What are the normal fears in early childhood? (newborns-3 yrs)
- Newborns – loss of support, loud noises
- 6mo-1 year – strangers, sudden, unexpectes noises/objects
- 1-3yrs – separation from attachment figure, strangers, toilet, loud noises
What are the normal fears for early school age children?
- Early School Age: animals, loud noises, dark, ghosts, monsters, sleeping alone, sudden
- changes, large objects
- Ages 7-8: staying alone, injuries, blood, injections, dr. visits, media events
What are the normal fears of early adolescents? (9-teens)
- 9-11: death, tests (EOGS), failure, performance, rejection, injuries, robberies, kidnapping, wars
- Teens: social evaluation, appearance, physical competence, and sexual anxiety
What are the types of anxiety disorders?
- Separation Anxiety Disorder
- Generalized Anxiety Disorder
- Social Phobia
- Specific Phobia
- Panic Disorder
- Obsesive compulsive disorder
What is separation anxiety disorders?
- Developmentally inappropriate & excessive anxiety concerning separation from home or attachment figures.
- Before 18 and lasts at least 4 weeks.
- Significant distress & impairment.
- Not due to another disorder
How does separation anxiety disorders present
- To be diagnosed 3 of the following must be present
- Excessive distress when separation from home or major attachment figures occurs or is anticipated.
- Persistent and excessive worry about losing, or possible harm to attachment figure.
- Persistent and excessive worry about events that might lead to separation (getting lost, kidnapped).
- Persistent reluctance or refusal to go to school because of fear of separation.
- Fearful or reluctant to be alone without major attachment figure at home or in other settings.
- Persistent reluctance to go to sleep without being near a major attachment figure or to sleep away from home.
- Repeated nightmares involving theme of separation.
How does development effect separation anxiety disorder?
- Developmental differences:
- Insidious Development
- Most often diagnosed in pre-pubescent children.
What is generalized anxiety disorder?
- Excessive anxiety or worry occurring more days than not for at least 6 months
- about a number of events or activities
- The person finds it difficult to control the worry
- At least one of the symtoms of generalized anxiety must be present
What are some of the symptoms for generalized anxiety disorder?
- 1) restlessness or feeling keyed up or on edge
- 2) being easily fatigued
- 3) difficulty concentrating or mind going blank
- 4) irritability
- 5) muscle tension
- 6) sleep disturbance (difficulty falling asleep, staying asleep, or restless unsatisfying sleep)
Why does it seem like ADHD has a higher prevalence than anxiety disorders?
Internalized versus externalized, ADHD are recognized more but anxiety prevalence is greater
What are the common worries of generalized anxiety disorder?
- Performance to the point of being perfectionistic
- Natural disasters (war, death, dying)
- Being physically attacked
- Adult concerns such as family finances, health of others
- Usually begins in middle childhood 9-13
- Somatic complaints, Tense, Avoidance
What are the main symptoms of social phobia?
- A marked or persistent fear of social or performance situations -person is exposed to unfamiliar people or scrutiny by others.
- The individual fears humiliation or embarrassment.
- Exposure to the feared social situation provokes anxiety –Panic Attack*
- In children, this may be expressed by crying, tantrums, freezing, or avoidance
- The person recognizes the fear is excessive and unreasonable. (Not necessarily with children).
- The feared social or performance situations are avoided or endured with intense anxiety or distress.
What needs to be present for a social phobia diagnosis
- The avoidance, anxiety, & distress impairs functioning
- The duration is at least 6 months.
What are the Common characteristics of social phobia
- Often have few friends
- Are reluctant to join group activities
- Endorse feelings of loneliness
- Considered shy and quiet
- Excessive concern with embarrassment, negative evaluation, and rejection
- Most often diagnosed in adolescents
- High risk for developing depression
What is the most common adult anxiety disorders?
What are specific phobias?
- Marked or persistent fear that is excessive and unreasonable, cued by anticipation of feared object.
- Exposure invokes anxiety response: In children this may involve crying, tantrums, freezing, or clinging
- Person recognizes the fear is excessive and unreasonable (Not necessary for children)
- The situation is endured with intense anxiety or distress
- Avoidance interferes with functioning at a clinically significant level.
