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Clinical Assessment of Children and Adolescents with Depression

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“Clinical Assessment of Children and Adolescents with Depression,”
Halifax, Nova Scotia, Canada; October 1, 2008
Pediatric Grand Rounds, IWK Health Centre
*Although the core symptoms of depression are similar across the life span, developmental differences exist and should be taken into account in the assessment
*With increasing age, there generally is an increase in melancholic symptoms, delusions, substance abuse, and suicidal ideation/attempts.
*In contrast, younger children tend to have more somatic sxs, separation anxiety, behavior problems, temper tantrums, and hallucinations
*Direct interviews with children and adolescents are critical because parents and teachers may not be aware of the youth’s depressive symptoms
*Discrepant information between parents and their children should be solve in a cordial and non judgmental way
*Assessment of suicidal and homicidal ideation and behaviors is mandatory
*The interview process and screening questions utilized by research interviews such as the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version (KSADS-PL) can be useful
*Detection and diagnosis can be enhanced by available parent and child self-report measures

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Clinical Assessment of Children and Adolescents with Depression

  1. 1. Clinical Assessment ofClinical Assessment of Children and AdolescentsChildren and Adolescents with Depressionwith Depression Carlo G. Carandang, MDCarlo G. Carandang, MD Diplomate, American Board ofDiplomate, American Board of Psychiatry and NeurologyPsychiatry and Neurology 4South Inpatient Mental Health,4South Inpatient Mental Health, IWK Health CentreIWK Health Centre
  2. 2. Key PointsKey Points Although the core symptoms of depression are similar across the life span, developmental differences exist and should be taken into account in the assessment With increasing age, there generally is an increase in melancholic symptoms, delusions, substance abuse, and suicidal ideation/attempts. In contrast, younger children tend to have more somatic sxs, separation anxiety, behavior problems, temper tantrums, and hallucinations
  3. 3. Key Points- cont.Key Points- cont. Direct interviews with children and adolescents are critical because parents and teachers may not be aware of the youth’s depressive symptoms Discrepant information between parents and their children should be solve in a cordial and non judgmental way Assessment of suicidal and homicidal ideation and behaviors is mandatory
  4. 4. Key Points- cont.Key Points- cont. The interview process and screening questions utilized by research interviews such as the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version (KSADS-PL) can be useful Detection and diagnosis can be enhanced by available parent and child self-report measures
  5. 5. IntroductionIntroduction We present a practical approach to evaluate young persons for depression. Much of what we do as clinicians is not exclusively informed by evidence or hard data. In the end, unless a connection is made with our young patients and their families and unless we master the process of assessing pediatric depression, no amount of evidence will be applied to its fullest.
  6. 6. Classification SystemsClassification Systems Diagnostic and StatisticalDiagnostic and Statistical Manual of Mental Disorders,Manual of Mental Disorders, 4th edition (DSM-IV)4th edition (DSM-IV)  This presentationThis presentation The focus is on the DSM-IVThe focus is on the DSM-IV depressive disorders, whichdepressive disorders, which include major depressiveinclude major depressive disorder and dysthymicdisorder and dysthymic disorder.disorder. WHO’s InternationalWHO’s International Classification of Diseases,Classification of Diseases, 10th edition (ICD-10)10th edition (ICD-10)
  7. 7. Goals of AssessmentGoals of Assessment Establish if the patient suffers from psychiatric disorder(s) Elicit the factors that may have caused or contributed to disorder (genetic, developmental, familiar, social) Evaluate patients’ normal level of functioning and the extent this has been impaired by the illness
  8. 8. Goals of Assessment- cont.Goals of Assessment- cont. Identify areas of strength as well as potential supports within the family and the wider social environment Build trust and rapport
  9. 9. General Recommendations aboutGeneral Recommendations about AssessmentAssessment The initial evaluation involves obtaining data from multiple sources, which include the youth, parents, and teachers.  This comprises interviews with the youth alone (and, if indicated, the parents alone) and interviews with both the youth and parents. Confidentiality should be discussed at the onset.  Confidentiality maintained unless the patient’s life or other persons’ lives are at risk.  Role of clinicians as mandated reporters of abuse.  Sensitive issues: substance abuse, sexual activity, pregnancy: do not break confidentiality unless special circumstances Youth and parental consent to contact other informants (e.g. teachers) should also be obtained.
