Transcript Slide 1

Anxiety and Depressive Disorders
Child and Adolescent
Historical Context:
 Separation anxiety disorder (DSM-III-R)
 Overanxious disorder (DSM-III-R)
 Avoidant disorder (DSM-III-R)
 Only separation anxiety disorder now
1) Dysregulation of normal response
2) Intense, disabling worry that does not
help to anticipate true future danger
3) Intense fear reactions in the absence
of a true threat
Primary and Secondary features of anxiety
• Primary: not specific to any particular
• Secondary: content features of specific
anxiety disorders:
SAD: worry about separation from parents
Social anxiety disorder: interpersonal
Panic disorder: uncued panic attacks
5) Expression of anxiety: behavioral,
cognitive, physiological, social
6) High degree of comorbidity
 Short-term prevalence: 2-4%
 Lifetime prevalence: 10-20%
Risk Factors
Biological processes:
1) Behavioral approach
system: involved in
approach behaviors
2) Behavioral inhibition
system: anxiety to
novelty or impending
punishment and
Risk Factors
 Hypothalamic-pituitary-adrenal axis (HPA) axis: release
of cortisol, which regulates behavioral and emotional
Risk Factors
 Cortisol secretion
protects when exposed
to danger
 Prolonged exposure is
neurotoxic and related
to anxiety:
• “D” attachment
• Maltreated children
diagnosed with PTSD
Risk Factors
Genetic Influences:
1) 33% of variance
accounted for by
• avoidance behaviors
2) Temperamental
inhibition: avoidance of
novelty, dependence on
parents, fearfulness,
autonomic hyperarousal
Risk Factors
1) Anxiety sensitivity: belief
that anxiety sensations (e.g.
heart beat awareness, increased
heart rate, trembling, shortness of
have negative social,
psychological, or physical
2) Interpretation of arousal
symptoms influence
experience of anxiety
Behavioral Learning Processes
Six Pathways:
1) Classical aversive
conditioning (Wolpe & Rachman,
Exposure to traumatic
25-55% of maltreated
children develop PTSD
Pre-existing trait anxiety
or D attachment?
Behavioral Learning Processes
2) Vicarious acquisition through
observational learning or modelling
(Bandura, 1982)
3) Verbal transmission of information
4) Operant conditioning
(Mowrer, 1960): withdrawal
negatively reinforced by
reduction of anxiety
Behavioral Learning Processes
5) Stages in cognition: encoding, interpretation,
a) interpretation and memory biases
b) attentional selectivity: over-allocating intellectual
resources toward threat
6) Lack of control over external and
internal threats: affect dysregulation
because events and sensations are
Social and Interpersonal Processes
Attachment theory: anxiety related to insecure
relationships to primary caregiver
Separation anxiety disorder related to C attachment
Overcontrolling parental behaviors influence childhood
prevent children from facing fear-provoking events
conveys message that fear-provoking events are threatening
• Short allele for serotonin transporter X low social
support  behavioral inhibition
Developmental Progression
(heterotypic continuity)
• Childhood anxiety
disorders are correlated
with adult anxiety and
depressive disorders
• Anxiety content related to
separation or loss of
parents (6-9 years old)
mortality, broader
concerns (10-13 years old)
social and performance
concerns (adolescence)
1) ADHD: 0-21%
2) CD and ODD: 313%
3) Depression: 120%
• Collectivist societies
expect conformity
and social inhibition,
increasing anxiety
• Control of emotions
stifles children's
understanding and
managing of internal
Sex Differences
Girls to boys: 2:1 ratio
Higher heritability estimates for girls than boys
Girls more willing to report symptoms
Girls more likely socialized to internalize
Theoretical Synthesis
1) Dysregulation of
anxiety response
2) Negative affect and
from physiological
3) Contents of anxiety are
developmentally based
Depressive Disorders
Depression is characterized by equifinality and
Controversies in diagnosis of depression:
• Continuity: childhood depression does not predict
adolescent or adult depression
• Discreteness and boundaries
• depression is continuous
• are thresholds too narrow or two broad?
• adolescents have normal negative mood states
a) Unipolar versus bipolar disorder
b) Psychotic versus not psychotic
c) Course (e.g. age of onset, recurrent or chronic, seasonal)
Age-specific manifestations
• Younger children might appear sad but do not
report their mood
• Pre-pubertal children might
lose interest in friends,
not libido
• Depression in very young children:
a) shorter duration requirement
b) modified DSM-IV criteria
 Low concordance among informants
 Self-reports more valid than reports by other informants
 Parents' reports more valid for children than adolescents
 Preschool children: 3 to 6 month prevalence = 1-2%
 Adolescents: lifetime prevalence = 15-20% (like adults)
Sex Differences
1) Biological changes in hormones
(increases in estrogen and testosterone)
2) Physical changes associated with body
3) Adolescent females experience more
interpersonal stress than adolescent
4) Adolescent females have greater preexisting vulnerabilities than males
adolescent females have greater
affiliative needs than males
adolescent females cope with adversity
in passive, ruminative way, while
adolescent males cope in active, avoidant
• Comorbidity might represent
a different disorder (e.g.
MDD and CD)
• Common etiological factors
between the two disorders
• Causal influence of one
disorder over another (e.g.
anxiety in childhood predicts
depression in adulthood)
Course and Outcome
Mean duration of MDD: 7-8 months
Mean duration of DD: 48 months
Double depression: superimposed episodes of MDD in
40-70% of depressed adolescents experience MDD in
Predictive of recurrence: severity, psychotic symptoms,
suicidality, DD, subthreshold symptoms, depressotypic
cognitive style, recent stressful life events, adverse
family environments, family history of MDD
Risk Factors
a) Genetics plays a greater
role in adolescent and adult
depression than childhood
b) Reuptake of serotonin
c) Brain-derived
neurotrophic factor (BDNF)
Risk Factors
d) Passive geneenvironment correlations:
genotype and
environments are
e) Evocative geneenvironment correlations:
genotype evokes
reactions in others
f) Active gene-environment
correlations: genotype
Risk Factors
g) Genes interact with environment to
increase susceptibility to stress (diathesisstress hypothesis)
h) Environment influences expression and
regulation of genes (epigenesis)
i) Genes  Temperament
( negative emotionality,  positive
emotionality  depression)
Risk Factors
Maladaptive parenting and abuse:
a) Low parental warmth, high intrusiveness
b) Childhood depression:
low emotional support, abuse,
family stress
a) Adolescent depression: early lack of
emotional support
Risk Factors
Biological Factors:
a) Neuroendocrinology – dysregulation of HPA
axis   cortisol production
b) Sleep architecture – increased REM density
c) Neurotransmitters – dysregulation of serotonin
and norepinephrine
d) Structural and functional brain correlates
1. smaller frontal white matter volume
2. larger frontal grey matter volume
3. larger left PFC white matter volume
Risk Factors
Cognitive factors:
a) Memory biases for
negative information
b) Low self-esteem,
self-efficacy, selfperceived
c) Are these factors
antecedents or
Risk Factors
Peer Relationships:
a) Peer rejection
b) Social skills deficits
c) Are these factors antecedents or sequalae?
Risk Factors
Life Stress:
a) Triggers depression in
children with pre-existing
b) Depression can produce
impaired functioning, which
produces stress
c) Negative interpersonal
life events are particularly
potent risk factors
Protective Factors:
Variables that
reduce risk in highrisk contexts:
1) Presence shifts
high-risk trajectory
in a more positive
2) Absence has no
influence on risk