Mood Disorders in Children and Adolescents

MAJOR DEPRESSIVE DISORDER

• Epidemiology

lifetime prevalence 

• pre-pubertal 1-2% (F:M=1:1)
• adolescents 4-18% (F:M=2:1)
• Of all children aged 4–11 with a mental disorder, children with a major depressive order on average missed the most days of school due to their symptoms (14 days in the previous 12 months). This was more than twice as high as for children with anxiety disorders (6 days) and more than 3 times as high as for children with ADHD (4 days)

• Clinical Features
  • only difference in diagnostic criteria for children and adolescents is that irritable mood may replace depressed mood
  • physical features:
    • insomnia (children)
    • hypersomnia (adolescents)
    • somatic complaints
    • substance misuse
    • decreased hygiene
  • psychological features:
    • irritability
    • boredom
    • anhedonia
    • low self-esteem
    • deterioration in academic performance
    • social withdrawal
    • lack of motivation
    • listlessness
• common comorbid diagnoses:
  • anxiety, ADHD, ODD, conduct disorder, eating disorders, and substanc misuse
• Treatment
  • majority never seek treatment
  • supportive therapy including
    • psychoeducation
    • active listening
    • lifestyle advice
  • CBT or IPT
    • internet-based therapy if in-person options unavailable
  • MEDICATIONS
    • 1st line SSRI: fluoxetine
    • 2nd line SSRIs: escitalopram, sertraline, citalopram
    • close follow-up for adolescents starting SSRIs to monitor for increased suicidal ideation or behaviour
    • in severe depression, best evidence for combined pharmacotherapy and psychotherapy
    • ECT or rTMS: limited evidence in this population, only for use in adolescents ≥12 y/o with severe illness, psychotic features, catatonic features, persistently suicidal
  • Prognosis
    • prolonged episodes, up to 1-2 yr = poor prognosis
  • prognosis variable; adolescents with depression more likely to have depression in adulthood than adolescents without
  • approximately 2% of adolescents with depression will develop bipolar disorder within 4 yr
  • complications:
    • negative impact on family and peer relationships
    • school failure
    • significantly increased
  • risk of suicide attempt or completion (however, suicide risk low for pre-pubertal children), substance use disorder

DISRUPTIVE MOOD DYSREGULATION DISORDER

• Clinical Features
  • severe, developmentally inappropriate, recurrent verbal or behavioural temper outbursts at least 3x/wk with persistently irritable mood in between
  • symptom onset
    • before age 10
    • occurring for ≥ 12 mo
    • in ≥ 2 settings
    • no more than 3 consecutive mo free from symptoms 
  • diagnosis should be made between ages 6-18 
  • criteria not met for intermittent explosive disorder, bipolar disorder (no mania/hypomania) 
  • supersedes diagnosis of ODD if criteria for both are met 
  • common comorbidities:
    • ADHD, anxiety disorders, depressive disorders 

BIPOLAR DISORDER 

• Clinical Features
  • mixed presentation and psychotic symptoms (hallucinations and delusions) more common in adolescent population than adult population 
  • often misdiagnosed in the adolescent population 
  • unipolar depression may be an early sign of adult bipolar disorder 
  • associated with
    • rapid onset of depression
    • psychomotor retardation
    • mood-congruent psychosis
    • affective illness in family
    • pharmacologically-induced mania 
• Treatment
  • lack of research in adolescent population, treatment guidelines based off of adult recommendations 
  • pharmacotherapy:
    • mood stabilizers (lithium, anticonvulsants) and/or antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole) 
  • psychotherapy:
    • CBT, family-focused therapy (a therapeutic modality designed for bipolar disorder that combines psychoeducation, communication skills training, and problem-solving skills training)

Anxiety Disorders in Children and Adolescents 

• prevalence 10% in childhood/adolescence; F:M=2:1 
• often not recognized 
• Clinical Features 
  • becomes problematic when it interferes with typical academic/social functioning 
  • children and adolescents may not vocalize their anxiety but instead exhibit behavioural manifestations 
  • associated with
    • school problems
    • unrealistic worries
    • physical/somatic symptoms (abdominal pain, headaches)
    • social and relationship problems
    • social withdrawal and isolation
    • sleep difficulties
    • tearful episodes or temper tantrums
    • lack of confidence
    • irritability and mood symptoms
    • alcohol and drug use in adolescents 
    • tension may look like fidgeting 
• Differential Diagnosis
  • depressive disorders, ODD, truancy
    • persistence and impairment to daily functioning differentiates anxiety disorder from normal anxiety  for school avoidance, differentiate social anxiety (fear of performance and humiliation) from generalized anxiety 
    • consider anxiety about separation, and rule out bullying and school refusal due to learning disorder 
• Course and Prognosis 
  • better prognosis with later age of onset, fewer comorbidities, early initiation of treatment, ability to maintain school attendance and peer relationships, and absence of social anxiety disorder 
  • with treatment, up to 80% of children will not meet criteria for their anxiety disorder at 3 yr follow-up, but up to 30% will meet criteria for another psychiatric disorder 
• Treatment 
  • similar principles for most childhood anxiety disorders due to overlapping symptomatology and frequent comorbidity 
  • psychoeducation of child and family 
  • psychotherapy: CBT has been shown to be effective in children and adolescents with anxiety 
  • pharmacotherapy: SSRIs can be helpful 

