Dr. Marjorie Robb
Assistant Professor, UOttawa
Children’s Hospital of Eastern Ontario
Some troubling statistics
• At least 20% of children under age 18 have significant
mental health problems
• 75% of those don’t get help
• Is 8 years old. He has a great family, lives in the country,
and likes to play outside.
• Jesse has a learning disability and has a hard time in
• Around age 7 ½ he started to worry a lot:
• Will there be enough time to play?
• Will there be enough time to do my homework?
• I won’t be able to do this homework.
• I don’t want mom to go out at night.
• He also started to complain of headaches and
stomachaches quite a lot.
• Parents say he is so anxious he doesn’t enjoy much.
• Taylor is 7. She does well at school and has friends there.
• At home she has started to be afraid to eat – she fears the
food will make her sick
She especially refuses to eat anything her older brother
has touched because “he’s gross”
She is afraid to go to sleep because she might get sick
Bedtime takes a very long time
She has frequent meltdowns when things “don’t go right”
She seems very tired and unhappy much of the time
She is not gaining weight as she should
• Cecelia is 9. She has developed a fear of germs
• She won’t use the washroom at school or at the mall
• She doesn’t want her parents to have visitors or to let
friends drive in their car (because they bring in germs).
• She has to wash her hands for a long time and frequently
• She insists that her family wash their hands whenever
anyone comes in from outside and has a meltdown if they
• After visitors leave she sprays disinfectant on the furniture
Anxiety Disorders
• Anxiety disorders are the most common mental health
• Many anxiety disorders start in childhood and if untreated,
they may persist into adulthood
• Children may have more than one kind of anxiety disorder
• Up to 6% of children and youth have an anxiety disorder
severe enough to need treatment
Why do children get anxiety disorders?
• Often there is a family (genetic) tendency to anxiety
• Children who live with too much stress can become
• Stress can be in family, school or neighborhood
• Anxious parents can model anxious behaviour for children
Kinds of Childhood Anxiety Disorders
• Separation anxiety
• Social phobia
• Generalized anxiety disorder
• Selective mutism
• Obsessive Compulsive Disorder
• Panic Disorder
• Phobias
• Post Traumatic Stress Disorder
Separation Anxiety Disorder
• Child is afraid of leaving their parent(s)
• They may worry that something bad will happen to the
parent or to someone they love or to themselves
• May refuse to go to school
• May have stomachaches, headaches, or throw up if they
fear separation
• May refuse to go to playdates at other people’s houses
• Diagnosed if it causes problems at school or socially and
has been going on at least 4 weeks
Generalized Anxiety Disorder
• Children with this kind of anxiety may:
• Have lots of worries and fears
• Have problems sleeping because of worries
• Have trouble concentrating
• Get tired easily or have tension headaches
• Be tense or restless
• Be perfectionist
• Have an anxious desire for approval
Obsessive-Compulsive Disorder
• OCD often begins in early childhood or adolescence.
