Emotional or Internalizing Disorders

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Some children develop depression and anxiety, disorders that involve not only maladaptive thoughts and emotions but also maladaptive behaviors. It is important to distinguish these disorders from common depressed mood or childhood worries and fears. Knowledge of normal development of emotions and cognitions is helpful in making these distinctions.


Anxiety disorders in children are most likely to fall into the DSM-IV diagnostic categories of generalized anxiety disorder, simple phobia, separation anxiety disorder, obsessive-compulsive disorder, or posttraumatic stress disorder. Children diagnosed with generalized anxiety disorder have a consistent pattern, lasting six months or more, of uncontrollable and excessive anxiety or worry, with the concerns covering a broad range of events or activities. In addition to worry, symptoms include irritability, restlessness, fatigue, difficulty in concentrating, muscle tension, and sleep disturbances. Deborah Beidel found that this disorder commonly begins at around age ten, is persistent, frequently co-occurs with depression, and is often accompanied by a number of physical symptoms such as sweating, suffering from chills, feeling faint, and having a racing pulse.

In contrast to generalized anxiety disorder, children with the other anxiety disorders have a much more narrow focus of their concerns. Simple phobia is typically focused on a specific situation or object. With separation anxiety, children display excessive fear and worry about becoming separated from their primary attachment figures. This disorder is often expressed as school refusal or school phobia. Obsessive-compulsive disorder consists of specific obsessions

(abnormal thoughts, images, or impulses) or compulsions (repetitive acts). Posttraumatic stress disorder symptoms develop in reaction to having experienced or witnessed a particularly harrowing event. Symptoms include sleep disturbances, irritability, attention problems, exaggerated startle responses, and hyper-vigilance.

For phobias and separation anxiety disorder, it is particularly necessary to determine if a child's fears reflect typical concerns of the age group or are clinically significant. Onset of a fear at a time that is different from children's age-typical fears is often an important indication of clinical significance. Other important indications of clinical significance include fear reactions that are strong, persistent, and intense and that interfere with school, family, or peer relationships. Similarly, it is essential to distinguish symptoms of obsessive-compulsive disorder from typical childhood rituals and routines.

Although generalized anxiety disorder and specific phobias are among the most common disorders in children, the other anxiety disorders are rare. Diagnosis of anxiety disorders is particularly difficult because it is so dependent on self-reports from the children. Children may not recognize that their fears are excessive and typically do not complain about them, although they will go out of their way to avoid situations that evoke the anxiety.

The anxiety disorders are typically viewed as having their origins in learning experiences. Children may learn fears through imitation, instruction, or direct reinforcement. Similarly, compulsive behavior can develop from a chance occurrence when a child felt positive reinforcement for engaging in a particular behavior because it was associated with reduced anxiety.

Anxiety disorders that begin in childhood often persist into adulthood. Thus it is particularly important to treat them early. Behavioral or cognitive therapies have been most successful. Treatment typically involves a combination of graduated exposure to the feared situation and teaching the child adaptive and coping self-statements. The effectiveness and safety of using medications was the subject of several studies at the beginning of the twenty-first century; some early findings showed promising results from the use of antidepressants.

Depression (Mood Disorders)

Depression is another relatively common disorder that often first appears in childhood or adolescence. The DSM-IV includes the depression diagnoses of major depression and dysthymia. To be diagnosed with major depression, children must experience either depressed mood (or irritability) or

Depression is a relatively common mood disorder that often first appears during childhood or adolescence. (Custom Medical Stock)

loss of interest in their usual activities plus other symptoms such as sleep or appetite disturbance, loss of energy, or trouble concentrating. These symptoms must be present nearly every day for two weeks or more. For dysthymia, the symptoms are typically of a lower level of severity but persist for one year or more. For both disorders, the symptoms must cause impairment and must reflect a change from the child's usual level of functioning. Standardized questionnaires are also used to measure depression and determine whether a child's level of symptoms are in the nondepressed range or indicate mild, moderate, or severe levels of depression.

Studies of community samples have found that from 2 percent to 5 percent of children have mood disorders. Rates increase with age. Although rates are about equal for boys and girls in childhood, beginning at puberty girls are twice as likely as boys to receive a depression diagnosis. Depression is a recurrent disorder, with each additional episode increasing the likelihood of a recurrence.

Early stages in the emergence of depression are often missed because children are not likely to recognize or report their distress. Once a depression disorder emerges, it is typically persistent and progresses from relatively mild symptoms to more severe symptoms.

Genetics contribute to the likelihood of a childhood depression occurring, as do neurobiological factors and stress. Children with particular patterns of thinking, such as blaming themselves for negative outcomes while not giving themselves credit for positive outcomes, may be more vulnerable to depression than others.

Treatments that have been found to be successful often involve intervention into the psychosocial components of the disorder. For example, treatment may involve helping the children identify and modify mal-adaptive beliefs and perceptions, develop social skills and problem-solving abilities, and broaden their resources for coping with stress. A particularly effective focus in treatment of adolescents with depression has been on interpersonal relationships, addressing the stage-salient concerns of adolescents. Although they are often prescribed, evidence for the effectiveness of antidepressant medication in children and adolescents has been mixed, possibly because of the methodological challenges of studying medications during periods of still rapid development.

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