Child and adolescent psychiatry: anxiety, mood and self-harm

• Anxiety disorders are the most common psychiatric conditions of childhood and adolescence, affecting roughly 1 in 12 children and 1 in 4 adolescents in some populations.^[3]
• Depression is less common in young children but rises in adolescence (about 1.3% of 10-14-year-olds and 3.4% of 15-19-year-olds), and suicide is the third leading cause of death in 15-29-year-olds.^[5]
• Self-harm is an emergency signal, not "attention seeking": it always needs a psychosocial assessment, a safety plan and close follow-up, and never a predictive risk score.^[2]
• In this age range, cognitive behavioural therapy (CBT) is first-line for most anxiety and depression; antidepressants (fluoxetine for depression, SSRIs for anxiety in higher-resource settings) are added when needed, with close monitoring for suicidal thoughts.^[1][3]
• Safeguarding is not an afterthought: it runs alongside assessment, and it changes who must be involved and what can be kept confidential.^[2]

By the end of this page you should be able to:

1. Distinguish normal developmental fear from an anxiety disorder, and name the main childhood anxiety disorders with their duration and impairment thresholds. ^[3]
2. Recognise and manage separation anxiety, selective mutism and school refusal, including how school refusal differs from truancy. ^[3][7]
3. Assess childhood depression, including risk of self-harm, and apply the stepped-care model to its treatment. ^[1]
4. Carry out a psychosocial assessment after self-harm, formulate risk without global scores, and make a safety plan. ^[2]
5. Outline safeguarding, confidentiality and consent for young people who self-harm. ^[2]
6. Adapt care in low-resource settings using mhGAP. ^[6]

Child and adolescent psychiatry looks at the same conditions that psychiatry looks at in adults, but in development. A worry that is normal at age 4 is pathological at 14; a tantrum that is communication at 2 is behaviour at 8. Age, family and school shape both how a problem shows and what treatment can work. This page covers the problems most likely to be met by a generalist: anxiety disorders (including separation anxiety, selective mutism and school refusal), depression, and self-harm, together with assessment, treatment and safeguarding. Attention-deficit and conduct disorders are covered with general child health topics, and bipolar disorder, schizophrenia and autism have their own pages.

Two cautions frame everything that follows. First, psychiatric diagnosis in a child is a team sport: one clinician's impression is rarely enough, and the parents and school are data. Second, in this age group behaviour is communication, and behaviour is also a safety signal.

Anxiety disorders are conditions in which fear or worry is excessive, out of proportion to the situation, and persistent, with avoidance or behavioural disruption that impairs the child's functioning in family, school or peer life.^[3] The common diagnoses in this age group are generalised anxiety disorder, separation anxiety disorder, social anxiety disorder, specific phobia, panic disorder, agoraphobia and selective mutism.

A key developmental note: separation anxiety is expected and brief in infants and toddlers. A diagnosis is made when it is developmentally inappropriate, excessive and lasts at least four weeks, with clinically significant distress or impaired functioning.^[3]

Selective mutism is a consistent failure to speak in specific social situations (usually school) despite speaking freely in others (usually home), and not explained by lack of knowledge of the language or a communication disorder. It is usually understood as one expression of social anxiety rather than a separate disease, and tends to improve with exposure-based CBT and, in severe cases, with an SSRI under specialist care.

Childhood and adolescent depression has the same emotional core as adult depression: low mood and loss of interest or pleasure, with cognitive and somatic accompaniments. The presentation drifts by age. Younger children may show irritability, somatic complaints and behavioural change; adolescents look increasingly like adults, with anhedonia, guilt, poor concentration and sleep and appetite change. NICE (NG134) covers identification and management of depression in people aged 5 to 18 years.^[1]

Self-harm and suicidality are defined in the MedGrasp topic on suicidality and self-harm; the short version needed here is that self-harm is intentional poisoning or self-injury, with or without intent to die, and suicidality is the broader spectrum from passive wishes to die through plans and attempts.

School refusal is the emotionally driven difficulty attending school, with emotional distress and parental awareness of the child's whereabouts, and usually without concealment and without severe conduct disturbance.^[7] It is not truancy, in which the child hides absences and the family is often unaware. School refusal is a behaviour that sits on top of another disorder (most often anxiety, but also depression or neurodevelopmental conditions), so treating the underlying condition is part of treating the absence.