- Duration is more than 6 months
What are common specific phobias
- Natural Environment (heights, storms, water)
- Situational (airplanes, elevators, dentist)
- Other (choking, vomiting, loud sounds, clowns)
- Phobic reaction is excessive and out of demand of the situation, leads to avoidance, persists over time, and is maladaptive compared to normal developmental fears
What are panic attacks?
- A discrete period of intense fear or discomfort, in which 4 or more peak in 10 minutes:
- heart palpitations
- trembling or shaking
- shortness of breath
- feeling of choking
- chest pain or discomfort
- nausea or abdominal distress
- feeling dizzy, lightheaded or faint
- derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself)
- fear of losing control or going crazy
- fear of dying
- chills or hot flashes
- One panic attack followed by one month of fear of more, worry about attack or its consequences, or change in behavior.
What may occur with panic disorders?
What is the difference between fear and anxiety?
There are normal fears common to each age group but anxiety is when fears are excessive, beyond voluntary control, cannot be reasoned with, are not age specific, and persist over time
Why is panic disorder diffucult to diagnose in children?
- Young children report a fear of becoming sick or vomiting
- Hard for young children to verbalize fears but there usually is a trigger
- Fears of specific autonomic symptoms usually occurs in adolescents.
What is obsessive compulsive disorder?
Either Obsessions or Compulsions:
What are some common obsessions with OCD?
- Recurrent and persistent thoughts, impulses, or images that are intrusive and inappropriate and cause marked anxiety.
- The thoughts, impulses, and images are not simply excessive worries about real-life problems.
- The person attempts to ignore or suppress such thoughts
- The person recognizes that the obsessional thoughts are a product of their own mind.
What are common compulsions with OCD?
- Repetitive behaviors (hand washing, ordering, checking) or mental acts (praying, counting, repeating words) that the person feels driven to perform in response to an
- The compulsions are aimed at preventing or reducing distress or some dreaded event or situation but are not connected in a realistic way or are clearly excessive.
- The obsessions or compulsions cause marked distress and are time consuming (take more than one hour per day) and significantly impair functioning
What is often seen with children with OCD versus normal behavior?
- Normal developmental rituals (arranging toys & night-time rituals) are not excessive, differ in content from OCD rituals & typically dissipate by age 9
- Children with OCD often do not recognize the unreasonable nature of their obsessions or compulsions.
- In very young children (6-8) compulsions often occur without cognitive obsessions and are described as “urges”
- Mean onset is between 10 and 12.
- In 90% of children -the symptom pattern changes over time
Explain the developmental trajectory of anxiety.
- Birth: Anxious Temperament/Fussy
- Toddler: Behavioral Inhibition
- Pre-K,KG: Separation Anxiety Disorder
- Elem. Years: Generalized Anxiety Disorder
- Adolescence: Social Phobia
- Adulthood: Depression/Anxiety/Panic
- What are some developmental trajectory facts pertaining to the occurance of anxiety disorders and children and the liklihood of the disorder persisting into adulthood.
- Single disorders are episodic
- Comorbid disorders are common and chronic
- Significant impairment and family burden
- Strongly predict adult psychopathology
- When does anxiety become a disorder?
- When fear results in Avoidance, Interference or Distress then anxiety develops
What is the prevalence of anxiety disorders in youth?
- Between ages 9-16 -13.3% three month prevalence of any psychiatric disorder
- 36.7% of all youth will have one psychiatric disorder at some point
- 25% have 2 or more (comorbidity)
- 10% of 9-16 year olds will have an anxiety disorder (12% girls, 8% boys)
- Anxiety disorders are among the most common conditions affecting youth
- Eleven of 15 epidemiological studies estimate the lifetime prevalence of ANY impairing anxiety disorder at greater than 10%, several as high as 25%
What are common comorbidities?
