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Depressive Disorders in Childhood and Adolescence

Azza Mohammad Abd El-Latif,MD

Mood is subjective internal feeling state and refers to the pervasive emotional tone

 Depression

as a morbid mood

 

Depression as a single symptom Depression as a symptom cluster

 Depression

as a subclinical syndrome  Depression as a disorder

The key differences

 The

extent  The severity  The impact of symptoms

Classification of disorders where mood is a major feature in ICD10 Disorders where mood is a major feature Mood disorders Affective conditions with Specific causes or features .

Mood disorders Recurrent depressive Persistent depressive disorders disorders Bipolar affective disorders Dysthymia Cyclothymia .

Cultural background held that children were largely a product of their environments and could not develop what was thought to be an autonomous disorder.Depressive Disorders in Childhood and Adolescence (history) Although case reports of depression in children date back to the 17th century. . until 1970 many investigators doubted that preadolescent children were capable of experiencing depression.

. engendering use of such terms as masked depression and depression equivalent.There was a believe that children and adolescents who are not able to articulate their internal emotional states and might instead act out.

. it was found that children and adolescents experience depressive symptoms comparable to adult depression but with developmental differences.With the advent of systematic research and data from large scale epidemiological studies.

Developmental differences in symptom presentation  Depression in children and adolescents resembles adult depression in its core features. and their irritability may at times lead to aggressive behavior. children and adolescents who are depressed may display a primarily irritable rather than sad mood.  But unlike adults. . especially in those children with poor impulse control.

tantrums. separation anxiety. school refusal. low self esteem. somatisation. failure to thrive. school refusal. hyperactivity. interpersonal problems. behavioral problems. irritability. psychotic symptoms   . Older children: somatisation. substance abuse. biological symptoms. Young children: apathy. poor feeding. suicidal acts.regressed behavior ( enuresis. soiling). sleep disturbance and acting out vs regression Adolescents: melancholia. atypical features. aggression. poor school performance.

. have no current or past history of manic or hypomanic episodes.  There  Exclude psychoactive substance use or any organic mental disorder.Symptoms needed to meet criteria for depressive episode in ICD-10  The depressive episode should last for at least 2 weeks.

Depressive episode                    General criteria for depressive episode ……………………………………………… (B) -Depressed mood -Loss of interest and enjoyment -Reduced energy and decreased activity ……………………………………………… (C) -Reduced concentration -Reduced self-esteem and confidence -Ideas of guilt and unworthiness -pessimistic thoughts -Ideas of self-harm -Disturbed sleep -Diminished appetite ……………………………………………… Mild depressive episode Moderate depressive episode Sever depressive episode (with or without psychotic symptoms) .

Somatic Syndrome (Melancholic depression)         marked loss of interest or pleasure lack of emotional reactions to events that normally produce an emotional response. waking in the morning 2 hours or more before the usual time. depression worse in the morning objective evidence of psychomotor retardation or agitation Marked loss of appetite Weight loss (5% in the past month) Marked loss of libido .

male ratio of 2:1 similar to the adult population .Epidemiology of major depressive disorder: 2% prevalence in preadolescents children with roughly equal prevalence in boys and girls 6% prevalence in adolescents with a female -to.

Course and outcome of depression      The average duration of an untreated major depressive episode in a child or adolescent is 7-9 months. 50% of youth relapse and recurrence rate are high. and 6% to 10% will have a chronic course. . 40% will have another episode within 2years. There is increase the risk of developing a recurrent episode in adulthood for the adolescent with MDD Therefore. 70% within 5years. educating the youth and family about the course of the illness is a critical part of treatment.

.)     The overall prognosis is worsened by comorbidity with conduct disorder and with conflict within the youth family. There is a significant increase in the suicide and substance abuse. Depression can result in many serious complications in academic. 20% to 40% of patients with the following risk factors will develop bipolar disorder in 5years: (a) psychotic features or psychomotor retardation at presentation (b) a family history of bipolar disorder. and family spheres. or (c) the patient developed hypomanic episode as a result of antidepressant treatment. interpersonal.Course and outcome of depression (cont.

it is critical to treat depressive disorders early and target not only depressive symptoms. but also associated problems in functioning . poor self-image and continuing subclinical depression can occur. Thus.Course and outcome of depression (cont.)  Following an episode of the depression.

