CHILD AND ADOLESCENT DEPRESSION
One of the most frequent questions I get from parents is, “Is my teenager going through a phase; is this normal adolescent stuff or does my child have a serious problem?” Generally speaking, most parents aren’t trained in child and adolescent psychology, so how can parents know? Because normal behaviors vary from one childhood stage to another, it can be difficult to tell whether a child who shows changes in behavior is just going through a temporary “phase” or is suffering from depression. It’s an important question because about 11 percent of adolescents have a depressive disorder by age 18 according to the National Institute of Mental Health. Girls are more likely than boys to experience depression. The risk for depression increases as a child gets older. According to the World Health Organization, major depressive disorder is the leading cause of disability among Americans age 15 to 44. In the past, people believed that children could not get depression. Teens with depression were often dismissed as being moody or difficult. Today we know that youth who have depression may show signs that are slightly different from the typical adult symptoms of depression. Children who are depressed may complain of feeling sick, refuse to go to school, cling to a parent or caregiver, or worry excessively that a parent may die. Older children and teens may sulk, get into trouble at school, be negative or grouchy, or feel misunderstood.
So, what can parents do if they suspect their child may be suffering from depression? By far the best course of action is talking to your kids. This can be a challenge with adolescents, who often answer “yes,” “nothing,” and “fine,” to any question. Persistence pays off and gentle probing with more specific questions often starts the conversation. Don’t be afraid to ask about changes in behavior you have observed, including withdrawing from friends or usual social and recreational activities, falling grades and poor school attendance, or giving away important possessions. Express concern and be objective when discussing these things; the key here is to get information, rather than push or blame or discipline your child. If your teen tells you she is depressed, continue a conversation to determine if there is a cause, such as a recent break up or loss. Sometimes there is no explanation for feelings of depression, even severe depression. Clinically significant depression can be caused by imbalances in brain neurotransmitters, sometimes referred to as ‘chemical imbalance.’ Another thing to look at is family history. Most serious mental disorders have an inherited pattern. Ask yourself if anyone in the immediate family, mother, father or siblings have been diagnosed or treated for an emotional disorder, including substance abuse. Sometimes a relative hasn’t been diagnosed but you strongly suspect they have an emotional problem; if the answer is yes, there is an increased likelihood of mental illness present. When in doubt, seek professional guidance.
HOW IS ADOLESCENT DEPRESSION TREATED?
For mild to moderate depression, the first step in treatment is psychotherapy. There are specific types of therapy such as Cognitive Behavioral Therapy which are particularly effective in this age group. For more severe depression, medication is often a rational treatment option. Most studies show that a combination of psychotherapy and medication is most effect in the child and teen population. Often, mild depression which can be traced to a definite cause can be successfully treated with psychotherapy alone. One of the fears that patients and families have is related to the widely publicized warnings that antidepressants can cause suicide.* While it is possible for antidepressants to cause thoughts of self harm, the FDA based its warnings on short term studies that did not look at the outcome after 12 weeks. There were no actual suicides in any of the studies. The same studies showed that over age 25, there were fewer suicidal thoughts from antidepressants. In fact, it is far more likely that children and teenagers with severe depression will gain long term benefits from antidepressants, and these benefits far outweigh the risks. However antidepressants should only be taken under the supervision of a physician who is familiar with their use. The important thing here is for family and the treating doctor to be aware of any signs of suicidal thinking, or behaviors such as cutting themselves, especially during initial weeks of treatment and to get the patient help immediately if this happens. For more on the symptoms and treatment of Depression, go to http://www.fairfaxmentalhealth.com/depression-treatment/
Information provided by the National Institute of Mental Health: http://www.nimh.nih.gov/index.shtml
*Although antidepressants are generally safe, the U.S. Food and Drug Administration has placed a “black box” warning label—the most serious type of warning—on all antidepressant medications. The warning says there is an increased risk of suicidal thinking or attempts in youth taking antidepressants. Youth and young adults should be closely monitored especially during initial weeks of treatment.
