The Challenges Kids Face Holly Lem Ph D

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The Challenges Kids Face: Holly Lem, Ph. D. Mood Disorders October 30, 2015

The Challenges Kids Face: Holly Lem, Ph. D. Mood Disorders October 30, 2015

Case Study: Aisha 4 y. o African-American girl Intact family, middle class, professional parents

Case Study: Aisha 4 y. o African-American girl Intact family, middle class, professional parents “bored by everything” Low energy, low interest, “whiny” Father: “She’s spoiled” Mother: “What’s wrong with her? ”

Assessment for Depression Start with what is normative, allowing for ethnic/cultural and SES differences

Assessment for Depression Start with what is normative, allowing for ethnic/cultural and SES differences Thorough developmental history (circumstances around pregnancy, birth, developmental milestones, relationship with partner) Temperament Goodness-of-fit Mom’s psychiatric history Relationship history

Depression in Preschool Aged Children (Luby, 2010) Sadness/irritability* (across time, settings, people) Loss of

Depression in Preschool Aged Children (Luby, 2010) Sadness/irritability* (across time, settings, people) Loss of sleep* Loss of appetite* Nightmares/night terrors Anhedonia* Agitation May rock Social withdrawal Somatic complaints May see delay or regression in milestones

Melancholic Subtype in Preschoolers 1. 3 -5 year olds 2. Anhedonia*** 3. Lack of

Melancholic Subtype in Preschoolers 1. 3 -5 year olds 2. Anhedonia*** 3. Lack of reactivity or brightening around positive events 4. Psychomotor retardation 5. Strong family history of depression 6 More severe symptoms

Diagnostic Classification: DC: 0 -3 R Axis I Clinical Disorders Axis II Relationship Classification

Diagnostic Classification: DC: 0 -3 R Axis I Clinical Disorders Axis II Relationship Classification Axis III Medical and Developmental disorders Axis IV Psychosocial stressors Axis V Emotional and Social Functioning

Parent-Child Interaction Therapy SAMHSA’s National Registry of Evidence. Based Programs and Practices Traditionally treatment

Parent-Child Interaction Therapy SAMHSA’s National Registry of Evidence. Based Programs and Practices Traditionally treatment for “disruptive behavioral disorders, ages 2 -8 Adapted by Luby for use with depressed preschoolers Short-term, approx. 15 weeks, 1 hour session Live Coaching

Parent-Child Interaction Therapy Phase I: Relationship Enhancement (Child Directed) Nurturing the relationship, praise, reflection,

Parent-Child Interaction Therapy Phase I: Relationship Enhancement (Child Directed) Nurturing the relationship, praise, reflection, imitation, enjoyment Phase II: Discipline and Compliance (Parent Directed) Structure, consistency, compliance http: //www. youtube. com/watch? v=unmx. S 2 OY P 2 I

Case Study 2: Jennifer 13 y. o Caucasian girl Single mom, low to mid-SES

Case Study 2: Jennifer 13 y. o Caucasian girl Single mom, low to mid-SES “very moody” Journal: “depressing thoughts” Interest in end of the world books/movies “hard to reach”

DSM-5 Criteria for MDD Five or more of the symptoms present for 2 weeks

DSM-5 Criteria for MDD Five or more of the symptoms present for 2 weeks and represents a change from previous functioning 1. Depressed mood (irritability in children)* 2. Diminished interest * 3. Significant weight gain/loss 4. Insomnia/hypersomnia (nearly every day) 5. Psychomotor agitation/retardation (nearly every day)

DSM-5 criteria for MDDcont. 6. Fatigue/loss of energy 7. Feelings of worthlessness 8. Diminished

DSM-5 criteria for MDDcont. 6. Fatigue/loss of energy 7. Feelings of worthlessness 8. Diminished ability to think or concentrate 9. Recurrent thoughts of death/SI

Differential Diagnosis Major Depressive Disorder Persistent Depressive Disorder (formerly known as Dysthymia) Adjustment Disorder

Differential Diagnosis Major Depressive Disorder Persistent Depressive Disorder (formerly known as Dysthymia) Adjustment Disorder with depressed mood Other Specified Depressive Disorder Unspecified Depressive Disorder

