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Child Case: 5-yo Danica, Part 1

Adolescent Case: 15-yo Jennifer, Part 1

Epidemiology

Prevalence

• 1% of preschoolers (age 3-5) (Luby, 2010)
• 2% children (i.e. under 12) (Birmaher, 2007)
• 4-8% adolescents (age 12-18) (Birmaher, 2007)

More common than asthma and most other chronic medical problems in this age group) (Jackson, & Lurie, 2006)

• Gender: 2:1 female:male ratio

Risk factors include:

• Family history of depression especially parents with depression

Prognosis

• Preschool depression has 50% persistence rate
• Mother with mental health issues is a negative prognostic factor
• Etiology of Wellness

Normal Development

Infants require various things for well being which include:

• Healthy attachments with caregivers,
• Basic needs such as sleep, nutrition, exercise (i.e. movement),

Children and youth require various elements which include

• Healthy attachments with caregivers,
• Basic needs such as sleep, nutrition, exercise (i.e. movement),
• Purpose (e.g. work, school, or the other things we do in life that keep us busy)
• Meaning (i.e. knowing that our life has meaning)
• Hope (e.g. knowing that will continue to go well, or will get better in the future)

Mental wellness occurs when one’s needs are met.

When the above needs are unmet (e.g. such as having problems with attachments and basic needs), there is a risk of mental health problems.

Clinical Presentation / Signs and Symptoms

There are similarities and differences on how signs/symptoms of depression present over the lifespan.

Depression in infants / toddlers

When “depressed”, infants and toddlers may present with ‘depressive equivalents’, such as

• Failure to thrive
• Problems with attachment, i.e. insecure attachment. When faced with parental separation, the infant/toddler may be:
  • Avoidant: Doesn’t seem to react when caregivers leave ; Doesn’t cry, nor turn to parents for his/her needs
  • Anxious : Overly anxious with parental separation, “clings on” to parents
  • Disorganized: Odd or ambivalent behavior with separation or reunion, e.g. When parent returns, may initially seek out parent but then run away, curl up in a ball, hit the parent (i.e. fight/flight/freeze)

Depression can present in preschoolers (age 3-5)

Depressed preschoolers may appear (Luby, 2000)

• Less joyful;
• More prone to guilt;
• Fail to enjoy activities and play;
• Changes in sleep, appetite, and activity as compared to healthy peers.
• Often undetected by parents/caregivers, as symptoms less disruptive (than in older children).

Depression in Children/Adolescents (aged 6-17)

Children may have

• Sad mood, and express they are sad/depressed
• Mood lability,
• Irritability /anger, temper tantrums,
• Low frustration tolerance,
• Somatic complaints (e.g. unexplained physical symptoms (such as headaches, fatigue, stomach aches, nausea) which do not have any obvious medical cause)
• Social withdrawal

History / Interviewing Questions

Children

Start with parents and the child together. 

Ask about:

• When did the problems with the mood start?
• Any particular stresses?
• Mood
  • "How has your mood been these days?"
  • "On a scale between 0 and 10, if 10 is the best mood possible, and 0 is the worst mood, how is your mood between 0 and 10?"
  • Non-depressed patients tend to report report moods between 5-10
  • Patients with major depression may report moods <5, and as low as 1 if severely depressed.

Later, meet alone with the child to ask about sensitive topics such as suicidal ideation, abuse, drug use. 

Later, meet alone with parent(s) to ask about sensitive topics such as parental mental health, parental trauma, or even the child’s symptoms — some children become distressed hearing their parent(s) say negative things about the child.

Adolescents

Usually start with the adolescent and parent(s). However, if there is extremely high conflict between adolescent and parent, consider stopping the joint meeting, and meet alone instead with the adolescent, given higher adolescent needs for autonomy.

Meeting alone with the adolescent: Start by asking, “Now that we are alone, is there anything in particular you’d like to discuss?” Topics when meeting alone with the adolescent include: suicidal ideation, substance use, drug use.  

Diagnosis

Diagnostic Criteria for Preschool Major Depressive Disorder (Age 3-5)

The problem with using standard DSM-IV criteria for depression in preschoolers (aged 3-5), is they miss 76% of preschoolers that were felt to be depressed (Luby, 2002). Thus, the following modified criteria have been developed and validated for preschoolers (Luby, 2002):

Five (or more) of the following symptoms have been present but not necessarily persistently over a 2-week period and represent a change from previous functioning: at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure in activities or play. If both (1) and (2) are present, a total of only four symptoms are needed.

