Jane Roberts1 and Aaron Vallance2
1 Clinical Innovation and Research Centre, Royal College of General Practitioners, London, UK
2 Metabolic and Clinical Trials Unit, Department of Mental Health Sciences, The Royal Free Hospital, London, UK
This chapter considers the presentation and management of anxiety and depression in children and young people, and explores the challenges clinicians face in responding to the needs of children and their families. As in adults, the two conditions are frequently comorbid, but they will be discussed in turn.
In primary care, the consultation is an opportunity for a therapeutic encounter. However, GPs often report feeling anxious and uncertain when faced with young people experiencing emotional distress – a state that can lead to inertia or disengagement and leave the young person isolated and unsure where to turn.
A first consultation should begin the GP showing an interest and concern, thereby reinforcing that mental health issues are taken as seriously as, say, acne or period pain. This involves attentive listening and a non-judgemental stance, displaying compassion and curiosity in the young person’s story. Using natural language and a lightness of tone, appropriate and judicious use of humour can serve to minimise the formal tone that clinicians can unwittingly adopt and which young people often report as a barrier. Focusing initially on the wider psychosocial context (e.g. family, friends, education/employment, how they spend their time) not only provides information but may ‘break the ice’ for exploring sensitive emotional issues later on. Asking about drug and alcohol use (e.g. as counterproductive coping strategies), and sexual activity/orientation are also important, but you may sense it is more appropriate to raise this later on. Establishing rapport is important for the long term: depression and anxiety in adolescence are often persistent or recurrent. Enquire about the family’s mental health history: this not only might be relevant to the young person’s experience, but also may cast light on the meaning of mental illness in the family. The child may have been a young carer. Moreover, evidence shows that treating parental depression or anxiety can help the child’s disorder. Humah’s case reflects how depression and anxiety may afflict those across generations, as well as the importance of understanding religious/cultural perspectives.
Depression is not uncommon in young people: the 1-year global prevalence rate exceeds 4% in mid–late adolescence, with increasing preponderance in girls with age. Diagnostic criteria are as for adults, although irritability, oppositional behaviours and somatic symptoms tend to be more common, whilst functionality and enjoyment in activities can often be preserved (Box 2.2). Potential contributing factors include: genetic and personality factors; parental mental health problems, conflict and lack of warmth; previous and current life events (including loss and trauma); and physical illness. School can harbour both protective factors (e.g. routine, activity, peers), exacerbating factors (e.g. bullying, stressful peer dynamics, academic worries) and consequences (e.g. deteriorating school grades or peer relationships).
To aid diagnosis, ask direct questions about: persistence and severity of low mood, concentration, energy, enjoyment, negative thoughts, and sleep, eating and weight patterns. Risk should be evaluated at the first appointment (see below). It is better to aim for a therapeutic consultation rather than an exhaustive one; building trust is important. Ideally book further consultations there and then, which may help the young person to feel more cared for.
Assessing risk can be done sensitively; for example, start by asking about hopelessness and whether life’s worth living, then eventually build up to direct questions on wanting to die and then on self-harming or suicidal ideation, intent or plan (Box 2.3). There is no evidence that asking such questions increases risk, whilst an accurate risk assessment would reduce risk.
Suicidal ideation is common at some point in adolescence, although a genuine intent to kill oneself is relatively rare. Depression is particularly associated with self-harm and suicide, although teenagers may cut themselves in the absence of psychiatric disorder. Deliberate self-harm also commonly occurs with emotionally unstable personality traits, other features of which include feelings of emptiness, emotional volatility and relationship difficulties, whilst a history of trauma or rejection is common. What to cover when assessing risk is outlined in Box 2.3. Find out about the chronology of any cutting behaviour, triggers, exacerbating and relieving factors. Although most adolescent self-harm is not acutely associated with suicide, the long-term likelihood of eventual death by suicide (in adult years) increases 50–100-fold.
