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    Mood Dsrdr Mood Dsrdr Document Transcript

    • MOOD DISORDERS MOOD DISORDERS: DEPRESSIVE AND BIPOLAR DISORDERS I t is distressing for parents to see their child or adolescent sad, withdrawn, or irritable. Yet KEY FACTS episodes of sadness and frustration are com- mon during childhood and adolescence. How, ■ The prevalence of mood disorders then, can a parent or primary care health profes- in children and adolescents ages sional determine whether a child or adolescent is 9–17 years is approximately 6 showing signs of a mood disorder? Mood disorders percent (U.S. Department of Health are disorders characterized by disturbances in mood and Human Services, 1999). and include major depressive disorder, dysthymic ■ Only one-third of U.S. teenagers disorder, and bipolar disorder. with depressive disorders receive Depressed mood falls along a continuum. Brief periods of sadness or irritability in response to disap- treatment (King, 1991). pointment or loss are a normal part of growing up and ■ Seventy percent of children with a usually resolve quickly in a supportive environment. single major depressive episode will But some children and adolescents experience intense experience a recurrence within 5 or long-lasting sadness or irritability that may interfere years (Birmaher et al., 1996a). with self-esteem, friendships, family life, or school per- formance. These children or adolescents may be suffer- ■ Approximately 20 percent of all ing from a depressive disorder. Depressive disorders patients with bipolar disorder include dysthymic disorder as well as single and recur- experience their first manic episode ring episodes of major depressive disorder. during adolescence (Geller and Another type of mood disorder that can pre- Luby, 1997; McClellan and Werry, sent in childhood or adolescence is bipolar disorder. 1997). Although bipolar disorder has been considered ■ More than 4,000 youth (ages uncommon in prepubertal children, evidence sug- 15–24) in the United States gests that it may not be as rare as previously thought, and that it is often difficult to distinguish committed suicide in 1998 from severe forms of attention deficit hyperactivity (Murphy, 2000). disorder (ADHD). A child or adolescent who pre- sents with recurrent depressive symptoms, persis- tently irritable or agitated/hyperactive behaviors, markedly labile mood, reckless or aggressive behav- iors, or psychotic symptoms may be experiencing the initial symptoms of a bipolar disorder. 271
    • MOOD DISORDERS DESCRIPTION OF SYMPTOMS Descriptions of how these mood disorders can present in childhood and adolescence are summarized below. Dysthymic Disorder (Diagnostic code: 300.4) Middle Childhood and Adolescence Adapted from DSM-PC. Selected additional information from ■ Decreased interest in or participation in activities DSM-IV-TR is available in the appendix. Refer to DSM-PC ■ Feelings of inadequacy; low self-esteem and DSM IV/DSM-IV-TR for full psychiatric criteria and fur- ■ Social withdrawal; guilt or brooding ther description. ■ Irritability The symptoms of dysthymic disorder are less ■ Increases or decreases in sleep or appetite severe than those of a major depressive disorder but are more persistent, lasting for at least 1 year. Dysthymic disorder is infrequently diagnosed in infancy and early childhood. In middle childhood and adolescence it may present with the following symptoms: Major Depressive Disorder (Diagnostic codes: 296.2x, major depressive disorder, sin- While major depressive disorders in childhood gle episode; 296.3x, major depressive disorder, recurrent) and adolescence generally appear similar to adult Adapted from Sherry and Jellinek, 1996. Selected additional depression, additional warning signs may be present information from DSM-IV-TR is available in the appendix. according to developmental age. Table 14 presents pos- Refer to DSM-PC and DSM-IV/DSM-IV-TR for full psychiatric sible signs of major depressive disorder in infancy, criteria and further description. early childhood, middle childhood, and adolescence. (Although major depressive disorder has rarely been diagnosed in infants, they can show intense distress, similar to depressive reactions.) 272
