Thompson: APSY 683 Final Exam (2)

Final Exam, Section Two Shauna Thompson 10017221 University of Calgary APSY 683 - Fall 2008

Thompson: APSY 683 Final Exam (2) Childrens mental health is a key concern for parents, teachers, and all others who work with young

people. While childhood for many is a time of joy, wonder, and the adventure of new experiences, not all children experience it that way. Its only within the past couple of generations that real gains have been made in the research and practice of childrens mental health issues. It was not so long ago that many physicians believed that children lacked the necessary psychological and cognitive structures to experience significant depressive disorders, and therefore did not believe such a disorder could affect them. However, research has confirmed that children and adolescents not only experience the whole spectrum of mood disorders, but they are also susceptible to the significant morbidity and mortality associated with them. Unique in and of themselves, but related to disorders of depression, anxiety symptoms and disorders are one of the most common psychiatric problems of children and adolescents. As well as having a harmful impact on the child's social and academic functioning, anxiety can have serious long-term consequences. Many children who suffer from anxiety and depressive disorders will suffer intermittently for the rest of their lives. Within this paper, we will consider these two areas of psychopathology as they relate to children and adolescents. We will examine the prevalence, typical features, comorbidity, and domains of impairment related to anxiety and depressive disorders, with consideration for the way they are interrelated. Finally, we will reflect on some important considerations for working with children who may be experiencing these disorders. Anxiety Anxiety is a part of life, a basic human emotion. It is an adaptive mechanism that alerts us to situations that might be threatening, allowing our fight or flight response to be engaged. Transient fears and anxieties are a normal part of development, but for some children, these fears and anxieties are extreme and long-lasting, leading to severe impairments in functioning that can persist into

Thompson: APSY 683 Final Exam (2) adolescence and adulthood (Bernstein, Borchardt, & Perwien, 1995). Aside from the negative emotionality associated with the anxiety itself, childhood anxiety disorders have often been found to be associated with depression, as well as suicidal ideation and suicide attempts (Kendall and Ollendick, 2004). According to the DSM-IV-TR (American Psychological Association, 2000), children can be diagnosed with any of the nine anxiety disorders. Anxiety is the predominant feature among the disorders, expressed through specific cognitive, physiological, and behavioral reactions. What differentiates between the subtypes is the focus of the anxiety. Anxiety disorders listed in the DSM-

IV-TR include separation anxiety disorder, panic disorder, agoraphobia, generalized anxiety disorder, social phobia/social anxiety disorder, specific (simple) phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and acute stress disorder. Prevalence Albano, Chorpita, and Barlow (2003) note that anxiety disorders are widely recognized as among the most common psychiatric disorders affecting children and adolescents, with prevalence rates estimated between 8% and 12% (Angold & Costello, 2006; Bernstein & Borchardt, 1991; Mash & Barkley, 2007). Separation anxiety disorder has the highest rate of prevalence, ranging from 2% to 12.9%, while social phobia has the lowest prevalence, between .5% and 2.8% (Mash & Barkley, 2007). A familial link exists in child and adolescent anxiety disorders, wherein up to 60% of anxious parents have been found to have a child with an anxiety disorder (Cartwright-Hatton, McNicol, & Doubleday, 2006). Further research has indicated that more than 80% of parents of children with anxiety disorders exhibit significant anxiety symptoms themselves (Fisak Jr. & Grills-Taquechel, 2007). In general, girls have more symptoms of anxiety than boys, particularly in the case of separation anxiety.

Thompson: APSY 683 Final Exam (2) Typical Features

The most common symptoms in anxiety disorders are over-concern about competence, excessive need for reassurance, fear of the dark, fear of harm to a loved one, excessive worry and concern, and somatic complaints. Bernstein and Borchardt (1996) note that the sources of anxiety more commonly reported for adolescents than for preadolescents include fear of heights, public speaking, blushing, excessive worrying about past behaviour, and self-consciousness. Separation anxiety disorder and specific phobia have the earliest average age of onset among anxiety disorders, (approximately 7 years old), whereas generalized anxiety disorder and obsessive-compulsive disorder typically have their onset in middle-childhood (around 9-10 years old). With adolescence comes an increased vulnerability to and prevalence in other anxiety disorders, including panic disorder, agoraphobia, and social phobia. Comorbidity Anxiety disorders are highly comorbid with disruptive behavior problems (particularly for adolescents), depressive disorders, and other anxiety disorders (Kendall et al., 1994), with rates of cooccurrence ranging up to 65% in community epidemiological samples (Angold & Costello, 2006). Generalized anxiety disorder, separation anxiety disorder and social phobia frequently co-occur, with intra-anxiety comorbidity rates ranging between 12.6% and 18.7%. Domains of Impairment Impairment experienced by anxious children and adolescents impacts on a wide range of activities and situations. Functioning may be adversely affected by the high comorbidity among different anxiety disorders, and comorbidity with disorders such as depression and ADHD (Albano, Chorpita, & Barlow, 2003). Children and adolescents with anxiety problems experience significant and often long-lasting psychosocial impairment in the areas of academic performance, social problems, and

