Mood and anxiety disorders in childrenDr. Marjorie Robb

Assistant Professor, UOttawa

Children’s Hospital of Eastern Ontario

Some troubling statistics• At least 20% of children under age 18 have significant

mental health problems• 75% of those don’t get help

ANXIETY IN CHILDREN

Jesse• Is 8 years old. He has a great family, lives in the country,

and likes to play outside.• Jesse has a learning disability and has a hard time in

school• Around age 7 ½ he started to worry a lot:

• Will there be enough time to play? • Will there be enough time to do my homework?• I won’t be able to do this homework. • I don’t want mom to go out at night.

• He also started to complain of headaches and stomachaches quite a lot.

• Parents say he is so anxious he doesn’t enjoy much.

Taylor• Taylor is 7. She does well at school and has friends there.• At home she has started to be afraid to eat – she fears

the food will make her sick• She especially refuses to eat anything her older brother

has touched because “he’s gross”• She is afraid to go to sleep because she might get sick• Bedtime takes a very long time• She has frequent meltdowns when things “don’t go right”• She seems very tired and unhappy much of the time• She is not gaining weight as she should

Cecelia• Cecelia is 9. She has developed a fear of germs• She won’t use the washroom at school or at the mall• She doesn’t want her parents to have visitors or to let

friends drive in their car (because they bring in germs).• She has to wash her hands for a long time and frequently• She insists that her family wash their hands whenever

anyone comes in from outside and has a meltdown if they don’t

• After visitors leave she sprays disinfectant on the furniture

Anxiety Disorders• Anxiety disorders are the most common mental health

disorders

• Many anxiety disorders start in childhood and if untreated, they may persist into adulthood

• Children may have more than one kind of anxiety disorder

• Up to 6% of children and youth have an anxiety disorder severe enough to need treatment

Why do children get anxiety disorders?

• Often there is a family (genetic) tendency to anxiety

• Children who live with too much stress can become anxious

• Stress can be in family, school or neighborhood

• Anxious parents can model anxious behaviour for children

Kinds of Childhood Anxiety Disorders• Separation anxiety• Social phobia• Generalized anxiety disorder• Selective mutism• Obsessive Compulsive Disorder• Panic Disorder• Phobias• Post Traumatic Stress Disorder

Separation Anxiety Disorder• Child is afraid of leaving their parent(s)• They may worry that something bad will happen to the

parent or to someone they love or to themselves

• May refuse to go to school• May have stomachaches, headaches, or throw up if they

fear separation• May refuse to go to playdates at other people’s houses

• Diagnosed if it causes problems at school or socially and has been going on at least 4 weeks

Generalized Anxiety Disorder• Children with this kind of anxiety may:• Have lots of worries and fears• Have problems sleeping because of worries• Have trouble concentrating• Get tired easily or have tension headaches• Be tense or restless• Be perfectionist• Have an anxious desire for approval

Obsessive-Compulsive Disorder• OCD often begins in early childhood or adolescence.

Children with this kind of anxiety may:

• Have frequent uncontrollable thoughts (obsessions)• Usually they don’t like these thoughts, or they may think

they don’t make sense

• Perform certain behaviours or rituals to try and prevent something bad from happening (or to get rid of thoughts)

• Examples are: handwashing a lot if there is a fear of germs; checking that doors are locked; special touching rituals

Panic Disorder• Happens less often with younger children• People with this kind of anxiety have panic attacks• Feel very scared• Heart pounding, hard to breathe• May feel shaky, dizzy, or sick • May feel like they are going crazy or something really

awful is going to happen• Sometimes they avoid school or want to stay in the house

• Frequent panic attacks = panic disorder

Selective Mutism• Children may not talk to anyone who is not close to them,

such as immediate family• They may look down, withdraw, turn red if required to talk• Often they whisper if they do speak in a situation where

they are anxious• Up to 2% of school age children may have these

symptoms• Some kids outgrow it; some go on to have social phobia

Social Anxiety/Social Phobia• Happens more in teens than in young children• Fear and worry about social situations

