Emotional Disorders in Children

CHAPTER I

INTRODUCTION

Mental health problems in children are a common problem in children. This

problem includes several types of emotional disorders which include depression,

anxiety, obsessive-compulsive disorder, and trauma which is characterized by the

internalization of the problem. Emotional problems in children such as anxiety,

depression, and post-traumatic stress disorder tend to appear in late childhood. The

disorder is often difficult for parents or caregivers to recognize because many

children have different speech developments to express their emotions clearly. Many

clinicians have difficulty distinguishing between normal emotional development (eg,

crying, fear) and severe and prolonged emotional distress, which is called

disturbance.1

Emotional disturbances (internalization) can be grouped into several

syndromes, although there is often overlap among these symptoms: depression,

withdrawal, anxiety and feelings of loneliness. Some additional features of

internalizing disorder are low self-esteem, suicidal behavior, poor academic

performance, and social withdrawal. Grief can cause bigger problems, such as social

withdrawal, suicidal behavior or thoughts, and other unexplained physical

symptoms.2

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 CHAPTER II

LITERATURE REVIEW

A. Definition

According to the Diagnostic and Statistical Manual of Mental Disorders fifth

edition (DSM-5) emotional disorders in children are characterized by high levels

of negativity, which include:3,4

1. Anxiety disorder

2. Depressive disorder

3. Obsessive-compulsive disorder and others

4. Disorders related to trauma and stressors

B. Anxiety Disorders

Anxiety disorders(anxiety disorders) are the most common disorders in

young people, affecting an estimated 10% to 20% of young children and

adolescents. The hallmark of all anxiety disorders is the recurrent emotional and

physiological arousal in response to the perception of excessive threat or danger.

The anxiety disorders commonly found in children are separation anxiety disorder,

generalized anxiety disorder, social phobia and selective mutism.4,5

Separation anxiety is a normal stage of human development, starting at less

than one year of age, increasing around the ages of 9 and 18 months and

decreasing then disappearing at the age of 2 and a half years, which allows

children to still feel comfortable when separated from their parents while at

3
school. About 15% of children show fear, embarrassment, and withdraw from

intense and persistent social situations when encountering new people or

environments. Children with this pattern have a higher risk of developing

separation anxiety disorder, generalized anxiety disorder and social phobia. These

children exhibit physiological traits such as increased resting heart rates and higher

morning cortisol levels. Separation anxiety disorder is a level of fear or anxiety

that occurs due to separation from parents or caregivers that exceeds normal

development. Diagnostic criteria for separation anxiety disorder according to the

Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5),

namely:3–5

1. Fear or anxiety caused by separation from the individual's primary attachment,

which is developmentally inappropriate and manifested by at least three of the

following symptoms:

a. Recurrent excessive distress in anticipation of or experiencing separation

from home or attachment figures.

b. Excessive and persistent feelings of anxiety about losing a major

attachment figure or about possible harm to them such as illness, trauma,

disaster or death.

c. Excessive and persistent feelings of anxiety that you will have an

unwanted experience that will result in separation from your primary

attachment figure.

d. Persistent reluctance or refusal to go outside, away from home, to school,

work, or other places caused by fear of separation.

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 e. Excessive and persistent fear or aversion about being alone or without a

major attachment figure in the home or other setting.

f. Reluctance or refusal to sleep away from home or sleep away from major

attachment figures.

g. Recurring nightmares with the theme of separation.

h. Physical complaints or symptoms (eg headache, stomach pain, nausea,

vomiting) on separation from the primary attachment figure.

2. Persistent fear, anxiety or avoidance persisting for at least 4 weeks in children

and young adults and 6 months in adults.

3. The disturbance causes significant distress or causes impairment in social,

academic, occupational or other important areas of functioning.

