1. Mood and anxiety disorders in children
Dr. Marjorie Robb
Assistant Professor, UOttawa
Children’s Hospital of Eastern Ontario

2. Some troubling statistics
At least 20% of children under age 18 have significant mental health problems
75% of those don’t get help

3. ANXIETY IN CHILDREN

4. 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.

5. 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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. DEPRESSION IN CHILDREN

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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!

30. 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

31. 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

32. Putting it all together:

33. 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

34. 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

35. 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

36. 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!

37. 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

38. Relationship Matters Because 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

39. Resources www.ementalhealth.ca www.anxietybc.com
Provides information about mental health disorders, recommendations for books and videos, and details about where to look for help
Good information about self-help which parents can adapt for kids
From the Canadian Pediatric Society
Information on a range of mental health problems

40. Question Time