Paulette Pitt, PhD
Kelly A. Curran, MD, MA
Recognize common presenting signs and diagnostic criteria of depression and anxiety in children and adolescents
Identify screening tools for anxiety and depression for use in clinical practice
Conduct suicide screening and recognize a mental health emergency in a pediatric patient
Epidemiology
Diagnostic Criteria
Clinical Presentation
Screening Tools
Self-injury
Suicide Assessment
Epidemiology
Question (in the 12 months before the
study)
United States Oklahoma
Felt sad or hopeless(almost every day for 2 weeks or more in a row so that they stopped doing some usual activities)
31.5% (CI 29.6–33.4%) 31.8% (CI 28.0–35.8%)
Seriously consideredattempting suicide
17.2% (CI 16.2–18.3%) 19.1% (CI 15.8–22.8%)
Made a plan about how they would attempt suicide
13.6% (CI 12.4–14.8%) 13.4% (CI 11.1–16.2%)
Attempted suicide 7.4% (CI 6.5–8.4%) 11.2% (CI 8.9–13.9%)
Suicide attempt resulted in an injury, poisoning or overdose that had to be treated by a doctor or nurse
2.4% (CI 2.1–2.9%) 3.7% (CI 2.5–5.5%)
Adapted from ”Youth Online High School Results” from the CDC, accessed at nccd.cdc.gov
Depression is increasing in the United States◦ Across all populations, even when controlling for demographics
◦ Increasing faster in adolescents
Anxiety disorders are increasing
Suicide on the rise◦ ~45,000 US citizens per year (age 10 and older)
◦ 10th leading cause of all deaths in US
◦ About ½ of suicide deaths had no prior diagnosis of mental illness
◦ 2nd leading cause of death in older teens (age 15-19)
3rd in young teens (age 10-14)
Weinberger AH, Gbedemah M, Martinez AM, et al. Trends in depression prevalence in the USA from 2005 to 2015: widening disparities in vulnerable groups. Psycho Med. Jun; 48(8): 1303-1315.Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance — United States, 2017. MMWR Surveill Summ 2018;67(No. SS-8):1–114. DOI: http://dx.doi.org/10.15585/mmwr.ss6708a1Bitsko RH, Holbrook JR, Reem M, et al. Epidemiology and Impact of Health Care Provider–Diagnosed Anxiety and Depression Among US Children. Journal of Developmental & Behavioral Pediatrics, 2018; 1 DOI: 10.1097/DBP.0000000000000571
Hard to estimate true prevalence (disease vs. diagnosis)
Anxiety ~31.9% lifetime prevalence for teens
Depression affects an estimated 13% annually
Mojtabai R, Olfson M, Han B. National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics 2018; e20161878. DOI: 10.1542/peds.2016-1878NIHM. ”Statistics: Major Depression.” Accessed at https://www.nimh.nih.gov/health/statistics/major-depression.shtmlNIMH. “Statistics: Any Anxiety Disorder.” Accessed at https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml
Lots of speculation…◦ Increasing economic factors?
◦ Increasing isolation?
◦ Rise of technology?
◦ Increasing stress/pressures?
◦ Diagnosis bias?
No answers
DSM 5 Diagnoses
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder (MDD)
Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder (PMDD)
Substance/medication-Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
Other Specified Depressive Disorder
Unspecified Depressive Disorder
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Depressed mood Diminished interests Weight loss or gain Sleep dysregulation Psychomotor interference Fatigue Negative feelings Cognitive interference Suicidal ideation/attempt
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Severe recurrent temper outbursts
Outbursts inconsistent with developmental level
Three or more times per week
Mood between outbursts irritable/angry
Present for 12 or more months
Present in two of three settings – severe in at least one setting
Do not diagnose before age 6 years or after age 18 years
CANNOT coexist with ODD, IED, or bipolar disorder
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Depressed mood most of day for at least 1 year (children/adolescents)
Two or more◦ Appetite disturbance
◦ Sleep disturbance
◦ Fatigue/low energy
◦ Low self-esteem
◦ Problems concentrating or making decisions
◦ Hopelessness
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder Panic Disorder Generalized Anxiety Disorder Agoraphobia Anxiety Disorder Due to Another Medical Condition Other Specified Anxiety Disorder Unspecified Anxiety Disorder
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Fears social situations in which may be scrutinized
Fears negative evaluation
Social situations provoke fear◦ Crying◦ Tantrums◦ Freezing◦ Clinching◦ Shrinking◦ Failing to speak
Socialization avoided to avoid fear
Out of proportion to actual threat
Lasting at least 6 months
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Excessive anxiety/worry◦ More days than not
◦ 6 months
◦ Number of activities/events
Difficult to control worry
Three or more of following:◦ On edge/restless
◦ Fatigued
◦ Problems concentrating/going blank
◦ Irritability
◦ Muscle tension
◦ Sleep disturbance
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Recurrent panic attacks◦ Following symptoms:
Palpitations, pounding heart, accelerated heart rate
Sweating
Trembling/shaking
Shortness of breath
Chest pain/discomfort
Feelings of choking
Nausea/abdominal distress
Feeling dizzy/unsteady
Chills/heat sensation
Paresthesias
Derealization
Fear of losing control
Fear of dying
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Persistent concern about having additional
Significant maladaptive change in behavior related to attacks
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Why Care?
