Treating Children with Depression

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WELCOME TO
Treating Children with Depression by Dr. Scott
Adams
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Treating Children with Depression

• Scott J. Adams, Psy.D.
• WICHE Mental Health Program

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Objectives

• Discuss epidemiological and other relevant data
  regarding depression in childhood.
• Discuss behavioral observation of children for
  signs/symptoms of depression.
• Cover questions PCPs can ask of children and
  their parents to help assess the presence of
  depression.
• Talking with children and parents about treatment
  options.

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Prevalence

• 1-2 Major Depression in children (occurs as
  early as pre-school) and 3-8 in adolescents
  (Costello et. al., 1996).
• Epidemiological studies show 20-25 lifetime
  prevalence of depression by end of adolescence
  (e.g., Lewinshon, Hops, Seeley, 1993 Kessler,
  Avenevoli, Merikangas, 2001).
• Ethnic minorities tend to be less likely to have
  major depression, but are also less likely to be
  treated for depression.
• Depression is equally common in male and female
  children, but more common in female adolescents.
• Awareness of and attitudes toward childhood
  depression limit recognition and treatment.
• a. An inverse relationship exists between age of
  onset and help seeking.
• Rates vary with method of analysis (e.g., self
  report or clinical interview).

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Case Study

• Dans problems started in fifth grade when his
  grades took a sharp downward spiral.
• Prior to that time, before homework became so
  important and when after-school activities were
  those chosen by his parents, Dan was a good
  student.
• He had always done well in school and teachers
  described him as bright and able. He always
  tested in the very superior range of the many
  tests administered to him by schools and
  counselors.
• Socially, he had many friends.

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Case Study cont.

• Teachers described Dan as distracted and
  withdrawn at school.
• His parents cut off TV on school nights and began
  to monitor his study habits more closely.
• He had always been strong willed when it came to
  discipline and responded by becoming
  argumentative, and he hid information teachers
  sent home for his parents.
• Friction at home increased with no apparent
  improvement in his school performance.
• The parents described Dan as having sad spots,
  during which he would feel sad for a few days in
  a row, after which the sadness would subside.

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Case Study cont.

• On a teachers recommendation Dan was brought to
  a mental health professional (the first of
  several they would see).
• His family history included depression and
  alcohol abuse (although it was not clear who).
• He was evaluated for ADD and depression, as well
  as intellectual skills. The therapist concluded
  that Dan was not depressed, nor did he have a
  learning disability, but instead had poor coping
  skills.
• He underwent a year of psychotherapy, but his
  school performance was still declining and his
  6th grade teachers described him as inattentive,
  tired, withdrawn, and very depressed.
• Yet he continued to be very social, going to
  sleepovers and joining the lacrosse team.

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Case Study cont.

• Further mental health testing at school resulted
  in a diagnosis of ADD and Oppositional Defiant
  Disorder (ODD).
• He was described by the new therapist as
  withdrawn from life, but not depressed. His
  parents were told he should be watched for
  depression.
• Dan began taking Adderral. There was a dramatic
  improvement in his grades and he interacted more
  with his parents.
• There were occasional sad spots and
  argumentativeness. He did not express his
  feelings to them unless he was angry.
• He was taken off of Adderal for the summer on the
  recommendation of his neurologist.
• His mood changed drastically. He spent most of
  his days inside watching movies and refused to
  contact friends to play.
• Dan was put back on Adderal in the fall. However,
  they did not see improvements, in fact his
  behavior worsened. He began to get in minor
  fights in school which resulted in some
  disciplinary action.

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Three Areas of Assessment
School
Home
Social

• Look for consistencies and inconsistencies across
  areas.
• Take note of transitional issues (e.g., entering
  school, conflict/divorce, move to a new area,
  financial problems, illness).
• Issues in each area will somewhat change over
  time.

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Symptom Progression Over Time
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Epidemiology

• Parental psychopathology is the strongest
  predictor of child and adolescent depression and
  is mediated by stressful (to child) life events.
• Other factors that increase risk are pre- and
  perinatal factors (e.g., maternal depression
  during pregnancy), developmental conditions
  (autism etc.), physical illness (diabetes, asthma
  etc.), environmental adversity (e.g., low SES).
• Depression is associated with many negative
  outcomes including, academic problems, early
  pregnancy, cigarette smoking, and a thirty-fold
  increase in completed suicide.

