Mood+and+Anxiety+Disorders+in+Children+and+Adolescents

=**Mood and Anxiety Disorders in Children and Adolescents**=


 * 1. Cite the prevalence of anxiety disorders, tics, and mood disorders.**

Separation anxiety disorder affects 3-4% of children, peaking at age 7-9 and affecting males and females equally. Generalized anxiety disorder affects 2-5% of children with onset between 8-11 years.

Tourette's tic disorder affects 30/10,000 children and 1-2/10,000 adults with 3x as many males affects as females. Motor tics have onset by 7 years while vocal tics present later at 11 years.

Major depressive disorder has a 6% prevalence among adults, with more females presenting than males; bipolar disorder affects 1% of adults and is evenly distributed between males and females.

In children, prepubescent males experience more mood disorders than prepubescent females, but more postpubescent females experience more mood disorders than postpubescent males. Prevalence of mood disorders is 0.3-0.9% among preschoolers, 2% in school age children and 4.7% in adolescents. Prevalence of dysthymia is 2.5% in school children and 3.3% in adolescents. Prevalence of bipolar I disorder in children is 0.6% and is higher in bipolar II disorder.


 * 2. Formulate the theoretical causal factors of mood and anxiety disorders.**

Family studies have shown that children of adults with anxiety disorders have an increased prevalence of anxiety disorders and mothers of children with anxiety disorders have higher current and lifetime rates of anxiety disorders. Additionally, children learn to evoke an anxiety response from vicarious learning of caregiver reactions to certain stimuli. Stressful life events also increase the risk of developing anxiety disorder. These findings suggest that anxiety disorder has biopsychosocial etiological causes that are both inherited and learned.

Mood disorders also have biospychosocial etiological causes. Biological models have some some correlation with mood disorder with specific tests such as dexamethasome suppression test (DST does not suppress cortisol in affected kids), thyroid releasing hormone stimulation test (TRH does not increase thyroid hormone release in affected kids), urinary MHPG, etc. However, these biological findings are not sensitive or specific to mood disorders. Psychological stresses such as bereavement, life stress, behavioral reinforcement and learned helplessness, and cognitive distortion models as well as social role and social stresses, parental-child relation model also play a role in mood disorder etiology. The cohort affect shows that kids who are diagnosed with dysthymia have an increased risk of major depressive disorder symptoms as adults.


 * 3. Recognize the development of anxiety and anxiety disorders in children.**

Kids develop normal anxiety responses including:
 * Infants – fear of loud noises
 * 8 mos – stranger anxiety
 * 1-3 years – separation anxiety
 * 4-6 years – super ego anxiety/guilt
 * School age – performance anxiety

These responses are normal emotions; however, if anxiety becomes so great that it begins to affect normal functioning of the child, then it may become a disorder.

__Separation Anxiety__ Separation anxiety is inappropriate and excessive anxiety over separation from home or attachment figures. A common example is if a child refuses to go to school and experiences such anxiety about going to school that it disrupts function. It is treated usually by return to school as soon as possible, education of child and caregivers about separation dynamic, individual and family therapy as needed. Medications such as antidepressants (usually SSRI’s) may be used in extreme cases but are generally not front line treatments.

__Generalized Anxiety__ General anxiety disorder is characterized by excessive and uncontrollable anxiety and worry, most days, about a number of everyday activities such as school performance, sports, and acceptance by peers.

__Other Anxiety Disorders__


 * 4. List the criteria for the diagnosis of separation anxiety and anxiety disorders in children.**

__Separation Anxiety__ Three or more of the following: (1) recurrent excessive distress when separated from home or major attachment figure occurs or is anticipated (2) persistent and excessive worry about losing or about harm befalling major attachment figures (3) persistent and excessive worry that an untoward event will lead to separation from major attachment figure such as getting lost or being kidnapped (4) Persistent reluctance or refusal to go to school or elsewhere because of fear of separation.

Symptoms must be severe enough to cause excessive and functional impairment, not better accounted for by another disorder, due to drugs, etc.

