Children are at high risk of emotional disorders. These have become the most common reasons for their visits to the psychiatrist. They include mood disorders, anxiety disorders, and trauma and stress-related disorders. This slide explains each of these in details. Enjoy

1. Emotional disorders in
children
Dr. Kaggwa Mark Mohan

2. Outline
•Mood disorder
• Major depressive disorder (MDD)
• Disruptive mood dysregulation
disorder
• Premenstrual dysphoric disorder
• Bipolar disorder
•Anxiety disorders
• Separation anxiety disorder
• Social anxiety disorder
• Selective mutism
• GAD
• Specific phobia
•Truama and stressor related
disorders
• PTSD
• Reactive attachment disorder
• Disinhibited social engagement
disorder
• Acute stress disorder
• Adjustment disorder

3. Mood disorders
• Major depressive disorder (MDD)
• Disruptive mood dysregulation disorder
• Premenstrual dysphoric disorder
• Bipolar disorder

4. Epidemiology
•Pre-pubertal 1-2% (no gender difference)
•Post pubertal 4 – 18% (F:M = 2:1)
•Peak prevalence of depression is at adolescence
•Prevalence 2.8 in children below 13 yrs (Chee. et.al., 2020)
• 5.6% between 13 and 18 yrs

5. Etiology
• Biological
• genetic:
• 65-75% MZ twins & 14-19% DZ twins
• 2-4 fold increased risk in first-degree relatives
• neurotransmitter dysfunction:
• Decreased activity of 5-HT, NE, and DA at neuronal
synapse
• Changes in GABA and glutamate
• Various changes detectable by fMRI
• Neuroendocrine dysfunction: Abnormal HPA axis
activity
• Neuroanatomy and neurophysiology:
• Decreased hippocampal volume, increased size of
ventricles
• Deceased REM latency and slow-wave sleep
• Increased REM length
• Immunologic:
• Increased pro-inflammatory cytokines IL-6 and TNF
• secondary to medical condition, medication,
substance use disorder
• Psychosocial
• Psychodynamic e.g.
• low self-esteem
• Unconscious aggression towards self or loved ones
• Disordered attachment
• Cognitive e.g.
• Distorted schemata
• Beck’s cognitive triad: negative views of the self, the
world, and the future
• Environmental factors e.g.
• Punishment from school
• Bereavement
• History of abuse or neglect
• Early life adversity
• comorbid psychiatric diagnoses e.g.
• Anxiety
• Substance abuse
• Developmental disability
• Eating disorder

6. MDD
•Risk factors
• sex: F>M, 2:1
• Family history: depression, alcohol abuse, suicide attempt or
completion
• Childhood experiences: loss of parent before age 11, negative home
environment (abuse, neglect)
• Personality (among adolescents) and temperament
• neuroticism, insecure, dependent, obsessional
• Recent stressors: illness, financial, legal, relational, academic
• lack of intimate, confiding relationships or social isolation
• low socioeconomic status

7. Clinical presentation
• Same diagnostic criteria as for
adults
• Symptoms include
• Irritability or anger
• Continuous feelings of sadness and
hopelessness
• Social withdrawal
• Increased sensitivity to rejection
• Changes in appetite -- either
increased or decreased
• Changes in sleep -- sleeplessness or
excessive sleep
• Vocal outbursts or crying
• Difficulty concentrating
• Fatigue and low energy
• Physical complaints (such as
stomachaches, headaches) that
don't respond to treatment
• Reduced ability to function during
events and activities at home or with
friends, in school, extracurricular
activities, and in other hobbies or
interests
• Feelings of worthlessness or guilt
• Impaired thinking or concentration
• Thoughts of death or suicide

8. Clinical presentation
• Only difference in diagnostic criteria
is that irritable mood may replace
depressed mood
• Physical factors:
• Insomnia (children)
• Hypersomnia (adolescents)
• Somatic complaints
• Substance abuse,
• Decreased hygiene
• Psychological factors:
• Irritability
• Boredom
• Anhedonia
• Low self-esteem
• Deterioration in academic
performance
• Social withdrawal
• Lack of motivation
• Listlessness
• comorbid diagnoses
• Anxiety
• ADHD
• ODD
• IED
• Conduct disorder
• Eating disorders