1. Depressed mood for a portion of the day for several days, as observed (or reported) in behaviour. Note: May be irritable mood.
2. Markedly diminished interest or pleasure in all, or almost all, activities or play for a portion of the day for several days (as indicated by either subjective account or observations made by others).
3. Significant weight loss when not dieting, or weight gain or decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) that may be evident in play themes.
8. Diminished ability to think or concentrate or indecisiveness, for several days (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without specific plan, or a suicide attempt or a specific plan for committing suicide. Suicidal or self-destructive themes are persistently evident in play only.

DSM-5 Criteria for Major Depressive Disorder

A. At least five of the following symptoms for at least two weeks duration; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure:

1. Depressed mood or loss of interest/pleasure
2. Anhedonia
3. Weight change; in children, consider failure to make expected weight gain
4. Sleep problems such as insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive guilt
8. Concentration problems
9. Suicidal thoughts, whether passive or active

B. Symptoms cause distress or impairment in function

C. Episode is not due to substance use or a medical condition

D. Not better explained by other conditions such as schizoaffective disorder, schizophrenia, or other psychotic disorders.

E. There has never been a manic episode or hypomanic episode.

• Specify:
• With anxious distress
• With mixed features
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern

DSM-5 Childhood Persistent Depressive Disorder (formerly known as Dysthymia, Dysthymic Disorder)

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others. In children and adolescents, mood can be irritable and duration must be at least 1 year (vs. 2-years for adult dysthymia)

B. Presence, while depressed, of two (or more) of the following:

• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feeling of hopelessness

During the 2 year period (1 year for children of adolescents) of the disturbance, the individual has never been without symptoms in Criteria A and B for more than 2 months at a time. Criteria for a major depressive disorder may be continuously present for 2 years.

Differential and Comorbid Diagnoses (DDx)

Medical Differential Diagnosis

Are there any medical conditions that are contributing to poor mood, or perhaps which contribute to neurovegetative symptoms (such as fatigue, inattention, appetite problems) such as:

Physical Exam (Px)

There are no specific physical exam findings to major depressive disorder, however physical exam is important to help rule out medical conditions that may mimic, or contribute to a mental health condition.

Investigations

General screening tests

If suspected

Management/Treatment: Psychoeducation

Provide the family with basic education about depression, such as:

• “Thank you for coming in today. I have bad news and good news… The bad news it appears your child has symptoms of depression. The good news is that there are many things we can do to support, and treat the depression."

Consider giving the family a Google Slides presentation about depression 

• Google Slides for Educating Families about Depression -- PILOT PROJECT  

Consider giving them a family / patient handout 

• Helping Your Child/Youth with Depression
  
• Helping Your Child/Youth with Self-Harm including Self-Cutting
  
• Helping Children/Youth who are feeling suicidal
  
• Safety Plan

FOR YOUTH

Are you looking for a handout to give out to youth about depression, anxiety or other topics?

Depression: Youth Edition

https://www.ementalhealth.ca/index.php?m=article&ID=23584

Self-Harm: Youth Edition

https://www.ementalhealth.ca/index.php?m=article&ID=24894

For more handouts 

https://www.ementalhealth.ca/Ottawa-Carleton/ArticlesByCategory/index.php?m=articlesByCategory&ageSelection=1&written_for_ages=youth

Management/ Treatment: Lifestyle strategies

Educate the family about lifestyle strategies that will help ensure a healthy brain, keeping in mind motivational interviewing principles. I.e. if the patient / family is ready, willing and able to implement a lifestyle strategy (e.g. getting outside regularly), then wonderful. If the patient/family is not ready, not willing nor able, then use motivational principles to gently nudge them. 

• Ensuring healthy sleep hygiene, with a goal of 8-11 hrs/sleep at night. 
  • For more information 
• Ensure proper nutrition. In particular, studies show that Mediterranean diets that are low in processed foods, low in fast foods, low in added sugar foods, and high in fruits and vegetables may be helpful for depression. 
  • For more information 
• Ensure regular nature time: For proper eye health, a minimum of 10 hrs outdoors per week has been suggested. Note that some studies suggest that recommending nature time is even more important than recommending physical activity, because as long as kids get outside, they will be physically active. 
  • For more information
• Physical activity: Standard guidelines recommend at least 1-hr daily of physical activity for children for general health plus studies show physical activity has anti-depressant effects. 
  • For more information 
• Limits on screen time: No more than 1-2 hrs day of screen time for the average child (Canadian Paediatric Society Screen Guidelines). In children with emotional/behavioural issues however, circumstances might warrant less screen time. 
  • For more information 
• Ensure the child spends face-to-face time with fellow humans, such as caregivers, and friends/family.