Adjustment Disorder with Depressed Mood (DSM-5, 2013) The development of emotional or behavioral symptoms

Adjustment Disorder with Depressed Mood (DSM-5, 2013) The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). Marked distress or significant impairment Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months

DSM-5 Criteria for Persistent Depressive Disorder (Dysthmia) Depressed mood for most of the day

DSM-5 Criteria for Persistent Depressive Disorder (Dysthmia) Depressed mood for most of the day for at least 2 years (in children and adolescents, mood can be irritable and duration must be at least 1 year). Includes two or more of the following: 1. Poor appetite/overeating 2. Insomnia or hypersomnia 3. Low energy/fatigue 4. Poor concentration 5. Feelings of hopelessness

Persistent Depressive Disorder 70 -76% will have subsequent MDD 69% “double depression” Hard to

Persistent Depressive Disorder 70 -76% will have subsequent MDD 69% “double depression” Hard to diagnose Hard to recognize for the individual Ego Syntonic Outcome uncertain

Other Specified Depressive Disorder/Unspecified Depressive Disorder (NOS) Significant distress or impairment in social, academic/occupational/,

Other Specified Depressive Disorder/Unspecified Depressive Disorder (NOS) Significant distress or impairment in social, academic/occupational/, or other domains Does not meet full criteria for depressive disorders Specify why doesn’t meet criteria (e. g. , short duration, insufficient symtpoms)

Depression as a Continuum? “Viewing depression dimensionally rather than categorically seems more appropriate and

Depression as a Continuum? “Viewing depression dimensionally rather than categorically seems more appropriate and captures their (children and adolescents) experience… There is no discrete separation between kids diagnosed with depression and those with subclinical symptom. ” (Hankin, et. al. , 2005)

Bipolar Disorder in Children: Fact or Fiction? Nearly 1/3 of all kids discharged from

Bipolar Disorder in Children: Fact or Fiction? Nearly 1/3 of all kids discharged from psych hospitals carry the diagnosis (Blader, 2007) Rise in outpatient visits for suspected Bipolar Disorder (Moreno, 2007): 1994 -95 20, 000 2002 -2003 800, 000 Increase in atypical antipsychotics with children (Olfson, 2006): 1993 201, 000 2002: 1, 224, 000

Bipolar Diagnosis in Children: Is it real? “I have been a child psychiatrist for

Bipolar Diagnosis in Children: Is it real? “I have been a child psychiatrist for nearly five decades and have seen diagnostic fads come and go. But I have never witnessed anything like the tidal wave of unwarranted enthusiasm for the diagnosis of bipolar disorder in children that now engulfs the public and the profession. ” (Kaplan, 2011)

“Juvenile bipolar disorder is a serious illness that is estimated to affect approximately 1

“Juvenile bipolar disorder is a serious illness that is estimated to affect approximately 1 percent to 4 percent of children. ” (Biederman, 2004)

The Bipolar Child (Papolos & Papolos, 2006) Over 200, 000 copies sold, 3 rd

The Bipolar Child (Papolos & Papolos, 2006) Over 200, 000 copies sold, 3 rd edition “The shot that was heard around the psychiatric world” Popularized the notion of kids having BPD Adults with BPD reported having first episode in childhood/adolescence http: //www. bpchildresearch. org/publicsurveys/jjs urvey. cfm? which=Jeannie

Rebecca Riley, died Dec. 13, 2006

Rebecca Riley, died Dec. 13, 2006

DSM-5 Criteria for Mania A. 1. 2. 3. 4. 5. 6. 7. Distinct period

DSM-5 Criteria for Mania A. 1. 2. 3. 4. 5. 6. 7. Distinct period of abnormally and persistently elevated, expansive or irritable mood (for one week)*** 3 or more symptoms Inflated self-esteem* Decreased need for sleep More talkative Flight of ideas Distractibility Increase in goal activity Excessive involvement in pleasurable activity*

Bipolar in Children… Low arousal in morning, more energetic later Abrupt mood swings multiple

