Prevalence

The incidence of depression in adolescents is similar to that found in adults, ranging from 0.4% to 8.3%. Rates are lower in preadolescents, ranging from 0.4% to 2.5%.⁴ Epidemiology studies rarely include preschool-aged children; however the available data suggest that depression occurs in approximately 1% of preschool children.^5,6 Gender ratios in rates of depression also change with age. Among preadolescents, similar rates of depression are found in boys and girls. In adolescence, the rate of depression in girls increases dramatically, resulting in a gender ratio of 2 : 1, similar to that found among adults.⁴

Estimation of the prevalence of bipolar disorder in childhood and adolescence is complicated by the general lack of agreement concerning the core characteristics of the disorder, which are discussed further in the diagnosis section of this chapter.⁷ No epidemiological studies currently exist for children. In a study of 14- to 18-year-olds, Lewinsohn and colleagues⁸ found lifetime prevalence rates for a diagnosis of bipolar disorder to be approximately 1%; an additional 5.7% reported subthreshold symptoms. Adolescents with subsyndromal symptoms of bipolar disorder experienced functional impairments similar to those in adolescents with bipolar disorder, which continued into young adulthood. This study was based solely on interviews with adolescents, however, and more recent research has emphasized the importance of including parent report in diagnosing bipolar disorder.⁹

These incidence rates indicate that a significant proportion of children and adolescents suffer from mood disorders. In addition, the overall rates of depression in children and adolescents appear to be increasing.⁵

Course

Mood disorders often have a chronic or relapsing course, associated with continuing impairment. Episodes of MDD last 7 to 9 months on average, with relapse rates of 40% within 2 years and 70% within 5 years.⁴ Weissman and colleagues¹⁰ monitored adolescents with MDD into adulthood and found that 63% had additional depressive episodes within the following 10 to 15 years. These adolescents had a fivefold risk of suicide in comparison with control participants who had no psychiatric diagnosis in adolescence. Those with MDD also experienced continuing impairment in family, work, and social functioning. Dysthymic disorder lasts an average of 4 years and is associated with a high risk of developing MDD within 2 to 3 years, which results in double depression.⁴ Bipolar disorder has a particularly chronic course in childhood, as evidenced by the findings of Geller and colleagues¹¹ in their 4-year follow-up of children with bipolar disorder, in which they reported that children met criteria for a mood episode, on average, for two thirds of the follow-up period.

Effect on Child and Family

Mood disorders can affect several aspects of a child’s development, including social and academic development. Children accomplish many developmental tasks through normal interactions with their environment, such as interpersonal relationships and academic tasks. Mood disorders interrupt these normal interactions. For example, social interaction may be disrupted when a child experiences social withdrawal or is rejected by peers because of unusual behaviors. Similarly, a child may miss considerable instructional time in the classroom because of impaired concentration or behavioral problems related to irritability or disruptive manic behaviors. Once a child has fallen behind in social or academic development, catching up can be extremely difficult. When children experience long mood episodes and frequent relapses, the effect on development is dramatic. As one example, U.S. Department of Education statistics indicate that only 29% of children with an “emotional disturbance” graduated with a standard high school diploma in 2001, whereas 65% dropped out, in comparison to an 86% high school completion rate for all students in the same year.^12,13 Teachers rate children with depression as having more withdrawn and disruptive social behaviors than do nondepressed peers.¹⁴ Adolescents with MDD also experience impairments in social, family, and academic functioning.¹⁵ In comparison with children with attention-deficit/hyperactivity disorder (ADHD), children with bipolar disorder have been found to have impaired relationships with parents and peers, higher rates of placements in special education classes, and higher rates of hospitalization.^16,17

A child’s mood disorder can affect the entire family. Symptoms of irritability and mood lability can increase conflict in the child’s family interactions. Parenting stress also increases because parents are faced with a child’s mood and behavior problems that do not respond to typical parenting strategies.¹⁸ Besides the stress associated with managing the child’s symptoms, families can also suffer from the financial burden associated with the cost of medication and other treatments and lost time from work for doctor appointments. With more severe cases of mood disorders, multiple hospitalizations and legal difficulties related to the child’s behavior further disrupt family life.

Effect on Society

Beyond the direct effect of these conditions on the child and family, there is also a significant effect on society in terms of both human and financial costs. These costs are difficult to estimate, because they include the amount of money invested in treatment and educational services, reduced productivity, lost employment, mortality, and juvenile justice services.¹⁹ Ringel and Sturm³ estimated a national annual expenditure of $11.68 billion on child mental health services (inpatient treatment, outpatient treatment, and psychotropic medications) in the United States, with average costs of $293 per adolescent, $163 per child, and $35 per preschooler. In addition, in 2001, more than 475,000 students aged 6 to 21 received educational services for emotional disturbance under the Individuals with Disabilities Education Act (IDEA); this population constituted 8.1% of all students served under IDEA.¹³ The risk of death or physical injury related to mood disorders is also substantial. Approximately 2000 adolescents in the United States die from suicide every year, many of whom suffer from mood disorders, and an additional 700,000 require medical attention after a suicide attempt.²⁰ According to World Health Organization estimates, MDD is the first and bipolar disorder is the fifth leading cause of years of living with a disability among 15- to 44-year-olds worldwide.¹⁹

Genetics

There is considerable evidence for the heritability of mood disorders in adult populations, with bipolar disorder more strongly influenced by genetics than is unipolar depression. Meta-analyses of adult studies have attributed approximately 60% of the variance in bipolar disorder and 37% of the variance in MDD to genetic factors.^21,22 More recent research, using family and twin studies, has focused on the genetic influences on child and adolescent mood disorders. There is some evidence that earlier onset of a mood disorder is associated with increased prevalence of mood disorders in family members in comparison with later onset, which suggests that earlier onset may signify a more substantial genetic basis.²¹

Studies of the offspring of depressed parents have clearly demonstrated a familial association in childhood and adolescent depression, which could be the result of genetic influences, parent-child interactions, or other environmental influences. Having a parent with depression is one of the strongest predictors of depression in childhood and adolescence.⁵ Several twin studies have been conducted to explore heritability; results have varied widely, depending on measurement strategy, informant, age, and gender. Heritability estimates of parent-rated depressive symptoms range from 30% to 80%.²³ Twin studies have been based on questionnaire reports of depressive or more general internalizing symptoms, and further research is needed with clinical interviews to establish diagnosis.²³

Studies of parents with bipolar disorder have indicated that their offspring are at increased risk for mood disorders in general and bipolar disorder specifically. Among children of parents with bipolar disorder in a meta-analysis, 52% developed some type of mental disorder (2.7 times the risk in comparison with parents without bipolar disorder), 26.5% developed a mood disorder (4 times the risk in comparison with parents without bipolar disorder), and 5.4% developed bipolar disorder (in comparison with none of the control group).²⁴ Studies have consistently demonstrated that for children with bipolar disorder, the rates of bipolar disorder in family members are higher, and younger age at onset is related to stronger family statistical loading of bipolar disorder.^7,21 Children with psychotic depression also tend to have a family history of bipolar disorder and have a higher chance of going on to develop bipolar disorder.⁷ Twin studies of childhood-onset bipolar disorder have yet to be conducted, but the evidence available from family studies suggests that early-onset bipolar disorder may have a particularly strong genetic basis, and young patients may be good candidates for molecular genetic studies.^21,25 Investigators are beginning to explore the molecular genetics of childhood-onset bipolar disorder, but consistent findings have yet to emerge.^7,21

Biological Factors

Research in adults has identified several neurobiological correlates of mood disorders, including abnormalities in basal cortisol, cortisol regulation, corticotropin-releasing hormone, thyroid hormones, growth hormone regulation, and electroencephalographic sleep measures. Research in children and adolescents has been relatively sparse and has inconsistently replicated adult patterns.^26,27

A review by Kaufman and colleagues²⁶ indicates that consistency among child, adolescent, and adult studies has been found only in response to the dexamethasone suppression test and to selective serotonin reuptake inhibitors (SSRIs). Across the lifespan, patients with depression demonstrate nonsuppression of cortisol after the dexamethasone suppression test, which is suggestive of dysregulation of the body’s stress response system. There is also evidence that children and adolescents with depression respond to some SSRI medications in similar ways as do adults, which is discussed in more detail later in this chapter. However, responses to serotonergic probes in children have generally opposed findings in the adult literature, which indicates that there may be developmental differences in the dysregulation of the serotonergic system.²⁶

Other neurobiological studies have yielded inconsistent findings. Studies in children with depression indicate that they show blunted response to agents that trigger growth hormone release, which is similar to adults’ responses; however, results have not been as consistent in adolescents.²⁶ Blunted responsiveness to growth hormone has also been found in nondepressed children who are at increased risk for depression because of family history; this finding indicates that this response may reflect a predisposition to depression.⁵ Sleep studies have shown that adolescents with depression may demonstrate some electroencephalographic sleep responses similar to those of adults with depression, including reduced rapid-eye-movement latency and increased rapid-eye-movement density; however, these patterns have typically not been found in children.²⁶ In contrast to the adult literature, abnormalities in basal levels of thyroid hormones, basal cortisol levels, and corticotropin-releasing hormone have not been consistently observed in children and adolescents.²⁶