    • MOOD DISORDERS Table 14. Possible Signs of Major Depressive Disorder in Infants, Children, and Adolescents Infancy Early Middle Adolescence Childhood Childhood Failure to thrive, speech and motor ✔ delays, decrease in interactiveness, poor attachment Repetitive self-soothing behaviors, ✔ ✔ withdrawal from social contact Loss of previously learned skills (e.g., ✔ ✔ self-soothing skills, toilet learning) Increase in temper tantrums or irritability ✔ Separation anxiety, phobias, poor self- ✔ ✔ ✔ esteem Reckless and destructive behavior (e.g., ✔ ✔ ✔ unsafe sexual activity, substance abuse) Somatic complaints ✔ ✔ ✔ Irritability or withdrawal ✔ ✔ Poor social and academic functioning ✔ ✔ Hopelessness, boredom, emptiness, loss ✔ ✔ of interest in activities Source: Adapted, with permission, from Sherry and Jellinek, 1996. Bipolar Disorder (Diagnostic codes: 296.0x; 296.4x–296.8x) Bipolar disorder often presents differently in chil- Adapted from DSM-PC with additional information from dren and adolescents than in adults. Manic symptoms McClellan and Werry, 1997. Selected additional information are the key feature of bipolar disorder. Ways that these from DSM-IV-TR is available in the appendix. Refer to DSM- symptoms might present in childhood and adoles- PC or DSM-IV/DSM-IV-TR for full psychiatric criteria and fur- cence are described as follows. ther description. (continued on next page) 273
    • MOOD DISORDERS Description of Symptoms (continued) Bipolar Disorder (continued) Middle Childhood Adolescence ■ Persistently irritable mood is described more than ■ Markedly labile mood euphoric mood ■ Agitated behaviors, pressured speech, racing ■ Aggressive and uncontrollable outbursts, agitated thoughts, sleep disturbances behaviors (may look like attention deficit hyperac- ■ Reckless behaviors (e.g., dangerous driving, sub- tivity disorder [ADHD] with severe hyperactivity stance abuse, sexual indiscretions) and impulsivity) (See bridge topic: Attention Deficit ■ Illicit activities (e.g., impulsive stealing, fighting), Hyperactivity Disorder, p. 203.) spending sprees ■ Extreme fluctuations in mood that can occur on the ■ Psychotic symptoms (e.g., hallucinations, delusions, same day or over the course of days or weeks irrational thoughts) ■ Reckless behaviors, dangerous play, inappropriate sexual behaviors COMMONLY ASSOCIATED DISORDERS In Children and Adolescents with In Children and Adolescents with Depressive Disorders Bipolar Disorder According to the American Academy of Child and According to Geller and Luby (1997) and Wilens Adolescent Psychiatry (1998), the following are et al. (1999), the following percentages apply: commonly associated disorders in children and ■ Attention deficit hyperactivity disorder (ADHD): 90 adolescents with depressive disorder: percent (prepubertal patients); 30 percent ■ Anxiety disorders: 30–80 percent (postpubertal adolescent patients) (See text on ■ Substance abuse: 20–30 percent ADHD in the introduction, p. 271, for further discussion.) ■ Disruptive disorders (including oppositional defiant ■ Anxiety disorders: approximately 30 percent disorder and conduct disorder): 10–80 percent (prepubertal patients); approximately 10 percent ■ Somatoform disorders (physical complaint not fully (postpubertal adolescent patients) explained by another medical condition or mental ■ Conduct disorder: approximately 20 percent disorder) ■ Substance use disorders: approximately 10 percent (child-onset bipolar disorder); approximately 40 percent (adolescent-onset bipolar disorder) 274
    • MOOD DISORDERS INITIAL INTERVENTIONS A mood disorder can devastate a child’s or ado- lescent’s emotional, social, and cognitive develop- ment. Primary care health professionals are increasingly the primary source of care for children and adolescents with mild to moderate depressive symptoms. Even after referring a child or adolescent with mood symptoms for mental health assessment and treatment, primary care health professionals need to collaborate with mental health profession- als in supporting the child or adolescent and family. The following suggestions focus on interventions in the key areas of self, family, school, and friends. (See Bright Futures Case Studies for Primary Care Clini- cians: Depression: Too Tired to Sleep [Hinden and Rosewater, 2001] at http://www.pedicases.org.) Child or Adolescent 1. Ask all children, adolescents, and families about depressive feelings or symptoms the child or adolescent may have (e.g., feelings of sadness, sleep problems, loss of interest in activities). general screening tools such as the Pediatric Parents should also be asked about depressive Symptom Checklist (Jellinek et al., 1988; feelings. (See bridge topic: Parental Depression, Jellinek et al., 1999) or the Child Behavior p. 303.) Depression, even of moderate to severe Checklist (Achenbach, 1991). (See Tool for intensity, may not always be apparent in the Health Professionals: Pediatric Symptom Check- child’s or adolescent’s day-to-day