The document discusses anxiety and depression in children and adolescents. It provides information on different types of anxiety disorders like generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and obsessive compulsive disorder. It also discusses depression in youth and risk factors. The document aims to help distinguish normal behavior from clinical disorders and offers treatment options like cognitive behavioral therapy and medications.

1. Empower Yourself!
Anxiety and Depression in Children
and Adolescents: When it is More
than Temper Tantrums
Presented by:
Dora Leibu-Lerman, D.O., MBA
Nancy Moran, LCSW, ACT
October 10, 2018

2. Lecture Objectives
• Inform and educate about various types of anxiety in children
and adolescents
• Inform and educate about various types of depression in
children and adolescents
• Risk factors predisposing children and adolescents to having
anxiety and depression
• Help with distinguishing normal behavior patterns and reactions
to stressors to true anxiety and depression disorders
• Offer insight into possible therapy options
• Offer parents/caregivers tools to recognize “red flags” in their
children
• Dispel common misconceptions about mental in health in
children and adolescents

3. Conflict of Interest
• None

4. Anxiety Disorders in Children &
Adolescents
• Normal reactions to stressors aka NOT
anxiety disorders
• Types of anxiety disorders
 Generalized Anxiety Disorder
 Separation Anxiety Disorder
 Social and Specific Phobias
 Panic Disorder
 Obsessive Compulsive Disorder

5. Common & Appropriate
Fears in Children
• Infants (up to the age of 10 months)- loud noises,
being startled, strangers
• Toddlers (1-6 y/o)- imaginary creatures (monsters),
dark, separation anxiety
• School Aged children- worrying about injuries to
themselves and loved ones, natural events (storms,
floods etc.)
• Adolescents (>13 y/o)- school performance, social
competence, health issues (body imaging, sexual
and physical development)

6. Anxiety can be your friend

7. Common Anxiety Pattern in
Children and Adolescents
• Child enters difficult situation
• Child becomes fearful
• Fear escalates to anxiety and child gets stuck
• Child avoids the situation or is asking for help
• Child continues to think the situation is
dangerous/harmful and feels helpless against
it

8. Separation Anxiety Disorder
• A universal human developmental
phenomenon starting <1 y/o
• Peaks between 9 months to 18 months and
may persist until 2.5 y/o
• Seen in 15% of children
• Can later develop into another form of an
anxiety disorder
• Usually seen in shy and introverted children

9. Separation Anxiety Disorder
• Fear regarding being separated from
caregiver that is beyond developmental
expectations
• Excessive worry that harm might come to the
caregiver that leads to extreme distress and
nightmares
• Must go on for at least 1 month
• Manifests as refusal to go to school, physical
complaints and distress upon separation

10. Generalized Anxiety Disorder
• Extreme disruption in activities of daily living due to
any perceived danger in many areas such as school,
family and social settings
• Child often feels fearful in multiple settings and
almost always expects negative outcomes when
faced with various challenges
• Affected children are often perfectionists and seek
contact reassurance
• May experience physical issues such as headaches,
abdominal pain, N/V, palpitations, chest tightness,
dizziness and sweating

11. Specific Phobias
• Fear of a particular object/situation
which is either avoid or endured with
great distress to the child
• Children often do not see it as
unreasonable fear, while adolescents
and adults do
• Avoidance from the particular stressor

12. Social Anxiety Disorder
• Intense fear in one social setting or another
• Often impaired by their fear of scrutiny/humiliation by
their peers in social situations
• May manifest as excessive crying, tantrums, freezing,
mutism and avoidance
• Symptoms stop when away from the social situation
• Child/adolescent must be observed to be
anxious/fearful in presence of their peers

13. Social Anxiety Disorder –
Why is it important?
• Decreased level of satisfaction in leisure
activities
• Increased rate of school drop out
• Decreased productivity at the workplace in
adulthood
• Increased rates of remaining single
• About 50% with this Dx do not receive proper
treatment

14. Obsessive Compulsive Disorder
• Recurrent, intrusive thoughts associated with fear
and/or repetitive, purposeful mental/behavioral
actions that are aimed at reducing the tensions
caused by obsessions
• Up to 25% of cases are seen by the age of 14 y/o
• Manifestations are similar to that of adults, however,
children and adolescents often do not see it as
irrational
• Likelihood increases with age
• Children with first degree relatives are 10 times more
at risk of developing it themselves
• Presence of chemical imbalance

