Depression and anxiety

in childhood

Dr Brendan Belsham

Child and adolescent psychiatrist

www.drbelsham.com

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What is abnormal? Normal temperament

Cultural thresholds for abnormality

Normal reactions to stressful environments The home

The school

Adjustment disorder The development of emotional or behavioural symptoms (including

inattentiveness and hyperactivity) occurring within 3 months of a stressor

once the stressor has terminated, the symptoms do not persist for more than an additional 6 months

Abnormal reactions to stressors: PTSD

Various disorders

Normal temperament

Behaviours or traits appearing in the first year of life, which are

stable across time and across situations

They are innate, inborn, genetic

These traits are normal!

Dimensions of temperament

1. Mood

The prevailing mood of the child

2. Approach-withdrawel

The child’s characteristic response to a new situation or strangers

3. Adaptability

How the child copes with transitions and changes

4. Intensity

The energy level of a response, whether positive or negative

5. Persistence Continuing with activities in the face of obstacles

Thomas and Chess, 1963

Attachment

The close emotional bonds of affection that develop between

infants and primary caregivers (mothers)

A biological phenomenon

Occurs in a critical window period, 18-24 months

Securely attached children have:

Increased attention spans (Maslin-Cole and Spieker, 1990)

Greater persistence in problem-solving (Matas et al, 1978)

Better delay of gratification (Olsen et al, 1990)

Better social interactions (Lyons-Ruth et al, 1993)

Less chance of later anxiety disorders, depression

Healthy attachment:

Requires a mother who is

Consistently present

Attuned to the infant’s needs for eye contact,

focused attention, physical affection, stimulation

Cannot occur if the mother is

Unavailable

Erratic

Unpredictable

(NB post-natal depression)

Types of disorders: Categorical

NormalDisorder

Level of impairment

normal disorder

Types of disorders: Dimensional

Number and intensity of symptoms

Zone of ambiguity

So when is it a disorder?

Developmental appropriateness

Situational appropriateness

Symptom count

Chronicity of symptoms

Number of settings in which the symptoms occur

Family history of mental illness

Functional impairment

Anxiety levels

Level of functioning

Prevalence of anxiety disorders

■ 15-20% of youth have an anxiety disorder

■ The most frequent psychiatric disorders in children and adolescents

■ majority of anxiety disorders have their onset in childhood and

adolescence

■ …earliest of all forms of psychopathology

■ Less than one-fifth of affected youth ever receive treatment

■ Overall girls>boys, by adolescence, 2-3:1

Aetiology of anxiety disorders

Genetic vulnerability

Environment

Gene-environment interactions

Gene

expression

Environment

DNA methylation

Inherited

genome

CLINICAL

DISORDER

Features common to anxiety disorders

Avoidance behavior

Frequent midline physical complaints:

headaches, tummy aches, nausea, butterflies

Catastrophic thinking

Impaired functioning:

Classroom performance

Social interactions

Sporting performance

Sleep disturbance

Subjective distress

Anxiety Disorders of Childhood

■ Generalised Anxiety Disorder

■ Separation Anxiety Disorder

■ Social anxiety disorder (social phobia)

■ Selective mutism

■ Panic Disorder

■ Agoraphobia

■ Specific phobia

■ Obsessive Compulsive Disorder

■ PTSD

‘paediatric anxiety

disorder triad’

Post Traumatic Stress Disorder

■ Exposure to an event involving real or threatened death, serious injury or sexual violence, associated with:

1) Re-experiencing phenomena:

■ Memories, nightmares, flashbacks, severe physical reactions

2) Avoidance symptoms

3) Negative cognitions and mood

4) Changes in arousal or reactivity

■ exaggerated startle response

■ hyperactivity

■ inattentiveness

Post Traumatic Stress Disorder

■ DSM 5 introduces new developmental subtype:

■ PTSD in preschool children:

■ Makes allowance for:

■ Type of trauma (dog bites, invasive medical procedures)

■ Observed affect with intrusion symptoms

■ Avoidance symptoms: constricted play

■ Arousal symptoms: extreme temper tantrums

■ Risk of PTSD in those with ADHD 4x greater

than controls

■ ADHD associated with fear circuitry

abnormalities which may predispose to ADHD (ventromedial prefrontal cortex, hippocampus)

■ Faulty processing of the trauma?

