Emotional Disorders with Childhood Onset
James C. Harris
Childhood is a time of considerable developmental plasticity, and research has shown that most children with emotional disorders do not remain symptomatic and do not present as disordered adults. Still, some childhood anxiety disorders can be precursors to continued anxiety and mood disorders in adulthood, especially if there are predisposing temperamental features of behavioral inhibition (social anxiety) in the child and a strong family history of anxiety disorder. Some emotional disorders in childhood appear as quantitative exaggerations of normal developmental trends rather than as qualitatively abnormal behavior. Moreover, symptom complexes beginning in early childhood form less clearly defined entities than adult disorders. From a developmental perspective, the appropriateness of emotional behavior must be gauged in terms of its intensity, frequency, age of onset, duration, and the setting in which it occurs.
Separation anxiety, social phobia, obsessive-compulsive disorder, and generalized anxiety disorder are categorized as anxiety disorders. A child with one anxiety disorder may have other concurrent anxiety disorder diagnoses, so several forms of anxiety disorder may occur simultaneously. Panic attacks accompanying an anxiety disorder ordinarily begin in adolescence, although they may occur in preadolescence.
Children and adolescents may develop fears that are focused on a wide variety of objects or situations. Fears or phobias are not necessarily a part of normal development; some fears, however, do seem specific to a particular developmental phase and may arise in a majority of children (e.g., fear of animals in preschool children). A distinction is made between fearfulness that is qualitatively different from normal behavior and fears that are exaggerations of normal behavior. The developmental age is considered along with the degree of anxiety. Some fears are specific to a particular situation, and others are part of a more generalized anxiety disorder.
In preschool children, transient fears of insects, animals, monsters, and the dark are common. Fears of storms, heights, and bodily harm are common in school-aged children, and fears of entering social situations and concerns about appearance (dysmorphobia) are common in adolescents. If these symptoms persist beyond the developmental period when they are common and are associated with sufficient anxiety to interfere with everyday activities, referral for treatment is recommended.
SEPARATION ANXIETY DISORDER AND SCHOOL REFUSAL
School-related problems, including school refusal as a result of separation anxiety disorder, are a rapidly growing part of pediatric practice. Excessive school absence is a problem of considerable importance nationwide, with both health and social implications. Patterns of absence are established early in the school career; thus, a small proportion of children makes up a large percentage of the absences. Families at high risk for chronic medical and psychosocial problems should be identified by monitoring school absence patterns. School attendance has been suggested as one marker of how well a child is coping with chronic stress. Attending school is the first of many prolonged separations. Eighty percent of preschool children have difficulty adapting to school. By 6 to 8 years of age, symptoms are more common in only children and in those who have been overly dependent.
The child with anxiety causing school refusal was initially described as being truant. However, researchers discovered that these children with school refusal feared that something terrible would happen to their mother, and this fear made them run home for reassurance and relief of anxiety. By 1941, the designation school phobia was used to distinguish it from the more common delinquent variety of nonattendance. Phobic tendencies and obsessional symptoms were described, and it was suggested that, if cases were left untreated, a more crippling adult disorder could develop.
Epidemiology
Children with separation anxiety disorder commonly have a second psychiatric diagnosis. Rates are highest during the following periods: at the time of school entry and soon after (5 to 7 years of age), when separation anxiety alone is the most common presentation; at about 11 years of age, when symptoms may be associated with school changes; and at 14 years of age and older, when symptoms begin to differ in type and severity and are associated with more severe psychiatric disorders.
The prevalence of all forms of school refusal is reported to be approximately 4% in young school-aged children; this represents 5% to 8% of referrals to child psychiatry clinics. In 10- to 11-year-old children, the rate is lower (1% to 3%).
Etiology
Most often, school refusal is part of an emotional disturbance; however, the term does not designate one cause. Symptoms may develop in several ways according to the various theories, as follows:
Psychodynamic theory: Phobic symptoms arise from externalization of frightening impulses and displacement to a neutral object, which is then avoided.