15. Obsessive Compulsive Disorder-
cont.
• Extreme fears of contamination- exposure to germs, dirt or
disease followed by worries related to harm befalling
themselves or their loved ones
• Obsessive need for symmetry, exactness, excessive religious or
moral concerns
• Typical rituals include: cleaning, checking, counting, repetitive
behavior patterns or item arrangement
• Often get very anxious when unable to perform the rituals above
• Often referred to professionals when their rituals interfere with
ADL’s

16. Panic Disorder
• Recurrent unexpected surge of intense fear/discomfort that
reaches a peak within minutes during which 4 of the following
may occur
 Palpitations
 Sweating
 Shaking
 Shortness of breath
 Choking feeling
 Chest pain/tightness
 Abdominal pain, GI discomfort
 Numbness and tingling
 Fear of losing control or “going crazy”
 Fear of dying
 Depersonalization (detached from oneself)

17. Panic Disorder- cont.
• Peak onset 15-19 y/o
• Generally last for 20-30 minutes (rarely >60 min.)
• At least 1 of the attacks has been followed by more
than 1 month or more of one of the following
 Persistent concern about additional attacks
 Changes in behavior to avoid the attacks
• Attacks cannot be explained by medical (organic)
condition and NOT due to substance use
• Attacks cannot be explained by other mental
disorders

18. What is NOT considered an
Anxiety Disorder?
• Attention deficit hyperactive disorder- usually see
worsening of anxiety with onset of treatment
• Asperger’s syndrome
• Learning disabilities
• Depression
• Psychosis
• Medication/substance induced anxiety
• Medical conditions- thyroid dysfunction, anemia,
vitamin deficiencies

19. Red Flags
• Avoidance- school truancy, avoiding parties, camp,
self isolation
• Changes in eating habits- under or overeating
• Inattention and decline in concentration- seen as
poor academic performance
• Sleep changes- insomnia or hypersomnia (over
sleeping), frequent visits to parents’ room
• Excessive need for reassurance by parents, peers
• Risky behavior such as substance abuse
• Impairment in ADL
• Physical complaints

20. Physical Complaints and Anxiety
Disorders
• Children (toddlers, pre-school) cannot express their feelings
(anxiety, depression etc.) so as caretakers, parents and
teachers we will perceive physical complaints first such as:
 Headaches
 GI upset- abdominal pain, N/V, changes in BM
 Changes in sleep
 Chest pain/tightness
 Tight neck/back
 Fatigue, exhaustion
 Easily irritable
 Increased vulnerability to common viruses

21. Treatment Options
• Parent/caregiver- child interactions,
family intervention
• Classroom interventions and
accommodations
• Primary care, pediatricians interventions
• Cognitive behavioral therapy
• Medications

22. What Not to Do
• Do not try and convince them it will be alright
• Do not minimize their experiences
• Do not tell them to fight the anxiety
• Do not physically force them to face the
situation
• Do not verbally bully them into the situation
• Do not be afraid to share your concerns with
educators, primary health care providers

23. What to Do
• Accept/acknowledge their feelings
• Demonstrate understanding
• Cooperate with them and respond to their
needs rather than react
• Catch your breath
• Accept negative feelings
• Label emotions
• Implement/teach problem solving skills and
coping mechanisms

24. Cognitive Behavioral Therapy
• Understanding the connection between
thoughts, emotions, actions and
physiology.
• Increasing awareness of unhelpful
behavioral responses or irrational
thought patterns

25. Cognitive Behavioral Therapy-
cont.
• There are 3 primary
components-
 Cognitive
 Emotional/physiological
 Behavioral
Thought
processes
FeelingsBehavior

26. Cognitive Behavioral Therapy-
cont.Unhealthy
Process
Healthy
Process
Thought processes Distorted thinking, overly
negative, self critical,
selective and biased
More positive,
acknowledging success,
balanced thinking and
recognition of personal
strengths
Feelings Unpleasant, anxious,
depressed, angry,
frustrated
Pleasant, relaxed,
happy, calm, confident
Behavior Avoidant, quick to give
up, irritable,
inappropriate
Confident to try new
things, ready to tackle
problems, appropriate

