ABC of Anxiety and Depression
ABC of Anxiety and Depression
Anxiety and Depression in Children and Adolescents
Jane Roberts 1 and Aaron Vallance 2
1 Clinical Innovation and Research Centre, Royal College of General Practitioners, London, UK
2 Metabolic and Clinical Trials Unit, Department of Mental Health Sciences, The Royal Free Hospital, London, UK
Anxiety and depression are not uncommon in children and young people, particularly those with coexisting medical problems or learning difficulties.
The primary care consultation offers an opportunity to explore the young person's problem from their own perspective, but inclusion of a family member or carer is usually necessary.
Anxiety and depression are risk factors for self-harm and suicide.
The stepped care approach should be followed in the management of children and young people with anxiety and/or depression.
Psychological therapies should be considered in the first instance, and antidepressants only initiated after assessment within specialist services.
GPs should understand referral pathways, including how to refer for specialist care.
The third sector offers resources to support the young person and their family, and the role of the school should be recognised.
This chapter considers the presentation and management of anxiety and depression in children and young people, and explores the challenges clinicians face in responding to the needs of children and their families. As in adults, the two conditions are frequently comorbid, but they will be discussed in turn.
Box 2.1 Introducing Humah
Humah, 15, lives with her extended family. She is doing well at the local school, although feels her parents' expectations put all of the siblings under pressure. She has a good circle of school friends, mostly Pakistani girls approved by her parents. She likes talking to Jess next door, when she comes over to look after her three younger brothers (although can't understand why she isn't trusted... or why her older brother Shochin isn't expected to do this). She feels her mother likes chatting with Jess; in fact she only smiles when Jess is around.
Humah feels sad most of the time and gets upset when her father and grandparents tell her she's lucky and has a bright future. She wonders whether to share her feelings with Jess, but fears she'll laugh; Jess always seems so cheerful.
Primary care – an opportunity to make a difference
In primary care, the consultation is an opportunity for a therapeutic encounter. However, GPs often report feeling anxious and uncertain when faced with young people experiencing emotional distress – a state that can lead to inertia or disengagement and leave the young person isolated and unsure where to turn.
A first consultation should begin the GP showing an interest and concern, thereby reinforcing that mental health issues are taken as seriously as, say, acne or period pain. This involves attentive listening and a non-judgemental stance, displaying compassion and curiosity in the young person's story. Using natural language and a lightness of tone, appropriate and judicious use of humour can serve to minimise the formal tone that clinicians can unwittingly adopt and which young people often report as a barrier. Focusing initially on the wider psychosocial context (e.g. family, friends, education/employment, how they spend their time) not only provides information but may 'break the ice' for exploring sensitive emotional issues later on. Asking about drug and alcohol use (e.g. as counterproductive coping strategies), and sexual activity/orientation are also important, but you may sense it is more appropriate to raise this later on. Establishing rapport is important for the lon