Mood Disorders (18.19-2-2010)

1. Mood Disorder in Children
Dr.Eman Gaber

2. Major Depressive Disorder:
Diagnostic Criteria
5 of following symptoms, must include one
of first two, occurred almost every day for two
weeks
• Depressed mood
• Pleasure or interest/ Loss
• Appetite
• Sleep disturbance, too much or too little
• Agitation or retardation
• Fatigue
• Feelings of worthlessness or guilt
• Difficulty concentrating or deciding
• Recurrent thoughts of death

3. Depressive Symptoms Mnemonic:
”Space Drags
S leep disturbance D epressed mood
P leasure/interest (lack R etardation movement
of)
A ppetite disturbance
A gitation
G uilt, worthless,
C oncentration useless
E nergy (lack
of)/fatigue

4. Common presentation of
Depression in Children
• Frequent vague, non-specific physical complaints such
as headaches, muscle aches, stomachaches or
tiredness
• Frequent absences from school or poor performance in
school
• Talk of or efforts to run away from home
• Outbursts of shouting, complaining, unexplained
irritability, or crying
• Being bored
• Lack of interest in playing with friends
• Alcohol or substance abuse

5. Common presentation of
Depression in Children
• Social isolation, poor communication
• Fear of death
• Extreme sensitivity to rejection or failure
• Increased irritability, anger, or hostility
• Reckless behavior
• Difficulty with relationships

6. Assessment
• Consider the following when assessing a
child/young person
• with depression and record in the notes:
• potential co morbidities
• social, educational and family context for the
patient and family members
• quality of patient’s relationships with family
members, friends and peers.

7. Assessment
• Assess with the young person their social
network before treatment starts
• identify factors that:
– contributed to the development and
maintenance of depression
– impact in a positive or negative way on
treatment efficacy.
• Indicate ways to work in partnership with
their social and
• professional network

8. Assessment
• Always ask the child/young person and
their parents directly about the patient’s:
– alcohol and drug use
– experience of being bullied
– experience of being abused
– self-harm
– ideas about suicide

9. Assessment
• Give young people the opportunity to
discuss these issues initially in private.
• Pay special attention to:
– confidentiality
– young person’s consent (including
competence)
– parental consent
– child protection

10. Assessment
Consider parents’ mental health
● Consider the possibility of parental
depression and substance misuse (or
other mental health problems and
associated problems of living).
● Obtain a family history to check for uni-
polar or bipolar depression in parents and
grandparents in all children/young people
with suspected mood disorder.

11. General treatment
considerations
• Treat most children/young people on
an outpatient or community basis

12. Mild depression
• Antidepressant medication should not be
used for the initial treatment of children
and young people with mild depression

13. Moderate to severe
depression
first-line treatment:
• specific psychological therapy
– individual cognitive behavioral therapy [CBT],
– interpersonal therapy or
– shorter-term family therapy
• it is suggested that this should be of at least 3 months’
duration.
• Antidepressant medication should not be offered to a
child or young person with moderate to severe
depression except in combination with a concurrent
psychological therapy

14. • Fluoxetine should be prescribed as this is
the only antidepressant for which trials
show that benefits outweigh the risks.
• The starting dose should be 10 mg daily,
increased if necessary to 20 mg daily after
1 week.
• Consider lower doses for children of lower
body weight.
• ●).

15. • Consider the use of another
antidepressant (sertraline or citalopram
are the recommended second-line
treatments
• The starting dose should be half the daily
starting dose for adults,
• increased if necessary to the daily adult
dose gradually over 2 to 4 weeks.
Consider lower doses in children of lower
body weight

16. Length of treatment
• After remission (no symptoms and full
functioning for at least 8 weeks)
continue medication for at
least 6 months (after the 8-week
period).

17. Childhood Bipolar Disorder
• Forget a lot of what you know about adult
bipolar disorder symptoms
• symptoms of bipolar in children are quite
different. Mood swings in children can be
extremely fast, and various angry and
irritable behaviors are very common

18. Symptoms of mania
• euphoria (elevated mood)—silliness or elation that is inappropriate
and impairing
• grandiosity
• flight of ideas or racing thoughts
• more talkative than usual or pressure to keep talking
• irritability or hostility when demands are not met
• excessive distractibility
• decreased need for sleep without daytime fatigue
• excessive involvement in pleasurable but risky activities (daredevil
acts, hyper sexuality)
• poor judgment
• hallucinations and psychosis
For an episode to qualify as mania, there must be elevated mood plus
at least three other symptoms, or irritable mood plus at least four
other symptoms.

19. Symptoms of depression
• lack of joy and pleasure in life
• withdrawal from activities formerly enjoyed
• agitation and irritability
• pervasive sadness and/or crying spells
• sleeping too much or inability to sleep
• drop in grades or inability to concentrate
• thoughts of death and suicide
• fatigue or loss of energy
• feelings of worthlessness
• significant weight loss, weight gain or change in appetite

20. Very Common presentation of
Childhood Bipolar Disorder
• Separation anxiety
• Rages & explosive temper tantrums (lasting up to se
• Marked irritability
• Oppositional behavior
• Frequent mood swings
• Distractibility
• Hyperactivity
• Impulsivity

21. • Racing thoughts
• Restlessness/ fidgetiness
• Silliness, goofiness
• Sexualized behavior unusual for the child’s age
• Aggressive behavior
• Grandiosity
• Delusional beliefs and hallucinations
• Risk-taking behaviors
• Depressed mood
• Lethargy
• Low self-esteem

22. Challenges in Diagnosing
Children's Bipolar Disorder
• Distinguishing between normal behaviors and those that
may indicate bipolar disorder in a kid is more challenging
because:
• There are a significant number of other conditions whose
symptoms overlap with bipolar disorder, including
attention deficit hyperactivity disorder (ADHD),
oppositional defiant disorder (ODD), conduct disorder
(CD), obsessive compulsive disorder (OCD), anxiety,
depressive disorders and learning disabilities

23. Lines of treatment
A good treatment plan includes
• Medication,
• Close monitoring of symptoms,
• Education about the illness,
• Counseling or psychotherapy for the individual
and family,
• Stress reduction,
• Good nutrition,
• Regular sleep and exercise, and
• Participation in a network of support.

24. Psychotherapy
can help patients and their families
understand the illness, can teach the
importance of early relapse detection, and
ensure compliance with medication
• It include:
– Cognitive behavioral therapy
– interpersonal therapy
– multi-family support groups

25. Medication
• Atypical Antipsychotics Agents
• Risperdal, Zyprexa, Seroquel, Aripiprazole– These
newer agents are often used to treat bipolar disorders
in adults, children and adolescents and appear to be
effective mood stabilizers
• Mood Stabilizers
– Lithium
– anticonvulsant
• sodium valproic acid
• Carbamazepine
• Oxcarbazepine
• Lamotrigine