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
• Childs ability to respond to warmth of
  interviewer
• Childs ability to identify strengths and
  enjoyable experiences
• The interviewers 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

51

• In some instances what looks like ADHD evolves
  into frank BPD. Families often find this
  diagnostic drift confusing

52

• These cases are always challenging and always
  require multidimensional, integrated treatment

53

• Course may be chronic with intermittent
  exacerbations and recurrent suicidality

54

• Development of long term treating
  relationships and long range treatment plan can
  be very helpful

55

• Remember not every child or adolescent who has
  emotional and behavioral dysregulation has
  Bipolar Disorder

56

• There is a group of children who present
  significant problems especially with affect
  regulation difficulties, impulse control
  problems, aggressiveness and poor response to
  frustration

57

• Some are experiencing sequellae of abuse and
  some have incipient personality disorders

58

• These childrens problems often include
  explosiveness, a lack of self control that
  often requires police involvement and/or
  psychiatric hospitalization

59

• These childrens difficulties also often
  involve juvenile justice, multiple
  hospitalizations, school failure, expulsions and
  alternative school placement and polypharmacy

60

• Outbursts usually occur following frustration,
  perceived slights or disrespect, often within a
  context of emotional invalidation and disregard

61

• These patients require treatment of these
  problems in addition to psychopharmacology to
  limit arousal and manage periods of low mood

62
A wide range of initial difficulties may lead to
this clinical picture

• Previous significant abuse or maltreatment (may
  include domestic violence)
• CPS placement, placement transitions
• Mental retardation or significant brain injury
• Parental inconsistency
• Substance Abuse
• Marked Attachment Problems

63
This is complicated by

• Diagnostic confusion
• Lack of continuity of care
• Multiple placements

64

• Reinforcement of aggressive/explosive behavior
• Lack of effective family involvement
• Therapeutic inconsistency

65
Defining Features

• Absence of expansive mood and decreased need for
  sleep
• Episodes are related to frustration, failure
  and/or criticism
• Episodes are generally discrete and goal
  directed, frequently viewed as defensive
  reactions

66
A variety of diagnosis may be appropriate
including

• PTSD
• Complex PTSD
• ODD
• Conduct Disorder
• Depression
• ADHD

67
Common features of the children include

• Poor affect regulation
• Poor impulse control
• Poor attachment experiences
• Limited consideration of consequences of
  behavior
• Overall irritable mood

68
Important considerations

• Role of negative coercive interactions
• Limited involvement in satisfying activities and
  prosocial peer groups

69
Treatment Approaches

• Limit arousal (psychopharmacology)
• Improve mood or decrease anxiety with SSRIs (if
  warranted)
• Promote attachment
• Develop a crisis plan
• Decrease negative expressed emotion

70

• Promote satisfying activities and relationships
• Chart episodes of high arousal, aggressiveness
• Enhance family relationships/functioning
• Teach tolerance for frustration

71

• Observe and alter provocation patterns
• Teach self soothing and build social support