Mood Disorder in Children

Dr.Eman Gaber

Major Depressive Disorder: Diagnostic Criteria

5 of following symptoms, must include one of first two, occurred almost every day for two weeks

• Depressed mood• Pleasure or interest/ Loss • Appetite• Sleep disturbance, too much or too little• Agitation or retardation• Fatigue• Feelings of worthlessness or guilt• Difficulty concentrating or deciding• Recurrent thoughts of death

Depressive Symptoms Mnemonic:“Space Drags

S leep disturbance

P leasure/interest (lack of)

A gitation

C oncentration

E nergy (lack of)/fatigue

D epressed mood

R etardation movement

A ppetite disturbance

G uilt, worthless, useless

Common presentation of Depression in Children

• Frequent vague, non-specific physical complaints such as headaches, muscle aches, stomachaches or tiredness

• Frequent absences from school or poor performance in school

• Talk of or efforts to run away from home • Outbursts of shouting, complaining, unexplained

irritability, or crying • Being bored • Lack of interest in playing with friends • Alcohol or substance abuse

Common presentation of Depression in Children

• Social isolation, poor communication

• Fear of death

• Extreme sensitivity to rejection or failure

• Increased irritability, anger, or hostility

• Reckless behavior

• Difficulty with relationships

Assessment

• Consider the following when assessing a child/young person

• with depression and record in the notes:• potential co morbidities• social, educational and family context for the

patient and family members• quality of patient’s relationships with family

members, friends and peers.

Assessment• Assess with the young person their social

network before treatment starts• identify factors that:

– contributed to the development and maintenance of depression

– impact in a positive or negative way on treatment efficacy.

• Indicate ways to work in partnership with their social and

• professional network

Assessment• Always ask the child/young person and

their parents directly about the patient’s:– alcohol and drug use

– experience of being bullied

– experience of being abused

– self-harm

– ideas about suicide

Assessment

• Give young people the opportunity to discuss these issues initially in private.

• Pay special attention to:– confidentiality

– young person’s consent (including competence)

– parental consent

– child protection

AssessmentConsider parents’ mental health

● Consider the possibility of parental depression and substance misuse (or other mental health problems and associated problems of living).

● Obtain a family history to check for uni-polar or bipolar depression in parents and grandparents in all children/young people with suspected mood disorder.

General treatment considerations

• Treat most children/young people on an outpatient or community basis

Mild depression

• Antidepressant medication should not be used for the initial treatment of children and young people with mild depression

Moderate to severe depression

first-line treatment:• specific psychological therapy

– individual cognitive behavioral therapy [CBT],– interpersonal therapy or – shorter-term family therapy

• it is suggested that this should be of at least 3 months’ duration.

• Antidepressant medication should not be offered to a child or young person with moderate to severe depression except in combination with a concurrent psychological therapy

• Fluoxetine should be prescribed as this is the only antidepressant for which trials show that benefits outweigh the risks.

• The starting dose should be 10 mg daily, increased if necessary to 20 mg daily after 1 week.

• Consider lower doses for children of lower body weight.

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• Consider the use of another antidepressant (sertraline or citalopram are the recommended second-line treatments

• The starting dose should be half the daily starting dose for adults,

• increased if necessary to the daily adult dose gradually over 2 to 4 weeks. Consider lower doses in children of lower body weight

Length of treatment

• After remission (no symptoms and full functioning for at least 8 weeks) continue medication for atleast 6 months (after the 8-week period).

Childhood Bipolar Disorder

• Forget a lot of what you know about adult bipolar disorder symptoms

• symptoms of bipolar in children are quite different. Mood swings in children can be extremely fast, and various angry and irritable behaviors are very common\

Symptoms of mania • euphoria (elevated mood)—silliness or elation that is inappropriate

and impairing• grandiosity• flight of ideas or racing thoughts• more talkative than usual or pressure to keep talking• irritability or hostility when demands are not met• excessive distractibility• decreased need for sleep without daytime fatigue• excessive involvement in pleasurable but risky activities (daredevil

acts, hyper sexuality)• poor judgment• hallucinations and psychosis

For an episode to qualify as mania, there must be elevated mood plus at least three other symptoms, or irritable mood plus at least four other symptoms.

Symptoms of depression

• lack of joy and pleasure in life• withdrawal from activities formerly enjoyed • agitation and irritability• pervasive sadness and/or crying spells• sleeping too much or inability to sleep• drop in grades or inability to concentrate• thoughts of death and suicide• fatigue or loss of energy• feelings of worthlessness• significant weight loss, weight gain or change in appetite

Very Common presentation of Childhood Bipolar Disorder

• Separation anxiety• Rages & explosive temper tantrums (lasting up

to several hours)• Marked irritability• Oppositional behavior• Frequent mood swings• Distractibility• Hyperactivity• Impulsivity

• Racing thoughts• Restlessness/ fidgetiness• Silliness, goofiness• Sexualized behavior unusual for the child’s age• Aggressive behavior• Grandiosity• Delusional beliefs and hallucinations• Risk-taking behaviors• Depressed mood• Lethargy• Low self-esteem

Challenges in Diagnosing Children's Bipolar Disorder

• Distinguishing between normal behaviors and those that may indicate bipolar disorder in a kid is more challenging because:

• There are a significant number of other conditions whose symptoms overlap with bipolar disorder, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), obsessive compulsive disorder (OCD), anxiety, depressive disorders and learning disabilities

Lines of treatment

A good treatment plan includes • Medication, • Close monitoring of symptoms, • Education about the illness, • Counseling or psychotherapy for the individual and

family, • Stress reduction, • Good nutrition, • Regular sleep and exercise, and • Participation in a network of support.

Psychotherapy

can help patients and their families understand the illness, can teach the importance of early relapse detection, and ensure compliance with medication

• It include: – Cognitive behavioral therapy – interpersonal therapy– multi-family support groups

Medication • Atypical Antipsychotics Agents• Risperdal, Zyprexa, Seroquel, Aripiprazole– These

newer agents are often used to treat bipolar disorders in adults, children and adolescents and appear to be effective mood stabilizers

• Mood Stabilizers– Lithium– anticonvulsant

• sodium valproic acid• Carbamazepine • Oxcarbazepine• Lamotrigine