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Depression and Anxiety Disorders of Children and Adolescents

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  1. Depression and Anxiety Disorders of Children and Adolescents Internalizing DisordersSheree Shafer, MSN, CRNP, FNP-BC, PMHCNS- BCDoctor of Nursing Practice Program Robert Morris UniversityDepartment of Nursing and Health Sciences

  2. Objectives • 1. Provide systematic identification of children and adolescents at risk for depressive and anxiety disorders • 2. Provide a comprehensive assessment and evaluation of children and adolescents with ADHD • 3. Integrate knowledge of the use of screening tools as part of the evaluation of ADHD in children and adolescents into practice • 4. Provide systematic follow-up and management to children and adolescents with depressive and anxiety disorders

  3. Operational Definitions • Psych0therapy: treatment in which a therapist and patient(s) work together to ameliorate functional impairment through focus on the therapeutic relationship • Therapist: one who treats illness or disability • Behavioral Health Evaluation: process for screening, diagnostic, and treatment planning

  4. Operational Definitions • Triage: a process of sorting individuals based on their need and likely benefit from immediate treatment • Follow-up visit: scheduled medical visit to evaluate ongoing status or treatment response • Active Monitoring: treatment plan that includes regular visits, supportive care, and treatment goals while awaiting specialty care

  5. Internalizing Disorder?

  6. Definition: Depression, Spectrum Disorder • Depression: A change in mood characterized by sadness, irritability, negativity for at least two weeks

  7. DSM IV Criteria: Major Depressive Disorder • 1. Sad, down, negative mood, empty feeling • 2. Anhedonia • 3 & 4. Changes in sleep and appetite (scored as separate symptoms) • Irritable, easily frustrated, argumentative. Focused on negative events, interprets events as negative, discounts positives. “I don’t care” attitude • Not enjoying or quitting activities (self or account by others) • May sleep, eat more or less.

  8. DSM IV Criteria: Major Depressive Disorder • 5. Decreased concentration, decisiveness • 6. Psychomotor agitation or retardation, observable by others • Easily swayed by others, changes mind, may question if developed ADHD, amotivation • Complaints of feeling agitated, noted pacing/ increased negative energy, or “couch potato”, amotivation

  9. DSM IV Criteria: Depression • 7. Complaints of fatigue • 8. Feelings of worthlessness or excessive guilt • 9. Death wish, Suicidal ideation, not a fear of death • Regardless of increased or decreased sleep • Negative about self, low self esteem, may feel responsible for events out of their control, discount positives and focus on negatives • May think family would be better off without them for fleeting moments or chronically, think life isn’t worth it, want to hurt self but no plan, or have a plan, and/or intent

  10. Depression: DSM Criteria • At least 5/9 symptoms and noted dysfunction • 5-6 symptoms= “mild” depression • 6-7 symptoms=“moderate” depression • 8-9 symptoms &/or suicidal thoughts=“severe” • Believe there is a depression but inadequate amount of symptoms for diagnosis endorsed=“Depressive D/O NOS (not otherwise specified” • Specify single episode, recurrent, with psychotic features

  11. Depression: Stages • Treatment Response: Period of significant decrease in symptoms or no symptoms for at least 2 weeks • Remission: Period extended 2 weeks-2 months • Recovery: Period greater than 2 months • Relapse: DSM depression reoccurs during remission • Recurrence: DSM depression occurs during recovery (new episode)

  12. Depression: Example of Diagnosis • Major Depressive Disorder, recurrent, severe, with psychotic features (describes individual with 8 symptoms, second episode, and believes others are able to read their thoughts)

  13. Definition: Dysthymic Disorder • Dysthymia: Sad down mood that does not fully meet criteria for depression, symptoms present for at least one year (Down mood and two other symptoms) • Irritable • Appetite Change • Low energy • Low self esteem • Difficulty making decisions/ poor concentration • Feelings of hopelessness • Little motivation

  14. Adjustment Disorder with Mixed Emotional Features • “Reactive depression” • Overreaction to a situation as noted in mood and emotions but not fully meeting criteria for depression • If criteria is met for depression: diagnose depression

  15. Depression: ICD-9-CM Codes • 296.20 Major Depressive Disorder (MDD), unspecified (NOS) • 296.21 MDD, mild • 296.22 MDD, moderate • 296.23 MDD, severe, without psychotic features • 296.24 MDD, severe, with psychotic features • 296.25 MDD, partial remission • 296.26 MDD, in full remission • Recurrent MDD, change “.2” to a “.3” for bolded diagnosis • Dysthymic D/O, 300.40 • Adjustment D/O, 309.28

  16. Depression: Incidence, Prevalence, General Facts • 20% of teens will experience a clinical depression before adulthood • 8% of teens suffer from depression at any one time (AACAP, 2007); adults one year point prevalence is 5.3% (Surgeon General Report, 2008)

