MOOD DISORDERS: DEPRESSIVE AND BIPOLAR DISORDERS
It is distressing for parents to see their child oradolescent sad, withdrawn, or irritable. Yetepisodes of sadness and frustration are com-mon during childhood and adolescence. How,
then, can a parent or primary care health profes-sional determine whether a child or adolescent isshowing signs of a mood disorder? Mood disordersare disorders characterized by disturbances in moodand include major depressive disorder, dysthymicdisorder, and bipolar disorder.
Depressed mood falls along a continuum. Briefperiods of sadness or irritability in response to disap-pointment or loss are a normal part of growing up andusually resolve quickly in a supportive environment.But some children and adolescents experience intenseor long-lasting sadness or irritability that may interferewith self-esteem, friendships, family life, or school per-formance. These children or adolescents may be suffer-ing from a depressive disorder. Depressive disordersinclude dysthymic disorder as well as single and recur-ring episodes of major depressive disorder.
Another type of mood disorder that can pre-sent in childhood or adolescence is bipolar disorder.Although bipolar disorder has been considereduncommon in prepubertal children, evidence sug-gests that it may not be as rare as previouslythought, and that it is often difficult to distinguishfrom severe forms of attention deficit hyperactivitydisorder (ADHD). A child or adolescent who pre-sents with recurrent depressive symptoms, persis-tently irritable or agitated/hyperactive behaviors,markedly labile mood, reckless or aggressive behav-iors, or psychotic symptoms may be experiencingthe initial symptoms of a bipolar disorder.
KEY FACTS The prevalence of mood disorders
in children and adolescents ages917 years is approximately 6percent (U.S. Department of Healthand Human Services, 1999).
Only one-third of U.S. teenagerswith depressive disorders receivetreatment (King, 1991).
Seventy percent of children with asingle major depressive episode willexperience a recurrence within 5years (Birmaher et al., 1996a).
Approximately 20 percent of allpatients with bipolar disorderexperience their first manic episodeduring adolescence (Geller andLuby, 1997; McClellan and Werry,1997).
More than 4,000 youth (ages1524) in the United Statescommitted suicide in 1998(Murphy, 2000).
DESCRIPTION OF SYMPTOMSDescriptions of how these mood disorders can present in childhood and adolescence are summarized
(Diagnostic code: 300.4)
Adapted from DSM-PC. Selected additional information fromDSM-IV-TR is available in the appendix. Refer to DSM-PCand DSM IV/DSM-IV-TR for full psychiatric criteria and fur-ther description.
The symptoms of dysthymic disorder are lesssevere than those of a major depressive disorder butare more persistent, lasting for at least 1 year.
Dysthymic disorder is infrequently diagnosed ininfancy and early childhood. In middle childhood andadolescence it may present with the followingsymptoms:
Dysthymic DisorderMiddle Childhood and Adolescence Decreased interest in or participation in activities Feelings of inadequacy; low self-esteem Social withdrawal; guilt or brooding Irritability Increases or decreases in sleep or appetite
(Diagnostic codes: 296.2x, major depressive disorder, sin-gle episode; 296.3x, major depressive disorder, recurrent)
Adapted from Sherry and Jellinek, 1996. Selected additionalinformation from DSM-IV-TR is available in the appendix.Refer to DSM-PC and DSM-IV/DSM-IV-TR for full psychiatriccriteria and further description.
Major Depressive Disorder While major depressive disorders in childhood
and adolescence generally appear similar to adultdepression, additional warning signs may be presentaccording to developmental age. Table 14 presents pos-sible signs of major depressive disorder in infancy,early childhood, middle childhood, and adolescence.(Although major depressive disorder has rarely beendiagnosed in infants, they can show intense distress,similar to depressive reactions.)
Table 14. Possible Signs of Major Depressive Disorder in Infants, Children, and Adolescents
Failure to thrive, speech and motor delays, decrease in interactiveness, poor attachment
Repetitive self-soothing behaviors,withdrawal from social contact
Loss of previously learned skills (e.g., self-soothing skills, toilet learning)
Increase in temper tantrums or irritability
Separation anxiety, phobias, poor self-esteem
Reckless and destructive behavior (e.g.,unsafe sexual activity, substance abuse)
Irritability or withdrawal
Poor social and academic functioning
Hopelessness, boredom, emptiness, loss of interest in activities
Infancy Early Middle AdolescenceChildhood Childhood
(Diagnostic codes: 296.0x; 296.4x296.8x)
Adapted from DSM-PC with additional information fromMcClellan and Werry, 1997. Selected additional informationfrom DSM-IV-TR is available in the appendix. Refer to DSM-PC or DSM-IV/DSM-IV-TR for full psychiatric criteria and fur-ther description.
