childhood depression and anxiety disorders - childhood depression and anxiety...history of childhood...

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Childhood Depression and Anxiety Disorders Robin Welsh, MD Director Child Development and Behavioral Health Director of Pediatric Palliative Care Department of Pediatrics Palmetto Health USC Medical Group

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Childhood Depression and Anxiety Disorders

Robin Welsh, MD

Director Child Development and Behavioral Health

Director of Pediatric Palliative Care

Department of Pediatrics

Palmetto Health USC Medical Group

History of Childhood Depression

• Case reports of children exhibiting symptoms resembling depression were described as early as the 17th century.

• Early theories of depression discounted the existence of the disorder in children

• The late 1970s – evidence supporting childhood depression first emerges

• The early 1980s – increase in research; evidence begins to accumulate

• The late 1980s – focus of research changes to studying epidemiology, biological correlates and predictors

Epidemiology of Depression

• 1-2% in children

• 4%-8% in adolescents

• By the end of adolescence - 20%

• Male : Female ratio

1 : 1 during childhood

1 : 3 during adolescence

The majority of children and adolescents with depressive disorders go undiagnosed

Suicide Statistics

• ~15% of teens seriously contemplate suicide

• ~7% attempt suicide

• Girls attempt more often than boys

• Boys have higher rate of suicide than girls

• Suicide’s ranking by age as cause of death and suicide rates

Age 10 – 14: #3 (1.3/100,000)

Age 15 – 19 #3 (8.2/100,000)

white males>nonwhite males>white females>nonwhite females

Risk Factors for Adolescent Suicide

• Break up of a major relationship

• Problems with gender identity or sexual orientation

• Access to lethal weapon or means

• Substance Abuse

• History of previous attempt

• Chronic pain

• Disfiguring illness

• Decreased social support

• Family history of suicide

• Hopelessness

• Explicit plan

• Psychosis or impaired reality testing

DSM -5 Criteria

A. Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

• Depressed mood most of the day, nearly daily

• Diminished interest

• Significant weight loss

• Insomnia/hypersomnia nearly daily

• Psychomotor agitation

• Fatigue

• Feelings of worthlessness

• Difficulty concentrating

• Thoughts of death

DSM-5 Criteria Continued

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

D. The occurrence of the major depressive episode is not better explained by another mental disorder

E. There has never been a manic episode or hypomanic episode.

Severity/Course Specifiers

• Mild

• Moderate

• Severe

• With psychotic features

• Partial features

• Full remission

• Unspecified

Additional Specifiers

• With melancholic features

• With atypical features

• With mood-congruent psychotic features

• With catatonia

• With seasonal pattern

• With peripartum onset

• With anxious distress

• With mixed features

Depression is difficult to recognize in children

• Primary Care physicians receive inadequate training in psychiatric illness

• Symptoms of depression may be nonspecific or mild

• Patients emphasize somatic complaints

• Some PCPs are reluctant to stigmatize

• Notion that reactive depressions are not pathological

Clinical Presentation - Children

• Irritability• School performance deteriorates• Drop out of extracurricular activities• Low frustration tolerance• Temper tantrums• Somatic complaints• Social withdrawal• Separation anxiety• Phobias• School refusal

Clinical Presentation - Adolescents

• Academic difficulties

• Apathy

• Anhedonia

• Behavioral changes

• Social withdrawal

• Low self esteem

• Irritability

• Frequent school absences

• Hypersomnia

• Weight change

• Substance Abuse

Other Possible Symptoms of Masked Depression in Adolescents

• Problems with authority figures• Increased sensitivity to rejection• Extreme rebelliousness• Perfectionistic• Frequent disappoint themselves or others• Running away from home• Impaired personal hygiene• Intolerance of praise and rewards• Prone to frequent yelling• Difficulty making decisions

Comorbidities

• Most depressed children have other psychiatric disorders

• Most frequent comorbidities:

