Document 63717

Childhood Mood Disorders:
Depression, Anxiety, Bipolar
Dr Susan Fralick-Ball, PsyD, MSN, RN, CH, CLNC
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
 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
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.
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.
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 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 is significantly more common in boys
under the age of 10.
◦ By age 16, girls have a greater incidence of
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
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
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
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
Muscle tension
Sleep disturbance
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
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
 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.
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)
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
◦ 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
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
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.
Management usually consists of pharmacological and psychological
Drugs most commonly used are mood stabilizers and atypical
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
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
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
 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
 Antidepressants and psychostimulants can
increase mania and rapid cycling into depression
and may increase suicidality and hospitalizations
Thank you for attending
Please get your attendance sheet stamped.
Dr Susan Fralick-Ball, PsyD, MSN, RN, CH, CLNC