Anxiety, defined as dread or apprehension, is not considered pathologic, is seen across the life span, and can be adaptive (e.g. the anxiety one might feel during an automobile crash). Anxiety becomes disabling. Interfering with social interactions, development. Achievement of goals or quality of life. Can lead to slow self esteem, social withdrawal. Academic underachievement. The average age of onset of anxiety disorder is 11 years. This is the most common psychiatric disorders of childhood. Occurs in 5-18% of all children and adolescents. Prevalence rate is comparable to physical disorders such as asthma and diabetes. One of the most common childhood anxiety disorder. Prevalence- 3.5-5.4% Girls ˃ boys Common in prepubertal children. Average age of onset 7.5 yrs. It is developmentally normal when it begins about 10 month of age and tapers off by 18 month. By 3 years of age, most children can accept the temporary absence of their mother or primary caregiver. SAD is characterised by unrealistic and persistent worries about separation from home or a major attachment figure.

1. Anxiety disorders and Mood
disorders in children
Speaker-Dr Chayanika Mishra
Paediatrician, Dr BC Roy PGPIS, Kolkata

2. Anxiety Disorder
• Anxiety, defined as dread or apprehension, is not considered pathologic, is seen
across the life span, and can be adaptive (e.g. the anxiety one might feel during
an automobile crash).
ANXIETY
Cognitive Behavioral
component
Expressed in worrying &
wariness
Physiologic component
Mediated by autonomic
nervous system

3. Pathologic Anxiety
• Anxiety becomes disabling.
• Interfering with social interactions, development.
• Achievement of goals or quality of life.
• Can lead to slow self esteem, social withdrawal.
• Academic underachievement.

4. Physical manifestations
• Weight loss
• Pallor
• Tachycardia
• Tremors
• Muscle cramps
• Paraesthesia
• Hyperhidrosis
• Flushing
• Hyperreflexia
• Abdominal tenderness

5. • The average age of onset of anxiety disorder is 11 years.
• This is the most common psychiatric disorders of childhood.
• Occurs in 5-18% of all children and adolescents.
• Prevalence rate is comparable to physical disorders such as asthma and
diabetes.

6. Normative fears:

7. Differential diagnosis of Anxiety Disorders
• Shyness
• Substance abuse/withdrawl
• Hyperthyroidism
• Arrhythmias
• Pheochromocytoma
• Mast cell disorders
• Carcinoid syndromes
• Anaphylaxis
• Lupus
• Autoimmune encephalitis
• Body dysmorphic disorder
• Autism spectrum disorder
• Major depressive disorder
• Delusional disorder
• Oppositional defiant disorder
• Embarrassing medical condition

8. Primary
Symptoms
Worry.
Are there
unusual
behaviors??
NO
GAD
Adjustment disorder with anxiety
Yes
OCD
PANDAS
Fear
Arise from
trauma
exposure??
Yes
Acute stress disorder
PTSD
No
Specific phobias
Social anxiety disorder
Separation Anxiety disorder
Selective mutism
Panic
Panic disorder
Agoraphobia

9. Separation anxiety disorder(SAD):
• One of the most common childhood anxiety disorder.
• Prevalence- 3.5-5.4%
• Girls ˃ boys
• Common in prepubertal children. Average age of onset 7.5 yrs.
• It is developmentally normal when it begins about 10 month of age and tapers
off by 18 month.
• By 3 years of age, most children can accept the temporary absence of their
mother or primary caregiver.
• SAD is characterised by unrealistic and persistent worries about separation from
home or a major attachment figure.

10. SAD….
• Concerns:
Possible harm befalling the affected child or the child’s primary caregivers.
Reluctance to go to school or to sleep without being near the parents.
Persistent avoidance of being alone.
Nightmares involving themes of separation.
Numerous somatic symptoms.
Complaint of subjective distress.