Anxiety

Dysthymia

Disruptive behavior disorders/ADHD

Substance use disorders

Eating disorders

Developmental Disorders

Presence of comorbidities generally increases the risk of longer duration, recurrence, treatment resistance, poorer functional outcome

Differential Diagnosis

• Medical Disorders

Hypothyroidism, Mononucleosis, Chronic Pain, Anemia, Cancer, Chronic Fatigue Syndrome, Sleep Apnea, Autoimmune disorders, Premenstrual dysphoric disorder, Epilepsy, DM, Dialysis

• Substance/medication induced depression

Alcohol, Opiates, Cocaine withdrawal, Stimulants, Steroids, Contraceptives, Clonidine, Sedatives, Antibiotics

• Other Psychiatric Disorders such as:

Bipolar Disorder - family history of BPAD, history of pharmacologically induced mania, history of hypomanic symptoms

Anxiety

Eating problems- associated with Eating or Feeding disorders

Sleep problems – associated with stress or other disorders

Mood and self-esteem problems – frequent in children with developmental, learning or ADHD.

Clinical Course

• Typical duration of episode ranges between 3-6 months

• Longer if comorbid conditions are present

• Most will recover from the first episode

• Recurrence up to 70% by 1-2 years after remission

• 10-20% will develop Bipolar disorder

Poorer Prognosis

• Increased severity of symptoms• Parental history of early onset mood problems• Recurrence• Comorbidity• Hopelessness• Lack of total remission of symptoms• Negative cognitive style• Family problems• Sexual abuse history• Exposure to ongoing negative life events

Other Mood Disorders

• Disruptive Mood Dysregulation Disorder

• Persistent Depressive Disorder/Dysthymia

• Premenstrual Dysphoric Disorder

• Substance/Medication Induced Disorder

• Depressive Disorder NOS

• Adjustment Disorder

Etiology

• Genetic• Twin, family and adoption studies indicate effects of both genetic and environmental

factors for depression• Twin studies show a heritability of 40-65% with higher concordance rates in identical

twins

• Environmental • Abuse or neglect, break up of a relationship, death of a family member or friend,

families with high level of discord, addition of family members, move to a new house, divorce of parents, parents who are hostile and rejecting

• Biological• Baseline EEG studies documented reduced left frontal electrical activity• Growth hormone - hypersecretion in some depressed adolescents• Sleep – increased sleep latency, decreased REM latency, decreased sleep efficiency• Dysregulation of serotonin and norepinephrine systems

Developmental Framework for Childhood Depression

• Transitions in development are times of increased risk of depression

• Multiple domains are effected – physical, sexual, cognitive, and social

• Depression can interfere with developmental milestones

• Problems with interpersonal relationships

• Problems with school performance

• Delays in social, emotional and cognitive development

• Can have persistent psychosocial problems in adult life including dysfunctional interpersonal relationships, low educational attainment, poor occupational functioning, unemployment, early pregnancy, suicidal behavior

Evaluation of Depression

• History/obtain information from parent

• History/obtain information from child

• Obtain information from school

• Rating Scales – Child Depression Inventory; Child Depression Rating Scale; BASC

• Bio-Psycho-Social Approach

Treatment is multimodal

• Psychosocial interventions

• Psychoeducation

• Individual therapy

• Group therapy

• Family therapy

• School consultation

• Evaluation for comorbid illnesses

• Medication

Practice Parameter for the Assessment and Treatment of Children and Adolescents with

Depressive Disorders• Recommendation 1: Confidentiality

• Recommendation 2: Screening

• Recommendation 3: Screening for other comorbid psychiatric and medical disorders

• Recommendation 4: Suicide assessment

• Recommendation 5: Social assessment – ongoing or past exposure to negative events; environmental factors; family psychiatric history

Recommendations continued

• Recommendation 6: acute treatment phase and continuation phase and sometime maintenance phase

• Response: no symptoms or a significant reduction in symptoms for at least 2 weeks

• Remission: at least 2 weeks and less than 2 months with no or few symptoms

• Recovery: absence of significant symptoms for greater than 2 months

• Relapse: DSM criteria during remission

• Recurrence: emergence of symptoms during recovery; a new episode

Recommendations Continued

• Recommendation 7: Psychoeducation, supportive management, and family and school involvement at each phase of treatment.

