms prior to age 19 • Occurs in 1-2% of the adult population • Bipolar spectrum disorder 5-6 % • Children • Prevalence is unknown

29. Epidemiology • Adolescents • 0.06- 0.1 % (Bipolar I) • 0.85% (Bipolar II and Cyclothymia) • 5 -10 % (Bipolar Spectrum) • Boys outnumber girls 3.85 times in being diagnosed with Bipolar Disorder prepubescently. • Bipolar Disorder occurs equally in males and females in late adolescence and adulthood.

30. Heritability • Family and Twin studies show that Bipolar disorder has a definite genetic component. • Multiple genes contribute to the risk of developing Bipolar Disorder • Genes have yet to be identified

31. Environmental Influences • Environmental factors may influence a genetic predisposition towards the development of the illness. • Acute stress (lack of sleep, recent losses) or chronic stress or chaos will worsen illness course.

32. Treatment • Pharmacotherapy • Mood Stabilizers: Depakote, Lithium, Divalproex, Oxcarbazepine, Carbamazepine, Lamotrigine, Topiramate • Antipsychotic Agents: Seroquel, Risperdal, Olanzapine, Aripiprazole, Ziprasidone • Antidepressants: typically not used alone but used with a mood stabilizer • Stimulants: to treat ADHD symptoms. Used also with mood stabilizers or antipsychotics.

33. Treatment • Psychosocial Interventions • Family Therapy • Psychoeducation (Diagnosis, Treatment) • Emphasize Compliance • Mood monitoring • Social skills training • Strategies aimed at increasing life style regularity (Adhering to regular schedule, normal sleep/wake cycle) • Parent training in behavioral interventions to deal with problematic behavior • Therapist helps family see family dynamics that may be contributing to patient’s illness.

34. Treatment • Individual Therapy • Cognitive Behavioral Therapy • Psychoeducational Interventions • Individualized Educational Plans • 504 Plans • Tutoring • Safety Plan

35. Sample Mood Log

36. Cyclothymia • For at least one year, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for Major Depressive Episode • During the above 1 year period, the person has not been without the symptoms for more than 2 months at a time. • No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 1 year of the disturbance

37. Useful Web Resources • Child and Adolescent Bipolar Foundation www.bpkids.org • Georgia Childhood Bipolar Foundation www.gcbf.org • National Alliance for the Mentally Ill www.nami.org • Depression and Bipolar Support Alliance www.dbsalliance.org • Atlanta Depression and Bipolar Support Alliance www.atlantamoodsupport.com

38. ANXIETY DISORDERS

39. Separation Anxiety Disorder • Developmentally inappropriate and excessive anxiety concerning separation from home or from an individual they are attached to. • Recurrent distress when separation occurs or is anticipated • Worry about losing or something happening to major attachment figure • Worry that an event will lead to separation from attachment figure • Refusal to go to school or other places because of fear of separation • Refusal to be alone • Must sleep near major attachment figures • Nightmares involving fear of separation • Somatic complaints

40. Separation Anxiety Disorder • Lasts at least 4 weeks • Onset before age 18 • Causes significant distress and impairment in functioning • More likely in preadolescents than adolescents • Females more than males

41. Generalized Anxiety Disorder • Excessive anxiety and worry for 6 months about multiple events. • Person is unable to control the worry • Symptoms of: • Restlessness or being keyed up • Easily fatigued • Poor concentration • Irritability • Muscle tension • Sleep disturbance • “worry warts”

42. Generalized Anxiety Disorder • Females more than males • Need for reassurance is more common in young children • Adolescents brood or ruminate

43. Etiology • Temperament • Attachment • Parental Anxiety • Parenting Style • Life experiences

44. Treatment • Pharmacologic: • Selective Serotonin Reuptake Inhibitors • Tricyclic Antidepressants • Benzodiazepines • Psychosocial: • Cognitive behavioral therapy • Most data to support its effectiveness.

45. Post Traumatic Stress Disorder • Exposure to a traumatic event • Person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. • Person’s response involved intense fear , helplessness, or horror (in children may be expressed instead by disorganized or agitated behavior

46. Event is reexperienced in the following ways • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. May be repetitive play with traumatic themes • Frightening dreams • Acting or feeling as if the event was recurring (in young children trauma specific reenactment) • Intense distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event • Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

47. Persistent Avoidance of Stimuli Associated with the Trauma and Numbing of General Responsiveness • Avoid thoughts, feelings, or conversations associated with the trauma • Avoid activities, places, or people, that arouse recollections of trauma • Inability to recall an important aspect of the trauma • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect • Sense of a foreshortened future

48. Persistent symptoms of increased arousal • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response • Symptoms last more than one month • Symptoms interfere with normal functioning

49. Etiology • Psychoanalytic Theory • Social Learning Theory • Neurobiology

50. Pharmacologic Selective Serotonin Reuptake Inhibitors Alpha adrenergic Agonists (Clonidine or Tenex) Beta Blockers (Propanolol) Benzodiazepines Mood stabilizers Psychosocial Individual therapy Play therapy Group Therapy Cognitive Behavioral Therapy Family therapy Treatment