4. The disturbance is not better explained by another mental disorder.

Children with generalized anxiety disorder experience significant distress in

daily activities, often the fear focuses on the child's disability in various areas,

such as performance in school and social situations. Also, children with

generalized anxiety disorder tend to experience fear in some situations and expect

negative outcomes in the face of academic or social challenges, compared to their

peers. Young children and adolescents with generalized anxiety disorder may

experience autonomic symptoms such as tachycardia, shortness of breath,

sweating, nausea or diarrhea when anxious compared to children who do not

experience anxiety. Diagnostic criteria for generalized anxiety disorder according

to the DSM-5 are:3–5

5
1. Excessive worry most days for at least 6 months about a number of events or

activities (such as work or school performance).

2. Individuals have difficulty controlling their anxiety.

3. The anxiety is associated with three (or more) of the following six symptoms

(at least some of the symptoms have been present on most days during the

past 6 months): Note: In children only one symptom is required.

a. Nervous

b. Easily tired

c. Difficulty concentrating or mind going blank

d. Irritable

e. Muscle tension

f. Sleep disturbances (difficulty falling or staying asleep, or restlessness, or

unsatisfactory sleep)

4. The anxiety or physical symptoms cause significant distress or impairment in

social, occupational or other important areas of functioning.

5. The disturbance is not due to the physiological effects of a substance of abuse

(eg, drug abuse), or another medical condition (eg, hyperthyroidism).

6. The disturbance is not better explained by another mental disorder.

Children with social phobia are characterized by experiencing intense

discomfort and pressure in social situations, and are affected by their fear that they

will be humiliated. This pressure can be expressed in the form of crying, tantrums,

avoiding, not wanting to move or even being silent in this situation. Any situation

that makes the child feel exposed to the possibility of being coerced by others can

6
create fear or anxiety, and the child will often try to avoid these social situations.

This impairment has significant consequences for future achievement, such as an

increased incidence of being dropped out of school, lower productivity at work as

an adult, and an increase in the rate of being unpaired. The DSM-5 criteria for

social phobia are:3–5

1. Fear or anxiety about one or more social situations in which the individual is

exposed to being coerced by others. Examples include social interactions (eg

chatting or meeting new people), being observed (eg while eating or

drinking), and performing actions in the presence of large crowds (eg giving

speeches). Note: in children anxiety must appear in the peer environment and

not only during interactions with adults.

2. The individual fears that he will show symptoms of anxiety that will be

judged badly by others (eg being embarrassed or being rejected or ridiculed by

others).

3. Social situations almost always cause fear and anxiety. Note: in children, fear

or anxiety can be expressed by crying, tantrums, not wanting to move or not

wanting to talk).

4. Social situations are avoided or faced with intense fear or anxiety.

5. The fear or anxiety is greater than the actual threat faced in the context of

social situations or social culture.

6. Persistent fear, anxiety or avoidance, usually lasting 6 months or more.

7. The fear, anxiety or avoidance causes significant distress or impairment in

social, occupational or other important areas of functioning.

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8. The fear, anxiety or avoidance is not caused by the effects of a substance (eg

drug abuse), or another medical condition.

9. The fear, anxiety or avoidance is not better explained by the symptoms of

another mental disorder.

10. If a medical condition is present, the fear, anxiety or avoidance is completely

unrelated and greatly exaggerated.

When talking to other individuals in social interactions, children with

selective mutism will not initiate conversation or reply to people who are talking

to them. Lack of talk occurs in social interactions with peers or adults. Children

with selective mutism will speak at home when accompanied by family members

but often do not speak even when in front of their house, or when there are friends

who are not too close, or distant relatives such as cousins or grandparents.

Children with selective mutism often refuse to talk at school, which causes

academic distraction. The criteria for selective mutism according to the DSM-5

are:3–5

1. Persistent failure to speak in certain social situations where speaking is

expected (eg school) despite speaking in other situations,

2. The disturbance causes impairment in educational or occupational

achievement or social communication.

3. The duration of the disturbance has been at least 1 month (not limited to the

first month of school).

4. Failure to speak is not caused by ignorance, or comfort regarding the language

used in social situations.

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 5. The disturbance is not better explained by a communication disorder and is

not attributable to an autism spectrum disorder, schizophrenia or another

psychotic disorder.