Kids and teens often have different presentations than adults
Few will present to care reporting depression or anxiety◦ Developmentally may not have the language to describe emotions
◦ Families may focus on “outcome” (e.g. bad grades) instead
Clinicians may have to “dig” in the history for clues
Essential to get history separately from the family◦ HEADSS screening in adolescents
Low energy
Excessive worry
Excessive guilt
Anhedonia
Social withdrawal
Behavior problems
Sadness
Irritability
Poor concentration
Anger
Poor school performance
Somatic symptoms
Gudmundsen GR, Rhew IC, McCauley E, et al. J Clin Child Adolesc Psychol 2018;7:1-15. doi: 10.1080/15374416.2017.1410823
Boys more likely to exhibit sad mood, fatigue, and trouble concentrating
Often teens with MDD had symptoms of anxiety and depression present in elementary school
Gudmundsen GR, Rhew IC, McCauley E, et al. J Clin Child Adolesc Psychol 2018;7:1-15. doi: 10.1080/15374416.2017.1410823
Flat, depressed or anxious affect
Psychomotor slowing
Weight changes
Self injury marks (e.g. cutting)
Depression◦ USPSTF: Screen MDD in ages
12-18 (if adequate resources for follow up), grade B Category I for children age 11 and
younger
◦ AAP: Screen MDD annually age 12 and older, grade II At risk patients should be
monitored over time, grade II
Anxiety◦ No USPSTF or AAP
recommendation for anxiety screening
USPSTF. Depression in Children and Adolescents: Screening. Accessed at https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-children-and-adolescents-screening1Zuckerbrot RA, Cheung A, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics 2018; 141(3) e2017408. DOI: 10.1542/peds.2017-4081
PHQ 9: Modified for Teens◦ Adolescent diagnostic criteria
◦ Language specific to adolescents
◦ Severity indicator
◦ Addresses dysthymia
◦ Suicidality
SCARED◦ Parent
◦ Child
Spence Children’s Anxiety Scale◦ Parent
◦ Child
Beck Youth Inventory, Second Edition
Incredibly common!◦ 15 % of teens
◦ 17 % - 35 % of college students
Onset age 14 – 24
Bimodal peak ages 12- 14 and ages 18 - 19
Kerr PL, Muchlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med 2010; 23(2): 240-59.
Cutting*
Skin carving
Burning*#
Abrading/scratching
Punching/hitting#
Biting
Inserting sharp objects under skin
Bone breaking
Auto amputation
Ocular enucleation
# Most common SI in men* Most common SI in women
Kerr PL, Muchlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med 2010; 23(2): 240-59.
Borderline Personality Disorder: 70 – 75 % have SI
Dissociation and Dissociative Disorders: 69 % have SI
~42% of those with SI meet criteria for MDD
Kerr PL, Muchlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med 2010; 23(2): 240-59.
Disclosure Provide understanding of behavior Validating Motivational interviewing◦ Understand function of behavior◦ Risk assessment◦ Motivate treatment receptivity
Assessment◦ Severity of SI (frequency, number of methods)◦ Risk of suicide attempt◦ Regular assessment of high risk patients
Kerr PL, Muchlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med 2010; 23(2): 240-59.
STOPS FIRE ◦ Suicidal ideation during or before SI
◦ Types of SI
◦ Onset of SI
◦ Place (location) on body
◦ Severity/extent of damage
◦ Functions of SI
◦ Intensity of SI
◦ Repetition of SI
◦ Episodic frequency of SI
Kerr PL, Muchlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med 2010; 23(2): 240-59.
Family history of suicide attempts
Exposure to violence
Impulsivity
Aggressive behavior
Access to firearms
Bullying
Helplessness
Hopelessness
Loss
Rejection
American Academy of Child and Adolescent Psychiatry. Facts for Families: Teen Suicide. Accessed at www.aacap.org/AACAP/Families_and_youth/Facts_for_families/FFF-Guide/Teen-Suicide-010.aspx
Making statements
Change in eating habits
Change in sleep patterns
Withdrawal
Complaints about physical symptoms
Decline in grades
Preoccupation with death/dying
Failure to plan for future
Giving away possessions
American Academy of Child and Adolescent Psychiatry. Facts for Families: Teen Suicide. Accessed at www.aacap.org/AACAP/Families_and_youth/Facts_for_families/FFF-Guide/Teen-Suicide-010.aspx
Psychiatric diagnoses Thoughts of death Suicidal ideation Plan for suicide Means available Intent Impulse control Protective factors Family history of suicide Previous attempts
McDowell AK, Lineberry TW, Bostwick JM. Practical Suicide Risk Management for the Busy Primary Care Physician. Mayo Clin Proc. 2011; 86(8): 792 -
800. doi: 10.4065.mcp.2011.0076
Medication initiation
Individual and group psychotherapy
Rest
Social services intervention
Identification of supports
Educating family on removing harmful items
Provide crisis line numbers
McDowell AK, Lineberry TW, Bostwick JM. Practical Suicide Risk Management for the Busy Primary Care Physician. Mayo Clin Proc. 2011; 86(8): 792 -
800. doi: 10.4065.mcp.2011.0076
40% of SI have suicidal thoughts while engaged in SI
50 – 85% have attempted suicide
Those who attempt have longer histories of SI and varied methods of SI
As severity of SI increases, suicidality increases
Kerr PL, Muchlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med. 2010; 23(2):240-59.
Differentiation of SI and suicidality◦ Intent – SI reducing emotional distress/increase positive affect, not
death; 1.4 – 2 % deaths (cutting)
◦ Method – lethal vs. nonlethal behaviors
◦ Psychological impact
Repeated/chronic behavior
¼ of SI engage in 11 – 50 episodes of SI
9.9 % = >50 episodes
Kerr PL, Muchlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med. 2010; 23(2):240-59.
SI likely to convert if repulsed by life
Attracted to death
Unafraid of suicide/death
Chronically self-critical
Apathetic
Tenuous family connections (parental criticism)
Kerr PL, Muchlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med. 2010; 23(2):240-59.