Investigators have only begun to examine the brain anatomy and functioning of children and adolescents with mood disorders; therefore, many results are preliminary. Neuroimaging studies with adults can be confounded by long duration of illness and the effects of treatment. Studies with children hold particular promise for identifying brain regions associated with the pathogenesis of mood disorders.²⁸

The prefrontal cortex is influential in mood regulation and has been the focus of much of the neuroimaging research in adult depressive disorders.^5,29 A growing series of child and adolescent studies have also focused on this area. One study revealed patients with MDD who had no family history of mood disorder had larger prefrontal cortical volume than did control patients and patients with MDD who did have a positive family history of mood disorder.²⁸ In another study, glutamatergic concentrations in the anterior cingulate cortex were shown to be decreased by approximately 19% in patients with MDD in comparison with matched controls.^30,31 In addition, significant increases in choline compounds have been found in the left dorsolateral prefrontal cortex of child and adolescent patients with MDD.^32,33 Together, these studies reveal anatomical and biochemical anomalies in the prefrontal cortex in childhood and adolescent MDD. Furthermore, within a group of patients with MDD, Ehilich and colleagues³⁴ found that white matter hyperintensities were associated with history of suicide attempts. Replication and extension of these findings are necessary to establish a clearer understanding of the role of the prefrontal cortex in childhood mood disorders.

In at least 11 studies, children and adolescents with bipolar disorder have been studied with magnetic resonance imaging.³⁵ As reviewed by Frazier and associates,³⁵ these studies collectively show that early-onset bipolar disorder is associated with a variety of functional, anatomical, and biochemical abnormalities in brain regions associated with emotional regulation and processing, including the limbic-thalamic-prefrontal circuit and the limbic-striatal-pallidal-thalamic circuit.

Environmental Factors

The strong familial association in early-onset mood disorders, discussed earlier, probably reflects a combination of genetic influences and family environment influences. Parental mood disorders can affect parent-child interaction, as well as events in the home. In comparison with control families, parent-child interaction in families with depressed children is characterized by higher levels of criticism, less warmth, more conflict, and poorer communication.^15,36–39 Research on expressed emotion has suggested that a low level of parental criticism is predictive of recovery from depressive symptoms, whereas a high level of criticism is associated with the persistence of the mood disorder.⁴⁰ The depressed child’s behavior also plays a role in evoking more negative interactions from parents.⁴¹ Disruptions in the family environment, such as marital discord, abuse, and poor support, can also affect parent-child interaction and the child’s risk for depressive symptoms.^4,42 Furthermore, life stressors in general have been found to precede and exacerbate depressive symptoms.⁵

The mechanisms by which environmental factors are associated with depressive symptoms have been the focus of more recent research. Diathesis-stress models suggest that depression results from an interaction between an internal predisposition and environmental stressors. This predisposition can take the form of a genetic or biological tendency or may be related to cognitive factors, such as poor coping skills or depressive cognitive style. According to the review by Hammen and Rudolph,⁵ several investigators have tested the diathesis-stress model as it pertains to cognitive vulnerabilities and have found significant interactions between cognitive style and stressful events.

The association between family or psychosocial factors and depressive disorders has been clearly demonstrated across the lifespan.^4,5 In a few studies, Researchers have also begun to examine those factors in childhood bipolar disorder. In Geller and colleagues’ long-term follow-up of children with bipolar disorder, children experiencing poor maternal warmth were about four times more likely to suffer relapse after recovery than were children with high maternal warmth.^11,43 Children and adolescents with bipolar disorder have also been found to experience more life stressors than children with ADHD and children with no psychiatric diagnosis.⁴⁴ These stressors included those clearly caused by the child’s symptoms or behavior (e.g., hospitalization), those possibly related to the child’s symptoms or behavior (e.g., removal from the home), and those unrelated to the child’s symptoms or behavior (e.g., death of a parent).

Barriers to Identification

The rate of recognition and treatment for children with psychological disorders in general is quite low. Data suggest that approximately 20% to 50% of children with a psychological problem are identified and only a portion of those cases are referred for evaluation and treatment.^1,47,48 Internalizing problems, such as mood disorders, are identified much less frequently than are externalizing problems and are more likely to be identified when they are accompanied by a comorbid externalizing condition.⁴⁹ In view of the negative effects of mood disorders on the child’s school, social, and family functioning, as well as the suicidal behaviors that can accompany mood disorders, the low rate of identification and treatment is a significant concern. Because of low rates of identification and treatment, outcomes in community settings have not kept pace with advances in the development of effective treatments for mood disorders in children and adolescents.⁵⁰

Primary care pediatricians are in an ideal position to identify mental health conditions in general and mood disorders in particular. Most children have at least one primary care visit per year, and children with psychological problems are likely to have more frequent visits.⁴⁹ Many children, particularly those from families of low socioeconomic status, receive care from only a primary care pediatrician.¹ Several factors can prevent accurate identification in a primary care setting, including pediatricians’ limited training in mental health issues, parents’ failure to report mental health concerns without direct questioning, limited time available for screening of nonsomatic concerns, limited referral resources, and limited availability and use of screening instruments.¹ Pediatricians can play a very important role in improving identification of mood disorders but may require education and resources to support them in this role.^1,49 The development of screening instruments and the availability of onsite support and treatment options are promising strategies for removing these barriers to identification and treatment.^1,2,50

Symptom Manifestation

The same criteria used for adults are used to diagnose childhood mood disorders. There is consensus that childhood depressive disorders have the same clinical features as the adult form of the disorders, with a couple of differences as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR)⁵¹ (i.e., irritability can take the place of depressed mood; considering failure to make expected weight gains; 1-rather than 2-year duration for dysthymia). The child’s cognitive and emotional development can affect symptom manifestation and profile over time, but the clinical features of depressive disorders remain fairly consistent over time.⁵²

There is controversy, however, over the definition of bipolar disorder in children. The core symptoms necessary for diagnosis, the necessity of discrete episodes, and the definitions of cycling in children all continue to be points of debate in the literature, and definitions of bipolar disorder have varied across studies.⁷ DSM-IV-TR diagnostic criteria for a manic episode include “a distinct period of persistently elevated, expansive, or irritable mood.”⁵¹ However, because irritability is so pervasive across childhood disorders, some investigators have required hallmark criteria of expansive/elated mood or grandiosity to help distinguish mania in children. In addition, many children meet symptom criteria for mania, with the exception of the duration criterion. These children may have intense rapid mood swings and often receive a diagnosis of Bipolar Disorder Not Otherwise Specified.

To help clarify the various conceptualizations of childhood mania, Leibenluft and colleagues⁵³ proposed definitions for narrow, intermediate, and broad phenotypes of mania. In the most narrow phenotype, children meet strict DSM-IV-TR criteria for mania or hypomania, with the hallmark symptoms of elevated mood and/or grandiosity, and meet full duration criteria. Two intermediate phenotypes were identified: mania not otherwise specified (hallmark symptoms present, but symptoms do not meet duration criteria) and irritable mania (irritability without hallmark symptoms; full duration criteria met). The broad phenotype includes symptoms of severe mood and behavioral dysregulation without the hallmark symptoms or episodic cycling. Further research is needed to determine how these various phenotypes are related and whether there are differences in terms of etiology, treatment, and prognosis among the types.

Diagnosis of mood disorders in children and adolescents can evolve and change over time. Seventy percent of children with dysthymic disorder eventually experience a major depressive episode, and 20% to 40% of children who initially present with MDD eventually experience a manic episode.⁴ It is important to monitor the progression of symptoms over time to ensure that appropriate treatment strategies are used. Children who have early-onset depression, depression with psychotic features or psychomotor retardation, a family history of bipolar disorder, or a very strong family history of any mood disorders are at increased risk for developing mania.⁴

The clinical symptoms of mood disorders in children are often different from those typically seen in adults. Depressed affect, low self-esteem, and somatic complaints are more common in children than in adults, whereas anhedonia, diurnal variation, hopelessness, psychomotor retardation, and delusions increase with age.⁵⁴ Children with bipolar disorder are more likely than adults to display continuous cycling (<365 cycles per year), mixed episodes, irritable mood swings with an insidious and chronic course beginning in early childhood, and high rates of comorbidity.^16,45,55

It is important to consider developmentally relevant symptom manifestations in diagnosis in children. Cognitive maturation influences the ways children experience and express emotion.⁵⁶ Children may be less able to express symptoms such as hopelessness, which require abstract thought until around puberty, when children begin to develop more abstract cognitive abilities.⁵⁶ As another example, during their early school years, children become cognitively capable of comparing and evaluating themselves with regard to others; thus, the symptom of low self-esteem is more relevant than in younger years.⁵⁶ In diagnosing childhood mania, it is particularly important to consider how DSM-IV-TR symptoms such as grandiosity, “increase in goal-directed activity,” and “excessive involvement in pleasurable activities” may manifest at different ages and how they differ from typical childhood behaviors. Children have certain constraints on their behavior by virtue of being monitored by adults, being required to attend school and other activities regularly, and not having resources such as credit cards or independent transportation to engage in the types of behaviors that adults may display.

