4/13/2012 Childhood Mood Disorders: Depression, Anxiety, Bipolar Dr Susan Fralick-Ball, PsyD, MSN, RN, CH, CLNC PsychMedEd for Advance 2012 Depressive symptoms  The symptoms of depression in children vary. ◦ It is often undiagnosed and untreated because they are passed off as normal emotional and psychological changes that occur during growth. ◦ Early medical studies focused on "masked" depression, where a child's depressed mood was evidenced by acting out or angry behavior. ◦ While this does occur, particularly in younger children, many children display sadness or low mood similar to adults who are depressed.  The primary symptoms of depression revolve around sadness, a feeling of hopelessness, and mood changes. Primary symptoms… Fatigue and low energy. Physical complaints (such as stomachaches, headaches) that do not respond to treatment – especially school-aged kids  Reduced ability to function during events and activities at home or with friends, in school, extracurricular activities, and in other hobbies or interests.  Feelings of worthlessness or guilt.  Impaired thinking or concentration.  Thoughts of death or suicide.   Childhood Depression Childhood depression is different from the normal blues/downs and everyday emotions that occur as a child develops.  Just because a child seems sad, this does not necessarily mean he or she has significant depression.  If the sadness becomes persistent, or if disruptive behavior that interferes with normal social activities, interests, schoolwork, or family life develops, it may indicate that he or she has a depressive illness.  Keep in mind that while depression is a serious illness, it is also treatable.  Primary Depressive Symptoms  Irritability or anger.   Continuous feelings of sadness, hopelessness. Social withdrawal, especially in very young or kids or teens. Increased sensitivity to rejection. Changes in appetite -- either increased or decreased. Weight loss or gain. Changes in sleep -- sleeplessness or excessive sleep. Vocal outbursts or crying. Difficulty concentrating. ◦ Grumpy, sad, or bored most of the time      Symptom caveats Not all children have all of these symptoms. Most will display different symptoms at different times and in different settings.  Although some children may continue to function reasonably well in structured environments, most kids with significant depression will suffer a noticeable change in social activities, loss of interest in school and poor academic performance, or a change in appearance.  Children may also begin using drugs or alcohol, especially if they are over the age of 11/12.   1 4/13/2012 Symptom caveats… Although relatively rare in youths under 12, young children do attempt suicide -- and may do so impulsively when they are upset or angry.  Girls are more likely to attempt suicide, but boys are more likely to actually kill themselves when they make an attempt.  Children with a family history of violence, alcohol abuse, or physical or sexual abuse are at greater risk for suicide, as are those with depressive symptoms and those bullied.  Cause/Prevention Depression in children can be caused by any combination of factors that relate to physical health, life events, family history, environment, genetic vulnerability and biochemical disturbance.  It is not a passing mood, nor is it a condition that will go away without proper treatment.  Children with a family history of depression are at greater risk of experiencing depression themselves.  ◦ Children who have parents that suffer from depression tend to develop their first episode of depression earlier than children whose parents do not. ◦ Children from chaotic or conflicted families, or children and teens who abuse substances like alcohol and drugs, are also at greater risk of depression. Treatment     Treatment options for children with depression are similar to those for adults, including psychotherapy( CognitiveBehavioral counseling) and medication. The role that family and the child's environment play in the treatment process is different from that of adults. A pediatrician/counselor may suggest psychotherapy first, and consider antidepressant medicine as an additional option if there is no significant improvement. The best studies to date indicate that a combination of psychotherapy and medication is most effective. However, studies do show that the antidepressant Prozac is effective in treating depression in children and teens. ◦ The drug is officially recognized by the FDA for treatment of children 8-18 with depression. Who’s depressed? About 2.5% of children in the U.S. suffer from depression.  Depression is significantly more common in boys under the age of 10.  ◦ By age 16, girls have a greater incidence of depression.  Bipolar disorder (BPD) is more common in adolescents than in younger children. ◦ Bipolar in children can, however, can be more severe than in adolescents. ◦ It may also occur with, or be hidden by, attentiondeficit hyperactivity disorder(ADHD), obsessivecompulsive disorder(OCD), or conduct disorder(CD). Diagnosing depression    If the symptoms of depression in the child have lasted for at least two weeks, one should schedule a visit with his/her doctor to make sure there are no physical reasons for the symptoms and to make sure that the child receives proper treatment. A consultation with a mental healthcare professional who specializes in children is also recommended. A mental health evaluation should include interviews with the parents and child, and any additional psychological testing that is necessary. ◦ Information from teachers, friends and classmates can be useful for showing that these symptoms are consistent during the child's various activities and are a marked change from previous behavior.  