C. Depressive Disorders

depressive disorders(depressive disorder) in children will produce long-term

consequences on cognitive, social and psychological development. This disorder

affects about 2%-3% of children and up to 8% of young adolescents. Depression is

genetically inherited, with the highest risk in children whose parents have early-

onset depression, with environmental stressors being the highest risk factor for

major depressive disorder in children.

Most children and adolescents with depressive disorders do not attempt or

commit suicide; however, children with major depressive disorder can have

suicidal ideation, and suicide remains the worst risk factor for major depressive

disorder. Developmental problems affect the expression of depressive symptoms.

For example, an unhappy child who exhibits recurrent suicidal ideation rarely

makes suicide plans or carries out those plans. Children's moods are very

vulnerable to the effects of social stressors, such as long-term family disputes,

neglect and violence. Many children with major depressive disorder have a history

of violence, neglect and a family of psychosocial burdens such as parents with

mental illness, substance abuse or poverty. Children with depressive disorders in

families where the stressor is present may experience remission of depressive

symptoms when the stressor is removed or when they are in a more supportive

9
family environment. In children, there are two common depressive disorders,

namely major depressive disorder and dysthymia. The criteria for depressive

disorder according to the DSM-5 are:3,4

1. Five (or more) of the following symptoms that have lasted for 2 weeks and

reflect a change in previous functioning; at least one of the symptoms is (a)

depressed mood or (b) loss of interest or pleasure:

Note: does not include symptoms caused by other medical conditions

a. Depressed mood most of the day, nearly every day (note: in children

symptoms may include irritable mood)

b. Diminished interest or pleasure in all, or almost all, activities that last

most of the day, occur almost every day.

c. Significant weight loss when not on a special diet or weight gain, or

decrease or increase in appetite most days (Note: in children, consider

failure to thrive)

d. Insomnia or hypersomnia nearly every day.

e. Psychomotor agitation or retardation nearly every day.

f. Fatigue or loss of energy nearly every day.

g. Feelings of worthlessness or excessive guilt nearly every day.

h. Reduced ability to think or concentrate, unable to make decisions, nearly

every day.

i. Recurrent thoughts of death (not just fear of death), recurrent suicidal

ideation without a plan, or a suicide attempt or a plan to commit suicide.

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2. The symptoms cause significant distress or impairment in social, occupational

or other important areas of functioning.

3. The episodes are not caused by the effects of a substance or other medical

condition.

4. The presence of a major depressive episode is not better explained by

schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional

disorder or another psychotic disorder.

5. There were no manic or hypomanic episodes.

Diagnostic criteria for dysthymic disorders are:3

1. Depressed mood that lasts most days, occurs almost every day and lasts for at

least 2 years. Note: in children and adolescents, the mood may be irritable and

the duration is at least 1 year.

2. By day two (or more) of the symptoms associated with depression:

a. Poor appetite or overeating

b. Insomnia or hypersomnia

c. Low energy or tired easily

d. Low self-esteem

e. Difficulty concentrating or difficulty making decisions

f. The feeling of having no hope

3. During a 2-year period (1 year in children and adolescents) of the disturbance,

the symptoms of criteria 1 and 2 have not resolved for more than 2 months.

4. Criteria for major depressive disorder can last for 2 years.

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 5. Never had a manic or hypomanic episode, and never met criteria for

cyclothymic disorder.

6. The disturbance is not better explained by schizoaffective disorder,

schizophrenia, delusional disorder, or another psychotic disorder.

7. The symptoms are not due to the effects of a substance (eg drug abuse) or

another medical condition (eg hypothyroidism).

8. The symptoms cause significant distress or impairment in social, occupational

or other important areas of functioning.