9. Treatment
Note
• Majority never seek treatment
• Psychotherapy
• Individual (CBT, IPT)
• Family therapy and education
• Modified school program
• Pharmacotherapy
• SSRIs:
• Strongest evidence for fluoxetine.
• Escitalopram and sertraline would be
second line medications of choice
• Close follow-up for adolescents starting
SSRIs to monitor for increased suicidal
ideation or behaviour
• In severe depression, best evidence
for combined pharmacotherapy
and psychotherapy
• ECT:
• Only in adolescents who have severe
illness, psychotic features, catatonic
features, persistently suicidal
• Internet based psychotherapy
• light therapy
• Self-help books

10. Prognosis & complications
•Prognosis
• Prolonged episodes, up to 1-2 yr
• Adolescent onset predicts chronic mood disorder; up to 2/3 will have
another depressive episode within 5 yr
• Median duration with symptoms of depression is 7 – 9 months
(Chee. Et.al., 2020)
• Relapse more among children with early onset
•Complications:
• Negative impact on family and peer relationships
• School failure significantly increased risk of suicide attempt (10%) or
completion (however, suicide risk low for pre-pubertal children)
• Substance abuse

11. DISRUPTIVE MOOD DYSREGULATION DISORDER
Clinical Presentation
• Severe, developmentally inappropriate, recurrent verbal or
behavioural temper outbursts at least 3 times per week
• Mood is predominantly irritable or angry in between outbursts, as
observable by others
• These symptoms occur before 10 yr, have been occurring for 12
month, with no more than 3 consecutive month free from symptoms
• high rates of comorbidities;
• ADHD
• ODD
• Anxiety disorders,
• Depressive disorders

12. Premenstrual Dysphoric Disorder
• In the majority of menstrual cycles, at least five symptoms must be
present in the final week before the onset of menses, start to improve
within a few days after the onset of menses, and become minimal or
absent in the week post menses.
Symptoms
• One (or more) of the following symptoms must be present
• Marked affective lability (e.g., mood swings: feeling suddenly sad or tearful,
or increased sensitivity to rejection).
• Marked irritability or anger or increased interpersonal conflicts.
• Marked depressed mood, feelings of hopelessness, or self-deprecating
thoughts.
• Marked anxiety, tension, and/or feelings of being keyed up or on edge.

13. Premenstrual Dysphoric Disorder
• One (or more) of the following symptoms must additionally be present,
to reach a total of five symptoms when combined with symptoms from
above.
• Decreased interest in usual activities (e.g., work, school, friends, hobbies).
• Subjective difficulty in concentration.
• Lethargy, easy fatigability, or marked lack of energy.
• Marked change in appetite; overeating; or specific food cravings.
• Hypersomnia or insomnia.
• A sense of being overwhelmed or out of control.
• Physical symptoms such as breast tenderness or swelling, joint or muscle
pain, a sensation of “bloating,” or weight gain.

14. BIPOLAR DISORDER
•Presentation almost similar to adult presentation
Unique presentation include
• Mixed presentation and psychotic symptoms (hallucinations and
delusions) more common in adolescent population than adult
population
• Unipolar depression may be an early sign of adult bipolar disorder
• ~30% of psychotic depressed adolescents receive a bipolar diagnosis
within 2 yr of presentation
• Associated with:
• Rapid onset of depression
• Psychomotor retardation
• Mood-congruent psychosis
• Affective illness in family
• Pharmacologically-induced mania

15. BIPOLAR DISORDER
Treatment
• pharmacotherapy:
• mood stabilizers and/or antipsychotics
• Second generation antipsychotics better for adolescents
• psychotherapy:
• CBT,
• Family Focused Therapy

