Mood Disorders in Children and Adolescents
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Transcript of Mood Disorders in Children and Adolescents
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Mood Disorders in Children and Adolescents
John Sargent, M.D.
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• 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.
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Depression affects 3% of children and 6 – 8% of adolescents 2 of 3 depressed teens are girls
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Depression represents a gene – environment interaction
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• Family and contextual risk factors influence the occurrence
• Individual cognitive distortions, global and personal attribution styles and pessimism also increase its likelihood
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• Family risk factors include– Parental depression– Family stressors such as moving, job
loss, homelessness and poverty
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– Persistent marital or post divorce conflict
– Persistent parent – child conflict or distrust
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• 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
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• Symptoms of Depression in Children and Adolescents– Poor concentration– Irritability– Experience of boredom– Quitting or decreased involvement in
activities or relationships
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• Further symptoms develop as depression persists– Poor school performance– Social isolation– Family conflict– Appetite and sleep changes
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– Appetite disorders – substance abuse, eating disorder, cutting among adolescents
– Hopelessness– Acute and chronic suicidal ideation– Suicide attempts
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Depression associated with…
• Child neglect• Parental depression or substance
abuse
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• Significant childhood difference (handicap, illness, learning disability)
• Domestic violence, marital conflict or persistent post separation parental conflict
• Other forms of child abuse
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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
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• Specific risk factors for suicide in depressed teens– Obesity – Teasing and bullying– Previous suicide attempts
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– History of childhood maltreatment– Access to firearms– Fluctuations in developmental maturity
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– Concerns about sexual orientation– Drug or alcohol intoxication– Rejection, shaming failure or argument
with important person (attachment figure)
– Impulsivity
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• During the interview the examiner will often note that he/she feels sad while talking with the child
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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
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• Peer Relationships• Legal difficulties and sexual activity
(for children over age 11)• Substance use/abuse• School performance
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• Previous Psychiatric treatment• Family history of psychiatric disorder• Suicidal ideation, intent, attempts
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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
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• Treatment Approaches– Identify suicidality and develop a plan to
limit suicidal behavior– Build connections and competence
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– Involve family in treatment and address family problems especially parental depression
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– Identify problems caused by depression and develop methods of separating depression from the person
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– Limit substance abuse, treat co-morbid problems and encourage academic success and pro social behaviors and peer relationships
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– 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
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It is essential to monitor and support return to normal development in school, with peers and in family during treatment
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Remember 10% of depressed children and adolescents will progress to develop Bipolar Disorder, often these teens have strong family history of Bipolar Disorder
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Be wary of suicidal behavior during treatment, especially at points of conflict and perceived isolation
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Build on unique skills, strengths and talents of both the child and his/her family
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Prepare family and adolescent for the possibility of relapse including identifying early signs warranting return to treatment
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Be aware of the influence of a culture of violence upon child or adolescent behavior
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Bipolar Disorder
Alternating periods of depression and mania. Occurs in approximately 0.5-1% of population
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Mania
• Distinct period of time where child manifests symptoms of mania– Grandiosity, expansive mood– Pressured speech, flight of ideas– Decreased need for sleep
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– Engaging in potentially dangerous, risky behaviors, sexual promiscuity, excessive spending, engaging in dubious or risky projects (Impulsivity)
– Enhanced sense of well-being/perceived productivity
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– May include irritability, law breaking, substance abuse, teen pregnancy/paternity and aggressiveness. These symptoms more likely in children with a history of maltreatment.
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Children are more likely to have rapid (hourly to daily) changes in mood. Older adolescents more likely to have classical (adult) mania
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Impulsivity, consequences of risky behavior, intoxication, incarceration and isolation are precursors of suicidal behavior in bipolar youth
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Treatment of bipolar disorders in children and adolescents often extremely challenging
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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
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Family psychoeducation/decreasing family expressed emotion is extremely helpful
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Suicide prevention plan always part of treatment. This includes attention to firearms, planning for impulsivity and rejecting and shaming experiences
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Psychopharmacology may include mood stabilizers, atypical anti- psychotics and often both. Attention to side effects is essential
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Bipolar Disorder Treatment
• Antimanic psychopharmacology– Depakote or Lithuim– Atypical antipsychotics
• Abilify• Risperdal
– 2 drug treatments– Limited effectiveness of anticonvulsant drugs
• Trileptal• Topomax• Lamictal• Neurontin
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Co morbid ADHD, academic and legal problems may complicate situation and must be addressed
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Building self – awareness, self assessment and self management are important
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Parenting Support
• Parental consistency• Reducing negative expressed
emotion• DBSA – parental support• Consistent longitudinal care/crisis
plan
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Frequently family psychosocial circumstances complicate treatment and outcome (due to poverty, parental difficulties, single parenthood, lack of insurance and limited access to care)
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In some instances BPD may be comorbid with ADHD. In these cases treat BPD first, and then add ADHD treatment
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• In some instances what looks like ADHD evolves into frank BPD. Families often find this diagnostic drift confusing
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These cases are always challenging and always require multidimensional, integrated treatment
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Course may be chronic with intermittent exacerbations and recurrent suicidality
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Development of long term treating relationships and long range treatment plan can be very helpful
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Remember not every child or adolescent who has emotional and behavioral dysregulation has Bipolar Disorder
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• There is a group of children who present significant problems especially with affect regulation difficulties, impulse control problems, aggressiveness and poor response to frustration
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Some are experiencing sequellae of abuse and some have incipient personality disorders
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These children’s problems often include explosiveness, a lack of self – control that often requires police involvement and/or psychiatric hospitalization
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These children’s difficulties also often involve juvenile justice, multiple hospitalizations, school failure, expulsions and alternative school placement and polypharmacy
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• Outbursts usually occur following frustration, perceived slights or disrespect, often within a context of emotional invalidation and disregard
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These patients require treatment of these problems in addition to psychopharmacology to limit arousal and manage periods of low mood
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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
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This is complicated by…
• Diagnostic confusion• Lack of continuity of care• Multiple placements
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• Reinforcement of aggressive/explosive behavior
• Lack of effective family involvement• Therapeutic inconsistency
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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
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A variety of diagnosis may be appropriate including
• PTSD• Complex PTSD• ODD• Conduct Disorder• Depression• ADHD
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Common features of the children include
• Poor affect regulation• Poor impulse control• Poor attachment experiences• Limited consideration of
consequences of behavior• Overall irritable mood
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Important considerations
• Role of negative coercive interactions
• Limited involvement in satisfying activities and prosocial peer groups
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Treatment Approaches
• Limit arousal (psychopharmacology)• Improve mood or decrease anxiety
with SSRI’s (if warranted)• Promote attachment• Develop a crisis plan• Decrease negative expressed
emotion
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• Promote satisfying activities and relationships
• Chart episodes of high arousal, aggressiveness
• Enhance family relationships/functioning
• Teach tolerance for frustration
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• Observe and alter provocation patterns
• Teach self – soothing and build social support