  10. 10. CONDUCTING THECONDUCTING THE ASSESSMENT INTERVIEWASSESSMENT INTERVIEW Youth interview is critical because parents and teachers tend to underreport depressive symptoms Children are less likely to answer questions reliably about mood, time concepts, comparing themselves to their peers, and judgment Interviewing the parent first allows the eliciting of relevant information and the time course of symptoms, which can be used later when interviewing the child
  11. 11. CONDUCTING THECONDUCTING THE ASSESSMENT INTERVIEW- cont.ASSESSMENT INTERVIEW- cont. Mood constructs  have the child point to a face on a chart with a variety of expressions/emotions. Time constructs  “your parents said you have been sad since the New Year” rather than “tell me about your moods over the last 2 months.” Comparing to peers and assessing judgment  ask parents and teachers
  12. 12. CONDUCTING THECONDUCTING THE ASSESSMENT INTERVIEW- cont.ASSESSMENT INTERVIEW- cont. Questions need to be simple, dealing with one concrete issue at a time Avoid leading questions (more likely to draw “yes” answers and more false positives) Avoid vague, open-ended questions (more likely to draw “I don’t know” answers and more false negatives)
  13. 13. RECONCILING CONFLICTING DATARECONCILING CONFLICTING DATA AMONG PARENT, YOUTH, AND OTHERAMONG PARENT, YOUTH, AND OTHER SOURCESSOURCES Many instances arise when youth give opposite information to their parents. Further inconsistencies can come from other sources, such as teachers, friends, and medical records. To reconcile these differences, clinicians can use either the “Best-Estimate Diagnoses” or the “OR” Rule.
  14. 14. RECONCILING CONFLICTING DATA:RECONCILING CONFLICTING DATA: Best Estimate DiagnosesBest Estimate Diagnoses Best Estimate DiagnosesBest Estimate Diagnoses  the process by which clinicians synthesize all available data, resolve discrepancies between data sources, and use their clinical judgment to arrive at the final diagnosis.
  15. 15. Best-Estimate DiagnosesBest-Estimate Diagnoses Data from direct interviews are given more weight than to other reports. When data are limited regarding family history, positive reports receive greater weight than negative reports. Regardless of source, positive reports of symptoms in excess of the minimum requirements to meet diagnostic criteria receive more weight than positive reports of symptoms that barely meet criteria.
  16. 16. Best-Estimate Diagnoses- cont.Best-Estimate Diagnoses- cont. Symptoms supported by more convincing examples should be given more weight than those supported by vague or ambiguous examples. Data from informants with greater contact with the patient are given more weight than from those with less contact.
  17. 17. ““OR” RuleOR” Rule “OR” Rule, where a symptom is counted toward the criteria if either the parent or youth endorses the symptom. The “OR” Rule maximizes sensitivity at the cost of specificity  May be useful in cases in which young persons minimize symptoms. This method may result in an increase in the number of comorbid diagnoses.
  18. 18. SIGECAPSSIGECAPS Mnemonics are helpful to remember theMnemonics are helpful to remember the DSM-IV criteria for mood disordersDSM-IV criteria for mood disorders 5 out of 9 criteria, with one being5 out of 9 criteria, with one being depressed or irritable mooddepressed or irritable mood At least 2 weeks durationAt least 2 weeks duration
  19. 19. SIGECAPS- cont.SIGECAPS- cont. Functional impairment (home, school,Functional impairment (home, school, peer relations)peer relations) KSADS: developmentally appropriateKSADS: developmentally appropriate questions to elucidate each symptomquestions to elucidate each symptom
  20. 20. DEVELOPMENTAL DIFFERENCES IN THEDEVELOPMENTAL DIFFERENCES IN THE CLINICAL PRESENTATION OFCLINICAL PRESENTATION OF DEPRESSIONDEPRESSION Children and adolescents with depression have an overall clinical presentation that is similar to adults. Discrepancies can be attributed to age and developmental level.
  21. 21. DEVELOPMENTAL DIFFERENCES IN THEDEVELOPMENTAL DIFFERENCES IN THE CLINICAL PRESENTATION OFCLINICAL PRESENTATION OF DEPRESSION- cont.DEPRESSION- cont. Children  more somatic complaints, psychomotor agitation, anxiety symptoms, behavior problems, ADHD-like symptoms, hallucinations, and depressed affect Adolescents  more melancholic symptoms (e.g., anhedonia, guilt, early morning awakenings, weight loss), delusions, suicidal behaviors, and substance abuse
  22. 22. Child Presentation ofChild Presentation of DepressionDepression Joel is a 9-year-old boy who lives with his mother and younger sister. He presents to his pediatrician with excessive stomach pains. On further interview, Joel has been very moody, irritable, and extremely defiant with his mother. His stomach pains worsen at school, resulting in frequent visits to the school nurse.
