by Lorraine Foy, Provisional Psychologist Learning Links
Anxiety and Depression
Anxiety and depression are common concerns in childhood and adolescence.
Most children learn to cope with a range of normal fears and worries, such as the dark, loud noises, storms, and monsters. Anxiety becomes a concern when it stops children from participating in activities at school or socially; when the fears and worries seem out of proportion; or if children feel more anxious than other children their age and level.
The most common anxiety disorders in primary aged children are separation anxiety, phobias, and generalised anxiety disorder. Research estimates that between approximately 2% and 9% of children and adolescents in Australia present with anxiety disorders. The Australian Bureau of Statistics (2007) reported that 1 in 14 (7%) young people aged between 12-17 years has one or more anxiety disorder. It is likely that this figure has significantly increased over the last ten years.
Depression is an extremely common mood disorder, and the causes are not exactly known. While feelings such as sadness and worry are normal emotions that occur for everyone from time to time, depression involves strong feelings of sadness that don’t go away easily (Lyneham, Schniering, Wignall & Rapee, 2006). Depression affects children’s thinking as well as their mood and behaviour and can stop them enjoying the things they normally like to do, or participating in their usual activities.
Children with depression can be hard to engage and motivate, may appear tired all the time, be sleeping poorly, and be particularly irritable. They may also feel that nothing is worthwhile. A diagnosis of depression is only made when the mood has lasted more than two weeks, when it is intense, and when the symptoms are affecting the individual’s ability to manage everyday things.
Anxiety is a normal and healthy reaction, we all have it! When danger is perceived, our bodies prepare us to respond to the danger. The classic responses are known as ‘fight’, where we fight the perceived danger, or ‘flight’, where we run away from it. The fight-or-flight response was useful in the distant past when physical dangers threatened survival, and this response has remained part of our make-up (Andrews et al., 2013).
During the body’s response to threat, we feel frightened; we breathe quickly; the heart beats quickly and there can be a feeling of panic and shakiness. These responses are normal and generally occur instinctively. Anxiety only becomes a difficulty when the normal response is exaggerated or triggered without any reason.
Separation Anxiety Disorder (SAD) has been reported as the only anxiety disorder based on specific child criteria and commencing in childhood (Eisen et al., 2011). SAD is common in young children and relates to the child’s fear of being away from family, or major attachment figures. Generally, children fear that something bad will happen to family members while they are apart. This fear of separation is considered developmentally normal till the age of two, but should lessen as children get older. Children with Separation Anxiety find it particularly difficult to go on school camps or for sleepovers, and may often complain of feeling sick, or even refuse to go to school.
Phobias are commonly diagnosed in children when they have developed an intense fear around an object, situation or event. Common phobias in children are spiders, heights, injections, and storms, when realistically the threat of harm is small.
Children and adolescents may suffer with Social Phobia, which usually includes symptoms of extreme levels of shyness and self-consciousness. Situations where this may become uncomfortable for the child include talking to new people, presenting in front of the class or performing in public.
The term Generalised Anxiety Disorder is used where there is a broader range of worries for children, including concerns around things that might happen, about past behaviour, how popular they are, or how well they do at school. Children suffering with this disorder often lack confidence and constantly seek reassurance.
Depression, like anxiety, becomes a concern when it interferes with a person’s ability to cope with everyday situations. Individuals who are depressed tend to feel they are hopeless failures. They generally demonstrate a negative view of themselves and the world, often blaming themselves when something bad happens. Other symptoms include reduced concentration and attention, loss of interest and pleasure, low mood, tiredness, and changes in appetite and sleep patterns. In severe cases depression can lead to thoughts of self-harm or suicide.
Younger children experiencing depression may complain of stomach aches and headaches, and generally mope around, becoming socially withdrawn and less enthusiastic about school. In children with depression, irritability may be more noticeable than sadness.
As with anxiety, there are many forms of depressive disorders. A common feature of all these disorders is the presence of sad, empty, or irritable mood, together with changes in physical performance, such as lack of concentration, and thought processes that significantly affect the person’s ability to function (American Psychiatric Association, 2013).
Depression and anxiety can be present at the same time. About a third of all children suffering with one or more forms of anxiety will go on to have depression. Symptoms in children with both disorders may be more severe. The age for typical onset is around 3 years for anxiety and 10-12 years for depression.
Depression affects children’s thinking as well as their mood and behaviour.
Psychological therapy is generally needed to help children and adolescents identify their negative ways of thinking, and teach them how to think in a “more realistic and helpful way” (Andrews et al, 2013, p.249). The goal of therapy is for the individual to see that they have some control over what happens to them, and to foster resilience, helping them to realise that they can have input into positive outcomes in their lives.
The established treatments for depression include psychotherapy and medication (Andrews et al., 2013). It is reported that over half of all depressed individuals treated with psychotherapy get better (Andrews et al., 2013). Cognitive Behaviour Therapy (CBT) is a popular choice of treatment to treat both anxiety and depression in children (over the age of 8 years) and adolescents.
