Assessing Anxiety and Depression in Kids
For the sake of simplicity, I’ll be discussing anxiety and depression with males vs females and other considerations. A huge factor with mood disorders is the age (before puberty) or little kids who usually don’t have the words to express themselves. Therefore, symptoms can physically be seen as grumpy, hyper, body “hurts”, frowns, crying spells, anger, throwing objects…etc. A small child will not naturally say “I’m depressed, I can’t focus, or I’m guilty”…etc. so the social and behavioral cues are important.
Quick side bar: the DSM-5 criteria for depression and anxiety is assumed for all ages.
Behavioral modifications/therapy can help with these symptoms but when should the provider be concerned enough to medicate? Here are personal thoughts because most people, including providers, are against medicating a young child, so hopefully, this criteria is useful:
- Poor behavior is consistently unprovoked or unpredictable: yelling for hours means the child is not able to learn or process information (because they can’t stop screaming). Regulating the emotions are also important, because when there is a real problem, it can be taken serious (as opposed to crying wolf).
- The mood is affecting the quality of life (QOL): if the child is constantly getting punished due to bad behaviors, frequently isolated (constantly in time-out), or unable to play… it can affect the child’s development and make the child’s mood/emotions get worse. Yes, do not reward bad behaviors, but discussed with the family how the consequences will also affect the emotional development (like someone who’s been institutionalized).
- The child is shutting down, less engaged, or motivated: this is when I’m the most concerned because the child needs to be properly developing, it’s similar to me as a failure to thrive diagnosis… again I’m worried about delays that may permanently affect the child or require intensive treatment.
Overall, who knows why a 4y/o gets angry? It could be a billion reasons but when a child is not able to play, have fun, express themselves, and get isolated that’s going to cause more distress. Depression and anxiety may occur regardless of whether things are good or bad but people usually can’t differentiate and this is when psychiatric care becomes stigmatized and challenging.
Parents will ask well how can a child be depressed? or they got all A’s on the report card so I don’t know why there are any problems…etc. and that’s true! stuff can be manage and do well without extra interventions. However, when the child is shutting down, less engaged, moody, etc. it could be that the entire world is telling the kid to smile when anxieties and depression are more than just feelings or a particular face. Truly look at the child’s QOL and the key points above are a great reason to start medications.
In the assessment, everything should be ruled out as much as possible before starting on medications but you only have like 10min to decide in reality. There are so many options and directions but my best tip is to go from little to bigger changes and that’s with diagnosis and medications.
Usually you want to start treating one problem at a time, but if the child is very hostile, I start treating the aggression/ODD first or if the child is non-threatening, I generally assess for ADHD. There are many situations where the child presents with both diagnoses, but try to treat the worse dx first to not mix/confused the treatment plan or to avoid starting multiple medications at once. Plus sometimes treating one behavior can also treat the other symptoms but here are some other things to consider with small kids (in EACH visit):
- Assess SLEEP: sleep is the 5th vital sign in mental health so you’ll hear me say this A LOT. Emphasize healthy sleep habits and rule out bedwetting. More information about sleep.
- What’s Working: sometimes kids already have medications that are working for them or in the past, so if there’s no major problem, maybe all you need to do is increase the dose, the frequency, or address things that are still ongoing such as a lack of focus or sleep to have more effective outcomes.
- Target Parenting: try to get the family to focus on POSITIVE reinforcements. Redirect the conversation back to the plan of care. Acknowledge the family’s concern, but note how if you only give the child attention when they do something bad, then they will continue to do bad things (for attention). Discuss major red flags like harming self or others and if they do something bad such as destroying the property reinforce boundaries and consequences.
- Focus on how well the child is learning: determine if the child is responding and engaging appropriately and rule out ADHD. So if the child isn’t destructive and appears to not listen or pay attention, the child will have educational delays so treatment is important ASAP. Think about ADHD like a CVA, time is brain! and we want to minimize the damage of not learning and processing information. Focusing on parenting again, I sometimes ask the parents what educational activities are being done at home? discussing the home environment can also get the parent to understand how learning needs should be prioritized.
Personal Go-To Treatment for Kids
Boys (escitalopram, sertraline), Girls (sertraline, fluoxetine). If the child has numerous medical conditions e.g. autoimmune, POTS,…etc. sertraline has been the most helpful, 2nd line is escitalopram. If the child is having frequent crying spells and difficult moods, fluoxetine effectively treats anxiety and moods, especially with females. For special needs i.e. ASD, escitalopram, and sertraline are usually the most tolerable, and I’ve inherited some on trazodone but I normally don’t start with it due to priapism risks. Overall, consider how antidepressants have been proven to treat moods and are well researched in kids.
