BEHAVIOURAL PAEDS,  MOOD DISORDERS,  PAEDIATRICS,  PSYCHIATRY

Depression (kids)

  • 2% of children
  • 5-8% of adolescents
  • Upto 15% of adolescents have mood disorders: (dysthymia, Depressive Disorder, Depressive adjustment disorder)
  • >17% of adolescents with depression present with substance abuse
  • MDD does occur in children aged 5–12 years.
  • MDD has a negative impact on the child’s psychological and social development, and its earlier onset is associated with increased risk of recurrence, psychiatric morbidity and impaired quality of life going into adulthood

Presentation

  1. Similar to adults (SADAFACES)
  2. Negative self image
    1. Blame themselves for difficulties in their lives
    2. Feelings of worthlessness, guilt or hopelessness
  3. Diminished ability to concentrate
  4. Somatic complaints are common
    1. Headache
    2. abdo pain
    3. MSK pain
    4. fatigue
  5. Mood lability
  6. Behaviour problems
    1. Grouchiness
    2. aggression are common
    3. irritability
    4. temper tantrums
    5. indecisiveness
    6. clinginess
    7. “externalizing” behaviours
  7. Anxiety
    1. ↑/new onset of anxiety symptoms
  8. Anhedonia
    1. Neglect of personal hygiene
    2. Diminished interest in play, work, activities which usually afford pleasure or interest
    3. apathy
  9. social withdrawal, school difficulties
  10. self harming
  11. insomnia
  12. weight
    1. Weight loss or gain, or failure to grow because Of diminished food intake.
  13. Increased emotionality and sensitivity to feelings of rejection
  14. Depressive Delusions and Hallucinations uncommon (rare before puberty)

MDD symptomsHow symptoms may present in a child
Depressed moodIrritable, temper outburst, cranky, unhappy, miserable
Anhedonia/lack of interestLoss of interest in pleasurable activities (eg does not want to see friends, do usual activities)
Somatic symptomsStomach ache, headache, musculoskeletal pain, fatigue
Sleep disturbanceChange in sleep
Appetite disturbanceFailure to meet expected weight gain, not getting hungry, eating too much
ConcentrationConcentration difficulty
MotorMoving and walking slowly, restlessness
CognitionsGuilt, fear of bad things going to happen, being bad person, hating themselves, thinking no one loves them, negative comments about themselves
Suicidal ideationThoughts of death/talk about death/wanting to kill themselves
BehaviourAnger, aggression, poor impulse control, separation anxiety
FunctionSocial withdrawal, impairment in relationships with family/friends, reduced activities, decline in academic performance

Diffrence between children and adolocents

  • Younger children unable accurately to describe their inner mental states
  • Irritability common
  • Somatic symptoms common
  • Reduced weight gain rather than weight loss

Risk factors

Family

  1. Persistent family disagreement 
  2. Parental discord
  3. Single parent
  4. Abuse/ neglect
  5. Exposure to DV

Friends

  1. Absence of intimate relationships
  2. Low number & infrequent contact with friends
  3. Being bullied &/or bullying
  4. Recent, severe personal disappointment with a close friend

High risk group

  1. Refugees/ asylum seekers
  2. ATSI
  3. Children in out of home care
  4. People with sexual minority status (girls)
  5. Homeless

Individual

  1. Fhx of psychiatric illness
  2. Past history of MDD
  3. ADHD
  4. Neurodevelopmental disorder/ ASD/ Learning disorder
  5. Complex physical illness/ disability

Psychosocial interview 

  • The HEEADSSS interview is a useful screening tool, that can also aide engagement. 
  • It is best completed with the adolescent alone. 
  • Parents should be asked if they have any concerns prior to leaving the room and again at the close of the interview  
  • Try to use open-ended, non-judgmental questions that avoid assumptions 
  • General statements instead of personalising questions can be less intrusive
    • (eg “some young people experiment with cigarettes, alcohol or drugs. In your year, do people smoke/drink/use illicit drugs? What about your friends? And you?”) 
  • The HEEADSS framework is designed to progress from important but less threatening questions to those considered highly personal  
  • It is often not possible to cover every aspect of the interview in a single encounter. 

The HEEADSSS psychosocial interview for adolescents 

Home: who, where, recent changes (moves or new people), relationships, stress or violence, smartphone or computer use (in home vs room) 
Education & Employment: where, year, attendance, performance, relationships and bullying, supports, recent moves, disciplinary actions, future plans, work details 
Eating and Exercise: weight and body shape (and relationship to these), recent changes, eating habits and dieting, exercise and menstrual history 
Activities: extra-curricular activities for fun: sport, organised groups, clubs, parties, TV/computer use (how much screen time and what for) 
Drugs and Alcohol: cigarettes, alcohol and illicit drug use by friends, family and patient. Frequency, intensity, patterns of use, payment for, regrets and negative consequences 
Sexuality and Gender: gender identity, romantic relationships, sexuality and sexual experiences, uncomfortable situations/sexual abuse, previous pregnancies and risk of pregnancy, contraception and STIs 
Suicide, Depression  & Self-harm: presence and frequency of feeling stressed, sad, down, ‘bored’, trouble sleeping, online bullying, current feelings (eg on scale of 1 to 10). thoughts or actions of self-harm/ hurting others, suicide risk: thoughts, attempts, plans, means and hopes for future 
Safety: serious injuries, online safety (eg meeting people from online), riding with intoxicated driver, exposure to violence (school and community), if high risk – carrying weapons, criminal behaviours, justice system 

