Child and adolescent psychopathology by Wilmhurst (second edition) – Summary chapter 7

Disorder

SEPARATION ANXIETY DISORDER

Clinical description

These children experience developmentally inappropriate intense feelings of distress upon separation of the caregiver lasting for at least four weeks. The disorder manifests itself before 18 years of age and 6 is early onset. School refusal is common with this disorder.

Symptoms

At least three of the following for at least four weeks:

• Excessive distress in anticipation of separation about the caregiver.
• Excessive worry about potential harm to the caregiver.
• Preoccupation with a future adverse event causing separation from the caregiver.
• Reluctance to go away from familiar territory.
• Reluctance to be alone or sleep away from home.
• Nightmares about separation.
• Repeated physical complaints when separation is anticipated.

Prevalence and course

The prevalence is 4% in general populations but up to 10% in clinical populations. It is more frequent in females than in males and is comorbid with GAD, depression and somatic complaints. It may be a precursor for increased risk for disorders in adulthood (e.g. depression; anxiety disorders) and agoraphobia and panic attacks for females in adulthood.

Aetiology

A lot of children with SAD have mothers with a history of anxiety disorders. Overprotectiveness and reinforcement of the child’s avoidance behaviours can maintain SAD. This can be the result of maternal depression and family dysfunction.

Assessment and treatment

It can be treated using cognitive-behavioural interventions (e.g. Coping Cat programme). Focusing on coping skills or exposure can be useful. Treatment of school refusal can be an important component (e.g. structured contingency management).

Disorder

SELECTIVE MUTISM

Clinical description

These children demonstrate a reluctance to verbalize when expected, lasting at least one month. It is not the response to weak language skills or a speech problem.

Prevalence and course

The prevalence ranges from .03% to 1% with higher rates in clinical populations. Children often outgrow it but may be a risk for social anxiety disorder.

Aetiology

The onset is associated with the beginning of formal schooling. Children who are prone to negative affectivity or behavioural inhibition may be at increased risk for the disorder. Parental history of shyness (1), indicators of social anxiety (2) and social isolation (3) are risk factors.

Assessment and treatment

Behavioural methods (1), systematic desensitization (2) and modelling (3) appear effective.

Disorder

PHOBIAS AND FEARS

Clinical description

These children experience a persistent, significant fear of an object or place that does not have a reasonable basis. There is frequent avoidance of the object or event and exposure may elicit significant physiological responses. The focus of fear is anticipation of harm. There often is a strong desire to escape. It leads to a significant impairment in functioning.

Symptoms

This includes excessive reactions to encountering a feared object or situation and can include the following:

• Immediate fear or anxiety.
• Avoidance.
• Excessive responses.
• Persistence.

Prevalence and course

The prevalence is 5% for young children and 16% in adolescence. More females than males have phobias. Situation-specific phobias tend to occur later than phobias related to environmental concerns. The number of fears tend to decline with age but worries tend to escalate. Protective behaviour as a result of a phobia can lead to insecure attachment as the child does not learn how to internalize information on how to cope with distressing circumstances.

Aetiology

Phobias can develop as a result of individual conditioning experiences (e.g. classical conditioning). Anxious attachment is a risk factor. Temperament (1), family characteristics (2), exposure to conditioning experiences (3), parent psychopathology (4), family communication styles (5), parenting practices (6) and attachment history (7) are risk factors for the development of specific phobias.

Assessment and treatment

Modelling and reinforced practice can be used as treatment for phobias.  The models can be live or videotaped and can be selected from a wide range of sources (e.g. parents; peers). In-vivo exposure is most effective. Systematic desensitization can be used.

Disorder

SOCIAL ANXIETY DISORDER

Clinical description

These children have a pervasive fear of embarrassment or humiliation that leads to avoidance of social or performance situations. A diagnosis requires that the anxiety occurs in presence of peers and not only in the presence of adults for at least six months. Children may demonstrate avoidant reactions (1), escape behaviours (2), negative self-appraisals (3) and increased physiological arousal (4).

Symptoms

In situations where people feel that they may be scrutinized excessive fear and anxiety may be:

• Exaggerated beyond any actual threat posed.
• Persistent.
• Causing significant distress or impairment.

There typically is evidence of normal social interaction with familiar people and pervasive fear across situations.

Prevalence and course

The lifetime prevalence is between 3% and 13%. For children, the prevalence is 1% to 2% and is more common (27%) in children with GAD and children with separation anxiety disorder (i.e. 5%). The prevalence for adolescents and adults is 7%. Children with social anxiety disorders tend to be older (1), have higher levels of severity (2) and are more likely to become depressed later in life (3). The onset is typically in adolescence. They are at risk for school dropout and decreased quality of life. Few people seek treatment.

Aetiology

Children with behavioural inhibition experience more social rejection and this may lead to the development of avoidant coping mechanisms, which is a risk factor for social anxiety disorder. Parental communication (1), attachment (2), parenting style (3) and first-degree relatives with social anxiety disorder (4) are a risk factor for social anxiety disorder.

Assessment and treatment

Social skills training (1), exposure (2), modelling (3), reinforced practice (4) and systematic desensitization (5) can be used.

Disorder

PANIC ATTACKS

Clinical description

These children experience an intense, overwhelming inescapable fear that penetrates thoughts, feelings and sensations. The attacks last about 10 minutes, are sudden and acute. In adulthood, the attacks are often mistaken for heart attacks. They can accompany an anxiety disorder and can be triggered by situations.

