Anxiety and Mood Disorders in Childhood - Needham SEPAC

Anxiety and MoodDisorders in ChildhoodJessica Leavell, Ph.D., Pediatric NeuropsychologistIntegrated Center for Child Development, Newton, MAjjleavell@iccdpartners.org

Learning Objectives Increase your understanding ofanxiety, depression and bipolardisorder in childhood. Review essential aspects oftreatment and empiricallysupportedtreatment models. Offer model of treatment integrationinto the school setting.Jessica A. Leavell, Ph.Djleavell@iccdpartners.org

Anxiety Disorders Overview Children with anxiety disorders oftenpresent as highly moody and defiant They struggle with a persistent feeling ofbeing out of control of themselves andoften attempt in any method possible togain control. FMRI imaging studies are identifyingatypical brain activity in emotion an fearprocessing centers. The research of tomorrow…

Anxiety Disorders: Diagnoses Panic Disorder:DSM-IV TR Diagnoses Recurrent and unexpected panic attacks. Anxiety related to fear it will happen again andimplications or consequences. Can exist with or without agoraphobiaavoidanceof places where an attack would beembarrassing or difficult to escape For children this could mean school or largersocial events.

Anxiety Disorders: Diagnostic Panic Attack:Criteria Sudden onset of intense apprehension,fearfulness or terror associated with feelingsomething bad is going to happen. Physical Sensations: Palpitations, heartaccelerated, sweating, trembling/shacking,shortness of breath, feeling of choking, checkdiscomfort/pain, nausea, dizzy/unsteady,derealization/depersonalization, fear of goingcrazy/loosing control, fear of dying,numbness/tingling sensations, chills/hotFlashes

Anxiety Disorders Specific Phobia: Specific feared object orsituation resulting in avoidance. Social Phobia: Anxious and avoidant ofcertain social or performance situations. Selective Mutism: Consistent failure to speak in certain socialsituations where expected but will speak inother situations Interferes with school or social functioning 1 month durations (not first month ofschool)

Anxiety DisordersObsessive-Compulsive Disorder: Obsessions causingdistress paired with compulsions to neutralize anxiety.Posttraumatic Stress Disorder: Re-experiencing traumatic event general increased arousal and avoidance ofassociated stimuli. Lasts >1month Children may present as disorganized or generallyagitated.Acute Stress Disorder: Similar to PTSD with dissociative symptoms 2 days minimum-4 weeks maximum

Anxiety Disorders Generalized AnxietyDisorder/Overanxious Disorder ofChildhood:6 months of persistent and excessiveanxiety/worry about numeroussituations.Difficult to control worryChildren would be highly irritable anddefiantMay appear somewhat obsessive

Anxiety Disorders Separation Anxiety Disorder Excessive anxiety at separation from home ormajor attachment figures. Worry some harm with come to attachmentfigure School refusal/fear of being home alone Refusal to go asleep without attachment figureor sleep away from home. Repeated nightmares involving themes ofseparation Physical complaints when separation occursor is anticipated. At least 4 weeks duration

Mood Disorders Overview Grouping of disorders with disturbance inmood as primary feature. Approximately past 10 years it has becomemore accepted that children suffer thesedisorders. Various types of mood episodes:Major Depressive EpisodeManic EpisodeHypomanic EpisodeMixed Episode

Depression and Childhood Children express symptoms differently fromadults Highly irritable, defiant, easily angered Difficulty complying with routine activities. Somatic symptoms/complain of feeling sick Excessive clinging/worry about parent dying Older children/adolescents: sulk/grouchy, exhibitbehavioral problems at school, feelmisunderstood. FMRI research found altered processing inreward centers (decreased) and amygdala(increased) of the brain.

Major Depressive Episode Pervasive sadness Sleeping too much or too little Feeling restless or not wanting to move Agitation and irritability Withdrawal from preferred activities Low Energy Feeling worthless and guilty Difficulty concentrating/indecisive (seen inschool) Thoughts of death Appetite changesJessica A. Leavell, Ph.D.

Mood Disorders Major Depressive Disorder: 2 or more major depressive episodes with at least2 months between episodes. Of note, episodes are marked change from statusquo. Dysthymic Disorder: Milder version but lasts longer/more constant. Depressed mood most of the day for most days(2 years duration adults, 1 year children) Again, watch for irritable mood in children as signof depressed mood

What is Bipolar Disorder? A neuro-developmental brain disorderinvolving remarkable fluctuations in mood,energy, behavior, thinking and physiological(body) rhythms Involve shifts between manic stages anddepression. Fundamentally a disorder of self regulation. Patients can also suffer crippling anxiety andpsychosis and dangerous impulsiveness Impedes functioning in all levels of life.Jessica A. Leavell, Ph.D.

