Pediatric Anxiety and Depression

Occupational therapy practitioners (OTP) use meaningful activities and activities that children want or need to do to promote their wellness and health. Children who experience anxiety and depression may be challenged in ADLs, education, social participation, play, leisure, sleep, and rest. OTPs can use task and activity analysis to identify facilitators and barriers to participation in these activities across settings – school, home,  and the community.¹ 

Anxiety and Depression Impact

Anxiety is an internalizing mental disorder that often starts during childhood.²  It is characterized by excessive fear or worry.³  Anxiety and depression frequently occur together.⁴  Besides decreased participation in occupations, anxiety may affect family problems, health risk behaviors, and financial costs to the family and community.⁵  Anxiety and depression were 2 of the top 20 conditions associated with the highest health care costs among US children in 2013.⁶  Furthermore, anxiety frequently persists into adulthood and is associated with risks of co-occuring conditions (e.g., autism spectrum disorder), lower income, and earlier mortality.^7 8 9 

Children with anxiety who do not outgrow their fears and worries that are typical may be diagnosed with an anxiety disorder, especially if it interferes with school, home, and play activities.

Depression in Children and Teens

Classified as a mood disorder with cyclical symptoms (disappear and reappear) that can interfere with thoughts, feelings, and behaviors. This results in difficulties with occupational performance and overall well-being. Depression in children and teens is considered a serious illness due to its impact on functioning, mental health, and risk for suicide.¹⁰ 

Depression Risks

• Family history: depression, dysthymia, bipolar disorder
• Unstable situations/environment
  • Financial uncertainty
  • Poverty
  • Substance use/abuse
  • High levels of conflict
  • Frequent moving¹⁰ 

Types of Pediatric Anxieties

• Separation anxiety
• Phobias, e.g., dogs, insects, dentist
• Social anxiety
• General anxiety – being worried about the future or bad things happening in general
• Panic disorder – repeated episodes of sudden and unexpected fear with symptoms of heart-pounding, dyspnea, feeling dizzy, shaky, or sweaty.¹¹ 

Anxiety Causes and Prevention

• Biology vs temperament vs environment
• Trauma/traumatic birth
• Violence
• Stress
• Being maltreated (bullied, rejected) ¹¹ 

Anxiety Symptoms

• Fear
• Excessive worry
• Irritability/restlessness
• Anger
• Difficulty sleeping/sleep disturbances
• Fatigue/tiring easily
• Headaches
• Stomachaches¹¹ 
• Effect on cognitive skills (attention, sequencing, problem-solving; concentration)
• Muscle tension
• Low-self esteem
• Distorted self-image
• Disrupted habits, roles, and routines
• Decreased quality of life and wellbeing¹ 

Depression Symptoms

• Loss of enjoyment or interest in activities or people
• Difficulty with cognitive tasks such as concentration or decision-making
• Sudden changes in affect and behavior
• Changes in sleep patterns
• Changes in sleep activity levels of energy
• Changes in appetiteite
• Increased feelings of incompetence, hopelessness, and worthlessness

Outcome Measures

• Patient Health Questionnaire (PHQ) ¹² 

Occupational Therapy Treatment

• Types of Intervention
  • Promotion: mental and physical health at the universal level. Educate about the value of enjoyable activities and encourage children to share their feelings through social interactions and creative expression.
  • Prevention: for at-risk groups with self-esteem, sensory modulation, socializing, and social skill-building.
  • Intensive intervention: for those with diagnosis or symptoms with targeted needs and education. Modifications of school demands and schedules may be necessary.¹⁰ 
• Levels of Intervention
  • Universal, e.g.,  school (Tier 1)
  • Targeted groups (Tier 2)
  • Individual (Tier 3)- Recommend schedule modifications to reduce anxiety.¹³ 
• Settings:
  • Home: develop a low-stress home environment and provide education about the impact of symptoms. Focus on favorite activities and enhance social participation.
  • School: collaborate with stakeholders and modify as necessary to reduce stress and create a positive learning environment. Address sleep and schedules.
  • Community: Set realistic functional goals and offer opportunities for low-stress social situations and activities.¹⁰ 
• Use occupation-based and/or occupation-focused interventions to promote self-care, productivity, and leisure/play.^14 15 
• School-based and general cognitive-behavioral therapy (CBT) targets symptoms of depression and can have a positive effect on changing behavior and self-esteem.¹⁶ 
• Create a sensory modulation kit.
• Create a sensory diet.
• Use CBT and Social and Emotional Learning (SEL) to help clients develop the skills to recognize their thoughts, emotions, and behaviors.
  • Help clients practice strategies of positive self-talk in different environments.
• Teach relaxation techniques.
• Promote participation in meaningful leisure activities.¹⁷ 
• Support the child’s healthy eating plan with the team.¹⁸ 
• Collaborate with parents to use strategies such as having open discussions, providing encouragement without pressure, slowing down thoughts and the body to minimize symptoms, and discussing potential situations while acknowledging emotions that may accompany anxiety.¹⁹ 

EBP

• Overall, a systematic review of studies shows that mindfulness-based interventions in children and youths are promising for improving cognitive performance and resilience to stress.²⁰ 
• (Family-centered research) Mindfulness-based interventions may potentially have long-term effects on stress levels and the psychological wellbeing of parents of children with ASD.²¹ 
• There are benefits to using CBT-based technology-derived interventions when access to traditional psychotherapies is limited or delayed.²² 
• Physical activity is associated with lower depression and improved physical self-concept in children and youth.²³ 
• Yoga that was provided at higher frequencies (2-3x/wk) was associated with a significant decrease in anxiety.²⁴ 
• (Limiting screen time) Screen time may be a risk factor for anxiety and depression in adolescents.²⁵ 