• Recommendation 8: Education, support, and case management may be sufficient for uncomplicated or brief depression

• Recommendation 9: A trial with specific types of psychotherapy and/or antidepressants is indicated

• Recommendation 10: Continue treatment for 6-12 months to avoid relapse

• Recommendation 11: Some should be maintained for longer periods of time

Recommendations Continued

• Recommendation 12: Specific somatic treatments may be required for depressed patients with psychosis, seasonal and bipolar depression

• Recommendation 13: Manage comorbid conditions

• Recommendation 14: Frequent follow up contacts to monitor clinical status, environmental conditions, and side effects

• Recommendation 15: For nonresponse, consider factors associated with poor response

• Recommendation 16: Early intervention for children with risk factors associated with development of depression

J Am Acad Child Adolesc Psychiatry, 2007 Nov;46(11): 1503-26

Medications

• SSRI’s

• FDA approved treatment of child and adolescent depression (ages 8-18) – Fluoxetine

• FDA approved treatment of adolescent depression ( ages 12-17) –Escitalopram

• TCA’s no more efficacious than placebo and poor side effect profile

Texas Children’s Algorithm

• Monotherapy with SSRI

• If inadequate response, monotherapy with alternative SSRI

• If partial responder, augment

• If partial response or nonresponse, monotherapy with alternative class

Treatment for Adolescents with Depression Study

Treatment Response Rate

Week 12 Week 18 Week 36

CBT + Fluoxetine 73% 85% 86%

Fluoxetine 62% 69% 86%

CBT 48% 65% 81%

Placebo 35%

Randomized, controlled trial conducted in 13 academic and community sites in the US.

Arch Gen Psychiatry.2007;64(10):1132-1143.

FDA approved SSRIs in Children and Adolescents• Fluoxetine (7-18 OCD; 8-18 depression)

• Sertraline (6-18 OCD)

• Escitalopram (12-18 depression)

• Fluvoxamine (8-18 OCD)

Treatment with SSRI’s

• Start low, go slow

• Treat for at least 4 weeks and assess clinically

• Response time – 2-6 weeks

• No response after 8 weeks of treatment, increase initial med or switch to alternative med

• Follow up visits weekly for first 1-4 weeks

• Bi-weekly after that

• Monitor closely for the first few months for clinical worsening, suicidality, agitation or other significant changes

• Treatment time 6-12 months after resolution of symptoms

• Recovery influenced by age at onset, severity, comorbid disorders and parental history of depression

• Discontinuation – short taper

Side Effects of SSRIs

• Gastrointestinal – nausea, diarrhea, heartburn

• Headaches

• Behavioral activation

• Appetite changes

• Sleep changes

• Autonomic symptoms

• Tremors

• Sexual dysfunction

• Rash

Serotonin Syndrome

• Fever, agitation, increased reflexes, tremor, diaphoresis, dilated pupils, diarrhea, autonomic instability, shivering, myoclonus

• Can progress to seizures, rhabdomyolysis, renal failure, shock and DIC

• Can be fatal

• Usually occurs within several hours of taking a new drug or increasing the dose of a drug.