Bipolar Disorder Symptoms of mania Elevated mood can be oddly positive/happy orirritable Sudden Rages Excessive risk taking/increased activities Grandiose Poor judgment Cognitive distortions/delusions Decreased sleep (really feel they don’t need) Racing thoughts and pressured speech (keeptalking) 1 wk duration Jessica A. Leavell, Ph.D.

Variations of Bipolar Hypomania: Milder symptoms than mania,less impacts on function and nopsychosis. Mixed episode: Criteria met for both manicand depressive episode every day for 1wk. Bipolar I vs Bipolar II Cyclothymic disorderJessica A. Leavell, Ph.D.

Brain Involvement Decreased prefrontal cortex volume (executivearea) and subcortial connection includinglimbic system (amygdala and hyppocampus;emotion and memory). Thalamus Occipital lobe Basal gangliaJessica A. Leavell, Ph.D.

NeuropsychologicalConsiderations Numerous cognitive processing issues areoften apparent even when emotions arestabilized. Learning disabilities and ADHD arecommon Social processing and problem solvingweaknessesJessica A. Leavell, Ph.D.

What is Pediatric BipolarDisorder? This is a controversial question Unique Characteristics: Ultra rapid cyclingand mixed mood states, chronic irritability Difficulty interpreting social and emotionalcues.Jessica A. Leavell, Ph.D.

The Controversy Severe mood dysregulation (SMD)(Leibenluft) Studies found… PBP have family history/carry it toadulthood SMD prone to future depression andanxiety disorder. SMD affects 3.2% of population; PBDconsistent with adult average Functional brain differences Temper dysregulation disorder (TDD)Jessica A. Leavell, Ph.D.

Psychological Treatments Treatment plans should becomprehensive and integratepsychological and school interventionsand often include medication. Overall goals should be to improve selfregulation skills, ability to self monitor, selfconcept and social functioning. Evidence-based interventions: EmpiricallySupported Treatments (EST’s)Jessica A. Leavell, Ph.D.

Cognitive Behavioral Therapy(CBT)Very robustly studied and supportedBlend of 2 therapies:Cognitive Therapy:• Developed by Aaron Beck in 1960’s.• Aimed at changing thinking and making itmore adaptive Behavioral Therapy:• Focus on actions• Aim to change unhealthy behavior patterns

CBT OverviewCognitive Triad (Beck)thoughtsbehaviorsemotionsJessica A. Leavell, Ph.D.

CBT Overview In CBT one learns how to:Identify distorted thinking patternsRecognize and change inaccuratebeliefsRelate to others in increasingly positivewaysChange behaviors accordingly orpractice increasingly healthy behaviors

CBT and Childhood AnxietyAimed to help develop a more adaptiveresponse to fear.Exposure therapy for specific phobia,PTSD or OCDConfront fear or memory in a safe andsupported environmentPatient learns anxiety can lessen overtime and with use of coping skills

CBT and Childhood Anxiety Studies found high quality individual/group CBTeffective for childhood and adolescent anxiety. Recent CDC study found exposure therapyeffective in treating trauma disorders in childrenand adolescents. Coping Cat-Evidence Based CBT for AnxiousChildren (GAD, social phobia, separationanxiety) 8-14 yrs, 16 individual/18 group sessions Education, coping skills training and gradedexposure.

CBT and Childhood AnxietyTrauma Focused TreatmentsChild-Parent Psychotherapy: Birth through age 5-suffered at least 1 traumatic event Primary goal to support and strengthen parent-childrelationshipTrauma-Focused CBT: Children aged 0-17-parallel and conjoint parent-childsessions Psychosocial treatment model PRACTICE: Psycoeducation/parenting skills,Relaxation skills, Affect expression/regulation skills,Cognitive coping skills/processing, Trauma narrative,In vivo exposure, Conjoint parent child session,Enhancing safety, and Future development

CBT and Childhood Depression CBT in depression:Targets the negative thinking patternscommonly present.Helps interpret interactions and eventsin a more realistic and positive mannerTeaches coping skills and lifestylechangesResearch found CBT to be mosteffective for minor to moderate illness