There are no specific tests -- medical or psychological -- that can clearly show depression, but tools such as questionnaires (for both the child and parents) combined with personal information can be very useful. Childhood Anxiety     Generalized Anxiety Disorder If your child has generalized anxiety disorder, or GAD, he or she will worry excessively about a variety of things such as grades, family issues, relationships with peers, and performance in sports. Children with GAD tend to be very hard on themselves and strive for perfection.They may also seek constant approval or reassurance from others. One of six symptoms must be present: ◦ ◦ ◦ ◦ ◦ ◦ Restlessness/feeling keyed up Easily fatigued Difficulty concentrating Irritability Muscle tension Sleep disturbance 2 4/13/2012 Anxiety variants..       Obsessive-Compulsive Disorder (OCD) OCD is characterized by unwanted and intrusive thoughts (obsessions) and feeling compelled to repeatedly perform rituals and routines (compulsions) to try and ease anxiety. Most children with OCD are diagnosed around age 10, although the disorder can strike children as young as two or three. Boys are more likely to develop OCD before puberty, while girls tend to develop it during adolescence. There is a high occurrence with tic disorders and PANDAS (pediatric autoimmune neuropsychiatric disorders associated with strep) Kids who are inhibited at early ages tend to have parents diagnosed with panic disorder or agoraphobia; they are at increased risk for developing anxiety in later childhood/teens Anxiety variants…      Posttraumatic Stress Disorder (PTSD) Children with PTSD may have intense fear and anxiety, become emotionally numb or easily irritable, or avoid places, people, or activities after experiencing or witnessing a traumatic or life-threatening event. Not every child who experiences or hears about a traumatic event will develop PTSD. It is normal to be fearful, sad, or apprehensive after such events, and many children will recover from these feelings in a short time. Children most at risk for PTSD are those who directly witnessed a traumatic event, who suffered directly (such as injury or the death of a parent), had mental health problems before the event, and who lack a strong support network. Violence at home also increases a child’s risk of developing PTSD after a traumatic event. Separation anxiety…   This disorder is most common in kids ages 7 - 9. When separation anxiety disorder occurs, a child experiences excessive anxiety away from home or when separated from parents or caregivers ◦ Extreme homesickness and feelings of misery at not being with loved ones are common. Other symptoms include refusing to go to school, camp, or a sleepover, and demanding that someone stay with them at bedtime.  Kids with separation anxiety commonly worry about bad things happening to their parents or caregivers or may have a vague sense of something terrible occurring while they are apart.  Anxiety variants… Panic Disorder  Panic disorder is diagnosed if your child suffers at least two unexpected panic or anxiety attacks—which means they come on suddenly and for no reason—followed by at least one month of concern over having another attack, losing control, or "going crazy."  Anxiety variants…   Separation Anxiety Disorder Many children experience separation anxiety between 18 months and three years old, when it is normal to feel some anxiety when a parent leaves the room or goes out of sight. ◦ Usually children can be distracted from these feelings. It’s also common for a child to cry when first being left at daycare or pre-school, and crying usually subsides after becoming engaged in the new environment.  If a child is slightly older and unable to leave a parent or another family member, or takes longer to calm down after being left than other children, then the problem could be separation anxiety disorder, which affects 4 % of children.  Anxiety variants Social Anxiety Disorder Social anxiety disorder, or social phobia, is characterized by an intense fear of social and performance situations and activities such as being called on in class or starting a conversation with a peer.  This can significantly impair a child’s school performance and attendance, as well as his or her ability to socialize with peers and develop and maintain relationships.   3 4/13/2012 Anxiety variants      Selective Mutism Children who refuse to speak in situations where talking is expected or necessary, to the extent that their refusal interferes with school and making friends, may suffer from selective mutism. Children suffering from selective mutism may stand motionless and expressionless, turn their heads, chew or twirl hair, avoid eye contact, or withdraw into a corner to avoid talking. These children can be very talkative and display normal behaviors at home or in another place where they feel comfortable. Parents are sometimes surprised to learn from a teacher that their child refuses to speak at school. The average age of diagnosis is between 4 and 8 years old, or around the time a child enters school. Which fears are normal?       Most children, when asked, are able to report having several fears at any given age. Some research shows that 90% of children between the ages of 2-14 have at least one specific fear. Here is a list of fears that are found to be VERY COMMON for children at specific ages: INFANTS/TODDLERS (ages 0-2 years) loud noises, strangers, separation from parents, large objects PRESCHOOLERS (3-6 years) imaginary figures (e.g., ghosts, monsters, supernatural beings, the dark, noises, sleeping alone, thunder, floods) SCHOOL AGED CHILDREN/ADOLESCENTS (7-16 years) more realistic fears (e.g., physical injury, health, school performance, death, thunderstorms, earthquakes, floods Anxiety variants   Specific Phobias A specific phobia is the intense, irrational fear of a specific object, such as a dog, or a situation, such as flying. ◦ Common childhood phobias include animals, storms, heights, water, blood, the dark, and medical procedures.  