Mood presentations in children and adolescents

How does developmental period relate to epidemiology of depression?

Prepubertal/childhood rates are lower, with marked increases in adolescence/after puberty.

Many first episodes occur before adulthood

Female rates exceed male rates following puberty

Higher comorbidity for depression among children/adolescents

How might depression present in childhood?

Irritability

Somatic complaints

Behavioural change

School refusal

Absence of joyful play

Low frustration tolerance

How might depression present in adolescence?

Hopelessness

Self-criticism

Rumination

Social withdrawal

Self-harm

How might depression present in adulthood?

Persistent low mood

Occupational impairment

Anhedonia

What developmental impact might adolescent depression have on family?

Conflict, withdrawal

What developmental impact might adolescent depression have on school?

Reduced achievement, school refusal

What developmental impact might adolescent depression have on peers?

Isolation, rejection

What developmental impact might adolescent depression have generally? (think of specific developmental tasks it interferes with)

Identity formation, autonomy, future orientation

While many young people experience ______ depressive sx, many have ______ symptomology after a first episode.

transient; recurrent/persistent

Importantly, recurrent depression increases what?

Risk of treatment resistance, leading to chronic depression.

What are poorer outcomes of depression in adolescence associated with?

Greater sx severity

Chronicity or multiple recurrent episodes

Comorbidity

Suicidal thoughts and behaviour

Poorer functioning

Sleep difficulties

Female sex

Recurrent or chronic depression is particularly detrimental because it _________ and _______. Therefore, preventing recurrence during early stages can avert _____ and limit ______.

interferes with normal developmental milestones; successful transition to adulthood; treatment resistance; early-onset disability

According to Rapee’s conceptual model, what biological developmental changes increase depression vulnerability?

Puberty

Hormones

Sleep changes

According to Rapee’s conceptual model, what cognitive developmental changes increase depression vulnerability?

Self-consciousness

Social comparison

Rumination — girls more likely to engage in shared rumination, which increases risk while increasing closeness in relationships

According to Rapee’s conceptual model, what social developmental changes increase depression vulnerability?

Peer evaluation

Social status

Romantic relationships

According to Rapee’s conceptual model, what family developmental changes increase depression vulnerability?

Increasing autonomy

Parent-adolescent conflict

What are biological risk factors with the strongest evidence for depression in young people?

Family hx, incl., parental depression

Puberty, incl., emergence of female predominance; increases emotional and social sensitivity

Sleep disturbance - later sleep onset and greater variability in teens

What are cognitive risk factors with the strongest evidence for affecting depression in young people?

Rumination, hopelessness, and self-criticism

What are family factors with the strongest evidence for depression in young people?

Factors influence both onset and maintenance

Parental depression, through both genetic vulnerability and modelling, stress, emotional availability

Family conflict

Low warmth, emotional disengagement

What are peer factors with the strongest evidence for depression in young people?

Bullying

loneliness

Rejection

Relationship difficulties

What are individual protective factors for depression in youth?

ER skills

Problem Solving

Self-efficacy

What are family protective factors against depression?

Warmth

Support

Connectedness

What are peer protective factors against depression?

Supportive friendships

Sense of Belonging

What are school protective factors against depression?

Positive teacher relationships

Connectedness

What are cultural and community factors that are protective against depression?

Cultural identity

Community belonging

Meaningful activities

What are common comorbidities for youth with depression?

Anxiety disorders (up to 70%)
Conduct disorder, ODD - increased risk for suicide

ADHD

Alcohol and substance use

Eating disorders

Autism spectrum

Non-suicidal self-injury

Learning dififculties

Post-traumatic stress disorder

What are overlapping symptoms between depression and normal adolescent distress? How can we distinguish this from depression?

Sadness, irritability, withdrawal; Symptoms fluctuate, are linked to stressors, functioning is largely preserved, and enjoyment remains

What are overlapping symptoms between depression and ADHD? How can we distinguish this from depression?

Poor concentration, low motivation, irritability;

Lifelong pattern, symptoms present before mood difficulties, chronic rather than episodic

What are overlapping symptoms between depression and PTSD/trauma-related difficulties? How can we distinguish this from depression?

Withdrawal, sleep problems, irritability, low mood; PTSD exclusive symptoms can include re-experiencing, avoidance, hypervigilance, trauma reminders

What are overlapping symptoms between unipolar depression and bipolar disorder? How can we distinguish this from depression?

Depressive episodes, irritability; history of mania/hypomania, decreased need for sleep, grandiosity, episodic course

What are overlapping symptoms between depression and emotional dysregulation? How can we distinguish this from depression?

Mood changes, self-harm, relationship difficulties

Rapid, reactive mood shifts are triggered by interpersonal events, and mood returns to baseline

How do rates of bipolar in young people compare to depression?

Much less common (1-2%), though most with bipolar experience onset <25, with a mean age of 18 for Bipolar I

Depression frequently precedes onset of mania/hypomania, with many (5-15%) of adolescents with MDD going on to develop Bipolar 1. This particularly happens after antidepressants.

Earlier onset → Greater impairment, comorbidity, recurrence

What is youth bipolar disorder associated with?

Recurrent mood episodes

Significant psychosocial impairment

Increased suicide risk

High rates of comorbidity

Strong familial history

What are the common comorbidities for bipolar disorder in youth?