behavior, as list, Mental Health Tool Kit, p. 16.) Screening many of the symptoms of depression are tools for depressive symptoms include internal. • The Children’s Depression Inventory (CDI) 2. Consider the use of a depression screening tool (Kovacs, 1992) and the Beck Depression Inven- for children or adolescents who present with tory-II (BDI-II) (Beck et al., 1996). The CDI, concerning behaviors or symptoms (such as which was derived from the BDI, can be used those outlined in Tool for Families: Common for children ages 7–17 but is written at a first- Signs of Depression in Children and Adoles- grade reading level. The BDI, which is written at cents, Mental Health Tool Kit, p. 147) or who are a fifth-grade level, may be more appropriate for identified as being at risk for mood disorders by use with adolescents (Hack and Jellinek, 1998). 275
    • MOOD DISORDERS • The Center for Epidemiological Studies • Teenage boys have a suicide completion rate Depression Scale for Children (CES-DC) four times higher than that of teenage girls, (Weissman et al., 1980) and the Center for although girls attempt suicide more often Epidemiological Studies Depression Scale (Jellinek and Snyder, 1998). (CES-D) (Radloff, 1977) for childhood through Children and adolescents who have depres- adolescence. (See Tool for Health Professionals sive or bipolar symptoms should also be and Families: Center for Epidemiological Stud- screened for the following risk factors, which ies Depression Scale for Children [CES-DC], may place them at higher risk for acting on sui- Mental Health Tool Kit, p. 57.) cidal thoughts: • The Children’s Depression Scale (CDS) 9–16 • Previous suicide attempt Years (Lang, 1987). • Family history of suicide • The Short Mood and Feelings Questionnaire • Friends who have committed suicide (SMFQ) (Angold et al., 1995) for children and • Access to a gun adolescents ages 8–18. • Conduct disorder Screening for depressive disorders can be com- plex because most screening measures have rela- • Psychotic disorder tively low rates of specificity (i.e., they result in • History of physical abuse, neglect, and/or sex- a high number of false positives) (Roberts et al., ual abuse 1991). Further evaluation is required for any • Concerns about sexual identity child or adolescent identified through a screen- • Increase in risky behaviors (e.g., reckless dri- ing process. ving, unsafe sex) 3. For children and adolescents with depressive or • History of impulsivity bipolar symptoms, assess risk for suicidal behav- ior. National and local statistics indicate that • Change in school functioning or social suicidal thoughts (suicidal ideation) and behav- functioning iors are common during adolescence. • Alcohol and/or substance abuse • Up to 60 percent of high school students Any child or adolescent with symptoms of a report having had fleeting thoughts of suicide mood disorder or who is at risk for a mood dis- (Harkavy-Friedman et al., 1987). order should be asked directly about suicidal • Almost 20 percent of high school students thoughts or actions. Some sample questions report having seriously considered suicide follow: (Kann et al., 2000). “Have you ever felt bad enough that you wished • Almost 8 percent of high school students have you were dead?” made an actual suicide attempt (Kann et al., “Have you had any thoughts about wanting to 2000). hurt or kill yourself?” 276
    • MOOD DISORDERS “Have you ever tried to hurt or kill yourself?” vices are needed. (See the following bridge top- “Do you have a plan?” ics: Substance Use Problems and Disorders, p. 331; Attention Deficit Hyperactivity Disorder, “Do you have a way to carry out your plan? Is p. 203; Anxiety Disorders, p. 191.) there a gun in your house?” 6. Assess the child or adolescent for organic illness Any child or adolescent who has suicidal as indicated by symptoms and signs (e.g., thy- thoughts should be asked if he has a plan to roid problems, anemia, neurological illness, lead harm himself. Immediate mental health evalua- toxicity, drugs, alcohol). tion is necessary for any child or adolescent who has a plan or who is at risk for suicide and also 7. Children and adolescents may benefit from describes suicidal thoughts. Referral to a mental referrals for a range of therapies and treatments. health professional is usually indicated for chil- Following are some examples of therapies, treat- dren and adolescents with suicidal thoughts and ments, and techniques that can help: depressive or bipolar symptoms. See American • Supportive individual treatment that helps a Academy of Child and Adolescent Psychiatry child or adolescent begin to express and (2001) for further information. address distressing thoughts and feelings 4. Recognize that disclosing painful feelings is • Cognitive-behavioral approaches such as chal- often distressing for a child or adolescent. lenging negative thoughts (e.g., helping an Consider following up assessment questions adolescent to “reality check” why her best with empathic responses such as, “I’m really friend might have forgotten to call her) glad you were able to tell me about how you feel, even though it’s not easy. Your telling me means that we can work together to find ways to help you feel better.” 