Step 2 CK · Psychiatry

Childhood Anxiety, Mood & Attachment Disorders

Name: Childhood Anxiety, Mood & Attachment Disorders
Creator: Veli Bakalov, MD

Stomachaches, silence, and rage — how childhood distress disguises itself

Psychiatry·Child & Adolescent Psychiatry·6 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

Study materialsNo account needed

Card deckActive-recall cards · quick checks · quiz

High-yield

Separation anxiety disorder is excessive fear of separation lasting ≥4 weeks in children, with school refusal, sleep refusal, and stomachaches on school mornings; it is the most common anxiety disorder before age 12.
School refusal is treated with CBT and a rapid, graded return to school, and every case needs a private screen for bullying or abuse.
Selective mutism is failure to speak at school despite normal speech at home for ≥1 month; treat with behavioral therapy or CBT, adding an SSRI if severe.
Pediatric anxiety is treated first with exposure-based CBT; CBT plus sertraline is most effective for moderate–severe cases, and benzodiazepines are avoided.
DMDD requires severe outbursts ≥3 times a week plus persistent irritability for ≥12 months, onset before age 10, and diagnosis between ages 6 and 18; it takes precedence over ODD.
DMDD is chronic and non-episodic and predicts adult depression and anxiety, whereas pediatric bipolar disorder has discrete episodes of elevated mood.
In youth, irritability can replace depressed mood; screen for depression at ages 12–18 (PHQ-A) and for anxiety at ages 8–18.
Fluoxetine is approved for depression from age 8 and escitalopram from age 12; the boxed warning is for suicidal thoughts and behaviors under age 25, requiring close early monitoring.
Reactive attachment disorder is an inhibited, withdrawn response to neglect; disinhibited social engagement disorder is indiscriminate friendliness toward strangers.

Separation anxiety and school refusal

Normal versus disordered fear. Stranger anxiety appears around 6–9 months, and separation anxiety peaks around 10–18 months, usually fading by about age 3. Preschoolers commonly fear the dark, animals, and imaginary monsters; school-age children worry about injury and performance; adolescents fear social evaluation. A disorder is diagnosed only when fear is excessive for the developmental stage, persistent, and impairing.

Separation anxiety disorder. The child shows excessive, developmentally inappropriate fear of separation from attachment figures: persistent worry that a parent will be harmed or that an event such as getting lost will separate them, reluctance to attend school or sleep alone, nightmares about separation, and stomachaches or headaches on school mornings that disappear on weekends and holidays. Symptoms must last at least 4 weeks in children and adolescents (typically 6 months in adults). It is the most common anxiety disorder in children younger than 12.

School refusal. School refusal is a symptom, not a diagnosis. Common causes are separation anxiety (fear of leaving the parent), social anxiety (fear of peers' scrutiny), specific phobia, depression, and learning disorders; bullying or abuse must always be explored by interviewing the child alone, especially after an abrupt change or unexplained injuries. Unlike truancy, which is hidden from parents, school refusal happens with their knowledge.

Brief medical assessmentAvoid extensive testing when complaints follow a school-day pattern.
Screen privatelyBullying, abuse, mood, and learning difficulties.
CBT with parent involvementGraded exposure and coaching parents to stop accommodating avoidance.
Rapid, graded return to schoolEvery day at home reinforces avoidance.
SSRI if moderate–severe or refractorySertraline or fluoxetine; no benzodiazepines.

Selective mutism and childhood phobias

Selective mutism. The child consistently fails to speak in specific social settings, usually school, while speaking normally at home, for at least 1 month (not just the first month of school), and not because of a communication disorder or an unfamiliar language. It usually begins before age 5, is often first noticed at school entry, and most affected children also have social anxiety. Exclude hearing loss, language disorders, and autism. Treatment is behavioral therapy or CBT (stimulus fading, which gradually adds new people and settings while the child speaks to a trusted person, plus shaping and rewards), with an SSRI such as fluoxetine for severe or unresponsive cases.

Social and specific phobias. In children, fear may appear as crying, tantrums, freezing, clinging, or refusing to speak. In social anxiety disorder the anxiety must occur in peer settings, not only with adults. Both social and specific phobia require at least 6 months of symptoms. Blood-injection-injury phobia is unique in causing a vasovagal faint, so exposure is paired with applied tension, in which the child tenses large muscles to raise blood pressure.