The Etiological Approaches of Mood Disorders .

The Etiological Approaches of Mood Disorders Biological Factors Genetic theories Amine dysregulation theories Endocrine dysregulation theories Immune system dysfunctional theories Circadian rhythm de-synchrony theories Psychosocial Factors and Life Events Psychoanalytic theories Behavioral theories Cognitive theories Personality and temperament Family systems theories Poor social support Short-term life events (stressful events)……loss. neglect Long-term difficulties (prolonged stress) . abuse.

Biological Theories and Treatment implications Genetic theories Some vulnerability in Genetic counseling the neurophysiological or endocrine systems is inherited. and a polygenic mechanism of transmission is involved .

Biological Theories and Treatment implications Amine dysregulation theories Depression occurs when •Antidepressant there is dysregulation of medication the amine systems involving centers of the brain. which subserve rewarding and punishment-related experiences. Noradrenalin. serotonin and dopamine are the main neurotransmitters involved. .

Impaired immune system functioning increase susceptibility to infections and subsequent illness may maintain or exacerbate depression .Biological Theories and Treatment implications Immune system dysrfunction theories Exposure to chronic •Reduce life stress so stress or acute loss as that immune system bereavement leads to functioning improve both impaired immune system functioning and depressive symptoms.

Biological Theories and Treatment implications Circadian rhythm desynchrony theories Depression occurs when there is a desynchrony in the circadian rhythm which governs the sleep-waking cycle •Assess REM onset latency help to diagnose depression •Temporarily relieve depression through partial or complete sleep deprivation .

associated with dysregulation of hypothalamic-pituitaryadrenal axis following chronic stress •Use of dexamethasone suppression test in diagnosis •Identification of subclinical hypothyroid function • Augmentation by thyroid hormones •New antidepressant modulating CRF .Biological Theories and Treatment implications Endocrine dysregulation theories Depression is due to (1) a drop in thyroxin levels associated with a dysregulation of the hypothalamic-pituitarythyroid axis and (2) raised cortisol levels.

.Biological Theories and Treatment implications Seasonal rhythm dysregulation theories Depression occur in winter when reduced day-light leads to increased secretion of melatonin by the pineal gland. oversleeping. an increase in appetite and weight gain Treat seasonal affective disorders by (1) administrating light therapy (2) altering melatonin secretion through administrating melatonin orally at key times during the day. and this results in hibernation-like features of fatigue.

. This usually follows the loss of a loved care giver and the anger is directed as part of the self that represent loss object.Psychoanalytic and dynamic Theories  Freud's introjected anger theory  Depression occurs when a person turns anger towards the self.

Psychoanalytic and dynamic Theories Bibring's low self esteem theory Depression occurs when low self-esteem develops as a result of perceiving a gap between the actual and ideal self. The wide gap results from an unrealistic ideal self based on internalizations of early parental injunctions which were probably highly critical or perfectionistic .

punitive parents .Psychoanalytic and dynamic Theories Blatt's attachment and autonomy theory    There are two types of depression associated with two distinct types of early parent-child relationship which engender vulnerability to depression when faced with two distinct types of stresses in later life: -loss of attachment relationships may precipitate depression in those who experienced neglecting or overindulgent parenting -loss of autonomy may lead to depression in those who experienced critical.

This transference is interpreted and worked through so that more realistic standards for self-evaluation and more trusting internal working models for relationships are developed . and ideals of abandonment or loss of autonomy are projected onto the therapist.Treatment implications of psychodynamic Theories  Individual psychodynamic psychotherapy in which transference develops so that selfdirected hostility. self-criticism.