16. Anxiety Disorders

17. Epidemiology
• lifetime prevalence 10-20%; F:M = 2:1

18. Anxiety Disorders
List in order of common occurrence
Separation anxiety disorder (SepAD)
Generalized anxiety disorder (GAD)
Social anxiety disorder (SocAD)
Selective mutism (SM)
Specific phobias (SP)
Panic disorder (PD)
Agoraphobia

19. Specific phobia
Marked by meaningful and disproportionate fear when the youth
encounters a specific object or situation.
The specific object or situation almost always is associated with
marked fear and results in avoidance or extreme distress if it
cannot be avoided
Common categories of SP
•Animals/insects (e.g., bees, dogs)
•Darkness
•Blood-injection-injury type (e.g., needles, shots)

20. Specific phobia
Example
• If a child is afraid of spiders and requests a parent to come kill spiders
when present in the house
• This fear does not necessarily warrant a diagnosis of SP as it is not
necessarily resulting in avoidance or extreme distress
• If, however, this child refuses to go back into the room in the house
where there was a spider a few days ago even if it has been killed
or
• If he or she is excessively distressed by a family hike – crying
hysterically and experiencing an elevated heart rate – as there may be
a spider in the woods along the hike, this avoidance and distress
(respectively) indicate a clinical diagnosis may be warranted

21. Youth Social anxiety disorder
•Experience anxiety surrounding how they will be perceived by
others in social situations.
•They often avoid social situations or endure them with great
distress due to concerns that they will be rejected or laughed at
by others
•A youth must almost always experience persistent anxiety in a
variety of social situations and experience symptoms
Symptoms include
• Difficulty asking questions in class
• Starting or joining conversations
• Ordering for oneself at a restaurant
• Eating in front of others
• Attending social events such as birthdays or parties

22. Separation anxiety disorder
•Excessive and developmentally inappropriate anxiety when
separating from a parent or other attachment figures
•This diagnosis is not given to children under the age of six as
trouble separating from attachment figures is seen as
developmentally normative until this point
•Youth often worry about potential harm to oneself or one’s
parents when separated
•Avoidance of being alone
•Refusal to go to certain places without one’s parents
•May have nightmares with separation them

23. Separation anxiety disorder
•Have trouble going to sleep alone or in their own room
•Refuse to go to school due to their distress surrounding
separation
•Wish to contact their caregivers (e.g. frequent calls or text)
when caregiver is not present
•Associated with anxiety symptoms when a youth
experiences/anticipates separation
Note
• With other disorders such as social disorders the parents may serve
as safety figures for the youth and may have symptoms as separation
disorders but they feels unsafe rather than finding the attachment
unsafe.

24. Generalized anxiety disorder in youth
•Associated with excessive and persistent worry about various
topics including academics, changes in plans, perfectionism,
performing up to a high standard, local or world affairs, and the
future
•To receive a diagnosis of GAD
• Youth must have persistent symptoms that occur more days than not
• Experience the worry as difficult to control
• Have at least one associated physical or behavioral symptom such as
muscle tensions, irritability, or excessive reassurance seeking
behaviors

25. Generalized anxiety disorder in youth
•Children and adolescents with GAD may engage in other related
behaviors such as:
• Avoiding doing something that may not work out how they want it
to
• Redoing work to perfection,
• Procrastinating due to anxiety about the task
•The worry is inappropriate as compared to peers in same
situation

26. Selective mutism
•Characterized by a failure to speak in certain, specific social
situations not attributable to a lack of knowledge or comfort
with the spoken language
•They have full ability to speak and can do it in some places e.g.
at home
•To meet diagnosis, the mutism should be able to affect
functioning
•Sm is typically comorbid with SocAD

27. Treatment of anxiety disorders
•CBT
•Involves
• Psychoeducation
• Relaxation training
• Cognitive restructuring
• Problem solving
• Exposure to anxiety-
provoking situations
•Programs
• The coping cat program
• Cool kids program
•SSRI
•Gold standard for youth that
don’t respond to CBT
•Common drugs
• Sertraline, fluvoxamine,
paroxetine, and venlafaxine
•Treatment response
•55% (SSRIs alone)
•60% (CBT alone)
•80% (SSRIs and CBT
combined)