• Anxiety is the most common psychiatric condition in children and adolescents: around 6.5% of children worldwide, nearly 1 in 12 children aged 3-17 in the USA, and between 1 in 7 and 1 in 4 adolescents depending on severity.^[3]
• Specific phobias are the single most common anxiety disorder (around 20%), with social anxiety disorder around 9%, separation anxiety disorder around 8%, and agoraphobia, panic disorder and generalised anxiety disorder around 2% each.^[3]
• Anxiety is more common in older than in younger adolescents: about 4.1% of 10-14-year-olds and 5.3% of 15-19-year-olds experience an anxiety disorder.^[5]
• One in seven (14.3%) 10-19-year-olds experience a mental health condition of any kind, producing about 15% of the global burden of disease in that age group.^[5]
• Depression affects about 1.3% of 10-14-year-olds and 3.4% of 15-19-year-olds.^[5]
• Suicide is the third leading cause of death in 15-29-year-olds.^[5]
• School refusal affects roughly 2-5% of school-aged children and adolescents, is equally common in boys and girls, and peaks at ages 5-6 and 10-11.^[7]

Risk factors for childhood anxiety include family history of anxiety, low socioeconomic status, exposure to violence, trauma and adverse life events, as well as a shy or inhibited temperament.^[3] Parental anxiety in particular increases the child's risk of impairment.^[3] Depression has a similar profile with additional weight on loss events, family discord, bullying, physical illness, parental depression or substance misuse, and multiple stacked risk factors rather than a single bad event.^[1]

School refusal is more common in children with anxiety, depression, learning difficulties, autism spectrum disorder and attention-deficit hyperactivity disorder, and it is strongly associated with being bullied, with family conflict or separation, and with parental mental illness.^[7]

Self-harm risk is not a score but a picture: is there a credible means, is there a plan, are there escalating episodes, is there hopelessness, and are there supports. NICE (NG225) directs clinicians not to use global risk labels to predict future behaviour or to decide treatment or discharge.^[2]

Anxiety is a normal survival system turned up too high. A child who startles at a loud noise and then separates from a parent to follow the parent is responding normally. The disorder is when the alarm fires before anything has happened, is hard to reason with, and is maintained by avoidance. Avoidance is the engine of the problem: every time the child escapes the feared situation and the anxiety drops, the brain learns that escape was necessary. Exposure therapy works by deliberately breaking that loop.

Depression in this age group is understood in the same biopsychosocial way as in adults: genetic vulnerability and neurobiological change (sleep and circadian, stress reactivity), interacting with cognitive style (hopelessness, self-criticism) and with social context (bullying, loss, family). The difference is that neurodevelopment is still in progress, so early treatment has long-term consequences.

A good history comes from the child and from the adults around them, separately. Children depend on parents and school for most of their daily functioning, so collateral is clinical information, not a courtesy.

Anxiety. Children rarely say "I am anxious." They complain of stomach ache, headache and sleep difficulty, or of clinginess, avoidance and tantrums. Ask about onset, triggers and avoidance, and about what the child can and cannot do now compared with six months ago. Ask about sleep, school attendance, friendships and play. Ask about family history of anxiety and depression.

Depression. Ask about low mood, loss of interest, energy, concentration, appetite and sleep, and about worthlessness and guilt. In adolescents ask directly about self-harm and suicidal thoughts. Ask about substance use. Ask what keeps them going (protective factors matter as much as risk).

Self-harm. Ask directly, with normalising, non-leading questions. Ask what they did, how, how often, whether anyone knew, and whether the aim was to die, to stop feeling, to communicate, or to punish. Ask about current intent and plan and about access to means. Asking directly does not create suicidal ideas and usually relieves them.

The mental state examination in this age group is an observation of how the child relates, plays and talks, as much as answers to questions. Note the quality of the parent-child interaction, the child's affect and engagement, speech, thought form and content, perception, and insight. Physical examination is usually short and targeted: rule out a medical mimic of anxiety such as hyperthyroidism, asthma, arrhythmia or substance effect, and assess nutrition and self-injury in a child who self-harms.^[3]

Anxiety in children is often confused with:

• a normal developmental fear (separation anxiety in a 2-year-old; fear of the dark; stranger anxiety), which is brief, flexible and not impairing;
• a medical condition (hyperthyroidism, asthma, cardiac arrhythmia, epilepsy, substance effect) that produces palpitations, breathlessness or panic;
• another psychiatric diagnosis (depression with somatic anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, autism spectrum disorder, attention-deficit hyperactivity disorder);
• in selective mutism, a language or speech disorder or autism.