Learning theory: Maladaptive responses are learned through operant conditioning by adult attention to symptoms.
Interpersonal or family interaction difficulty (60% to 80% of younger children): An unduly dependent child is affected by maternal anxieties and conflicts and becomes symptomatic when he or she must leave home. An often mutual and hostile dependency in the parent-child relationship exists. Symptoms result from a fear of leaving home.
Precipitating factors may be a minor accident, illness, or operation, leaving home for a new camp or school, the departure or loss of a school friend, or death of or illness in a relative to whom the child was attached. These events are experienced as threats and elicit anxiety. Fear of real situations at school or concerns related to self-esteem make up 50% of cases of school refusal in school-aged children. School refusal has also been reported in children with cancer who have been at home with continuous care over longer periods of time.
In addition, behavioral inhibition may be an early expression of a genetic predisposition to separation anxiety. Animal models suggest that variants of the corticotropin-releasing hormone gene may be associated with being prone to anxiety.
It is also important to determine when there are multiple causes of the child’s problem (e.g., when anxiety is related to some aspect of the school situation and the child also has separation anxiety). A depressive disorder must be distinguished from demoralization, especially in the older child and adolescent. A depressive subgroup of school refusers is important to identify, because depressive disorder with suicide has been reported in children and adolescents with school refusal. Eldest and youngest children may be affected more frequently.
Clinical Presentation
The essential feature of a separation anxiety disorder is excessive anxiety concerning separation from the home and from those to whom the child is attached. Separation symptoms are more common in girls than boys and present with the following:
Vague complaints before school or reluctance to attend school progress to total refusal to go or remain in school despite entreaty, recrimination, and punishment.
Overt signs of overanxiety and panic when the time comes to leave for school. The child often cannot set out for school or returns after going halfway. When the parent takes the child to school, the separation moment is dramatic, with clinging to the parent and refusal to separate.
Symptoms may assume a somatic disguise, with loss of appetite, nausea, vomiting, syncope, headache, abdominal pain, vague malaise, diarrhea, limb pains, and tachycardia. Complaints may be expressed in the morning before school or even in school without a clear expression of the fears, which are elicited only on careful inquiry. The child may anticipate the occurrence of symptoms, expecting to be ill, but becomes quickly asymptomatic when allowed to stay home.
Separation anxiety may be manifested as school refusal. The onset may be acute in young children and more gradual in its onset in adolescents and older children, with a decline in peer group activities and activities outside the home. The child may cling to the mother and try to control her, may become stubborn and argumentative in contrast to earlier compliance, and often directs anger toward the mother. There may be no precipitating event other than a change to a more senior school. In this older age group, closer examination may demonstrate depressive symptoms or other behavior problems or, rarely, a psychotic illness. Long-standing family dysfunction may be noted, with a personal history of anxiety when entering social situations. Lack of normal independence and immature sexual identification may be part of the young person’s problems in coping with independence.
Diagnosis
Toddlers and preschool children normally show anxiety over real or potential separation from caregivers. A separation anxiety disorder is diagnosed when the fear over separation interferes with developmental tasks and persists, leading to impairment in peer and family relationships. Diagnostic criteria for separation anxiety disorder are described in Box 103.1.
Treatment
Treatment is individualized. Family therapy is recommended to reestablish parent-child boundaries and roles. An immediate goal is to assign family tasks, beginning with immediate return to school after clarifying the child’s experience of the school situation.
For those children who fail to respond to psychotherapy or behavioral approaches, pharmacotherapy may be considered for separation anxiety disorder. Treatment studies combining antidepressants with cognitive behavioral therapy for separation anxiety disorder have been effective; however, these medications require careful monitoring for side effects. Serotonin
reuptake inhibitors, such as fluoxetine and fluvoxamine, are preferred for anxiety disorders but are best combined with psychological treatments. Careful monitoring for drug side effects is necessary.
reuptake inhibitors, such as fluoxetine and fluvoxamine, are preferred for anxiety disorders but are best combined with psychological treatments. Careful monitoring for drug side effects is necessary.