  23. 23. Child Presentation ofChild Presentation of Depression- cont.Depression- cont. Joel often worries that something dire will happen to his mother, and he has missed many days of school over the past several months, frequently calling his mother to pick him up. His teacher is concerned because Joel is usually a good student and is not having the good grades he had achieved previously. He hardly sleeps due to the stomach pain and is not hungry. After his parents’ divorce last year, he rarely sees his father and has recently started talking about dying.
  24. 24. Adolescent Presentation ofAdolescent Presentation of DepressionDepression Chantal is a 16-year-old girl, entering grade 11. She lives at home with her mother, father, and younger brother. She is anxious, self- conscious, and gets average grades in school. At the beginning of the school year her performance deteriorated and she complained of being unable to focus in class. She began experimenting with cannabis, stating it helped her to relax. Her parents noticed increasing irritability at home and with friends.
  25. 25. Adolescent Presentation ofAdolescent Presentation of Depression- cont.Depression- cont. She refused to follow her parents’ rules, despite having been compliant in the past, and she became openly defiant and disrespectful. She was observed making negative comments about herself. She also reported chronic tiredness. A few months later, she became tearful, spent most of her time in her room, and did not want to go out with her friends. She was eating more, mainly junk food, gaining 15 pounds in 4 months. She had trouble sleeping, felt exhausted, and “dragging her feet” throughout the day.
  26. 26. Dysthymic DisorderDysthymic Disorder 3 of 7 criteria (with 1 being low or irritable mood)3 of 7 criteria (with 1 being low or irritable mood) 1 year of sustained mood symptoms1 year of sustained mood symptoms Functional impairmentFunctional impairment
  27. 27. Dysthymic DisorderDysthymic Disorder David is a 15-year-old boy in grade 9. He lives with his parents and younger sister. David has been failing school over the past year. He exhibits much anger at school and at home most days of the week. He often becomes angry at school because he does not want to deal with people, and he has received multiple in- school suspensions. He feels “crummy” about himself and that he is not getting enough credit for the effort he is putting to complete his schoolwork.
  28. 28. Dysthymic Disorder- cont.Dysthymic Disorder- cont. He is not able to concentrate, and this frustrates him even further as he claims he tries to complete the work. He has difficulty falling asleep and is fatigued throughout the day. He denies suicidal ideation, feelings of guilt or hopelessness, reports good appetite, and still enjoys hanging out with his friends and playing his guitar. Besides school, his other problem is his relationship with his father, who tells David what to do, is very short and punitive, especially about school problems.
  29. 29. Differential DiagnosisDifferential Diagnosis  Several disorders can present with similar symptoms  Differential diagnosis for depression:  Bipolar depression  Adjustment disorder with depressed mood  Bereavement  Posttraumatic stress disorder (PTSD)  Oppositional defiant disorder (ODD), ADHD  Pervasive developmental disorder  Mood disorder related to a general medical condition (including substance-induced depression)
  30. 30. Mania: 3 symptoms for 1 weekMania: 3 symptoms for 1 week
  31. 31. Adjustment Disorder withAdjustment Disorder with Depressed MoodDepressed Mood In adjustment disorder, depressive symptoms (sadness, tearfulness, hopelessness) appear after the occurrence of an identifiable stressor and do not meet criteria for a major depressive episode, and does not last long enough to meet time criteria for dysthymic disorder The symptoms should occur within 3 months of the onset of the stressor(s), and must not last 6 months after the offset of the stressor(s).
  32. 32. BereavementBereavement Young persons can present with depressive symptoms immediately after the death of a loved one. The symptoms may include sadness and associated symptoms of poor appetite, insomnia, and lack of concentration. If the symptoms last 2 months, or are particularly severe (e.g., psychotic, high suicidality) or incapacitating, then major depressive disorder should be considered.