11. Age ˂ 8 yr 9-12 yr 13-16 yr
Symptoms School
refusal.
Excessive
fear that
harm will
come to a
parent.
Excessive
distress
when
separated
from a
parent
School
refusal
Physical
complaint
Symptoms vary depending on age:

12. SAD…
• Comorbidity: common in SAD.
• Children with comorbid tic disorder and anxiety, SAD is a/w tic severity.
• Children with SAD compared to those without SAD are 3 times more likely to
develop panic disorder in adolescence.
• Treatment:
• CBT- Cognitive Behavioural Therapy
• SSRI- Selective Serotonin Reuptake Inhibitor

13. Social anxiety disorder:
• Childhood onset social phobia (SP).
• Excessive anxiety in social setting (including the presence of unfamiliar peers, or
unfamiliar adults) or performance situations, leading to social isolation.
• A/W social scrutiny & fear of doing something embarrassing.
• Avoidance or escape from the situation usually dissipates anxiety in social phobia,
unlike GAD, where worry persists.
• Onset- typically during or before adolescence. More common in girls.
• 70-80% patients have at least one comorbid psychiatric disorder.
• A family history of SP or extreme shyness is common.
• But most shy patients do not have SP.

14. • Anxiety can manifest as panic attack.
• SP is a/w decreased quality of life, with
increased likelihood of failed at least 1 grade,
and a 38% likelihood of not graduating.
• Treatment:
• SET-C Social effectiveness therapy for
children.
• SET-C alone or with SSRIs, is considered the
treatment of choice for SP.
• Beta blocker is used to treat SP- subtype with
performance anxiety and stage fright. (Not
approved by US FDA)

15. School Refusal
• Occurs in approx. 1-2% of children.
Associated with
Anxiety 40-50%
Depression 50-60%
Oppositional
behaviour
50%
School refusal
Young children
Separation
Anxiety Disorder
Older children
Social Phobia
Most likely to
have

16. School refusal…
• Somatic symptoms like abdominal pain and headache are
common.
• Contributing factors:
• Increasing tension in the parent –child relationship.
• Indicators of family disruption (domestic violence, divorce, or
other major stressors)
• Management:
• Parent management training and family therapy.
• Need special attention from teachers, counsellors or school
nurses.
• Parents are coached to calmly send the child to school and to
reward the child for each completed day of school.
• Referral to a child psychiatrist in resistant cases.
• SSRI may be helpful.

17. Selective mutism
• Conceptualised as a disorder that
overlaps with social phobia.
• Children talk almost exclusively at
home, they are reticent in other
settings, such as school, daycare or
even relatives home.

18. Selective mutism…
• Mutism must be present for ≥ 1 month.
• Stressors such as new classroom or conflicts with parents or siblings, may drive an already shy
child to become reluctant to speak.
• Obtain history of normal language use in at least one situation to rule out:
1. Any communication disorder (fluency disorder)
2. Neurologic disorder
3. Pervasive developmental disorder (autism, schizophrenia)
• Treatment:
• Fluoxetine in combination with behavioural therapy is effective for children whose school
performance is severely limited.

19. Panic Disorder (PD)
• A panic attack is an abrupt surge of intense fear or intense discomfort that
reaches a peak within minutes and during that time 4 ( or more) of the following
symptoms occur. [ DSM-5 Diagnostic Criteria]
Palpitations, pounding heart, or accelerated heart rate Feeling dizzy, unsteady, light-headed, or faint.
Sweating. Chills or heat sensations.
Trembling or shaking. Paresthesias (numbness or tingling sensations).
Sensations of shortness of breath or smothering. Derealization (feelings of unreality) or
depersonalization (being detached from oneself).
Feelings of choking. Fear of losing control or “going crazy.”
Chest pain or discomfort. Fear of dying.
Nausea or abdominal distress.

20. PD…
• Uncommon before adolescence.
• Peak age of onset 15-19 yrs.
• Common in girls.
• Treatment:
• CBT & SSRIs appears to be effective.
• Recovery rate is approx. 70%.
• No RCT evaluated the role of antidepressants.

21. Agoraphobia
• Patients must have marked, persistent ( ≥ 6 months)
fear of or anxiety about 2 or more of the following 5
situations: [ DSM-5 criteria]
1. Using public transportation (e.g. automobiles, buses,
trains, ships, planes).
2. Being in open spaces (e.g. parking lot, marketplace,
bridges).
3. Being in an enclosed place (e.g. shops, theaters,
cinemas).
4. Standing in line or being in a crowd.
5. Being alone outside the home alone.
• Agoraphobic situations almost always provoke fear or
anxiety.