__Generalized Anxiety Disorder__ See Objective 5.

__Other Anxiety Disorders__ Obsessive compulsive disorder is as common in children as in adults and typically has high comorbidity with other anxiety disorders, depressive disorders, disruptive behavior disorders, tics, and Tourette’s disease. OCD is characterized by intrusive obsessions that result in compulsions to defuse the anxiety about obsessions. Patient typically realizes the irrationality of his or her behavior.

Other anxiety disorders such as simple/social phobias, panic disorder, and selective mutism can also develop in children.


 * 5. List the criteria/symptoms for generalized anxiety disorder in children and differentiate from separation anxiety disorder.**

General anxiety disorder is excessive and uncontrollable anxiety about everyday activities during most days, such as school performance, sports, and acceptance by peers. It is different than separation anxiety which is an anxiety just about separation from home or caregiver.

General anxiety disorder is associated with restlessness, fatigue, difficulty concentrating, irritablility, muscle tension, and restless sleep or problems falling asleep. Children tend to experience worry about future events, concern about past events and competence, physical complaints, perfectionistic and self-conscious perception, continued need for reassurance, and inability to relax.


 * 6. Define selective mutism.**

Silent, whisper or single-syllable words during the stressful situation, typically in school but speak freely at home. It may be classified as a subtype of social phobia and may be caused by a speech delay, trauma, or maternal anxiety/overprotection. It usual onset is by 5 or 6 years old and affects 3/10,000 to 5/1,000. Treatment is by behavioral and SSRI (fluoxetine) treatment with a generally good prognosis.

Selective mutism is defined as consistent failure to speak in specific social situations despite speaking in other situations resulting in a disturbance that interferes with educational or occupational achievement, or social communication. Duration of this disturbance is at least 1 month, not limited to the first month of school. Failure to speak is not due to lack of knowledge or comfort with the spoken language required in the social situation and not better accounted for by a communication disorder such as stuttering or any other disorder.


 * 7. Describe the manifestation and prognosis of different tic disorders. Include Tourette's, chronic motor, vocal tics, and transient tic disorder.**

Tic disorder is characterized by rapid and repetitive muscle contractions resulting in movements or vocalizations that are involuntary but can be temporarily suppressed. Tic disorder symptoms typically wax and wane in severity over time and may include abnormal motor movements such as eye blinking, facial expression muscle movement, or throat-clearing. There is high comorbidity with ADHD (over 50%), OCD, and depressive disorders; treatment of ADHD can worsen tic symptoms.

Etiology of tic disorders suggest some genetic component, possible effects of excess dopamine and norepinephrine since DA and NE receptor antagonists tend to help mediate disease, and immunological because post-streptococcal infection is associated with tic disorders and OCD.

__Tourette’s Disorder__ Tourette’s disorder is characterized has having both multiple motor and at least one vocal tics that have been present during one time during the illness, but not necessarily concurrently. Tics may occur several times a day, usually in bouts, and nearly every day or intermittently thorough a period of //more than 1 year// without a tic-free period longer than 3 consecutive months. Age of onset must be //before age 18// and the disturbance must not be caused by something else.

Treatment includes behavioral therapy via habit reversal (focusing on improving suppression of tics), stress reduction, and relaxation. Antipsychotics such as haloperidol and pimoxide, antidepressants like SSRIs, and alpha-2 adreniergic antagonists such as clonidine and guanfacine may be used. More than 2/3 respond with more than 2/3 symptom reduction.

__Chronic Motor or Vocal Tic Disorder__ Chronic tic disorder is defined as single or multiple motor or vocal tics but not both present at some time during the illness. Tics may occur several times a day, usually in bouts, and nearly every day or intermittently thorough a period of //more than 1 year// without a tic-free period longer than 3 consecutive months. Age of onset must be //before age 18// and the disturbance must not be caused by something else. Criteria cannot be met for Tourette’s tic disorder. __Transient Tic Disorder__ Transient tic disorder is characterized by single or multiple motor or vocal tics that occur many times a day for at //least 4 weeks but no longer than 12 consecutive months//. Transient tic disorders should be specified as single episode or recurrent. Age of onset must be //before age 18// and the disturbance must not be caused by something else. Criteria cannot be met for Tourette’s or chronic motor or vocal tic disorder.