Bipolar disorder, also known as manic-depressive illness, is a brain disorder characterized by episodes of mania and depression. These episodes are associated with unusual shifts in mood and energy. Until the early1990′s, few experts believed that bipolar disorder could occur in childhood. Depression and bipolar disorder weren’t considered brain illnesses, and distinct treatments for each illness did not exist. Clinicians could not distinguish between severe irritability and bipolar disorder in children, which would make it possible to develop more effective treatments for each. Recently, a large, nationally representative survey shows that at least half of all cases of bipolar disorder start before age 25. Community studies estimate lifetime prevalence of bipolar spectrum disorders to be 0% to 3% among adolescents, depending on the assessment measure and the range of symptoms considered (e.g., Bipolar II, cyclothymia). Prevalence of child-onset bipolar is not well established due to debate about the appropriate definition among preadolescents.
In the past 20 years, major advances in the diagnosis and treatment of Bipolar disorder in children and adolescents have been made. Imaging studies are beginning to reveal brain activity patterns and connections associated with specific traits associated with children who have bipolar disorder, such as mood instability and difficulty interpreting social or emotional cues.
Early onset bipolar disorder, which starts during childhood or during the teen years, may be more severe than forms that first appear in older teens and adults. Some evidence suggests that young people with the illness may have more frequent mood switches, be sick more often, and have more mixed episodes (both manic and depressive symptoms).
Due to concerns that many children are being mistakenly diagnosed with bipolar disorder, many researchers are working to refine the diagnostic criteria. For example, one subset of children whose primary symptom is chronic, severe irritability may instead have severe mood dysregulation or temper dysregulation disorder, while another group of children with rapidly changing moods and high energy may not have bipolar disorder at all, despite showing symptoms commonly associated with it.
- Approaches to treatment for children and adolescents with bipolar is similar to that for adults, with medication as the first line of treatment. For more information, go to http://www.fairfaxmentalhealth.com/bipolar-disorder/
- Some medications have been approved for treating bipolar disorder in children and teens, and psychotherapies, such as family focused therapy, also appear to be effective in helping children to manage their symptoms. Though there is currently no way to prevent bipolar disorder, National Institute of Mental Health (NIMH) is studying how to limit or delay the first symptoms in children with a family history of the illness.
- Children respond to medications in different ways, so the type of medication depends on the child. Some children may need more than one type of medication because their symptoms are complex. Different kinds of psychotherapy can also help children with bipolar disorder.
- Children with bipolar disorder can have co-occurring disorders, such as attention deficit hyperactivity disorder, anxiety disorders, or other mental disorders, in addition to bipolar disorder. Scientists and doctors now know that, while having co-occurring disorders can hinder treatment response, treating bipolar disorder can have positive effects on treatment outcomes and recovery from co-occurring disorders as well.
- Bipolar Disorder can run in families. Genetic research reveals genetic similarities among bipolar disorder, depression, and schizophrenia. Such studies point to possible common pathways that give rise to these disorders but also highlight limitations in focusing on specific diagnoses in research. This issue has spurred a new NIMH initiative—the Research Domain Criteria (RDoC) project—to make sense of research findings that don’t fit neatly into current diagnostic categories.
Attention deficit hyperactivity disorder (ADHD) is one of the most common mental disorders in children and adolescents. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and very high levels of activity. Studies show that the number of children being diagnosed with ADHD is increasing, but it is unclear why. The Lifetime Prevalence of ADHD is: 9.0% of 13 to 18 year olds; Lifetime Prevalence of “Severe” ADHD is 1.8% of 13 to 18 year olds. Most educators and parents no longer see ADHD as a behavioral disturbance caused by factors such as inconsistent parenting. ADHD likely stems from interactions between genes and environmental or non-genetic factors. Several genes have been implicated in the risk for developing ADHD. The difference appears to be a delay in development of the frontal cortex, a part of the brain that supports the ability to suppress inappropriate actions and thoughts, focus attention, remember things moment to moment, work for reward, and plan ahead. In contrast, the motor cortex—the area that controls movement—tends to mature faster than normal in children with ADHD, an exception to the pattern of delay. This mismatch in brain development may account for the restlessness and fidgety symptoms commonly associated with ADHD.
