Anxiety and depression


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  • Welcome – Introduce myself and SMHA My background as a clinician specializing in treating children with anxiety disorders and as a consultant to schools, and program developer In all cases of anxious kids, whether with ocd, gad, sel mutism or sep anx, I often work closely with schools, and have found their assistance absolutely crucial. Wearing my other hat, I have been struck by how many consultations from schools I receive for problem behaviors, and how few for students with anxiety disorders. So I am here today with a 2 fold mission – first, to present information on what is normal worry and anxiety, and when it becomes problematic. Second, to increase the sensitivity, awareness, and concern about anxiety disorders in schools so students receive the early identification and assistance they need.
  • The blue dotted lines show how avoidance reinforces the connections between avoidance and decreased anxiety, thereby increasing the liklihood of continued avoidance, and the connection between the stimulus and anxiety, thereby cementing the anxious symptoms. Because of generalization, and because of the extremely negative experience of anxiety- children will not only avoid situations that make them anxious, but situations like them, or situations close to them in time. (For example – sep anxious child who also stays close to parent in the home) Secondarily, since avoidance robs the child of the opportunity to “test” out safe situations, it cements the symptoms Conclusion: to address anxiety sx, must find a way to eliminate avoidance
  • This is not a small problem! Highlight issues on slide and give examples
  • Despite these facts, as I mentioned, it is under recognized in schools Anxious children may be ideal students Hard to know what is normative – especially at young ages, many students have transient or limited anxiety symptoms – this doesn ‘t mean it is a disorder This may seem to argue for caution in making diagnosis, however, lets look at the impact of anxiety for students
  • Why is the school so important It is the place child spends most of time – what good is a treatment that eliminates a problem for 4 hrs/day, or only 2 days/week Children will spend 6-8 hours daily for upwards of 12 years in school – any reasonable treatment must generalize to that setting School is impossible if you’re thinking is impaired – or if all your psychic energy is spent on managing your anxiety School is also a social setting – and so many of the anxiety disorders have direct or indirect effects on social functioning – This means failure to address anxiety disorders will impair students social functioning in the academic setting School personnel are a powerful resource – not only because of the time they spend with students, but because of the nature of their relationship
  • Review DSM diagnosis – and differences for children Emphasize the pathology and give examples
  • Anxiety and depression

    1. 1. Understanding and TeachingStudents with Anxiety and DepressionRona Milch Novick, PhD Rev 1/11
    2. 2. Erica’s StoryErica is a middle school student, who has always been a bit clingy, shy and nervous. This year, during a school trip she got sick and threw up on the bus. Ever since, she has refused to go on the school bus. She will not take gym class, complaining that running around makes her feel like she will be sick. She refuses to go to school many mornings, and spends a lot of time in the nurse’s office, saying she thinks she is going to be sick.
    3. 3. Yossi’s StoryYossi transferred to the all boy’s high school for 10th grade saying he wanted a new start. He failed most subjects in 9th grade and his parents say he became really withdrawn, no longer hanging out with his friends. When asked about it he said it’s just not fun anymore. He says he hopes the change in school will help but doubts it since he is not really good at anything and will probably fail. His parents also find him more angry and disrespectful, and he seems to want to sleep constantly.