If you are concerned about a significant and acute risk, act promptly. Confidentiality issues need to be considered, in particular deciding at what point parents need to know, and what they are told. There is often a complex balancing act between respecting the young person’s right to confidentiality and maintaining short- and long-term rapport on one hand, with needing to tell parents to prevent serious risk of harm and galvanise family support and communication on the other. Gently encouraging the young person to share details with parents is often helpful. Advise parents on keeping the home safe (e.g. securing sharps and medicine).
Make an immediate referral to CAMHS (Child and Adolescent Mental Health Services) if concerned about mental health and risk, and provide as much information as possible; the time scale of a CAMHS assessment will depend on risk severity. In emergencies, CAMHS can usually respond with a same or next-day assessment; sending the young person with their family to the Emergency Department (ED) may be required. Contact your local safeguarding clinical lead or safeguarding team immediately for child protection concerns. You can seek advice from the duty social worker, without necessarily first disclosing the child’s name. Share concerns with an experienced colleague and document everything clearly.
GPs often feel they can offer little. However NICE (2005) suggests a stepped-care approach with active monitoring as the first option, unless the young person has moderate or severe depression (NICE Guidelines 28 and 90). This represents an opportunity to build a therapeutic relationship and adopt a resilience-building approach where the skills and assets of the young person themselves, and local supports, can be better employed. With permission, contacting the school can determine what they can offer (e.g. school counsellors, nurses and access to youth workers). Learning difficulties can sometimes contribute to depression and schools are well placed to intervene.
Other resources may exist locally, including NHS or charity-sector youth counselling and support, and some primary care services have links to youth workers.
If depression persists or is moderate or severe, then consider referring to specialist CAMHS services. CAMHS may offer psychological therapy including cognitive behavioural therapy (CBT), and possibly family therapy or psychotherapy. The NICE (2005) guideline for children and young people suggests psychological therapy before medication is considered; however, some experts advise earlier use of medication in severe depression. In addition, particularly in the current financial climate, waiting times for specialist intervention may necessitate pragmatic clinical decisions in the best interests of the patient.
Usually antidepressant prescribing is initiated and monitored by specialist CAMHS services. NICE (2005) advises fluoxetine as the first-line medication for paediatric depression as evidence suggests it has the best risk-benefit profile; other selective serotonin reuptake inhibitors (SSRIs – e.g. sertraline, citalopram) are generally second-line. SSRIs have been associated with suicidal ideation and non-fatal acts (~4%, vs 2% in placebo groups) in paediatric studies.
Overall, the majority of adolescents recover within 1 year, with episode durations typically ranging from 2 to 9 months. There is, however, a significant risk of later relapse and/or continuation into adulthood.
Anxiety is a normal experience, one powerfully shaped by evolution: its very function is to keep the individual safe. Over millennia, genes bestowing the most potent ‘fight-or-flight’ response are passed through the generations. Anxiety comprises emotional (e.g. distress), physiological (e.g. muscle tension), cognitive (e.g. anticipation) and behavioural (e.g. escape, avoidance) responses.
Disorders are defined if anxiety is excessive and/or inappropriate to context or developmental stage, causing significant distress and/or impairment. The developmental aspect is important: different childhood stages are normally associated with different fears, influenced by cognitive capacity and social development. Fears of animals, monsters and darkness are typical in younger children (e.g. 3–6 years), whilst fears of failure, rejection, performance and social situations are common in teenagers. What is considered normal in a younger child may constitute a disorder in an older child. Paralleling the development of normal fears, generalised anxiety, social phobia, agoraphobia and panic disorder usually arise in adolescence, whilst separation anxiety and simple phobias occur in younger children. The evolutionary role of anxiety may explain the high aggregate point-prevalence rate of anxiety disorders of approximately 4%. One-third have two or more anxiety disorders, and 40% have another psychiatric disorder (particularly depression).
Humah suffers from generalised anxiety disorder and depression, reflecting their strong comorbidity, possibly underpinned by a shared genetic substrate. Generalised anxiety disorder involves persistent and varied worries (e.g. health, family, friends, school) lasting 6+ months (Box 2.4). In contrast, panic disorder consists of spontaneous momentary bouts of severe anxiety occurring for more than 1 month. Its unpredictability can lead to anticipatory fears of further attacks.
