This section discusses anxiety and mood disorders, which are common mental health presentations to medical practitioners. More severe problems are also discussed but present less frequently than generalised anxiety disorders and mood disorders.

Anxiety disorders

General principles

• A thorough history should include details of anxiety symptoms, length of time anxiety has persisted, the degree to which the child is impaired in their day-to-day activities and their relationships.
  
• Behavioural analysis: how is the problem manifest in the child’s behaviour?
  
• Cognitive analysis: what are the child’s thoughts and emotions associated with the problem?
  
• Family, school and developmental assessment.
  
• Individual interviews of the child or adolescent to help understand the nature of the symptoms and their impact as age appropriate. This will also help with building a therapeutic rapport with the child or adolescent.
  
• Structured instruments and questionnaires may be useful. These include the Anxiety Disorder Interview Schedule, Diagnostic Interview Schedule for Children IV, Revised Child Manifest Anxiety Scale, Childhood Depression Inventory, Children’s Depression Rate Scale and Yale Brown Obsessive Compulsive Scale.

Specific features

Generalised anxiety/phobias

• If symptoms are mild, explore behavioural and/or family support interventions with the child and family and review.
  
• Specific fears (e.g. phobias) and more severe or generalised anxiety disorders will require referral to a mental health specialist.

School refusal

• Conduct a physical examination if the child presents with somatic symptoms.
  
• Assess the source of the anxiety and consider whether further management is required, e.g. family therapy, school-based services such as school counsellor etc.
  
• Return to school is a high priority. If necessary this can be done by gradually increasing the child’s time at school over a short period of time.

• Limited application in early childhood.
  
• In strictly diagnosed ADHD, methylphenidate or dexamphetamine can enhance concentration and attention and reduce morbidity (see chapter 11, Common behavioural and developmental problems, p. 143).
  
• In severe depression, SSRIs such as fluoxetine may be helpful on a case-by-case basis with careful monitoring.
  
• In severe anxiety disorders, imipramine may be helpful.
  
• Benzodiazepines have no proven role in anxiety or depressive disorders in children, and may produce paradoxical agitation.
  
• In adolescents with psychosis, early treatment with newer antipsychotics in collaboration with specialised youth psychiatric services are beneficial.

SSRIs and suicidality

A number of studies have indicated that SSRIs are prescribed for a variety of childhood problems including anxiety disorders, major depressive episodes, ADHD and other disorders. Prescribing rates are increasing in Australia, USA and Europe.

There has been some concern regarding increased risk of suicidality and deliberate self-harm associated with SSRI use in children, although the evidence to date is relatively weak. Risk of deliberate self-harm appears to be highest in the first 2–4 weeks of starting an SSRI. The following guidelines should therefore be adhered to:

• Start with a low dose and increase slowly. Side effects are dose-dependent, but efficacy is not. Always use the lowest effective dose.
  
• Only use as an adjunct to psychotherapy.
  
• Explain to parents (and child if appropriate) about possible adverse effects of antidepressants. Discuss the issues of deliberate self-harm and suicidality and the need for close monitoring, especially in the first 2–4 weeks.
  
• Explain the discontinuation syndrome, which occurs when an SSRI is withdrawn abruptly. This can result in irritability, mood lability, insomnia, anxiety, vivid dreams, nausea, vomiting, headache, dizziness, tremor, dystonia, fatigue, myalgia, rhinorrhoea and chills.
  
• Monitor closely for adverse effects in the first 4 weeks; consider using structured rating instruments.

Somatic responses to stressful situations are common (e.g. sweating during a job interview, or diarrhoea before taking an exam). Somatic complaints in children are also believed to be relatively common and appear as physical sensations related to affective distress.

Psychosomatic or somatoform disorders refer to the presence of physical symptoms suggesting an underlying medical condition without such a condition being found, or where a medical problem cannot adequately account for the level of functional impairment.

Common symptoms include:

• Headache.
  
• Abdominal pain.
  
• Limb pain.
  
• Fatigue.
  
• Pain/soreness.
  
• Disturbance of vision.
  