27. Depression in Children &
Adolescents
• Normal sadness vs. Depression
• Define major depression in children and
adolescents
• Risk factors predisposing to depression
• Screening and diagnostic tools
• Treatment Modalities
• Resources

28. Is it Depression?
• Severity- the more severe it is, the less likely
it is a passing mood; “red flags” include:
changes in appetite, substance use, isolation
from family and friends and hobbies, feelings
of hopelessness and apathy
• Duration- usually 2 weeks or longer without
disruption
• Domain- encompasses school, family, home
lives

29. Major Depressive Disorder
• Must consist of at least 5 manifestations that
last at least 2 weeks or longer-
 Depressed/irritable mood
 Loss of interest/pleasure
 Appetite fluctuations leading to changes in weight (>5% of
weight change in a month)
 Sleep changes- too much or too little
 Psychomotor agitation/retardation
 Daily fatigue
 Feeling worthless/ inappropriate guilt
 Inability to concentrate at tasks at hand
 Recurrent thoughts of death

30. Major Depressive Disorder- cont.
• Most common mental health disorder in children and
adolescents
• Only 50% of adolescents with depression are
diagnosed before reaching adulthood
• In primary care setting- 2 out of 3 youths are not
identified by their physician and thus do not receive
treatment
• When identified only ½ receive treatment
• Severe shortage in mental health providers, primary
care physicians are the main resource to raising
awareness and starting treatment

31. Statistics
• Risk for depression increases during
childhood
 3-5 y/o: 0.5% prevalence
 6-11 y/o: 1.4% prevalence
 12-17 y/o: 3.5% prevalence
• Pre-adolescence: Females < Males
(2:1)
• Adolescence: Females> Males (2:1)

32. Risk Factors for
Developing Depression
• Low birth weight
• Family Medical History of depression (first degree relative- x2,
both parents- x4)
• Family dysfunction
• Exposure to early adversity
• Psychosocial stressors
• Gender dysphoria
• Traumatic brain injuries
• Chronic illness
• Other existing mental health issues- anxiety, ADHD, substance
abuse, learning disabilities, ODD

33. Screening Tools &
Diagnostic Tools
• Starts at home and continues in the classroom
• At the doctor’s office- questionnaire (PHQ-9A) and discussing
with the adolescent alone (>12 y/o) every year
• Discuss limits of confidentiality
• Emphasize healthy habits
• Multiple sources of intervention have shown most promise
• Safety Planning
 Restrict access to controlled substances, weapons, medications
 Emergency plan

34. How to Determine
Who is at Risk?
• Family members (past/present) who
were diagnosed with depression, bipolar
D/O, substance abuse or suicide
attempts
• Substance abuse involved
• Prior Suicide Attempts
• Is there a plan in place?

35. Treatment Modalities
• Mild Depression- active support by family,
school and peers with healthcare provider
involved (1-2 months)
• Moderate to severe depression - counseling
with mental health specialist with or without
medication regimen
 Psychotherapy - CBT, IPT-A, PCIT-ED
 Medications - SSRI’s

36. Treatment Modalities - cont.
• CBT- cognitive behavioral therapy
• IPRT-A: interpersonal psychotherapy that focuses on
ways in which depression interferes with
interpersonal relationships with emphasis on a
separation from parents, authority figures, peer
pressures and dyadic relationships
• PCIT-ED: Parent child interaction therapy emotion
development; modules that strengthen parent-childs
relationship by coaching parents in positive play
techniques, giving effective directives to the child and
teaching parents to respond to disruptive behavior in
a firm but not punitive manner

37. Alternative Treatment
Modalities
• Supplements: Vitamin D, Vitamin C
• Exercise
• Light therapy
• Biofeedback
• Art therapy
• Meditation
• SPARX - computerized CBT

38. Resources for Parents
• Teachers and educators - get to know them
• Family physicians, pediatricians
• Parents’ medication guide:
http://www.parentsmedguide.org/
• SPARX: https://www.sparx.org.nz/about
• Pediatric Psychiatry Collaborative in NJ:
http://njaap.org/programs/mental-health/ppc/