Bipolar in Children… Low arousal in morning, more energetic later Abrupt mood swings multiple times a day Intense temper tantrums Poor frustration tolerance Switch from irritable, easily annoyed, angry to silly, goofy, giddy states Depression Low self-esteem Social Withdrawal

Differences between Adult & Child Presentation Not Euphoria, but irritability Not episodic but more

Differences between Adult & Child Presentation Not Euphoria, but irritability Not episodic but more chronic and continuous In children, significant comorbidity with ADHD 60 -80% Usually not grandiose Disruptive Mood Dysregulation Disorder? (DSM-5, 2013)

Differential Diagnosis: Various Levels of Cranky ADHD- less irritable than Bipolar; Bipolar less vindictive

Differential Diagnosis: Various Levels of Cranky ADHD- less irritable than Bipolar; Bipolar less vindictive than Conduct Disorder: Rage (Mick et al. , 2007)

Treatment of Choice for Bipolar Disorder Medication: Lithium, atypical antipsychotics, mood stabilizers, sometimes given

Treatment of Choice for Bipolar Disorder Medication: Lithium, atypical antipsychotics, mood stabilizers, sometimes given together

Etiology of Adolescent Depression 1. Genetic (30 -50%) 2. Interpersonal 3. Cognitive 4. Environment/attachment

Etiology of Adolescent Depression 1. Genetic (30 -50%) 2. Interpersonal 3. Cognitive 4. Environment/attachment 5. temperament

Interpersonal Explanations Peer contagion (Prinstein 2007) Co-rumination (Rose, 2002) Reassurance Seeking (Joiner, 1999)

Interpersonal Explanations Peer contagion (Prinstein 2007) Co-rumination (Rose, 2002) Reassurance Seeking (Joiner, 1999)

Excessive Reassurance Seeking “Relatively stable tendency to excessively and persistently seek assurances from others

Excessive Reassurance Seeking “Relatively stable tendency to excessively and persistently seek assurances from others that one is loveable and worthy regardless of whether such assurance has already been provided” (Joiner et al 1999)

Cognitive/Explanatory Style Negative Triad (Beck, 1997) negative thinking results in helplessness, hopelessness and worthlessness

Cognitive/Explanatory Style Negative Triad (Beck, 1997) negative thinking results in helplessness, hopelessness and worthlessness Learned Helplessness (motivational, cognitive and emotional challenges) (Seligman, 1986) Negative Attribution Style (Abramson, 1999) When something bad happens: (internal, stable, global) When something good happens: (external, unstable, specific)

Environmental Causes Parenting style: authoritative vs. authoritarian, Expressed Emotion-Crit Parental Psychopathology Attachment Neglect and

Environmental Causes Parenting style: authoritative vs. authoritarian, Expressed Emotion-Crit Parental Psychopathology Attachment Neglect and Abuse Violence Hostile environment

Co-Morbidities Anxiety (8 x more likely) ADHD/ODD (5 x more likely) PDD/Dysthymia (69% will

Co-Morbidities Anxiety (8 x more likely) ADHD/ODD (5 x more likely) PDD/Dysthymia (69% will have both) Eating Disorders Substance Abuse (MDD predates by about 4 years)

Factors that contribute to resilience 1. Strong supportive family/parents 2. Academic Achievement 3. Good

Factors that contribute to resilience 1. Strong supportive family/parents 2. Academic Achievement 3. Good self-esteem 4. Religious faith 5. Strong ethnic identity

Treatment for Depression Parent-Child Interaction Therapy: 14 -16 sessions- Child Directed Interaction/Parent Directed Interaction,

Treatment for Depression Parent-Child Interaction Therapy: 14 -16 sessions- Child Directed Interaction/Parent Directed Interaction, In vivo feedback sessions, Parental involvement mandatory Interpersonal Psychotherapy for Depressed Adolescents(IPT-A): 12 weeks, 3 phases, Parental Involvement recommended, grief/role disputes, role transitions, interpersonal challenges Cognitive Behavioral Therapy/Insight-oriented Medication (Black Box Warning 2004, 2006) Combination