Behavioral and cognitive theories Lewinsohn's behavioral theory People with depression avoid situations where they can receive response-contingent positive reinforcement (RCPR) because they lack the social skills required for eliciting rewarding interactions from others •Social-skill training which aims to train clients in skill necessary for receiving RCPR and to arrange the environment so that there are many opportunities for using these social skills .

Behavioral and cognitive theories Rehm's self-control behavioral theory Depression occurs when a person selectively monitors the occurrence of negative events to the exclusion of positive events. sets overly stringent criteria for evaluating actions. makes negative attributions for personal actions. engages in little self-reinforcement for adaptive behaviors. self-evaluation and self-reinforcement . selectively monitors immediate rather long-term consequences of actions. and engages in excessive selfpunishment •Training which aims to improve the skills required for more effective selfmonitoring.

Behavioral and cognitive theories Beck Depression theory Depression occurs when life events involving loss occur and reactivate negative cognitive schemas formed early in childhood as a result of early loss experiences. Negative schemas (sociotropy& autonomy) give rise to negative automatic thoughts and cognitive distortions which maintain depressed mood •Cognitive therapy which aims to train clients to monitor situations where depressive automatic thoughts and distortions occur. to evaluate the validity of depressive assumptions and distortions and to engage in activities that provide evidence to refuse the negative assumptions .

Examples of cognitive distortions as described by Beck       All or nothing thinking Selective abstraction Overgeneralization Magnification Personalization Emotional reasoning .

stable attributions of these failures (and external. specific unstable factors and success to internal. stable factors Change the environment so that the likelihood of successful experiences greatly overweighs the likelihood of failure experiences Train to reduce preferred successes that are beyond the client ability . specific.Cont.Behavioral and cognitive theories Reformulated learned helplessness theory (Seligman) Depression occurs when a person repeatedly fails to control the occurrence of aversive stimuli and makes internal. unstable attribution for success) Attributional retraining where clients learn to attribute failure to external. global. global.

Psychological theories Family systems’ theory Depression occurs when the structures and functioning of the family prevent child from completing ageappropriate developmental tasks. divorce. abuse. such as individuation in adolescence . attention to failure and ignoring success. excessive criticism. conflict over individuation may be associated with depression Family therapy in which family members develop supportive relationships with the depressed child and facilitate him in completing ageappropriate developmental tasks. Bereavement. parental discord.Cont.

Vulnerability to depression A model for psycho education Genetic vulnerability Early loss vulnerability Recent stress Depressed mood .

Management of Depression in children and adolescent .

.  Rating scales may be helpful for more information about the child’s or adolescent’s symptoms but should not be relied on to make diagnosis.Assessment  The clinical interview remains the most accurate methods for assessment  It is important to interview the child or adolescent separately.

 Both parents and youth should be asked about the presence of any suicide risk factors. .Cont. Assessment  Assessment of suicidality is an essential component of assessment of depression.  Comorbid conditions should be evaluated. and laboratory testing should be done to rule out medical causes.  Physical examinations. review of systems.

Assessment  Laboratory tests to be considered: -complete blood picture with differential to rule out infections and anemia -Thyroid function tests -Electrolytes -drug and alcohol screens -Renal and liver functions tests  EEG if there history suggest seizure disorder  CT or MRI if there neurologic abnormality in history or examination .Cont.

lupus.Differential diagnosis  Medical conditions Medication or substance induced Endocrine or metabolic disorders Infections Neurological disorders Others: anemia. irritable bowl syndrome  Other psychiatric disorders  Uncomplicated grief .

Comorbidity  40-70% have comorbid psychiatric disorder  The most frequent are: Anxiety disorders Disruptive behavior disorders Substance use disorders ِADHD .

indicated as a sole treatment strategy in isolation of psycho education. if ever. its nature. So treatment plan should address safety issues. maintaining factors.  Medication is rarely.  Treatment of depression is most effective when multimodal. .  There is no evidence that “no harm” contracts protects against suicide.Treatment Treatment essentials for depressed youth  Treatment begins with psycho education about depression as a disease. prognosis.

