Professeur docteur oussama chaalane

Dr Usama Fouad Shaalan MD- PhD MiniEncyclopedia الموسوعه المصغره للدكتور  أسامه فؤاد شعلان


Anxiety disorders


September 28, 2009 — Atypically high levels of depression and anxiety are common among very young children, a large population-based study suggests.

The longitudinal study of 1759 children, ranging in age from 5 months to 5 years, found that 15% of study participants had unduly high symptoms of depression and anxiety and that these children were more likely to have mothers with a history of depression. The study also found that difficult temperament at 5 months was the most important predictor of depression and anxiety in children.

"As early as the first year of life, there are indications that some children have more risks than others of developing high levels of depression and anxiety. We also found that these symptoms increase in frequency during the first 5 years of life," one of the authors, Sylvana Côté, PhD, from the Université de Montréal in Quebec, told Medscape Psychiatry.

The study was published online June 10 and appears in the October print issue of The Journal of Child Psychology and Psychiatry.

A Leading Cause of Disability

This latest research appears to support the findings of an article published in August in which investigators found that children as young as 3 years could develop major depressive disorder (Arch Gen Psychiatry. 2009;66:897-905).

Although depressive and anxiety disorders are among the top 10 leading causes of disabilities, little is known about the onset, developmental course, or early risk factors for depressive and anxiety symptoms (DAS), the authors write.

The aim of the study was to track the developmental trajectories of DAS during early childhood and to identify risk factors for atypically high DAS in a large population sample of 1759 children.

The study subjects were born in 1997 or 1998 and were followed yearly from 5 to 60 months of age. Trained interviewers conducted yearly home interviews with the mothers about family characteristics and about parental and child behaviors. The average response rate over 6 years of data collection was 93.48%.

The study’s main outcome variable was DAS in preschool. Using select questions from the Preschool Behavior Questionnaire, the person most knowledgeable about the child — the mother in 98% of cases — was asked how frequently the child:

  • is nervous, high strung, or tense
  • appears fearful or anxious
  • appears worried
  • is not as happy as other children
  • has difficulty having fun.

Researchers used these data to identify children who followed atypical and elevated developmental trajectories of DAS and to identify the associated risk factors.

First Study of Its Kind

Among the study group, 29.9% of children had low and relatively stable levels of DAS. The so-called "moderate-rising" group accounted for the majority of children (55.4%), and the high-rising group — those who exhibited notably higher and rising levels of DAS — accounted for 14.7% of the children.

Difficult temperament at 6 months of age and lifetime maternal depression significantly distinguished the high-rising group from the moderate-rising group. As expected, there were more risk factors in the high-rising group than in the low group.

According to the investigators, this study is the "first to model the developmental trajectories of depressive and anxiety symptoms from infancy to school entry. It is also the first to identify risk factors for high-rising DAS during early childhood," they write.

The identification of the 3 trajectory groups is "important because they show, for the first time with a population sample, that the frequency of DAS substantially increases during the preschool period," the authors write.

Quiet Children Easily Overlooked

Dr. Côté pointed out that an increase in levels of anxiety and depression is expected as children develop. At this point, she said, the majority (55.4%) of children are considered to be in the normative group.

However, she added, when children become unduly fearful or sad to the point where it interferes with their ability to function, it is problematic. One of the major challenges with these children is recognizing them.

Many children with DAS, said Dr. Côté, internalize their emotions and withdraw, so they often fly beneath the radar and go undetected.

"Anxious and depressed children tend to be very discreet. They tend to disappear and they don’t disrupt anybody and so often they are ignored," she said. "As a result, they are much less likely than children with overt behavioral symptoms, such as aggression, to receive appropriate treatment."

Need for Preventive Action

According to Dr. Côté, infants of mothers who have a lifetime history of depression should undergo preventive interventions, particularly if the child has a difficult temperament.

In addition, she said, there are many high-quality preschool programs that offer social skills training to help them recognize and manage their emotions. Such programs have potential benefit for all young children, not just those who are symptomatic. In addition, she said, there are many parenting programs designed to help parents meet the challenges of raising children.