Medications that can precipitate Serotonin Syndrome

• Antidepressants (SSRIs, SNRIs, TCAs, MAOIs, Bupropion)

• Antimigraine meds (Sumatriptan, Carbamazepine, and Valproic Acid)

• Analgesics (meds with codeine, meperidine, fentanyl, oxycodone, pentazocine),

• Lithium,

• Antiemetics (ondansetron, metoclopramide),

• Linezolid,

• Dietary supplements (St. John’s wort, ginseg, nutmeg,tryptophan), Cold meds (dextromethorphan),

• Drugs of abuse ( LSD, Ecstasy, cocaine, amphetamines)

Serotonin Discontinuation Syndrome

• Dizziness

• Moodiness

• Insomnia

• Flu-like syndrome

• Nausea, vomiting, myalgia

• Tiredness, irritability, somatic complaints

• Discontinuation symptoms possible within 24-48 hours of discontinuation

FDA black-box warning

• 2004 FDA issued black-box warning for antidepressants

• Thought to be associated with an increased risk of suicidal thinking, feeling and behavior

• Prescriptions for SSRI for children decreased by approx. 20% between 2003 and 2005

• 2007 FDA added depression itself was associated with an increased risk of suicide

Evidence Based Psychotherapies for Depression in Children and Adolescents

• Cognitive Behavioral Therapy (CBT) – for children and adolescentsA psychosocial intervention that is the most widely used evidence-based psychotherapy

Guided by empirical research, it focuses on developing coping strategies to solve problems and change unhelpful patterns in cognitions such as thought, beliefs, and attitudes, behaviors and emotional regulation.

Explore how thoughts, feelings and automatic negative thoughts effect behavior and correct misinterpretations.

Examples: Exposure therapy, response preventions, self-monitoring, self-management procedures, stress inoculation, cognitive processing therapy, relaxation training, habit reversal training, imagery, journaling, challenging beliefs, mindfulness

• Interpersonal therapy (IPT) – for adolescentsCenters on resolving interpersonal problems and symptomatic recovery. It is highly structured and lasts 6-12 weeks.

Anxiety Disorders

• Anxiety is a normal reaction to stress; it can be a good thing

• Pathological anxiety is when it is present for almost all of the time and causes impairment

• Appropriate fears and worries at each stage of development• Infants: strangers, sudden movement

• Toddlers: the dark, separation from loved ones, large animals, loud noises

• School-age: bodily injury, bad people

• Adolescents: school performance, social status, illness

Etiology of Anxiety

• Biological – genetics - increase risk for children if their parents have anxiety; high rates of concordance in twin studies

• Psychological – modeling and fear conditioning; anxious parents; temperament of behavioral inhibition or shyness

• Social- parental behaviors (high levels of discipline; overprotection; direct modeling); low prosociality in school; inattention

Anxiety Disorders

• 6-20% of school aged children and adolescents

• Girls: boys, 2:1

• Preschool: separation anxiety disorder, selective mutism

• School age: separation anxiety, specific phobia (most common anxiety disorder), generalized anxiety disorder, selective mutism (early years)

• Adolescence: social anxiety disorder, panic disorder

Assessment

• Interview/Obtain information from child

• Interview/Obtain information from parent

• Obtain information from school

• Screening Tools:

SCARED - screen for child anxiety related emotional disorders

YBOCS – assess symptoms of OCD

BASC – Behavior Assessment System for children

CBCL – Child Behavior Checklist

.

Treatments

• Biological – SSRIs

• Psychological – CBT psychotherapy

• Social – school, extracurricular activities

• Mild severity - CBT

• Severe – combination of CBT and SSRIs.

CAMS Study

• Child/Adolescent Anxiety Multimodal treatment study

• 6 year, six site, randomized controlled trial.

• 488 children and adolescents, ages 7-17; with DSM-IV-TR diagnoses of SAD, GAD, or Social Phobia

• Four treatment groups; CBT; Sertraline; CBT +Sertraline, and placebo

• Treatment for 12 weeks

• Combination treatment superior 80.7% response; CBT 59.7%; Sertraline 54.9%, placebo 23.7%

Walkup JT, et al. N Engl J Med, 2008

Cognitive Behavioral Therapy

• Cognitive restructuring – change thinking patterns

• Behavioral Activation – learn to overcome obstacles

• Psychoeducation – structured learning experiences that teach patients to monitor and write down their negative thoughts and mental images