  17. Depression: Incidence, Prevalence, and General Facts • Research: Point prevalence for adolescents with depression being seen in primary care: • GLAD-PC:II, 2007 28%

  18. Depression: Incidence Prevalence, and General Facts • A teen depressive episode usually lasts 8 months, or longer (8.3% will experience depression for at least one year) • 40% will experience a reoccurrence of a depressive episode within 2 years, 70% before adulthood

  19. Depression: General Facts • Teens with depression have a higher incidence of STD’s, pregnancy, substance abuse, physical illness and complaints; lower rate of seeking higher education, satisfaction in relationships • 30% will develop a substance abuse problem

  20. Depression: General Facts • Untreated depression is the number one cause of suicide • A depressed teen is 12 times more likely to attempt suicide • Less than 33% of teens with depression get help, but 80% could be helped with treatment

  21. Depression: General Facts • 2/3 have a co-morbid condition (anxiety, dysthymia, substance abuse problem, ADHD, ODD, conduct disorder) • 20% of those with a depression as a child or adolescent will eventually develop bipolar disorder. (Bipolar disorder=manic episode)

  22. Evidenced Based Treatment Guidelines: 10-21 years • American Academy of Child and Adolescent Psychiatrists: “Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders” (2007) • American Pediatric Association: Guidelines for Adolescent Depression in Primary Care, “GLAD-PC Tool Kit” (2007)

  23. Depression: Risk FactorsEndogenous / Exogenous • Family history of mood disorders, depression • Past history of depression • Other psychiatric disorders (anxiety, externalizing disorders) • Substance abuse • Trauma • Psychosocial adversity • Chief complaint of emotional problem • Chronic Illness

  24. Depression: Developmental Issues (GLAD-PC, 2007) Pre-pubertal Children Adolescents Irritability Apathy: “I don’t care” attitude Low self esteem Aggression / antisocial behavior Substance abuse Can give a reliable and detailed history • Increased somatic complaints • Psychomotor agitation • Mood congruent Hallucinations • School refusal • Phobias, separation anxiety, increased worry

  25. Depression: Developmental Issues (Surgeon General’s Report, 2008) Pre-pubertal Children Adolescents 1-year prevalence 8-9% Female/ Male Ratio: 2/1 • 1-year prevalence 0.4-2.5% • Female/ Male Ratio: 1/1 • Increased risk for bipolar

  26. Assessment: Behavioral Scales • Screening tools, not diagnostic • GLAD-PC refers to scales as “diagnostic aids” • Help to objectify significance of symptoms • Provide talking points • Important to know ages and settings in which the tools were tested • Be a part of behavioral evaluations and ongoing management

  27. Mood and Feeling Questionnaire (MFQ) • User friendly, free, takes 5-10 minutes to complete, seconds to score • Both a child and parent form • A score of 20or more is considered to be significant for depressive symptoms, 29 or greater highly sensitive and specific for depressive disorder • Specific for depression • Tested in 7-19 years including non MH clinic patients

  28. Child Depression Inventory: Kovacs (2003) • Tested in primary care, and extensively • Child, parent, teacher forms • Exclusive for depression • 5-10 minutes to complete, seconds to score • Not public ($.20 per scale) • Appropriate for 7-17 years • Significant sore 13 or greater • Has subscales to measure mood, self esteem, ineffectiveness, anhedonia, interpersonal problems, and inconsistency index

  29. Depression: Assessment • Establish basic rules: confidentiality, when confidentiality must be broken • Interview t0gether and alone, parent before child • There are no wrong answers • Not a time for discussion of treatment • When do you remember being happy • How long have you felt this way • Beware of assumptions

  30. Depression: Assessment • Onset • Location • Duration • Characteristics (mood, thoughts, behavior) • Associated symptoms • Relieving Factors • Timing

  31. Depression: AssessmentUse of a Timeline • Pregnancy, birth, delivery • Infancy • Toddler years • Preschool • K-third grade • 4-6 grade • Junior high • Senior high • Include development, social, medical, and family history, ADL’s

  32. Depression: Assessment • Determine symptom severity & progression • Frequency • Intensity • Duration • Impairment?

  33. Risk Assessment: Suicide, Surgeon General’s Report, 2008 • Completed Act: Male/Female Ratio 4:1 • Attempts: Female/Male Ratio 2:1 • Diagnosis of Depression (Most significant risk factor in females) • Previous suicide attempt (Most significant risk for males) • Substance Abuse Problem/ Disruptive Behavior (two fold increase in males) • Stressful life event (individual perception) • Low levels of parent-child communication

  34. Risk Assessment: SuicideWho is at Risk? • Real or media accounts of suicide (locally, intensive media coverage, fictional character): increases risk in vulnerable teens, especially young teens • Availability of lethal agents • History of trauma • Family history of suicidal behavior • 60% of those with depression have thought about suicide, 30% attempt (AACAP, 2001)

