Child Mood & Anxiety Problems: It Takes a Team

1. Child Mood & Anxiety Problems: It Takes a Team Alessandra N. Kazura, MD, FAAP Director, Pediatric Psychiatry Consultation-Liaison Services Maine Medical Center January 17, 2008

2. Disclosures • 2006 - Honorarium for CME development, Haymarket Medical, funded by Shire Pharmaceuticals • Research funding: NCI, NIDA, Robert Wood Johnson Foundation, American Academy of Child and Adolescent Psychiatry, Brown University Consortium on Translational Brain Research

3. Objectives • Learn about screening options for childhood mood and anxiety disorders • Consider treatment options in the context of resource limitations

4. Depressed Mood • Q: How do you know a child or adolescent has a depressed mood? • A: • Ask • Sadness is just one presentation • Irritability is common • Loss of pleasure • Observe • Use multiple informants

5. The Informant Matters • Parents commonly under- and over-report child’s mood and anxiety feelings (internalizing symptoms) • Parents are typically good reporters of disruptive behaviors such as hyperactivity & aggression (externalizing symptoms)

6. Depressed vs Depressive Episode Q: What is the difference between a depressed mood and a depressive episode? A: • Mood is the subjective feeling state • An episode is a cluster of specific, associated symptoms that occur over a defined period of time • DSM-IV-TR definition

7. Major Depressive Episode Criteria: 5+ during same 2 weeks • Depressed mood - most of the day, most days • Anhedonia • Appetite change, weight loss, FTT • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of worthlessness or inappropriate guilt • Poor concentration and/or indecisiveness • Recurrent thoughts of death or suicidal ideation

8. Major Depressive Disorder • Must have distress/impairment • R/O causative medical and/or drug condition • R/O Bereavement • R/O mixed mood episode • This is additionally rated • Single vs. Recurrent • Mild, Moderate, Severe • With or Without Psychotic Features

9. Depressed vs MDE Q: Does it matter? A: YES - for prognosis & treatment • Episode • First step in diagnosing a disorder • If disorder present, offer treatment • Psychosocial treatment most important • Consider medication • Mood only • Depressed mood present with multiple disorders • Treatment depends on diagnosis • Depressed mood typically temporary, non-clinical • No medication

10. Depressed Mood: Diagnostic Considerations? • Simple depressed mood (no diagnosis) • Adjustment Disorder(s) • Dysthymia • Major Depressive Disorder • Bipolar Disorder, Depressed • Schizoaffective Disorder, Depressed • Depressed mood associated with another diagnosis • Substance Use/Substance Use Disorder • Medical Condition

11. Irritable Mood:Diagnostic Considerations • Simple irritable mood (no diagnosis) • Adjustment Disorder(s) • Dysthymia • Major Depressive Disorder • Bipolar Disorder, Depressed or Hypomanic or Manic or Mixed Episode (or “NOS”) • Psychotic (Thought) Disorders

12. Irritable Mood:Diagnostic Considerations • Oppositional Defiant Disorder • ADHD • Anxiety Disorders, e.g. PTSD • Sleep Disorder • Substance Use/Substance Use Disorder • Medical Condition • Personality Disorder

13. Hypomanic & Manic Episodes • Distinct period of abnormal & persistent mood change - elevated, expansive, or irritable • 3+ corresponding sx • Inflated self-esteem • Decreased need for sleep • More talkative; pressured talk • Flight of ideas or thought racing • Distractibility • Increase in goal-directed activity or agitation • Excessive involvement in risky pleasurable activities

14. Hypomanic & Manic Episodes • R/O Somatic causes, e.g. medical conditions, drug effect • Not a mixed mood episode • Unequivocal change in function • Hypomania vs mania • Time • Degree of impairment • Presence/absence of psychotic symptoms

15. Anxiety Q: What does this look like in children and adolescents? A:

16. Anxiety vs Anxiety Disorder(s) Important to determine • Impairment present? • Circumstances? • Associated symptoms?

17. Anxiety Disorders • Adjustment Disorder(s) • PTSD • Social Phobia • Other Phobias • Obsessive Compulsive Disorder • Panic Disorder (panic attacks necessary but not sufficient for diagnosis) • Generalized Anxiety Disorder • Separation Anxiety Disorder • Substance Use/Substance Use Disorders • Medical Condition

18. Diagnostic Precision Q: Why is this important? A: For prognosis & treatment - Evidence-Based Medicine

19. Clinical Case • 10 year old female • Chief complaint of parents - she fights a lot and is not compliant • Has trouble falling asleep • Poor concentration and falling grades in school • Mopes around the house, doesn’t seem as interested in doing things with her friends

20. Possibilities • Depressed mood • Adjustment Disorder • Major Depressive Disorder • Bipolar, Depressed • NB: ~ 30% of children with Major Depressive Episode are eventually diagnosed with Bipolar Disorder

21. Other possibilities?

22. Screening • What do you want to screen? • Who do you want to screen? • What will you do with positive screens?

23. Diagnostic Evaluation • Do it yourself • Make a referral • Type of provider • Insurance • Availability • Communication

24. Referrals • Time frame - how urgent? • Level of care • For ongoing treatment? • For evaluation and recommendations only? • Clinical decision-making • Importance of specialist training and experience • Limited # of specialists • Family barriers to using mental health services • Is suboptimal treatment better than no treatment?