SEPARATION ANXIETY DISORDER 

• excessive and developmentally inappropriate anxiety on real, threatened, or imagined separation from attachment figures or home, with physical or emotional distress for at least 4 wk 
• persistent worry about losing attachment figures or experiencing an untoward event to self; reluctance to go places, be alone, or sleep alone; nightmares involving separation; physical symptoms when separated 
• often school refusal, comorbid major depression 

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) 

• anxiety, fear, and/or avoidance provoked by situations where child feels under the scrutiny of others 
• must distinguish between shy child, child with issues functioning socially (e.g. autism), and child with social anxiety 
• diagnosis only if anxiety interferes significantly with daily routine, social life, academic functioning, or if markedly distressed. Must occur in settings with peers, not just adults 
• features:
  • crying, tantrums, freezing, clinging behaviour, mutism, excessively timid, stays on periphery, refuses to be involved in group play 
  • significant implication for future quality of life if untreated
  • lower levels of satisfaction in leisure activities, higher rates of school dropout, poor workplace performance, increased rates of remaining single 

SELECTIVE MUTISM 

• consistent failure to speak in specific social situations where speaking is expected, despite speaking in other situations for ≥1 month
• the disturbance interferes with educational or occupational achievement or with social communication 
• not due to lack of knowledge of language or communication disorder 

GENERALIZED ANXIETY DISORDER 

• diagnostic criteria same as adults (note: only 1 item is required in children for Criteria C) 
• children worry about many things (e.g. school, future, family, past) 
• often redo tasks, show dissatisfaction with their work, and tend to be perfectionistic 
• often fearful in multiple settings and expect more negative outcomes when faced with academic or social challenges, and require reassurance and support to take on new tasks 

SPECIFIC PHOBIA 

• common phobias in childhood: fear of heights, small animals, physicians, dentists, darkness, loud noises, thunder, lightning 

OCD 

• diagnostic criteria same as adults 
• note: young children may not be able to articulate the aims of their compulsions

 

Oppositional Defiant Disorder 

• prevalence: 2-16%, M=F after puberty 
• difference between normal behaviour and ODD is frequency of symptoms
  • most days if age <5 yr
  • weekly if age ≥5 yr
  • exceeds what is normative for one’s age gender, culture 
• Diagnosis 
  • pattern of negativistic/hostile and defiant behaviour for 
    • ≥6 mo, with ≥ 1 non-sibling
    •  ≥4 symptoms manifested in 3 areas of: 
      • angry/irritable mood: 
        • easily loses temper
        • touchy or easily annoyed
        • often angry and resentful 
      • argumentative/defiant: 
        • argues with adults/authority figure
        • defies requests/rules
        • deliberately annoys
        • blames others for their own mistakes or misbehaviour 
      • vindictiveness: 
        • spiteful or vindictive twice in past 6 mo 
  • behaviour causes significant distress or impairment in
    • social, academic, or occupational functioning 
  • diagnosis of disruptive mood dysregulation disorder supersedes ODD if criteria for both are met 
• Clinical Features 
  • first symptoms
    • usually appear during preschool
    • rarely later than early adolescence 
  • associated with
    • poor school performance
    • few friends
    • strained parent/child relationships
    • risk of developing mood disorders later on, often precedes CD 
• Treatment 
  • parent: parent management training, psychoeducation for parents and family 
  • behavioural therapy: to teach, practice, and reinforce prosocial behaviour 
  • social: school/day-care interventions 
  • pharmacotherapy for comorbid disorders 

Conduct Disorder 

• prevalence: 1.5-3.4% (M:F=4:1) 
• Aetiology 
  • parental/familial factors:
    • parental psychopathology (e.g. ASPD, substance abuse)
    • child-rearing practices (e.g. child abuse, discipline)
    • low socioeconomic status (SES), family violence 
• child factors:
  • difficult temperament
  • ODD
  • learning problems
  • ADHD
  • neurobiology 
• Diagnosis 
  • pattern of behaviour that violates rights of others and age appropriate social norms
    • ≥3 criteria noted in past 12 montha and
    • ≥1 in past 6 month:
      • aggression to people and animals: 
        • bullying, initiating physical fights, use of weapons, forced sex, cruel to people and/or animals, stealing while confronting a person (i.e. armed robbery) 
      • destruction of property: 
        • arson, deliberately destroying others’ property 
      • deceitfulness or theft: 
        • breaking and entering, conning others, stealing nontrivial items without confrontation 
      • violation of rules: 
        • out all night before age 13, often truant from school before age 13, runaway ≥2 times at least overnight or for long periods of time 
      • disturbance causes clinically significant impairment in social, academic, or occupational functioning 
      • if ≥18 yr, criteria not met for ASPD 
• diagnostic types
  • childhood-onset ( ≥1 criterion prior to age 10) 
  • adolescent-onset (no criteria until age 10) 
  • unspecified onset (insufficient information) 
  • mild, moderate, severe 
• differential:
  • ADHD, depression, head injury, substance misuse 
• Treatment
  • early intervention necessary and more effective; long-term follow-up required 
• psychosocial:
  • parent management training
  • anger replacement training
  • CBT, family therapy
  • education/ employment programs
  • social skills training 
• Prognosis 
  • poor prognostic indicators include: 
    • early-age onset
    • high frequency
    • variety of behaviours
    • pervasiveness (i.e. in home, school, community)
    • comorbid ADHD
    • early sexual activity
    • substance misuse 
  • 50% of children with CD develop ASPD as adults