Children will avoid situations or things that they fear, or endure them with anxious feelings, which can manifest as crying, tantrums, clinging, avoidance, headaches, and stomachaches. ◦ Unlike adults, they do not usually recognize that their fear is irrational.  Typically, children who are experiencing a phobia should be referred for treatment by a psychologist. Anxiety management at home         Pay attention to your child’s feelings. Stay calm when your child becomes anxious about a situation or event. Recognize and praise small accomplishments. Don’t punish mistakes or lack of progress. Be flexible and try to maintain a normal routine. Modify expectations during stressful periods. Plan for transitions (For example, allow extra time in the morning if getting to school is difficult). A child’s anxiety disorder diagnosis is NOT a sign of poor parenting. Treatment for Anxiety Anxiety treatment… Combination therapy with a childhood counselor and pharmacotherapy has yielded the best results.  Cognitive-behavioral therapy, or CBT, is a type of talk therapy that has been scientifically shown to be effective in treating anxiety disorders.   ◦ CBT teaches skills and techniques to your child that she can use to reduce her anxiety. ◦ A child will learn to identify and replace negative thinking patterns and behaviors with positive ones. ◦ He will also learn to separate realistic from unrealistic thoughts and will receive “homework” to practice what is learned in therapy. ◦ These are techniques that a child can use immediately and for years to come. Acceptance and commitment therapy, or ACT, uses strategies of acceptance and mindfulness (living in the moment and experiencing things without judgment) as a way to cope with unwanted thoughts, feelings, and sensations.  Dialectical behavioral therapy, or DBT, emphasizes taking responsibility for one’s problems and helps children examine how they deal with conflict and intense negative emotions. 4 4/13/2012 Childhood Bipolar Disorder Selective serotonin reuptake inhibitors (SSRIs) are currently the medications of choice for the treatment of childhood and adult anxiety disorders. The U.S. Food and Drug Administration has approved the use of some SSRIs for the treatment of pediatric obsessive-compulsive disorder (e.g., Prozac, Paxil).  Other types of medications, such as tricyclic antidepressants and benzodiazepines, are less commonly used to treat children.  WARNING: SSRIs may increase suicidal thoughts and behavior in a small number of children and adolescents.  Bipolar symptoms  Depressive symptoms of BD often include ◦ sadness, irritability, an inability to enjoy one's usual activities, changes in appetite or weight, and/or sleeping more than normal or having difficulty falling/staying asleep even when tired.  Manic symptoms of BD may include: ◦ inflated or unrealistic self-esteem; less need for sleep; talking more/faster than normal; changing the topic of conversation so quickly/often that it interferes with communication; experiencing "racing" thoughts; increased distractibility; difficulty sitting still; an unusual drive to engage in activities or pursue goals; and engaging in risky or dangerous behaviors. Treatment   Management usually consists of pharmacological and psychological therapy. Drugs most commonly used are mood stabilizers and atypical antipsychotics. ◦ ◦ ◦ ◦ ◦  Lithium Divalproex (Depakote). Carbamazepine (e.g., Tegretol). Lamotrigine (Lamictal). Valproate (Depacon). Antipsychotics such as: ◦ Quetiapine(Seroquel). ◦ Risperidone (Risperdal). ◦ Aripiprazole (Abilify).  Psychological treatment usually combines education on the disease, groups therapy, and CBT. Bipolar Disorder (BD) is characterized by extreme changes in mood that range from depressive "lows" to manic "highs" (typified by feelings of excessive happiness or rage).  It is important to note that these moods exceed normal responses to life events, represent a change from the individual's normal functioning, and cause problems in daily activities --- for instance, in getting along with family, friends and teachers, or in completing schoolwork.  Identifying BD in youth is challenging because, while adults with BD often have distinct periods of depression and mania that last for weeks, months, or longer, youth with BD frequently have depressive and manic symptoms that occur daily, and sometimes simultaneously.  Co-existing problems with bipolar…       Substance abuse. Both adults and kids with bipolar disorder are at risk of drinking or taking drugs. Attention deficit/hyperactivity disorder, or ADHD. Children with bipolar disorder and ADHD may have trouble staying focused. Anxiety disorders, like separation anxiety. Children with both types of disorders may need to go to the hospital more often than other people with bipolar disorder. Other mental illnesses, like depression. Some mental illnesses cause symptoms that look like bipolar disorder. Tell a doctor about any manic or depressive symptoms your child has had. Sometimes behavior problems go along with mood episodes.Young people may take a lot of risks, like drive too fast or spend too much money. Some young people with bipolar disorder think about suicide. Watch out for any sign of suicidal thinking.Take these signs seriously and call your child's doctor. Watchful Waiting Since diagnosis translates into treatment, thee is a wave of intervention now known as Watchful Waiting.  All mood episodes are, by definition, self-limited; they sometimes DO NOT need treatment.  Identification of bipolar illness in kids must be concurrent with assessment for family history, mood swings, course of illness, and treatment information.  Antidepressants and psychostimulants can increase mania and rapid cycling into depression and may increase suicidality and hospitalizations  5 4/13/2012 Thank you for attending Please get your attendance sheet stamped. Dr Susan Fralick-Ball, PsyD, MSN, RN, CH, CLNC PsychMedEd 6