22. Generalized Anxiety Disorder(GAD)
• Children who often experience unrealistic worries
about different events or activities for at least 6
months with at least one of the following somatic
complaint.
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 disturbances (difficulty falling or staying
asleep or restless, unsatisfying sleep).

23. GAD…
• Children with GAD are extremely self-conscious and perfectionistic and struggle with more
intense distress than is evident to parents or others around them.
• GAD is usually a/w simple phobia and panic disorder.
• Onset may be gradual or sudden.
• Boys & girls are equally affected before puberty, when GAD becomes more prevalent in girls.
• Prevalence of GAD 2.5-6% of children.
• Hypermetabolism in frontal precortical area and increased blood flow in the right dorsolateral
prefrontal cortex may be present.
• Treatment:
• CBT & SSRI
• Buspirone may be used as an adjunct to SSRI therapy.
• Recovery rate is approx. 80%.

24. Obsessive-compulsive disorder (OCD)
• Obsession is defined by: [DSM-5 criteria]
• Recurrent or persistent thoughts, urges, or
images that are experienced, at some time
during the disturbance, as intrusive and
unwanted, and that in most individuals
cause marked anxiety or distress.
AND
• The individual attempts to ignore or
suppress such thoughts, urges, or images, or
to neutralize them with some other thought
or action (i.e. by performing a compulsion)

25. OCD…
• Compulsions are defined by: [DSM-5 criteria]
• Repetitive behaviours (e.g. hand washing,
ordering, checking) or mental acts (e.g.
praying, counting, repeating words silently)
that the individual feels driven to perform in
response to an obsession or according to
rules that must be applied rigidly.
AND
• The behaviors or mental acts are aimed at
preventing or reducing anxiety or distress, or
preventing some dreaded event or situation;
however, these behaviors or mental acts are
not connected in a realistic way with what
they are designed to neutralize or prevent,
or are clearly excessive.

26. OCD…
• DSM-5 diagnostic criteria for OCD
1. Presence of obsessions, compulsions, or both.
2. The obsessions or compulsions are time-consuming (e.g., take more than 1 hr per
day) or cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
3. The obsessive-compulsive symptoms are not attributable to the physiologic effects of
a substance (e.g., a drug of abuse, a medication) or another medical condition.
4. The disturbance is not better explained by the symptoms of another mental disorder.

27. OCD…
• Valid methods for identifying children with OCD:
1. C-YBOCS -Children's Yale-Brown Obsessive-Compulsive Scale
2. ADIS-C -Anxiety Disorders Interview Schedule for Children
3. LOI- Leyton Obsessional Inventory
Comorbidity Common in OCD
Tic disorders 30%
Major depression 26%
Developmental disorders 24%

28. OCD…
• Treatment:
• CBT alone
• CBT with SSRI- when symptoms are moderate to severe (YBOCS ˃21)
• Four FDA approved medication for paediatric OCD:
1. Fluoxetine
2. Sertraline
3. Fluvoxamine
4. Clomipramine
• May be role of glutamate modulating medications (Riluzole, memantine)

29. Pediatric Autoimmune Neuropsychiatric Disorder Associated
with Streptococcal infection (PANDAS)
• In 10% of children with OCD, symptoms are triggered or exacerbated by group A β-hemolytic
streptococcal infection.
• Group A βhemolytic streptococci trigger antineuronal antibodies that cross-react with basal
ganglia neural tissue in genetically susceptible hosts, leading to swelling of this region and
resultant obsessions and compulsions.
• This subtype of OCD, called PANDAS is characterized by sudden and dramatic onset or
exacerbation of OCD or tic symptoms, associated neurologic findings, and a recent streptococcal
infection.
• Increased antibody titers of ASO and antiDNAse B correlates with increased basal ganglia
volumes.
• Plasmapheresis is effective in reducing OCD symptoms in some patients with PANDAS and also
decreasing enlarged basal ganglia volume.
• OCD has also followed episodes of acute disseminated encephalomyelitis.
• The pediatrician should be aware of the infectious cause of some cases of tic disorders, and
OCD.

