Mood and anxiety disorders in children

1. Mood and anxiety disorders in children Dr. Marjorie Robb Assistant Professor, UOttawa Children’s Hospital of Eastern Ontario

2. Some troubling statistics • At least 20% of children under age 18 have significant mental health problems • 75% of those don’t get help

3. ANXIETY IN CHILDREN

4. Jesse • Is 8 years old. He has a great family, lives in the country, and likes to play outside. • Jesse has a learning disability and has a hard time in school • Around age 7 ½ he started to worry a lot: • Will there be enough time to play? • Will there be enough time to do my homework? • I won’t be able to do this homework. • I don’t want mom to go out at night. • He also started to complain of headaches and stomachaches quite a lot. • Parents say he is so anxious he doesn’t enjoy much.

5. Taylor • Taylor is 7. She does well at school and has friends there. • At home she has started to be afraid to eat – she fears the food will make her sick • She especially refuses to eat anything her older brother has touched because “he’s gross” • She is afraid to go to sleep because she might get sick • Bedtime takes a very long time • She has frequent meltdowns when things “don’t go right” • She seems very tired and unhappy much of the time • She is not gaining weight as she should

6. Cecelia • Cecelia is 9. She has developed a fear of germs • She won’t use the washroom at school or at the mall • She doesn’t want her parents to have visitors or to let friends drive in their car (because they bring in germs). • She has to wash her hands for a long time and frequently • She insists that her family wash their hands whenever anyone comes in from outside and has a meltdown if they don’t • After visitors leave she sprays disinfectant on the furniture

7. Anxiety Disorders • Anxiety disorders are the most common mental health disorders • Many anxiety disorders start in childhood and if untreated, they may persist into adulthood • Children may have more than one kind of anxiety disorder • Up to 6% of children and youth have an anxiety disorder severe enough to need treatment

8. Why do children get anxiety disorders? • Often there is a family (genetic) tendency to anxiety • Children who live with too much stress can become anxious • Stress can be in family, school or neighborhood • Anxious parents can model anxious behaviour for children

9. Kinds of Childhood Anxiety Disorders • Separation anxiety • Social phobia • Generalized anxiety disorder • Selective mutism • Obsessive Compulsive Disorder • Panic Disorder • Phobias • Post Traumatic Stress Disorder

10. Separation Anxiety Disorder • Child is afraid of leaving their parent(s) • They may worry that something bad will happen to the parent or to someone they love or to themselves • May refuse to go to school • May have stomachaches, headaches, or throw up if they fear separation • May refuse to go to playdates at other people’s houses • Diagnosed if it causes problems at school or socially and has been going on at least 4 weeks

11. Generalized Anxiety Disorder • Children with this kind of anxiety may: • Have lots of worries and fears • Have problems sleeping because of worries • Have trouble concentrating • Get tired easily or have tension headaches • Be tense or restless • Be perfectionist • Have an anxious desire for approval

12. Obsessive-Compulsive Disorder • OCD often begins in early childhood or adolescence. Children with this kind of anxiety may: • Have frequent uncontrollable thoughts (obsessions) • Usually they don’t like these thoughts, or they may think they don’t make sense • Perform certain behaviours or rituals to try and prevent something bad from happening (or to get rid of thoughts) • Examples are: handwashing a lot if there is a fear of germs; checking that doors are locked; special touching rituals

13. Panic Disorder • Happens less often with younger children • People with this kind of anxiety have panic attacks • Feel very scared • Heart pounding, hard to breathe • May feel shaky, dizzy, or sick • May feel like they are going crazy or something really awful is going to happen • Sometimes they avoid school or want to stay in the house • Frequent panic attacks = panic disorder

14. Selective Mutism • Children may not talk to anyone who is not close to them, such as immediate family • They may look down, withdraw, turn red if required to talk • Often they whisper if they do speak in a situation where they are anxious • Up to 2% of school age children may have these symptoms • Some kids outgrow it; some go on to have social phobia

15. Social Anxiety/Social Phobia • Happens more in teens than in young children • Fear and worry about social situations • Going to school • Speaking in class • Social events including recess and lunch • Shy, self-conscious • Easily embarrassed • These kids tend to be sensitive to criticism and find it hard to be assertive