Thompson: APSY 683 Final Exam (2) family conflict (Mash & Barkley, 2007). Anxiety has been shown to be significantly associated with lower academic achievement; In a study reviewed by Ialongo and colleagues (1994, as outlined by

Cartwright-Hatton, McNicol, & Doubleday, 2006), children with high anxiety levels were 7.7 and 2.4 times more likely to be in the lowest quartile of reading and math achievement, respectively. After 4 years, anxiety in first grade was a significant predictor of anxiety in fifth grade (Bernstein, Borchardt, & Perwein, 1995). Depression Depression affects a significant number of youth during critical stages of development, especially during adolescence. It often follows a destructive course across development and leads to impairment in many spheres of youths lives. Children and adolescents with depression experience impaired functioning characterized by irritability, deep, persistent sadness, boredom, apathy, and an inability to experience pleasure (anhedonia). They are quite unresponsive to people and activities that previously brought relief. The behaviors of depressed children and adolescents are seen by others to be changed from those that were previously normal for them depression is not just the normal ups and downs that accompany human development. According to the DSM-IV-TR (American Psychiatric Association, 2000), depressive disorders exist on a continuum and are classified on the basis of severity, persistence, and the presence or absence of mania. Adjustment disorders with depressed mood are at the mildest end of the continuum; they are mild, self-limited, and present in response to a clear stressor. Minor depression is diagnosed if depressed mood, anhedonia, or irritability is present with up to three symptoms of major depression. Dysthymic disorder is a chronic condition that follows a course of at least one year (for children and adolescents), with fewer symptoms than major depression. Minor depression and dysthymic disorder impair function, and are often precursors to major depression. Major depression is the most severe

Thompson: APSY 683 Final Exam (2) depressive condition, with either sad or irritable mood or anhedonia, plus a minimum of five other cognitive, physiological, or behavioral symptoms, such as feelings of worthlessness or guilt, changes in sleep pattern or appetite, decreased motivation or concentration, social withdrawal, or suicidal thoughts or behaviors. Prevalence Studies have shown that the prevalence of depression rises with age, so it is more common after puberty than among children and youth in preadolescence. According to Zalsman and his colleagues

(2006), the prevalence of depressive disorders is 1% of preschoolers, 2% of school-aged children, and 5% to 8% of adolescents; there is a reported lifetime prevalence of approximately 20% by the end of adolescence. Of interesting note, studies of adults and children with anxiety disorders have suggested that each successive generation since 1940 is at greater risk for developing depressive disorders, and that these disorders are being recognized at a younger age (Kovacs and Gatsonis, 1994; Ryan et al., 1992; Sung & Kirchner, 2000). Typical Features The main symptoms of depression are seen across the lifespan from school-aged children and adolescents to adulthood. These signs and symptoms include feelings of sadness and hopelessness, increased fatigue, lack of motivation, loss of interest in formerly pleasurable activities, decreased concentration and decision-making abilities, and general pessimistic and self-criticizing feelings. The clinical presentation of depression is variable across prevalence and severity of symptoms at different developmental stages. Depressive symptoms of preschoolers must be identified through evaluation of their observable behaviors, including withdrawal, apathy, and the delay or regression of developmental milestones, as these children are typically unable to express feelings of sadness themselves (Sung & Kirchner,

Thompson: APSY 683 Final Exam (2) 2000). School-aged children are cognitively able to internalize environmental stressors (e.g. family conflict, criticism, and academic failure), displaying low self-esteem and excessive guilt when depressed. Much of their distress comes out in the form of somatic complaint, anxiety, and overall irritability. In some cases, these children attempt to compensate for low self-esteem by trying to gain acceptance through pleasing others. As a result, their inner turmoil is hidden behind people-pleasing and good behaviour, and their depressive symptoms may go unnoticed. Adolescence is a period of individuation, where young people work to separate from their parents, become autonomous and establish their own identities, at the same time becoming increasingly dependent on their peers. At this time of familial separation, adolescents are vulnerable to a deeper sense of hopelessness and despair. There is increased risk for suicidal thoughts and attempts during this developmental phase. Adolescents also exhibit more anhedonia, hypersomnia, weight change and substance abuse when depressed than younger children. Gender Differences Similar to studies of older preadolescent children, evidence suggests that prevalence of preschool depression is similar among boys and girls. In preadolescence, girls are no more prone to depression than boys, but a strong gender imbalance appears in adolescence, with a 2:1 female-to-male ratio.

