ANXIETY DISORDERS AND DEPRESSION IN CHILDREN AND ADOLESCENTS
Acknowledgements: Most of the information included in this chapter was obtained from the Handbook
of Psychiatry, 2005, Mental Health Information Centre of SA, Department of Psychiatry, University of
Stellenbosch.
Chapter by Professor Susan Hawkridge, Dr Linda Keyter and Dr Bennie Steyn
A. ANXIETY DISORDERS
Separation anxiety disorder
Separation anxiety is a normal phenomenon in children during the toddler years. It begins at 6-8
months and lasts until 18 months, after which it gradually diminishes. When the child is better able to
understand, anxiety (including separation anxiety) is influenced more by the reality of the child’s
environment.
Any child will be anxious when, for example, s/he attends a new school for the first time, but the
healthy child will quickly adjust. In some children, separation from the mother remains anxiety
provoking, and this can develop into a typical syndrome such as school refusal.
There is often a family history of anxiety disorders, particularly separation anxiety disorder in the
mother. Family pathology is often present. Sometimes the mother suffers from depression or another
psychiatric or general medical illness. Marital conflict between the parents with threats that one of
them will leave home is also a factor that must be taken into account in children with separation
anxiety disorder. The mother may for one or other reason be anxious about her role as a parent (often
she was an orphan, a foster-child or herself unhappy in childhood). Often the family is very
enmeshed, with over-involvement of grandparents or overprotection of the child, etcetera. The
problem may also lie with a mother who herself experiences separation anxiety and wants to keep her
child with her. The condition is often precipitated by an event such as the death or illness of a family
member, a change in environment, a new school etcetera.
Generalised anxiety disorder in children
Generalised anxiety disorder appears to be more common in families from higher socio-economic
levels, as well as in small families preoccupied with academic performance. It is more often seen in
first-born children. Boys and girls are equally affected. There is often a family history of anxiety
disorders.
Associated symptoms include perfectionism, over-conscientiousness and precocious maturity. Habits
such as nail biting and hair pulling may also be present. Often these children are unwilling to
participate in sport or other group activities, and social or other phobias may also be present.
Panic disorder in children
Panic disorder does occur in children, and may be misdiagnosed as asthma, “hyperventilation” or
“manipulative behaviour”.
Social phobia (social anxiety disorder) in children
Children differ just as much as adults in their social tendencies. Some converse easily with strangers,
while others take longer to become accustomed to someone they don’t know. The latter have also
been called “slow to warm up” children. It is important not to label behaviour that falls in a child’s
normal developmental spectrum as a “disorder”.
Associated symptoms include a lack of self-confidence and an inability to act assertively. Often a
further diagnosis can be made, for example, generalised anxiety disorder, and the condition may be
complicated by school refusal. Depressed mood frequently develops as a result of social isolation or
poor school performance.
Selective mutism
It has been speculated that selective mutism might be a subtype of social phobia, because the
symptoms only occur in social situations,5 and up to 90% (but not all) of these children do meet the
criteria for social phobia. In isolated cases, a child may develop the syndrome after an identifiable
stressor. When this occurs it could possibly be seen as a form of posttraumatic stress disorder.
The prevalence is 3-8 per 10 000. This rare condition occurs more frequently in girls than in boys.
These children do speak to their parents and familiar family members, but refuse to converse in the
normal way at school. They may sometimes use gestures or whisper single words. Onset is usually at
the age of 5 or 6 years.
There may be a history of delayed or abnormal development of speech that possibly contributes to
the problem. High levels of anxiety and overprotection are often found in the family. Other problems
such as oppositional behaviour or outbursts are also often present at home. Thus genetic,
developmental and family factors are being studied as possible causes.
Obsessive-compulsive disorder (OCD) in children
Normal children enjoy ritualistic play and often like to carry out actions in a certain order. Magical
thinking is a normal phenomenon. It means that one has to do something in order to prevent
something else (bad) happening. Any child, when he is anxious, feels safer in the presence of familiar
objects and habits, and a tendency to obsessional rituals is reinforced under stress. There is a
developmental stage around 5-8 years when ritualistic games and behavioural occur normally. Rituals
and obsessional behaviour only become a disorder if they cause the child distress or impair his
functioning.
Although most people with OCD are adults, many of them can describe a very early onset of their
symptoms. In particular, children who suffer from Tourette’s disorder are inclined to develop OCD
early, usually around 11 years of age.
Obsessions:
1
Recurrent and persistent thoughts, impulses or images that are experienced as intrusive and
inappropriate, and cause distress
2
The above is not just excessive worry about real problems
3
The child attempts to suppress the thoughts etc., or to neutralise them with another thought or
action
4
The child is aware that the thoughts are his/hers, i.e., they do not originate outside him/herself
Compulsions:
1
Recurrent behaviour (e.g., hand washing) or thoughts (e.g., praying, counting) that the child
feels compelled to carry out as a response to obsessions or certain “rules”
2
The goal is reduction of anxiety or prevention of a terrible consequence; the connection
between the two is unrealistic
Specific phobias
Irrational fears for part of any child’s developmental process, especially during the phase of magical
thinking (around 4 - 7 years). In children these fears particularly concern the natural environment and
blood/injection/injury fears. Sometimes there is a preceding traumatic event and sometimes not.