CBT and Childhood Depression Cognitive Behavioral Therapy for AdolescentDepression: Evidence Based Intervention (manualized) Adaptations include• Emphasis on psychoeducation• Exploration of autonomy/trust issues• Concrete examples, less abstractions than foradults• Focus on in session distortions/affective shifts• Problems solving, affect regulation and socialskills

CBT and Childhood Depression Adolescent Coping With DepressionEvidence Based Group Intervention Age13-1716-2-hours sessions over 8 weeksTargets irrational thinking, social skills,and increasing pleasant activitiesModifications for teens includeenhanced role playing and problemsolving within the group

CBT and Childhood Depression Cultural Adaptation of CBT for Puerto RicanYouth: Evidence based individual or group short termintervention Aged 13-17, primarily Spanish speaking,severe depression CBT model considering cultural,developmental and socioeconomic factors Goals to improve cognitions, behaviors andrelationships

Individual and Multi-FamilyPsychoeducation Developed by Mary Fristad, Ph.D. andcolleagues for parents and school-aged childrendiagnosed with mood disorders. Goals: Increase knowledge and understanding;improve management of the symptoms; improvecommunication and problem-solving skills; andincrease the child and family’s sense of support. Multi-family-2 randomized control trials Individual family psychoeducation-1 randomizedcontrol trial

Interpersonal Psychotherapy(IPT)Brief psychotherapy developed for the treatment ofdepressionTheory: Stressful interpersonal events lead todepression because people lack skills to findsolutionsThree areas of focus:1. Grief2. Interpersonal role disputes3. Interpersonal role transitionsEmpirically supported for use with unipolardepression and dysthymia in adults andadolescents, beginning the process of researchingfor bipolar disorderJessica A. Leavell, Ph.D.

Family- Focused Therapy forAdolescents (FFT-A) Developed initially for adults with bipolardisorder then adapted for adolescents Includes parents, siblings and affected child Theory: Individual vulnerability (stress-diathesis)plus family system influence course of disorder 3 Components:1. Family Psychoeducation on BPD2. Communication enhancement training3. Problem solving skill developmentJessica A. Leavell, Ph.D.

Family- Focused Therapy Cont.One 2-year randomized control studyfound compared with control group FFT-A had: Shorter times to recovery fromdepression Spent less time in depressive episodes Reported lower depression severityscores over the 2-year period of study.Jessica A. Leavell, Ph.D.

Child–and Family-FocusedCognitive-Behavioral Therapy(CFF-CBT) Adaptation of FFT model to addressdevelopmental needs of younger children (6-12) with bipolar disorder Comprehensive biopsychosocial approach Stresses involvement of whole family, peers& school RAINBOW Preliminary studies for individual and grouphave been promising and a randomizedcontrol trial is being conducted.Jessica A. Leavell, Ph.D.

Dialectical Behavioral TherapyDeveloped by Marsha Linehan, Ph.D. to treat suicidalthoughts and actions in adults.Dialectical referring to the blending of 2 views.Focus on validating client’s feelings and behaviorswhile teaching skills and practicing dealing withconflict and intense emotions.Individual sessions to learn skills/group sessions topractice.A small open trial of 10 adolescents with bipolardisorder found decreased suicidality, non-suicidal selfinjury,emotional dysregulation, depression symptoms

Interpersonal and Social RhythmTherapy (IPSRT) Treatment for bipolar disorder Theory: Instability in circadian rhythmsand neurobiological systems arevulnerabilities to developing BPD Treatment addresses:Three interrelated pathways to illness:• Medication non-adherence• Disruption of social and sleeproutines• Psychosocial stressStabilization of routines &improvement in interpersonalJessica A. Leavell, Ph.D.relationships

IPSRT Cont. EST for adults Recent open trial of 12 adolescentswith bipolar found significantimprovements in manic, depressive,and general psychiatric symptomsover 20 week period.

Other Interventions/ModalitiesPlay Therapy: Use of toys, art and games to help thechild recognize, identify, and verbalize feelings.Psychodynamic Psychotherapy: Emphasizes understanding the issues that motivateand influence a child's behavior, thoughts, andfeelings. It can help identify a child's typical behavior patterns,defenses, and responses to inner conflicts andstruggles.Mindfulness Training/MeditationExercise/Yoga

Psychological TreatmentSummary Taken together, research has shown us thatpediatric psychological interventions for thesedisorders should: Target the unique characteristics of thedisorders in childhood Take a developmental perspective Expanded systems-based perspective• Environmental regulation• Involvement of family and all caregivers in thetherapeutic and intervention process• Incorporation of interventions into all systems• Consideration of multicultural andsociopolitical stressorsJessica A. Leavell, Ph.D.