• Going to school• Speaking in class• Social events including recess and lunch

• Shy, self-conscious• Easily embarrassed• These kids tend to be sensitive to criticism and find it hard

to be assertive

Post Traumatic Stress Disorder• Symptoms start after a physical or emotional trauma or

very frightening event• Can be marked by several of

• Behavioural changes• Repetitive play• Zoning out, numbing of feelings• Jumpiness and watchfulness of surroundings• Nightmares and sleep problems• “Flashbacks”

Not very common in young children

Anxiety disorders - What to watch for:• Avoidance of school (refuses to go)• Frequent stomachaches or headaches in the morning

before school• Avoidance of activities• Easily upset – distress out of proportion• You spend a lot of time comforting your child and/or

urging her/him to participate in regular activities• You feel that your family functioning is being disrupted by

your child's fears and worries, or meltdowns

What you can do:• Be patient, calm and reassuring• Be positive about their ability to manage the situation

(with support)• Help your child succeed by doing “small steps”• Reward and praise your child’s efforts as well as

successes• Be a model for your child – manage your own anxieties• Help your child “avoid avoidance” with planned gradual

exposure to things they fear• Teach your child positive self-talk

What you can do:• Teach your child basic relaxation strategies such as belly

breathing and muscle relaxation• Teach your child to visualize or imagine a pleasant,

relaxing “happy place”• Keep stress low at home. Avoid parental conflict when

the children are present. Be calm and positive as much as possible.

• Deal with external situations that require adult intervention, such as bullying

• Healthy living: enough sleep, regular routines, balanced diet, exercise

• Take time to have fun and relax with your child

Don’t:• Criticize or yell at your child• Tease or make fun of your child for anxiety• Ignore the problem or wait for the child to get over it• Tell the child to “toughen up”• Pressure your child to do more than s/he can do• Have unrealistic expectations• Make it easy for your child to avoid anything that scares

them

Treatment of anxiety• If your child is having significant problems with school,

missing a lot of school, or having other problems functioning, you should talk to your doctor

• Anxiety disorders can be treated!• The most common treatment is cognitive behaviour

therapy (CBT) in groups or individually• In CBT children learn relaxation and stress management

plus• Gradual exposure to things that make them anxious, to decrease

the fear• Coping strategies to reduce anxiety

CBT is first choice, but medication may be needed in severe situations

DEPRESSION IN CHILDREN

Tyler• Tyler is a 9 year old boy who lives with his mom and sees

his dad every second weekend• His parents have been in a bitter custody battle • He has trouble getting to sleep and is always tired in the

morning• He still plays with his friends, but doesn’t seem to enjoy

himself as much as he used to; he wants to quit hockey• He is angry and cranky with mom much of the time and he

has meltdowns over small things• Sometimes he falls asleep in school; he can’t concentrate

and his marks have gone down

Emily• Emily is 8 and lives with mom, dad and 2 brothers• Recently she has started to complain of stomachaches

often in the morning• She sometimes says “I’m stupid” or “I’m ugly” • She cries at night and sometimes says “I wish I wasn’t

here”• She plays with her dolls by herself and doesn’t want to go

outside after school• When frustrated she will sometimes hit herself on the

head• She says other kids are mean to her

Depression• Depression is common: in Canada and US about 1 in 5

children will go through a depression before finishing high school

• 4 – 8 of 100 children have a major depression at any point in time

• Symptoms include:• Feeling sad, irritable or angry• Not enjoying life, school or activities as much• Trouble coping with home, school or work• Feeling hopeless or worthless• Problems with sleep, appetite, energy and concentration

What causes depression?• Family history (genetics)• Stress, including:

• Conflict between parents, or with parents or siblings• Depression or too much stress in parents• Separation or divorce of parents• Conflicts with friends or classmates, • Social stress• School stress – not doing well, or too much pressure• Bullying• Loss of someone important

What should you do if you think your child is depressed?• Take your child to your family doctor or pediatrician

• The doctor can check for medical problems that could be causing the changes in behaviour

• She/he may suggest mental health services (psychologist, counselor, social worker, psychiatrist)

• IF YOU ARE WORRIED YOUR CHILD MAY HURT HIMSELF/HERSELF, TAKE IMMEDIATE ACTION

• Call your doctor, the crisis line or the emergency department

Can depression be treated?• YES

• Young children are most often treated with their family.• Working with parents to help them help their child• Family therapy if family problems are part of the problem