16. Post Traumatic Stress Disorder • Symptoms start after a physical or emotional trauma or very frightening event • Can be marked by several of • Behavioural changes • Repetitive play • Zoning out, numbing of feelings • Jumpiness and watchfulness of surroundings • Nightmares and sleep problems • “Flashbacks” Not very common in young children

17. Anxiety disorders - What to watch for: • Avoidance of school (refuses to go) • Frequent stomachaches or headaches in the morning before school • Avoidance of activities • Easily upset – distress out of proportion • You spend a lot of time comforting your child and/or urging her/him to participate in regular activities • You feel that your family functioning is being disrupted by your child's fears and worries, or meltdowns

18. What you can do: • Be patient, calm and reassuring • Be positive about their ability to manage the situation (with support) • Help your child succeed by doing “small steps” • Reward and praise your child’s efforts as well as successes • Be a model for your child – manage your own anxieties • Help your child “avoid avoidance” with planned gradual exposure to things they fear • Teach your child positive self-talk

19. What you can do: • Teach your child basic relaxation strategies such as belly breathing and muscle relaxation • Teach your child to visualize or imagine a pleasant, relaxing “happy place” • Keep stress low at home. Avoid parental conflict when the children are present. Be calm and positive as much as possible. • Deal with external situations that require adult intervention, such as bullying • Healthy living: enough sleep, regular routines, balanced diet, exercise • Take time to have fun and relax with your child

20. Don’t: • Criticize or yell at your child • Tease or make fun of your child for anxiety • Ignore the problem or wait for the child to get over it • Tell the child to “toughen up” • Pressure your child to do more than s/he can do • Have unrealistic expectations • Make it easy for your child to avoid anything that scares them

21. Treatment of anxiety • If your child is having significant problems with school, missing a lot of school, or having other problems functioning, you should talk to your doctor • Anxiety disorders can be treated! • The most common treatment is cognitive behaviour therapy (CBT) in groups or individually • In CBT children learn relaxation and stress management plus • Gradual exposure to things that make them anxious, to decrease the fear • Coping strategies to reduce anxiety CBT is first choice, but medication may be needed in severe situations

22. DEPRESSION IN CHILDREN

23. Tyler • Tyler is a 9 year old boy who lives with his mom and sees his dad every second weekend • His parents have been in a bitter custody battle • He has trouble getting to sleep and is always tired in the morning • He still plays with his friends, but doesn’t seem to enjoy himself as much as he used to; he wants to quit hockey • He is angry and cranky with mom much of the time and he has meltdowns over small things • Sometimes he falls asleep in school; he can’t concentrate and his marks have gone down

24. Emily • Emily is 8 and lives with mom, dad and 2 brothers • Recently she has started to complain of stomachaches often in the morning • She sometimes says “I’m stupid” or “I’m ugly” • She cries at night and sometimes says “I wish I wasn’t here” • She plays with her dolls by herself and doesn’t want to go outside after school • When frustrated she will sometimes hit herself on the head • She says other kids are mean to her

25. Depression • Depression is common: in Canada and US about 1 in 5 children will go through a depression before finishing high school • 4 – 8 of 100 children have a major depression at any point in time • Symptoms include: • Feeling sad, irritable or angry • Not enjoying life, school or activities as much • Trouble coping with home, school or work • Feeling hopeless or worthless • Problems with sleep, appetite, energy and concentration

26. What causes depression? • Family history (genetics) • Stress, including: • Conflict between parents, or with parents or siblings • Depression or too much stress in parents • Separation or divorce of parents • Conflicts with friends or classmates, • Social stress • School stress – not doing well, or too much pressure • Bullying • Loss of someone important

27. What should you do if you think your child is depressed? • Take your child to your family doctor or pediatrician • The doctor can check for medical problems that could be causing the changes in behaviour • She/he may suggest mental health services (psychologist, counselor, social worker, psychiatrist) • IF YOU ARE WORRIED YOUR CHILD MAY HURT HIMSELF/HERSELF, TAKE IMMEDIATE ACTION • Call your doctor, the crisis line or the emergency department