Specific or simple phobias are categorised according to circumstances/objects (e.g. situational, animal, nature and blood). Agoraphobia involves anxiety in two of: public places, crowds, leaving home or travelling alone. Social phobia, defined by a disproportionate fear of judgement or ridicule (e.g. whilst performing in class, social events) often leads to avoidance, thereby reinforcing anxiety. Unlike in autistic spectrum disorder, the capacity to socialise is generally intact. Social anxiety disorder in childhood and separation anxiety disorder (excessive anxiety about, or separating from, attachment figures) can lead to school refusal. Avoidance behaviour is common in all these anxiety subtypes. Different subtypes probably evolved to confer additional protection against specific dangers.
Family studies reveal strong associations between parental anxiety/depression and anxiety disorders in their children. Twin studies point to non-shared environmental and genetic factors: heritability is 40%; complex gene–environmental interplay is likely. Neuroimaging studies reveal reduced volume in some brain regions (e.g. the limbic system). Temperament is a risk factor, including: ‘inhibited temperament’ (tendency to express apprehension and autonomic reactivity in unfamiliar situations), shyness and an ‘anxious-resistant’ attachment style.
Environmental risk factors include: parental over-control, over-protection and rejection, and modelling of anxious behaviours. Such parenting may impede the child’s development of autonomy and inner security. Chronic stressors and traumatic events are also implicated. Moreover, research shows a relationship between prenatal maternal stress and childhood anxiety, a potentially evolutionary adaptive mechanism to protect the child against environmental threats. Finally, medical conditions (e.g. asthma) that cause recurrent dyspnoea increase risk, particularly for panic disorder and separation anxiety.
Affected children may explicitly complain of somatic symptoms rather than frank anxiety: 79% of children presenting to primary care with non-organic recurrent abdominal pain have anxiety disorder. Distinguishing normal fears from anxiety disorder is important: evaluate the triggers, severity, impact, distress and impairment.
Differential and comorbid diagnoses include: autistic spectrum disorder, depression and post-traumatic stress disorder. Exclude medical disorders and drugs that can mimic or induce anxiety states; further investigations may be indicated. Examples include: hyperthyroidism (e.g. Graves’ disease), arrhythmias (e.g. supraventricular tachycardia), phaeochromocytoma, asthma and epilepsy. Implicated drugs include: street drugs (e.g. amphetamines), pseudoephedrine and caffeine.
Referral to specialist CAMHS services may be indicated. Therapeutic guidelines can be tentatively extrapolated from NICE (2011) guidance on generalised anxiety and panic disorders in adults, where psycho-education and self-help are first steps, and followed by medication or CBT if necessary. CAMHS services would usually consider cognitive-behavioural strategies in the first instance, with medication added if anxiety is severe, debilitating or non-responsive. Research indicates that combining medication with CBT is the most effective intervention.
Cognitive-behavioural therapy comprises both cognitive (e.g. challenging negative thoughts, weighing-up evidence for-and-against, positive self-talk) and behavioural methods (e.g. relaxation exercises, exposure-and-response prevention). Family and school can help the child apply coursework in between sessions. Manuals (e.g. Think Good, Feel Good – see ‘Further reading’) can provide accessible material for clinicians, young people and families, whilst evidence also supports computerised or group CBT.
Evidence leans towards SSRI medication, particularly fluoxetine, fluvoxamine and sertraline. Medication is usually continued for 6–12 months after symptom remission. Studies do not support benzodiazepines, which can carry risks (e.g. behavioural disinhibition, dependence). There is little paediatric evidence on beta-blockers.
Overall, anxiety or depression in adolescence is associated with a 2–3 times increased risk for adult anxiety disorders. Although most children with anxiety disorder are spared it in adulthood, most adults with anxiety or depressive disorders probably had anxiety disorder as children. Continuity into adulthood may be homotypic (where the same subtype of anxiety disorder re-emerges) or heterotypic (where a different subtype occurs).
Anxiety and depression are not uncommon in children and young people, and the primary care clinician has an important role to play in detection, and working with parents, schools and third-sector youth workers to support management of the young person.