Differentials

  • Comorbidity is the rule – concurrent symptoms of anxiety and behavioural disturbance are present in almost all cases.
  • neurodevelopmental disorders
    • ADHD
    • Anxiety disorders
  • developmental
    • learning disorders
    • speech and language functioning
  • Psychiatric
    • Sadness
    • Anxiety
    • Separation anxiety
    • Persistent depressive disorder (dysthmia)
    • Adjustment disorder with depressed mood
    • bipolar depression – rare in this age group, but need to consider in family history of bipolar disorder or psychotic illness.
  • Medical conditions causing/contributing to MDD
    • anaemia
    • thyroid dysfunction
    • vitamin deficiencies
    • viral (and post-viral) illnesses and diabetes 

Investigations

Limited evidence exists to guide pathology investigations in children with MDD.

Organic

  1. FBC (anaemia)
  2. TFT
  3. Vitamin deficiencies (B12)
  4. Viral screen

Screen

  1. Preschool Feelings Checklist
  2. Mood Feeling Questionnaire (MFQ)
  3. Children’s Depression Inventory 2 (CDI 2)


Formulation

 PredisposingPrecipitatingPerpetuatingProtective
Biological



Genetic (considering the gene-environment interaction)
Physical illness
Hormonal effect, puberty
Physical illness, medications
Impact of past episodes
Physical illness, medications
Absence of comorbidity



Psychological





Temperament
Cognitive style
Poor emotion regulation skills
Low perceived academic and social competence
Acute life event and its meaning for child




Impact of past episodes




Absence of comorbidity
Sense of humour
High to normal intelligence
Adaptive emotion regulation skills
Problem-focused coping style
Social




Familial adversity
Life events
Parental mental illness


Acute and chronic life events



Impact of past episodes
Continuing familial adversity
Poor peer relationships
Positive friendship networks
Close relationship with one or more family members
Socially valued
Personal achievements

Treatment

  1. Biological
    • Address sleep problems
    • Initiate behavioural activation & scheduling of fun activities
    • Encourage exercise
    • Encourage healthy diet
  2. Psychological
    • Psycho-education for child, family, school
    • Offer self help approaches eg. Online resources, help lines, peer/social/family support groups
    • Treat co-morbidities
    • Follow up – monitor trajectory/ response to treatment
  3. Social
    • Enhance child & family’s strengths/ protective factors
    • Liase with school
    • Address modifiable risk factors eg. Bullying, abuse, neglect
  4. Formal psychological interventions/ referral
    • Refer to psychiatrist at any point of uncertainty
    • Refer to psychology if no improvement & mild illness after 4/52, or initially if moderate-severe illness
      • CBT, IPT, family therapy, psychodynamic psychotherapy
  1. Cognitive behavior therapy (CBT)
    • behavioral activation techniques and methods to
      • increase coping skills
      • improve communication skills and peer relationships
      • solve problems
      • combat negative thinking patterns
      • regulate emotions
  2. Interpersonal Therapy
    • focuses on adapting to changes in
      • relationships
      • transitioning personal roles
    • forming interpersonal relationships
  3. A combination of CBT and medication has been shown to be more effective than medication alone in attaining remission of depression.
  4. Interpersonal therapy has not been compared with medication, combination treatment, or placebo, but it has been proven more effective than wait-list control groups with no therapy, and as effective or more effective than CBT

Medications

  • can be considered in severe illness
    • if symptoms do not improve with an adequate trial of psychological therapy (about six sessions)
    • if symptoms are particularly disabling.
  • If an antidepressant is started, the child should be reviewed weekly for the first month to assess
    • suicidal thoughts
    • behavioural changes
    • side effects
  • medication only be prescribed by a child psychiatrist and alongside psychotherapy.
  • There is mixed evidence to suggest the combination of medication and psychotherapy may have superior efficacy to either alone
  • fluoxetine is the only antidepressant with demonstrated efficacy over placebo
    • No antidepressant, including fluoxetine, is approved by the Therapeutic Goods Administration for use in patients under 18 years of age, but they can still be legally prescribed
    • In the UK, fluoxetine and sertraline, and in the US, fluoxetine and escitalopram, are licensed for the treatment of moderate-to-severe depression in children aged 8 years and older
  • Venlafaxine and paroxetine should be avoided in children because of significant adverse effects

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