Depression has to be separated from normal (situational) sadness after a single difficult event, from adjustment disorder, from medical illness (hypothyroidism, anaemia, in adolescents substance use) and from bipolar disorder, which looks like recurring irritable episodes with grandiosity and markedly decreased need for sleep.

For school refusal, the differential is truancy versus absence due to illness, bullying-driven avoidance, phobia of a specific school situation, and neurodevelopmental difficulty masquerading as refusal.

Table 1 lists the DSM-5 anxiety disorders commonly seen in childhood with their diagnostic thresholds.

There is no blood test that diagnoses anxiety or depression. Diagnosis rests on a clinical interview and collateral. Screening tools help quantify and monitor but never replace judgment.

• USPSTF recommends screening for anxiety disorders in children and adolescents aged 8-18; there is insufficient evidence to screen under 8.^[3]
• For anxiety: the SCARED (Screen for Child Anxiety Related Emotional Disorders) for ages 8-18 (a score of at least 25 on the 41 items, or at least 3 on the 5-item short form, may indicate an anxiety disorder) and the SCAS (Spence Children's Anxiety Scale) for ages 6-15 (parent 8-item version with a cut-off of 7.5).^[3]
• For depression: the Mood and Feelings Questionnaire (MFQ) as an adjunct to clinical judgement; NICE NG134 suggests questionnaires such as MFQ or age-appropriate standardised measures.^[1]
• History, physical examination and targeted tests to rule out mimics: thyroid function for suspected hyperthyroidism, ECG for palpitations, etc.^[3]

Severity is judged clinically: mild depression or anxiety leaves the child functioning with effort, moderate causes clear functional impairment, and severe adds marked impairment or risk features (self-harm, suicidal ideas, psychosis, inanition).

Depression is diagnosed on the same symptom groups as in adults (low mood or anhedonia, plus five of nine), but in NICE NG134 the operative categories for management are mild versus moderate-to-severe, with age splits (5-11 and 12-18) and comorbidity modifying the choice.^[1] A child older than 11 referred to CAMHS without a diagnosis should be screened with a self-report questionnaire as part of assessment.^[1]

The flowchart summarises the overall approach from presentation to treatment.

CBT with exposure is the best-supported first-line treatment for anxiety disorders in this age group, with consistent trial evidence of improvement in symptoms, remission and functioning.^[3] For mild-moderate symptoms it is offered before medication; CBT plus an SSRI is more effective than either alone (81% versus 60% and 55% in a trial of 488 children with social, generalised or separation anxiety; number needed to treat 2 for the combination versus 3 for each monotherapy).^[3] Treatment usually runs 12-20 weeks with booster sessions. Parents are part of the treatment: a parent who is anxious models anxiety, and a parent who avoids feeds avoidance, so parental anxiety work is often a prerequisite for the child's progress. School liaison is essential for separation anxiety and school refusal: graded return to school is itself the exposure.

AACAP's 2020 clinical practice guideline, as summarised by AAFP, recommends that children and young people aged 6-18 with social anxiety, generalised anxiety, separation anxiety, specific phobia or panic disorder receive CBT or an SSRI, or combination therapy preferentially.^[3][4] WHO (mhGAP, 2023) takes the opposite, precautionary position for non-specialist settings: pharmacological interventions are not recommended in children and adolescents with anxiety disorders, and care should centre on CBT and other psychosocial interventions.^[6] This is a genuine difference of view, driven by setting and resource, not by ignorance on either side; a generalist should know both and follow their regulator and formulary.

SSRIs are first-line when medication is used, and are generally well tolerated.^[3] Fluoxetine, sertraline and escitalopram are commonly used to treat childhood anxiety; duloxetine is the only medication approved by the FDA for generalised anxiety disorder in children 7 years and older, and extended-release venlafaxine has shown benefit for generalised anxiety disorder and social phobia in 6-17-year-olds in a trial.^[3]

Start at the lowest dose available, titrate after about a week if tolerated, and monitor symptoms regularly. CBT lasts 12-20 weeks. Medication is usually continued for 6-12 months after anxiety resolves and tapered during a stress-free time. Antidepressants carry an FDA boxed warning about increased suicidal thoughts and behaviours in children and adolescents; informed consent, selective use and close early monitoring are essential, and any new suicidal behaviour needs urgent contact with the prescriber.^[3]

Management follows stepped care, with increasing intensity as needed.^[1]