28. Other treatment options
•Parent programs
• The child anxiety tales (copy cat for parents)
• Makes the parent feel empowered and more knowledgeable about their
children's anxiety
• Parent-Child Interaction Therapy (PCIT)
• More like CBT for the parents
• In this therapy, the parent-child interaction is changed in order to improve
the child’s behavior
• Adopted from methods used in treating disruptive behaviours
• The SPACE Program (Supportive Parenting for Anxious Childhood
Emotions)
• only intervention that targets the accommodating behaviors of the parents
that are related to the youth’s anxiety

29. Other treatment options
•Acceptance
•Mindfulness
•Meditation based interview
•Art therapy
•Music therapy
•Play therapy
•Benzodiazepine
• Have produced mixed findings about their efficacy
• Common drugs include
• Alprazolam
• Clonazepam

30. School refusal

31. Reasons for school refusal
•To escape from school situations that cause distress (e.g. Riding
on the school bus, a teacher, or a particular class or area of
school)
•To escape from unpleasant social or performance situations
(e.g. Playing or working with peers, speaking or reading in front
of the class, or attending assemblies)
•To get attention from others (e.g. To spend time with a parent)
•To pursue fun activities outside of school (e.g. To spend time
with friends, go to the mall, or to be home alone sleeping,
watching TV, etc.)

32. School refusal
•Not a DSM V diagnosis
•It’s a described symptom of other disorders such as
• Anxiety disorder
• Generalized anxiety disorder
• Specific phobia
• Major depression
• Oppositional defiant disorder
• Post-traumatic stress disorder
• Adjustment disorder, etc.

33. Epidemiology
•Approximately 2% to 5% of all school-aged children have school
refusal
•The incidence is similar between boys and girls
•Although school refusal occurs at all ages, it is more common in
children ages 5 to 6 and 10 to 11 years of age
•The longer a child is out of school, the harder it is to return
•No socioeconomic differences have been noted

34. Reasons for school refusal
•To escape from school situations that cause distress (e.g. Riding
on the school bus, a teacher, or a particular class or area of
school)
•To escape from unpleasant social or performance situations
(e.g. Playing or working with peers, speaking or reading in front
of the class, or attending assemblies)
•To get attention from others (e.g. To spend time with a parent)
•To pursue fun activities outside of school (e.g. To spend time
with friends, go to the mall, or to be home alone sleeping,
watching TV, etc.)

35. FACTS
•More than ¼ of all youth will engage in some degree of school
refusal during their schooling years, ranging from complaints
and threats to avoid school, to missing school for months or
even years at a time.
•Fear or a specific phobia about something at school only
accounts for a small percent of youth refusing school
•School refusal peaks at several points of development, including
with entry into Kindergarten, and again with entry into Middle
or High School.
•Boys and girls are equally affected by school refusal behaviour.

36. SIGNS & SYMPTOMS
Thoughts (Note: very young children may
be unable to identify specific fear
thoughts)
• I’m no good at school anyway
• It’s more fun at the mall/being at
home where I can do what I want
• It’s not fair that I have to go to
school. I want to stay home with
mum and the new baby
• The other kids will laugh at me
• What if grandma doesn’t pick me up
after school?
• What if I can’t find my classroom?
Physical feelings:
• Dizziness or light headedness
• Frequent urination and/or diarrhea
• Headaches
• Muscle tension
• Racing heart
• Shaking or trembling
• Shortness of breath or
hyperventilation
• Stomachaches or abdominal pain
• Vomiting

37. SIGNS & SYMPTOMS
Emotions:
• Anger
• Anxiety/worry/fear
• Embarrassment
• Irritability
• Loneliness
• Sadness
• Shame
Behaviors:
• Clinging or refusal to separate from a
parent
• Complaining
• Crying or tantrums
• Failing to turn in homework or assignments
• Frequent phone calls or texts to a parent
• Lying
• Running away or hiding
• Skipping class or cutting school
• Trouble concentrating
• Withdrawal from others