"These children tend to be overlooked more often than others because they are quiet and not disruptive. But this is not a reason to neglect them. Depression and anxiety are major health problems that are associated with significant costs, and these people suffer," she said.

Dr. Côté and her colleagues will continue to follow the children and their parents. Their next research steps include looking at long-term outcomes of the 3 study groups, including school performance, social relationships, and possible diagnoses of mental health problems.

The authors have disclosed no relevant financial relationships.

J Child Psychol Psychiatry. 2009;50:1201-1208. Abstract

Clinical Context

Depressive and anxiety disorders are among the top 10 leading causes of disabilities. Studies have demonstrated that clinically significant levels of DAS can be detected in early childhood. Individuals with frequent DAS during childhood not only experience depression as adults but also are at significant risk for other problems such as substance use and abuse, suicidal behaviors, and premature death. Currently, little is known about the onset, developmental course, and early risk factors for DAS.

The aim of this study was to model the developmental trajectories of DAS during early childhood and to identify risk factors for atypically high DAS.

Study Highlights

  • In this study, group-based developmental trajectories of DAS conditional on risk factors were estimated from annual maternal ratings (1.5 – 5 years) in a large population sample (n = 1759) of children born in the province of Québec between 1997 and 1998.
  • From the Preschool Behavior Questionnaire, mothers were asked to rate their child on a frequency scale indicating whether the child never (0), sometimes (1), or often (2) exhibited the following DAS symptoms (in the last 12 months): "is nervous, high strung, or tense"; "appears fearful or anxious"; "appears worried"; "not as happy as other children"; and "has difficulty having fun."
  • The internal consistency value (alphas) was 0.81 during 1.5 to 5 years.
  • Risk factors that were assessed included child characteristics (eg, sex of the child and child temperament), maternal and family characteristics (eg, maternal depression, maternal antisocial behaviors, maternal education, and insufficient household income), and family processes at 5 months after birth (eg, Family Dysfunction scale and the Parental Cognitions and Conduct Toward the Infant Scale).
  • Results identified a 3-group model of DAS developmental trajectories: high-rising, moderate-rising, and low.
  • DAS increased substantially in 2 of the 3 distinct trajectory groups identified: high-rising (14.7%), moderate-rising (55.4%), and low (29.9%). The low group included children with low and relatively stable levels of DAS.
  • 2 factors distinguished the high-rising group from the other two: difficult temperament at 5 months (high-rising vs moderate-rising: odds ratio [OR], 1.32; 95% confidence interval [CI], 1.13 – 1.55; high-rising vs low: OR, 1.31, 95% CI, 1.12 – 1.54) and maternal lifetime major depression (high-rising vs moderate-rising: OR, 1.10; 95% CI, 1.01 – 1.20; high-rising vs low: OR, 1.19; 95% CI, 1.08 – 1.31).
  • 2 factors significantly distinguished the high-rising group from the low group: high family dysfunction (OR, 1.24; 95 %CI, 1.03 – 1.5) and low parental self-efficacy (OR, .71; 95% CI, .54 – .94).
  • Limitations of this study included principal reliance on maternal ratings, maternal bias, and unmeasured variables (eg, genetic factors and other types of DAS).

Clinical Implications

  • Individuals with frequent DAS during childhood are twice as likely to experience depression and are at increased risk for substance use and abuse, suicidal behaviors, and premature death.
  • DAS tend to increase in frequency during the first 5 years of life; the most important risk factors for atypically high levels of DAS are difficult temperament at age 5 months and maternal lifetime depression.

What are Neurobiological Disorders (NBDs)?

NBDs are biological brain disorders that interfere with normal brain chemistry. Children often have multiple conditions. Each disorder manifests with overlapping symptoms of various presentations and severity (see diagram).