Both chronic and transient tick disorder have higher prevalence than Tourette’s disorder. They are more prevalent in males than girls and are usually self-limiting. Treatment is dependent on severity and frequency.


 * 8. Classify the types of mood disorders that occur in children and adolescents.**

See Objective 9.

Characteristics of mood disorders at all ages include depressed mood, diminished concentration, insomnia, and suicidal ideation.

Children at younger ages also may present with depressed appearance, low self-esteem, and somatic complaints. Children at older ages also may present with anhedonia, diurnal variation (different feelings at different times during day), hopelessness, psychomotor retardation, and delusions.


 * 9. Describe the symptoms and signs of each mood disorder.**

//Major Depressive Episode:// Almost daily for two weeks, five or more symptoms (including at least one of the first two)
 * Depressed (irritable) mood
 * Diminished interest or loss of pleasure
 * Weight or appetite change
 * Sleep disturbance
 * Psychomotor agitation or retardation
 * Loss of energy or fatigue
 * Worthlessness or guilt
 * Concentration, indecisiveness
 * Suicidal ideation/attempt

See Mood Disorders for Major Depressive Disorder diagnosis.

//Dysthymia:// Depressed (irritable) mood for at least two years (one year in children) and at least two of the following (never without symptoms for more than two months at a time):
 * loss of Appetite
 * increased or decreased Sleep
 * Low energy or fatigue
 * Low self-esteem
 * lack of Concentration or indecisiveness
 * Hopelessness

//Adjustment Disorder with Depressed Mood://
 * Within 3 months of the onset of identifiable stressor(s)
 * Time-limited: acute – 6 months, and ends within 6 months of termination of stressor
 * More than expected, marked distress or significant impairment in social or academic functioning

//Manic episode:// A distinct period of abnormally and persistently elevated, expansive or irritable mood lasting at least a week At least 3 of the following:
 * Inflated self-esteem or grandiosity
 * Decreased need for sleep
 * Talkative or pressured speech
 * Flight of ideas or racing thought
 * Distractibility
 * Psychomotor agitation or increased activities
 * Excessive involvement in pleasurable activities
 * Severe functional impairment

//Hypomania:// same as Manic episode, but with reduced severity such that normal function is not impaired and for at least 4 days.

//Cyclothymia:// For at least 2 years (1 year in children), presence of numerous hypomanic episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criteria of Major Depressive Episode. Never without symptoms for more than 2 months at a time

//Bipolar I and II:// Bipolar I disorder is defined as one or more manic or mixed episodes with or without major depressive episodes. Manic episodes trump major depressive episodes so even if a patient has a history of major depressive episodes and only one manic episode, the patient will be automatically bumped into bipolar I disorder. Bipolar II disorder is defined as one or more major depressive episodes plus at least one hypomanic episode.


 * 10. Distinguish the characteristics of mood disorders of children and adolescents from those of adults.**

Epidemiological data shows that more boys are affected than girls before puberty and then girls more than boys following puberty. The prevalence of mental illness increases with age until adulthood. In younger ages MDe presents with depressed appearance, low self-esteem, somatic complaints. In older children MDE presents with anhedonia, diurnal variation, hopelessness, psychomotor retardation, delusions. Typically the period of time needed to define an episode for children is shorter than in adults.


 * 11. Discuss the strategies for treatment of mood, anxiety, and tic disorders.**

Mood disorders are treated the same in children and adults, though there may be difficulty in making a correct diagnosis in children because of their rapidly fluctuating moods compared to adults. RCTs are difficult to conduct on children so their efficacy is not proven for an FDA label in children (Prozac is the one exception). Anxiety disorders in children can be classified as separation anxiety or general anxiety. Separation anxiety is treated through returning to school, education on the separation dynamic, Individual or family therapy, and medication. General anxiety is often is treated with individual, family or group therapy, and medication.

Tic disorders are treated with, medication and psychotherapy only when there is substantial interference with ordinary activities. Stress reduction and habit reversal has shown some efficacy. Drugs used to treat tics, dopamine and norepinephrine receptor blockers have shown some success, but etiology is not fully understood. There is also some indication that tic disorders (as well as OCD) are associated with streptococcal infection.