Anxiety Disorders in Young Children: Etiology, Epidemiology, Symptoms and Treatment - Klaus Minde, M.D. Professor of Psychiatry and Pediatrics ...

Anxiety Disorders in Young
     Children: Etiology,
Epidemiology, Symptoms and
         Treatment
             Klaus Minde, M.D.
    Professor of Psychiatry and Pediatrics
              McGill University
                  Montreal
                 October 2012

What I will talk about
 Recent findings about the epigenetic
    origins of psychiatric symptoms and the
    resulting brain plasticity
   the incidence of anxiety disorders in young
    children
   treatment approaches
   Cognitive Behaviour Therapy (CBT) as
    treatment of choice
   special challenges encountered in using
    CBT with young children

Traditional Concepts of Development
 Genetic and environmental effects are
  additive
 Genes and environment do not affect each
  other
                      YET
 Evolution means adaptation – hence must
  involve genes
 There is significant evidence of differential
  susceptibility to identical stress

Some Biological Parameters - Mother

 Maternal life experiences have an impact on
  maternal postnatal behaviour via regulation
  of the hypothalamic pituitary axis (HPA) and
  spatial working memory
 Higher diurnal cortisol levels are associated
  with lower executive functioning
 Both are associated with lower maternal
  sensitivity and lower parenting competence
            Remediation is possible
 Gonzalez et al. 2012

Path analysis model testing HPA function and spatial working
  memory as mediators in the association between early life
          experiences (ELE) and maternal sensitivity

 Gonzalez et al. 2012

Effects on the infant
 Important brain wiring takes place in late
  pregnancy and during infancy
 Early adversity (e.g., a stressed pregnant
  mother) can profoundly influence this
  wiring process
 Changes in the neurodevelopmental
  patterns are possible throughout life

Assumptions

 Environmental interventions can change
  gene expression
 Interventions will be more powerful
  during early life and in high risk
  conditions

Clinical Examples
 Better long-term outcome in autistic
  children receiving treatment before age 4
 Better long-term psychosocial outcome in
  individuals receiving treatment within 20
  weeks after the onset of psychosis
 Better response to SSRIs in depressed
  youngsters with < 14 weeks of symptoms

Early
   Environmental
    Experiences

Individual Differences
  in Stress Response

Individual Differences
  in Stress Response

      Risk of
  Psychopathology
(depression, anxiety)

In Rodents...
               Increased stress
               response
 Maternal
separation     Poor cognitive
               ability
 Complete
 maternal
               Impaired social
deprivation    behavior
               Hyperactivity

In Humans...
   Parental                   Low care and high
   Bonding                    control associated with
                              increased risk of
                              depression

  Abuse and                   Cognitive impairments
  /or neglect                 High risk of physical
                              and psychiatric
                              disorders

...these studies show strong correlations but do not
address the issue of causality

Postpartum Maternal Care in the Rat
                     9%

            6%
                                                         no contact

                                                   37%   licking

                                                         licking & arched-back
                                                         nursing
                                                         arched-back nursing

                                                         blanket nursing

      37%                                                passive nursing
                                              1%
                                        10%

Champagne et al., Physiology and Behavior, 2003

Frequency Distribution of Maternal Licking & Grooming
             of Female Rats (cumulative)
   300
              LOW LG                      HIGH LG

   200

   100

     0
         .5   3.0   5.5   8.0   10.5   13.0   15.5   18.0   20.5
                    % time spent licking/grooming pups

ADOPTION/CROSS FOSTERING STUDIES

biological mother     adoptive mother

     LOW                  HIGH

    HIGH                  LOW

% time spent licking/grooming

   16         *
   14                    *
   12
   10
    8
    6
    4
    2
    0
         Low- High- High- Low-
         Low High Low High

Summary
 Early environmental experiences can lead
  to epigenetic changes that result in long-
  term changes in gene expression and
  behaviour.
 Transmission of traits over generations
  can be achieved through epigenetic
  modifications

However, humans show
  differential susceptibility to
    identical environmental
stresses, leading to behavioural
            plasticity

Maternal Empathy and Externalizing Problems
     Moderated by Early Difficult Temperament

Pitzer et al. 2011

Rates of Anxiety Disorders:
Preschoolers compared with older children
Any anxiety dx

              PTSD

Specific phobia

 Social phobia

              GAD

              SAD

                     0%   2%   4%      6%      8%      10%

   2-5 year olds (PAPA study)
   5-17 year olds (median in studies from 1993 to present)
 Egger 2006

Roza et al. 2003

Definition

Anxiety disorders can be seen in their
 overt manifestations (e.g., phobias,
  obsessions)
 cognitive correlates
 physiological correlates (e.g., flight, fight)
 neurochemical correlates (e.g., amygdala)

A theoretical experimental paradigm (Pine 2007)

LeDoux 1994

Anxiety Spectrum Disorders

    Simple phobias
    Social phobia
    Separation anxiety disorder
    General anxiety disorder
    Panic disorder
    Agoraphobia
    Obsessive-compulsive disorder
    Selective mutism

Some epidemiological facts about
        anxiety disorders in children
 Commonly seen in young children (ca 10%)
 2 – 4 x more common in children of anxious parents
 2 – 4 x more common in very shy and inhibited
 children
However: only 50% of inhibited children develop
 pediatric anxiety disorders
Only 50% of anxious children will manifest adult
 psychopathology
Hence there are both genetic and environmental
 predeterminants for this condition

