Pediatric Primary Care Case Studies (54 page)

What instruments could you use in your practice to assist in the diagnosis of depression in children?

Assessment

Symptom Analysis

In order to complete a full assessment and evaluation of an adolescent for depression, the healthcare provider will need to integrate information from multiple sources. Children and adolescents tend to be reliable in reporting internal symptoms, whereas parents and teachers are more reliable in reporting external symptoms. It is important to interview both the adolescent and the parents separately. Often, use of a screening questionnaire can help in guiding the interview. The Children’s Depression Inventory is one such tool (Kovaks, 2003). This is a 27-item symptoms-oriented scale designed for children and adolescents ages 7–17 years. Questions focus on severity of depression symptoms in the last 2 weeks. Whether using a questionnaire or an interview strategy, questions for adolescents need to focus on the following:

•   
Mood:
Does the adolescent feel sad, down, irritable, or grouchy? Does the teen feel this way most of the time? Does he or she often cry? Does the teen get into more arguments with others recently, including parents, teachers, or peers?

•   
Anhedonia:
Is the teen able to enjoy things he or she used to enjoy? Does he or she have less interest in doing fun things, often feel bored and tired, or have less energy than usual?

•   
Guilty feelings or negative self-image:
Does the teen feel bad about him- or herself or feel bad about things they have done? Does the young person feel worthless? Does the teen have any friends and feel that other kids like them?

•   
Neurovegetative signs:
Have changes occurred in sleep patterns—not able to sleep, waking up more, sleeping all the time? Are there changes in appetite—increased or decreased? Are there difficulties concentrating in school? Have grades dropped? Does the child or teen not want to go to school because it takes too much energy?

•   
Somatic symptoms:
Does the boy or girl have headaches, stomachaches, or body aches? How often and how severe?

•   
Suicidal ideation:
Has the child or teen wished to be dead or made a comment that they wished they were not here? Does he or she have any plans for self-harm? How detailed is the plan? What are the means? Has the youth tried to hurt him- or herself? How long ago did these feelings arise? What was going on when these feelings arose?

•   
Substance use:
Is the youth using any drugs or alcohol, and if so, which ones? For how long? How much? Is this a recent change?

Questions for parents encompass similar areas:

•   
Mood/affect:
How do they see the child’s mood? Has it changed recently? Is the child sad, angry, irritable? Is he or she arguing more? Does he or she avoid doing things he or she used to enjoy doing? Is he or she more withdrawn?

•   
Neurovegetative signs:
Have they noticed changes in the child’s sleep patterns? Difficulty getting and staying asleep? Sleeping more? Any changes in appetite? Increased or decreased? Weight changes? Changes in energy level?

•   
Suicidal ideation:
Has the child voiced any thoughts about wishing he or she was dead? Has the child tried to hurt him- or herself? Are they worried that the child may harm him- or herself? Have they seen that the child is preoccupied with death? Is he or she listening to, writing, or watching more morbid things?

•   
Impaired school or peer functioning:
Have the child’s grades declined? Is the child showing less interest in social or after-school activities? Has the child missed a lot of school from not feeling well? Is he or she spending less time with peers? Has the peer group changed?

•   
Drug abuse:
Are there any signs of substance use (e.g., lethargy, hyperactivity, hypervigilance, deviant or risk-taking behavior, absences or suspension from school, poorer school performance, withdrawal from family or friends, changes in friends, angry outbursts)?
Tom scores positively for depression on the Children’s Depression Inventory which you administer in the office.
This instrument validates the history that you obtained earlier.

Physical Examination and Laboratory Studies

What physical examination data should you collect?

As a primary care provider, it is important to complete a physical exam and laboratory screenings to rule out any physical causes for these symptoms, such as anemia; vitamin B
₁₂
deficiency; Cushing syndrome; connective tissue disorders such as juvenile arthritis or lupus; diabetes mellitus; chronic fatigue syndrome; fibromyalgia; hypothyroidism; infections such as mononucleosis, hepatitis, or human immunodeficiency virus (HIV); inflammatory bowel disorder; multiple sclerosis; seizure disorder; or tumors (Kaye, Montgomery, & Munson, 2002).
Tom’s physical examination, including a careful neurological examination considering his headaches, is normal for his age.

Are any laboratory studies indicated for initial diagnosis and screening of depression in children?

Laboratory screenings for thyroid abnormalities, CBC, and toxicology are important. No abnormalities were found on the screening lab work for Tom.

Could these symptoms be the result of medication use?

A thorough history of use of other medications is needed. Steroids, thyroid supplements, megavitamins, benzodiazepines, beta-blockers, clonidine, Accutane, and oral contraceptives, for example, can all contribute to mood changes.
Tom has not taken any medications or substances.

In addition, it is important to rule out ADHD, bipolar disorder, substance use/abuse, and anxiety disorders.

Making the Diagnosis

The results from the history, the positive results of the Childhood Depression Inventory, and data from both Tom and his parents lead you to make a diagnosis of depression. There is no indication of drug use or chronic illness, physical examination data to support a physical illness, or laboratory work indicating physical ailments that might account for his feelings. He has not had suicidal thoughts or other thoughts about harming himself or others.

Management

As a primary care provider, you want to refer Tom to a mental health specialist for care. However, you also have a role to play in advocating for mental health treatment and arranging for a referral, and need to be acquainted with the care the mental health specialist will provide.

Psychoeducation

The following are actions you can expect from the mental health specialist that you can support (Kaye et al., 2002):

•   Review stressors and contributing factors to mood changes.

•   Clarify coping strategies that the patient and family have to support the adolescent’s capacity to discuss their feelings.

•   Destigmatize the acknowledgement of emotional difficulties.

•   Normalize developmental struggles.

•   Identify self-esteem–enhancing activities and skills such as any school-based activities, sports, or camps.

•   Reinforce good self-care habits. (Establishing regular eating, sleeping, and exercise habits help mental health.)

•   Rule out maltreatment as a contributing factor.

•   Educate the teen and family about signs of increasing depression such as sleep disturbances, changes in appetite, school problems, and argumentativeness.

Cognitive Behavioral Therapy

Psychotherapy is used for mild cases of depression. The largest randomized clinical trial for adolescent depression, the Treatment of Adolescent Depression Study (TADS) (March et al., 2004) showed that moderate to severe adolescent depression is best treated with a combination of an antidepressant and cognitive behavioral therapy (CBT). Other studies demonstrate the effectiveness of CBT (Compton et al., 2004; Hazell, 2004; Powers, Jones, & Jones, 2005).

CBT is often the therapy of choice because depression is considered a cognitive dysfunction. CBT is based on the assumption that the way a person thinks, perceives, and actively interacts within the environment determines his or her feelings and behaviors (Beck, 1976). An individual’s emotions and behaviors are, in large part, determined by the way in which he or she cognitively appraises the world. The primary care provider who understands basic CBT concepts can better support the mental health specialist’s work.

CBT can be understood best as an integrated theory that links cognitive, affective, social, and developmental processes to behavior. An individual’s cognitions are termed
schemas
and are central to thought and perception. They have a fundamental influence on emotion and behavior and can be either positive or negative. They help process and organize complex information into meaningful patterns over time (Beck, 1976).

Beck’s theory takes into account metacognitions, which are defined as “thoughts about thinking” that emerge during middle childhood. It is at this time that children become more skilled in identifying information needed to solve problems. The development of metacognitions is necessary for the child to develop a sense of self. By 8 years of age, children have been found to distinguish between thoughts and behavior (Flavell, Green, & Flavell, 2000; Quakley, Coker, Palmer, & Reynolds, 2003).