25. Screening Tools • Broad • Specific

26. Broad Screening Tools • PSC - Pediatric Symptom Checklist • DPS - DISC Predictive Scale • CBCL - Child Behavior Checklist • BASC - Behavior Assessment System for Children

27. Pediatric Symptom Checklist • FREE (e.g. Bright Futures website) • Parent and youth version, ages: 4-16 • Simple to score and interpret • Helps identify those in need of further mental health evaluation and intervention • 2/3 with positive score will have moderate to serrious mental health problem • 6-16 yrs: positive >= 28 • 4-5 yrs: positive > = 24 • Helps to screen out those not in need • 95% accurate • Does not provide a diagnosis

28. CBCL • Several versions, by age and informant • (1.5 - 5); 6-18; 11-18 • Parent, teacher, youth • Instruction manual $150 plus $.50/form • Modest needs for training in scoring and interpretation • 15-20 minutes to fill out • Time for hand scoring • Does not yield a diagnosis, but separates clinical/non-clinical scores in multiple domains that are DSM oriented • Can be used to track clinical progress

29. BASC • Multidimensional approach • Comprehensive • Suggests, but does not make diagnoses • Maps on will to school IEP needs • Age 2 - 21 • Learning curve for scoring and interpreting • Time to administer & score • 10-20 minutes for parent to complete • Cost (hand-scored) • Starter set ~ $400 • Each test ~ $1.50

30. DISC Predictive Scale • DISC = Diagnostic Interview Scale for Children • No cost if participating in the Columbia TeenScreen program • Parent and youth versions • Uses “gate” questions: if positive, additional symptoms within that diagnosis are asked • Highly predictive of presence or absence of specific DSM diagnoses • More time needed for hand-scoring than PSC, interpretation straightforward • Watch for Quick DISC - under development

31. Specific Screening Tools • CES-DC • P-YMRS • SCARED

32. CES-D • Center for Epidemiological Studies Depression Scale for Chldren • FREE (e.g. Bright Futures website) • Validated for ages 6 - 17 • Easy to administer and score • 5 minutes to complete • Does NOT diagnose a depressive disorder • Score > 15 suggests depressive symptoms • Further evaluation required • Further evaluation also required if low score but impaired! • Can be used for tracking progress

33. P-YMRS • Parent version - Young Mania Rating Scale • FREE (e.g. schoolpyschiatry website) • Age 5 - 17 • Easy to administer and score • 5 minutes to complete • 0-60 range • > 13 suggests potential mania or hypomania • Interpretation can be difficult • High rate of false “positives” • Does NOT diagnose • Can be used to track progress

34. SCARED • Screen for Child Anxiety Related Disorders • FREE (e.g. schoolpsychiatry.org_ • Age 8+; parent and youth versions • 5 minutes to fill out • Scoring easy but needs a few minutes, interpretation fairly straightforward • Still need a comprehensive evaluation • Five factors that suggest specific, mostly DSM anxiety disorders: GAD, Separation Anxiety, Social Anxiety, School Avoidance • NB: PTSD and OCD are not screened

35. Clinical Pearls • Standardized rating tools are better than winging it • Some tools double for screening and treatment monitoring • Rating tools can be used as psychoeducational tools

36. Assessment of Dangerousness • Suicide • Homicide • Other risk-taking, e.g. • Running away • Drug use • Sexual risk-taking

37. Suicide - Partial Assessment • ASK!!!!!!!!!!!!!!!!!!!! • Thoughts • Intentions • Plans • Means • GET RID OF FIREARMS! • Social supports • Stressors • Psychiatric symptoms • Reasons to live • Problem-solving capacity

38. Contracting for Safety

39. Contract for Safety • Low protective value • Won’t hold up as legal defense of clinical judgment • Primary use, if at all, is as a procedure to facilitate the interview

40. Resources - Web-based • www.brightfutures.org • www.massgeneral.org/schoolpsychiatry/ • www.aacap.org • Facts for Families • NB: includes brief handout about what to expect from a child psychiatry evaluation

41. Resources - items on my shelves • DSM-IV-TR • Stubbe, Practical Guides in Psychiatry: Child and Adolescent Psychiatry, 2007 • May be useful as a quick reference for primary care • Pharmacology texts • Connor & Meltzer, Pediatric Psychopharmacology: Fast Facts • Dulcan, Helping Parents, Youth, and Teachers Understand Medications for Behavioral and Emotional Problems: A Resource Book of Medication Information Handouts, 2007. • Psychosocial treatment manuals

42. Supplemented with frequent PubMed & other literature searches!!!

43. MMC Child Psychiatry Referral Process • Intake # 761-6644 ext 2 • Referral forms – call 761-6644 ext 2 • Fax – 662-7081 • Information is reviewed (Kazura) • Triage (Kazura et al) • 1x outpatient consultation • NB: early childhood usually referred to PhD first • Therapist first (MD check-in for MaineCare) • Medication management • MUST HAVE THERAPY AT MCGEACHEY/MMC • “Rapid access” • Post-evaluation communication

44. Team Approach • Reality • Shortages for all child mental health professionals • And among licensed professionals, training and experience in using evidence-based treatments is not consistent • Child Psychiatrists • Need estimate of ~35,000 • Actual # ~7000 • How can we all work together to help our children?

45. Questions?Comments?