30. Post-Traumatic Stress Disorder(PTSD)
• PTSD is an anxiety disorder resulting from the long- and short-term effects of
trauma that cause behavioral and physiologic sequelae in toddlers, children, and
adolescents.
• Acute stress disorder , reflects that traumatic events often cause acute symptoms
that may or may not resolve.
• Separation anxiety is common in children with PTSD.
• The lifetime prevalence of PTSD by age 18 yr is approximately 6%.
• Events that pose actual or threatened physical injury, harm, or death to the child,
child's caregiver, or others close to the child, and that produce considerable stress,
fear, or helplessness, are required to make the diagnosis of PTSD.

31. PTSD…
• Three clusters of symptoms are also essential for diagnosis: reexperiencing, avoidance,
and hyperarousal.
• Persistent reexperiencing of the stressor through intrusive recollections, nightmares,
and reenactment in play are typical responses in children.
• Persistent avoidance of reminders and numbing of emotional responsiveness, such as
isolation, amnesia, and avoidance, constitute the 2nd cluster of behaviors.
• Symptoms of hyperarousal, such as hypervigilance, poor concentration, extreme startle
responses, agitation, and sleep problems, complete the symptom profile of PTSD.

32. PTSD…
• Treatment:
• CBT is the psychotherapeutic intervention
with the most empirical support.
• Clonidine or guanfacine may be helpful for
sleep disturbance, persistent arousal, and
exaggerated startle response.
• SSRIs may be considered in pediatric
patients with PTSD who have comorbid
conditions responsive to SSRIs, including
depression, affective numbing, and anxiety.

33. Mood Disorders
• Mood disorders are interrelated sets
of psychiatric symptoms characterized
by a core deficit in emotional self-
regulation.
Mood Disorders
Depressive
Dysphoric (low)
mood
Bipolar
Euphoric (high)
mood

34. Evaluation of Mood disorder

35. Major depressive
disorder (MDD)

36. Persistent depressive disorder

37. Disruptive Mood Dysregulation Disorder (DMDD)
• Severe, persistent irritability evident most of the day, nearly every day, for at least 12
month in multiple settings (at home, at school, with peers).
• The irritable mood is interspersed with frequent (≥3 times/wk) and severe (verbal
rages, physical aggression) temper outbursts.
• This diagnosis is intended to characterize more accurately the extreme irritability that
some investigators had considered a developmental presentation of bipolar disorder,
and to distinguish extreme irritability from the milder presentations characteristic of
oppositional defiant disorder (ODD) and intermittent explosive disorder.

38. Differential Diagnosis
Psychiatric disorders Medical conditions Medications
Autism spectrum disorder (ASD) Neurologic disorders (including
autoimmune encephalitis)
Narcotics
Attention-Deficit Hyperactivity
Disorder (ADHD)
Endocrine disorders (including
hypothyroidism and addison
disease)
Chemotherapy agents
Bipolar Infectious diseases β-blockers
Anxiety Tumors Corticosteroids
Trauma- and stressor-related Anemia & Uremia Contraceptives.
Disruptive/impulse
control/conduct
Failure to thrive
Substance-related disorders Chronic fatigue disorder and pain
disorder.

39. Screening
• Adolescents presenting in the primary care setting should be queried, along with their
parent(s), about depressed mood as part of the routine clinical interview.
• A typical screening question would be, “Everyone feels sad or angry some of the time,
how about you (or your teen)?”
• The parents of younger children can be queried about overt signs of depression, such
as tearfulness, irritability, boredom, or social isolation.
• A number of standardized screening instruments widely used in the primary care
setting.
1. Pediatric Symptom Checklist.
2. Strengths and Difficulties Questionnaire.
3. Vanderbilt ADHD Diagnostic Rating Scales.

40. Management
• Treatment decisions should be guided by the understanding that depression in
youth is highly responsive to placebo (50–60%) or brief nonspecific intervention
(15–30%).
• The goal of treatment is remission, defined as a period of at least 2 wk with no
or very few depressive symptoms.
• Ultimately recovery, defined as a period of at least 2 month with no or very few
depressive symptoms.
• By engaging in active listening (e.g., “I hear how upset you have been feeling,
tell me more about what happened to make you feel that way”), the pediatric
practitioner can begin to assess the onset, duration, context, and severity of the
symptoms and associated dangerousness, distress, and functional impairment.