• Mild depression: watchful waiting, then digital CBT, group CBT, group interpersonal therapy (IPT) or group non-directive supportive therapy, with individual CBT or attachment-based family therapy if those do not fit. Antidepressants are not used for initial treatment of mild depression.^[1]
• Moderate-severe depression: review by a CAMHS (tier 2/3) team. For 5-11-year-olds, family-based IPT, family therapy, psychodynamic psychotherapy or individual CBT, with or without fluoxetine. For 12-18-year-olds, individual CBT for at least 3 months, with or without fluoxetine; if CBT does not fit, IPT-A, family therapy, brief psychosocial intervention or psychodynamic psychotherapy.^[1]
• Combined treatment: fluoxetine plus psychological therapy may be considered as initial treatment for 12-18-year-olds with moderate-severe depression (off-label for initial combination use at the time of the guideline), and otherwise after 4-6 sessions if not responding.^[1]
• Fluoxetine is the only antidepressant with evidence that benefits outweigh risks in this group and is started at 10 mg daily, increased to 20 mg after one week if needed, with lower doses in lower body weight and little evidence for benefit above 20 mg. More generally, antidepressants other than fluoxetine are started at half the adult starting dose, titrated over 2-4 weeks. Sertraline or citalopram are second-line after a fair trial of fluoxetine, and paroxetine, venlafaxine and tricyclics should not be used.^[1]
• Supportive measures for everyone: regular exercise (typically up to 3 sessions per week of moderate duration for 10-12 weeks), sleep hygiene, advice on nutrition, and attention to bullying and to possible parental depression.^[1]
• Inpatient care when there is high suicide risk, high risk of serious self-harm or self-neglect, or need for intensive treatment; ECT only for very severe, life-threatening or treatment-resistant depression in young people, and not in children aged 5-11.^[1]
• Continue medication for at least 6 months after remission (defined as at least 8 weeks with no symptoms and full functioning); review regularly for 12 months before discharge to primary care.^[1]

When fluoxetine is used, there should be careful monitoring, including weekly contact in the first 4 weeks, particular attention to emergent suicidal behaviour, self-harm or hostility, and symptoms that might be side effects monitored for 7 days before starting where possible. Antidepressants in this age group are given only in combination with psychological therapy, and should only be prescribed after assessment and diagnosis by a child and adolescent psychiatrist.^[1]

Immediate management of an acute self-harm episode (including emergency care for poisoning) follows local poison and medical guidance; the child must also receive concurrent physical care and a psychosocial assessment as soon as possible.^[2]

• Every child or young person who self-harms gets a psychosocial assessment by a mental health professional experienced with this age group, covering family, peer, school and home context, caring responsibilities, social media use and safeguarding.^[2]
• Needs and safety focus rather than global risk scores: risk assessment tools and scales, and global low/medium/high labels, should not be used to predict repetition or suicide or to decide treatment or discharge.^[2]
• DBT adapted for adolescents (DBT-A) should be considered for young people with significant emotional dysregulation and frequent self-harm. No drug treatment is recommended specifically to reduce self-harm. Harm minimisation may be discussed collaboratively for those engaged in ongoing care.^[2]
• Develop a safety plan together, identifying means, triggers, personal coping strategies, social contacts for distraction, supportive people and emergency contacts, and removing or restricting lethal means.^[2]
• Initial aftercare within 48 hours if safety concerns persist, and no discharge from hospital without a psychosocial assessment, a management plan and agreed aftercare.^[2]
• Children on paediatric wards after self-harm should have CAMHS access round the clock, daily joint review, daily family access and regular multidisciplinary meetings.^[2]

Safeguarding and assessment run in parallel. All staff in contact with a young person who self-harms must understand the safeguarding principles of the Children Act 1989 and related legislation, ask about safeguarding concerns early (including domestic abuse, violence and exploitation), and follow local child protection procedures, seeking advice from the named safeguarding lead when needed.^[2] A multi-agency approach (education, social care, health and third sector) is used when referral under safeguarding procedures occurs, so that home, school, peer and online life are all considered.^[2]

Confidentiality: even if the young person has not consented to involving family, carers can still provide information about them. Involving family and carers improves safety, but statutory child protection duties mean information is shared when there is risk of significant harm. The decision about what to share, and with whom, should be explained to the young person from the outset, and documented.