- Specific phobias are most frequent, followed by Social phobia 7 -9%
- SAD, GAD and agoraphobia are in the range of 4 -6%
- OCD and panic disorder are less frequent, between 1 -3.5%
- Numerous studies, retrospective and prospective, have documented a high degree of comorbidity between anxiety and depressive disorders in community and clinical samples of
- adults and children
Describe the general approach to the psychological treatment of anxiety in children and adolescents.
- Cognitive and behavioral therapy
- Cognitive Behavioral Therapy (CBT) program includes: Psychoeducation, Affective education, Awareness of bodily reactions and cognitive activities when anxious
- Identifying anxious self-talk and modifying it to coping
- Graduated exposure to anxiety-provoking situations
- Homework Assignments
- Current, researched, effective treatments include: SSRI treatment (Zoloft, Luvox, Prozac) CBT using an approach called exposure with response prevention,
- Combination treatment
Describe the natural course of comorbidities of anxiety
- The onset for first episode of MDD is typically in late adolescence, early adulthood, and for
- some, in late life
- Studies have shown that the median age of onset for MDD is between 20-25 years
- Thus, about 5-8 years later than mean age of onset for anxiety disorders
Explain the criteria necessary for the diagnosis of major depressive disorder.
Major Depressive Episode involving a disorder of Mood and/or Capacity for Pleasure or Enjoyment At least 5 symptoms must be present and one of the 5 have to be Depressed or Irritable Mood* orLoss of Interest of Pleasure*Decline in Functioning that lasts At least 2 weeks durationOther S/S: Sleep Disturbance, Appetite or Weight disturbance, Psychomotor Agitation or Retardation, Low Energy or Fatigue, Poor Concentration or Memory, Guilt or Worthlessness Suicidal Ideation, Plan or Attempt
How does exposing the patient to the anxious stimulus work in CBT?
- Exposure with response prevention – exposes the child to thing that triggers anxiety
- Practice of newly acquired skills in increasingly anxiety provoking situations
- Role-play procedures and coping modeling by the therapist
How is dysthmic disorder different than major depression?
- Depressed or Irritable Mood
- At least one year duration
- Two or more additional symptoms:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- no suicidal ideations
- What is the difference between point prevalence and lifetime prevalence?
- Lifetime prevalence (LTP) is the number of individuals in a statistical population that at some point in their life (up to the time of assessment) have experienced a "case" (e.g., a disorder), compared to the total number of individuals (i.e. it is expressed as a ratio or percentage).
- point prevalence, the prevalence of disorder at a more specific (a month or less) point in time
- What did Lewinsohn et al. demonstrate in the Oregon Adolescent Depression Project concerning the prevalence of major depression in adolescents?
- Dysthymicdisorder: Point prevalence: .53, Lifetime prevalence: 3.22
- Bipolar Disorders: Point prevalence: .29, Lifetime prevalence: .58
- Much higher rates of depression in adolescents than in children
- Adolescents with MDD are more likely than children with MDD to have anhedonia, hypersomnia, weight change, lethal suicide attempts
What are gender differences in depression.
- In children, approximately equal gender distribution
- In adolescents, as in adults, depressed females outnumber depressed males 2:1
Inability to experience pleasure in normally pleasuble activities
What are some of the skills taught in the CBT model?
- Mood monitoring
- Affect regulation
- Pleasant activities scheduling
- Cognitive restructuring
- Social skills
- Conflict resolution
- Are any drugs approved by the FDA for the treatment of depression in children?
- Fluoxetineis the only medication approved by FDA for the indication of child or adolescent depression [3 positive studies]
- Other medications with some evidence of efficacy: sertraline[two small studies, when combined, led to significant results; citalopram[1 positive, 1 negative study]
What were the objectives of the TADS study?
In TADS, 439 adolescents from 13 sites, who had moderate to severe MDD and significant functional impairment were assigned to CBT, FLX, PBO, or CBT+FLX (COMB)Improvement in functioning was mediated by improvement in depression
Explain TADS conclusions.
- Suicidal ideation improves with all treatments
- CBT is significantly safer than FLX in terms of suicide-related events
- COMB gives the advantage of a faster and more complete response for depression and a greater degree of safety
- Safety is not absolute, either in COMB or in CBT-alone