  35. Risk Assessment : SuicideAssessment • Death wish, suicidal thoughts, acts • Any plan, organization of the plan • Preoccupation with morbid or death related music, games, art work, books, TV shows • Availability of firearms, ropes, poisons, alcohol/drugs, sharp knives • Giving away possessions • Loss of rationale thought • Protective factors

  36. Mental Health Examination • Appearance, behavior, attitude • Characteristics of talk • Emotional state, affective reactions • Awareness, insight, reasoning and judgement

  37. Differential Diagnosis: Bipolar Disorder • Expansive mood, tantrums that we could not replicate in terms of energy and duration, has times with decreased need for sleep. Behaviors not specific to home. • Appear and feel energetic and overly confident, feel special, risk taker • Talk rapidly, loudly, c/o racing thoughts • Work / activities completed creatively, but disorganized • Sexually preoccupied, uninhibited • Decreased need for sleep (hallmark symptom) • A Change!!!!

  38. Differential Diagnosis: Bipolar Disorder • DSM criteria: Elevated mood + 3 Irritable mood + 4 • Distractibility • Insomnia • Grandiosity (increased pleasurable activities) • Flight of ideas • Agitation, or increased goal directed activity • Self esteem inflated • Talkative (increased)

  39. Differential Diagnosis • Drug and Alcohol Abuse: Depressive symptoms occur in context of use • ADHD: May occur co-morbidly with depression. Note specifics of low self esteem, concentration, amotivation • Adjustment Disorder: Question of many social pressures: if meets criteria for depression, diagnose it • Dysthymia: May occur co-morbidly with depression (rare diagnosis)

  40. Differential Diagnosis: DepressionPossible Physical Causes / Work-up Thyroid: check growth and development family history, low threshold Anemia (complaints of fatigue, irritability, diet concerns): check CBC CMP: general work-up Obstructive Sleep Apnea: Noted abnormal snoring Adverse medication reaction (prescribed and nonprescribed)

  41. Common DSM Diagnosis Associated with Depression DSM Diagnosis Definition Significant family, peer relationship issues out of context with depressive symptoms, and a need to address in treatment (Divorce, adolescent relationships) Often co-occur, (fear that is stuck) • Relational Problem • Anxiety D/O

  42. Responsibilities of Primary Care Provider • Identify and screen those at risk • Evaluation for depression, basic differential diagnosis, co-morbid disorders • Use behavioral screens • Perform risk assessment, complete a safety plan (contract) • Perform psycho-educational , supportive counseling • Refer as needed • Establish responsibilities/roles of the provider, patient, family • Schedule follow-up appointment, goals

  43. Safety Plan/Contract • Identify adult(s) who are available and whom the adolescent will contact • Establish reasons to contact those adults • Give emergency numbers • Determine the adults will use the emergency numbers • Establish a regular check in time with the adults and health professional

  44. Emergency Services: Involuntary Hospitalization • Mental Illness • Clear and present danger to self or others • Behavior, due to a mental illness, likely to result in death in the near future • Unwilling to sign voluntary admission • Appropriate to use 911 as needed • Hospital provides safety,24 hour management

  45. Treatment Responsibilities • Patient: Open mind toward treatment, adhere to safety contract, honesty, healthy lifestyle changes • Family: Remain healthy, provide encouragement, follow safety contract (Consider own support) • Clinician: Follow-up every one-two weeks Refer or treat

  46. Supportive Counseling / Psycho-education • De-stigmatize depression • Provide general facts on depression • Counsel on evidence based treatment options, need for compliance with appointments • Restore hope, past effective copers • Assist with problem solving barriers to treatment • Provide active listening and reflection • Provide written information • Case management: Contact with schools, other health providers • Recommend healthy life style • Safety Contracts

  47. TAD’S: Evidenced Based Treatment • Cognitive Behavioral Therapy (CBT) • Medication Only (SSRI’s) • Combination Therapy: SSRI’s and CBT

  48. Depression: To Treat or Not to Treat in Primary Care Crossroad • Treatment As Usual: not acceptable Enhanced Mental Health Services In Primary Care Prudent Mental Health Services in Primary Care

  49. Depression: To Treat or Not to Treat in Primary Care • Level of Comfort • Caution with severe depression, co-existing conditions (previous differential diagnosis), maladaptive behaviors • Caution if roles & responsibilities (including confidentiality) of provider, family, patient can not be agreed upon • Patient &/or family desire alternative treatment that is not evidenced based practice

  50. Enhanced Child and Family Role for Treatment in Primary Care • There is no incorrect answer, honesty is all that is needed • Parents become coaches • Compliance with appointments • Participate /develop realistic treatment goals • Safety Contracts