In many settings a specialist child and adolescent mental health service does not exist. WHO mhGAP offers condensed, evidence-based protocols for non-specialists.^[6] Its recommendations for this age group include: choose psychosocial interventions first for children and adolescents with anxiety disorders (pharmacological interventions are not recommended in non-specialist settings); antidepressants are not recommended for children 12 or under with depression; and for adolescents 13-17 with moderate-to-severe depression that is unresponsive to psychosocial treatment alone, refer to (or consult) a specialist to consider fluoxetine with psychological treatment.^[6] For self-harm, the mhGAP materials (consistent with NG225) emphasise assessing imminent risk, removing means, mobilising family and community supports and arranging close follow-up.

This is also where much of the world's adolescent medicine happens: a clinician with basic training, a short visit, and a supportive family member.

• Untreated childhood anxiety persists into adulthood in a substantial proportion of cases; in one longitudinal study of 319 youths only 22% were in stable remission after 4 years, 48% had relapsed and 30% were chronically ill.^[3]
• Depression in adolescence predicts recurrent depression, substance misuse and impaired functioning in adult life.
• Self-harm is the strongest single indicator of future suicide risk, and repeated self-harm becomes habitual and physically damaging.
• Treatment delay makes all of the above more likely.

Early intervention, family and school support, CBT and, when needed, medication improve outcomes for both anxiety and depression.^[1][3] School refusal improves when the underlying condition is treated and the return is gradual and supported rather than forced or avoided. The outlook is best when treatment starts before the condition has reshaped the child's schooling and peer relationships.

Pregnancy and postpartum are uncommon in this population but relevant: adolescent depression may first present perinatally; fluoxetine in pregnancy requires specialist advice.

Developmental disorders. Anxiety (especially specific and social phobias) is very common in autism spectrum disorder and attention-deficit hyperactivity disorder, and school refusal is more common too. Standard CBT materials may need adaptation (visual materials, shorter sessions, more parental involvement).

Looked-after and marginalised young people have higher rates of self-harm and safeguarding concerns; they need priority access to assessment.

WHO lists the pillars of promotion: stable, supportive family and school environments; socio-emotional learning; prevention of bullying, violence and substance use; early identification through schools and primary care; and restriction of access to lethal means. Most of these are not clinical acts but systems acts, and a doctor is well placed to advocate for them.

• Anxiety disorders are the commonest psychiatric conditions of childhood and adolescence; depression is less common in younger children and rises in adolescence; self-harm can occur at any age. ^[3][5]
• Normal developmental fear is brief, flexible and not impairing; an anxiety disorder is persistent, disproportionate and impairs function. ^[3]
• Separation anxiety is normal under 2 and diagnosable after age-inappropriate, prolonged (at least 4 weeks) distress with impairment. ^[3]
• Selective mutism is usually understood as an expression of social anxiety and responds to exposure-based CBT.
• School refusal is emotionally driven, with parental awareness and no severe conduct disturbance; it is not truancy and usually rests on anxiety, depression or neurodevelopment. ^[7]
• School refusal affects about 2-5% of school-aged young people and peaks at 5-6 and 10-11 years. ^[7]
• Childhood depression is stepped care: mild first treated with watchful waiting and psychological therapy; moderate-severe needs CAMHS input, individual CBT (at least 3 months for 12-18-year-olds) and sometimes fluoxetine at 10 mg then 20 mg. ^[1]
• Fluoxetine is the only evidence-based antidepressant for depression in this age group, with paroxetine, venlafaxine and tricyclics avoided. ^[1]
• SSRIs are first-line medication for childhood anxiety in specialist/US guideline paradigms, and treatment is usually continued for 6-12 months after remission. ^[3]
• WHO mhGAP takes a stricter, psychosocial-first position in non-specialist settings. ^[6]
• Antidepressants carry an FDA boxed warning about suicidal thoughts in children and adolescents; combined with CBT and monitored closely. ^[3]
• Every self-harm episode needs a psychosocial assessment, a risk formulation rather than a score, a safety plan and prompt follow-up; no drug specifically reduces self-harm. ^[2]
• Safeguarding and confidentiality are part of assessment, not aftercare, and carers can contribute information even without consent. ^[2]
• Risk assessment tools and global low/medium/high labels should not be used to predict or to ration care. ^[2]
• Adapt materials (exposure-based CBT, school liaison, graded return) to development, neurodevelopment and resources. ^[1][3][6]

• Psychiatric history and the mental state examination
• Suicidality and self-harm
• Generalised anxiety disorder
• Adolescent medicine

This topic references MedGrasp topics on psychiatric history and mental state examination, suicidality and self-harm, generalised anxiety disorder and adolescent medicine as natural follow-ons.