Symptoms

It consists at least four of the following symptoms:

• Heart palpitations.
• Sweating.
• Trembling or shaking.
• Nausea and abdominal discomfort.
• Chills or heat.
• Feeling dizzy or lightheaded.
• A feeling of numbness or a tingling feeling.
• Feelings of loss of control.
• Depersonalization.
• Sensations of choking.
• Chest pain.
• Shortness of breath.
• Fear of dying.

Prevalence and course

The lifetime prevalence is between 3.3% to 11.6% in youth. It is more common in adolescents than in children but it can occur in children. It mainly occurs between the ages of 15 and 19. It can be triggered by a specific phobia or can be the response to separation anxiety disorder

Aetiology

Other anxiety and depressive disorders (1), negative affect (2), anxiety sensitivity (3) and separation anxiety (4) are a risk factor for the development of panic attacks and panic attacks are a risk factor for the development of these factors. Panic attacks may result from the interaction between temperament (e.g. behavioural inhibition) and attachment issues. Panic attacks may also result from misinterpretation of bodily sensations. Heightened sensitivity in panic-prone individuals may be a risk factor. 

Disorder

PANIC DISORDER

Clinical description

These children experience a persistent fear of recurrent panic attacks.

Symptoms

In the month after a panic attack, the following symptoms are demonstrated:

• There is persistent fear of having another panic attack AND/OR
• The attack results in significant behavioural change resulting from attempts to avoid having another panic attack.

Prevalence and course

Lifetime prevalence is 3.5% with onset typically between late adolescence and early thirties. Women are more likely than men to have a panic disorder. The course of panic disorder tends to be chronic when it onsets in adolescence.

Aetiology

Panic disorder is associated with depression, other anxiety disorders and bipolar disorder. Having a first-degree relative with a panic disorder is a risk factor. Irregular activity of norepinephrine is associated with the onset of panic attacks.

Assessment and treatment

Anti-depressant drugs which restore appropriate levels of norepinephrine can be successful in alleviating panic attacks. SSRIs may be effective in children and youth. Cognitive-behavioural treatment may be effective in developing coping skills to fend off panic attacks.

Disorder

AGORAPHOBIA

Clinical description

These children avoid certain situations. The situations provoke a sense of fear and anxiety and people have a sense that they might not be able to escape if something (e.g. panic attack) happens there.

Symptoms

The avoidance of two or more possible situations:

• Use of public transportation.
• Open spaces.
• Enclosed spaces.
• Standing in line.
• Being out of the home, alone.

Prevalence and course

The yearly prevalence is 1.7% and is more common in females than in males. The age of onset is typically in late adolescence or early adulthood. People often develop agoraphobia after a panic attack or a panic disorder.

Aetiology

There is a strong biological component and it has been associated with experiencing negative life events or other stressful situations. The family situation often lacks warmth and is high on parental overprotection.

Assessment and treatment

Treatment includes systematic desensitization (1), participant modelling (2) and reinforced practice (3).

Disorder

GENERAL ANXIETY DISORDER

Clinical description

These children do not have a specific focus for their worries but have pervasive worries that generalizes across situations and topics. There is excessive worry and an inability to control the worry. There are often perfectionistic tendencies and they may require excessive reassurance from others regarding their performance.

Symptoms

The following symptoms are included in the diagnosis for the duration of 6 months:

• Excessive worry.
• Pervasive mood.
• Significant impairment.
• Inability to control the worry.
• Muscle tension.
• Concentration.
• Easily fatigued.
• Restlessness.
• Irritability.
• Problems with concentration.
• Sleep disturbance.

Prevalence and course

The lifetime prevalence is between 2% and 5%. Early GAD is often comorbid with separation anxiety disorder and GAD in adolescence and adulthood is often comorbid with phobia or depression.

Aetiology

There is a large genetic component. The neurotransmitter GABA may malfunction and this can lead to continued firing and excitation which is a risk factor for GAD. Anxious individuals may anticipate and interpret ambiguous events in a negative way. They tend to engage in self-blame quicker and focus on the negative rather than positive aspects of events. Anxious parents may increase children’s tendencies to engage in anxious and avoidant behaviours.

Assessment and treatment

Children of anxious parents may not benefit from CBT to reduce anxiety unless the parents are also included. The Coping Cat programme may be effective in the treatment of GAD for children.

Disorder

OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

Clinical description

These disorders include obsessive thoughts and compulsive behaviours. The thoughts and behaviours differ per disorder. The compulsive behaviours are often attempts to neutralize the anxiety caused by the obsessive thoughts. The behaviours are typically excessive (i.e. take up more than an hour per day) and cause significant disruption to daily routines.

Prevalence and course

The prevalence is 1% in the general population and more females than males meet the requirements for OCD. Males typically have an earlier onset. Hoarding symptoms are more common among older adults than children but can appear in early adolescence. Prevalence rates for body dysmorphic disorder are 2% and do not differ between males and females.

Aetiology

OCD has been linked to low levels of serotonin and a dysfunction in the orbital region of the frontal cortex. A malfunction of the caudate nuclei is a risk factor. People with family history of Tourette’s disorder have increased risk of developing OCD.

Assessment and treatment

Treatments for OCD are primarily based on behavioural programmes or medical management (e.g. SSRI). Exposure and response prevention (ERP) treatment may be effective in the treatment of OCD. CBFT may also be effective.