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Makkallai atanka - anxiety in children

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  • 1. Anxiety in Children Dr. Shamanthakamani Narendran MD(Pead), PhD(Yoga Science)
  • 2. Depressed Mood
    • Q: How do you know a child or adolescent has a depressed mood?
    • A:
      • Ask
        • Sadness is just one presentation
        • Irritability is common
        • Loss of pleasure
      • Observe
      • Use multiple informants
  • 3. The Informant Matters
    • Parents commonly under- and over-report child’s mood and anxiety feelings (internalizing symptoms)
    • Parents are typically good reporters of disruptive behaviors such as hyperactivity & aggression (externalizing symptoms)
  • 4. Depressed vs Depressive Episode
    • Q: What is the difference between a depressed mood and a depressive episode?
    • A:
      • Mood is the subjective feeling state
      • An episode is a cluster of specific, associated symptoms that occur over a defined period of time
        • DSM-IV-TR definition
  • 5. Major Depressive Episode
    • Criteria: 5+ during same 2 weeks
      • Depressed mood - most of the day, most days
      • Anhedonia
      • Appetite change, weight loss, FTT
      • Insomnia or hypersomnia
      • Psychomotor agitation or retardation
      • Fatigue or loss of energy
      • Feelings of worthlessness or inappropriate guilt
      • Poor concentration and/or indecisiveness
      • Recurrent thoughts of death or suicidal ideation
  • 6. Major Depressive Disorder
    • Must have distress/impairment
    • R/O causative medical and/or drug condition
    • R/O Bereavement
    • R/O mixed mood episode
    • This is additionally rated
      • Single vs. Recurrent
      • Mild, Moderate, Severe
      • With or Without Psychotic Features
  • 7. Depressed Mood: Diagnostic Considerations?
    • Simple depressed mood (no diagnosis)
    • Adjustment Disorder(s)
    • Dysthymia
    • Major Depressive Disorder
    • Bipolar Disorder, Depressed
    • Schizoaffective Disorder, Depressed
    • Depressed mood associated with another diagnosis
    • Substance Use/Substance Use Disorder
    • Medical Condition
  • 8. Irritable Mood: Diagnostic Considerations
    • Simple irritable mood (no diagnosis)
    • Adjustment Disorder(s)
    • Dysthymia
    • Major Depressive Disorder
    • Bipolar Disorder, Depressed or Hypomanic or Manic or Mixed Episode (or “NOS”)
    • Psychotic (Thought) Disorders
  • 9. Irritable Mood: Diagnostic Considerations
    • Oppositional Defiant Disorder
    • ADHD
    • Anxiety Disorders, e.g. PTSD
    • Sleep Disorder
    • Substance Use/Substance Use Disorder
    • Medical Condition
    • Personality Disorder
  • 10. Hypomanic & Manic Episodes
    • Distinct period of abnormal & persistent mood change - elevated, expansive, or irritable
    • 3+ corresponding sx
      • Inflated self-esteem
      • Decreased need for sleep
      • More talkative; pressured talk
      • Flight of ideas or thought racing
      • Distractibility
      • Increase in goal-directed activity or agitation
      • Excessive involvement in risky pleasurable activities
  • 11. Hypomanic & Manic Episodes
    • R/O Somatic causes, e.g. medical conditions, drug effect
    • Not a mixed mood episode
    • Unequivocal change in function
    • Hypomania vs mania
      • Time
      • Degree of impairment
      • Presence/absence of psychotic symptoms
  • 12. Anxiety
    • Q: What does this look like in children and adolescents?
    • A:
  • 13. Anxiety vs Anxiety Disorder(s)
    • Important to determine
      • Impairment present?
      • Circumstances?
      • Associated symptoms?
  • 14. Anxiety Disorders
    • Adjustment Disorder(s)
    • PTSD
    • Social Phobia
    • Other Phobias
    • Obsessive Compulsive Disorder
    • Panic Disorder (panic attacks necessary but not sufficient for diagnosis)
    • Generalized Anxiety Disorder
    • Separation Anxiety Disorder
    • Substance Use/Substance Use Disorders
    • Medical Condition
  • 15. Diagnostic Precision
    • Q: Why is this important?
    • A: For prognosis & treatment
    • - Evidence-Based Medicine
  • 16. Clinical Case
    • 10 year old female
    • Chief complaint of parents - she fights a lot and is not compliant
    • Has trouble falling asleep
    • Poor concentration and falling grades in school
    • Mopes around the house, doesn’t seem as interested in doing things with her friends
  • 17. Possibilities
    • Depressed mood
      • Adjustment Disorder
      • Major Depressive Disorder
      • Bipolar, Depressed
        • NB: ~ 30% of children with Major Depressive Episode are eventually diagnosed with Bipolar Disorder
  • 18. Screening
    • What do you want to screen?