41. Management…
• For mild symptoms (manageable and not functionally impairing) and in the
absence of major risk factors (e.g., suicidality; psychosis; substance use; history
of depression, mania, or traumatic exposures; parental psychopathology,
particularly depression; severe family dysfunction).
Guided self-help with watchful waiting
and scheduled follow-up may suffice.
Guided self-help can include provision
of educational materials,
strengthening the parent–child
relationship and modifying
depressogenic exposures (e.g., taking
action against bullying)
Supportive psychotherapy , which
can be delivered in individual or
group formats, focuses on
teaching thoughts & behaviors
known to ameliorate depressive
symptoms.

42. Management…
• Two selective serotonin reuptake inhibitors (SSRIs), fluoxetine and escitalopram, are the
only antidepressants approved by the U.S. Food and Drug Administration (FDA) for the
treatment of depression in youth, and fluoxetine alone is approved for preadolescents.
• Fluoxetine should be considered first-line therapy among antidepressants unless other
factors (e.g., comorbidities, side effect profiles, personal/family history of response to a
specific medication) favor an alternative antidepressant.
• Considering both efficacy and tolerability findings, next-best choices may be
escitalopram (for adolescents) and sertraline (for children and adolescents).

43. Baseline symptom severity should
be assessed using a standardized rating scale.
The initial dose
of fluoxetine for moderate to severe major depressive disorder generally would
be 10 mg for children age 6-12 yr and 20 mg for adolescents age ≥13.
Clinical
response, tolerability, and emergence of behavioral activation, mania, or suicidal
thoughts should be assessed weekly (per FDA recommendation) for the 1st 4 wk.
If the youth has safely tolerated the antidepressant, the baseline standardized
symptom rating scale should be readministered to assess response to treatment.
Because of the high rate of recurrence, successful treatment should continue
for 6-12 month

44. Bipolar and related disorder
• The bipolar & related disorders include
Bipolar I
Bipolar II
Cyclothymic
Other specified/unspecified bipolar and
related disorders
Bipolar and
related disorder caused by another
medical condition.

45. Bipolar…
• Bipolar I disorder -must have at least 1 manic episode, and the episode must not be better
explained by a psychotic disorder. The manic episode may have been preceded and may be
followed by hypomanic or major depressive episodes.
• Bipolar II disorder- must have at least 1 hypomanic episode and at least 1 major depressive
episode. A hypomanic episode is similar to a manic episode but is briefer (at least 4 days) and
less severe (causes less impairment in functioning, is not associated with psychosis, and would
not require hospitalization). In bipolar II disorder, there must never have been a manic disorder.
• Cyclothymic disorder is characterized by a period of at least 1 yr (in children and adolescents) in
which there are numerous periods with hypomanic and depressive symptoms that do not meet
criteria for a hypomanic episode or a major depressive episode, respectively.
• Other specified/unspecified bipolar and related disorders (subsyndromal bipolar disorder )
applies to presentations in which symptoms characteristic of a bipolar and related disorder are
present and cause distress or functional impairment, but do not meet the full criteria for any of
the disorders in this diagnostic class.

46. Manic Episode [DSM-5]
• A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally
and persistently increased goal-directed activity or energy, lasting at least 1 wk and present most of the
day, nearly every day (or any duration if hospitalization is necessary).
• During the period of mood disturbance and increased energy or activity, 3 (or more) of the following
symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticeable
change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hr of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported
or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
(i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in
unrestrained buying sprees, sexual indiscretions, or foolish business investments).

47. Hypomanic episodes [DSM-5]

48. Management:
• The FDA has approved aripiprazole, risperidone, quetiapine, and asenapine for the
treatment of bipolar disorder from age 10 yr, and olanzapine from age 13 years.
• The choice of antipsychotic medication is based on factors such as side effect profiles,
comorbidities, adherence, and positive response of a family member.
• Among traditional mood stabilizer s, only lithium is FDA approved for the treatment of
bipolar disorder from age 12 yrs.
• Medication trials should be systematic and their duration sufficient (generally 6-8 wk)
to determine the agent's effectiveness.
• The regimen needed to stabilize acute mania should be maintained for 12-24 month.
• Antidepressants alone should not be prescribed for depressive symptoms in bipolar I
disorder because of the risk of manic switch. Olanzapine/fluoxetine combination in
youth with depression in bipolar I has been FDA approved in patients age 10-17 yr.
• Psychotherapy is a potentially important adjunctive treatment for the bipolar disorders