Prediction of infant mental health
   problems for adult DSM-IV disorders
                 24 yrs later

Reef et al. 2010

Preschool anxiety disorders are often
   comorbid with other disorders
   1+ anx dx                     1 anxiety
     and 1+                      disorder
    non-anx                         58%
       dx
      26%

   2 or more
    anxiety
   disorders
      16%

Egger 2006

Treatments

Basic principles of intervention
 Teach parents about intergenerational transmission of
    mental processes and their potential pathways
   Obtain history of parental past life events to establish
    mutual trust and respect
   Assess meaning of child’s behaviours to the caretakers
    and their willingness to modify them
   Associate parental representations of child with
    parental past life events (ghosts in the nursery)
   Elicit and elaborate different interpretations of the
    child’s intentions based on mutually observed
    behaviours
   Help parents modify their parenting strategies and
    discuss the observed results in the child’s behaviour

Wait, Watch and Wonder (WWW)
Infants are hardwired to relate to others and
  must create their individual life space.
  Parents have to recognize and respect this
  and support their infant’s autonomy.
Appropriate cases are infants with anxiety
  disorders and sleep or eating problems.
The parent observes the child for 30 minutes
  while sitting on the floor. Following that both
  the actual behaviour of the infant and its
  representational level are discussed.

Cohen et al. 1999

Wait, Watch and Wonder (WWW) 2
 Program is appropriate for infants aged 10 – 30
    months
   Mother watches baby for 30 minutes, then discusses
    what she saw for 30 minutes with the therapist
   Mother is asked to interact with the baby only when
    he/she initiates it
   Mother is asked to reflect infant’s attempts to master
    the world
   This will usually bring up personal issues of mother
   Program changes attachment patterns and parenting
    style

CBT
              Definition
CBT is a form of treatment which
  acts on thoughts to change feelings and
   behaviors
  concentrates on interplay between
   conscious thoughts and feelings
  derives from psychoanalysis, cognitive
   and behavioural psychology

CBT and psychodynamic treatments:
           Similarities
 Both
    are interested in patients’
     mental health
    promote insight
    explain mental structures
    recognize complexities of
     mental processes

CBT and psychodynamic treatments :
           Differences

 CBT
  Deals with “here and now”
  Short-term treatment
  Is more directive
  Includes psycho-education
  Committed to empirical testing

Challenges of CBT in Children

 CBT imposes an adult model of
  psychopathology on children
 Insufficient number of therapists
 Patients must participate (collaborative
  empiricism), BUT
    children are cognitively less mature
    secondary gains of being anxious

More challenges
 High rate of co-morbid conditions
  (~70%)
 Parental collusion (partly due to
  shared genetics)
 Reluctance to do CBT homework
 Cultural factors
 Parental reluctance to accept
  medication when necessary

 Develop concrete representations of anxiety
    to measure discomfort, using drawings,
    stories, and imagery
   Assess and explain impact of secondary
    gains and comorbidities to parents
   Have parents present during all CBT sessions
    and do continuous psycho-education
   Use “String Test“ to document the power of
    the brain
   Give well defined and acceptable homework

Other things to discuss with parents
 Incidence of anxiety disorders
 Its genetic aspects
 Cognitive distortions (e.g., selective
    attention, biased appraisal of attended
    material)
   Brain functioning in anxious children
   Comorbidities
   Specific sensitivities of anxious children
   Common management difficulties (e.g.,
    parental reassurance, praise)

How easily can traditional aspects of
  CBT be used in young children?

 Psychoeducation of parents          +++
 Somatic management
     Relaxation training              ++
 Exposure                            +++
 Cognitive restructuring:
     Labelling maladaptive thoughts     +
     Gathering evidence of
     maladaptive thoughts               --

More Data
 Biologically endowed emotional
  regulation ability is variable, (e.g., self-
  soothing, temperament)
 From 2nd year on, children can regulate
  emotions by distraction and bidding for
  attention
 At age 2-3, 80% can cooperate with office
  based relaxation + exposure talks +
  drawing feelings in the body
 (Scheeringa, 2006)

How to engage anxious young
       children emotionally

 Meet their developmental level (e.g.,
  language disorders, learning difficulties)
 Assess strength of emotions and
  emotional regulation
 Partner with caretakers
 Concretize abstract concepts

String test

www.maginationpress.com

Medication
 Is required in about 20% of anxious
  children
 Specifically, in severely anxious and
  biologically compromised children
 Safest drug available is Prozac (fluoxetine)
 Medication must be continued for 6
  months after loss of symptoms

Challenges For the Clinician

 60% of children seem totally well and don’t
  have to practice their newly learned skills
 Children with selective mutism need much
  time to change
 Children with associated language disorders
  need medication and recover less quickly
 Children with OCD often need medication

8 to 13 years follow-up of CBT for childhood anxiety disorders

       Saavedra et al. 2010

My Equipment
 Toys including doll house, various hand and
  finger puppets
 Drawing materials (twistables, felt pens)
 Plasticine, playing cards, dominos
 Private drawers for art work
 Floor to ceiling blackboard, coloured chalk
 Couch
 Cookies

Take-Home Messages

   CBT can be very helpful in treating
    young children with anxiety disorders
   Non-manualized CBT programs with
    extensive parent involvement are most
    helpful
   Some 20% of anxious children require
    medication to make full use of CBT

Thank You