Normal Variations in Mood

All children undergo development in their understanding of and ability to regulate emotions. Children begin to understand and use basic emotional terms around ages 2 to 3; however, the understanding of more complex emotions and mixed emotions continues to develop through childhood. Toddlers and preschool-aged children tend to display tantrums in response to frustration but become better able to regulate their emotional expression by the time of school entry. Children begin to regulate their subjective feeling of negative emotions first through problem-focused coping strategies and later become able to use emotion-focused coping to tolerate situations that they cannot change.⁵⁸ During puberty, hormone changes can lead to an increase in mood lability. There are also temperamental differences among children in general levels of reactivity. These normal developmental processes and individual differences should be considered in the evaluation of mood disorders.

Response to Bereavement

When a child or adolescent has experienced a loss, such as the death of a loved one or pet, a family move, or a broken relationship, symptoms of depression are common. Children’s reactions to the death of a loved one can vary and may include dysphoria, crying spells, clinging to familiar routines and caregivers, impairments in school functioning, behavior problems, bedwetting, loss of interest in activities, sleep problems, and psychosomatic symptoms.⁵⁹ These symptoms are usually transient and can be differentiated from a mood disorder on the basis of the duration and associated impairment.⁶⁰ According to DSM-IV-TR criteria, symptoms of bereavement should not be diagnosed as a mood disorder unless they last longer than 2 months or are associated with significant functional impairment, worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

In children who have experienced parental death, grief or sadness lasting a year or more is common.⁶¹ In the largest prospective study to date of children after parental death, Cerel and colleagues⁶² found that bereaved children demonstrated more impairment over a 2-year period than did a control group but less impairment than did a comparison group of nonbereaved children with a diagnosis of a depressive disorder. Overall impairment and depressive symptoms improved significantly in the bereaved group over 2 years, and this improvement was more rapid than that seen in the depressed group. Level of impairment and coping skills should be carefully monitored after parental death, because up to 20% of children display symptoms serious enough to warrant specialized treatment.⁶¹ A child is more likely to display clinical levels of disturbance after parental death when he or she had a psychiatric disorder before the death, when the surviving parent displays high levels of depression before or after the death, or when the family has fewer socioeconomic resources.^61,62 The presence of multiple stressors in the child’s life is associated with slower improvement in depressive symptoms and overall impairment.⁶² Parental death by suicide is also related to higher levels of overall psychopathology.⁶³ When children witness elements of a traumatic death, such as parental murder or suicide, they are at risk for posttraumatic stress disorder.⁶¹

After the death of a parent, many children experience suicidal ideation; however they are less likely to attempt suicide than are children with depressive disorder.⁶⁴ The suidical ideation expressed by bereaved children more often reflects a desire to be with the deceased parent rather than a wish to end their lives.^61,64 As with all reports of suicidal ideation, bereaved children who report such thoughts should be carefully assessed for risk factors, development of a suicide plan, and access to means of harming themselves.

Differential Diagnosis

Cross-sectionally, the symptoms of mood disorders can appear similar to other childhood disorders and may be misdiagnosed as ADHD, anxiety disorders, developmental disorders, or behavior disorders. Furthermore, differential diagnosis among the mood disorders can present a challenge when only current symptoms are considered. Examination of the evolution of symptoms over time can help establish the presence of episodic mood changes and whether other symptoms fluctuate with mood. For example, symptoms of social withdrawal and self-doubt may reflect depression or social anxiety, which can be difficult to distinguish with a cross-sectional assessment. A history of social anxiety preceding the development of other symptoms of depression would signify the presence of an anxiety disorder. If the symptoms developed at the same time or became significantly worse along with other mood symptoms, then they could be considered symptoms of depression.

Irritability is frequently a symptom of childhood mood disorders, but it can also be prominent in ADHD, behavior disorders, anxiety disorders, and pervasive developmental disorders, as well as in children without psychopathology who are hot, hungry, tired, or stressed.⁴⁵ Manic irritability often can be distinguished by its episodic, intense, and prolonged nature.

Children with ADHD also tend to experience difficulties with emotional regulation related to general impairments in behavioral inhibition, which can lead to quick expressions of emotional reactions that change easily.⁶⁷ Children with mood disorders also have difficulty with emotional regulation; however, they can be differentiated by their intensity, duration, associated symptoms, and environmental triggers. Children with ADHD typically experience emotional overarousal in response to environmental disorganization and overstimulation. Children with depressive disorders, on the other hand, experience depression or irritability as their predominant mood state, and their mood does not change as much in response to environmental triggers. Bipolar disorder can be distinguished from the emotional overarousal of ADHD by the episodic, intense, and prolonged nature of emotional reactions, which are accompanied by associated symptoms not typically seen in ADHD.

Because of the symptom overlap between mania and ADHD, differential diagnosis can be particularly difficult. Distractibility, rapid speech, and increased energy are symptoms of mania that overlap with those of ADHD. Geller and colleagues⁵⁵ identified five symptoms of mania that provide the best discrimination between mania and ADHD: elated mood, grandiosity, racing thoughts, decreased need for sleep, and hypersexuality. In assessment for bipolar disorder, the clinician should pay careful attention to these distinguishing symptoms, as well as symptom fluctuation with mood changes over time. In children with comorbid ADHD, distractibility, rapid speech, and increased energy should be considered symptoms of mania only when they increase beyond the child’s unique baseline level as his or her mood changes.

Hypersexual symptoms, such as those demonstrated by the example of David previously, are common in childhood-onset bipolar disorder. In Geller and colleagues’ sample,⁵⁵ 43% of children displayed hypersexuality. Children who display hypersexual behaviors should be carefully assessed for evidence of sexual abuse or exposure to sexual content inappropriate for the child’s age.⁶⁸ Sexual behavior with a pleasure-seeking quality that fluctuates with other mood symptoms may be a symptom of mania.⁶⁹

Psychosis is common in both MDD and bipolar disorder in childhood and may be incorrectly diagnosed as a schizophrenia spectrum disorder.^5,70 Psychotic symptoms that are congruent with mood and fluctuate with mood symptom severity are more likely to be an associated symptom of the mood disorder.⁷⁰

Mood Symptoms

Specific information should be gathered during the clinical interview about severity of mood symptoms. Mood symptoms should be evaluated in the context of an understanding of normal variations in children’s mood. Frequency, intensity, number, and duration (FIND) guidelines can be used to assist in establishing the presence or absence of mood symptoms⁴⁵: Individual symptoms should fluctuate with mood and occur most days of the week (frequency), at a level that causes impairment (intensity), several times per day (number), and should last a significant portion of the day (duration).⁴⁵

Prospective mood charting can be helpful in making a diagnosis, as well as monitoring progress. Daily mood logs completed by parents or adolescents can provide valuable information about situational variables that trigger mood symptoms and response to treatment. Examples of mood logs can be found at www.bpkids.org/site/PageServer?pagename=lrn_mood or can be individually tailored to meet the needs of a particular child and family.

Clinician-rated mood scales can also be helpful in summarizing mood symptom severity and in tracking progress. The Children’s Depression Rating Scale-Revised has been shown to be a reliable, valid, and sensitive measure of depressive symptoms in both inpatient and outpatient samples.⁷¹ The Young Mania Rating Scale, which was developed for adult populations, has been shown to have acceptable reliability and validity in child samples.^72,73 Although widely used, this scale has several limitations, including a lack of published developmentally appropriate anchor criteria for interview-based ratings.⁶⁹ The Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) Mania Rating Scale and Depression Rating Scale are promising new instruments developed for child and adolescent populations and are based on DSM-IV-TR criteria.⁷⁴ Preliminary studies have found that these instruments have good psychometric properties, and further validation with larger samples is under way.^69,74

Mood History

The clinical interview should also gather information about history of mood symptoms. Mood disorders tend to wax and wane in manifestation, and a thorough history is thus necessary to fully understand the mood disorder. To understand how mood symptoms have evolved and fluctuated over time, it is necessary to construct a timeline of symptoms, reconstructing their onset and discontinuation in relation to significant life events, treatment history, and functioning at school, at home, and with peers. In children who initially present with symptoms of MDD, a thorough history is needed to determine whether the child has ever experienced a manic or hypomanic episode.