Children with this kind of anxiety may:
• Have frequent uncontrollable thoughts (obsessions)
• Usually they don’t like these thoughts, or they may think
they don’t make sense
• Perform certain behaviours or rituals to try and prevent
something bad from happening (or to get rid of thoughts)
• Examples are: handwashing a lot if there is a fear of
germs; checking that doors are locked; special touching
Panic Disorder
• Happens less often with younger children
• People with this kind of anxiety have panic attacks
• Feel very scared
• Heart pounding, hard to breathe
• May feel shaky, dizzy, or sick
• May feel like they are going crazy or something really
awful is going to happen
• Sometimes they avoid school or want to stay in the house
• Frequent panic attacks = panic disorder
Selective Mutism
• Children may not talk to anyone who is not close to them,
such as immediate family
They may look down, withdraw, turn red if required to talk
Often they whisper if they do speak in a situation where
they are anxious
Up to 2% of school age children may have these
Some kids outgrow it; some go on to have social phobia
Social Anxiety/Social Phobia
• Happens more in teens than in young children
• Fear and worry about social situations
• Going to school
• Speaking in class
• Social events including recess and lunch
• Shy, self-conscious
• Easily embarrassed
• These kids tend to be sensitive to criticism and find it hard
to be assertive
Post Traumatic Stress Disorder
• Symptoms start after a physical or emotional trauma or
very frightening event
• Can be marked by several of
• Behavioural changes
• Repetitive play
• Zoning out, numbing of feelings
• Jumpiness and watchfulness of surroundings
• Nightmares and sleep problems
• “Flashbacks”
Not very common in young children
Anxiety disorders - What to watch for:
• Avoidance of school (refuses to go)
• Frequent stomachaches or headaches in the morning
before school
Avoidance of activities
Easily upset – distress out of proportion
You spend a lot of time comforting your child and/or
urging her/him to participate in regular activities
You feel that your family functioning is being disrupted by
your child's fears and worries, or meltdowns
What you can do:
• Be patient, calm and reassuring
• Be positive about their ability to manage the situation
(with support)
Help your child succeed by doing “small steps”
Reward and praise your child’s efforts as well as
Be a model for your child – manage your own anxieties
Help your child “avoid avoidance” with planned gradual
exposure to things they fear
Teach your child positive self-talk
What you can do:
• Teach your child basic relaxation strategies such as belly
breathing and muscle relaxation
Teach your child to visualize or imagine a pleasant,
relaxing “happy place”
Keep stress low at home. Avoid parental conflict when
the children are present. Be calm and positive as much
as possible.
Deal with external situations that require adult
intervention, such as bullying
Healthy living: enough sleep, regular routines, balanced
diet, exercise
Take time to have fun and relax with your child
• Criticize or yell at your child
• Tease or make fun of your child for anxiety
• Ignore the problem or wait for the child to get over it
• Tell the child to “toughen up”
• Pressure your child to do more than s/he can do
• Have unrealistic expectations
• Make it easy for your child to avoid anything that scares
Treatment of anxiety
• If your child is having significant problems with school,
missing a lot of school, or having other problems
functioning, you should talk to your doctor
• Anxiety disorders can be treated!
• The most common treatment is cognitive behaviour
therapy (CBT) in groups or individually
• In CBT children learn relaxation and stress management
• Gradual exposure to things that make them anxious, to decrease
the fear
• Coping strategies to reduce anxiety
CBT is first choice, but medication may be needed in
severe situations
• Tyler is a 9 year old boy who lives with his mom and sees
his dad every second weekend
His parents have been in a bitter custody battle
He has trouble getting to sleep and is always tired in the
He still plays with his friends, but doesn’t seem to enjoy
himself as much as he used to; he wants to quit hockey
He is angry and cranky with mom much of the time and
he has meltdowns over small things
Sometimes he falls asleep in school; he can’t concentrate
and his marks have gone down
• Emily is 8 and lives with mom, dad and 2 brothers
• Recently she has started to complain of stomachaches
often in the morning
She sometimes says “I’m stupid” or “I’m ugly”
She cries at night and sometimes says “I wish I wasn’t
She plays with her dolls by herself and doesn’t want to go
outside after school
When frustrated she will sometimes hit herself on the
She says other kids are mean to her
• Depression is common: in Canada and US about 1 in 5
children will go through a depression before finishing high
• 4 – 8 of 100 children have a major depression at any point
in time
• Symptoms include:
• Feeling sad, irritable or angry
• Not enjoying life, school or activities as much
• Trouble coping with home, school or work
• Feeling hopeless or worthless
• Problems with sleep, appetite, energy and concentration
What causes depression?
• Family history (genetics)
• Stress, including:
• Conflict between parents, or with parents or siblings
• Depression or too much stress in parents
• Separation or divorce of parents
• Conflicts with friends or classmates,
• Social stress
• School stress – not doing well, or too much pressure
• Bullying
• Loss of someone important
What should you do if you think your child
is depressed?
• Take your child to your family doctor or pediatrician
• The doctor can check for medical problems that could be
causing the changes in behaviour
• She/he may suggest mental health services (psychologist,
counselor, social worker, psychiatrist)
• Call your doctor, the crisis line or the emergency
Can depression be treated?