D. Obsessive-Compulsive and Related Disorders

Data shows that up to 25% of obsessive-compulsive disorder cases have an

onset by the age of 14. Overall the clinical symptoms that appear in children with

obsessive-compulsive disorder are similar to those in adults, but when compared to

adults, children and adolescents often do not consider obsessive thoughts or

repetitive behavior as unreasonable. Some children find compulsive rituals a

rational response to excessive fear and anxiety. They recognize that the discomfort

and inability to carry out daily activities smoothly is due to the compulsions.4

The most frequently reported obsessions included excessive fear of

contamination or exposure to dust, germs or disease, followed by anxiety about

things that could hurt themselves, family members or fear of hurting others caused

by losing control over aggressive impulses. Also frequently reported are obsession

with symmetry or perfection, hoarding, and excessive religious or moral worry.

Compulsive ritual behavior that is often found in children and adolescents, namely

cleaning, checking again, counting, the behavior of arranging or assembling

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objects. This results in children and adolescents with obsessive-compulsive

disorder becoming avoidant, unable to make decisions, indecisive and slow in

completing tasks. In most cases of obsessive-compulsive disorder, obsessions and

compulsions are both present. The following are the diagnostic criteria for

obsessive-compulsive disorder according to the DSM-5:3,4

1. Presence of obsessions, compulsions or both:

Obsession is defined by:

a. Recurrent and persistent thoughts, urges or images that are experienced

and felt are intrusive and unwanted and cause distress and anxiety.

b. Individuals try to ignore or suppress these thoughts, urges or images, or

neutralize them with other thoughts or with a behavior (by doing

compulsions).

Compulsion is defined by:

a. Repetitive behavior (eg hand washing, stacking, checking) or mental

behavior (eg praying, counting, repeating words) that is perceived as a

response to an obsession or a rule that must be adhered to rigidly.

b. The behavior is carried out with the aim of preventing or reducing anxiety

or stress or preventing bad events or situations. This behavior is not really

related to what they are trying to neutralize or prevent, or is clearly

excessive.

2. Obsessions or compulsions that take up time (eg, spend more than 1 hour per

day) or cause significant distress or impairment in social, occupational, or

other important areas of functioning.

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 3. The obsessive-compulsive symptoms are not due to the effects of a substance

(eg, drug abuse) or another medical condition.

4. The disturbance is not better explained by the symptoms of another mental

disorder.

E. Trauma and Stressor-Related Disorders

According to the Diagnostic and Statistical Manual of Mental Disorder fifth

edition (DSM-5) trauma and stressor-related disorders include reactive attachment

disorder, disinhibited social engagement disorder, and post-traumatic stress

disorder. Post-traumatic stress disorder in children can look different and have

important implications for a child's development.4

Reactive attachment disorderand disinhibited social engagement disorder is

a clinical disorder characterized by deviant social behavior in children that reflects

very negligent parenting and abuse that interferes with the development of normal

attachment behavior. The second diagnosis of this disorder is thought to be caused

by the loss of a caregiver figure. This disorder was first described in DSM-3, and

evolved from attachment theory, which describes a child's need for protection,

nurturing, comfort and interaction between parents and children to meet these

needs. Diagnostic criteria for reactive attachment disorder according to the DSM-5

are as follows:3,4

1. Pattern of inhibition, emotionally withdrawn behavior toward caregivers that

occurs consistently, as indicated by the following:

a. Children rarely seek solace when under pressure

b. Children rarely respond to comfort when under pressure

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2. Persistent social and emotional disturbance is characterized by at least two of

the following:

a. Minimal social and emotional response to other people.

b. Limited positive affect.

c. Unexplained episodes of irritability, sadness, or fear that may be observed

even during non-threatening interactions with caregivers.

3. The child experiences an extreme pattern of inadequate care as demonstrated

by at least one of:

a. Persistent social neglect in the form of a social need for comfort,

stimulation and affection that is not met by caregivers.

b. Repeated changes in caregivers that limit opportunities to form stable

attachments (eg, frequent changing of foster homes).

c. Raised in an unusual environment that severely limited opportunities for

forming selective attachments (eg institutions with high child-caretaker

ratios).

4. Criterion 3 is thought to be the reason for the disturbed behavior in criterion 1

(eg the disturbance in criterion 1 occurs after a lack of adequate care in

criterion 3).