One study showed that brain areas controlling attention were thinnest in children with ADHD who carried a particular version of a gene associated with brain development. However, these brain areas normalized in thickness during the teen years, coinciding with clinical improvement. Although this particular gene version increased risk for ADHD, it also predicted better clinical outcomes and higher IQ than two other versions of the same gene in youth with ADHD.While it does tend to run in families, research studies are showing that it is based in brain development and structure, different “wiring” with a genetic basis.
Different types of psychotherapy are effective in treating ADHD. Behavioral therapy helps teach practical skills such as how to organize tasks and manage time to complete homework assignments. It also helps children work through difficult emotions. Therapists also teach children social skills such as how to wait their turn, share toys, ask for help, or respond to teasing. Studies show that interventions that include intensive parent education programs can help decrease ADHD problem behavior because parents are better educated about the disorder and better prepared to manage their child’s symptoms. They are taught organizational skills and how to develop and keep a schedule for their child. They are also taught how to give immediate and positive feedback for behaviors they want to encourage, and how to ignore or immediately redirect behaviors they want to discourage.
ADHD is commonly treated with stimulants, such as:
- Methylphenidate (Ritalin, Metadate, Concerta, Daytrana)
- Amphetamine (Adderall)
- Dextroamphetamine (Dexedrine, Dextrostat).
- In 2002, the FDA approved the nonstimulant medication atomoxetine (Strattera) for use as a treatment for ADHD.
- In February 2007, the FDA approved the use of the stimulant lisdexamfetamine dimesylate (Vyvanse) for the treatment of ADHD in children ages 6 to 12 years.
Findings from the Preschoolers with ADHD Treatment Study (PATS) indicate that using a very low dose of methylphenidate (e.g., Ritalin) to treat children 3–5 years old diagnosed with severe ADHD can be effective. However, for some very young children, early behavioral interventions designed to reduce their ADHD symptoms may be effective alternatives or additions to medication treatment. http://www.nimh.nih.gov/science-news/2006/preschoolers-with-adhd-improve-with-low-doses-of-medication.shtml
Studies are also helping to inform long-term treatment decisions. For example, NIMH researchers found that medication works best when treatment is regularly monitored by the prescribing doctor and the dose is adjusted based on the child’s needs. As children with ADHD mature, treatment decisions should adapt to the demands of adolescence and take into account long-term academic and behavioral problems commonly associated with ADHD.
Other research is focused on neurofeedback, an activity in which a person receives information about the frequency of his or her EEG brain waves while undergoing a task such as playing a video game. The person can then be trained to bring these frequencies into a range associated with healthy brain function, which theoretically can lead to improved behavior.
ADHD symptoms may decline for some children as they grow up. But others may face continuing problems. A recent study found that adults with untreated ADHD have higher than average rates of divorce, unemployment, substance abuse, and disability. Also, while many adults with ADHD receive treatment for other mental disorders or substance abuse, a smaller proportion receive treatment for their ADHD symptoms. For more information on Adult ADHD go to http://www.fairfaxmentalhealth.com/adult-adhd/
Other mental issues that can arise during childhood include social phobia, eating disorders, oppositional-defiant disorder, panic/anxiety disorders, pervasive developmental disorders, and other problems unique to childhood. Further information is available on our Resources page and is constantly being updated.
At Fairfax Mental Health, our psychiatrists treat this and other conditions. Call us at 703-830-1500 to discuss your needs or schedule an appointment.