Family History

Information about family history can further help establish the probability of mood disorder.⁶⁹ Although a family history of mood disorders is not diagnostic of mood disorders per se, it does add additional information about the child’s risk for the disorder.⁶⁹ Furthermore, because data suggest that children with MDD who have a family history of bipolar disorder are at increased risk for developing a manic episode in the future, this information may guide treatment decisions and follow-up strategies.⁴

Structured Interviews

It is important to assess for behavior, anxiety, mood, and other symptoms as part of the clinical interview. Structured or semistructured interviews can be used to systematically gather information about various childhood problems. Several options have demonstrated sensitivity and specificity in identifying relevant conditions and require varying levels of training and time to administer. Examples include the Diagnostic Interview Schedule for Children,⁷⁵ Children’s Interview for Psychiatric Symptoms (ChIPS),^76,77 Diagnostic Interview for Children and Adolescents,⁷⁸ and the Washington University at St. Louis KSADS (WASH-U-KSADS),⁷⁹ which includes an expanded section on the diagnosis of manic symptoms. Variations of the KSADS, such as the WASH-U-KSADS, are most commonly used in research settings, but require extensive time and specialized training for administration, which makes this instrument impractical for clinical use.⁶⁹ Symptoms of mania are often not thoroughly evaluated in developmentally appropriate terms in the briefer structured interviews; however the ChIPS shows the most promise for identifying manic symptoms in youth.⁶⁹

Questionnaires

Diagnosis of mood disorders can never be made on the basis of questionnaires alone. However, questionnaires can be useful as screening instruments to guide a clinical interview or as another source of information to integrate with interview data. The Child Behavior Checklist (CBCL) is a norm-referenced and widely used instrument in clinical practice and research to assess a variety of behavior problems in children and adolescents.⁸⁰ The CBCL behavior scales are not specific enough to differentiate depressive from anxiety disorders; however, high scores on the internalizing scale signal that additional information should be gathered about specific mood and anxiety disorders. The Children’s Depression Inventory⁸¹ is a self-report measure specifically designed to assess the severity of depressive symptoms. This inventory has been shown to differentiate between psychiatric patients and control subjects, but it does not differentiate well among psychiatric diagnoses.⁸²

Low scores on the externalizing scales of the CBCL are useful in ruling out bipolar disorder, but high scores are not specific enough to draw conclusions about the presence of bipolar disorder.⁹ The General Behavior Inventory⁸³ is a questionnaire that is used specifically to assess manic symptoms. Parent and youth versions of this inventory have demonstrated excellent psychometric properties; however, the complexity of many items may make it difficult for individuals with limited education or reading abilities.⁶⁹ Data suggest that youth and teacher questionnaires do not add anything beyond parent questionnaire data in the prediction of bipolar disorder diagnosis.⁹

The Pediatric Symptom Checklist⁸⁴ has been developed specifically to screen for a variety of mental health problems in primary care settings. It is brief, has empirically derived cutoff scores, and has been validated with racially diverse populations and populations of low socioeconomic status.¹ In settings in which resources are available to score and interpret the CBCL, it may be administered before the clinician meets with the family and used to help guide the interview. When a mood disorder is suspected, the Children’s Depression Inventory or General Behavior Inventory may be useful in the decision of whether to refer for a more thorough evaluation.

Comorbidity

Comorbidity is common among childhood diagnoses. Approximately 40% to 70% of children and adolescents with depression have at least one other psychiatric condition.⁴ A meta-analysis by Angold and colleagues⁸⁵ found that depression is most closely associated with anxiety disorders (odds ratio, 8.2), followed closely by conduct disorders (odds ratio, 6.6) and ADHD (odds ratio, 5.5). Substance abuse disorders are also commonly comorbid with depression and tend to begin an average of 4.5 years after the onset of the depressive disorder.⁴

High rates of comorbidity have also been found with early-onset bipolar disorder, particularly with ADHD, behavior disorders, and anxiety disorders. Rates of comorbidity range from 66% to 75% for ADHD, 46% to 75% for oppositional defiant disorder, 5.6% to 37% for conduct disorder, 12.5% to 56% for anxiety disorders, and 11% for pervasive developmental disorders.^7,69 The rates of comorbid substance abuse disorders increase with age, with rates up to 40% in adolescents.⁷

Treatment of Comorbidity

In treating conditions comorbid with bipolar disorder, it is important to first stabilize the mood symptoms and then evaluate the need for psychosocial or pharmacological treatment of any comorbid conditions.⁴⁵ There are no clear guidelines for the treatment of comorbid conditions with depression. If the mood disorder appears to be secondary to another condition, such as social anxiety or posttraumatic stress disorder, it may be useful to treat the primary condition first or concurrently with the treatment for depression.

Suidical Ideation

Children with mood disorders are at increased risk for suicidal ideation, attempt, and completion. Suicidal ideation has been reported in more than 60% of depressed children and adolescents, and MDD is the most common diagnosis among suicide victims.^5,86 Children with bipolar disorder are also at high risk for suicide, particularly when depressed, during a mixed episode, or when psychotic.^8,55,87 Geller and colleagues⁵⁵ reported suicidal ideation in 25% of their 7- to 16-year old participants with bipolar disorder. Comorbidity between mood disorders and substance abuse or disruptive behavior disorders further increases the risk of suicide.⁸⁶ These data highlight the importance of assessing suicidality in youths with mood disorders. Data from a randomized controlled trial indicate that assessing for suicidal ideation does not increase distress or suicidal ideation in adolescents.⁸⁸

In assessing for suicide risk, several factors should be taken into account; these are outlined in the American Academy of Child and Adolescent Psychiatry’s 2001 Practice Parameters regarding the assessment and treatment of adolescent suicidal behavior.²⁰ In addition to the presence of a mood and/or substance abuse disorder, individuals with previous suicide attempts, suicidal thoughts, plans for suicide, agitation, and psychosis are at greatest risk for suicide.²⁰ Other risk factors include family history of suicide; history of physical or sexual abuse; school problems; poor communication with parents; recent suicide of a peer; and gay, lesbian, or bisexual orientation.⁸⁶ Several questionnaires that have been developed to assess risk of suicide have high sensitivity but poor specificity because of the low base rates of suicide.⁸⁶ These questionnaires can best be used as screening tools in community samples. In children and adolescents at high risk for suicide, such as those with mood disorders, assessment should include direct interview with the child and parent.²⁰

Psychosis

Psychosis is more common in child and adolescent mood disorders than in adult mood disorders. Approximately 33% to 50% of preadolescents with MDD and up to 31% of adolescents with MDD experience hallucinations, most commonly auditory hallucinations.⁵ Estimates of the rates of psychosis in early-onset bipolar disorder range from 16% to 88%, depending on assessment strategy.⁷⁰ The most common type of psychotic symptom reported in early-onset bipolar disorder is mood-congruent grandiose delusions.⁷⁰

Depression

Bipolar Disorders

Definition of Key Terms

Anxiety, worry, and fear are related and yet distinct concepts, and the terms should not be used interchangeably.^7,8 Simply stated, anxiety is a mood state characterized by worry or apprehension about future or anticipated situations.⁹ The definition given by Barlow¹⁰ is more elaborate: Anxiety is “a future-oriented emotion, characterized by perceptions of uncontrollability and unpredictability over potentially aversive events and a rapid shift in attention to the focus of potentially dangerous events or one’s own affective response to these events” (p 104). It is represented by a tripartite response system, including verbal or cognitive components, motor or behavioral components, and somatic or physiological components.¹¹ The cognitive component pertains to thoughts, images, beliefs, and attributions about the situation and expected outcomes (e.g., “What if I have a heart attack because I cannot breathe?” “What if I fail this test and do not graduate?” “What if no one picks me up after school?”). The behavioral component consists of motor responses that involve escaping, avoiding, or taking action (e.g., trembling, running). The physiological component involves sensations of the flight-or-fight response or other somatic responses, such as muscle tension and increased heart rate.¹²

Worry involves thoughts and images that pertain to potentially threatening future events and is thus considered one of the cognitive components of anxiety.¹³ Borkovec and colleagues¹⁴ stated that “normal” worry manifests with minimal perceived or actual peripheral physiological activation and greater intrusions of negative thoughts in comparison with somatic aspects of anxiety. In addition, the content of worries differ from time to time and in response to changes in life circumstances. Silverman and Ollendick¹⁵ indicated that both worry and avoidance reflect maladaptive coping efforts in response to aversive states that are pervasive, intense, or uncontrollable. As worry persists and becomes excessive, it is deemed a dysfunctional process according to the fourth edition of the DSM (DSM-IV).⁵