Graphic describing the relationship between the various diagnoses


This diagram illustrates the complexity of the relationships between the various diagnoses for NBD. Symptoms such as inattention and lack of concentration are common to several diagnoses such as anxiety disorder, depression, OCD, bipolar disorder, ADHD/ADD, and other serious psychiatric illnesses. All of these disorders can coexist with a primary learning disability. The only way to accurately diagnose an NBD is through a comprehensive assessment. YOU CANNOT DIAGNOSE WITH A CHECKLIST.

NBDs Are No One’s Fault

They are not the result of poor parenting, poverty, or other interactions (Dr. D.J. Jaffe). They are all caused by various biological changes in the chemistry of the brain. The biological nature of these disorders has been well researched and medically recognized. Genetic factors may create a predisposition in some people and life events may trigger the onset of symptoms.

It is very important for parents and educational staff to recognize and accept the fact that, while the symptoms of these disorders may be behavioural, the causes are biological.

NBDs Can Be Treated

Treatment and management of NBDs has been compared to the treatment of diabetes; both are medical conditions. Treatment with medication rectifies the biological imbalance. No one would deny a diabetic their insulin but there is huge resistance to giving a child medication that will restore the balance of neurotransmitters.

These children will maximize their potential with specific and comprehensive treatment/management plan along with the coordination and support at home and in school.


Different biological disorders require different treatments and management approaches. Getting the correct diagnosis is absolutely critical.

Evaluation by a child and adolescent psychiatrist is appropriate for any child or adolescent with emotional or behavioural problems.

A developmental bio-psycho-social approach to clinical assessment of children and adolescents is what families should seek while working with our mental health system.

What gets in the way?

  • Societal resistance to labeling someone as having a neurobiological disorder and the stigma that results, often prevents children from receiving proper evaluation, necessary diagnosis, treatment and management.
  • Specialized training is required for the mental health professional to be able to identify and diagnose NBDs.


The inconsistency of the child’s functioning often confuses concerned adults.

It is the nature of these disorders that:

  • Children can appear to have a surprising lack of overt symptoms at school and yet be severely depressed.
  • The child may appear fine at school and seriously struggle at home (i.e. smiling depression).
  • Some children’s marks drop 20% while others are able to maintain very high marks.

For more information on Diagnosis, please read this.

The Impact of NBDs on the Family

The isolation, anxiety and sometimes demoralization of ordinary parents who are managing their best with challenging children is a heavy burden.   A lack of knowledge of medical issues and unnecessary guilt can play havoc with parents’ sense of well being and self-esteem. No one deserves such a burden: since disorders create invisible limitations, overt support and understanding is often not available to either children or their families (Pat Kirchner).

In order for the family to remain intact and well, support must be made available immediately to deal with the emotional stresses that come from day to day living with these children/adolescents as well as the added burden of stigma that is imposed by an ill informed society.

Sources of Support in the Community

Use the sources of support available in the community:

  • child and adolescent mental health clinics
  • support groups in the community specific to the child’s problem (i.e. ADHD, tourettes)
  • workshops or courses dealing with specific issues
  • libraries/bookstores as a resource for information
  • web sites for children and adolescents with NBDs
  • religious leaders i.e. priest, minister, chaplain, rabbi etc.
  • family doctors and paediatricians


Children who have this disorder will do better when they have support and commitment from their parents and family:

What does this mean?

  • Time commitment is required:
    • Alone time (a date) with your child regularly (at least once a week). This doesn’t need to involve the spending of money.
    • Time to take your child to therapy appointments.
    • Time for you, your spouse and other children in the family to attend counselling to help you cope with the emotional fallout.
    • Time to deal with crises that may arise.
    • Time away from work.
    • Time to maintain your marriage under the most trying circumstances.
    • Time to keep communication lines open with the school.
  • Understand that there is little time for couples and carving out a realistic way to spend even a few minutes together over a coffee is necessary to remain connected.
  • Temporary changes in your personal, marriage and family goals and plans may be required.
  • A temporary reduction in your commitments outside the family may be required.

In the confrontation between the stream and the rock, the stream always wins… not through strength, but through persistence.   — H. Jackson Brown

Reviewed by M. Kodsi, M.D., Child and Family Psychiatrist.


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