5. Does not meet the criteria for autism spectrum disorder.

6. The disorder was experienced before the age of 5 years.

7. The child has passed the developmental age of at least 9 months.

The diagnostic criteria for disinhibited social engagement disorder according to

the DSM-5 are:3

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1. Pattern of behavior in which the child actively approaches and interacts with

adults who are not recognized and exhibits at least two of the following:

a. Reduced or no reluctance to approach and interact with unfamiliar adults.

b. Words or physical behavior that are too familiar (inconsistent with

prevailing social culture and age bonds).

c. Reduced or absent rechecking with caregivers after being around, even in

unfamiliar surroundings.

d. The desire to go out with unfamiliar adults with little or no hesitation.

2. The behavior in criterion 1 is not induced by impulses (as in attention

deficit/hyperactivity disorder) but involves inhibited social behavior.

3. The child experiences an extreme pattern of observable parental neglect with

at least one of:

a. Persistent social neglect in the form of a social need for comfort,

stimulation and affection that is not met by caregivers.

b. Repeated changes in caregivers that limit opportunities to form stable

attachments (eg, frequent changing of foster homes).

c. Raised in an unusual environment that severely limited opportunities for

forming selective attachments (eg institutions with high child-caretaker

ratios).

4. Criterion 3 is suspected to be responsible for the disturbed behavior in

criterion 1 (eg the disturbance in criterion 1 occurred after negligent parenting

in criterion 3).

5. The child has passed the developmental age of at least 9 months.

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 The incidence of post-traumatic stress disorder in children and adolescents

exposed to violence and trauma is quite high. In America in children and

adolescents exposed to traumatic events, this disorder has a prevalence of 60%

with a lifetime prevalence of 80% to 90%. Traumatic events can include sexual

abuse, physical abuse, abuse, motor vehicle accidents, serious medical illnesses,

or natural disasters. In children younger than 6 years, intrusive and spontaneous

memories may be evident in ongoing activities, or appear as nightmares. The

child may also show unexplained agitation or fear. Diagnostic criteria for post-

traumatic stress disorder in children aged 6 years and under according to the

DSM-5 are:3,4

1. In children 6 years and younger, exposure to death or death threats, serious

injury, or sexual violence in one (or more) of the following:

a. Experiencing the traumatic event firsthand

b. Witnessing a traumatic event happening to someone else.

c. Seeing traumatic events that happened to parents or caregiver figures.

2. Presence of one (or more) intrusive symptoms associated with the traumatic

event, beginning after the traumatic event occurred:

a. Recurrent and unwanted intrusive memories of the traumatic event.

b. Recurring nightmares with content related to the traumatic event.

c. Dissociative reactions (eg flashbacks) in which the child feels or behaves

as if the traumatic event were taking place.

d. Intense and prolonged psychological distress when exposed to symbols or

aspects that describe the traumatic event.

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 e. Physiological reactions reminiscent of the traumatic event.

3. One (or more) of the following symptoms, reflecting either persistent

avoidance of stimuli associated with the traumatic event or negative changes

in cognition or mood associated with the fearful event, must be present,

started after the event or worsened after the event:

Avoiding persistent stimuli:

a. Avoiding or trying to avoid activities, places or physical activities that are

reminiscent of the traumatic event.

b. Avoiding or trying to avoid people, conversations or interpersonal

situations that are reminiscent of the traumatic event.

Negative changes from cognitive:

c. Increased frequency of negative emotions (eg fear, guilt, sadness, shame,

confusion).

d. Reduced interest in or participation in activities, including being less

playful.

e. Behavior withdraws from the social environment.

f. Diminished expression of persistent positive emotions.

4. Changes in reactivity related to the traumatic event, starting or worsening after

the traumatic event occurred, may be seen with two (or more) of:

a. Irritable behavior and angry outbursts (unprovoked or slightly provoked)

expressed by verbal or physical aggression toward people or objects

(including extreme tantrums).

b. Excessive alert.