Fear is an emotion that is related to the fight-or-flight system, which involves triggering the autonomic nervous system along with focusing attention on escaping the situation or fighting the potential threat.¹⁶ Thus, fear is viewed as a physiological response and is linked to the biological alarm system.⁸ Fear is essential in focusing attention to immediate danger, learning how to overcome dangerous situations, and learning how to differentiate threatening from harmless situations.¹² Two key differences between anxiety and fear are whether the interpretation of threat is immediate or future oriented and whether the physiological arousal is an alarm reaction or excessive apprehension.⁹

Complicating the conceptual distinction between anxiety and fear is the high correlation with depression. The construct of negative affectivity refers to the nonspecific component of generalized distress that is common to anxiety and depression.¹⁵ Examples of symptoms that reflect negative affect include anxious or depressed mood, sleep difficulties, and irritability. An elaborate study implemented by Chorpita and colleagues¹⁷ confirmed the distinction among anxiety, fear, and depression as separate constructs. Their data indicate that anxiety reflected general distress; fear was equated with heightened physiological arousal; and depression corresponded to low positive affect. Additional research is needed to further distinguish these constructs from others, such as attention-deficit/hyperactivity disorder (ADHD), and to describe their course of development.¹²

Function of Worry

Borkovec and colleagues^14,18 offered a detailed conceptualization of the formation and maintenance of worry, with implications for the development of anxiety disorders. According to these authors, worry represents the end result of an avoidance response to perceived threats. Behavioral inhibition is considered a temperamental category and appears related to the defensive reactions delineated by Barlow and colleagues.^10,16 It is defined in terms of reactions of withdrawal, wariness, avoidance, and shyness in novel situations.

Defensive reactions are started when a threatening stimulus (object, person, situation) is perceived by a person; these reactions include automatic activation and inhibition, behavioral avoidance and or inhibition, catastrophic images and thoughts. Worry as a cognitive process is considered an example of long-term cognitive avoidance of future catastrophes or negative events. Barlow and collagues^10,14 propose a suppression of physiological-affective processes as a direct outcome of such cognitive activity. They suggest that chronic worriers and nonanxious controls display activation of the frontal cortex during worrying, but chronic worriers display greater left than right frontal activation. Furthermore, worries about one topic tend to easily spread or generalize to related and unrelated topics. The results or consequences of such cognitive activity reportedly hinder new learning and maintain distressing emotional states.

Retrospective and prospective studies have linked certain early temperamental styles with anxiety and suggest that temperamental styles of high arousal, emotionality, and behavioral inhibition place youth at risk for developing later anxiety symptoms and disorders.¹⁹ In addition, adverse life events, especially uncontrollable ones, place individuals at greater risk of developing an anxiety disorder. Finally, the difference between a vulnerability and a disorder is probably a function of symptom severity and interference with daily activities.

Worry may serve two purposes or functions.²⁰ One function is preparational, whereby worry at a moderate level may motivate a person to accomplish tasks. Within this function, worry supposedly suppresses somatic responses and decreases uncomfortable emotional reactions, thereby allowing the person to prepare for anticipated negative events.¹⁴ A second function of worry is avoidance, with regard to distracting the person from other emotional events and situations. Worry involves efforts to prevent the occurrence of negative events or to cope if and, when these events occur, through problem-solving strategies. Theorists also propose that although worry may offer some advantages, such as initial reduction of somatic distress, it interferes with emotional processing of negative events. As such, efforts at problem solving are not often effective, and the anxiety response is maintained.^18,21

Normative Data on Worry

Many studies document the relatively common occurrence of fears in children. Almost 70% of children report worrying. Girls report more fears than do boys; at some point during their development, children experience between 9 and 13 fears on average 2 or 3 days per week.^12,22 In studies on the frequency and content of children’s worries, investigators have identified developmental, gender, and potentially ethnic differences.^8,23,24

The frequency of fears decreases, and their focus changes with age. From birth through age 18 years, fears change: Among preschool-aged children, they concern separation from caregivers and imaginary or supernatural creatures; in children aged 5 to 6 years old, they concern threats to physical well-being; among older children, they concern personal and social performance.^24,25 In general, the worries of school-aged children (i.e., 7 to 14 years old) center on school performance, health, and personal harm. Young adolescents appear to worry more intensely about social issues, such as war, money, and disasters. Some studies (e.g., Vasey et al²⁴) but not others (e.g., Silverman et al⁸) reveal age-related differences with regard to a greater number of worries in school-aged children than in younger children. Most experts in this area (e.g., Silverman et al⁸) suggest that the content of worries is associated with current social circumstances and media attention.

Girls are said to display more extreme symptoms and to report more worries than do boys in both clinical and community samples.^8,26 Children of African-American ethnicity reported more worries than did white or Hispanic children.⁸

Several studies have focused on the frequency, intensity, and content of worries of clinically referred children in comparison with community samples. Overall, it appears that the intensity but not the number of worries differs between these two samples.^27,28 The content of their worries—namely, school, health, disasters, and personal harm—are reflective of contemporary social challenges and concerns. The authors of these studies proposed that intensity more than specific content serves to differentiate children with anxiety syndromes or disorders from those without.

General Prevalence

The literature indicates that 18% of school-aged children are identified by their primary care clinicians as having a psychosocial problem.^29–31 Other studies (e.g., Wren et al³²) have revealed that clinicians identify mood or anxiety syndromes on only 3.3% of visits. Differences in these rates appear related to how well the clinician knew the child, whether the visit was a well-child appointment rather than for acute care, and the presence of comorbid behavioral problems.^30,32 Prevalence rates of specific anxiety disorders in children and adolescents typically range from 2% to 7%,³ whereas rates for clinical levels of anxiety among children range from 10% to 21%.³³ Some guidelines help distinguish “normal” fears and worries from those that are dysfunctional and suggest a true anxiety disorder¹²: First, the intensity of the worry/fear is out of proportion to the actual threat of the situation. Second, the frequency of the worry/fear increases despite reassurance. Third, the content of the worry/fear concerns a harmless object or situation that poses minimal harm. Fourth, the worry/fear seems spontaneous. Finally, escape or avoidance is often in reaction to the worry/fear.

Effect of Anxiety Disorders

Children and adolescents with anxiety syndromes or disorders are at risk for a variety of problems across domains of functioning. Longitudinal studies have demonstrated an association between anxiety disorders and educational underachievement and between these disorders and alcohol and other drug use.^3,34 The risk of other emotional problems is consistently documented in the literature^3,34; the occurrence of anxiety disorders commonly precedes those of depressive disorders and substance abuse disorders.^35,36 Alcohol and other drugs may be used to self-medicate or to manage symptoms of anxiety.³⁷ Difficulties in social and peer relations that contribute to feelings of loneliness and low self-esteem also are related to anxiety disorders.³⁸

The effect of anxiety disorders on health care utilization and health care costs is evident in the pediatric and adult literature. Studies on older adolescents and adults indicate high utilization of specialists and primary care physicians for symptoms of anxiety.^39,40 Increased utilization results from frequent visits to physicians and emergency rooms, extensive laboratory tests, medications, and prolonged hospitalizations.⁴⁰ Specialists most often seen include gastroenterologists for individuals with GAD, because of abdominal complaints; dermatologists and cardiologists for those with OCD, because of skin conditions and problems breathing; and neurologists and urologists for those with panic disorders, because of multiple physical symptoms. In one study, 54% of patients with irritable bowel syndrome had diagnoses of GAD, and 29% had diagnoses of panic disorder.⁴¹

Diagnostic Considerations

In a thorough review of the assessment literature on anxiety disorders, Silverman and Ollendick¹⁵ indicated that anxiety disorder diagnoses co-occur most frequently with other anxiety disorders, next most frequently with depression, and third most frequently with externalizing disorders, such as ADHD or oppositional defiant disorder. Symptoms of anxiety and resultant diagnoses tend to persist over time, and the condition is often refractory to intervention.^42,43 Two constructs are critical in understanding the comorbidity patterns and course of anxiety disorders: (1) threshold for clinical significance and (2) sensitivity and specificity of assessment measures.

The term threshold pertains to the frequency and intensity of symptoms necessary to detect the presence of a disorder, along with level of impairment. The phrase “clinical level” is used in a case when all diagnostic criteria are met and impairment is severe.²⁹ The term subthreshold, refers to cases in which diagnostic criteria are met but impairment is mild to moderate. An optimal threshold for clinical significance is currently arbitrary, but low thresholds may help identify youth at risk for psychopathology, whereas higher thresholds help identify those requiring immediate treatment. Less stringent impairment thresholds may be preferred with regard to internalizing disorders, such as anxiety disorders, because the nature of the symptoms is less overt and disruptive than are symptoms.^29,44

Silverman and Ollendick¹⁵ also proposed that discriminating between anxiety and other constructs is related to the diagnostic accuracy of anxiety assessment measures. The diagnostic value of these measures pertains to their sensitivity and specificity. Silverman and Ollendick¹⁵ defined sensitivity as the percentage of people who receive a diagnosis and who have been positively identified by rating scales, or true-positive cases. They defined specificity as the percentage of people who do not receive a diagnosis and who have not been identified by rating scales, or true-negative cases. Anxiety assessment measures are reviewed in the next section.

