Mood Disorders in Childhood

misconceptions

• children cannot be depressed

• children only exhibit masked depression (hyperactivity to ‘ward off’ sad feelings)

• only mood disorders involve grief and depression

Disruptive Mood Dysregulation Disorder (DMDD) criteria

children experience severe outbursts/tantrums disproportionate to situation at least 3x a week for 12 months.

6-18 years-old (starts before 10 y/o)

occurs in at least 2 settings

prevalence rate: new disorder so approx. 3.2%

common problems with DMDD

• difficulty calming self

• yells at others when angry

• looses temper/tantrums…

  • with parents

  • during daily routines

  • when tired, hungry or sick

  • to get something they want

  • when frustrated, angry, or upset

uncommon problems with DMDD

• hits, bits, or kicks others during tantrums

• looses temper/tantrums out of the blue

• breaks/destroys things during tantrum

• acts persistently irritable

• hot/explosive temper

differential diagnoses of DMDD

• ADHD (not aggressive like DMDD)

• Oppositional Defiant Disorder (ODD - less severe version of DMDD, anger towards specific person, less intense and doesn’t last as long)

• Bipolar Disorder (many misdiagnoses as bipolar, however, DMDD doesn’t have manic episodes and aggressive periods last longer than bipolar)

aetiology of DMDD

• misinterprets social cues and emotional expressions

• actual deficit in recognising negative emotions

• under-active amygdala

• greater negative arousal + activation of MFG and ACC

• selectively attend to negative social cues (predispose them to anger)

• misinterpret negative social cues

• issues with monitoring and regulating emotions

treatment of DMDD

• medications?

• family therapy

• sleep intervention

• psychosocial treatment

Major Depressive Disorder (MDD) DSM criteria

at least 5 of the following (includes 1st of 2nd)

• depressed mood for most of the day

• diminished/loss of interest/pleasure

• weight change (unintentional/unexplained)

• insomnia/hypersomnia

• shift in activity level

• loss of energy/fatigue

• negative self-concept/feelings of worthlessness/guilt

• difficulty concentrating and making decisions

• recurrent thoughts of death, suicidal ideation

significant impairment to functioning

not due to substance use, medical conditions, or other psychological disorders

no manic/hyper-manic epsiodes

Persistent Depressive Disorder (PDD) DSM criteria

Depressed mood for most of the day or irritable

Symptoms present for 2 years - 1 year in children

Including 2 or more of the following:

• poor appetite/overeating

• insomnia/hypersomnia

• low self-esteem

• difficulty concentrating, decision problems

• hopelessness

Not as severe MDD but lasts longer

Gradually develops

Pfeffer Spectrum of Suicidal Behaviour

1. Non-suicidal

2. Suicidal ideation

3. Suicidal threat

4. Mild attempt (did not pose danger)

5. Serious attempt (posed serious danger)

When to worry about suicidal behaviour in children?

Scale:

1. transient thoughts are common

2. recurrent thoughts of suicide with no plan (concern)

3. suicide plan: vague but thinking about it

4. research/knowledge and means to do it (very concerning)

MDD prevalence by age

preschoolers: 1-2%

school-aged: 6-9%

adolescents: up to 20%

by 18 y/o: girls = 28%; boys = 14% (2:1)

Ways children cope with depression

1. Active coping - address the stressor

2. Passive coping - avoidance or acting out

3. Mentally disengage from stressor - findings distractions (can be useful, less rumination)

Can social stress cause depression?

stress is related to depression via epigenetic changes (stress-diathesis model)

42-67% experienced stressful life event before first MDD episode (especially around puberty)

but stress only accounts for 2% variance in MDD

rejection ←→ stress ←→ depression (bidirectional)

Kindling model

early depression sensitises child to stressful event, and furthers depression

recurrent depression leads to lower stress threshold, then minor stress can more easily trigger depression

Cognitive Theories of Depression (Beck, 1967)

1. negative concept schemas

2. helplessness theory

3. dysfunctional attribution

4. hopelessness theory

Other factors which may impact likelihood of depression

• insecure attachment

• difficult temperament

• maternal depression

• intergeneration stress model (family stressors plus limited coping mechanisms)

• family conflict and expressed emotions

• peer relationships

Negative Cognitive Schemas

depressed people’s thinking is biased towards negative interpretation (unconscious belief undesirable outcome with occur underlying thought process)

schemas can evolve to more specific cognitive biases with negative triad pessimistic view of self, world, future

Example of negative schemas

• ineptness schema (expectation that self will fail)

• self-blame

• self-evaluation (self is worthless)

Example cognitive biases

• catastrophizing

• over-generalisation

• dichotomous thinking (think in terms of extremes, best or worst case scenario)

• mind-reading

• personalisation

• absolute thinking (thinking in terms of totality)

Helplessness theory of Seligman

study where animals received electric shock in a cage with/without escape

then both groups had ability to escape

results showed that animals without an escape first did not even try to escape later

mimics depression:

uncontrollable negative event → sense of helplessness → learned helplessness model of depression

Dysfunctional attribution

Depressed people are predisposed to view the causes of negative life events as:

• internal (“my fault”)

• global (“affects everything in my life” - broad)

• stable (“always going to happen”)

instead of:

• specific

• external (“not my fault”)

• unstable (“won’t always been like this”)

The Stepped-Care Model:

system to determine level of support needed in CAMHS

Tier 1: detection of symptoms and risk profiling (professionals who do not specialise in mental health, e.g. teachers)

Tier 2-4: recognition of disorder (mental health professionals who do not specialise, like a counsellor)

Tier 1-2: mild depression (non-direct therapy, group CBT, guided self-help)

Tier 2-3: moderate to severe depression (brief psychological therapy, medication - CAMHS specialists)

Tier 3-4: depression unresponsive to treatment/recurrent/psychotic depression (intensive therapy with medication - inpatient/highly specialised services)

Assessment for Diagnosis of different ages

Mood and Feelings Questionnaire: 11+ y/o

Children’s Depression Inventory (CDI): 7-17 y/o

Beck Depression Inventory-II: 13-80 y/o

Beck Youth Depression Scale: 7-14 y/o

Hopelessness Scale for Children: 6-13 y/o

Hopelessness Theory (Abramson et al., 1989)

the underlying thought process that…

• the undesirable outcome will occur

• the desirable outcome will not occur

• the person has no control to change that

anxiety and depression correlate: negative event that one foresees causes anxiety

Depression Formulation

1. Pre-disposing (factors that predispose individual to depression, e.g. biological, psychological, or contextual)

2. Perpetuating (factors which maintain risks (cycle) to depression e.g. sleep-wake cycle)

3. Precipitating (factors which trigger depression)

4. Protective (factors which decrease likelihood of developing depression)