Emotional disorders of childhood

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Classification according to ICD-10
F93.0 Separation anxiety disorder of childhood
F93.1 Phobic childhood disorder
F93.2 Social anxiety disorder of childhood
F93.3 Emotional disorder with sibling rivalry
F93.8 Other childhood emotional disorders
F93.9 Emotional disorder of childhood, unspecified
ICD-10 online (WHO version 2019)

Childhood emotional disorders describe a group of mental disorders in children and adolescents in which fear is caused by certain, generally harmless objects that are outside the person.

description

The group of disorders, according to the ICD-10, includes disorders that represent an intensification of normal developments . This is where they differ from phobic disorders . In the case of emotional disorders, the focus is on fear of a certain object or a certain situation, which is generally harmless.

It is often the case, for example, that children feel a certain fear of being separated from their parents. This phase rarely occurs before the 6th month; from the age of 5 this normal phenomenon can hardly be observed. Generally this is explained by the child's developing attachment to the parents. Separation anxiety often occurs in situations in which an affectionate person has left the child behind for a short or long period, mostly in an unfamiliar environment. This normal behavior of the child only receives a disorder value when it is "unusual, has an abnormal duration beyond the typical age group and due to clear problems in social functions". For example, attending primary school can become completely impossible for a child with this disorder. This behavior must also start in early childhood. Only then can, as in this example, of an emotional disorder with separation anxiety of childhood. as listed below.

A phobic disorder of childhood , as it is listed below, represents an intensification of developmental trends in childhood. It is typical in the development of children that they are afraid of certain things or situations. In a large number of children, fear of the dark and thunderstorms or fear of ghosts or dogs is normal and can be seen as a typical phase in their development. In order to be able to diagnose this particular disorder, a particular expression of fear must be present in the child. The child must clearly avoid situations in which he is exposed to the fearful things.

In childhood social anxiety disorder, there is a constant or recurring fear of strangers or avoidance of them, which is inappropriate for their age. This fear can affect both adults and children. The first signs of a developmentally appropriate fear of strangers can be observed at the age of 6–8 months. It is particularly pronounced at 10–12 months. From the 12th month this fear slowly subsides again.

In the case of the emotional disorder with sibling rivalry , there is particularly strong competition with a newborn sibling, which in particularly severe cases can lead to open hostility and physical violence. Fear, social withdrawal and loss of bladder and bowel control can also be a manifestation of this disorder.

Classification in the ICD-10

In ICD -10, the World Health Organization (WHO), in which all recognized diseases are listed and coded, the emotional disorders of childhood are divided into the following subgroups.

  • F93 childhood emotional disorders
    • F93.0 Separation anxiety disorder of childhood
    • F93.1 Phobic disorder of childhood
    • F93.2 Childhood social anxiety disorder
    • F93.3 Emotional disorder with sibling rivalry
    • F93.8 Other childhood emotional disorders
    • F93.9 Emotional disorder of childhood, unspecified

In DSM-IV , the emotional disturbances are not specifically mentioned. There they are mostly summarized in the coding for anxiety disorders of adults, phobias etc. and thus separated from their developmental components. This would include a childhood social anxiety disorder under social phobia code 300.23; a phobic disorder of childhood under the generalized anxiety disorder under code 300.02 in the DSM-IV. The emotional disorder with separation anxiety of childhood can be coded in the DSM-IV under disorder with separation anxiety (309.21). The emotional disorder with sibling rivalry can be coded under V61.8 Problem between siblings , although this diagnostic category is intended for general interpersonal problems and can also concern problems that are not related to the sibling rivalry.