Research clearly indicates that anxiety disorders in youths share the same underlying constructs, display solid covariation with each other over time, seldom occur as singular conditions, and exhibit comparable familial constellations with adult anxiety and depressive disorders.^4,10,45 Clinicians within primary care settings are expressing the need for practical and validated screening measures for mood syndromes and disorders in children and adolescents.³²

Semistructured and Structured Interviews

Semistructured and structured interviews offer the most reliable means of diagnosis because of the degree of information solicited from children and their parents.⁵¹ However, the 2 to 3 hours needed to complete these interviews may be prohibitive in some settings.⁴ The length appears related to the experience of the interviewer, the cooperation of the family, and the level of functional impairment of the youth. In addition, children report fewer symptoms than do their parents and may be less reliable in specifying symptom onset and duration.⁵² Examples of common interviews for school-aged children and adolescents include the Schedule for Affective Disorders and Schizophrenia in School-Aged Children⁵³ and the Diagnostic Interview Schedule for Children.⁵⁴ The Anxiety Disorders Interview Schedule for Children⁵⁵ assesses for the presence and severity of anxiety, mood, and externalizing disorders, and it screens for learning and developmental disorders, substance abuse, eating disorders, psychotic symptoms, and somatoform disorders. This measure has strong psychometric properties and has been studied extensively in the literature on anxiety disorders.¹⁵

Self-Report Rating Scales

Self-report rating scales provide information from the youth’s perspective about the frequency and intensity of cognitive, behavioral, and physiological aspects of anxiety. The majority of self-report scales for anxiety disorders require a second to third grade reading level but take only about 10 to 15 minutes to complete and can be manually scored easily.⁴ Examples of self-report rating scales for general anxiety include the Revised Children’s Manifest Anxiety Scale (RCMAS),⁵⁶ the State-Trait Anxiety Inventory for Children,⁵⁷ the Screen for Anxiety and Related Emotional Disorders (SCARED),⁵⁸ and the Children’s Anxiety Sensitivity Index.⁵⁹ The Negative Affect Self-Statement Questionnaire⁶⁰ may be considered because of the relevance of negative affect and comorbidity between anxiety and depression. Finally, the Youth Self-Report⁶¹ and the Behavior Assessment System for Children⁶² may be given as general self-report measures of both internalizing problems and externalizing problems. The SCARED appears to be useful in clinical practice, whereas the RCMAS and the State-Trait Anxiety Inventory for Children are used often in research.^4,15 Appendix A provides a listing of resources for ordering specific self-report and parent and teacher rating scales. The specific websites should be consulted about restrictions of who may order and administer these measures. Measures not listed in Appendix A can be obtained by contacting the authors noted in the reference section.

Parent and Teacher Rating Scales

Data from multiple informants are crucial for accurate assessment because of the high parent-child discordance, especially with internalizing disorders such as anxiety and depression.¹⁵ The perspective of parents and teachers should be solicited with regard to the range of symptoms shown by the youth, in order to place the anxiety symptoms within a context of other problems.⁴ In addition, symptoms may be quantified and may be monitored over the course of treatment.¹⁵ These rating scales are time and cost efficient and are fairly easy to administer and to score, with the use of hand-scoring templates or computer programs, but the problem of self-disclosure is considerable.^4,15 Examples of general, corresponding parent and teacher rating scales are the Child Behavior Checklist⁶³ and the Teacher Report Form,⁶⁴ the Conners’ Parent and Teacher Rating Scales,⁶⁵ and a parent version of the SCARED. A measure of family environment, such as the Family Environment Scale,⁶⁶ or of marital functioning, such as the Marital Adjustment Scale,⁶⁷ also may be administered to obtain additional data about family factors that affect the presence of anxiety symptoms.

Behavior Observations

Behavioral observations include such procedures as behavioral approach tests, observational ratings, and role-play tests. Behavioral approach tests usually consist of five 5-minute phases that are held in analogue settings (e.g., giving speech), under stimulated conditions (e.g., tape recordings of thunder or visual displays of spiders), or in a naturalistic setting (e.g., at school): adaptation, baseline, walking baseline, approach, and post-baseline to assess social anxiety, specific phobias, or generalized anxiety.⁴⁶ Observational ratings are provided by clinicians, parents, or teachers on diverse aspects of anxiety, including overt statements, trembling, and avoidance of the situation.⁶⁸ Direct observational procedures are most useful in specialty clinics or experimental settings because of their obtrusive nature and complexity of implementation.¹⁵ An alternative approach may be to videotape at home and view the tape in the clinic setting.⁴ Examples of direct observational measures include the Observer Rating Scale of Anxiety,⁶⁹ the Procedure Behavior Rating Scale,⁷⁰ and the Behavioral Assertiveness Test for Children.⁷¹ An addition to these methods is to observe family interactions in order to examine the factors that may be maintaining anxiety symptoms, such as misinterpreting ambiguous situations and reinforcing avoidant behavioral styles.¹⁵ These observations are categorized as the Family Behavioral Test.^17,72

Self-Monitoring

Self-monitoring involves monitoring and recording components of anxiety, including physical sensations, related thoughts, and behavior, along with the situation in which these symptoms occur.⁴ Self-monitoring is used to identify and quantify symptoms and controlling variables and to evaluate and monitor treatment outcomes.⁷³ Self-monitoring is of limited value because in many trials, only between 31% and 39% of children record requested information for a full 2-week period.¹⁵ A brief description of symptoms, specific antecedents, and consequences of these symptoms can be recorded in a diary format. In addition, an anxiety rating (on a scale of 0 to 100) may be given to each description, as well as to an overall daily rating. Thought-listing and think-aloud procedures may be included within this method of assessment.⁴⁶ Thought listing consists of recording thoughts associated with the anxious reaction,⁷⁴ whereas think-aloud procedures involve audiotaping verbalizations of thoughts and placing these thoughts into categories.⁷⁵

Physiological Assessment

Various physiological responses may be used as a measure of anxiety, although their reliability and validity have been mixed.^4,15 In addition, there are few normative data by which to compare baseline responses or changes after interventions. Examples of physiological measures include heart rate and blood pressure, to examine cardiovascular reactivity; respiration and skin temperature, to assess blood flow to extremities and physiological arousal; and electromyography, to measure electrical activity in tense muscles.^4,15

Generalized Anxiety Disorder

Data from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Washington, DC: American Psychiatric Association, 2000.

Finally, for a diagnosis of GAD, symptoms of anxiety cannot be caused by a substance, a medical condition, or other mental health disorder. The level of impairment in functioning required by all DSM-IV-TR diagnostic categories may prompt parents and teachers to seek referrals to health care or mental health care professionals.

COMORBIDITY

Additional findings reveal comorbidity with mood disorders; generalized anxiety most often occurs before depression.^36,85 Externalizing disorders, such as ADHD and oppositional defiant disorder, also appear to co-occur with GAD, but not more so than with any other anxiety disorder.^85,86

PREVALENCE

The prevalence of GAD in children and adolescents is between 2% and 5%⁸⁷; onset of the full syndrome generally occurs in later adolescence or early adulthood. The diagnosis is made twice as often in girls as in boys.⁸⁸ GAD is associated with a lower spontaneous recovery rate than are other anxiety disorders.²⁶

CAUSES

The combined roles of biological factors, psychological factors, and environmental factors are consistently delineated in the literature on the causes of GAD.¹⁹ Evidence is suggestive of a general predisposition toward anxiety rather than a specific heritability for GAD.⁸⁹ It appears that affected individuals possess an anxious vulnerability that is manifested as heightened sensitivity, greater emotionality, and enhanced physiological arousal in response to threat. This greater emotionality and physiological arousal foster a tendency to interpret situations as threatening and to develop an avoidant coping style. Avoidance of novel situations is rewarding by reducing distress and obtaining attention from others in the environment. Also, an anxious temperament allows the individual to solicit behaviors from others in the environment that support avoidant and other maladaptive coping styles. For example, parents’ heightened attention to the youth’s efforts to prevent or cope with anxiety may actually increase the youth’s perception of the degree of threat, even though, if the threat were not real, minimal attention would be devoted to it. Modeling and verbal statements from the family, along with cultural and social influences, seem to transmit information about anxious behaviors to youths.