5. Look for evidence of any co-occurring psychiatric problems (e.g., abuse of alcohol or other sub- stances, ADHD, anxiety), and treat or refer for treatment as symptoms indicate. Work to coordi- nate care if multiple ser- 277
    • MOOD DISORDERS • Stress management and problem-solving tech- 2. Assess for family history of depressive or bipolar niques disorders and other psychiatric illnesses. Help • Group approaches that focus on building self- family members access mental health services esteem or on handling peer conflicts and pres- (individual, couple, and/or family treatment) as sure symptoms indicate. (See Table 2, Referral for Mental Health Care, p. 10, in the Making Men- • Family therapy that addresses areas of concern tal Health Supervision Accessible chapter.) or communication difficulties 3. Educate the family and the child or adolescent 8. Consider options for pharmacological interven- about the symptoms of mood disorders, and try tion. (See Pharmacological Interventions, to address their questions and concerns. (See p. 281.) Tool for Families: Common Signs of Depression 9. Recognize that the child or adolescent may have in Children and Adolescents, Mental Health Tool concerns about the stigma of mood disorder. Kit, p. 147.) Discuss these concerns, and work with the child 4. Help the family support the child’s or or adolescent to support social interaction, espe- adolescent’s development by cially with peers. • Discussing with parents any concerns they 10. Encourage the child or adolescent to participate have about discipline practices or how to in activities that improve his self-esteem and manage conflicts at home sense of mastery (e.g., encourage a child or ado- lescent who likes to draw to take an art class). • Encouraging parents to set aside a regular time to talk with or engage in enjoyable activ- 11. Discuss the importance of a healthy lifestyle ities with their child or adolescent (e.g., participating in regular physical activity, eating healthy foods) in maintaining a sense of 5. Help the family find ways to improve well-being. In particular, regular physical activi- communication (e.g., by holding family ty can have a beneficial impact on depressed meetings in which the child or adolescent is mood (Tkachuk and Martin, 1999) and should included in family decision-making and can be discussed as an important element in any raise concerns in a supportive setting). comprehensive treatment plan for adolescents 6. Ask if there are any weapons in the home, and with depressive symptoms. discuss safety issues. 7. Consider a referral for parent or family therapy Family to support families who may be coping with sig- 1. Ask family members about any recent or current nificant levels of stress or who may need addi- stressors (e.g., death of someone close to the tional help with other concerns (e.g., addressing child or adolescent, marital conflict, divorce) marital discord or parental depression or sub- that may be affecting the child’s or adolescent’s stance abuse; implementing effective parenting mood. practices; maintaining supportive communica- 278
    • MOOD DISORDERS tion). (See bridge topic: Parental Depression, ty category of “emotional disturbance.” Support p. 303.) and encourage the adolescent or family in dis- cussing possible options with appropriate school personnel. Some parents may appreciate assis- Friends tance from the primary care health professional 1. Encourage the child or adolescent to interact in contacting the school. Ensure that parents with peers in a supportive environment (e.g., know that their child or adolescent may also during after-school activities, in clubs or sports, qualify for services under Section 504 of the at play dates [for younger children], through Rehabilitation Act. faith-based activities). For further information about eligibility and 2. Consider recommending social skills training as services, families can consult the school’s special a way to improve a child’s or adolescent’s self- education