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 c. Exaggerated startle response

d. Problems with concentration

e. Sleep disturbances (eg difficulty getting to sleep or difficulty maintaining

sleep or unsatisfactory sleep)

5. Duration of the disturbance is more than 1 month

6. The disturbance causes significant distress or interference in relationships

with parents, siblings, peers or other caregivers or with behavior while at

school.

7. The disturbance is not caused by the effects of a substance (eg a drug or

alcohol) or another medical condition.

Diagnostic criteria for post-traumatic stress disorder in children over 6 years old,

adolescents and adults according to DSM-5:3

1. Exposure to death or threatened death, serious injury or sexual violence in one

(or more) of:

a. Experiencing the traumatic event firsthand

b. Witnessing a traumatic event happening to someone else.

c. Seeing a traumatic event that happened to a family member or close

friend. In the case of death or death threats to family or friends, the

incident must be sadistic or accidental.

d. Experiencing repeated extreme exposure to details of a traumatic incident

(eg first person to find remains, or police repeatedly exposed to details of

child abuse).

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2. Presence of one (or more) intrusive symptoms related to the traumatic event,

starting after the traumatic event occurred:

a. Recurrent and unwanted intrusive memories of the traumatic event.

b. Recurring nightmares with content related to the traumatic event.

c. Dissociative reactions (eg flashbacks) in which the child feels or behaves

as if the traumatic event were taking place.

d. Intense and prolonged psychological distress when exposed to symbols or

aspects that describe the traumatic event.

e. Physiological reactions reminiscent of the traumatic event.

3. Persistent avoidance of stimuli related to the traumatic disorder, starting after

the traumatic event occurred, can be seen from:

a. Avoiding or trying to avoid memories, thoughts or feelings about or

related to the traumatic event.

b. Avoiding or trying to avoid external reminders (people, places,

conversations, activities, objects, situations) that evoke memories,

thoughts or feelings about or related to the traumatic event.

4. Negative changes in cognition and mood related to the traumatic event,

starting or worsening after the traumatic event occurred, as manifested by two

(or more) of:

a. Inability to remember important aspects of the traumatic event (usually

caused by dissociative amnesia and not caused by head injury, alcohol or

drugs).

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 b. Excessive and persistent negative beliefs about self, other people or the

world

c. Persistent cognitive distortions regarding the causes or consequences of

the traumatic event for which the individual blames himself or others.

d. Persistent negative emotions (eg fear, horror, anger, guilt or shame).

e. Reduced interest in or participation in activities.

f. Feelings of being disconnected from other people.

g. Inability to experience positive emotions (eg inability to feel happy,

content or love)

5. Changes in reactivity related to the traumatic event, starting or worsening after

the traumatic event occurred, may be seen with two (or more) of:

a. Irritable behavior and angry outbursts (unprovoked or slightly provoked)

expressed by verbal or physical aggression toward people or objects

(including extreme tantrums).

b. Excessive alert.

c. Exaggerated startle response

d. Problems with concentration

e. Sleep disturbances (eg difficulty getting to sleep or difficulty maintaining

sleep or unsatisfactory sleep)

6. The duration of the disturbance (criteria 2, 3, 4, and 5) is more than 1 month.

7. The disturbance causes distress or impairment in social, occupational or other

important areas of functioning.

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 8. The disturbance is not caused by the effects of a substance (eg drugs and

alcohol) or another medical condition.

F. Clinical Presentation

Emotional disorders in children include anxiety disorders, depressive

disorders, obsessive-compulsive disorders and trauma and stress related disorders.

