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

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