• Treatment is goal oriented and time limited, usually 14-16 weeks

• Patients take an active role and usually have homework assignments

• Strategies such as role playing, imagery, exposure, and relapse prevention are used

• Coping Cat (ages 8-13)and C.A.T. Project (ages 14-17)

Medications for Childhood Anxiety

• SSRIs only medications well-supported by placebo-controlled studies• Sertraline, Fluoxetine, Fluvoxamine

• Start low and go slow

• Try alternate SSRI if first one not effective

• Consider family history of medication therapy for anxiety– family members may be more likely to respond to same medications

Separation Anxiety

• Prevalence 4% in children; 1.6% in adolescents

• Most prevalent anxiety disorder in children younger than 12 yo

• Preschool to 18 yo

• Excessive anxiety about separation from home or from attached persons

• Developmentally inappropriate

DSM 5 Criteria

• Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the child is attached for at least 4 weeks with 3 of the following:• Recurrent excessive distress related to separation from home or attachment figures

• Persistent and excessive worry regarding a untoward event causing separation from attachment figure: illness, being kidnapped, etc.

• Persistent reluctance or refusal to go out, be away from home, to school, to work

• Persistent and excessive fear of or reluctance about being alone or without attachment figure

• Persistent reluctance or refusal to sleep away from home

• Repeated nightmares involving the theme of separation

• Repeated complaints of physical symptoms when separation occurs or is anticipated

Separation Anxiety Treatment

• CBT

• Family education

• Family psychosocial intervention

• Graded exposure therapy

• SSRIs/pharmacologic interventions if above ineffective

Selective Mutism

• Consistent failure to speak in specific social situations in which there is an expectation for speaking

• Interferes with educational or occupational achievement or social communication

• Duration of at least 1 month (not limited to the first month of school)

• Not attributed to another diagnosis

• Point prevalence 0.3-1%

• Most common in young children

Treatment of Selective Mutism

• Multimodal approach – collaboration with home and school; psychoeducation for the family and school

• Graded exposure treatment

• Adults should not speak for the child

• SSRIs may be effective

Generalized Anxiety Disorder (GAD)

• Excessive anxiety and worry on most days for at least 6 months about a number of events or activities

• Difficult to control the worry• Associated with at least 3 or more physical symptoms (only 1 is required in

children)• Restlessness or keyed-up feeling• Being easily fatigued• Difficulty concentrating• Irritability• Muscle tension• Sleep disturbanceSignificant impairment; not attributable to other case; and not better explained by another mental disorder

Generalized Anxiety Disorder

• 6.5% of preschoolers; 3% in school aged children; 3.7% in adolescents

• Increases risk for depression

• Treatment• SSRIs

• CBT – relaxation skills training, imagined or real-life exposure to anxiety provoking situations

School Refusal

• Affects 2-5% of school-aged children

• Most common 5-6 and 10-11 year olds

• Common around life changes like moving, starting school, academic transitions

• Parents can reinforce as often associated with physical symptoms such as: headaches, stomachaches, nausea or diarrhea.

• The longer the child is out of school, the more difficult it is to return

• Treatment strategies• Get the child back in school• Multimodal approach - meds (SSRIs), CBT, school support• Don’t offer homebound instruction

Social Anxiety Disorder (SAD)

• Marked persistent fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by other.

• The child fears showing anxiety symptoms that will be negatively evaluated

• The social situations almost always provoke fear or anxiety

• Situations are avoided or endured with intense fear or anxiety

• Fear or anxiety is out of proportion with actual threat posed by the social situation

• Lasts longer than 6 months

• Causes distress; not attributable to other condition

Social Anxiety Disorder

• 7% of children and adolescents. Prevalence decreases with age

• Females>males

• Increased rates of depression

Treatment

SSRIs

CBT

Social skills training

Panic Disorder

• Recurrent unexpected panic attacks or abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, with 4 or more of the following symptoms• Palpitations, pounding heart , accelerated HR• Sweating • Trembling or shaking • Sensations of shortness of breath or smothering• Feelings of choking• Chest pain or discomfort• Nausea or abdominal distress• Feeling dizzy, unsteady, light-headed• Chills or heat sensations• Paresthesias (numbness or tingling sensations)• Derealization or depersonalization• Fear of losing control or “going crazy”• Fear of dying