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Identification and Diagnosis of Depression

• DSM-IV criteria
• In children, somatic complaints, irritability,
  and social withdrawal are common.
• Also, depression in children will more frequently
  co-occur with disruptive behavior disorders,
  ADD/ADHD, and anxiety disorders.
• For teenagers, depression often co-occurs with
  disruptive behavior disorders, ADD/ADHD, anxiety
  disorders, substance-related disorders, and
  eating disorders.
• Many pediatric depression symptoms are also
  normal child behavior so consider number,
  duration, and severity of symptoms.
• Undetected learning disorders can cause apathy
  and trouble concentrating too. Rule out LDs,
  adjustment disorder, grief.

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Efficient Assessment Using Multiple Sources

• Look for behavioral indications of depression as
  kids wont always be able to describe their
  internal emotional experience as adults do.
• Ask parent and child about depression. Young
  children will need more concrete questions.
• Go through DSM-IV criteria with parent and child.
  
• If symptoms are present, ask parent (and child if
  possible) to specify the number, duration, and
  severity of symptoms in order to determine
  whether the behaviors are within the normal
  range.

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Efficient Assessment Questions

• Any history of mental illness in the family?
• How has your childs behavior/mood been lately?
• How do your childs teachers describe your
  childs behavior at school?
• Is your child involved in any extracurricular
  activities (scouting troop, sports, church group,
  etc.)? If so, what do coaches etc. say about
  your childs mood, interactions with other
  children, and behavior?
• Are substance abuse, learning problems, or a
  recent losses an issue for your child?
• Keep in mind that many of these questions can be
  worded differently and asked of children if they
  are old enough.

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Course Comorbidity

• Fifty percent of children with depression will
  have a recurrence in adulthood.
• Higher risk of recurrence for earlier onset and
  comorbid cases.
• The majority of youth with depression have a
  history of substance abuse or other mental health
  problem.
• Anxiety disorders (more common in girls).
• Conduct and substance abuse (more common in
  boys).
• ADHD.

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Discussing Treatment

• The primary treatments are psychotherapy or
  counseling and medication.
• As a general rule, the younger the child, the
  longer psychotherapy with the child will take.
  Instead, its better to work with parents.
• Family therapy may be the best option if there
  are multiple problems in the home. Sometimes a
  child becomes a focus of problems but is not the
  only one with problems.
• Many parents (understandably) do not want to put
  their kids on medications. One of the primary
  issues will be symptom severity.
• Brief explanations of how medications work go a
  long way in demystifying and destigmatizing them.

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Parent Resource List

• Depression Education Websites
• Mayo Clinic www.mayoclinic.com
• National Institute of Mental Health
  www.nimh.nih.gov
• Mental Health Americawww.mentalhealthamerica.net
• Books on How to Help Depressed Children
• The Depressed Child A Parents Guide for
  Rescuing Kids - Dr. Douglas A. Riley, Ph.D.
• The Childhood Depression Sourcebook - Jeffrey A.
  Miller, Ph.D.
• Helping Your Depressed Child - Martha Underwood
  Barnard, Ph.D.

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Pediatric Depression References

• Costello, E. J., Angold, A., Burns, B. J.,
  Stangl, D. K., Tweed, D. L., Erkanli, A.,
  Worthman, C. M. (1996). The Great Smoky Mountains
  study of youth Goals, design, methods, and the
  prevalence of DSM IIIR disorders. Archives of
  General Psychiatry, 53, 11291136.
• Kessler, R. C., Avenevoli, S., Merikangas, K.
  R. (2001). Mood disorders in children and
  adolescents an epidemiologic perspective. 
  Biological Psychiatry, 49, 1002-1014.
• Lewinson, P. M., Hops, H., Roberts, R. E.,
  Seeley, J. R., (1993). Adolescent Pychopathology
  I Prevalence and incidence of depression and
  other DSM-III-R disorders in high school
  students. Journal of Abnormal Psychology, 102,
  133-144.
• Rappaport, N., Bostic, J. Q., Prince, J. B.,
  Jellinek, M. (2006). Treating pediatric
  depression in primary care. Journal of
  Pediatrics, 148, 567-568.

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