Common manifestations in children with anxiety disorders include physical

symptoms such as increased heart rate, shortness of breath, sweating, tremors,

chest pain and nausea. Other symptoms include anxiety about things that haven't

happened yet, worry about family, school, friends, repetitive unwanted activities,

thoughts (obsessions) or actions (compulsions), fear of being embarrassed or of

making a mistake and feelings of trust. low self.1,6

Depression usually appears in children who are under stress, have

experienced a loss or experience behavioral disturbances, learning disorders or

anxiety disorders and other chronic physical illnesses. Symptoms of depression are

varied and often mimic physical and neurodevelopmental problems, including

lowered mood, recurrent feelings of sadness, crying, reduced interest or pleasure in

almost all activities. Or also the inability to feel pleasure in activities that

previously gave pleasure, feeling hopeless, persistent boredom, low energy, social

isolation, poor communication, low self-esteem and guilt, feelings of

worthlessness, hypersensitivity to rejection or failure, irritability, agitation, anger,

relationship difficulties,1,6

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G. Identification of Emotional Disorders in Children

Identification is very important to do to find the presence of children with

emotional and behavioral disorders. In educational programs, identification of

children with special needs has five functions, namely:7,8

1. Screening, namely marking the symptoms of children with emotional and

behavioral disorders in the classroom or school environment using a

predetermined identification tool, so that children with emotional and

behavioral disorders can be distinguished from normal students or other

students with special needs.

2. Transferring (referral), namely determining whether the child is sufficiently

handled by the teacher at school or it is necessary to involve competent parties

or experts.

3. Classification, namely the activity of sorting out which children with

emotional and behavioral disorders need further treatment and which ones can

immediately attend special education services in regular classes.

4. Learning planning, namely the preparation of learning programs that are

individualized according to each type and level of children with emotional and

behavioral disorders as a result of the classification.

5. Monitoring learning progress, to determine the success of the learning

program within a certain period of time, as well as monitoring program

failures and several related aspects, such as an incorrect diagnosis or program

implementation that needs to be improved.

The steps for identifying a child with emotional and behavioral disorders:7

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1. Collect data on the condition of all students in the class (based on symptoms

that appear in students) using an identification instrument.

2. Analyzing data and classifying children to find children classified as children

with emotional and behavioral disorders and recording findings based on

emotional and behavioral symptoms, then separating them from ordinary

students.

3. Hold consultation meetings with school principals for resolution suggestions

and follow-up.

4. Organize case conferences on identification findings to obtain feedback on

steps after this process. This meeting is coordinated by the school principal

and involves the teacher council, parents, relevant professionals, and special

accompanying teachers.

5. Compile reports on the results of case meetings in full with program planning

for identified children.

After the identification process, the following steps are taken:7

1. Expert referral, is a communication process regarding special disorders found

in children in the identification process to experts or professionals related to

children's emotional and behavioral problems. These professionals certainly

have certain considerations regarding the characteristics of disorders and

handling of children in accordance with the focus of their fields.

2. Assessment, which is a systemic process using relevant instruments to

determine learning behavior for placement and learning purposes. The

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 examination aims to dig deeper into all information related to the

characteristics of children in learning situations.

3. Determining the decision as a follow-up to the identification of children for

educational programs, will decide the types and causes of emotional and

behavioral disorders, especially in relation to education in schools and

describe the appropriate management.

4. Planning learning programs and organizing students.

5. Implementation of learning which is the stage of implementing plans and

learning designs and organizing students with emotional and behavioral

disorders. The course of implementing learning and setting targets is always

flexible according to the development and abilities of children.

6. Continuous monitoring of learning progress and evaluation to determine

teacher success or failure in managing emotional and behavioral problems in

children.

H. Epidemiology and Etiology

Anxiety disorders are present in about 5% of 10 year olds and an equal

proportion of adolescents. Genetic factor is an important factor; children who are

shy and slow to get close to others are at greater risk. Parents are often anxious and

express their anxiety by being overprotective. Examples are abnormal behavior

regarding infant care (eg teenagers still sleeping in the same bed with their

parents) and prohibiting things associated with normal social development (eg

teenagers going to parties). In some cases anxiety is exacerbated by stress and

25
 sometimes there is some relationship between anxiety and stress. For example,

separation anxiety is associated with a parent having a serious illness.5,6,9

Depressive disorders can occur in prepubertal children but are uncommon

(<0.5%). In adolescence, the prevalence of depressive disorders ranges from 2% in

