DEPRESSION & ANXIETY IN CHILDREN. Dr Jun Yong Ma 17 th June 2017

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2 DEPRESSION & ANXIETY IN CHILDREN Dr Jun Yong Ma 17 th June 2017

3 If you set out to describe a baby, you will find you are describing a baby and someone. Donald W. Winnicott (1964) Paediatrician and Psychotherapist

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5 ONCE UPON A TIME IN A BUSY GP CLINIC Leah, 35 years, brings in her son Jack, 10 years, on a school day. For the last month, he s been complaining of a sore tummy and nausea. This morning he vomited. This is the second time it s happened this week, in the past month he s been away from school half the time. Usually he s a pretty good kid, but lately he just hasn t been talking to me, and when I try to talk to him, he explodes into a rage! There s this big fight every time I ask him to do something. He s in his room all the time and he doesn t feel like going to hockey which he normally loves.

6 YOU VE KNOWN JACK SINCE HE WAS A BABY Jack s parents divorced when he was 2 years. Jack lives with Leah and Leah s parents Bob and Jan who are both really involved with his care. Jack sees his dad Pete every fortnight. Pete has depression and was frequently hospitalised when Jack was younger. He is more stable now. Jack is in year 5 at the local public school. He s an average student and is quite shy. He s a talented hockey player. Jack doesn t have a significant medical history and isn t on any regular medications. His developmental milestones were within normal range.

7 WHAT ARE YOU THINKING OF?

8 YOU ASK A FEW MORE QUESTIONS Two months ago, granddad Bob was hospitalised with a septic colon and required surgery. He has returned home now but is still recovering, so Jack s dad has been helping out with Jack more. Jack is still really worried that Bob will get sick again. Leah thinks Jack might be bullied at school but Jack refuses to talk about it. Earlier in the year he got suspended for fighting. Leah worries about Jack not eating because of nausea and sore tummy, though it doesn t seem to affect him on weekends. Jack worries about many things but doesn t want to tell Leah because he thinks (rightly) that she d get stressed by this.

9 WHAT ARE YOU THINKING NOW?

10 FURTHER ASSESSMENT Weight and height were within expected growth trajectory Physical examination was unremarkable Consider investigations for organic causes of nausea and vomiting, as well as mood and anxiety disorders Differential diagnoses include depression, dysthymia, anxiety, adjustment, somatic symptom disorders Common comorbidities e.g. ADHD, learning difficulty, sensory impairment, conduct problems

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12 A LAYER CAKE Jack presents with possible symptoms of depression and anxiety. This has impacted on his functioning at home, school and within himself. The main risk is to Jack s wellbeing and normal development. Predisposing: parental mental illness, life events, attachment Precipitating: his grandfather s illness and bullying Perpetuating: cognitive style, avoidance, family stress, family conflict Protective: a supportive social network and motivated parents

13 TREATMENT PRINCIPLES Assess risk and severity symptom severity, presence of suicidality, functional impairment indications for inpatient care Treating the child within their context interventions for parents, families and schools family factors (e.g. marital discord) modulate treatment response Stepped care model based on severity but psychosocial interventions (individual, parenting and family) generally first line everyone should receive psychoeducation, lifestyle advice and guided self-help

14 MANAGEMENT OF DEPRESSION Mild Watchful waiting up to 4 weeks Supportive management and guided self-help Psychotherapy (e.g. CBT) Moderate Supportive management Psychotherapy, if no response after 4-6 sessions + medication Severe Combined psychotherapy and medication Consider family and social factors in all cases!

15 MANAGEMENT OF ANXIETY Psychoeducation and supportive management Lifestyle interventions Skills based programs Group CBT such as Cool Kids Social skills training Individual psychotherapy such as ACT Parental involvement More likely to be important in younger children

16 EARLY INTERVENTION Treating parental psychopathology Whole of Family Supporting families Community Health Centres Relationships Australia Parenting programs Attachment: Circle of Security, RPP Social learning: Triple P/123 Magic/The Incredible Years Emotion coaching: Tuning into Kids/Tuning into Teens School programs Got It!, Safe Schools

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18 MEDICATION If prescribed, must always be in conjunction with psychological interventions (individual and family) Start low and go slow consider weight and age Evidence of high placebo response and family factors moderating response Limited evidence in prepubertal children, consider multidisciplinary input first In adolescents, fluoxetine is the medication of choice for both depression and anxiety. Fluvoxamine and sertraline can also be helpful in anxiety. Paroxetine, SNRIs (venlafaxine, duloxetine) and citalopram are not generally recommended Weekly contact (person/phone) in the first month, monitor for suicidality

19 WHEN TO REFER TO CAMHS/CYMHS? Severity Moderate to severe Mild to moderate consider headspace (12 25 years) Risk Acuity and level of risk Imminent versus chronic risk It s complicated Not responding to psychosocial interventions Family factors e.g. parental mental illness, intergenerational trauma Comorbidity e.g. eating disorders, substance use

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21 REFERENCE RESOURCES IACAPAP Textbook of Child and Adolescent Mental Health, Chapters E.1 and F.1 NICE Clinical Guideline 28: Depression in children and young people

22 SUPPORTIVE RESOURCES Factsheets Families AC410F265F93139B General