    4. 4. Think- Pair- ShareWhat Does This Have to Do WithSchool? List 3 ways anxiety could interfere with school success List 3 ways depression could interfere with school success
    5. 5. Stress/Anxiety-PerformanceCurvePerformance Anxiety
    6. 6. Anxiety and AvoidanceStimulus Anxiety Avoidance Decreased Anxiety
    7. 7. Components of AnxietyTriple Response Mode: Physiological arousal Hypervigilance/worry Behavioral avoidance (as a result)
    8. 8. Impacts of Anxiety In SchoolSettings Negatively affects academic work and school performance Impairments in social adjustment Decreased social acceptance Low global self worth Co-morbidity is significant  12% depression  15% oppositional defiant disorder  17% ADHD  50-75% another anxiety disorder
    9. 9. Psychiatric difficulties in youth American Academy of Pediatrics: 20% of children aged 4-15 have psychological or behavioral problems (2x increase since 1980) Estimates of actual psychiatric disorders:  12 million American children and teens  5-15% of 9-10 year olds  15-20% of adolescents  Adult comparison: 20% Criteria: DSM-IV, including symptom severity and impairment in functioning (family school, peers)
    10. 10. Etiology Biological disorders of neurotransmitters Emergence of disorders precipitated by:  genetic vulnerability  deficient social supports  family dysfunction  trauma  chronic environmental stress
    11. 11. How Prevalent Are AnxietyDisorders? Most common psychiatric disorder in children Estimated 10-20% incidence rate Anxiety symptoms are persistent over time Prognosis poor if untreated More common in girls Up to 30% of all children may exhibit subclinical levels of worry
    12. 12. Anxiety Interventions asResilience Builders Cognitive Behavioral Interventions  Cognitive techniques  Metacognitive lessons on healthy thinking  Skill building  Imagery, emotional literacy, other direct skills  Relaxation training
    13. 13. Negative Thinking Exercise With your group of 4, review the common negative thought patterns Create examples for three of these and, without indentifying which type of negative thought pattern they are, write them on your paper Groups will rotate around the room and attempt to indentify the negative thought pattern in each example
    14. 14. Exercise Debrief Pedagogic technique – having students create examples increases learning “Carousel” often involves movement, possibility for non-verbal responding, repeated practice
    15. 15. School Involvement in Treatment  Majority of child’s time is in school  School is child’s natural environment, generalization is essential  School requires intact cognitive and social functioning  School personnel are central in child’s life
    16. 16. Interventions Behavioral and Cognitive-Behavioral Treatments  Exposure  Response Prevention  Relaxation/Imagery  Reinforced practice/Operant techniques  Cognitive Techniques Family Treatment Psychopharmacology  Clomipramine  SSRI’s
    17. 17. Need for Sensitivity:Role of Schools Any and all school personnel can be part of solution or problem All school personnel must understand disorder and students’ needs All school personnel should respond sensitively and therapeutically Communication between school, home and outside professionals is essential
    18. 18. Intervention – Helping Those WithSpecial Needs Slow but steady movement Avoid avoidance Communication across settings Reinforcement of learned skills Generalization training
    19. 19. ReactionHandling Anxious Reactions Match anxiety with calm Prompt for skill use Attempt not to go backwards – even if forwards is impossible View as temporary crisis Reinforce non-anxious behavior but use caution in penalizing anxious behavior
    20. 20. Anxiety Disorder Diagnoses Separation Anxiety Disorder Generalized Anxiety Disorder Social Phobia Selective Mutism Obsessive Compulsive Disorder*School Phobia is not formal diagnosis
    21. 21. Generalized Anxiety Disorder Excessive and unrealistic worries  About competence, approval, future, past Extreme self-consciousness Excessive need for reassurance Inability to relax Somatic complaints  Trouble concentrating  Sleep disturbance  Fatigued Symptoms for 6 months or more
    22. 22. Separation Anxiety DisorderDevelopmentally inappropriate & excessive anxiety concerning separation from home or attachment figures, with 3 or more  recurrent excessive distress at separation  persistent and excessive worry about losing or harm befalling attachment figures  persistent reluctance or refusal to go to school or elsewhere  persistent fearfulness at being alone  persistent reluctance to go to sleep without being near major attachment figure  repeated nightmares about separation  repeated c/o physical symptoms at separation or when anticipated
    23. 23. Separation Anxiety - cont’d Duration of at least 4 weeks Onset before age 18 Clinically significant distress Not PDD, Schizophrenia, Psychotic disorder, or Panic Disorder in adolescents
    24. 24. Selective Mutism Rare, fewer than 1% of referrals Usually begins in preschool Many children reported as shy
    25. 25. School Phobia Not a formal diagnosis Variant of separation anxiety disorder, social phobia or other anxiety disorder Rarely actual phobia to school setting Distinguish from truancy and school refusal
    26. 26. Obsessive Compulsive Disorder Presence of obsessions or compulsion Obsessions are  persistent ideas - intrusive  unable to ignore Compulsions are  repetitive behavior or thought driven to perform in response to obsession  Aimed at preventing distress Causes marked distress Child knows O/C are unreasonable
    27. 27. Video Watching Guide (SelectiveMutism) What is one thing you heard that you didn’t know What is one thing you would do differently as a result of watching the video
    28. 28. Depression in Children andAdolescents How does depression effect learning? How does depression effect testing? How does depression effect other aspects of school functioning?