Psychological Treatment Cont. Psychoeducation Teaching emotional intelligence/processingskills Target thinking processes Build coping and emotional regulation skills Address physiological regulation issues Improve social processing and problemsolving Intensive behavioral planning (includingsafety) Aim to reduce Jessica the A. impact Leavell, Ph.D. on self conceptand general worldview

Integrating Treatment Intothe School Why integrate interventions into the school? Can you really have one without the other? School is full of stimulation & stressors that cantrigger symptoms Symptoms interfere with learning anddevelopment School is their primary social environment Generalization of skills is essentialJessica A. Leavell, Ph.D.

School-Based Intervention Create a collaborative andcomprehensive IEP forhome/community and school Program should include academic,behavioral, social and emotional goals. Should be a designated point person tocoordinated school plan and contactwith outside providers.Jessica A. Leavell, Ph.D.

School-Based Interventions Who should be on the team? Child Parents/guardians/caregivers Special educators/teachers/aides School psychologist and adjustment counselor Behaviorist (BCBA/experience with disorder) School Nurse Child’s individual therapist and psychiatrist Other outside consultants(Neuropsychologists, outside speechpathologists, OT)

School-Based Intervention Plan needs to be proactive and focus onimproving self regulation (thought, emotion,behavior and physiology), self monitoring andsocial functioning Inconsistency and ambiguity can lead to aworsening of symptoms Coordination and consistency among staff isessential Coordination between educational and outsidetreatment teams is essential Consistent interventions Jessica A. Leavell, should Ph.D. be used acrossdomains

School-Based Intervention:Staff Provide psychoeducation to teachers andsupport staff Training: provide educators with a tool box ofstrategies Build empathy for child Provide specific training for dealing withemotional escalation. Support: offer ongoing supportJessica A. Leavell, Ph.D.

School-Based Intervention1. Environmental regulation: Proactiveaccommodations Help child establish structure and routine(time, place, expectations); educate staffabout routine Teacher traits: Firm yet flexible Create plans for new experiences and anychanges in routine (e.g., substitutes,assemblies, holidays, field trips)/prior noticeof changesSet the stage for Jessica learning: A. Leavell, Ph.D. Controlenvironmental stimulation & task

School-Based Interventions Other Examples of SupportiveAccommodations Accommodate late arrival to school Morning check-in’s Allow for brief breaks as needed Indentify a safe place/person Allow child to sit where feel safe/with familiarpeers Regular check-in’s Create brief phrases/hand motions to cuecoping skills Provide notes or recordings or instruction

School-Based InterventionAccommodations cont.Prepare child for transitionsProvide planned time for physicalactivity/meditation (yoga)Peer supportSupport/facilitate peer interactions.Create peer time for older kids.

Components of School-BasedInterventions2. Behavioral planning: Behaviorist identifies targetbehaviors/stressors and triggers (e.g.,functional behavioral assessment) Create a plan focusing on positivereinforcement Implement plan: behaviorist trains all teammembers involved in implementation,including parents Behaviorist tracks progress (school &home) and make adjustments as neededJessica A. Leavell, Ph.D.

School-Based Interventions3. Affect regulation: Chart and track daily thoughts, moods,behaviors and physiological regulation-sharecharts with parents Constant cueing, support & facilitation of affectregulation and coping skills (classroom staff) Create plans for times of escalation; provide asafe retreat for the child. Consistent check-ins with school psychologist,daily and as needed Behavioral plan to encourage use of copingskills. Use methods consistent with external therapy/lead to consult regularly Jessica A. Leavell, with Ph.D. therapist

School-Based Interventions4. Teach Social/interpersonal and problemsolving skills:Social skills group to learn skills and practicein safe environmentFacilitated throughout the day and duringunstructured times (preview and review)5. Consider alternative environments as needed.Jessica A. Leavell, Ph.D.

Summary of Key Points Home, community and school-basedinterventions should integrate: Understanding of unique features A developmental perspective Integrative/biopsychosocial interventions Main goals-improve self-regulation, selfmonitoring, social skills and problemsolving. All plans, including school, should beproactive: focus on planning, generalization &consistency across environments Hang in there: Expect recurrences but bepersistent!Jessica A. Leavell, Ph.D.