• Young children are most often treated with their family.
• Working with parents to help them help their child
• Family therapy if family problems are part of the problem
• Therapy: by a counselor, psychologist or psychiatrist
• Cognitive Behavioural Therapy is proved to be very effective
• The child learns ways to manage stress, do things that help her feel
better, and think more positively
• Medication
• Only used when other treatments don’t work, or when the
depression is so severe that other treatments aren’t possible
• Antidepressants are safe and effective when used correctly and
monitored by a doctor
Remember the basics!!
• Get enough sleep
• Eat healthy meals and snacks
• Take vitamin D supplements and consider omega 3 fatty
Get exercise – an hour a day if possible.
Get enough sunlight (in winter, vitamin D supplements)
Plan enjoyable activities and one on one time with your
Parents need to take care of themselves too!
What else can parents do?
• Listen actively to your child. Let them know you notice
something is wrong.
Don’t overly pressure the child to talk, but make sure that
you do talk
Help the child problem-solve ways to deal with stresses
Step in as the parent when stresses are beyond the
child’s ability to handle
Speak to the school if there is school stress or if the
depression is affecting how your child does at school
Maintain an atmosphere of calm and consistency at home
Protect time for fun activities together
• Blame or criticize your child for symptoms of depression
• Tell your child to “just get over it” or “just snap out of it”
• Get into power struggles. Help your child have a sense of
control by giving choices whenever possible.
• Remove all expectations and let the child miss a lot of
school, not get up in the morning, play video games for
• Make home stressful by fighting, yelling, criticizing, etc.
• Dismiss or belittle the child’s problems
Putting it all together:
Red Flags to Watch For
• Feeling sad or depressed for more than 2 weeks
• Increase in irritability and anger
• Drastic changes in behaviour or personality
• Expressions of wanting to die or plans to harm
Severe mood swings affecting ability to function
Intense worries or fears that interfere with daily activities
Sudden overwhelming fear for no reason, often with
difficulty breathing and racing or pounding heart
Decline in school performance
Wanting to avoid school
What to do if you are worried
• Talk (and listen) to your child
• Keep a calm and positive attitude
• Problem-solve with your child
• Look for resources on-line or in books
• Teach your child positive self-talk and self•
Teach your child deep breathing and relaxation skills
Identify what is stressing your child and address it
Intervene on child’s behalf when appropriate
Call your doctor. Consider calling the school counselor.
Be aware of resources in your area
And what not to do:
• Ignore the problem
• Expect your child to “just snap out of it”
• Blame your child for the problem. These are medical
problems and cause changes in the brain.
• Keep it a secret. Anxiety and depression are very
common problems. Everyone gets hurt when they stay in
the shadows.
• Let your own anxiety or depression weigh down your child
If your child is being treated by a
• Take a matter-of-fact approach, as you would if they had a
broken leg
Ask what resources you should read or look at
Ask what you can do to help
Communicate with the professional
Remember you and your child are the most important
members of the treatment team!
Prevention – There’s lots you can do
• Make the home environment as calm and consistent as
Establish a regular routine: mealtimes, playtime,
homework time etc.
Eat meals together as a family. Avoid negative talk at
Enough sleep
Balanced meals and not too much junk food
Have frequent one-on-one time with your child
Make fun and enjoyable activities frequent and regular
Limit video game, computer and TV time
7-9 year olds are too young for cell phones and Facebook
Relationship Matters
Because Relationships Protect
• GO PLACES with your child:
• Give many more positive comments than negative ones.
• One on one time: have fun, laugh, do something you both
enjoy, play cards – make it a positive zone.
• Positive active responses whenever possible
• Listen more than you speak, validate the primary emotion
• Assert yourself calmly
• Connection before correction
• Emotional banking: everything you do counts
• Stick to your values but consider all points of view
• Provides information about mental health disorders,
recommendations for books and videos, and details about where to
look for help
• Good information about self-help which parents can adapt for kids
• From the Canadian Pediatric Society
• Information on a range of mental health problems
Question Time

Mood and anxiety disorders in children