    • Who do you want to screen?
    • What will you do with positive screens?
  • 19. Diagnostic Evaluation
    • Do it yourself
    • Make a referral
      • Type of provider
      • Insurance
      • Availability
      • Communication
  • 20. Three Components of Anxiety
    • Physical symptoms
    • Cognitive component
    • Behavioral component
  • 21. Physiology of Anxiety: Physical System
    • Perceived danger
    • Brain sends message to autonomic nervous system
    • Sympathetic nervous system is activated (all or none phenomena)
    • Sympathetic nervous system is the fight/flight system
    • Sympathetic nervous system releases adrenaline and noradrenalin (from adrenal glands on the kidneys).
    • These chemicals are messengers to continue activity
  • 22. Parasympathetic Nervous System
    • Built in counter-acting mechanism for the sympathetic nervous system
    • Restores a realized feeling
    • Adrenalin and noradrenalin take time to destroy
  • 23. Cardiovasular Effects
    • Increase in heart rate and strength of heartbeat to speed up blood flow
    • Blood is redirected from places it is not needed (skin, fingers and toes) to places where it is more needed (large muscle groups like thighs and biceps)
    • Respiratory Effects-increase in speed and dept of breathing
    • Sweat Gland Effects-increased sweating
  • 24. Behavioral System
    • Fight/flight response prepares the body for action-to attack or run
    • When not possible behaviors such as foot tapping, pacing, or snapping at people
  • 25. Cognitive System
    • Shift in attention to search surroundings for potential threat
    • Can’t concentrate on daily tasks
    • Anxious people complain that they are easily distracted from daily chores, cannot concentrate, and have trouble with memory
  • 26. “U” Shaped Function of Anxiety
    • Useful part of life
    • Expressed differently at various age levels
  • 27. Generalized Anxiety Disorder
    • Unfocused worry
  • 28. Generalized Anxiety Disorder: Diagnostic Criteria
    • Excessive anxiety or worry occurring more days than not for at least 6 months about a number of events or activities
    • Difficulty controlling worry
    • 3 of 6 symptoms are present for more days than not:restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
  • 29. Generalized Anxiety Disorder (GAD): Prevalence
    • ~ 4% of the population (range from 1.9% to 5.6%)
    • 2/3 or those with GAD are female in developed countries
    • Prevalent in the elderly (about 7%)
  • 30. Generalized Anxiety Disorder: Genetics
    • Familial studies support a genetic model (15% of the relatives of those with GAD display it themselves-base rate is 4% in general population)
    • Risk of GAD was greater for monozygotic female twin pairs than dizygotic twins.
    • The tendency to be anxious tends to be inherited rather than GAD specifically
    • Heritability estimate of about 30%
  • 31. Generalized Anxiety Disorder: Neurotransmitters
    • Finding that benzodiazepines provide relief from anxiety (e.g. valium)
    • Benzodiazepine receptors ordinarily receive GABA (gamma-aminobutyric acid)
    • GABA causes neuron to stop firing (calms things down)
  • 32. Generalized Anxiety Disorder: Neurotransmitters
    • Getting Anxious
    • Hypothesized Mechanism:
    • Normal fear reactions
    • Key neurons fire more rapidly
    • Create a state of excitability throughout the brain and body –perspiration, muscle tension etc.
    • Excited state is experiences as anxiety
    • Calming Down
    • Feedback system is triggered
    • Neurons release GABA
    • Binds to GABA receptors on certain neurons and “orders” neurons to stop firing
    • State of calm returns
    • GAD: problem in this feedback system
  • 33. GABA Problems?
    • Low supplies of GABA
    • Too few GABA receptors
    • GABA receptors are faulty and do not capture the neurotransmitter
  • 34. Generalized Anxiety Disorder: Cognitions
    • Intense EEG activity in GAD patients reflecting intense cognitive processing: low levels of imagery
    • Worrying is a form of avoidance
    • They restrict their thinking to thoughts but do not process the negative affect
    • Worry hinders complete processing of more disturbing thoughts or images
    • Content of worry often jumps from one topic to another without resolving any particular concern
  • 35. Generalized Anxiety Disorder: Treatment
    • Short term-benzodiazepine (valium)
    • Cognitive Therapy (focus on problem)
  • 36. Phobia: Diagnostic Criteria
    • Marked & persistent unreasonable fear of object or situation
    • Anxiety response
    • Unreasonable
    • Object or situation avoided or endured with distress
  • 37. Differential Diagnosis of Specific Phobia
    • Vs. SAD: not related to fear of separation
    • Vs. Social Phobia: not related to fear of a social situation or fear of humiliation
    • Vs. Agoraphobia: fear not related to closed places
    • Vs. PTSD: fear not related to a specific past traumatic event
  • 38. Phobias: Types
    • Specific phobias
    • Blood-Injection Injury phobias
    • Situational phobia
    • Natural environment phobia
    • Animal phobia
    • Pa-leng (Chinese) colpa d’aria (Italian)
    • Germs
    • Choking phobia…..