28. Can depression be treated? • YES • Young children are most often treated with their family. • Working with parents to help them help their child • Family therapy if family problems are part of the problem • Therapy: by a counselor, psychologist or psychiatrist • Cognitive Behavioural Therapy is proved to be very effective • The child learns ways to manage stress, do things that help her feel better, and think more positively • Medication • Only used when other treatments don’t work, or when the depression is so severe that other treatments aren’t possible • Antidepressants are safe and effective when used correctly and monitored by a doctor

29. Remember the basics!! • Get enough sleep • Eat healthy meals and snacks • Take vitamin D supplements and consider omega 3 fatty acids • Get exercise – an hour a day if possible. • Get enough sunlight (in winter, vitamin D supplements) • Plan enjoyable activities and one on one time with your child • Parents need to take care of themselves too!

30. What else can parents do? • Listen actively to your child. Let them know you notice something is wrong. • Don’t overly pressure the child to talk, but make sure that you do talk • Help the child problem-solve ways to deal with stresses • Step in as the parent when stresses are beyond the child’s ability to handle • Speak to the school if there is school stress or if the depression is affecting how your child does at school • Maintain an atmosphere of calm and consistency at home • Protect time for fun activities together

31. Don’t • Blame or criticize your child for symptoms of depression • Tell your child to “just get over it” or “just snap out of it” • Get into power struggles. Help your child have a sense of control by giving choices whenever possible. • Remove all expectations and let the child miss a lot of school, not get up in the morning, play video games for hours • Make home stressful by fighting, yelling, criticizing, etc. • Dismiss or belittle the child’s problems

32. Putting it all together:

33. Red Flags to Watch For • Feeling sad or depressed for more than 2 weeks • Increase in irritability and anger • Drastic changes in behaviour or personality • Expressions of wanting to die or plans to harm him/herself • Severe mood swings affecting ability to function • Intense worries or fears that interfere with daily activities • Sudden overwhelming fear for no reason, often with difficulty breathing and racing or pounding heart • Decline in school performance • Wanting to avoid school

34. What to do if you are worried • Talk (and listen) to your child • Keep a calm and positive attitude • Problem-solve with your child • Look for resources on-line or in books • Teach your child positive self-talk and self-encouragement • Teach your child deep breathing and relaxation skills • Identify what is stressing your child and address it • Intervene on child’s behalf when appropriate • Call your doctor. Consider calling the school counselor. • Be aware of resources in your area

35. And what not to do: • Ignore the problem • Expect your child to “just snap out of it” • Blame your child for the problem. These are medical problems and cause changes in the brain. • Keep it a secret. Anxiety and depression are very common problems. Everyone gets hurt when they stay in the shadows. • Let your own anxiety or depression weigh down your child

36. If your child is being treated by a professional • Take a matter-of-fact approach, as you would if they had a broken leg • Ask what resources you should read or look at • Ask what you can do to help • Communicate with the professional • Remember you and your child are the most important members of the treatment team!

37. Prevention – There’s lots you can do • Make the home environment as calm and consistent as possible • Establish a regular routine: mealtimes, playtime, homework time etc. • Eat meals together as a family. Avoid negative talk at meals. • Enough sleep • Balanced meals and not too much junk food • Have frequent one-on-one time with your child • Make fun and enjoyable activities frequent and regular • Limit video game, computer and TV time • 7-9 year olds are too young for cell phones and Facebook

38. Relationship MattersBecause Relationships Protect • GO PLACES with your child: • Give many more positive comments than negative ones. • One on one time:  have fun, laugh, do something you both enjoy, play cards – make it a positive zone. • Positive active responses whenever possible • Listen more than you speak, validate the primary emotion • Assert yourself calmly • Connection before correction • Emotional banking: everything you do counts • Stick to your values but consider all points of view

39. Resources • www.ementalhealth.ca • Provides information about mental health disorders, recommendations for books and videos, and details about where to look for help • www.anxietybc.com • Good information about self-help which parents can adapt for kids • www.caringforkids.cps.ca/behaviourparenting/Fears.htm • From the Canadian Pediatric Society • http://www.cmho.org • http://www.knowledge.offordcentre.com/ • Information on a range of mental health problems

40. Question Time