Psychological intervention for anxiety and depression
Cognitive Behaviour Therapy (CBT) is a structured, evidence-based intervention, which recognises that the way individuals think (cognition) and act (behaviour) affects the way they feel. CBT is frequently used to help children over 8 years manage their anxiety and/or depression.
An important initial component of CBT is explaining the nature of anxiety and/or depression to the child and their parents. This is known as psycho education. From here the child is taught skills to help them think more realistically and to challenge their negative thoughts. In treating anxiety, the behaviour aspect of the therapy may include providing relaxation techniques for use when the child is feeling anxious and exploring evidence to challenge the perception of danger.
Anxious children may be helped to develop of a ‘step-ladder’ of fears to be challenged over a period of time, one rung at a time. The aim here is to overcome anxiety-provoking fears by taking small steps to face them, working towards a goal of ultimately overcoming the largest fears, thereby reducing the anxiety experienced.
Beyond Blue reports that CBT has been found to be one of the most effective treatments for depression, and has proven useful for a wide range of ages, from children to older people. The therapist works with identifying thought and behaviour patterns that are leading to the depression, or which may be stopping the individual from managing their recovery from depression. With depression, CBT works to change the pattern of negative or unhelpful thought patterns by teaching rational thinking and supporting realistic, positive and problem-solving approaches.
While behaviour therapy is a major component of CBT, it can also be used independently. Behaviour therapy on its own focuses on encouraging the individual to engage in activities that are pleasant, satisfying or rewarding. It aims to identify and develop ways to support the child to resist withdrawal and inactivity, which make depression worse.
It can be seen that evidence supports the effectiveness of CBT as psychological intervention for both anxiety and depression.
Learning Links provides a range of options for treatment of anxiety and depression using evidence-based therapies, including CBT, delivered across a number of settings. Usually assessment of the severity of the presenting concern is undertaken prior to the commencement of therapy. This is completed by interviewing the parent and the child, as well as considering school/pre-school reports, and administering evidence-based questionnaires where appropriate. At the conclusion of a number of sessions, generally 10-16, there is an evaluation of the treatment’s effectiveness and recommendations are then made to sustain the progress made.
Learning Links offers counselling to both children and adults, with a major focus on children and adolescents. Services are offered at the Learning Links sites of Peakhurst, Maroubra, Liverpool and Bella Vista, and delivered at many schools where current agreements exist.
Several structured treatment programs are available for delivery in schools and also offered as holiday programs at the Learning Links’ offices during school breaks. For example, Get Lost Mr Scary, Cool Kids, and Chilled. The Cool Kids program has established success in anxiety with Australian children aged between 7 and 17 (Wuthrich, 2016). The Chilled program is aimed at the adolescent group and addresses depression in addition to anxiety.
All programs are based on the CBT framework, and include education about the nature of anxiety and/or depression; teach skills to support more realistic thinking, and behavioural strategies; and offer parent education in strategies to support their child. Depending on their age, children are taught skills in understanding and identifying their own emotions. Where children are still young, there is often more work with a parent to teach them skills to be used with their child, including in the home environment.
Therapy for all children and adolescents will involve goal setting; implementing strategies across home and school; homework and practice; and follow up with relapse prevention skills.
Families interested in obtaining more information about programmes and services available at Learning Links are encouraged to call to our intake team at Learning Links.
Some helpful resources:
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association.
Andrews, G., Dean, K., Genderson, M., Hunt, C., Mitchell, P., Sachdev, P., & Trollor, J. (2013) Management of mental disorders. Sydney, Australia. University of NSW.
Australian Bureau of Statistics. (2008). National Survey of Mental Health and Wellbeing: Summary of Results, 2007. Cat. no. (4326.0). Canberra: ABS.
Beyond Blue. https://www.beyondblue.org.au/the-facts/depression/treatments-for-depression/psychological-treatments-for-depression Accessed online 1/4/2017.
Eisen, A.R., Sussman, J.M., Schmidt, T., Mason, L., Hausler, L.A., & Hashim, R. (2011). Separation anxiety disorder. Handbook of Child and Adolescent Anxiety Disorders, 17. 245- 259. doi: 10.1007/978-1-4419-7784-7
Kids Matter http://www.kidsmatter.edu.au/mental-health-matters/mental-health-difficulties/anxiety Accessed online 1/4/2017.
Lyneham, H.J., Schniering, C., Wígnall, A. & Rapee, R.M. (2006). The Cool Kíds Adolescent & DepressionProgram – Parent Companion. MUARU: Macquarie University, Sydney.
Wuthrich, V. (2016). Cross-cultural efficacy of the Cool Kids programme for child and adolescent anxiety. Evidence Based Mental Health, 19(1), 29.
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