Panic Disorder

• Prevalence rates in adolescents varies 0.6-5%• Prevalence for adolescents and adults 2-3% • Onset typically in late adolescence and early adulthood (increases during

adolescence from 0.4% before age 14, possibly following the onset of puberty)

• Females>males• Increases risk of other anxiety disorders and depression• Treatment

Education for patients, families and school staffCBT – relaxation techniques, cognitive strategies, and exposure and response preventionSSRIs for symptoms that are persistent and impair function

Obsessive Compulsive Disorder

• Presence of obsessions or compulsions (or both)• Obsessions are define by:

• Recurrent persistent thought, impulses, or images that are experienced as intrusive

• Child attempts to ignore or suppress them

• Compulsions are defined by:• Repetitive behaviors or mental acts that a person is driven to perform in response to an

obsession(hand washing, ordering, checking, praying, counting, repeating words silently)

• The behaviors or mental acts are aimed at preventing or reducing distress but may be not connected in a realistic way with what they are to prevent

• Symptoms are time consuming and cause distress

• Not attributable to other cause

Examples of Obsessions

• Contamination

• Hoarding

• Ruminations, intrusive thoughts

• Pathological doubt

• Somatic

• Need for symmetry

• Aggressive

• Sexual

Examples of Compulsions

• Checking • Ordering• Washing• Cleaning• Praying • Rearranging• Counting• Confessing• Rituals• Symmetry • Hoarding

OCD

• Early onset- more severe

• Prevalence 1.2%

• Males>female in childhood; Females>males in adulthood

• PANDAS – Pediatric Autoimmune neuropsychiatric disorder associated with streptococcus group A• Sudden acute and debilitating onset of intense anxiety and mood lability accompanied by

OCD-like issues or Tics• Relapsing-remitting symptom pattern – OCD, tics, anxiety, personality changes and more• Mild strep infection that has usually occurred immediately prior to the symptoms• Treatments are experimental and controversial (antibiotics, IVIG, and plasmapheresis)• Treat tics and OCD conventionally (CBT, SSRIs, clonidine, antipsychotics)

Treatment of OCD

• The Pediatric OCD Treatment Study (POTS)-• Randomized control trial in 2004• 3 academic centers; 112 patients ages 7-17; DSM IV diagnosis of OCD• 4 groups: CBT alone, Sertraline alone, Combined CBT and Sertraline, or pill

placebo for 12 weeks• The rate of clinical remission:

CBT alone: 39.3% Sertraline alone: 21.4% Combined: 53.6%• Children and adolescents with OCD should begin treatment with the

combination of CBT plus a SSRI (sertraline) or CBT alone

JAMA 2004;292:1969-1976

Trichotillomania

• Recurrent hair pulling results in significant hair loss

• Repeated attempts to decrease or stop

• Causes distress and is not attributable to other cause

• Course is waxing and waning

• Significant distress• 1-2% of adolescents and adults

• Females=Males in children

• Females : Males in adolescents/adults - 10:1

Treatment of Trichotillomania

• Not one approach

• Most success in CBT - relatively robust initial response but recurs over time• Habit reversal

• Awareness training – of promontory urge

• Competing response training – squeezing a ball

• Contingency management – rewards

• Generalization training – spreading to all contexts such as home and school

• Relaxation training

• Meds not very effective – can use SSRIs

Summary

• For the past 3 decades, considerable advances have been made in the knowledge of depression and anxiety in children

• Epidemiologic and clinical research has helped identify risk factors for both disorders

• Genetics, neurobiological, cognitive, interpersonal, environmental, and developmental factors play a part in these multifactorial disorders

• Early detection and intervention is key