Treatment of Clinical Anxiety and Depression in Early Childhood

Introduction

Relatively little is known about anxiety and depression in early childhood, and diagnosis and treatment options for both are limited. However, interest in the area is growing.

Subject

There is increasing recognition that young children do experience symptoms of anxiety and depression, and are capable of experiencing these at clinical levels of severity. However, research into these conditions in young children has lagged substantially behind that of older children and adolescents.

Problems and Research context

Despite symptoms of anxiety and depression being common in this age group, we have very few treatment options specifically targeted to young children. Treatment research that has included this age group has often also included much older children and has not reported the results separately for different age groups. Therefore, treatments that, superficially, appear appropriate for younger children, may not be so. 

The question of whether we need to treat young children with these symptoms also remains. While in older children there appears to be some moderate degree of continuity of symptoms into adolescence and adulthood,^1,2 we simply do not know whether this is the case for younger children. Although unlikely, it is possible that younger children’s symptoms remit with time and that treatment is an unnecessary burden. Similarly, while experiencing early anxiety and depression is associated with difficulties in other areas, such as academic and interpersonal functioning,³ it is not known whether this is a cause or a consequence of the child’s mental health difficulties, nor whether these difficulties remit with successful treatment.

Key Research Questions

1. Should we treat symptoms of anxiety and depression in younger children?
2. How should we treat anxiety and depression in younger children?

Recent Research Results

Although we know that some temperament styles are associated with increased risk of mental health difficulties later on, we know very little about the predictive validity of early symptoms of anxiety and depression. This difficulty is compounded by the fact that, in early life, it can be difficult to distinguish between features of a healthy but inhibited temperament, and symptoms of emotional difficulties or anxiety, and in reality the edges are very blurred. For example, high levels of shyness can be part of the personality of a healthy child, or symptoms of a nascent social anxiety disorder.  While we might wish to treat a child with an anxiety disorder, it might be inappropriate to pathologize a quiet temperament. Where early intervention is offered, it needs to be done sensitively.

Cognitive Behaviour Therapy-based approaches

Initially, researchers attempted to “downsize” adult treatments for anxiety and depression, in particular, cognitive behaviour therapy (CBT).⁴ CBT for children has focussed on teaching them to recognize and challenge problematic thoughts, and using techniques such as exposure and behavioural activation, which are borrowed and modified, from the adult literature. These studies have tended to report fairly positive results^5,6 with an average of around 50-60% of children recovering from their primary diagnosis. However, these studies have generally included a wide range of ages, and, due to limited sample sizes, have been unable to look specifically at outcomes for younger children. In the case of depression, studies have typically not included children younger than nine years of age. However, there is some evidence from the anxiety literature that when applied sensitively, standard CBT approaches might be effective in children aged as young as six^7,8 and, when adapted further, using a play-based approach, to as young as four.⁹ 

Parenting-based approaches

A second approach, particularly in the anxiety literature, has been to work with parents of these young clients to enable families to provide a style of parenting that is best suited to their child’s temperament. For example, one parent-based intervention targeted at symptoms of anxiety in preschool children with a behaviourally-inhibited temperament, reduced diagnoses of anxiety disorders in participants.¹⁰ Another parenting-based approach is Parent Child Interaction Therapy (PCIT), a play-based, parent and child therapy informed by behavioural and social learning theories, that has shown some promise in the treatment of anxiety in young children.¹¹ Similarly, a parent-only, group-based cognitive-behavioural parenting intervention, aimed at providing young anxious children with a warm, calm, consistent parenting environment yielded significant reductions in anxiety diagnoses compared to an untreated group.¹² These parenting-based approaches tend to have been applied to the younger end of the age spectrum.

In practice, both the parenting-based and the cognitive behaviour therapy-based approaches tend to employ elements of the other: Parenting-based approaches usually coach parents in CBT-based exposure techniques, and most CBT interventions involve parents to some extent, teaching them some basic anxiety- or behaviour-management skills. However, despite evidence of high risk of family dysfunction in families of depressed children, few approaches to the treatment of depression that involve the family have been developed for young children.

Medication

Medication for anxiety and depression is generally recommended only as a last resort in young children. Although research has shown some efficacy for medication in depressed children aged as young as 6 years, safety concerns have led some national regulatory authorities to restrict or prohibit the use of SSRIs (selective serotonin reuptake inhibitors) in childhood.¹³

Unlike treatments for adults, and sometimes adolescents, treatments aimed at younger children tend to be quite generic, aiming to treat all types of anxiety or depression, rather than focussing on sub-diagnoses. This is probably quite appropriate, given our limited understanding of the validity of the different diagnostic categories in this age group.

Research Gaps

There is little research in this area, so there are many large gaps. We urgently need to know more about how and when symptoms of anxiety and depression in young children predict future mental health problems, and if so, at what stage we should attempt to intervene. In particular, we need to know when a normal, quiet temperament, which should be nurtured and celebrated, tips over into a disabling condition. If intervening, we need to know which approach works best for this age group. Input from cognitive developmental psychologists is likely to be beneficial in this endeavour, guiding the therapist towards features of the developmental process that have gone awry, and helping them to develop techniques that are most appropriate for clients at each developmental stage.

All of the promising psychological approaches to treating young children that are described above (with the exception of standard cognitive behaviour therapy) have thus far reported only a single small trial, wherein the intervention was compared to a no-treatment control. Further larger studies, from external research groups, employing placebo, and preferably other active treatment conditions, are needed.

Substantially more research into the treatment of depression in younger children is needed, as there are currently no interventions that have been tested for children younger than 9 years.

Conclusions and Implications

Much research is still needed to understand anxiety and depression in young children. Even when anxious and depressed young children are identified, many do not receive effective treatment. Although we are making some headway in understanding the causes of these conditions, and the contextual factors that influence them, evidence-based treatment options for this younger age group are very limited. Treatment research seems to have lagged behind the basic science, and rather than being based on our new-found understanding of the development of these conditions, has often developed downsized versions of adult treatments, such as cognitive behaviour therapy. While there is some modest evidence for the utility of these approaches in older children and adolescents, the research has not really focussed on young children, and there is considerable room for improvement. For depression in particular, where contextual factors (family breakdown, parental mental health, social and educational factors) have been shown to be critical in the development of the disorder, these have not generally been the focus of the treatments that appear in the research literature.

Although currently not clearly demonstrated, it seems very likely that significant symptoms of anxiety and depression at this age are predictive of future psychological disorders, and of social, academic, occupational and physical wellbeing. Therefore, it is likely that effective identification and treatment strategies that are focussed on early childhood will have substantial benefits not just for the individual, but at an economic and societal level too, and are, therefore, worth investing in. The most effective approaches are likely to involve parents, clinicians and child care settings working in partnership, in order to provide the most supportive environment for the child.

References

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