38. COMMON SITUATIONS OR AFFECTED AREAS
•Falling or failing grades
•Family disruption
•Marital strain
•Peer rejection
•Poor sleep
•Reduced job or career prospects
•School absenteeism
•Sibling discord

39. Treatment
• Multidisciplinary approach
• Cognitive behavior therapy
• Educational-support therapy
• Pharmacotherapy
• SSRI
• Short duration of benzodiazepines
• Parent-teacher interventions
• Treatment of underlying psychiatric
illness
• Behavior treatments
• Relaxation training
• Systematic desensitization (that
is graded exposure to the school
environment)
• Emotive imagery
• Social skills training
• Contingency management
• Dialectical behavior therapy (DBT)
• Based on 4 skill modules
• 2 sets of acceptance-oriented skills
(mindfulness and distress tolerance)
• 2 sets of change-oriented skills (emotion
regulation and interpersonal effectiveness)
• Treatment of family dysfunction
• Physicians avoid writing notes that
request children to stay out of school

40. Truancy
•Excessive anxiety or fear about attending school are not
commonly seen; rather child often tries to conceal absence
from parents
•Antisocial behavior such as delinquent and disruptive acts, for
example, lying and stealing, are frequent in the company of
antisocial peers.
•The child frequently does not stay home during school hours.
•Anxious school refusal and truancy are distinct but not mutually
exclusive and are significantly associated with psychopathology
as well as adverse experiences at home and school.

41. Elimination disorders

42. Elimination disorder
•Involve the inappropriate elimination of urine or feces and are
usually first diagnosed in childhood or adolescence.
They includes
• Enuresis
• The repeated voiding of urine into inappropriate places
• Subtypes
• Nocturnal (monosymptomatic) from diurnal (i.e., during waking hours) voiding for
enuresis
• Encopresis
• The repeated passage of feces into inappropriate places
• subtypes
• Presence or absence of constipation
• Overflow incontinence

43. Enuresis

44. Subtypes
•monosymptomatic enuresis(nocturnal only enuresis)
• Most common type
• Typically occurs in the first 1/3 of the night (REM sleep)
• Recall dreams when going to urinate
•Diurnal only subtype (urine incontinence)
• Urge incontinence
• sudden urge symptoms and detrusor instability
• Usually persist despite infection treatment
• voiding postponement
• consciously defer micturition urges until incontinence results
• Associated with social phobias or preoccupation with activities
• Most commonly occurs in the early afternoon on a school day
• May be associated with symptoms of disruptive behaviours
•noctumal-and-diurnal subtype (monosymptomatic enuresis)

45. Epidemiology
•5%-10% among 5-year-olds
•3%-5% among 10-year-olds
•Around 1% among individuals 15 years or older
•Risk similar in both male and female
•No cultural differences identified

46. Causes
•An inability to concentrate urine at night
• a lack of the normal circadian rhythm-induced increase in the
production of arginine vasopressin, a pituitary hormone
•Bladder overactivity
• Causes detrusor muscle contracts suddenly and unexpectedly before
the bladder is full resulting in reduced functional, rather than
anatomical, bladder capacity
•A failure to wake to bladder signals.

47. Risk factors
• Environmental factors
• Delayed or laxed toilet training
• Psychological stress
• Delayed development of normal circadian rhythm of urine production
• Normal polyuria
• Abnormalities of central vasopressin receptor sensitivity
• Reduced functional bladder capacities with bladder hyperreactivity (unstable
bladder syndrome)
• Genetics
• Nocturnal enuresis is a heterogenous disorder
• Risk is
• 3.6 times higher in offspring of mother with nocturnal enuresis
• 10.1 times in the presence of paternal h/o urinary incontinence

48. Comorbidities
•Developmental delays
•Encopresis
•Sleepwalking
•Sleep terrors
•UTI
•ADHD
•ODD
•Autism

49. Comorbidities
•Diabetes
•Constipation
•Full bladder compresses the rectum and cause
irritation hence overactivity
•Obesity
•6 times at risk of Enuresis
•Depression
•Secondary enuresis
•If it starts after six months of continuous dry nights
•Associated with organic or psychological problems

50. Effects
•Social anxiety
•Bullying
•Low self esteem
•Poor performance in school
•Depression
•Punishments

51. Key notes
•The child and family should be provided with explanations
about the cause of the condition so that they understand that
wetting is not the child’s fault and therefore punishment is
inappropriate.
•Treatment should be adjusted according to the needs and
preferences of the individual child and family.
•Children younger than seven years should not be excluded from
treatment solely because of their age.