• Therapy: by a counselor, psychologist or psychiatrist• Cognitive Behavioural Therapy is proved to be very effective• The child learns ways to manage stress, do things that help her

feel better, and think more positively

• Medication• Only used when other treatments don’t work, or when the

depression is so severe that other treatments aren’t possible• Antidepressants are safe and effective when used correctly and

monitored by a doctor

Remember the basics!!• Get enough sleep• Eat healthy meals and snacks• Take vitamin D supplements and consider omega 3 fatty

acids• Get exercise – an hour a day if possible. • Get enough sunlight (in winter, vitamin D supplements)• Plan enjoyable activities and one on one time with your

child• Parents need to take care of themselves too!

What else can parents do?• Listen actively to your child. Let them know you notice

something is wrong.• Don’t overly pressure the child to talk, but make sure that

you do talk• Help the child problem-solve ways to deal with stresses• Step in as the parent when stresses are beyond the

child’s ability to handle• Speak to the school if there is school stress or if the

depression is affecting how your child does at school• Maintain an atmosphere of calm and consistency at home• Protect time for fun activities together

Don’t• Blame or criticize your child for symptoms of depression• Tell your child to “just get over it” or “just snap out of it”• Get into power struggles. Help your child have a sense of

control by giving choices whenever possible.• Remove all expectations and let the child miss a lot of

school, not get up in the morning, play video games for hours

• Make home stressful by fighting, yelling, criticizing, etc.• Dismiss or belittle the child’s problems

Putting it all together:

Red Flags to Watch For• Feeling sad or depressed for more than 2 weeks• Increase in irritability and anger • Drastic changes in behaviour or personality• Expressions of wanting to die or plans to harm

him/herself• Severe mood swings affecting ability to function• Intense worries or fears that interfere with daily activities• Sudden overwhelming fear for no reason, often with

difficulty breathing and racing or pounding heart• Decline in school performance• Wanting to avoid school

What to do if you are worried• Talk (and listen) to your child• Keep a calm and positive attitude• Problem-solve with your child• Look for resources on-line or in books• Teach your child positive self-talk and self-

encouragement• Teach your child deep breathing and relaxation skills• Identify what is stressing your child and address it• Intervene on child’s behalf when appropriate• Call your doctor. Consider calling the school counselor.• Be aware of resources in your area

And what not to do: • Ignore the problem• Expect your child to “just snap out of it”• Blame your child for the problem. These are medical

problems and cause changes in the brain.• Keep it a secret. Anxiety and depression are very

common problems. Everyone gets hurt when they stay in the shadows.

• Let your own anxiety or depression weigh down your child

If your child is being treated by a professional• Take a matter-of-fact approach, as you would if they had

a broken leg• Ask what resources you should read or look at• Ask what you can do to help• Communicate with the professional• Remember you and your child are the most important

members of the treatment team!

Prevention – There’s lots you can do• Make the home environment as calm and consistent as

possible• Establish a regular routine: mealtimes, playtime,

homework time etc.• Eat meals together as a family. Avoid negative talk at

meals.• Enough sleep• Balanced meals and not too much junk food• Have frequent one-on-one time with your child • Make fun and enjoyable activities frequent and regular• Limit video game, computer and TV time• 7-9 year olds are too young for cell phones and Facebook

Relationship MattersBecause Relationships Protect

• GO PLACES with your child:• Give many more positive comments than negative ones.• One on one time:  have fun, laugh, do something you both

enjoy, play cards – make it a positive zone.

• Positive active responses whenever possible• Listen more than you speak, validate the primary emotion• Assert yourself calmly• Connection before correction• Emotional banking: everything you do counts• Stick to your values but consider all points of view

Resources• www.ementalhealth.ca

• Provides information about mental health disorders, recommendations for books and videos, and details about where to look for help

• www.anxietybc.com• Good information about self-help which parents can adapt for kids

• www.caringforkids.cps.ca/behaviourparenting/Fears.htm• From the Canadian Pediatric Society

• http://www.cmho.org

• http://www.knowledge.offordcentre.com/• Information on a range of mental health problems

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