If antidepressants don’t work, i.e. the child is still moody, destructive… then an antipsychotic is the next go-to, and mood stabilizers are 3rd line and/or combination with other medications. They both have pros: with antipsychotics, you can easily micro dose and start/stop or PRN, which may be a good option if there’s a concerned about metabolic side-effects, the kid is small, or sensitive, or simply trying to avoid over-medicating. The mood stabilizer advantage is how you can wean the child off the anti-psychotic or unhelpful medications to target the mood and agitation. The cons are the side-effects of anti-psychotics (weight gain, akathisia, sedation) and mood stabilizers (blood draws, sedation, losing hair, and weight gain) kids are relatively healthy but check labs and an EKG and with all meds -remember start low and go/titrate slow.
Assessing Anxiety and Depression in Teenagers
It can be difficult to assess and support teenagers struggling with mental health and emphasizing the unique challenges they face. Adolescents often display challenging behavior, such as rudeness or defiance, but these can stem from deeper issues exacerbated by external factors like bullying, abuse, relationships, medical conditions, or academic struggles.
The pandemic has further impacted their mental health, making it essential to evaluate the root causes of mood disturbances before deciding on treatment. Sometimes addressing underlying issues, like ADHD or sleep problems, can significantly improve both behavior and mood without using extensive treatment.
The approach to treating teens includes maintaining a positive tone during interactions, reducing tantrums/drama to avoid escalating conflict, and involving them in their treatment plan to foster adherence and improvement. In addition, advocate treating teenagers with respect and guiding them in decision-making, helping them regain stability and hope for the future.
About Treatment for Teenagers
A helpful tool to consider is first simply asking about how they feel about medications. Take some time to understand teenagers’ beliefs about treatment to address misconceptions, often fueled by inaccurate or sensationalized information online. Clarifying concerns and attitudes also help reduce stigma and foster a sense of normalcy and acceptance. Building rapport is essential before discussing medications and consider particular treatments:
Males
- Depression: here’s an unpopular opinion, I sometimes stay away from SSRIs and Trazodone. I try to avoid things that will cause sexual side-effects in males older > than teenagers. However, they are my go-to for special populations like substance abuse, autism, and certain conditions like OCD. Unless antidepressants worked prior or it was requested then I’ll prescribe them but with most of my male adult /teenage patients, I don’t start with SSRIs even if they worked due to the sexual AE because they may stop taking them and risk having a higher form of depression. I just go to a newer or different class of medications such as cariprazine, vortioxetine, buspirone, bupropion, mood stabilizers, stimulants…etc. Some literature suggests drug holidays or reducing the dose, but you risk the medication being ineffective or the teen being more depressed. Some people don’t mind the decrease in sexual urges but that’s rare and vasodilators is usually not covered in minors/avoid prescribing those or non-psych medications -consider referring the teen to urology or PCP…
- Anxiety: here’s another unpopular opinion, try to get males to avoid marijuana. Teenagers usually don’t have a medical card but got all these risky behaviors so who knows what they’re really smoking or drinking and it can easily be laced with crack. They may claim that “marijuana helps” and yet they’re in the office because of these “panic attacks” or uncontrolled anxiety. Be bold and let them know, that marijuana is NOT helping and can be making it worse. I medicate male anxiety like I’m possibly treating addiction and frequently consider propranolol, hydroxyzine, and clonidine. If the patient does not smoke or drink I still use these medications and reinforce staying away from substances.
- Agitation: I wanted to add this extra tidbit, in particular with young males or teenagers, I usually express avoiding high-impact sports. Activities that may cause frequent LOC or head injuries can cause a decrease in personality/memory/emotions/mood, thus should be avoided or take precautions. Therefore, sports like football, boxing, extreme sports, wrestling… etc. I try to tell parents to be extra careful or consider discontinuing risky activities to reduce harming the kid’s mental health. Here’s information regarding aggression with kids.
Females
- Depression: difficult moods and crying spells or conditions PMDD, PMS -fluoxetine or sertraline is my first line. They both help with PMDD and female conditions, including menopause but overall SSRIs are the best. If females are having agitation, aripiprazole has helped but has side-effects and risks like with all antipsychotics with higher dosages. Sometimes if a female has terrible PMS or PMDD I would dose the antipsychotic as a PRN just to cope. I had someone ask about birth control, but again with non-psych issues, they need to follow-up with PCP and document your recommendations to note how it was addressed. Overall, take precautions with putting a child or a person on anything affecting the fertility, it’s a liability so I personally wouldn’t risk it. SSRIs work well with females and I don’t get as creative with treatment as with my males. However, if I have a patient with major genetic interactions or if there not responding to the usual treatment, other great options include desvenlafaxine, non-stimulants, and bupropion can help as adjuncts.
- Anxiety: here’s the last unpopular opinion, drum roll please: benzodiazepines honestly works the best but mainly for adult females. However, due to risks like addiction, diversion, and concerns for teens/kids, they are not ideal first-line treatments and should be avoided. Benzodiazepines could be started sparingly and cautiously, in college-aged individuals, again weigh the pros and cons. Pregnancy also poses additional concerns, but in general try to avoid using benzodiazepines unless it’s an extreme situation like harm-reduction in active substance abuse problems. However the standard of care usually includes SSRI/SNRIs, hydroxyzine, bupropion, or other medications. Prioritizing sleep is also important across all age and gender groups.
