Children's Doctor

Behavioral Health

Diagnosing Depression

Taliba Weller, MD, and Elizabeth B. Weller, MD

NC is a 14-year-old female who presents to her pediatrician with a recent history of increasing fatigue and irritability. She has been performing worse on school assignments and has stopped spending time with her friends. Instead of having dinner with her family, she now goes to her room after school to complete her homework, eats snacks, and goes directly to bed as early as 5 p.m., sleeping until the next morning. She has gained 5 pounds and her parents say she is less attentive to her appearance. They describe her as being excited about starting high school 4 months ago. She tends to be overly sensitive to disagreements with her friends. Family history is significant for thyroid disease and mood disorder. NC’s physical examination is unremarkable. She is pleasant during examination but becomes tearful when asked about her friends and school, saying she “would prefer to be left alone.”

Discussion: NC meets the criteria for a major depressive episode that includes 5 or more of the symptoms in the box below, lasting at least a 2-week period and representing a change from previous functioning. These changes should not be attributable to drug or alcohol abuse, medications, or medical conditions, and they should cause distress or impairment in academic, employment, or social activities.

Anhedonia often manifests as boredom or apathy in adolescents. Common clinical presentations include declining school performance, conduct or oppositional problems, anxiety, somatic complaints (more in younger children), temper tantrums, substance abuse, verbalization of thoughts, or acts of self-harm. With severe depression, one might also present with delusions and hallucinations.

Special attention should be paid to make sure this is not bipolar depression or double depression (ie, depression superimposed on longstanding dysthymia or low-grade depression without psychotic symptoms or major interference in functioning). Children with at least one depressed parent are at least 3 times more likely to have a lifetime episode of unipolar depression compared with children of parents with no depression.

Some 90% of those affected remit 1 to 2 years after the initial onset. Remission and relapse are common in the natural course of the illness. There is a 40% to 60% relapse rate after successful acute therapy. This, combined with poor compliance and negative life events, should emphasize the need for continued follow-up and treatment. Even with good treatment, there is a 20% to 60% relapse rate 1 year after remission.

Contrary to popular belief, children do not “grow out of it” and depressed adolescents are at a significant risk for suicide. A thorough risk assessment for self- harm must be conducted and a safety plan put into place.

Supportive psychotherapy and cognitive behavioral therapy are helpful for mild to moderate unipolar depression. Antidepressants can be used for major depression, psychotic depression (with caution, as adolescents with psychotic depression are at high risk of developing mania), and symptoms that fail to respond to adequate psychotherapy. Fluoxetine (Prozac) is the only FDA-approved selective serotonin reuptake inhibitor for children 8 years and older. In an NIH study of short-term treatment, medication was more effective than cognitive behavioral therapy alone.

NC should be seen by a child and adolescent psychiatrist, psychologist, or licensed clinical social worker with experience in young people’s mood disorders. Special attention should be paid to the history of her depressive symptoms, their severity, any psychotic symptoms, any past history of manic or hypomanic symptoms, and any family history of mania or hypomania, suicidal thoughts or ideations. The care team should investigate medical causes for depression, or any medications the youngster is using (such as steroids or antihypertensive medications).

NC should have a complete biopsychosocial workup. Firearms and other lethal instruments should be effectively secured or eliminated from the home. If illicit substances or alcohol use are involved, it is important to educate the child and family about the effect of these substances on the central nervous system. A supportive adult should be available for NC to get her immediate help in the event that suicidal thoughts emerge. Acute stressors must be resolved.

When NC has completed her assessment and safely begun treatment, her pediatrician (depending on experience and comfort level) can assume responsibility for antidepressant prescribing and monitoring in collaboration with a psychologist, social work therapist, or psychiatrist. All involved parties should be in agreement with the treatment plan, which will foster the successful outcome of her treatment.

References and Suggested Readings
American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders.
J Am Acad Child Adolesc Psychiatry. 2008. 46:11. 1503-1526.

Weller EB, Weller RA, Danielyan, A. Mood Disorders in Adolescents and Prepubertal Children.
Textbook of Child and Adolescent Psychiatry. Third Edition. 2004. 411-485.

Treating Depression: The Pediatrician’s Role

Tami Benton, MD

You have made the diagnosis of depression in NC, the patient in the previous article. She has no thoughts of suicide or harming others, but she is having trouble keeping up with school because of low energy and poor concentration. What do you do now?

In the primary care setting, as many as 28% of adolescents meet criteria for depression at any point in time. Despite the seemingly high rates, the evidence suggests that depression in youth is in fact underidentified and undertreated. Because of the many barriers to access for mental health treatment, only a small number of depressed adolescents are treated by child and adolescent  psychiatrists or other pediatric mental health providers, so most adolescents with mental health problems receive treatment in primary care centers. These facts highlight the important role of  pediatricians in identifying and treating depression — and the interventions can be life-saving.