boys and 4% in girls. Children and adolescents with depressive disorders tend to

have parents with a history of depression, but this may be related to environmental

factors (eg family problems) rather than genetics. Genetic factors tend to become

stronger during adolescence. Depression in children is generally triggered by

adversity. About half of children with depression also have anxiety disorders and

one-fifth have behavioral disorders.5,6,9

Obsessive-compulsive disorder in children is rare (about 0.5% of

adolescents). Obsessive-compulsive symptoms are often associated with other

mental disorders such as depression and anorexia nervosa. The obsession

phenomenon is also seen in pervasive developmental disorders such as Asperger's

syndrome. The onset of this disorder tends to occur earlier in males than in

females. Childhood-onset obsessive-compulsive disorder is associated with disease

of the basal ganglia, a family history of the same disorder or tics, and stress in the

family.5,6,9

I. prevention

Many factors that affect emotional changes such as family, individual and

community factors can be identified using the screening system. This program

aims to detect and provide therapy more quickly and increase the potential for

26
parenting skills using approaches to children at risk of emotional and behavioral

disorders. The program includes several approaches including, home visits, parent

groups, need fulfillment, and videos to encourage parents to reflect on abilities.

This program shows results related to emotions, behaviors and the development of

more positive relationships.10

1. Program milestonesintended for children of all ages with the aim of reducing

the incidence of brain damage, mental retardation and education. Children

with emotional disorders are at risk for experiencing difficulty adapting. This

program is divided into two periods, namely the preschool period and the

school period.11,12

2. High-risk programs. Children may be placed in this program if they have

certain characteristics such as having a chronic medical illness, or if they have

problems with their parents (eg parents are divorced). When some of these

risk factors are used as high risk in screening, it must be understood that some

children who experience these will experience deviant behavior or emotions.

Some of the risk factors that can be considered high risk are: hospitalization,

divorce of parents, chronic medical illness and death of family members.11,12

3. Community-wide programpay attention not only to individual children but

also to pay attention to community factors, for example the level of

vandalism, the number of summons to the police and so on. There are two

focus types of intervention, namely the school environment and the

community.11,12

27
J. Therapy

Identification of an appropriate therapeutic strategy depends on the

examination of symptoms, the influence of parents and caregivers, the wider

socioeconomic environment, the child's developmental level and mental health.

This requires a multi-level and multi-disciplinary approach. The use of

pharmacotherapy is usually considered only in combination with psychological

and environmental interventions. Psychotherapy is the main therapy for the

management of children with emotional disorders:1,13

1. Parenting skills training

2. Different educational strategies from normal children

3. Child psychologically focused intervention

4. Behavior modification strategies and social communication

Pharmacological therapy is often given as a complement to psychotherapy.

Antidepressant therapy commonly used in children is serotonin selective reuptake

inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

These drugs work well and have few side effects when compared to tricyclic

antidepressants. Antidepressants can be used to treat major depression, anxiety,

dysthymia, obsessive-compulsive disorder and stress and trauma related

disorders.1.14

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 CHAPTER III

CONCLUSION

Mental disorders in children are common, have many consequences, but are so

difficult to recognize. One of the mental disorders in children is emotional disorders,

which according to the Diagnostic and Statistical Manual of Mental Disorders fifth

edition (DSM-5) are divided into: anxiety disorders; depressive disorders; obsessive-

compulsive disorder; stress- and trauma-related disorders. Diagnosis of emotional

disorders in children can be made using the diagnostic criteria from the DSM-5.

Identification to find children with emotional and behavioral disorders can be carried

out in schools, which aims to separate children with emotional disorders, children

with behavioral disorders and normal children, so that an education system that is

appropriate to each problem can be given. There are 3 programs commonly used to

prevent children from getting emotional disturbances, namely by monitoring children

who are at risk of developing these disorders: milstone programs, high-risk programs,

wide-community programs. In children with emotional disorders, the main therapy is

psychotherapeutic intervention, and pharmacotherapy is only used as a complement

to the combination with psychotherapy interventions

29
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