Transcript Mood Disorders in Children and Adolescents

Mood Disorders in Children and
Adolescents
John Sargent, M.D.
• 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.
Depression affects 3% of children
and 6 – 8% of adolescents
2 of 3 depressed teens are girls
Depression represents a gene –
environment interaction
• Family and contextual risk factors
influence the occurrence
• Individual cognitive distortions, global
and personal attribution styles and
pessimism also increase its likelihood
• Family risk factors include
– Parental depression
– Family stressors such as moving, job loss,
homelessness and poverty
– Persistent marital or post divorce conflict
– Persistent parent – child conflict or distrust
• 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
• Symptoms of Depression in Children
and Adolescents
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Poor concentration
Irritability
Experience of boredom
Quitting or decreased involvement in
activities or relationships
• Further symptoms develop as
depression persists
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Poor school performance
Social isolation
Family conflict
Appetite and sleep changes
– Appetite disorders – substance abuse,
eating disorder, cutting among
adolescents
– Hopelessness
– Acute and chronic suicidal ideation
– Suicide attempts
Depression associated with…
• Child neglect
• Parental depression or substance
abuse
• Significant childhood difference
(handicap, illness, learning disability)
• Domestic violence, marital conflict or
persistent post separation parental
conflict
• Other forms of child abuse
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
• Specific risk factors for suicide in
depressed teens
– Obesity
– Teasing and bullying
– Previous suicide attempts
– History of childhood maltreatment
– Access to firearms
– Fluctuations in developmental maturity
– Concerns about sexual orientation
– Drug or alcohol intoxication
– Rejection, shaming failure or argument
with important person (attachment figure)
– Impulsivity
• During the interview the examiner will
often note that he/she feels sad while
talking with the child
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
• Peer Relationships
• Legal difficulties and sexual activity
(for children over age 11)
• Substance use/abuse
• School performance
• Previous Psychiatric treatment
• Family history of psychiatric disorder
• Suicidal ideation, intent, attempts
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
• Treatment Approaches
– Identify suicidality and develop a plan to
limit suicidal behavior
– Build connections and competence
– Involve family in treatment and address
family problems especially parental
depression
– Identify problems caused by depression
and develop methods of separating
depression from the person
– Limit substance abuse, treat co-morbid
problems and encourage academic
success and pro social behaviors and
peer relationships
– 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
It is essential to monitor and support
return to normal development in
school, with peers and in family during
treatment
Remember 10% of depressed children
and adolescents will progress to
develop Bipolar Disorder, often these
teens have strong family history of
Bipolar Disorder
Be wary of suicidal behavior during
treatment, especially at points of
conflict and perceived isolation
Build on unique skills, strengths and
talents of both the child and his/her
family
Prepare family and adolescent for the
possibility of relapse including
identifying early signs warranting return
to treatment
Be aware of the influence of a culture
of violence upon child or adolescent
behavior
Bipolar Disorder
Alternating periods of depression and
mania. Occurs in approximately 0.51% of population
Mania
• Distinct period of time where child
manifests symptoms of mania
– Grandiosity, expansive mood
– Pressured speech, flight of ideas
– Decreased need for sleep
– Engaging in potentially dangerous, risky
behaviors, sexual promiscuity, excessive
spending, engaging in dubious or risky
projects (Impulsivity)
– Enhanced sense of well-being/perceived
productivity
– May include irritability, law breaking,
substance abuse, teen
pregnancy/paternity and aggressiveness.
These symptoms more likely in children
with a history of maltreatment.
Children are more likely to have rapid
(hourly to daily) changes in mood.
Older adolescents more likely to have
classical (adult) mania
Impulsivity, consequences of risky
behavior, intoxication, incarceration
and isolation are precursors of suicidal
behavior in bipolar youth
Treatment of bipolar disorders in
children and adolescents often
extremely challenging
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
Family psychoeducation/decreasing
family expressed emotion is extremely
helpful
Suicide prevention plan always part of
treatment. This includes attention to
firearms, planning for impulsivity and
rejecting and shaming experiences
Psychopharmacology may include
mood stabilizers, atypical antipsychotics and often both. Attention
to side effects is essential
Bipolar Disorder Treatment
• Antimanic psychopharmacology
– Depakote or Lithuim
– Atypical antipsychotics
• Abilify
• Risperdal
– 2 drug treatments
– Limited effectiveness of anticonvulsant drugs
• Trileptal
• Topomax
• Lamictal
• Neurontin
Co morbid ADHD, academic and
legal problems may complicate
situation and must be addressed
Building self – awareness, self
assessment and self management are
important
Parenting Support
• Parental consistency
• Reducing negative expressed emotion
• DBSA – parental support
• Consistent longitudinal care/crisis plan
Frequently family psychosocial
circumstances complicate treatment
and outcome (due to poverty,
parental difficulties, single parenthood,
lack of insurance and limited access to
care)
In some instances BPD may be
comorbid with ADHD. In these cases
treat BPD first, and then add ADHD
treatment
• In some instances what looks like
ADHD evolves into frank BPD. Families
often find this diagnostic drift confusing
These cases are always challenging
and always require multidimensional,
integrated treatment
Course may be chronic with
intermittent exacerbations and
recurrent suicidality
Development of long term treating
relationships and long range treatment
plan can be very helpful
Remember not every child or
adolescent who has emotional and
behavioral dysregulation has Bipolar
Disorder
• There is a group of children who
present significant problems especially
with affect regulation difficulties,
impulse control problems,
aggressiveness and poor response to
frustration
Some are experiencing sequellae of
abuse and some have incipient
personality disorders
These children’s problems often include
explosiveness, a lack of self – control
that often requires police involvement
and/or psychiatric hospitalization
These children’s difficulties also often
involve juvenile justice, multiple
hospitalizations, school failure,
expulsions and alternative school
placement and polypharmacy
• Outbursts usually occur following
frustration, perceived slights or
disrespect, often within a context of
emotional invalidation and disregard
These patients require treatment of these
problems in addition to
psychopharmacology to limit arousal
and manage periods of low mood
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
This is complicated by…
• Diagnostic confusion
• Lack of continuity of care
• Multiple placements
• Reinforcement of aggressive/explosive
behavior
• Lack of effective family involvement
• Therapeutic inconsistency
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
A variety of diagnosis may be appropriate including
• PTSD
• Complex PTSD
• ODD
• Conduct Disorder
• Depression
• ADHD
Common features of the children include
• Poor affect regulation
• Poor impulse control
• Poor attachment experiences
• Limited consideration of
consequences of behavior
• Overall irritable mood
Important considerations
• Role of negative coercive interactions
• Limited involvement in satisfying
activities and prosocial peer groups
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
• Promote satisfying activities and
relationships
• Chart episodes of high arousal,
aggressiveness
• Enhance family
relationships/functioning
• Teach tolerance for frustration
• Observe and alter provocation
patterns
• Teach self – soothing and build social
support