Usually this is a passing stage, but in some children it develops into specific phobias, which by
definition impair functioning or development.
Careful history taking can exclude the possibility of other psychiatric disorders (e.g., OCD, psychosis),
and the child can then be referred for psychotherapy. In children this therapy should preferably be
done by a trained child psychologist, due to the danger of traumatisation during systematic exposure
to the feared stimulus.
Posttraumatic stress disorder
Posttraumatic stress disorder (PTSD) occurs in children as well as adults. In our community it is more
common than previously thought, with more than 12% of teenagers in high school meeting the
diagnostic criteria.
Children who suffer from PTSD are often referred on account of nightmares, sleep difficulties,
tearfulness, school refusal, deterioration in school work, “obsessive” behaviour, “conversion
disorders”, social withdrawal, separation anxiety, oppositionality, irritability or after suicide attempts. It
must be remembered that children, especially young children, do not often have the ability to describe
symptoms clearly. The possibility of this disorder must always be borne in mind, because especially
following sexual abuse, the child has often not told anyone of the event.
If the diagnosis is not made and the child does not receive appropriate treatment, the child’s further
emotional development can be impaired. We have little information concerning treatment outcome in
local conditions, but preliminary studies suggest that effective treatment can lead to relief of
symptoms and improvement in functioning, at least in the short term.10 Undiagnosed and untreated
PTSD can have a poor long term outcome, including personality disorders, depressive disorders,
behavioural disorders and substance abuse.
In general, treatment comprises psychotherapy (play therapy in younger children) and where
appropriate, medication.
B. DEPRESSIVE DISORDERS
From the time of birth, signs of emotion can be observed in children. They are sometimes happy and
sometimes not. Psychodynamic theories of the causes of depression have in the past led some to
hypothesise that young children cannot experience depression. More recent research has shown that,
on the contrary, young children can become depressed, but that the clinical presentation can be
variable according to developmental stage. 12
There is sufficient evidence to state that mood disorders in children are fundamentally the same
illnesses as in those adults.
Genetic factors: In general there is an increased incidence of mood disorders in the children of
parents with mood disorders and in the family members of children with mood disorders. Having one
parent with a mood disorder doubles the chances of a mood disorder affecting the child, and having
two parents with mood disorders quadruples those chances.12
Biological factors may also play a role.12
Social factors: The fact that identical twins do not have 100% concordance for mood disorders implies
that there is a role for non-genetic factors. A boy whose father dies before the son is 13 years old has
an increased chance of suffering from a mood disorder.
Adolescents with a history of chronic physical illness, previous suicide attempts, childhood anxiety
disorders or childhood major depression have an increased risk of depression, as do those who are
abnormally dependent on the approval of others or who have poor social skills, or who are unhappy
about their school performance.3 A high incidence of parental aggression, marital conflict, blaming
and judgemental discipline is found in the families of children with depression.
C. SUICIDE AND SUICIDE ATTEMPTS
1
Suicide16
Successful suicide is occasionally described in prepubertal children, but occurs rarely. It appears that
although children often want to die, they lack the requisite practical skills to commit suicide
successfully. After the age of 14 years, successful suicide increases markedly. The incidence is
higher in boys than in girls, and there are often associated problems - substance abuse, behavioural
problems, conflict with authorities.
The method chosen influences the outcome, thus the most
common method in successful suicide in children is firearms.
If a young patient does commit suicide, remember that the family, and possibly you yourself, may
need support and counselling.
2
Suicide attempts16
The incidence of suicide attempts is higher in girls than in boys, and also rises steeply after puberty.
Suicide threats and attempts must always be viewed in a serious light. All children and adolescents
who attempt suicide must be thoroughly evaluated
a) for depression
b) for other problems that have led to a feeling of despair, and
c) for other psychiatric disorders.
Characteristics of adolescents who make suicide attempts:
1)
90% are female, 10% male
2)
Medication overdose is the most common method used
3)
There is a high incidence of family pathology and psychiatric disorders in the families of these
patients
4)
There is often a history of suicide/suicide attempts in the family
5)
The attempt is often impulsive and not premeditated
6)
There is nearly always an immediate precipitant, whereof the following are the most common:
a)
Conflict with parents
b)
Breaking up with boy/girlfriend
c)
Disciplinary crisis at school.
The typical profile of the less seriously intended adolescent parasuicide is thus a girl who
impulsively takes a small overdose of tablets following a relationship crisis or an argument with her
parents. It is however important to remember that any suicide attempt can be fatal, whether or not it
is so intended.
High-risk suicide attempts are characterised by:
1)
The presence of signs of depression before and after the suicide attempt
2)
Planning
3)
More serious attempt, e.g., a very large quantity of pills
4)
The presence of a suicide note
5)
Previous attempted suicide
6)
Secrecy, tells nobody, or takes overdose when there is a good chance that s/he will not be
found for a long time
7)
The use of certain methods, e.g., firearm, gassing, hanging, etc.
8)
The presence of severe problems without a possible solution that have led to a feeling of
despair, e.g., ongoing incestuous abuse
9)
After the attempt, there is persistence of suicidal ideation
10)
Associated problems with authorities, alcohol or substance abuse
11)
Male gender.
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