Chapter 2 Jane Roberts1 and Aaron Vallance2 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 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. 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 long term: depression and anxiety in adolescence are often persistent or recurrent. Enquire about the family’s mental health history: this not only might be relevant to the young person’s experience, but also may cast light on the meaning of mental illness in the family. The child may have been a young carer. Moreover, evidence shows that treating parental depression or anxiety can help the child’s disorder. Humah’s case reflects how depression and anxiety may afflict those across generations, as well as the importance of understanding religious/cultural perspectives. Depression is not uncommon in young people: the 1-year global prevalence rate exceeds 4% in mid–late adolescence, with increasing preponderance in girls with age. Diagnostic criteria are as for adults, although irritability, oppositional behaviours and somatic symptoms tend to be more common, whilst functionality and enjoyment in activities can often be preserved (Box 2.2). Potential contributing factors include: genetic and personality factors; parental mental health problems, conflict and lack of warmth; previous and current life events (including loss and trauma); and physical illness. School can harbour both protective factors (e.g. routine, activity, peers), exacerbating factors (e.g. bullying, stressful peer dynamics, academic worries) and consequences (e.g. deteriorating school grades or peer relationships). To aid diagnosis, ask direct questions about: persistence and severity of low mood, concentration, energy, enjoyment, negative thoughts, and sleep, eating and weight patterns. Risk should be evaluated at the first appointment (see below). It is better to aim for a therapeutic consultation rather than an exhaustive one; building trust is important. Ideally book further consultations there and then, which may help the young person to feel more cared for. Assessing risk can be done sensitively; for example, start by asking about hopelessness and whether life’s worth living, then eventually build up to direct questions on wanting to die and then on self-harming or suicidal ideation, intent or plan (Box 2.3). There is no evidence that asking such questions increases risk, whilst an accurate risk assessment would reduce risk.
Anxiety and Depression in Children and Adolescents
Primary care – an opportunity to make a difference
Depression in children and adolescents
What to cover in the consultation
Assessing and managing risk
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