diagnosis

Guiding symptoms

  • Separation anxiety disorder of childhood
    • Unrealistic and persistent concern that something might happen to the caregiver or that the person concerned could be separated from the caregiver due to unfortunate events
    • Persistent reluctance or refusal to go to school / kindergarten in order to be able to stay with the caregiver or at home
    • Persistent reluctance or refusal to go to sleep without a close relative or away from home
    • Persistent, inappropriate fear of being home alone or without a primary caregiver
    • Repeated nightmares about the breakup
    • Repeated occurrence of somatic symptoms (nausea, abdominal pain, vomiting or headache) before or during the separation
    • Extreme and repeated suffering in anticipation of, during, or immediately after being separated from a primary caregiver (e.g., unhappiness, screaming, outbursts of anger, clinging).
  • Phobic childhood disorder
    • Inappropriately pronounced fear of certain objects or situations that the majority of children experience as frightening at certain stages of development, e.g. B. loud noises, imaginary figures (ghosts), animals (dogs), darkness or thunderstorms
    • Typical vegetative side effects are palpitations, sweating, tremors, breathing difficulties as well as feelings of oppression and dizziness
    • Pronounced avoidance behavior towards such objects or situations
    • Forced confrontation with the fearful object or the fearful situation triggers pronounced fear and is typically answered with crying, screaming, running away or clinging to caregivers.
  • Social anxiety disorder of childhood
    • Persistent anxiety in social situations in which the child meets strangers, including people of the same age, with avoidant behavior.
    • Bias, embarrassment, or exaggerated concern about the appropriateness of behavior towards strangers.
    • Significant impairment and reduction of social relationships (including with peers), which are reduced as a result; In new or forced social situations, clear suffering and unhappiness with crying, silence or withdrawal from the situation.
  • Emotional disorder with sibling rivalry
    • Compete with the younger sibling for the parents' affection and attention
    • Mainly negative feelings towards the sibling, which in severe cases can lead to open hostility and physical aggression
    • Clear lack of positive consideration for the sibling and friendly interaction
    • Stubborn refusal to share
    • Regression, often with loss of psychophysiological skills such as B. Bladder and bowel control
    • Supply requests such as B. to be fed again
    • Difficulty falling asleep
    • Increase in oppositional and confrontational behavior towards parents
    • Outbursts of anger
    • Disgruntled states of fear, unhappiness and social withdrawal.

Emotional disorders associated with highly aggressive or oppositional behavior are excluded from these diagnoses. These are under:

The phobic disorder of childhood must also be differentiated from the phobic disorder , which can often already occur in childhood. In phobic disorder, fear also relates to specific situations (e.g. agoraphobia ) or certain things ( e.g. arachnophobia ). However, the fear of these situations or things cannot be seen as an age-inappropriate fear or reinforcement of a normal development phase, since children usually do not develop a specific fear of, for example, spiders. Generalized anxiety disorder must also be ruled out.

Comorbidities

There is a particularly high comorbidity with other anxiety disorders . About half of all children with one anxiety disorder have another. A third of those affected even had two other anxiety disorders. Also Depressive disorders are a very common. Anxiety disorders often precede the depressive disorder. This can intensify the symptoms of anxiety.

Other common comorbidities can be found too

frequency

Anxiety disorders are very common in the course of development. About 10% of children and adolescents meet the criteria for an anxiety disorder at least once.

The frequency of separation fears is estimated at 1–4 percent. Other authors assume a prevalence of 3.9 percent for a separation anxiety disorder.

causes

Psychoanalytic Theory

The psychoanalysis assumes that fear to a number of congenital affective dispositions belongs. A pathological expression of fear arises from the quality of the relationship between the child and the caregiver. The object relations theory assumes a great importance of early childhood relationships whose pathologizing is mainly caused by failure to observe the child's needs in the different stages of development. It is often the case that children who are more anxious also have anxious caregivers.

The theory is that anxiety is often related to childhood separation anxiety. Sufficient object constancy could not be developed in childhood . In the anxiety and panic states, the search is again for a safety-giving object.

Furthermore, according to A. Freud and her approach, ego psychology, a distinction must be made between superego fear. This could also be described as fear of conscience.

  • Xenophobia and separation anxiety

Sigmund Freud started from a simple model of the development of xenophobia. Upon seeing a stranger, the toddler concludes that the mother is absent and has left the child. It experiences this so threateningly, because it is exposed to its troubling urges. Thus the fear of strangers is comparable to the fear of separation. But this fact was refuted by the psychoanalyst Szekely.

According to Freud, many theories arose specifically about separation anxiety, which often contradict each other. Robert N. Emde , an infant psychoanalytic researcher , believes that xenophobia has a significant maturation component because it occurs at about the same time in many cultures.

John Bowlby and other researchers see xenophobia as conditional. The Strange Situation test of Mary Ainsworth studied the reactions of a child to strangers. So it is crucial in which situation and in which way a stranger approaches the child, or he leaves it up to the child how it approaches. A different course could also be determined in the fear of strangers as well as fear of separation, which have different climaxes. It is also not clear whether fear of others is part of normal development. Thus the original view that separation and fear of others are manifestations of the same developmental phenomenon is incorrect.

So-called social referencing has been identified as a further, better researched factor . Thereafter, at around nine months of age, a child begins to orientate itself on the mother's affects in situations with uncertain, ambiguous and contradicting feelings (such as the entry of a stranger) in order to gain more information for deciding on the character of the situation . Thus, the mother's emotional reaction is of paramount importance for the child's reaction in such situations. Under optimal conditions, an eight-month-old infant will respond to strangers with a mixture of curiosity and caution, not fear. The fear of foreigners also depends on the context (foreign environment, absence of the mother). Adults also react similarly to strangers. So the fear is more a function of the situation.