Treating pediatric anxiety. Exposure-based CBT is first-line for mild–moderate anxiety. For moderate–severe or refractory anxiety an SSRI (sertraline or fluoxetine) is added, and the combination is most effective. Benzodiazepines are avoided.

~80%response to CBT plus sertraline in the CAMS trial (ages 7–17)

~55–60%response to either CBT or sertraline alone

~24%response to placebo

Disruptive mood dysregulation disorder

Criteria. Severe recurrent temper outbursts, verbal rages or physical aggression grossly out of proportion to the situation and to developmental level, occur at least 3 times per week. Between outbursts, mood is persistently irritable or angry most of the day, nearly every day, and others notice it. Symptoms last at least 12 months without a symptom-free stretch of 3 months or more, appear in at least two of three settings (home, school, peers), and are severe in at least one. Onset is before age 10, and the diagnosis is made only between ages 6 and 18.

Why the diagnosis exists. DMDD was created to curb overdiagnosis of bipolar disorder in chronically irritable children, who tend to develop unipolar depression and anxiety as adults. It cannot coexist with ODD (DMDD takes precedence), intermittent explosive disorder, or bipolar disorder, and a distinct manic or hypomanic episode excludes it.

Chronic irritability versus episodic mood disorder

Feature	DMDD	Pediatric bipolar disorder	ODD
Course	Chronic, non-episodic	Discrete episodes with return to baseline	Persistent pattern ≥6 months
Hallmark	Severe outbursts ≥3/week plus constant irritability	Euphoria, grandiosity, decreased need for sleep, pressured speech	Argumentative, defiant, vindictive; milder outbursts
Adult outcome	Depression, anxiety	Bipolar disorder	Some progress to conduct disorder

Management. CBT and parent management training are first-line. Stimulants treat comorbid ADHD, and atypical antipsychotics are reserved for severe aggression.

Depression in children and adolescents

Presentation. Irritable mood can replace depressed mood, and failure to make expected weight gain counts toward the weight criterion. Clues include falling grades, social withdrawal, boredom, somatic complaints, and new substance use. Persistent depressive disorder requires only 1 year of symptoms in youth, versus 2 years in adults.

Screening. The USPSTF recommends screening adolescents aged 12–18 for major depression, for example with the PHQ-A (the adolescent PHQ-9), when systems for diagnosis, treatment, and follow-up are in place; evidence is insufficient below age 12. Anxiety screening is recommended from ages 8–18. Interview the teen alone, explain the limits of confidentiality, and ask directly about suicidal thoughts; asking does not increase risk.

Treatment. Mild depression is managed with active support, monitoring, and psychotherapy (CBT or interpersonal therapy for adolescents). Moderate–severe depression calls for an SSRI plus psychotherapy. Fluoxetine is FDA-approved from age 8 and has the strongest evidence; escitalopram is approved from age 12. In the TADS trial, fluoxetine combined with CBT produced the highest response. If the first SSRI fails, switch to another SSRI and add CBT. TCAs are ineffective in youth and lethal in overdose, and paroxetine is avoided. Treatment continues for 6–12 months after remission.

Antidepressants carry a boxed warning for increased suicidal thoughts and behaviors in patients under 25 (about 4% versus 2% on placebo); no completed suicides occurred in the pediatric trials, and untreated depression is the greater danger. Monitor closely during the first 1–3 months and after dose changes, create a safety plan, and restrict access to firearms and stored medications. Screen for past hypomania and a family history of bipolar disorder first, because antidepressants can trigger mania.

Attachment disorders after neglect

Shared background. Both disorders stem from grossly insufficient care, such as neglect, repeated changes of caregivers, or institutional rearing. The child must have a developmental age of at least 9 months, RAD must be evident before age 5, and neither is diagnosed when autism spectrum disorder explains the picture.

Reactive attachment disorder versus disinhibited social engagement disorder

Feature	RAD	DSED
Core behavior	Inhibited, emotionally withdrawn	Disinhibited, overly familiar with strangers
With caregivers	Rarely seeks or responds to comfort	Does not check back; wanders off with strangers
Emotional signs	Little positive affect; unexplained irritability, sadness, fear	Culturally inappropriate verbal or physical familiarity
Course with stable care	Improves with responsive caregiving	Often persists
Main differential	Autism (which has restricted, repetitive behaviors)	ADHD (social impulsivity)

Management. The core treatment is a safe, stable, nurturing caregiver, supported by caregiver-focused therapy that helps the adult respond consistently to the child's cues. Suspected neglect must be reported to child protective services. Medication does not treat the core disturbance.