Effective management of depression and other mood disorders in children may involve both pharmacotherapy with behavioral recommendations and psychotherapy, according to Stephen P. Whiteside, Ph.D., and Dr. John Huxsahl of the Mayo Clinic in Rochester Minn.
In a presentation at the American Academy of Pediatrics annual meeting in Washington, they reviewed the differences between various mood disorders because accurate diagnosis is a key component to management.
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A major depressive episode is among the more common mood disorders among children, but others include disruptive mood dysregulation disorder, persistent depressive disorder, and bipolar I disorder. Because most pediatricians have just 15 minutes or so with patients, Dr. Whiteside and Dr. Huxsahl recommended using screening questionnaires to identify children at risk for a mood disorder. Trying to determine why a child is experiencing these symptoms or feelings can help clinicians determine whether this is a chronic issue or a situational one. Asking about other concerns, such as anxiety or use of substances, also can help with diagnosis.
Depressive episodes
Occurring among approximately 2% of children and 4%-8% of adolescents, a major depressive episode lasts a median of 8 months, but has a very high rate of recurrence: 20%-60% at 1 or 2 years after remission and 70% at 5 years after remission. In a significant proportion of children – about 20%-40% – a major depressive episode forecasts bipolar disorder.
In fact, having a parent with a mood disorder doubles to quadruples a child’s risk of major depressive episodes, and the disorder frequently occurs with anxiety, estimated in approximately 61%-65% of children with a major depressive episode. An episode generally appears to result from a combination of genetic factors and environmental ones, including abuse, neglect, family conflict, childhood adversity, losses, and comorbid disorders.
More heterogeneous than in adults, major depressive episodes in children look different based on a child’s age, according to Dr. Whiteside and Dr. Huxsahl:
• Birth to age 2 years. Symptoms include whining, decreased growth, lack of responsiveness, disrupted sleep, and excessive fears.
• Ages 3-5 years. Symptoms include anxiety, somatic symptoms, tantrums, sadness, weight gain, tiredness/sleepiness, suicidal ideation, anger or irritability, apathy, illness, and social withdrawal
• Ages 6-12 years. Symptoms include sadness, an inability to experience pleasure, decreased energy, low self-esteem, irritability, and suicidal ideation.
• Ages 12-18 years. Symptoms include a volatile mood, rage, acting out, self-consciousness, withdrawal, suicidal ideation, and overeating and/or oversleeping.
Other mood disorders
Disruptive mood dysregulation disorder (DMDD) involves much more acting out at a younger age than major depressive episodes. In children with DMDD, outbursts greatly exceed what would be expected in response to a situation, whether in terms of how long the tantrums last or how intense they are. These outbursts also are unexpected developmentally, with an onset before age 10 years, although the disorder should not be diagnosed earlier than age 6 years. Diagnostic criteria also require that the outbursts occur at least three times weekly, on average, for at least 12 months in at least two settings with a persistently angry or irritable mood between outbursts.
One way to support a diagnosis of DMDD is to rule out what it’s not. DMDD can exist with comorbidities of major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and substance use disorders, and it’s most likely to grow into depression or anxiety. It cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, and it does not develop into bipolar disorder.
Persistent depressive disorder resembles MDD, with either a depressed mood lasting at least 2 years or an irritable mood lasting at least 1 year plus at least two of the following symptoms: poor appetite or overeating; insomnia or hypersomnia; low energy or fatigue; poor concretion or difficulty making decisions; feelings of hopelessness; and low self-esteem.
Bipolar disorder
“The most important part of managing bipolar I is episodes, episodes, episodes,” Dr. Whiteside said. Alternating with either hypomanic or major depressive episodes are manic episodes, in which a child experiences an abnormal “high,” a period of at least a week of extremely high energy nearly all day, every day, with a “persistently elevated, expansive, or irritable mood.”
For an episode to be considered manic, however, at least three of the following seven other symptoms must be present, and deviate from the patient’s otherwise normal behavior: grandiosity or an especially inflated sense of self-esteem; a decreased need for sleep (not just that the patient doesn’t sleep but doesn’t actually seem to need to); extreme talkativeness or use of pressured speech; a feeling of having racing thoughts or ideas flying about; a tendency to be easily distracted or unfocused; an increase in activities aimed at accomplishing certain goals (in any sphere, for example, school, work, social, or sexual); and risky behaviors with potentially severe, long-term consequences, such as more frequent sexual behavior or shopping sprees.