Angold and Costello (2006) show an increase in the occurrence of depression in girls ages 13 to 15; at the same time, for boys of the same age, they found no relationship between age and depression. Research by Zalsman, Brent and Weersing (2006) suggests that this higher rate of depression in girls after the onset of puberty may be caused by increased hormone production associated with the onset of puberty, and higher rates of anxiety disorder in adolescent girls. Comorbidity

Thompson: APSY 683 Final Exam (2) Comorbidity is the rule rather than the exception in depressed children and adolescents, with 40 to 70% of affected individuals experiencing comorbid psychiatric disorders. According to Hammen and Rudolph (2003), depression co-occurs commonly with anxiety disorders of all forms, as well as with disruptive behavior disorders, and eating disorders. Alcohol, drug, and tobacco abuse are associated with depression, and longitudinal studies suggest bi-directional causality, with substance abuse leading to and occurring as a result of depression (Birmaher, 1996; Sung & Kirchner, 2000). Ollendick, Shortt and Sander (2005) report that patterns of comorbidity in preschool children differ

from patterns found in older children and adolescents, in whom anxiety disorders are most frequently comorbid with major depression. Kashani and colleagues (1997) reported higher rates of externalizing behaviors, including aggression, anger, and uncooperativeness in dysthymic and depressed preschoolers. Among a group of preschoolers identified as depressed, 62% had comorbid oppositional defiant disorder, 42% had comorbid attention deficit hyperactivity disorder, and 41% were comorbid with both disorders. Only 28% of these depressed preschoolers had comorbid anxiety disorders. Domains of Impairment Deficits in social and academic competence have been implicated both as causes and consequences of depression in children. Depression may also lead to diminished social and cognitive functioning, which in turn may elicit responses from others that exacerbate depression (Fauber et al., 1987). Fauber et al. (1987) noted that often this spiral effect continues downward, with depression, decreased familial support, social incompetence, and diminished cognitive functioning in constant interplay. Children with depression may demonstrate motivational, cognitive, and attentional problems that, in turn, can lead to diminished school performance, lower grades, and poorer teacher evaluations. It is difficult for a child to feel adequate when they are not succeeding in school, since a childs educational performance is a socially accepted measure of their ability to succeed outside of the

Thompson: APSY 683 Final Exam (2) family. Since much of childhood is focused around school and academic achievement, failures in these areas may trigger additional depressive feelings. Language and learning disabilities, ADHD, school phobia, and any other condition that interferes with a childs learning increases a childs risk for this disorder (Birmaher, 1998). Parental approval and acceptance may also fluctuate with the childs academic performance, putting additional stress on the parent-child relationship, lending further support to the idea that depression can be an ever-widening downward spiral for many children and adolescents. Summary Anxiety disorders are associated with significant distress and impairment, and are recognized as the most common psychiatric illnesses in children and adolescents. Anxious children and adolescents have an elevated risk of depressive disorders, substance abuse, and even suicide. Childhood and adolescent depressive disorders are common, reoccurring, chronic conditions that often persist into adulthood. These disorders appear to be manifesting at an earlier age in successive generations, and are frequently accompanied by comorbid psychiatric disorders, along with an increased risk for suicide, substance abuse, and behavior problems. In addition, depressed youth frequently have poor psychosocial, academic, and family functioning, highlighting the importance of our role in early identification and prompt, effective treatment. While these are two distinctly different categories of disorders, they result in incredibly similar outcomes. Since they are both internalizing disorders, young people with depression and anxiety disorders are often likely to be unidentified as sufferers, unlike what is seen with externalizing disorders such as ADHD or ODD. With their high level of co-occurrence with one another, anxiety and depressive disorders leave children and adolescents distressed, emotionally wounded, isolated, and perpetually sliding deeper into the effects of the disorder if they go without intervention. Many

Thompson: APSY 683 Final Exam (2) adverse outcomes are associated with this untreated anxiety and depression, from interpersonal difficulties and educational underachievement, to substance abuse, poor family relationships, selfharm, and suicide.