Management/Treatment: Address Comorbid Conditions

Any comorbid conditions? Ensure these are addressed:

Management/ Treatment: Relationship Interventions

Ask the youth who they feel they can turn to, and try to engage those people as part of the youth’s support network. Usual options in order of priority might include parents, aunts/uncles, grandparents, friends of the family, neighbours, teachers, guidance counselor, coach, etc. In social prescribing, identifying possible adults, and then teaching them how to provide support is a key intervention.

Teach adult caregivers on how to co-regulate their child’s feelings, which are key strategies in numerous interventions, such as interpersonal psychotherapy (IPT), attachment therapy, and dialectical behaviour therapy (DBT).
 

Specific teaching points for caregivers are:

• When your child expresses difficult feelings to you, remember “connection before direction” or “support not solutions”.
• Start first with listening and validation.
• Do not start first with giving advice, minimizing or invalidating your child’s concerns.
• Don’t give advice until the child is feeling calm, or asking for advice. Especially with teens, it is best to cautiously ask them if they are ready for advice.

An example might be:

• Child: “I’m sad.”
• Parent: “Let’s sit down and tell me how you’re feeling.”
• Child: “The kids were mean to me at school…”
• Parent: “I’m so sorry… tell me more…”
• Child explains more.
• Parent: “That sounds really tough. I am so sorry. Let me give you a hug…”
• Child starts crying; parent gives child a tissue paper so the child can cry. Crying is particular good, as it helps human beings regulate difficult feelings, and then accept difficult situations that have happened.
• Parent: “How can I help? Do you just need me to listen? Or would you like some advice?”

Teach parents / caregivers to build regular time in the daily or weekly schedule for emotional support. Consider asking other adults as well, to commit to spending specific times with the child. 

For example:

• Clinician: “It will help to build in regular times in your schedule to check in with your child emotionally. There should be time every day. On weekends, longer periods. Like a morning or afternoon, where you can spend longer periods of quality time. This will give your child a chance to confide and share their emotions with you, and feel your acceptance and validation of their emotions.

Management/ Treatment: School Intervention

Involving the school can be helpful because:

• If the youth is having depression, most likely there is some impairment at school. 
• Or school may be one of the contributing stresses that could be addressed. 
• Even if there are no problems with school, attachments with school figures can be strengthened, providing an additional resiliency factor.

During an appointment, ask for the patient’s permission to call the school, then call the school. 

For example:

• Clinician: “I am Dr. ___, and I’d like to speak to you regarding your student ___. Do you have any concerns regarding? Anything I can do to be helpful?”

Most of the time, the school will be open and/or ask for your recommendations. Discuss these, and then write a school letter to formally document your recommendations.

For a sample letter:

• Visit “Depression in Children and Youth “ at http://primarycare.ementalhealth.ca/index.php?m=fpArticle&ID=18300 > click on “School/Workplace Letters”

Problem-Solving Stressors

Identifying and solving specific problems or stresses is important, and is a key part of problem-solving therapy (PST).

Management of Depression: Specific Interventions for Children (aged 0-12)

For aged 5-11 year olds

• Is mild depression persisting despite 2-weeks of watching waiting?
• Recommendations (NICE, 2019)
  • Less intensive
    • Online cognitive behavioural therapy (CBT)
    • Group CBT;
    • Group non-directive supportive therapy (NDST)
    • Group interpersonal psychotherapy)

Parent interventions:

• For depressed children (aged 0-12), consider parent interventions (as opposed to starting with child interventions such as individual therapy). Given that children have less developed reasoning skills (compared to adolescents), and given the stronger role of parental influences at this age, it makes sense that parent-child interventions are high yield. Studies confirm that group and individual CBT with children (under aged 12) are less effective. [NEED REFERENCE]

Parent Child Interaction Therapy-Emotion Development (PCIT-ED)

• Is the child aged 3-7? If available, PCIT-ED is an evidence-based treatment for depression in age 3-7 yo. It consists of 18 sessions, in which parents receive coaching and guidance on how to support their child with negative emotions.
• If PCIT-ED is not available, provide other interventions to improve parent’s ability to meet the child’s emotional needs, e.g. Triple P; Circle of Security; Watch, Wait and Wonder, or other attachment-based parenting programs.

Parent mental health services:

• Does the parent have unmet mental health needs? If the parent has ongoing mental health difficulties, then ensuring supports for the parent’s mental health may be particularly high yield as well.