BOX 103.1 Diagnostic Criteria for Separation Anxiety Disorder
Developmentally inappropriate and excessive anxiety exists concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated.
Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures.
Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped).
Persistent reluctance or refusal to go to school or elsewhere because of fear of separation.
Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings.
Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home.
Repeated nightmares involving the theme of separation.
Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.
The duration of the disturbance is at least 4 weeks.
The onset is before age 18 years.
The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
The disturbance does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and, in adolescents and adults, is not better accounted for by panic disorder with agoraphobia.
Specify if:
Early onset: if onset occurs before age 6 years.
Footnote
Reprinted with permission from
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Text revision. Washington, DC: American Psychiatric Association, 2000.
A specific treatment plan includes an early return to school, and the teacher and staff must be fully involved in treatment. The father or both parents should take the child to school in the morning. Regular support and praise for parents in their efforts are essential. Bringing in a school friend to go to school with the affected child may help. Regular interviews, focusing on potential anxiety or stress at home and school, are needed to establish a regular pattern of attendance. A breakdown in attendance after a weekend, after an illness of a day or two, or at the beginning of a new term may be expected. Family illness or bereavement and changes to a new classroom increase the risk of recurrence. The parents must understand that being firm is supportive and is not a rejection of the child’s needs, because the child’s pleas to stay home can be heartrending. Sometimes an outside person may have to be brought in to take the child to school. Regular office visits and telephone calls are required in the first weeks following the return to school. Family treatment and social work support may be needed, and parental disorders should be treated. The physician must establish a trusting relationship with the family, clarify situations causing anxiety at home, and desensitize, confront, and persist. Hospitalization may be needed if the parent-child bond is strong and outpatient intervention fails.
In most series, two-thirds or more of patients improve. The prognosis is related to the severity of symptoms and the response to psychosocial support.
SPECIFIC PHOBIA
A specific phobia is defined as a marked and persistent fear of a specific object or situation. It is distinguished from a panic attack, in which the fear is of having another panic attack, or from a social phobia, in which the fear is of humiliation or embarrassment in a social situation. In a specific phobia, exposure to the phobic stimulus ordinarily provokes an immediate response of anxiety, which is associated with a panicky feeling, sweating, tachycardia, and problems with breathing. The more physically distant the patient is from the phobic stimulus, the less severe the symptoms will be. Anticipatory anxiety is generally noted when confrontation with the phobic stimulus is expected.
A diagnosis of specific phobia is made only if avoidance of the phobic stimulus interferes with normal activities or relationships. The anxiety is not relieved by knowing that other people do not regard the situation as threatening. Subtypes include specific phobias of animals and natural events (e.g., heights, thunder) or situations (e.g., being in elevators or enclosed spaces). Diagnostic criteria for specific phobia are described in Box 103.2.
The age of onset of symptoms varies, but certain phobias such as animal phobias almost always start in childhood. These simple phobias beginning in childhood usually disappear without treatment. The degree of social impairment is related to how easily the child can avoid the phobic stimulus. Specific phobias may occur alone or along with another phobic condition, although the reported prevalence varies with the threshold chosen to determine impairment.
Phobias may be learned maladaptive responses. They may represent the persistence of age-related common fears, or they may have unrecognized personal psychological significance.
For phobias considered to be learned responses or developmental in nature, behavior therapy is the appropriate treatment. Methods used include direct exposure to the feared situation with social support or desensitization through systematic presentation of the child’s self-generated hierarchy of feared situations while the child is fully relaxed. Operant behavior methods also can be used by providing rewards to the child after planned entry into the feared situation. If the feared situation is social, role rehearsal before entering the situation or observing another child or adult deal with the feared situation is recommended. If the situation has a personal psychodynamic
meaning for the child, individual or family treatment approaches may be necessary. Future phobic symptoms can be prevented by teaching the child coping strategies to deal with fearful and unexpected situations.
meaning for the child, individual or family treatment approaches may be necessary. Future phobic symptoms can be prevented by teaching the child coping strategies to deal with fearful and unexpected situations.
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