coordinator, the local school district, esteem and peer relationships. Group therapy the state department of education’s special edu- may be particularly helpful for older children cation division, the U.S. Department of Educa- and adolescents. tion’s Office of Special Education Programs (http://www.ed.gov/offices/OSERS/OSEP), the Individuals with Disabilities Education Act School (IDEA) ’97 Web site (http://www.ed.gov/offices/ 1. The child or adolescent should be assessed, and OSERS/IDEA), or the U.S. Justice Department’s appropriate modifications should be made for a Civil Rights Division (http://www.usdoj.gov/ child or adolescent with a learning disorder or crt/edo). school difficulties that may be contributing to her sense of failure. 2. After receiving appropriate permission, obtain WHEN TO REFER FOR MENTAL information from teachers and guidance coun- HEALTH SERVICES selors about the child’s or adolescent’s school The decision to refer should be based on the functioning. Collaborate with the school team needs of the individual child or adolescent and to ensure that academic expectations and the family (e.g., severity of depressive symptoms, level of services are appropriate for the child’s or presence of bipolar symptoms, significant external adolescent’s needs and abilities. Involve school- stressors) and the primary care health professional’s based professionals such as school nurses, level of experience and expertise in managing mood school social workers, school psychologists, disorders. guidance counselors, and teachers in the child’s Primary care health professionals have differing or adolescent’s treatment plan. levels of comfort and experience in treating 3. Be aware that children and adolescents with children and adolescents with mild to moderate depressive or bipolar disorders may be eligible depressive symptoms. Even mild depressive for special education services under the disabili- symptoms can significantly interfere with a child’s 279
    • MOOD DISORDERS or adolescent’s social, emotional, and academic • Symptoms suggestive of a bipolar disorder (See development. Therefore, even when a primary care Bipolar Disorder, p. 273.) health professional is comfortable assessing and • Recurrent or unremitting depressive symptoms managing a child’s or adolescent’s symptoms, • Disturbances in sleep, weight, or activity levels referral for additional mental health services should that are significant enough to affect functioning be considered. Psychologists, child psychiatrists, and clinical social workers experienced in working • Significant impairment in school functioning or with children and adolescents can provide relationships with family and friends individual and family therapy to support children, • Possibility of abuse or neglect (See bridge topic: adolescents, and their families as they assess and Child Maltreatment, p. 213, regarding mandated monitor symptoms. School-based services, reporting responsibilities.) including additional academic support or ongoing • Health risk or delinquent behaviors (e.g., sexual contact with a school psychologist or counselor, indiscretions, drug or alcohol use, lying or steal- may also be needed. For children or adolescents ing, truancy) whose symptoms make it difficult for them to • Impaired parental functioning interact with peers, social skills groups or group therapy can be helpful. (See also Table 2. Referral • Strong family history of affective disorder or psy- for Mental Health Care, p. 10, in the Making chiatric illness Mental Health Supervision Accessible chapter.) Children or adolescents with bipolar disorder For children and adolescents with more severe require an intensive level of services. In order to symptoms or significant risk factors, referral to a provide adequate care for these children and adoles- mental health professional, usually a child psychol- cents, the primary care health professional should ogist, child psychiatrist, or developmental-behav- closely collaborate with mental health professionals ioral pediatrician, for diagnostic evaluation and as the following interventions are implemented: comprehensive treatment planning is indicated. • Assessment of the child’s or adolescent’s and Referral to a child psychiatrist is especially indicated family’s safety while symptoms are being for children and adolescents with psychotic or bipo- stabilized. (If the child or adolescent cannot be lar symptoms or for children or adolescents with safely kept at home, hospitalization may be other significant risk factors who may require med- required.) ication management, medical/neurological evalua- • Medication management by a child psychiatrist, tion, or hospitalization. Symptoms and risk factors including monitoring and addressing potential that indicate referral include adverse effects of medication (e.g., weight gain). • Suicidal thoughts (See discussion of suicide, • Implementation of long-term supports for the p. 276.) child or adolescent and the family, including • Psychotic symptoms (e.g., paranoia, delusional thoughts, hallucinations); these require immedi- ate evaluation 280
