Mood and Anxiety Disorders

Pediatric Mood & Anxiety: Mood Disorders - The Ups & Downs

• Major Depressive Disorder (MDD)
  • Irritability common (vs. sadness in adults); anhedonia, changes in sleep/appetite/energy.
  • Duration: ≥ 2 weeks of symptoms.
  • Screening: PHQ-9A (Adolescent).
• Persistent Depressive Disorder (Dysthymia)
  • Chronic depressed or irritable mood.
  • Duration: ≥ 1 year for children/adolescents (vs. 2 years for adults).
• Bipolar Disorder (BD)
  • Episodes of mania/hypomania (elevated/irritable mood, grandiosity, ↓ sleep, racing thoughts, risk-taking).
  • Often misdiagnosed as ADHD or ODD.
• Disruptive Mood Dysregulation Disorder (DMDD)
  • Severe recurrent temper outbursts (verbal/behavioral) inconsistent with developmental level.
  • Mood between outbursts: persistently irritable/angry.
  • Symptoms present for ≥ 12 months, in ≥ 2 settings.

  ⭐ DMDD cannot be diagnosed before age 6 or after age 18, and onset of symptoms must be before age 10.

• Management: Psychotherapy (CBT, IPT); Pharmacotherapy (SSRIs for depression; mood stabilizers/atypicals for BD). ⚠️ Monitor for suicidality with SSRIs (black box warning).

Pediatric Mood & Anxiety: Anxiety Issues - Worry Warts

• Generalized Anxiety Disorder (GAD): Excessive worry >6 months about various events/activities. Restlessness, fatigue, poor concentration, irritability, muscle tension, sleep issues.
• Social Anxiety Disorder (Social Phobia): Marked fear/anxiety about social situations where scrutiny by others is possible. Fear of negative evaluation. Avoidance of social situations.
• Separation Anxiety Disorder: Developmentally inappropriate, excessive fear/anxiety concerning separation from attachment figures. Distress, worry about harm to figures, reluctance to go out/sleep alone. Duration: ≥4 weeks in children/adolescents.
• Specific Phobia: Marked fear/anxiety about a specific object/situation (e.g., animals, heights, needles). Object/situation actively avoided or endured with intense fear. Duration: ≥6 months.
• Panic Disorder: Recurrent unexpected panic attacks. Abrupt surge of intense fear/discomfort. Followed by ≥1 month of persistent concern about additional attacks or maladaptive behavior change.

⭐ Selective mutism is characterized by a consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other situations, for at least 1 month.

• Management: CBT, SSRIs (e.g., fluoxetine, sertraline) often first-line pharmacotherapy if needed. Family therapy and school involvement crucial. 📌 SAD Separation Anxiety Disorder (commonest).

Pediatric Mood & Anxiety: OCD & Trauma - Stuck & Shaken

• OCD (Obsessive-Compulsive Disorder):
  • Obsessions (recurrent, intrusive thoughts) & Compulsions (repetitive behaviors/mental acts).
  • Causes significant distress or functional impairment.
  • Consider PANDAS for abrupt, dramatic onset of OCD symptoms.
• Trauma- & Stressor-Related Disorders:
  • Exposure to actual or threatened death, serious injury, or sexual violence.
  • PTSD (Post-Traumatic Stress Disorder): Symptoms >1 month.
    • Key features: Intrusion, avoidance, negative mood/cognition, arousal changes.
  • Acute Stress Disorder (ASD): Symptoms last 3 days to 1 month post-trauma.

⭐ For a diagnosis of PTSD in children 6 years and younger, specific criteria include spontaneous and intrusive memories that may not appear distressing and may be expressed as play reenactment.

Pediatric Mood & Anxiety: Dx & Rx Plan - Spotting & Supporting

• Assessment:
  • Multi-informant (child, parent, school).
  • Scales: SCARED, PHQ-9A.
  • Rule out organic: Thyroid, anemia.
• Management Plan:
  • Psychoeducation: Family crucial.
  • Therapy: CBT, IPT (first-line).
  • Meds: SSRIs (severe/refractory).
    • Start low, go slow.
    • ⚠️ Monitor for ↑ suicidal thoughts.
  • Support: School, regular F/U.

⭐ Fluoxetine is FDA-approved for Major Depressive Disorder in children aged ≥8 years and for Obsessive-Compulsive Disorder in children aged ≥7 years.

High‑Yield Points - ⚡ Biggest Takeaways

• SSRIs (Fluoxetine) are first-line for pediatric depression and anxiety.
• Separation Anxiety Disorder: Excessive distress on separation from attachment figures.
• School refusal may indicate underlying anxiety or mood disorders.
• DMDD: Chronic irritability and frequent, severe temper outbursts.
• Always assess suicide risk in adolescents with mood disorders.
• CBT is effective non-pharmacological therapy for anxiety/mild depression.
• Note FDA black box warning: ↑ suicidal ideation with antidepressants in youth.