Conditions commonly comorbid with anxiety

■ Another anxiety disorder

■ Learning disorder

■ Depression

■ ADHD

■ 23-33% of children with ADHD have an anxiety disorder

The school refusing child

One of the few emergencies in child psychiatry

Possible causes

Depression

Anxiety Disorders

Separation Anxiety D

Social Anxiety D

OCD

Bullying

Undiagnosed learning disorder

Screening for anxiety disorders

May present with:

Frequent need for reassurance

Unable to work independently

Avoidance behaviour

Frequent absenteeism

Underachieving child

Sometimes difficult, oppositional behaviour

Teachers and parents need to have a high index of suspicion

Talk to the child

Use developmentally appropriate language

Parent or teacher concerned

Speak to parent

monitor

Refer psychologist

Refer child/adolescent

psychiatrist (or adult

psychiatrist if >13)resolution

Treatment of childhood anxiety disorders

Early intervention is crucial

Psychoeducation

Addressing the environment Return to school is a priority

Alternative school placement?

Addressing family issues Parental psychopathology

Abuse

Cognitive behavioural therapy

Psychodynamic (play therapy)

Mindfulness therapies

Family-based interventions

Medication

Medication for childhood anxiety disorders

Usually once less invasive strategies have been attempted and failed

Selective serotonin uptake inhibitors (SSRI’s) are first line

May require augmentation, eg risperidone (Risperdal):

But associated with hormonal side-effects (increased prolactin)

Also with long-term side-effects (tardive dyskinesia)

Tricylic antidepressants (eg imipramine, Tofranil)

Medication for childhood anxiety disorders

Selective serotonin uptake inhibitors (SSRI)

Fluoxetine (Prozac, Lorien, Nuzak)

Fluvoxamine (Luvox)

Paroxetine (Aropax)

Sertraline (Zoloft, Sertra)

Citalopram (Cipramil, Cilift)

Escitalopram (Cipralex, Lexamil)

Little evidence for one over the other in various anxiety disorders

Course of anxiety disorders

May remit but mostly chronic

Early onset anxiety disorders (<13 years of age) have a tendency to

follow a chronic course, and to have a more disabling and severe

character

Increased risk of later:

Depression

Substance abuse

Suicide attempts

Poorer long term functioning:

physical health, interpersonal, educational, financial

Childhood depression

Prevalence

2% of children

4-8% of adolescents

5-10% of children and adolescents have subsyndromal depression

Gender ratio

1:1 in childhood

1:2 in adolescence

In the prevalence of depression increasing?

Yes:

Each successive generation after 1940 is at greater risk of

depression, with onset at younger age, than the previous

generation

Why??

Why do children get depressed?

Genetic risk

Adoption studies, Twin studies

The single most predictive factor

Environmental stressors affect onset and recurrences:

Losses

Neglect

Abuse

Ongoing conflict and frustration

But the effect of these stressors depends on the child’s attributional style

Interaction between genetic and environmental factors

Why do children get depressed?

Comorbid conditions

Anxiety disorders

Persistent depressive disorder

ADHD

Substance abuse

Medical illness

Diabetes

The South African context

Violence

Poverty

Migrant labour

HIV epidemic

Child-headed homes

Inadequate education

Good Childhood Survey

South Africa ranked 13th out of 15

DSM5 Major Depressive Disorder (MDD) Depressed or irritable mood; AND

Reduced interest or enjoyment of activities; plus 4 or more of : Diminished ability to think or concentrate

Markedly reduced energy levels

Insomnia or excessive sleeping

Decreased or increased appetite, or excessive weight gain or weight loss (or failure to achieve expected weight gain)