  33. 33. POSTTRAUMATIC STRESS DISORDER PTSD shares symptoms with and can mimic depression:  anhedonia (numbing of responsiveness)  social isolation (detachment from others)  hopelessness (sense of foreshortened future)  disrupted sleep patterns (increased arousal) irritability (increased arousal)  difficulty concentrating (increased arousal)
  34. 34. POSTTRAUMATIC STRESS DISORDER- cont. Consider depression if the patient also has suicidality Consider PTSD if there has been abuse or if the patient reexperiences the traumatic event Comorbidity of PTSD and depression is common
  35. 35. ODD and ADHDODD and ADHD Depressed youth may be more prone to oppositional and defiant behaviors as a consequence of irritability Temper tantrums may be a manifestation of depressed mood However, in depression, the behavioral problems usually start after the onset of depressive symptoms
  36. 36. Pervasive DevelopmentalPervasive Developmental DisorderDisorder Depressive-like symptoms can appear to overlap with symptoms of autism:  lack of social reciprocity  failure to develop peer relationships  poor eye contact
  37. 37. MOOD DISORDER DUE TO GENERAL MEDICAL CONDITION Medication-induced depression  thorough evaluation of current and previous medications  special attention to the onset and offset of symptoms in relation to medication changes  Corticosteroids, contraceptives, isotretinoin are associated with depression, (last one with suicidal behaviors) Substance-induced depression  thorough evaluation of substance use  urine toxicology screen Infectious diseases  mononucleosis
  38. 38. MOOD DISORDER DUE TO GENERAL MEDICAL CONDITION- cont. Neurologic disorders  migraine  traumatic brain injury (TBI) Endocrine illnesses  thyroid disorders  diabetes Other conditions  anemia  electrolyte abnormalities  malnutrition
  39. 39. Depression Rating Scales- cont.Depression Rating Scales- cont.
  40. 40. Depression Rating Scales- cont.Depression Rating Scales- cont.
  41. 41. Mood and FeelingsMood and Feelings Questionnaire: MFQQuestionnaire: MFQ Screening depression in the community:Screening depression in the community:  Short MFQ-C, 13 questions, selfShort MFQ-C, 13 questions, self clinical cutoff 10clinical cutoff 10  Short MFQ-P, 13 questions, parent-reportShort MFQ-P, 13 questions, parent-report clinical cutoff unknownclinical cutoff unknown Rating severity of depression in clinic:Rating severity of depression in clinic:  MFQ-C, 33 questions, selfMFQ-C, 33 questions, self clinical cutoff 29clinical cutoff 29  MFQ-P, 34 questions, parent-reportMFQ-P, 34 questions, parent-report clinical cutoff 27clinical cutoff 27
  42. 42. Summary: Assessment ofSummary: Assessment of Pediatric DepressionPediatric Depression Utilize the interview process to establishUtilize the interview process to establish rapport and elicit informationrapport and elicit information Developmental differencesDevelopmental differences  Decreasing age, more somatic sxs, anxiety,Decreasing age, more somatic sxs, anxiety, disruptive behaviorsdisruptive behaviors  Increasing age, more melancholic sxs,Increasing age, more melancholic sxs, suicidal ideations/attempts, substance abusesuicidal ideations/attempts, substance abuse SIGECAPS (MDE)SIGECAPS (MDE)  5 out 9 criteria including low mood/irritability5 out 9 criteria including low mood/irritability
  43. 43. Summary: Assessment ofSummary: Assessment of Pediatric Depression- cont.Pediatric Depression- cont. SIGECA (Dysthymic Disorder)SIGECA (Dysthymic Disorder)  3 out of 7 criteria including low mood/irritability3 out of 7 criteria including low mood/irritability Differential DiagnosisDifferential Diagnosis Utilize depression rating scalesUtilize depression rating scales  Mood and Feelings Questionnaire (MFQ)Mood and Feelings Questionnaire (MFQ)
  44. 44. Summary: Assessment ofSummary: Assessment of Pediatric Depression- cont.Pediatric Depression- cont. Assess overall functioningAssess overall functioning  Children’s Global Assessment Scale (CGAS)Children’s Global Assessment Scale (CGAS) Monitor treatment longitudinally withMonitor treatment longitudinally with scalesscales  MFQ, CGASMFQ, CGAS Rating scales not a substitute for clinicalRating scales not a substitute for clinical interviewinterview
  45. 45. Treating Child and AdolescentTreating Child and Adolescent DepressionDepression Authors: Rey J and Birmaher B (editors)Authors: Rey J and Birmaher B (editors) Hardcover: 312 pagesHardcover: 312 pages Price: $69.96 (US)Price: $69.96 (US) Publisher: Lippincott Williams & Wilkins; 1Publisher: Lippincott Williams & Wilkins; 1 edition (January 1, 2009)edition (January 1, 2009) Language: EnglishLanguage: English ISBN-10: 0781795699ISBN-10: 0781795699 ISBN-13: 978-0781795692ISBN-13: 978-0781795692

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