Mood Disorders in Children and Adolescents

1. Mood Disorders in Children and Adolescents John Sargent, M.D.

2. Learning Objectives: • 1) Learn about the signs, symptoms and prevalence of depression and bipolar disorder in children and adolescents. • 2) Learn about integrated care for youth with mood disorders.

3. Depression affects 3% of children and 6 – 8% of adolescents 2 of 3 depressed teens are girls

4. Depression represents a gene – environment interaction

5. Family and contextual risk factors influence the occurrence • Individual cognitive distortions, global and personal attribution styles and pessimism also increase its likelihood

6. Family risk factors include • Parental depression • Family stressors such as moving, job loss, homelessness and poverty

7. Persistent marital or post divorce conflict • Persistent parent – child conflict or distrust

8. Other factors inciting or exacerbating depression include • Parental loss • Chronic conflict with a step parent or paramour • Family suicidality or family history of completed suicide

9. Symptoms of Depression in Children and Adolescents • Poor concentration • Irritability • Experience of boredom • Quitting or decreased involvement in activities or relationships

10. Further symptoms develop as depression persists • Poor school performance • Social isolation • Family conflict • Appetite and sleep changes

11. Appetite disorders – substance abuse, eating disorder, cutting among adolescents • Hopelessness • Acute and chronic suicidal ideation • Suicide attempts

12. Depression associated with… • Child neglect • Parental depression or substance abuse

13. Significant childhood difference (handicap, illness, learning disability) • Domestic violence, marital conflict or persistent post separation parental conflict • Other forms of child abuse

14. Depression is often co-morbid with other problems • Substance Abuse in Adolescents • Anxiety and Post Traumatic Stress Disorder • Unresolved grief • ADHD • School failure/learning disability • Conduct problems

15. Specific risk factors for suicide in depressed teens • Obesity • Teasing and bullying • Previous suicide attempts

16. History of childhood maltreatment • Access to firearms • Fluctuations in developmental maturity

17. Concerns about sexual orientation • Drug or alcohol intoxication • Rejection, shaming failure or argument with important person (attachment figure) • Impulsivity

18. During the interview the examiner will often note that he/she feels sad while talking with the child

19. History should always include… • Family status • Family stresses and transitions (moving, divorce, death of family member, economic distress/loss of job) • History of abuse – physical, sexual, emotional

20. Peer Relationships • Legal difficulties and sexual activity (for children over age 11) • Substance use/abuse • School performance

21. Previous Psychiatric treatment • Family history of psychiatric disorder • Suicidal ideation, intent, attempts

22. Severity is indicated by… • Presence of suicidality • Child’s ability to respond to warmth of interviewer • Child’s ability to identify strengths and enjoyable experiences • The interviewer’s experience of hopelessness and helplessness

23. Treatment Approaches • Identify suicidality and develop a plan to limit suicidal behavior • Build connections and competence

24. Involve family in treatment and address family problems especially parental depression

25. Identify problems caused by depression and develop methods of separating depression from the person

26. Limit substance abuse, treat co-morbid problems and encourage academic success and pro social behaviors and peer relationships

27. Use psychopharmacology when needed to facilitate treatment • Assist patient and family in deciding on and monitoring psychopharmacology • Monitor for switching to mania and for increased suicidal impulses

28. It is essential to monitor and support return to normal development in school, with peers and in family during treatment

29. Remember 10% of depressed children and adolescents will progress to develop Bipolar Disorder, often these teens have strong family history of Bipolar Disorder

30. Be wary of suicidal behavior during treatment, especially at points of conflict and perceived isolation

31. Build on unique skills, strengths and talents of both the child and his/her family

32. Prepare family and adolescent for the possibility of relapse including identifying early signs warranting return to treatment

33. Be aware of the influence of a culture of violence upon child or adolescent behavior

34. Bipolar Disorder Alternating periods of depression and mania. Occurs in approximately 0.5-1% of population

35. Mania • Distinct period of time where child manifests symptoms of mania • Grandiosity, expansive mood • Pressured speech, flight of ideas • Decreased need for sleep

36. Engaging in potentially dangerous, risky behaviors, sexual promiscuity, excessive spending, engaging in dubious or risky projects (Impulsivity) • Enhanced sense of well-being/perceived productivity

37. May include irritability, law breaking, substance abuse, teen pregnancy/paternity and aggressiveness. These symptoms more likely in children with a history of maltreatment.

38. Children are more likely to have rapid (hourly to daily) changes in mood. Older adolescents more likely to have classical (adult) mania

39. Impulsivity, consequences of risky behavior, intoxication, incarceration and isolation are precursors of suicidal behavior in bipolar youth

40. Treatment of bipolar disorders in children and adolescents often extremely challenging

41. Family involvement and family stability are essential in effective treatment. Pay attention to the role of poverty, limited access to care and family chaos for child and family

42. Family psychoeducation/decreasing family expressed emotion is extremely helpful

43. Suicide prevention plan always part of treatment. This includes attention to firearms, planning for impulsivity and rejecting and shaming experiences

44. Psychopharmacology may include mood stabilizers, atypical anti- psychotics and often both. Attention to side effects is essential

45. Bipolar Disorder Treatment • Antimanic psychopharmacology • Depakote or Lithuim • Atypical antipsychotics • Abilify • Risperdal • 2 drug treatments • Limited effectiveness of anticonvulsant drugs • Trileptal • Topomax • Lamictal • Neurontin

46. Co morbid ADHD, academic and legal problems may complicate situation and must be addressed

47. Building self – awareness, self assessment and self management are important

48. Parenting Support • Parental consistency • Reducing negative expressed emotion • DBSA – parental support • Consistent longitudinal care/crisis plan

49. Frequently family psychosocial circumstances complicate treatment and outcome (due to poverty, parental difficulties, single parenthood, lack of insurance and limited access to care)

50. In some instances BPD may be comorbid with ADHD. In these cases treat BPD first, and then add ADHD treatment