Most antidepressants for pediatric depression are prescribed in the primary care setting. Recent events, however, have left clinicians unsure about their roles in depression management. The FDA has recently added “black box” warnings on antidepressant labels, after drug trials suggested statistically significant increases in suicidality among young participants, prompting calls for heightened monitoring. These findings have resulted in declining numbers of antidepressant prescriptions for pediatric patients diagnosed with depression.

For the pediatrician faced with a depressed adolescent, the decision to initiate treatment will likely be based upon the availability of mental health resources for the family, the pediatrician’s ability to access and collaborate with mental health professionals, her own comfort with diagnosing and managing depression, and the time available for monitoring any adverse events from treatment.

Treatments for pediatric depression

Cognitive behavioral therapy (CBT) is the recommended initial treatment for adolescents with mild depression, and it has the strongest empirical support. CBT encourages adolescents to increase self-awareness and to challenge ideas that perpetuate negative thoughts. Pediatricians are not likely to provide formal CBT, but they can use some of the techniques to advise parents and adolescents how to address negative thinking. Pediatricians can also encourage patients to use “natural antidepressants,” such as increasing pleasurable activities, including exercise. It also is helpful to recommend that adolescents and their families note and record mood states.

For patients who demonstrate moderate to severe depression — like NC, the patient in the previous article, who demonstrated impairments in academic, social, and family functioning — antidepressants should be considered in addition to CBT.

Selective serotonin reuptake inhibitors (SSRIs) are still the antidepressant of choice for adolescents with depression, despite the reported limitations in antidepressant studies, the black box warnings, and high levels of monitoring required at the initiation of treatment. The choice of the antidepressant should be guided by considerations of the optimum combination of safety and efficacy data. While fluoxetine has the greatest empirical support, many factors, such as drug interactions, must be considered when choosing an antidepressant. The FDA recommends weekly visits for 4 weeks at the initiation of treatment, every other week for the second month, and then every month or more frequently, if clinically appropriate.

The pediatrician should discuss with the family the possibility of manic activation or thoughts of suicide. If the adolescent has thoughts of harming herself or anyone else, or increases in impulsivity, agitation, irritability, or decreased sleep after starting antidepressant treatment, emergent evaluation is appropriate. If the treatment is effective and the adolescent is improving, the antidepressant should be continued for 9 to 12 months after symptom remission.

For adolescents with comorbidities such as substance abuse or anxiety disorders, referral to a mental health professional is appropriate.

Pediatricians may appropriately assume many roles when treating depression: as a prescribing clinician collaborating with mental health professionals, or as the primary care provider working with a prescribing psychiatrist. Even if the pediatrician has referred the adolescent to a mental health provider for primary depression management, the pediatrician should continue to follow up with the patient. Many resources are available to guide the pediatrician treating depression, such as the guidelines for Adolescent Depression in Primary Care (GLAD-PC) and the Practice Parameters for the Treatment of Depression in Adolescents from the American Academy of Child and Adolescent Psychiatry. Willingness on the part of primary care providers to treat adolescent depression could augment the significant reductions in adolescent suicide rates since the advent of SSRIs. Careful assessment for depression in the primary care setting, with medications and therapy if indicated, may be life-saving.

References and Suggested Readings
Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management.
Pediatrics (2007 Nov). 120;1313-1326.

Rapaport N, Bostic JA, Prince JB, Jellinek M. Treating pediatric depression in primary care: coping with the patients’ blue mood and the FDA’s black box.
J Pediatr (2006 May). 148(5); 567-8.

Distressed Teen

Anbreen Naeem, MD

Parents bring their 16-year-old boy to your office with complaints of insomnia and sores on the knees, and the observation that he seems angry and distant. “Bobby” tells you he experiences distressing, violent images and impulses, such as thoughts of stabbing himself or loved ones with a knife. He is afraid he might act on these thoughts, though he does not want to. He says he has always had obsessive-compulsive tendencies, which have become worse in the last 2 years. He says he repeatedly prays for God’s forgiveness for these thoughts. Lately, he is withdrawn and doesn’t want to communicate with his siblings, parents, or friends. He walks with his arms wrapped around himself. He is taking 150mg of sertraline (Zoloft), which has helped to some extent, but he continues to have aggressive images nonetheless.

Discussion: This child presents with obsessive-compulsive disorder (OCD), characterized by recurrent obsessions or compulsions severe enough to cause distress or interfere in one’s life. Obsessions are persistent thoughts, images, or impulses that are egodystonic, intrusive, and senseless. Compulsions are behaviors or thoughts the person feels driven to perform in response to an obsession.

The mean age of onset for childhood OCD may range from 6 to 11 years. Research suggests OCD may be the result of a frontal lobe-limbic-basal ganglia dysfunction. Neurotransmitter  dysregulation, genetic susceptibility, and environmental triggers appear to play a role in developing the disorder.