Psychomotor agitation or psychomotor slowing

Feelings of guilt or excessive worthlessness

Recurrent thought of death, suicidal thinking or suicidal behaviour

These symptoms must persist for 2 weeks or more

and cause significant functional impairment

Important differences from adult depression

Mood may be depressed or irritable

May display behavioural symptoms rather than verbalizing sadness

Low frustration tolerance

Tantrums

Social withdrawal

Less appetite and sleep disturbance

Other common symptoms of childhood

depression

School refusal, or frequent absenteeism from

school

Academic underachievement

Frequent physical complaints

Frequent complaints of boredom

Reckless behaviour (‘masked depression’) in

adolescents

Dysthymic disorder

Now known as Persistent Depressive Disorder

Consists of a persistent, long-term change in mood (depressed

mood or irritability for >1 year)

Less intense but more chronic than major depressive disorder

As impairing or more impairing than MDD

Often overlooked

Internalising and externalising disorders

EXTERNALISING INTERNALISING

•ADHD

•Oppositional

defiant d.

•Anxiety disorders

•Depression

Depression: differential diagnosis

Persistent depressive disorder

Anxiety

ADHD

Oppositional Defiant Disorder

Substance abuse

Medical disorders

Bereavement

Adjustment disorder

Psychotic depression

Presence of hallucinations

May include command hallucinations (suicide)

Less commonly delusions

Associated with:

family history bipolar disorder

More severe depression

Resistance to antidepressants

Increased risk of bipolar dis

Prognosis

20-60% probability of recurrence within 1-2 years after remission

70% recur after 5 years

Higher risk for suicide

Higher risk for substance abuse

20-40% will develop bipolar disorder, especially if:

Family loading for bipolar

Psychotic depression

Pharmacologically - induced manic symptoms

Childhood Bipolar Disorder

Recurrent episodes of depression and

MANIA:

Grandiosity

Less need for sleep

Flight of ideas/ racing thoughts

Excessive involvement in pleasurable activities

Level of impairment normal disorder

What about sub-syndromal conditions?

Number and intensity of symptoms

x

Significant impairment

High genetic loading

Increased risk for MDD

Increased risk for suicide

Suicidal children

60% of depressed youth think about suicide, 30% will make

suicide attempt

Suicide in South African children aged 10-14 has more than

doubled in the past 15 years

Completed suicide very rare in preteens

Risk factors for youth suicide

Previous suicide attempts (especially multiple attempts)

Comorbid psychiatric disorders

Anxiety disorder is a risk factor for suicide even in the absence of

depression

Impulsivity and aggression

Availability of lethal agents

Exposure to negative events

Family history of suicide

Cutting

Genuine attempt?

Depression, other mood disorder

Relief from emotional pain?

Endorphin release

“I just want to feel something”

Personality disorder (Borderline)

Copy-cat?

Treatment of childhood depression

Admission?

Psychoeducation

Supportive management

Family involvement

School involvement

Individual psychotherapy

Medication in childhood depression

High placebo response rate (30-60%; eg tricyclic antidepressants

have not been shown to be superior to placebo)

SSRI’s the gold-standard:

Fluoxetine (Prozac) FDA approved

Recent controversy around induction of suicidality

Atypical antipsychotics (eg risperidone):

For psychotic depression

As an augmentation strategy

Treat comorbid conditions

receptor

Serotonin

SERT

the serotonergic synapse

Direction of transmission

Side-effects of SSRI’s GIT

Nausea, vomiting

Diarrhoea

Stomach cramps

Headaches

Tiredness

Sleep disturbance

Appetite disturbance, weight gain

Behavioural activation (may only emerge 3 months after treatment) Disinhibition, Defiance, Impulsivity, Insomnia

Mania

Treatment-emergent suicidality

Monitoring medication

Requires good communication between:

Home (both homes where relevant)

School

Doctor

Other professionals

Monitor clinical response

Duration of treatment

Take-home messages

Anxiety and depression are common in childhood

… especially in South Africa

Often unrecognized

… especially in South Africa

A source of significant morbidity

Effective treatments are available