Separation anxiety can be observed from the eighth to ninth month. However, discomfort when separated from the mother occurs from the first few days. It is almost always possible for a stranger to calm the child down during the first six months. After that, this is almost impossible. This could be related to the development of object constancy according to J. Piaget . Only when the child has got an exact idea of ​​the mother and a lasting idea of ​​the mother has established itself, even if the child cannot see the mother, could the presence of a stranger who does not correspond to the pattern of the mother just formed , Cause fear.

In addition to socialization , genetic causes are also seen today as the basis for developing an anxiety disorder. However, according to psychoanalytic theory, the parents and the child's environment have a greater and ultimately decisive influence. From the point of view of psychoanalysis, genetic influences primarily include increased excitability and the inability to control and regulate the excitement.

The extent to which a child reacts when separated from its mother in a strange situation also depends on the quality of the bond . This was examined and evaluated by J. Bowlby and M. Ainsworth in attachment theory. According to this, children develop different attachment styles, which can be proven in a specific test. The results suggest these different attachment stalks, which also suggest the quality of anxiety a child experiences in the sudden absence of the mother. Most of the children in the test suggested by Bowlby and Ainsworth are clearly fearful.

Finally, in object relationship theory, fear of separation and fear of others is seen as a projection of negative object representations. The absence of the mother is perceived by the child as frightening. Negative feelings and fantasies are projected onto the stranger who is then experienced as terrifying. M. Klein , an early object relationship theorist, was of the opinion that the first object relationships overcome an innate death drive that triggers the fear of self-destruction. In the absence of the security-giving object, this fear reappears. Donald Winnicott then emphasized the importance of transitional objects (stuffed animals, "comforters" or cuddly blankets ) for acquiring the autonomy that is important in developmental psychology. By clinging to transitional objects, the -temporary- loss of the caregiver can be better endured.

  • Phobias

Specific phobias are always seen within psychoanalytic theory as a shift from fear to an object or situation. The shift is one of the defense mechanisms within psychoanalytic theory . A fear of a certain idea is suppressed and then occurs in a different form, for example as a fear of spiders or, for example, darkness and thunderstorms, as it behaves in the case of a phobic disorder in childhood.

The repressed fears and conflicts can be of very different types. Separation, jealousy and the like can also trigger anxiety here. It is important here that shifting the child's fear of a certain idea to an external situation or an object has two important functions. An external object or situation can be actively avoided, as opposed to a (frightening) idea that can be compulsory; Second, it can keep a relationship free from conflict, since the fear has been shifted to another object or situation. A simple example here would be that a child is not afraid of separation with its mother, but of being alone in the dark. Another fear is warded off with fear .

The type of phobia that arises depends on the child's level of development. Younger children are more likely to develop a fear of thunderstorms than of spiders, as is the case with more mature disorders. To which external object the fear is now shifted could also be related to the symbolization processes . This would create fear of an object, which symbolically represents real, but repressed fear. Simple conditioning could also play a role.

Learning theories and cognitive approach

Learning theories

According to the learning theories , fears can be acquired through classical conditioning and maintained through operant conditioning . An originally neutral stimulus (e.g. a dog) is paired with a stimulus that already triggers fear (e.g. sudden noise or the like). The spatiotemporal coincidence ( contiguity ) of the two stimuli can lead to conditioning; the originally neutral stimulus now also triggers fear. John B. Watson demonstrated this process in a classic experiment (see Little Albert experiment ). In the presence of a rat ( neutral stimulus ), a toddler (“little Albert”) was startled by a loud noise ( unconditioned stimulus ) ( unconditioned reaction ). After this process had been repeated a few times, the child (who had played with the rat without fear at the beginning of the experiment) now also showed the fear reaction (now: conditioned reaction ) when looking at the rat alone (now: conditioned stimulus ). Through conditioning, the neutral stimulus becomes a predictor of the unpleasant consequence.

Due to the conditioning, the actually neutral and (mostly) harmless stimulus triggers fear. The person therefore avoids being confronted with the fear-inducing object or situation. This will prevent the fear that would be triggered by the stimulus. The avoidance behavior is thus maintained through negative reinforcement ( operant conditioning ).

In addition, fear can also arise in social interaction. In model learning , fear is learned through role models ; H. The fearful reaction of the mother (e.g. of dogs) can also contribute to the development of fear in the child.