• Symptoms suggestive of neurological disorders.

Conversion disorder may present with dramatic symptoms such as:

• Gait disturbance.
  
• Paraesthesia.
  
• Paralysis.
  
• Pseudoseizures.

In this situation the onset of the symptom is closely associated to a psychological stressor. Conversion disorders are generally relatively short-lived. They are often alleviated by identification and management of the stressor(s) and in some instances, symptomatic treatment of the physical problem.

Somatisation disorders may present in children whose families have a history of illnesses or psychosomatic disorders. Such patterns may be evident at a multigenerational level where physical symptoms appear to be the ‘currency’ by which affective states are communicated. Possible family relationship difficulties (including sexual abuse) should be considered as part of a thorough assessment.

Children and adolescents with chronic illnesses such as asthma and diabetes may present with exacerbations of their physical symptoms that relate to their affective state. Such responses may be related to a precipitating stressor or may reflect the child’s changing responses to their illness. Increased understanding of the illness and its implications and developmental changes will influence a child’s response to their medical condition.

Children and adolescents may be angry, resent the limitations their condition imposes, and may be particularly sensitive to being different from their peers. Additionally, responses by their parents (e.g. over-or under-protectiveness) may contribute to adjustment problems. Along with somatisation, other difficulties may emerge, such as non-adherence with treatment and family relationship problems.

Management

Management depends on the nature, severity and duration of the problem. Some general principles are:

• It is important to recognise the child’s physical symptoms as genuine and distressing.
  
• Thorough clinical examination, investigation and mental health assessment is usually required. Hospital admission may be required to facilitate this.
  
• Discussion of mind–body interactions can be useful. Discuss early on the possibility that psychological factors are contributing to symptoms or well-being. This may allow the child and family to begin to discuss possible psychological stressors, reducing resistance to mental health input.
  
• Symptomatic treatment (e.g. heat packs, relaxation exercises, physiotherapy, mild analgesia) may be appropriate, along with supportive counselling and/or mental health referral.
  
• Avoid medical over-investigation based on the family’s coercion or unwillingness to consider psychological factors.
  
• It is important that the child and family do not feel they have ‘wasted your time’ if there is no evident medical problem. Maintain an interest in the child and family with a review appointment or follow-up telephone enquiry as appropriate.

Infant mental health

Infant mental health is an area of clinical work aimed at understanding the psychological and emotional development of infants from birth to 3 years and the particular difficulties that they and their families might face.

Babies come into the world with a range of capacities and vulnerabilities and, together with their parents, negotiate their way through the next months and years. This process of attachment, growth and development may be challenged by a range of experiences that stress or interrupt this course. Examples include traumatic events, developmental concerns, hospitalisation of the infant or parent, prematurity, illness or disability, an experience of loss, changing family circumstances or postnatal depression.

Referral to an appropriate mental health clinician may be considered for:

• Persistent crying, irritability or ‘colic’.
  
• Gaze avoidance.
  
• Bonding difficulties.
  
• Slow weight gain.
  
• Persistent feeding or sleeping difficulties.
  
• Persistent behavioural symptoms, e.g. tantrums, nightmares, aggression.
  
• Family relationship problems.
  
• Infants with chronic ill health.
  
• Premature babies and their families.

Family relationship difficulties

A family-sensitive approach is crucial to the assessment and management of childhood mental health issues. Behavioural and/or emotional difficulties in a child can occur in the context of chronic family dysfunction. Conversely, such difficulties can arise in the context of well-functioning families where the child’s temperament, personality or precipitating stressors may lead to behavioural/emotional difficulties for the child and/or parent–child relationship difficulties. When a child is presenting with behavioural and/or emotional difficulties, assessment should include an understanding of the family situation including:

• Family tree, living arrangements and caregiving roles.
  
• Quality of family relationships.
  
• Early attachments/relationships.
  
• History of significant losses, stressors, precipitating factors.
  
• Social/family support networks.
  
• Identifiable ‘risk’ factors such as poverty, illnesses, absent social supports.