A multivariate twin analysis of more than 1000 pairs of twin girls⁹⁰ suggests that the genetic influences for anxiety disorders are accounted for by two factors: one for phobia, panic, and bulimia and the other for GAD and major depression. Studies also support a familial basis of anxiety in that parents exhibit a cognitive bias toward threats and reinforce an avoidant response in their children.⁷²

The literature dictates that worry as the principal component of GAD reflects a style of cognitive avoidance.^19,23 Cognitive avoidance with regard to GAD is conceptualized as composed of cognitive activity or “verbal” content.^91,92 The verbal content of worry allows the person to avoid fearful images and to decrease arousal. Subsequently, the avoidance of fearful images and physiological arousal maintains worry, but at the cost of not dealing with the emotional aspect of the worries. In relation to worry, key features of GAD are intolerance of uncertainty and poor problem orientation.⁹³ This intolerance of uncertainty is defined as the way an individual perceives information in uncertain or ambiguous situations and responds to this information with a set of cognitive, emotional, and behavioral reactions.⁹⁴

ASSESSMENT

In general, the range of assessment methods and measures outlined in this section are applicable for diagnosis, symptom identification, and treatment outcome in GAD. The SCARED is recommended by several investigators to detect GAD in children and adolescents because of sufficient sensitivity and specificity (e.g., Muris et al⁹⁵). The RCMAS also is used in clinical practice to examine overall levels of anxiety.

DIAGNOSTIC CRITERIA

The diagnostic criteria for OCD are listed in Table 18B-1. The obsessions appear to be irrational, are difficult to remove, and usually pertain to perceived risk or harm.⁹⁶ The compulsions are performed in an effort to suppress, organize, or ignore the obsessive thoughts.⁹⁷ Common content of obsessions include contamination by dirt or germs, aggression, inanimate-interpersonal objects (e.g., locks, bolts), sex, and religion.⁹⁸ Compulsive behaviors often seen are hand washing, cleaning, checking, repetitive touching, counting, and ordering. These obsessions and compulsions generally take up more than an hour a day and cause distress or functional impairment in academics, with peers and family members, and with activities of daily living.⁵

Long-term follow-up studies of OCD in children and adolescents reveal a chronic, waxing-and-waning course, regardless of medication or behavior therapy treatment.^99,100 Symptoms persist but change over time; for example, checking rituals may become ordering compulsions, and contamination fears may become counting rituals.¹⁰⁰ In two follow-up studies of OCD in children,^101,102 43% to 68% of children continued to meet diagnostic criteria for OCD, and 28% to 57% did not have the disorder at follow-up. The literature provides minimal information on prognostic indicators other than that developmentally appropriate rituals are not predictive of obsessions or compulsions.^103,104

Subtypes of OCD in adults appear applicable to youths with OCD. The first classification pertains to the presence or absence of a tic disorder; the second classification pertains to familial versus nonfamilial OCD.^105,106 Children without tics seem to have a higher incidence of contamination fears, washing, and repetitive requests for reassurance.¹⁰⁷ Children with nonfamilial OCD may have other disorders suggestive of a central nervous system dysfunction.¹⁰⁴ These subtypes may have implications for etiology and treatment response.^105,107

There is some diagnostic confusion with regard to the phenomenological overlap between obsessions and worry and between pathological worry and covert compulsive behavior.¹⁰⁸ Although both worry and obsessions involve cognitive activity, worry may be more abstract and verbal in nature, whereas obsession is more imaginative in form.¹⁰⁹ Whether this distinction applies to children is not known, especially as it pertains to differential diagnosis between OCD and GAD.¹⁰⁹ Compulsive behavior in children with OCD and in children with GAD may be distinguished in terms of frequency, rigidity, quality, and function, but empirical verification of these differences is not available in the literature.¹⁰⁸

COMORBIDITY

Coexisting symptoms and disorders are common in children and adolescents with diagnosed OCD; 62% to 84% exhibit co-occurrence¹¹⁰ of SAD and GAD. Depressive symptoms and dysthymia¹⁰⁶ also co-occur frequently. Neurological conditions, particularly tics and Tourette syndrome, frequently co-occur in this group, especially in boys. Youths with OCD and Tourette syndrome tend to display more violent and aggressive obsessions and harm-avoidance compulsions.¹¹¹

PREVALENCE

The average age at onset of OCD is between 7.5 years and 12.5 years,¹¹² and the prevalence is about 1% to 3%.¹¹³ Another 1% to 19% of children may show “subthreshold” or problem levels of OCD.¹¹⁴ It is diagnosed in twice as many boys as girls during childhood and adolescence, but this pattern reverses in adults with OCD.¹¹⁵ Earlier age at onset seems related to a familial pattern of OCD.¹¹⁶ Few differences appear in the frequency of specific obsessions or compulsions across age groups,^100,117 although adolescent boys may report more religious/moral obsessions than do younger boys.¹⁰⁷

CAUSES

Although the exact origin of OCD is not known, possible organic causes focus on focal brain lesions, specifically to the basal ganglia, and on immune-mediated sequelae of streptococcal infections.^104,116 Through neuroimaging techniques, the frontal-striatal-thalamic pathway is implicated in the pathophysiology of OCD, along with the neurotransmitters serotonin and ocytocin.^104,107

The role of heredity was elucidated through one twin study and several family studies, in which the prevalence of OCD was higher among first-degree relatives of patients than among those of controls (11% to 25% vs. 2.7%).^118,119 Concordance for treated youths with OCD was 33% in monozygotic twins, in comparison with 7% in dizygotic twins.¹²⁰ A familial component is also suggested by a higher incidence of OCD diagnosed in relatives of youths who received diagnoses of OCD before the age of 17 years.¹¹⁹ Even higher prevalence rates exist in parents considered to have subthreshold or problematic OCD (8.8% to 42%).

ASSESSMENT

A basic question that clinicians can ask youths is “Do you have thoughts that you cannot get out of your mind or have behaviors you do over and over?” The Leyton Obsessional Inventory-Child Version¹²¹ is a 20-item self-report measure of obsessions and compulsions used for diagnostic screening. Several factors include general obsessive thoughts and rituals, dirt-contamination fears, lucky numbers, and school-related habits. This measure does not provide a rating of severity. Separate child and parent interviews are necessary to determine the extent and the nature of the obsessions and compulsions because of the covert aspect of these symptoms.¹¹⁶ In addition, if parents have subthreshold or problematic obsessive and compulsive symptoms, they may either become involved in or accommodate the child’s ritual.¹¹⁶ The first choice for rating severity of OCD symptoms is the Children’s Yale-Brown Obsessive-Compulsive Scale.¹²² The basic 10-item scale is used to rate obsessions and compulsions in terms of degree of severity, interference, distress, resistance, and control. Normative data are available to assist with symptom identification and, subsequently, severity ratings.¹¹⁶

A neurological examination is recommended because of the high prevalence (33%) of soft signs and choreiform movements in youth with OCD,¹²³ reports of streptococcal pharyngeal infections triggering obsessive-compulsive symptoms,¹²⁴ and occurrence of obsessive-compulsive symptoms in various neurological disorders, including basal ganglia disorders, Huntington’s chorea, and Tourette syndrome.¹¹⁶ The presence of focal neurological signs may prompt a brain imaging study, such as computed tomography or magnetic resonance imaging study of the brain.¹¹⁶

DIAGNOSTIC CRITERIA

Some difficulty separating from home or attachment figures is normal and expected for children aged 7 months to 6 years.²⁶ When this distress lingers beyond normal development or is abnormally intense, a child may meet DSM-IV criteria for SAD.⁵ Furthermore, the DSM-IV specifies that the distress upon separation cannot be attributable primarily to pervasive developmental disorder or a psychotic disorder (e.g., schizophrenia) and, in adolescents, cannot be better accounted for by panic disorder with agoraphobia. Diagnostic criteria for SAD are provided in Table 18B-2.

TABLE 18B-2 Diagnostic Criteria for Separation Anxiety Disorder

Note: The DSM-IV-TR specifies that the distress on separation cannot be attributable primarily to pervasive developmental disorder or a psychotic disorder (e.g., schizophrenia) and, in adolescents, cannot be better accounted for by panic disorder with agoraphobia.

Data from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Washington, DC: American Psychiatric Association, 2000.

Children with SAD may first come to the awareness of a physician because of refusal to go to school or physiological symptoms, such as recurrent abdominal pain. In a physician’s office, these children may present as “clingy.” Parents may complain about bedtime routines, nightmares, or a child’s refusal to engage in normal peer relationships, such as spending time at a friend’s house. SAD may initially manifest in situations in which the child is expected to separate from a caregiver (e.g., school), when the child becomes extraordinarily distressed and avoidant of separation situations. Careful observation of these symptoms may reveal a cyclical pattern in which symptoms are exaggerated during times when a child is anticipating or has separated from home or parent.¹²⁵ For example, if a child’s symptoms may increase just before a parent leaves for work. Refusal to go to school may also be seen in other disorders, such as specific phobia, social phobia, and/or depression.