  • 39. What are your fears???
  • 40. Developmentally Normal Fears Performance in school, peer scrutiny, appearance, performance 12-18 Supernatural, bodily injury, disease, burglars, failure, criticism, punishment 6-12 Year Strangers, storms, animals, dark, separation from parents, objects, machines loud noises, the toilet 1-5 Year Strangers, looming objects, unexpected objects or unfamiliar people 7-12 Months Loud noises, loss of physical support, rapid position changes, rapidly approaching other objects Birth- 6 Months Normal Fear Age
  • 41. Normal Rituals and Behaviors
    • Even some ritualistic behaviors are normal
    • Any rituals?
  • 42. Phobias: Prevalence
    • Fears are very prevalent
    • Phobias occur in about 11% of the population
    • More common among women
    • Tends to be chronic
  • 43. Etiology of Phobias: Genetics
    • 31% of first degree relatives of phobics also had a phobia (compared to 11% in the general population)
    • Relatives tended to have the same type of phobia
    • Not clear if transmission is environmental or genetic
  • 44. Specific Phobia: Behavioral Perspective
    • Case of Little Albert
    • Two-factor model:
    • Acquisition-classical conditioning
    • Maintenance-operant conditioning
  • 45. Specific Phobia: Behavioral Perspective
    • Classical conditioning
    • Modeling
    • Stimulus generalization
  • 46. Specific Phobia: Behavioral-Evolution Perspective (Preparedness)
    • Discussion Section Topic
  • 47. Specific Phobia: Cognitive Perspective
  • 48. Specific Phobia: Social and Cultural Factors
    • Predominantly female
    • Unacceptable in cultures around the world for men to express fears
  • 49. Specific Phobia: Treatment
    • Systematic Desensitization
  • 50. Social Phobia
    • Fearful apprehension
    • Social situations
  • 51. Social Phobia: Diagnostic Criteria
    • Marked or persistent fear in one or more social or performance situations
    • Exposure to fear situation is associated with extreme anxiety
    • Person recognizes that fear is excessive or unreasonable
    • Feared social and performance situations are avoided or endured with intense anxiety
  • 52. Social Phobia: Prevalence
    • 13% of the general population
    • About equally distributed in males and females, however, males more often seek treatment
    • Usually begins around age 15
    • Equally distributed among ethnic groups
  • 53. Etiology Social Phobia: Emotions
    • Temperament and Biological Theories (Kagan)
    • Behaviorally inhibited children 2 remained inhibited at age 7 and 12 (see video)
    • Biological preparedness
    • We are prepared to fear rejecting people
    • Social phobics more likely to foucs on critical facial experessions
  • 54. Biological Basis of Temperament
    • Kagan proposed temperamental differences related to inborn differences in brain structure and chemistry:
    • He found inhibited children have:
    • Higher resting heart rates
    • Greater increase in pupil size in response to unfamiliar
    • Higher levels of cortisol (released with stress)
  • 55. Temperament and Anxiety Disorders
    • Inhibited temperament: risk factor in social phobia
  • 56. Kagan’s Temperamental/Biological Theory and Prevention
    • Early identification of at risk children
    • Parental training
    • Avoid overprotecting
    • Encourage children to enter new situations
    • Help kids to develop coping skills
    • Avoid forcing the child
  • 57. Encouraging Shy Children: helpful hints
    • Use rewards
    • Arrange don’t push
    • No nagging
  • 58. Social Phobia: Treatment
    • Cognitive-Behavioral Therapy
    • Assess which social situations are problematic
    • Assess their behavior in these situations
    • Assess their thoughts in these situations
    • Teaches more effective strategies
    • Rehearse or role play feared social situations in a group setting
    • Medication
    • Tricyclic antidepressants
    • Monoamine oxidase inhibitors
    • SSRI (Paxil) approved for treatment
    • Relapse is common with medications are discontinued

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