Children can be symptom-bearers for family relationship difficulties. In such instances, treatment of the presenting symptom is unlikely to be successful in the long term without appropriate family and/or couple counselling.

When working with families:

• Conduct at least one family interview when dealing with a child with significant behavioural or emotional difficulties.
  
• Interview all family members (including siblings, who are often insightful commentators on family life) and provide an empathic response to each member’s point of view. In the case of young children, observing and commenting upon play themes is useful.
  
• Do not assume that different family members agree on what is the presenting problem. It is often useful to ask family members to rank their concerns such as:

– What is the problem you are most worried about today?

– What is the number one worry you have at the moment … number 2… number3?

– Who in the family is most worried about this problem? Who is the least worried?

• If family members are not present, seek further understanding by questions such as: – If your husband were here today, what would he say about this problem?

– Who else in the family has noticed the changes you have described today?

• Encouraging families to find solutions to their difficulties is more likely to provide longterm change. This may involve helping families identify negative or unhelpful patterns of interaction, helping families identify strengths and resilience and noting small changes/ improvements.

Developmental disorders

Mental health problems occur in children with a wide range of developmental disorders. See chapter 11, Common behavioural and developmental problems and chapter 14, Developmental delay and disability.

Oppositional behaviour

See chapter 11, Common behavioural and developmental problems, p. 139.

Grief and loss

Experiences of grief and loss are inevitable. Where losses are severe or traumatic or where a child has pre-existing vulnerabilities, these experiences can contribute to mental health problems or result in complicated grief reactions. Children may believe that they caused a loved one’s death or illness. Bereaved children may feel different from other children or have difficulty managing the reactions of their peers.

In most instances, the bereaved child can be supported through family, school, community and religion. Family-based counselling/therapy can be helpful to address the child’s grief in the context of other family members’ reactions; it may feel less ‘blaming’ for the child.

Grief and loss experiences for children occur in situations other than bereavement (e.g. chronic illness, refugee status or having a parent with a mental illness). Parental divorce is a common source of grief and loss in children. Grief associated with this situation can be complicated and often remains unacknowledged by significant adults. Children may experience feelings of guilt and self-blame, harbour fantasies of a parental reunion, struggle with divided loyalties and feel anxious about their own future relationships. Feelings of anger, rejection and sadness may lead to behavioural or emotional manifestations of their grief.

Management

• Acknowledge the child’s loss in an empathic and appropriate manner; this can be helpful even when a loss is not recent.
  
• Where a grieving child presents with behavioural or emotional difficulties, gently probe their beliefs about why the loss occurred. This can help the clinican understand the child’s predicament. For example:

– Sometimes when I see children who have lost their (mum/brother, etc.) they feel like it’s their fault that they died or got sick. Does it ever feel like that for you?

– How do you imagine your life would be different if your mum and dad were still together?

– Why do you think people get (cancer, etc.)?

• Assist the family in gaining access to appropriate support and counselling.
  
• Seek further specialist mental health services when a child continues to exhibit extreme distress or prolonged behavioural or emotional difficulties.

See chapter 15, Adolescent health, p. 185.

Psychosis is a general term for states in which mental function is grossly impaired, so that reality testing and insight are lacking, and delusions, hallucinations, incoherence, thought disorder or disorganised behaviour may be apparent.

In the case of ‘organic’ psychosis there may also be a clouding of consciousness, confusion and disorientation, as well as perceptual disturbances. Short-term memory impairment is common in organic brain syndromes.

Anticholinergics, anticonvulsants, antidepressants, antimalarials and benzodiazepines have been associated with psychotic reactions in young people, as have substances of abuse (amphetamines, cocaine, marijuana, opiates and hallucinogens). Organic brain syndromes may follow even minor head injury.

Adolescents may occasionally present in an acutely psychotic state with no prior history of drug ingestion or head injury. In this case the possibility of a ‘functional’ psychosis, schizophrenia or bipolar disorder should be considered. The latter often presents with an elated mood, grandiose ideas, increased energy and reduced sleep requirements.

Management

Children presenting with such symptoms require admission for a full psychiatric and medical assessment.