52. Assessment
•When the wetting started.
•How many nights a week.
•How many times a night it happens.
•The volume of urine that appears to be passed.
•If the child wakes after voiding at night.
•How often do you empty your bladder and bowel during
day/night
Note
oThese questions may increase parental intolerance if they believe the
child is waking before voiding. This should be addressed, as should
any other concerns.

53. Assessment
•History to assess over activity over the bladder
• Time, type and volume of drinks
• Time and quantity of voids (the child will need to pass urine into a
receptacle, so that it can be measured),
• Any wetting or dampness
•Estimates of the expected bladder capacity
• (age in years + 1) x 30 = EBC in mL
• Compare to the total volume voided in a day vs intake
•Bowel overactivity
• Should also be assessed

54. Intake and passing advise during management
•Passing advice
•Passing urine on waking
•Twice during school hours
•After school
•At about the time of the evening meal
•Just before sleep
•Other advice
• Waking the child to go the toilet in the night
• Reward system limited to only benefits

55. Intake and passing advise during management
•Intake
•Encouraged with water-based daytime fluid intake
•Advised to avoid fizzy and caffeinated drinks as these can
cause bladder overactivity and diuresis
•Avoid drinks in the last hour of bed
•High protein and high salt foods should be avoided especially
in the evening

57. Treatment (incase advise fails )
•Alarms
• Requires parents cooperation
• More effective in children with reduced bladder capacity
• Treatment is continued until child has 12 consecutive dry nights
• Children on this treatment, should be reviewed monthly
•Desmopressin
• A synthetic analogue of arginine vasopressin
• Reduces overnight urine production and is most likely to be helpful
for children with nocturnal polyuria
• Given to children 5 yrs and above requiring rapid improvement
•TCA

58. Encopresis

59. Subtypes
•Feces in the with constipation and overflow incontinence
• Feces are poorly formed
• Leakage can be infrequent to continuous
• Occurring mostly during the day and rarely during sleep
• Only part of the stool is passed during toileting
• Constipation treatment resolves incontinence
•without constipation and overflow incontinence
• Normal formed feces
• soiling is intermittent
• Feces may be deposited in a prominent location
• Associated with ODD & CD
• May be a consequence of anal masturbation
• Less common subtype

61. Associated features supporting diagnosis
•School refusal
•Low self esteem
•Punishments and its associated complication
•Smearing feces on walls or other surfaces
• An attempt to clean or hide the feces passed involuntary
•Deliberate incontinence
• Present in children with CD, ODD
•Associated constipation have urine reflux in the bladder and
enuresis

62. Epidemiology
•1- 4% of children age 5 years have encopresis
•1-2% in children at 7 years
•1.6% in children 10 -11 years
•More in male than females (3 to 6 times more in boys)

63. Developmental course
•Diagnosis not made until the chronological age of 4
•Predisposing factors
• Inadequate or inconsistent toilet training
• Psychological stress e.g.
• Entering school
• Birth of a younger sibling
• Bullying
•Types
• Primary
• Patient has never had proper fecal continence
• Secondary
• After an established period of fecal continence

64. Causes
•Abnormality in anorectal motility and sensation
•Defecation involves both voluntary and involuntary actions
•Needs signals from pelvic flow and the nervous system
•The nerves involved need to have completely finished
myelination
• Complete by 18 months though earlier in girls
•Genetics
•Noted positive family history
•Mental retardation
•Psychiatric conditions

65. Evaluation
• Under go thorough physical and neurological examinations

66. Treatment
•laxatives
•Education
•Toilet training
•Positive motivation