The differential diagnosis includes major depressive disorder, which includes obsessive ruminations, though the thoughts are more content specific. Patients with Tourette’s syndrome also may have obsessive compulsive symptoms. In pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection, there is a sudden onset of OCD and/or tics after being infected with group A beta-hemolytic streptococcus (GASHS), and the course of illness is characterized by dramatic, acute worsening of symptoms, with periods of remission.

The American Academy of Child and Adolescent Psychiatry favors cognitive behavioral therapy (CBT) as the initial treatment for OCD, particularly for younger children and for those with milder symptoms and no significant comorbidity. Some suggest pharmacotherapy as the initial treatment because of severity of illness, the child’s inability to participate in CBT, or the absence of skilled CBT therapists.

An increasing body of literature supports the short-term efficacy of tricyclic antidepressants (TCA), clomipramine, and selective serotonin reuptake inhibitors (SSRIs) in children and adolescents with OCD. Tricyclics are effective but no longer commonly used because of anticholinergic side effects, lethal overdoses, and the necessity of frequent EKG monitoring because of concerns about tachycardia and prolonged QTC interval.

SSRIs are more frequently prescribed. Sertraline has an FDA approved indication for the treatment of OCD in children ages 6 years and older, fluoxetine for children 7 and older, and fluvoxamine for children 8 years and older. Generally, a 12-week trial of an SSRI with adequate dosage is considered necessary. Many patients, however, do not experience symptom relief until 6 to 12 weeks after a trial begins. For patients who partially respond to an SSRI, augmentation strategies should be considered.

March and colleagues (1994) reported that patients treated with both medications and CBT seemed to have greater improvement and lower relapse rates. The Pediatric OCD Treatment Study (POTS), published in JAMA in 2004, is the largest controlled child OCD trial to date. This multicenter trial compared CBT, an SSRI (sertraline), and their combination to a pill placebo. This study showed that the combined treatment (CBT plus medication) was superior to either CBT or sertraline on its own.

Bobby showed only partial response to SSRI monotherapy, and augmentation with CBT, as well as exposure and response prevention (ExRP) was indicated. In the initial phase of ExRP, the focus is on educating the patient and family about OCD to address feelings including guilt, stigma, or  embarrassment on the part of the child, and anger, blame, or hopelessness on the part of the family. The next step involves collaborating with the patient to develop a list of symptoms from the least to the most distressing. Next, the patient is “exposed” to the lowest-distress symptom until his anxiety decreases on its own.

In Bobby’s case, he and the therapist looked at a picture of a knife until Bobby’s anxiety went away; in later sessions, Bobby gradually was able to hold an actual knife, and later to do so with his mother present. For homework, Bobby was asked to remain in contact each day with a feared stimulus and resist all related rituals or other anxiety-reduction actions over the entire exposure period, until his anxiety had diminished.

References and Suggested Readings
Obsessive Compulsive Disorder,
Child and Adolescent Psychiatry. Ed. Wiener JM, Dulcan MK, 575-588.

Pediatric OCD Treatment Study Team (2004). Cognitive behavioral therapy, sertraline, and their combination for children and adolescents’ obsessive-compulsive disorder: The Pediatric
OCD Treatment Study (POTS) randomized controlled trial.
JAMA 292, 1969-1976.

Residents’ Corner

Laurel Weaver, MD, PhD

The Defiant Child

Oppositional defiant disorder (ODD) is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, to be “a pattern of negativistic, hostile, and defiant behavior,” and its prevalence is as high as 16%. For diagnosis, evidence of ODD has to be present for 6 months and include 4 of 8 suggested characteristics:

ODD Characteristics

A diagnosis requires 4 of these criteria to occur often:

It is important to distinguish behavior associated with ODD from that of developmentally normative disruptive behavior, and clinicians should assess for the presence of co-occurring disorders, such as anxiety or ADHD. Risk factors for ODD include:

Parent-child interactions are posited to be reciprocal (ie, difficult children may elicit more negative parenting responses). In general, the etiology of ODD is multifactorial. Models implicate learned behavior (ie, reinforcing a child’s tantrum by giving him a treat to end it), poor attachment, and a deficiency in the child’s ability to process social information.

Earlier onset of ODD conveys poorer prognosis and more likely progression to conduct disorder. (Estimates of untreated ODD suggest that as many as 30% of children with early-onset ODD may progress to conduct disorder.)

Evidence suggests treatment should involve individual and family psychotherapy, as well as social interventions, such as school-based interventions, though head-to-head clinical data comparing treatment approaches is sparse. Medication management is generally reserved for the treatment of comorbid conditions, such as ADHD.

Evidence-based individual treatment approaches emphasize problem-solving skills, while family treatment approaches emphasize guidance to families in effective disciplining and supervision, with an emphasis on reinforcing prosocial behavior and consequences like “time outs” for disruptive behavior.


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