Bipolar Disorder Bipolar disorder often presents differently in chil-
dren and adolescents than in adults. Manic symptomsare the key feature of bipolar disorder. Ways that thesesymptoms might present in childhood and adoles-cence are described as follows.
Source: Adapted, with permission, from Sherry and Jellinek, 1996.
(continued on next page)
Middle Childhood Persistently irritable mood is described more than
euphoric mood Aggressive and uncontrollable outbursts, agitated
behaviors (may look like attention deficit hyperac-tivity disorder [ADHD] with severe hyperactivityand impulsivity) (See bridge topic: Attention DeficitHyperactivity Disorder, p. 203.)
Extreme fluctuations in mood that can occur on thesame day or over the course of days or weeks
Reckless behaviors, dangerous play, inappropriatesexual behaviors
Adolescence Markedly labile mood Agitated behaviors, pressured speech, racing
thoughts, sleep disturbances Reckless behaviors (e.g., dangerous driving, sub-
stance abuse, sexual indiscretions) Illicit activities (e.g., impulsive stealing, fighting),
spending sprees Psychotic symptoms (e.g., hallucinations, delusions,
Description of Symptoms (continued)
In Children and Adolescents withDepressive Disorders
According to the American Academy of Child andAdolescent Psychiatry (1998), the following arecommonly associated disorders in children andadolescents with depressive disorder:
Anxiety disorders: 3080 percent
Substance abuse: 2030 percent
Disruptive disorders (including oppositional defiantdisorder and conduct disorder): 1080 percent
Somatoform disorders (physical complaint not fullyexplained by another medical condition or mentaldisorder)
COMMONLY ASSOCIATED DISORDERSIn Children and Adolescents withBipolar Disorder
According to Geller and Luby (1997) and Wilenset al. (1999), the following percentages apply:
Attention deficit hyperactivity disorder (ADHD): 90percent (prepubertal patients); 30 percent(postpubertal adolescent patients) (See text onADHD in the introduction, p. 271, for furtherdiscussion.)
Anxiety disorders: approximately 30 percent(prepubertal patients); approximately 10 percent(postpubertal adolescent patients)
Conduct disorder: approximately 20 percent
Substance use disorders: approximately 10 percent(child-onset bipolar disorder); approximately 40percent (adolescent-onset bipolar disorder)
Bipolar Disorder (continued)
INITIAL INTERVENTIONSA mood disorder can devastate a childs or ado-
lescents emotional, social, and cognitive develop-
ment. Primary care health professionals are
increasingly the primary source of care for children
and adolescents with mild to moderate depressive
symptoms. Even after referring a child or adolescent
with mood symptoms for mental health assessment
and treatment, primary care health professionals
need to collaborate with mental health profession-
als in supporting the child or adolescent and family.
The following suggestions focus on interventions in
the key areas of self, family, school, and friends.
(See Bright Futures Case Studies for Primary Care Clini-
cians: Depression: Too Tired to Sleep [Hinden and
Rosewater, 2001] at http://www.pedicases.org.)
Child or Adolescent1. Ask all children, adolescents, and families about
depressive feelings or symptoms the child or
adolescent may have (e.g., feelings of sadness,
sleep problems, loss of interest in activities).
Parents should also be asked about depressive
feelings. (See bridge topic: Parental Depression,
p. 303.) Depression, even of moderate to severe
intensity, may not always be apparent in the
childs or adolescents day-to-day behavior, as
many of the symptoms of depression are
2. Consider the use of a depression screening tool
for children or adolescents who present with
concerning behaviors or symptoms (such as
those outlined in Tool for Families: Common
Signs of Depression in Children and Adoles-
cents, Mental Health Tool Kit, p. 147) or who are
identified as being at risk for mood disorders by
general screening tools such as the Pediatric
Symptom Checklist (Jellinek et al., 1988;
Jellinek et al., 1999) or the Child Behavior