Principles of prescribing practice in childhood and adolescents 1. Target symptoms. multiple medications are often required. Begin with less. In sever illness. . Allow time foe adequate trial of treatment. 3. 4. go slow and prepared to end with more. 6. 2. 5. where possible. not diagnosis (co morbidity is very common). change one drug at a time. Patient and family education is essential.

Treatment Modalities Multimodal treatment Psychosocial (begin with in mild to moderate depression and in Preschool children) Psychopharmacological .

Suggested algorithm for treatment of major depression  Mild-moderate episode  Sever episode 4-6w Psychosocial treatment 6-12w Add SSRI 6-12w Switch SSRI 6-12w Augment or switch antidepressant class  1st episode….6-12m  2nd episode continue 1-3y 4-6w Psychosocial treatment plus SSRI 6-12w switch SSRI 6-12w Augment or switch antidepressant class 1st episode ….1-3y  2nd or more episode continue 3y to life long  .

Psychosocial Interventions for Major Depression .

Core of Psychosocial Interventions

     

Psycho education Self monitoring Interventions focusing on activity Interventions focusing on changing family relationship Intervention focusing on cognition Social skills and problem-solving training School intervention Management of parental mood problems

Psycho education
 Offered

early in the consultation process so the adolescent and his family share a common understanding of depression  Help the youngsters and their families to learn how to control and changes patterns of thinking, action and relationship that maintain depression  Allow the youngster and the family to view themselves as a problem-solving team

Self-monitoring and goal setting
Invite the youngster and the family to keep a simple type of diary.  The date and time of entry  A mood rating on a 10-point scale  The activity that preceded the mood rating  The relationship that preceded the mood rating  The thoughts that the person had about the activity or relationship that contribute to the mood rating

Self-monitoring form for depression Day Mood Activity and rating before mood time 1-10 Relation ship before mood rating rating Thought about activity or relations hip before mood rating Coping response Changed activity Changed relationsh ip Mood rating after coping 1-10 Changed thought .

Interventions focusing on activity  Scheduling graded tasks  Scheduling pleasant events  Remembering pleasant events  Scheduling age-appropriate challenges  Scheduling physical exercise  Using relaxation skills .

Interventions focusing on changing family relationship  Family communication training and problem-solving training  Facilitating support  Renegotiating role relationships (completion of age appropriate developmental tasks) .

stable vs. specific . global. external.The pie game on positives  Reattribution  Focusing . unstable). changing explanatory style (internal.Intervention focusing on cognition  The challenge test reward method (challenging negative automatic thoughts) training.

Changing child’s automatic pessimism The ABC Model: A : Adversity B : Beliefs C : Consequences .

The ABCDE Model: A : Adversity B : Beliefs C : Consequences D : Disputation E : Energization .

 Training in social problem solving as being criticized. Training in assertiveness and negotiation. laughed at or embarrassed and generate possible alternative ways to deal with these difficult social situations .Social skills and problem-solving training  Group activity programmers  Training in social skills so that they can initiate and maintain social interactions with peers.

take the other person perspectives  Step 3.plan of action: what are the pluses and minuses of each path?  Step 5.how did it go?: if the solutions didn’t work.go for the goal: choose a goal and put a list of possible paths  Step 4.slow down: stop and think  Step 2. try another .Practice problem solving  Step 1.

School interventions  Help the school teacher to understand. develop supportive patterns of interactions with the child and create opportunities where the depressed child can interact with peers. .

Management of parental mood problems  Reduction of parental stress  Amplification of parental support .

what do you hope your family would think/do/feel?  Suppose you harmed yourself but did not died. what do you hope your family would think/do/feel?  Do you want to escape from something or some situation?  Do you want to punish somebody by harming yourself? .Assessment and manage of suicide risk Questions to be asked:  Have you thought of harming yourself?  How strong is the urge to harm yourself?  Have you plan to harm yourself?  What preparations have you made to harm yourself?  Suppose you harmed yourself and died.

problem solving. and affective regulation deficits psycho-education and interventions  Family .Suicide interventions targets  Treatment of current psychopathology  Remediation of social.

Thank you .

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