    29. 29. Depressed mood and depressivedisorders Depressed mood relatively common:  10% school-age children  40% adolescents If persistent and severe:  Affective disorders, including Major Depressive Disorder, Bipolar Disorder, Dysthymic Disorder Fewer than 1 in 5 young people who need tx for depression get it
    30. 30. Historical trends “Parents are too stern, chide, brawl, whip and strike… children are so disheartened they never have a merry hour in their lives…” (Burton, 1621) Depression-like features in children whose attachment was not initiated, interrupted, or lost (Bowlby, Spitz, A. Freud, ’30s-’60s) “Masked depression” (’50s-’70s) Mood disorders of youth parallel adults (70s+)
    31. 31. Models of depression – with relevancefor school settings Learned helplessness (behavior independent of reinforcement) =gFmFOmprTt0 Cognitive distortions (negative views of self, environment and the future) Life stress (SES, family factors, poor social supports) Genetic/Biochemical (neurotransmitters)
    32. 32. Neurotransmitters Serotonin: low levels associated with violence, suicidality (decreased CSF concentration of 5HIAA) Dopamine: increase of dopamine activity implicated in psychotic depression Norepinephrine: abnormalities found in urinary MHPG of depressed patients
    33. 33. Assessment Need for multiple respondents Clinical interview (structured?) Rating scales (CDI, Beck, CBCL, BASC) Psychological testing Behavior observation DSM-IV
    34. 34. Mood disorders Major Depressive Disorder Dysthymic Disorder Depressive Disorder NOS Bipolar Disorder Mood Disorder NOS Mood Disorder due to Medical Condition Substance Induced Mood Disorder Adjustment Disorder w/ Depressed Mood
    35. 35. Major Depressive Disorder (MDD) Depressed or irritable mood Loss of interest or pleasure Weight loss or weight gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue, loss of energy Feelings of worthlessness, excessive guilt Poor concentration or indecisiveness Suicidality 5 or more of above in same 2-week period
    36. 36. MDD: How common?  Preschoolers: 1%  School-age: 2%  Adolescents: 4-9%  Adults: 6-9%  Relapse rates: 50-60%  Recent cohort studies: increased incidence, earlier age of onset, more severe sx (implications as aging occurs)  Sex differences: none for school-age; by teen years, affects more females than males, across cultures
    37. 37. Dysthymic Disorder Insidious onset Chronic course Duration greater than one year High risk for MDD (“Double depression”) Prevalence: 4-8%
    38. 38. Bipolar Disorder No special DSM-IV provisions for children Complicated differential diagnosis (nonaffective psychoses, unipolar depression, organic syndromes, ADHD, and disruptive behavior disorders) Prevalence: 1-2% with no sex differences MDD, dysthymia as precursors
    39. 39. “Sub-threshold” Issues How depressed is depressed? Issue of criterion Determination of diagnosis especially difficult in context of “adolescent turmoil” Even if formal criteria are not met, still requires sensitivity to subclinical depressed mood
    40. 40. Adolescent depression M:F=1:2, across cultures Greater frequency, intensity, earlier onset in each generation since the ’40s May or may not parallel adult form Irritable, angry affect may predominate (different from “typical” oppositionalism) More mood variability (can look fine at times) Course: episode duration in clinical samples: 7-9 months; 40-60% relapse in 2 yrs Less inclined to be referred for tx than disruptive disorders
    41. 41. Treatment considerations Identifying teens who need professional help for depression can be difficult Introversive teen can be overlooked, disruptive, substance-abusing teens may not be seen as depressed Finding treatment can be difficult (7,000 child and adolescent psychiatrists in US), especially in low- income areas Demand outweighs resources
    42. 42. Treatments: Psychosocial Cognitive therapy (addresses negative views of self, world and the future) Interpersonal therapy (emphasis on current relationships; use of rehearsal, role play) Family therapy (communication skills, structural realignment) Dialectical behavior therapy (DBT)
    43. 43. Suicidality A symptom, not a disorder itself Teen suicide: still a rare event Often (but not exclusively) associated with depression 3rd leading cause of death ages 15-19 Threefold increase from ’50s to early ’90s Recent decreases across racial groups
    44. 44. Protective factors Family cohesion Social supports Religiosity Problem-solving skills Ability/willingness to verbalize Treatment
    45. 45. Prevention efforts In general, problematic School-based educational programs create more risk than benefit Screenings: many false positives; also question of available resources (600 calls/month at SCH) Crisis hotlines: mixed effects; most studies show no significant effects; teens do not tend to use them
    46. 46. Exercise In your groups of 4:  Consider a school activity that could either foster/ enhance depression, or help a student recover  What could a teacher do to make the activity a health-ful one  Example: Standardized test – teacher could berate students about need for excellence, or be more supportive