Symptom manifestation is related to developmental stage: Younger children with SAD tend to have more symptoms and focus on unrealistic worry about harm to a caregiver, whereas older children exhibit excessive distress during times of separation. In adolescence, SAD is typified by somatic complaints and refusal to go to school.¹²⁶

PREVALENCE

The prevalence rate of SAD is approximately 4% among children and adolescents in community samples; the incidence of SAD is higher among girls and younger children.^87,127 The average age at first presentation is 7.5 years. In clinical samples, SAD accounts for approximately one third of anxiety referrals¹²⁸ and is the most frequently occurring anxiety disorder in preadolescents.¹¹⁵ Although girls appear to show more symptoms of SAD than do boys in screening surveys, boys affirm separation anxiety more often in clinical samples, perhaps because these symptoms are less well accepted in boys. Therefore, SAD symptoms in boys may more likely result in a referral for treatment.¹²⁹

CAUSES

Although the specific origin is largely unknown, SAD reportedly has an acute onset, with initial or subsequent occurrence often triggered by a major stressor, such as change of schools, death of a parent, or prolonged illness.¹²⁸ Familial patterns are noted for SAD; the risk is increased for children whose parents have panic disorder with features of agoraphobia.^130,131

The course of SAD is generally favorable for most children. In a study of over 150 children and adolescents with SAD, 80% of cases were improved at an average of 18-month follow-up.¹³² Individual and family factors related to a continued SAD diagnosis seem to include the presence of externalizing problems, such as oppositional defiant disorder or ADHD symptoms; parental psychopathology; and parental marital difficulties.¹²⁵ In addition, children with persistent SAD may be more likely to receive diagnoses of depressive disorder or another anxiety disorder at a later date.

ASSESSMENT

Parents’ and children’s reports of SAD symptoms differ; children report more symptoms than do parents, which highlights the importance of multi-informant assessment in diagnosis.¹³³ There is no parent or self-report questionnaire designed to assess solely diagnostic criteria for SAD. Several of the self-report measures of anxiety have separation anxiety subscales that can be used with children aged 8 years and older, including the SCARED,⁵⁸ the Multidimensional Anxiety Scale for Children¹³⁴ and the Spence Children’s Anxiety Scale.¹³⁵ For the interested clinician, a full report regarding assessment of SAD can be found in Perwein and Bernstein.¹³³ Specific questions suggested for use in initial assessment of SAD include the following: “Are you afraid of something that might happen to your mom or dad?”; “Do you sometimes get nervous when you are alone?”; and “Do you worry about getting lost or kidnapped?” Questions to ask parents include “Does your child have difficulty falling asleep or sleeping alone?”; “Does your child cry or have temper tantrums when anticipating being left with others?”; “Does your child follow you from room to room?”; “Does your child’s worries ever keep her or him from normal activities, including school or other fun activities away from home?”; and “Does your child complain of headaches, stomachaches, or body aches frequently on weekdays but not on weekends?”¹³⁶

DIAGNOSTIC CRITERIA

The types of trauma that children and adolescents may experience include motor vehicle collisions, house fires, natural disasters, child maltreatment, violence, and witnessing domestic abuse. These experiences make children vulnerable to PTSD. Table 18B-3 lists the DSM-IV-TR criteria for PTSD.⁶

TABLE 18B-3 Diagnostic Criteria for Posttraumatic Stress Disorder (PTSD)

Data from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Washington, DC: American Psychiatric Association, 2000.

If the child or adolescent’s response to the extreme stressor does not meet full criteria for PTSD, or if the pattern of PTSD symptoms occurs for a situation that is not extreme (e.g., parental divorce), a diagnosis of Adjustment Disorder should be considered. Presence of avoidance, numbing, and increased arousal before the stressor are suggestive of another underlining pathological process, such as a different anxiety disorder or mood disorder. If the symptoms have occurred for less than 1 month, a diagnosis of Acute Stress Disorder is warranted initially. The types of PTSD to be specified are acute (less than 3 months), chronic (longer than 3 months), or delayed onset (6 months after the most recent PTSD stressor).

Knowledge of developmental differences in the manifestation of PTSD is essential. Some scholars question the validity of the DSM-IV-TR criteria for very young children, because nearly half the criteria require verbal descriptions of thoughts and feelings that a young child is unlikely to articulate.¹³⁷ Young children may have trauma-specific nightmares initially but more generalized nightmares as time passes. Young children with PTSD symptoms may also exhibit fear of the dark, awake frequently at night, and report generalized fears such as “monsters.”^138,139 All children may have difficulties separating from parents in the days or weeks after the trauma. Older children and adolescents may report difficulties concentrating on schoolwork or may attempt to self-medicate with drugs and alcohol to alleviate painful reminders of the event.¹⁴⁰ Adolescents may engage in risky behaviors to lesson emotional pain.¹⁴¹ In addition, older children and adolescents may report extreme levels of guilt for surviving a traumatic experience, when others did not survive.

COMORBIDITY

Children who meet criteria for a diagnosis for PTSD may also meet criteria for other psychiatric conditions, especially mood disorders, such as major depressive disorder and dysthymic disorder.^142,143 The trauma experience, especially those involving maltreatment, may increase the susceptibility to a mood disorder¹⁴⁴ or dissociative disorder.¹⁴⁵ Comorbidity with externalizing disorders such as ADHD, oppositional defiant disorder, and conduct disorder suggests a need for a thorough psychological assessment.

PREVALENCE

The prevalence of PTSD in children and adolescents in the general population is largely unknown. In a clinical sample of children aged 6 to 18, just over 3% of youths in the juvenile justice system and 3% using mental health services met diagnosis for PTSD.¹⁴⁶ Children who were the victims of parental abuse were nearly twice as likely to show signs of PTSD as were those who witnessed domestic violence,¹⁴³ of whom 13% met criteria for PTSD.¹⁴⁷ After a category 4 hurricane, 30% of 568 students in third through fifth grades demonstrated severe or very severe PTSD symptoms 3 months later,¹⁴⁸ and 18% demonstrated severe or very severe symptoms 10 months after the hurricane.¹⁴⁹ In a British study, of children who experienced an automobile collision, 35% met diagnostic criteria for PTSD.¹⁵⁰ In general, girls tend to be more symptomatic than are boys.^150,151

Children who are susceptible to anxiety conditions before a traumatic event are at greater risk for the development of PTSD after a stressor. For example, preexisting anxiety symptoms were predictive of a child’s PTSD symptoms 3 and 7 months after Hurricane Andrew.¹⁵² There is a strong association between PTSD and other anxiety conditions, such as GAD and SAD.^153,154

CAUSES

Factors contributing to the development of PTSD include the severity of trauma, reactions of attachment figures to the trauma, and time since the trauma. Children and adolescents with a history of family psychopathology, violence, child behavior problems, and child maltreatment may be more susceptible to extreme stressors. Children’s coping with traumatic stressors is often reflective of parental coping.¹⁵⁵

ASSESSMENT

In order to make a diagnosis of PTSD, it is important to assess aspects of the child’s earlier functioning, severity of the trauma and child’s initial reaction, current symptoms, and their effect on the child’s life. PTSD-specific assessment measures can help determine whether a child should be referred to a mental health provider for further assessment and treatment. The Traumatic Events Screening Inventory for Children¹⁵⁶ is a self-report checklist that assesses exposure and intensity of the child’s response to the trauma and can be used for children as young as 8 years of age. The Children’s Post-Traumatic Stress Reaction Index¹⁵⁷ is a 20-item instrument that assesses the severity of PTSD symptoms; however, not all DSM-IV-TR criteria are represented. This index can be read aloud to children as a semistructured interview as well.¹⁵⁸

Because it is difficult for children to assess their reactions at the time of the trauma, an observer report is helpful. However, parents may have difficulty accurately reporting the intensity of their child’s PTSD symptoms.¹⁵⁹ Parents’ reports are necessary, but they should not be the sole informants. The Child Stress Disorders Checklist¹⁶⁰ is a 36-item observer report measure of PTSD and acute stress disorder. This measure assesses PTSD symptoms in five domains: reexperiencing, arousal, avoidance, numbing and dissociation, and impairment in functioning. Parent and teacher information is important for gaining a better understanding of pretrauma functioning, inasmuch as young children may not be able to reflect accurately on their previous thoughts and behaviors, because of their relative cognitive immaturity.¹⁴¹

In addition to self-report and observer report instruments, empirical evidence supports asking children directly about the exposure in order to assess symptoms of PTSD.¹⁶¹ Initially, children should be given the opportunity to recall the event in their own words. Subsequently, prompts regarding specific aspects of the diagnosis are helpful: for example, “What did you think/feel/hear in your body when the trauma occurred?”¹⁵⁸

DIAGNOSTIC CRITERIA

The hallmark feature of social phobia, also known as social anxiety disorder, for children and adolescents is excessive fear of embarrassment in social or performance situations. These feelings of anxiety may advance into a panic attack,¹⁶² and refusal to go to school is a common presenting problem. The diagnostic criteria for social phobia as it relates to children and adolescence is outlined in Table 18B-4.

TABLE 18B-4 Diagnostic Criteria for Social Phobia, Specific Phobia, and Panic Disorder