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Children and adolescents with concurrent anxiety and depressive disorders have been reported in both clinical and general population samples (Bernstein, Borchardt, & Perwein, 1995; Kendall, 1994). An increased severity in both anxiety and depressive symptoms is associated with the comorbidity of anxiety and depressive disorders in children and adolescents (Bernstein & Borchardt, 1991), compared to children with pure anxiety or pure depressive disorders. Adolescents with anxiety disorders who develop major depression are at a high risk for attempting suicide. Because the risk of school failure and suicide is quite high in depressed and anxious children and adolescents, close collaboration with a mental health professional is often necessary when depression and anxiety are identified. The increased risk and prevalence of depression and anxiety in girls, particularly in early adolescence, should be a key consideration to those working with these girls. Girls experience the psychological and biological changes of puberty ahead of boys, and often worry more about their body image and outward appearance. Girls tend to worry more about their body image, are more likely to be exposed to sexual abuse, and may experience more pressure to conform to restrictive social roles than boys. They tend to internalize more, and Birmaher and his colleagues (1998 p2) suggest that girls are more likely to deal with problems with a ruminative and self-focused style than boys, further perpetuating the pattern of internalization. We know that depression and anxiety have high comorbidity rates that start early, and that children and adolescents use drugs, alcohol, and cigarettes to self-medicate. Suicide has become a growing concern in our society as successive generations have shown a parallel increase of suicide and

Thompson: APSY 683 Final Exam (2) depression in the pediatric age group. Early identification and intervention for at-risk children and adolescents must be of highest priority, and a prevention approach should be pursued in our work with children in schools and the community we must find a way to identify children at risk for

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depressive and anxiety disorders, and help them develop healthier patterns of coping and interacting in the world, so we do not always have to be at the ready to intervene. Awareness of the epidemiology of anxiety and depressive disorders is of critical importance. We must take the opportunity to educate our teachers, parents, administrators and students about issues in childrens mental health, particularly in the areas of depression and anxiety, which are so often missed, even when they are right in front of us. It is our responsibility to be present in our schools and community groups when we work with young people, to be awake and aware to the possibility that all might not be well, and to provide practical and reasonable supports and solutions so this harmful and dangerous cycle is not allowed to continue.

Thompson: APSY 683 Final Exam (2) References

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Albano, A.M., Chorpita, B.F., & Barlow, D.H. (2003). Childhood anxiety disorders. In E.J. Mash & R.A. Barkley (Eds), Child Psychopathology, (2nd ed., pp. pp 279-319). New York: Guilford Press. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th edition. Washington, DC: American Psychiatric Association. Angold, A., & Costello, E.J. (2006). Puberty and depression. Child and Adolescent Psychiatric Clinics of North America, 15: 919-937. Barkley, R.A. & Mash, E.J. (2003). Child Psychopathology, 2nd Edition. New York: Guilford Press. Bernstein, G.A. & Borchardt, C.M. (1991). Anxiety disorders of childhood and adolescence: A Review. Journal of the American Academy of Child and Adolescent Psychiatry, 30(4): 519-532. Bernstein, G.A., Borchardt, C.M., & Perwein, A.R. (1995). Anxiety Disorders in Children and Adolescents: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 35(9): 1110-1119. Birmaher, B., Ryan, N.D., Williamson, D.E., et al. (1996). Childhood and adolescent depression: a review of the past 10 years. Part 1. Journal of the American Academy of Child and Adolescent Psychiatry, 35(11): 1427-39. Birmaher, B., Brent, D., et al. (1998). Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 37(S10): 63S-82S. Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children. Clinical Psychology Review, 26: 817 833. Fisak, B., & Grills-Taqueche, A.E. (2007). Parental modeling, reinforcement, and information transfer: Risk factors in the development of child anxiety? Clinical Child and Family Psychology, 10(3): 213-231. Hammen, C. & Rudolph, K.D. (2003). Childhood mood disorders. In E.J. Mash & R.A. Barkley (Eds), Child Psychopathology, (2nd ed., pp. pp 233-268). New York: Guilford Press. Kashani, J.H., Allan, W.D., Beck, N.C. Jr., et al. (1997). Dysthymic disorder in clinically referred preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 36(10): 142633. Kendall, P.C. (1994). Treating anxiety disorders in children: Results of a randomized clinical trial. Journal of Clinical Child Psychology, 62(1): 100110. Kendall, P.C., Ollendick, T.H. (2004). Setting the Research and Practice Agenda for Anxiety in Children and Adolescence: A Topic Comes of Age. Cognitive and Behavioral Practice, 11: 6574. Kovacs, M., & Gatsonis, C. (1994). Secular trends in age at onset of major depressive disorder in a clinical sample of children. Journal of Psychiatric Research, 28(33): 319329.

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Thapar, A., & Rice, F. (2006). Twin studies in pediatric depression. Child and Adolescent Psychiatric Clinics of North America, 15: 869881. Zalsman, G., Brent, D.A., & Weersing, V.R. (2006). Depressive disorders in childhood and adolescence: An overview; Epidemiology, clinical manifestation, and risk factors. Child and Adolescent Psychiatric Clinics of North America, 15: 827841.