Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 31: Child Psychiatry

Mood disorders in children and adolescents have been stud- ied increasingly over the last two decades, culminating in large sample multisite randomized controlled trials such as the Treat- ment of Adolescent Depression (TADS) study, which provides evidence of the efficacy of both cognitive-behavioral therapy as well as selective serotonin reuptake inhibitors (SSRIs). Further- more, when the preceding modalities are combined, the great- est efficacy is achieved. Increased recognition of depressive disorders in preschool populations has sparked clinicians and researchers to develop psychosocial interventions such as the Parent-Child Interaction Therapy Emotion Development (PCIT- ED), which target treatment specifically for this age group. The expression of disturbed and depressed mood appears to vary with developmental stage. Very young children with major depression are often observed to be sad, listless, or apathetic, even though they may not articulate these feelings verbally. Perhaps surprisingly, mood-congruent auditory hallucinations are not infrequently observed in young children with major depression. Somatic complaints such as headaches and stom- achaches, withdrawn and sad appearance, and poor self-esteem are more universal symptoms. Patients in late adolescence with more severe forms of depression often display pervasive anhe- donia, severe psychomotor retardation, delusions, and a sense of hopelessness. Symptoms that appear with the same frequency, regardless of age and developmental status, include suicidal ideation, depressed or irritable mood, insomnia, and diminished ability to concentrate. Developmental issues, however, influence the expression of depressive symptoms. For example, unhappy young chil- dren who exhibit recurrent suicidal ideation are rarely able to propose a realistic suicide plan or to carry out such a plan. Children’s moods are especially vulnerable to the influences of severe social stressors, such as chronic family discord, abuse and neglect, and academic failure. Many young children with major depressive disorder have histories of abuse, neglect, and families with significant psychosocial burdens such as paren- tal mental illness, substance abuse, or poverty. Children who develop depressive disorders in the midst of acute toxic family stressors may have remission of depressive symptoms when the stressors diminish or when a more nurturing family environ- ment is introduced. Depressive disorders are generally episodic, albeit typically lasting close to a year; however, their onset may be insidious and remain unidentified until significant impair- ment in peer relationships, deterioration in academic function, or withdrawal from activities emerges. Attention-deficit/hyper- activity disorder (ADHD), oppositional defiant disorder, and conduct disorder are not infrequently comorbid with a major depressive episode. In some cases, conduct disturbances or dis- orders occur in the context of a major depressive episode and resolve with the resolution of the depressive episode. Clini- cians must clarify the chronology of the symptoms to determine whether a given behavior (e.g., poor concentration, defiance, or temper tantrums) was present before the depressive episode and is unrelated to it or whether the behavior is occurring for the first time and is related to the depressive episode. Epidemiology Depressive disorders increase in frequency with increasing age in the general population. Mood disorders among preschool-age

Jaycox LH, Cohen JA, Mannarino AP, Walker DW, Langley AK, Gegenheimer KL, Children’s mental health care following Hurricane Katrina: A field trial of trauma-focused psychotherapies. J Traum Stress. 2010;23:223–231. Jaycox, LH, Langley AK, Dean KL. Support for students exposed to trauma: The SSET program: group leader training manual, lesson plans and lesson materials and worksheets. Santa Monica, CA: RAND Health. 2009. Meighen KG, Hines LA, Lagges AM. Risperidone treatment of preschool children with thermal burns and acute stress disorder. J Child Adolesc Psychopharma- col. 2007;17:223–232. Robb AS, Cueva JE, Sporn J, Vanderberg DG. Sertraline treatment of children and adolescents with posttraumatic stress disorder: A double-blind placebo- controlled trial. J Child Adolesc Psychopharmacol. 2010;20:463–471. Rynn M, Puliafico A, Heleniak C, Rikhi P, Ghalib K, Vidair H. Advances in phar- macotherapy for pediatric anxiety disorders. Depress Anxiety. 2011;28:76–87. ▲▲ 31.12 Mood Disorders and Suicide in Children and Adolescents 31.12a Depressive Disorders and Suicide in Children and Adolescents Depressive disorders in youth represent a significant public health concern, in that they are prevalent and result in long- term adverse effects on the individual’s cognitive, social, and psychological development. These disorders affect approxi- mately 2 to 3 percent of children and up to 8 percent of ado- lescents, so the need for early identification and access to evidence-based interventions such as cognitive-behavioral therapies (CBTs) and antidepressant agents, is essential. Although major depression runs in families, with the highest risk in children whose parents experienced early onset depres- sion, twin studies have demonstrated that major depression is only moderately heritable, approximately 40 to 50%, high- lighting environmental stressors and adverse events as major contributors to major depressive disorder in youth. The core features of major depression in children, adolescents, and adults bear a striking resemblance; however, clinical presenta- tion is strongly influenced by the developmental level of the child or adolescent. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) utilizes the same criteria for major depres- sive disorder in youth as in adults, except that for children and adolescents, irritable mood may replace a depressed mood in the diagnostic criteria. Most children and adolescents with depressive disorders nei- ther attempt nor complete suicide; however, severely depressed youth often have suicidal ideation, and suicide remains the most serious risk of major depression. Nevertheless, many depressed youth do not ever have suicidal ideation, and many children and adolescents who engage in suicidal behavior do not have a depressive disorder. There is epidemiological evidence to suggest that depressed youth with recurrent active suicidal ide- ation, including a plan, and who have made prior attempts, are at higher risk to complete suicide, compared to youth who express only passive suicidal ideation.