Management of Mild to Moderate Depression: Specific Interventions for Adolescents (aged 12-17)

Is patient aged 12-18?

• Are symptoms of mild depression continuing after 2 weeks of watchful waiting, and without significant comorbid problems or active suicidal ideas or plans?
• Recommendation (NICE, 2019)
• Trial of one of the following for 2-3 months
  • Digital CBT
  • Group CBT
  • Group NDST
  • Group IPT
  • Dialectical behaviour therapy (DBT)

Management of Moderate to Severe Depression

For moderate to severe depression, or for depression that has not yet responded, consider medications in addition to psychotherapy/counselling.

• For depression in children, some evidence exists for fluoxetine
• For depression in adolescents, there is good evidence for fluoxetine (TADS study); some evidence for escitalopram, citalopram and sertraline

Do NOT use the following in “children and young people” (NICE, 2019)

• Paroxetine
• Venlafaxine
• Tricyclic antidepressants (TCA)

Monitoring / follow-up

• Have weekly follow-up or monitoring q one weekly for the first four weeks
• Is there new onset suicidal ideation, that seems associated with the new medication?
• If so, then stop the new medication

Duration of treatment

• Has the child/youth responded to treatment?
• If so, then continue treatment for at least 6-months after remission

Reference

• GLAD-PC, 2018

Switching from one medication to another? Consult this guide for switching medications

• ​http://wiki.psychiatrienet.nl/index.php/SwitchAntidepressants

Management of Depression with Psychotic Features

Is the patient have symptoms of depression plus depression?

• Children and young people prescribed a second-generation antipsychotic medication should be monitored carefully for side effects. [2005]

Deciding on Treatment Setting: Outpatient, Inpatient, Day Hospital

Is there acute suicidal ideation ? 

• If so, consider inpatient treatment.
  

Are there persistent depressive symptoms, despite intensive outpatient treatment? 

• If so, consider:
  • More intensive treatment, e.g. more frequent appointments; day hospital treatment.
  • Elective admission to inpatient unit for diagnostic clarification.

Child Case: 5-yo Danica, Part 2

You are seeing Danica, a 5-yo female brought by her mother for problems with depressed mood. Your assessment shows that indeed, she meets criteria for major depression. Mother has had longstanding struggles with depression as well, along with post-partum depression following the birth of Danica. She loves her daughter, but life has not been easy for the mother.

You do the following :

• Refer mother (and father) to the local publicly funded children’s mental health agency that provides a program in positive parenting (Triple P program). Mother learns new ways to meet her daughter’s needs, that she never experienced during her own upbringing, and Danica’s mood improves.

Adolescent Case: 13-yo T., Part 2

You ask about stresses and she reports:

• She was dating a boyfriend and “he was the first person who really understood me”, but unfortunately he broke up with her
• Since the breakup, “There will never be anyone else who will understand me again”
• She skips school often because he is in many of her classes, and it is just too difficult to have to continue seeing him every day

You ask about her relationships and supports and she reports:

• Mother/father: She does not feel that she can confide in her mother nor her father – “they never understand, they just want to lecture me”
• Friends: She does not feel she can confide in them since they have a tendency to share everything on social media.

You do the following:

• Diagnose depression, and give the patient and mother basic information about depression.
• Provide short-term course of psychotherapy for the patient and mother.
• You teach mother how to provide emotional support through providing empathy, validation and unconditional acceptance, rather than lecturing her daughter. This allows the patient to start confiding in her parents, and their support helps her deal with her stressors.

References

National Institute for Health and Care Excellence (2019 June). Depression in children and young people: identification and management (NICE guideline NG134). Available at https://www.nice.org.uk/guidance/ng134/chapter/Recommendations. Accessed Nov 3, 2019.

Birmaher et al.: Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders, J. Am. Acad. Child Adolesc. Psychiatry, 2007; 46(11): 1503-1526.

Jensen P, Cheung A, Zuckerbrot R, Ghalib K, Levitt A: Guidelines for Adolescent Depression in Primary Care (GLAD-PC), 2010.

www.glad-pc.org

Authors

Written by Dr's Michael Cheng, FRCP(C), Psychiatrist, CHEO, uOttawa; Dhiraj Aggarwal, Psychiatrist, CHEO, uOttawa.

Conflicts of Interest: No competing interests declared.

Disclaimer

This information is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a qualified expert or health professional. Always contact a qualified expert or health professional for further information in your specific situation or circumstance.

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