1. American Occupational Therapy Association. (2012). Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth: Anxiety Disorders. Retrieved from https://www.aota.org/-/media/corporate/files/practice/children/schoolmhtoolkit/anxiety%20disorders%20info%20sheet.pdf[↩][↩]
2. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A).
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3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 5th. Washington, DC: American Psychiatric Association; 2013.[↩]
4. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Birmaher B, Brent D, AACAP Work Group on Quality Issues., Bernet W, Bukstein O, Walter H, Benson RS, Chrisman A, Farchione T, Greenhill L, Hamilton J, Keable H, Kinlan J, Schoettle U, Stock S, Ptakowski KK, Medicus J J Am Acad Child Adolesc Psychiatry. 2007 Nov; 46(11):1503-26.[↩]
5. Long-term economic costs of psychological problems during childhood. Smith JP, Smith GC Soc Sci Med. 2010 Jul; 71(1):110-5.[↩]
6. Spending on Children’s Personal Health Care in the United States, 1996-2013. Bui AL, Dieleman JL, Hamavid H, Birger M, Chapin A, Duber HC, Horst C, Reynolds A, Squires E, Chung PJ, Murray CJ JAMA Pediatr. 2017 Feb 1; 171(2):181-189.[↩]
7. Mental health outcome of long-term and episodic adolescent depression: 15-year follow-up of a community sample. Jonsson U, Bohman H, von Knorring L, Olsson G, Paaren A, von Knorring AL J Affect Disord. 2011 May; 130(3):395-404.[↩]
8. Changes in prevalence of parent-reported autism spectrum disorder in school-aged U.S. children: 2007 to 2011-2012. Blumberg SJ, Bramlett MD, Kogan MD, Schieve LA, Jones JR, Lu MC Natl Health Stat Report. 2013 Mar 20; (65):1-11, 1 p following 11.[↩]
9. Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. Visser SN, Danielson ML, Bitsko RH, Holbrook JR, Kogan MD, Ghandour RM, Perou R, Blumberg SJ
   J Am Acad Child Adolesc Psychiatry. 2014 Jan; 53(1):34-46.e2.[↩]
10. American Occupational Therapy Association. (2012). Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth: Depression. Retrieved from https://www.aota.org/-/media/corporate/files/practice/children/schoolmhtoolkit/depression.pdf[↩][↩][↩][↩]
11. CDC. (2021). Anxiety and Depression. Retrieved from https://www.cdc.gov/childrensmentalhealth/depression.html#anxiety[↩][↩][↩]
12. Gilbody, S., Richards, D., Brealey, S., & Hewitt, C. (2007). Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): A diagnostic meta-analysis. Journal of General Internal Medicine, 22(11), 1596-1602.[↩]
13. Bazyk, S., et. al. (n.d.). Occupational Therapy and School Mental Health. Retrieved from https://www.aota.org/-/media/corporate/files/practice/children/browse/school/mental-health/ot%20%20school%20mental%20health%20fact%20sheet%20for%20web%20posting%20102109.pdf[↩]
14. Fisher, A (2013) Occupation-centred, occupation-based, occupation-focused: Same, same or different? Scandinavian Journal of Occupational Therapy 20(3): 162–173.[↩]
15. Cahill, S. M., Egan, B. E., & Seber, J. (2020). Activity-and occupation-based interventions to support mental health, positive behavior, and social participation for children and youth: a systematic review. American Journal of Occupational Therapy, 74(2), 7402180020p1-7402180020p28.[↩]
16. Das, JK, Salam, RA, Lassi, ZS, et al. (2016) Interventions for adolescent mental health: an overview of systematic reviews. Journal of Adolescent Health 59: S49–S50.[↩]
17. American Occupational Therapy Association. (2012). Occupational Therapy’s Role in Addressing Anxiety Disorders. Retrieved from https://www.aota.org/-/media/corporate/files/practice/children/schoolmhtoolkit/anxiety%20disorders%20info%20sheet.pdf[↩]
18. CDC. (n.d.). Children’s Mental Health: Anxiety and Depression. Retrieved from https://www.cdc.gov/childrensmentalhealth/depression.html#anxiety[↩]
19. Occupational Therapy Helping Children. (n.d.). Social and Emotional Skills. Retrieved from https://occupationaltherapy.com.au/anxiety-in-children/[↩]
20. Zenner, C., Herrnleben-Kurz, S., & Walach, H. (2014). Mindfulness-based interventions in schools—a systematic review and meta-analysis. Frontiers in psychology, 5, 603.[↩]
21. Cachia, R. L., Anderson, A., & Moore, D. W. (2016). Mindfulness, stress and well-being in parents of children with autism spectrum disorder: A systematic review. Journal of Child and Family Studies, 25(1), 1-14.[↩]
22. Grist, R., Croker, A., Denne, M., & Stallard, P. (2019). Technology delivered interventions for depression and anxiety in children and adolescents: a systematic review and meta-analysis. Clinical Child and Family Psychology Review, 22(2), 147-171.[↩]
23. Dale, L. P., Vanderloo, L., Moore, S., & Faulkner, G. (2019). Physical activity and depression, anxiety, and self-esteem in children and youth: An umbrella systematic review. Mental Health and Physical Activity, 16, 66-79.[↩]
24. Weaver, L. L., & Darragh, A. R. (2015). Systematic review of yoga interventions for anxiety reduction among children and adolescents. American Journal of Occupational Therapy, 69(6), 6906180070p1-6906180070p9.[↩]
25. Maras, D., Flament, M. F., Murray, M., Buchholz, A., Henderson, K. A., Obeid, N., & Goldfield, G. S. (2015). Screen time is associated with depression and anxiety in Canadian youth. Preventive medicine, 73, 133-138.[↩]