    • MOOD DISORDERS - Case-management services lescents is beyond the scope of this guide, guide- - Home-based services to help families develop lines for considering pharmacological treatment for and implement behavior plans child and adolescent depressive disorders are offered below. Primary care health professionals are referred - Respite and residential services as needed to Bostic et al., 1997; Findling and Blumer, 1998; - Financial or insurance coverage for needed ser- and Wilens, 1999 for further information on specif- vices ic medications. - Individual and/or group therapy • Clinicians should be aware that 20–30 percent of • Review of a child’s or adolescent’s educational children and adolescents who have experienced a plan, and appropriate school placement and pro- major depressive episode will develop bipolar vision of school services disorder (McClellan and Werry, 1997). Therefore, any child or adolescent who undergoes a trial of an antidepressant should be closely monitored PHARMACOLOGICAL for signs of increased agitation or irritability. If a INTERVENTIONS child or adolescent exhibits these signs or other In addition to interventions such as individual bipolar symptoms, referral to a child psychiatrist therapy and working with the child’s or adoles- for assessment for bipolar disorder is indicated. cent’s family, school, and peers, medication may • Children and adolescents with co-occurring dif- help some children and adolescents with depressive ficulties, such as suicidal thoughts, significant disorders. The assessment, treatment planning, and irritability or impulsivity, anxiety, ADHD, sub- medication management issues of depressive stance abuse, or significant conduct problems, symptoms in prepubertal children and young are likely to present diagnostic and treatment adolescents going through puberty are sufficiently challenges that are ideally addressed by a child complex to warrant a referral to a child psychiatrist. psychiatrist. For older adolescents, primary care health • While the safety and efficacy of selective sero- professionals may choose to treat moderate tonin-reuptake inhibitor (SSRI) antidepressants depressive symptoms with medication. In these have not been as well established for children and cases, initial and periodic consultation with a child adolescents as for adults, available data indicate psychiatrist regarding medication selection, dosing, that the short-term use of SSRIs appears safe and duration of treatment, and management of adverse potentially useful in the treatment of childhood effects is highly recommended. Children and and adolescent depression (Emslie et al., 1999). adolescents with bipolar symptoms should always • For an older adolescent with a moderately severe be referred to a child psychiatrist (or adult depressive disorder and good family support, pri- psychiatrist in the case of older adolescents) for mary care health professionals, after thoroughly assessment and medication management. evaluating the adolescent’s symptoms, function- While a detailed discussion of medication treat- ing, and stressors and assessing for potential ment for depressive disorders in children and ado- 281
    • MOOD DISORDERS medical causes, may consider using an SSRI in Resources for Families certain situations: Child & Adolescent Bipolar Foundation - In adolescents with a clear family history of 1187 Wilmette Avenue, PMB #331 depressive disorders (not bipolar disorder) that Wilmette, IL 60091 have responded well to medication treatment Phone: (847) 256-8525 - In adolescents who had previously been func- Web site: http://www.bpkids.org tioning well, with acute impairment due to depressive symptoms National Depressive and Manic-Depressive Association - In adolescents whose depressive symptoms 730 North Franklin Street, Suite 501 have continued even after individual, group, Chicago, IL 60610-3526 and/or family therapy Phone: (800) 826-3632 • An adolescent who does not respond to an initial Web site: http://www.ndmda.org trial of an SSRI or who experiences adverse effects with a medication trial should be referred for fur- ther psychiatric evaluation. 282