ADHD(1 in 6), Anxiety (64%), SUbstance use (31%), Disruptive behavior disorders (31%)

WHat is the developmental presentation of bipolar?

Mania looks similar to adults with the same symptoms

Older adolscents have more classic manic/depressive symptoms and distinct episodes. Children tend to have more mixed and rapid cycling presentations

How does being bipolar differ from typical adolescence?

Typical vs Bipolar

• Emotional rxns to events vs distinct mood epsiodes

• Mood varies throughout day vs days-weeks sustained mood change

• Poor sleep, feels tired vs reduced need for sleep in absence of fatigue

• Risk-taking within context vs marked increase from baseline

• Identity exploration vs grandiosity

How does being bipolar differ from ADHD

ADHD vs bipolar

• Chronic vs episodic

• Lifelong pattern vs distinct periods of change

• Always distractible vs distractible during episodes

• Persistent hyperactivity vs increased activity from baseline

• No grandiosity vs may occur

• Sleep difficulties vs decreased need for sleep

• Trait-like symptoms vs state-like symptoms

What are characteristics of comorbid ADHD and Bipolar? (i.e., how does ADHD affect Bipolar presentations)

Shorter euthymic intervals

Younger age of onset

Greater externalising problems, ADHD symptoms, reactivity/aggression, irritability

More mood changes

Poorer response to mood stabiliser

Emotion dysregulation vs bipolar

• Triggered by interpersonal events vs mood episodes

• Rapid mood changes vs days to weeks long

• Can last minutes to hours vs persistent changes in energy and sleep

• Returns to baseline vs distinct shift from baseline

• Pattern vs episodic

Disruptive mood dysregulation disorder vs bipolar

DMDD has persistent irritability that is not typical of BP

DMDD also has severe temper outbursts, symptoms present between outbursts, and onset before 10

What is the main distinguishing factor between bipolar vs psychotic-like disorders?

Psychotic symptoms in bipolar occur in context of mood episodes

Schizophrenia is more of a thought disorder

What adolescent groups are at highest risk of developing bipolar disorder?

Family history

Recurrent depression

Mood instability

Sleep disturbance (decreased need for sleep)

ADHD comorbidity and psychotic symptoms

What is one of the leading causes of death in adolescents worldwide?

Suicide

Up to how many youth who are clinically depressed report having thoughts of suicide?

60%

About 1/3 attempt

While suicidal ideation is ______ across psychological disorders, ________ increase with depression.

common; attempts

Adolescence is a peak period for onset of what?

Self-harm

Self-harm is a strong predictor of what?

Future suicide attempts. Specific characteristics of NSSI include severity, number of methods, and function

What are individual risk factors for self-harm and suicide in young people?

Depression

Bipolar disorder

Hopelessness

Emotion dysregulation

Substance use

What are individual protective factors for self-harm and suicide in young people?

Problem solving

Distress tolerance

Hope

Future orientation

What are family risk factors for self-harm and suicide in young people?

conflict

maltreatment

parental psychopathology

What are peer risk factors for self-harm and suicide in young people?

Bullying, rejection, isolation

What are historical risk factors for self-harm and suicide in young people?

Previous self-harm, previous attempts

What are familial protective factors for self-harm and suicide in young people?

Support

Monitoring

COnnectedness

What are peer protective factors for self-harm and suicide in young people?

belonging

supportive friendships

What are school protective factors for self-harm and suicide in young people?

connectedness

positive adults

What are cultural protective factors for self-harm and suicide in young people?

cultural identity

spirituality

community connection

What are two broad functions of self-injury? (2 points, with 4 subpoints each)

Intrapersonal (most common)

• Emotion regulation (need feelings to stop)

• Reducing arousal (Anxiety, shame, anger)

• Ending numbness (wanting to feel something)

• Self-punishment (gult, shame, self-criticism)

Interpersonal

• Communicating distress (I didn’t know how to explain how bad I felt)

• Seeking help

• Influencing relationships (attempting to gain support or responsiveness)

• Reduce interpersonal demands

What does the four-function model of self-harm state?

Self-harm is maintained because it serves one or more function

Most adolescents self-harm for multiple functions simultaneously

Automatic and Social

Negative and positive reinforcement

What does the behavioural maintenance model assume?

Self-harm continues because of reinforcement

Trigger → Emotional distress → Urge to SH → SH behavior → Temporary relief (reinforcing) → shame or guilt → return to distress

What is the experiential avoidance model of NSSI?

NSSI functions as an attempt to avoid, escape, or reduce unwanted internal experiences

Experiential avoidance is heightened in adolescence

What is the interpersonal theory of suicide?

Some distressed people think of suicide because of a combination of:

• Thwarted belonging (“I am alone”, bullying, disconnection, exclusion)

• Perceived burdensomeness (“I am a burden, problem, guilt) → Combines with former to create desire

• Acquired capacity (through repeated exposure to pain, self-harm, and fear → leads to lethal or near lethal attempts)

What are warning signs within a community of suicide contagion?

Evidence of mass texting

Increase of attempts, heightened emotional atmosphere

Known links

Similarities between individauls

>1 suicide

Mass gatherings of young people