Some researchers assume that fear of certain situations and / or certain objects is not learned through conditioning experiences, but is innate (e.g. fear of height ). Insufficient confrontation with the fear-inducing situation prevents the individual from learning that the situations or objects are not dangerous. So the fear also remains.

Cognitions

AT Beck assumes that emotional disorders arise from the so-called cognitive triad. Here at he takes three triggers. A negative self-image, a negative interpretation of past experiences and a nihilistic view of the future. Beck sees the cause of such thought patterns in childhood and adolescence, when such negative processing patterns arise. These schemes lead to cognitive thinking errors:

  • Events in the environment are extremely related to one's own person (personalization).
  • It is thought in extremes. Differentiation possibilities do not exist. (Polarized thinking)
  • Individual aspects of an event are selected and overrated (selective)
  • Unfounded experiences are generalized to general statements (over-generalization).
  • Insignificant changes or events are assigned inappropriate importance (exaggeration).

treatment

Gradient forms

Overall, boys at kindergarten age seem to be less affected by anxiety disorders than girls (> formation of gender-specific thinking, behavior and communication reflexes, later deepened, for example, through sanctioned active and passive selection of surroundings). The remission rate for anxiety disorders is higher than for other disorders. Anxiety disorders often begin in childhood - this is especially true for phobias that often start very early - and can become chronic into adulthood. Here, the various disorders, depending on their severity, can have a very negative effect on development. For example, a child's social anxiety disorder can hinder the normal development of age-appropriate behavior. Serious comorbid disorders can also arise in the course of the disease. Little is known about the exact course, especially early disorders.

intervention

Treatment can include a variety of interventions. In most cases, outpatient treatment is promising. Treatment should usually be multimodal. Several treatment steps can be combined, often in different order:

Today it is generally regarded as important to educate parents as well as the child or adolescent about the disease. This avoids prejudices about the disease in question and creates the possibility of successful treatment.

Depending on the severity of the impairment, psychotherapeutic intervention is also necessary. Various methods can be used here. Both behavioral therapy and psychodynamic procedures can be used here one after the other as part of a comprehensive treatment.

In the context of family interventions, both family therapeutic intervention and family counseling can help to reduce the child's anxiety symptoms. Family interventions are particularly useful when parents themselves are fearful. It is also important that parents learn how to deal appropriately with their child's avoidance behavior.

In the event of abuse in the preverbal phase, access is possible on the non-verbal level, especially with the methods of family therapy or body psychotherapy (working with limits). Source: Somatic psychotherapy with children. In: Gustl Marlock, Halko Weiss: Handbook of body psychotherapy. Schattauer, 2006, p. 796.

Inpatient treatment

Inpatient or partial inpatient treatment is usually not necessary. Outpatient treatment is only insufficient in particularly severe cases.

literature

References

  1. ↑ a b R. Oerter, L. Montada (Ed.): Developmental Psychology -Ein Textbook-. 4th edition. PVU, Weinheim 1998, p. 239.
  2. ↑ a b c d e Horst Dilling, Werner Mombour, Martin H. Schmidt: International Classification of Mental Disorders. ICD-10 Chapter V (F). Clinical-diagnostic guidelines Edition: 5th Huber, Bern 2002.
  3. ↑ a b c d e Dt. Ges. F. Child and adolescent psychiatry and psychotherapy etc. a. (Ed.): Guidelines for the diagnosis and therapy of mental disorders in infants, children and adolescents. 2nd revised edition. Deutscher Ärzte Verlag, 2003.
  4. ↑ a b Dt. Ges. F. Child and adolescent psychiatry and psychotherapy etc. a. (Ed.): Guidelines for the diagnosis and therapy of mental disorders in infants, children and adolescents. Deutscher Ärzte Verlag, Cologne 2000.
  5. ↑ E. Heinemann, H. Hopf (2004): Mental disorders in childhood and adolescence. Stuttgart, Kohlhammer
  6. ↑ a b c d e f P. MG Emmelkamp, ​​TK Baumann, A. Scholing: Anxiety, phobias and compulsion. 2nd Edition. Hogrefe, Göttingen 1998.
  7. ^ Resch et al.: Developmental Psychopathology of Childhood and Adolescence - A Textbook. PVU, Weinheim 1999.
  8. ↑ M. Dornes: The early childhood - developmental psychology of the first years of life -. Fischer, Frankfurt am Main 1997.
  9. ↑ John B. Watson, Rosalie Rayner: Conditioned emotional reactions . In: Journal of Experimental Psychology. Volume 3, No. 1, 1920, pp. 1-14.
  10. ↑ fh-dortmund.de

See also