How to Spot & Manage Depression Among Children and Teens with AD/HD

Major Depressive Episode

This is Marked by the experience nearly every day for at least two weeks of: Feelings of sadness, emptiness or loss of zest Daily Activities no longer hold interest of pleasure Feelings of worthlessness or guilt Recurrent thoughts of death Altered ability to concentrate or make decisions Irritability Sleep problems, fatigue, restlessness, loss of energy or unintentional weight loss

Dysthymic Disorder
Depression for more days then not over a two year period. (Children/adolescents are only required to be irritable for at least one year) Physical symptoms as seen in major depressive episode -During this period symptoms never resolve for more than two months -Functional impairment in a person s life

Core Symptoms According to the Child s Age

Younger children may be unable to verbalise their sadness. Symptoms caregivers may notice are: Irritability Getting into fights or avoidance Physical symptons: Headaches Abdominal pain

Core Symptoms According to the Child s Age

Older children and adolescents typical core symptoms: Sadness Emptiness Loss of motivation Loss of energy Loss of self-esteem

Real Life Symptoms

Sadness Feeling of emptiness Self esteem problems Withdrawal/loss of interests Irritability Bodily complaints Sleep Appetite problems Concentration problems Stress on the family Stress on the teacher

Bipolar Depression
Mood disorder that rapidly shifts between depression and mania Depressive Episode, marked by: Sad Flat Down Empty feelings Loss of interest Altered appetite Altered sleep patterns

Bipolar Depression
Manic Episode; expansive, unrealistic, disorganised and grandiose behaviours Manic Episode marked by: Person may appear pressured and over talkative His ideas may be loosely connected Extreme irritability which is typical form of mania in children Very goal directed behaviour often to the detriment of other needs Poor judgement Extreme sensitivity to stimuli Manic episodes Little sleep requirement

Manic Episodes Continued

Manic Episodes: Extreme craving for sweets Extreme fear of death Extreme sexuality Oppositional or obsessive traits Hallucinations Suicidal tendencies Substance abuse risk Bedwetting Severe separation anxiety Precociousness as children

Manic Episodes
Typically, most symptoms are shown primarily at home Parents may be surprised to hear that their child is a little angel at school

Consider BD rather than ADHD (or in addition to ADHD) when.......

A strong family history of BD or substance abuse Prolonged temper tantrums and mood swings (BD angry, violent, sadistic and disorganised outbursts can last for hours) Bipolar rages arising typically from parental limit setting (vs ADHD usually from over stimulation)

Consider BD rather than ADHD (or in addition to ADHD) when.......

Walking around with angry chip on your shoulder (BD people often walk around looking miserable for no apparent reason; tend to be irritable while ADHD are easily irritated) Oppositional and defiant behaviours intentionally aggressive, explosive or risk seeking behaviours Morning irritability that may last hours in BD versus minutes in ADHD

Bipolar in Children
Typically begins in late teens or early adult years Increasingly being recognised in children as well The moods can alternate ultra-rapidly up to several times per day or even occurs simultaneously Manic stage is typically marked by irritability then euphoria

Challenges that Co-exist with ADHD

Learning disability Ineffective coping Risk-taking behaviours Lack of resources & feelings of alienation Loss of support system Intense anger Change in academic performance Loss of family status

Challenges that Co-exist with ADHD Continued

Recent loss of love object or rejection Recent move or change in school Hopelessness, depression Heavy drug use Pregnancy Running away Suicide attempts Preoccupation with the violent death of another person

Assessing Adolescents
Symptoms of depression may not be indicated as directly as when assessing adults Young people are ineffective in expressing depression This is referred to as masked depression

Masked Depression
Classic Symptoms: Somatic complaints or chronic complaints of headaches, backaches and stomach aches Behavioural; evidenced by acting out behaviours: Drug abuse Promiscuity Shoplifting Finding boredom in school Peers and family and the world

Bipolar Episodes
The key is to underwhelm by keeping it predictable, calm and secure Make routines predictable Give adequate notifications before making transitions Allow plenty of breaks both planned & as needed Arrange secret hand codes Allow and encourage use of a minute to reflect

Bipolar Episodes (Continued)

Allow the child to pull back whenever he feels overwhelmed with no hassling questions If classroom commotion is de-stabilizing force have a child sit in the quiet part of the room or next to a child who is calm and quiet Avoid direct confrontation Some bipolar kids need and aide Say something nice frequently e.g. Every 5 min; 12 nice things for every negative comment

Bipolar Episodes (Continued)

Teach other students to accept diversity Do not punish children for behaviour that is out of their control Try not to get involved in power struggles. Give palatable alternatives Avoid excessive classroom heat, dim lights that interfere with attention Observe what academic areas child needs more work or causing so much stress

Bipolar Episodes (Continued)

Observe what times of the day where child is likely to attend, more tolerant of frustration or effects of medications Allow them to have physical outlets for their driven energy. Given them chores to do Direct them to productive hands-on projects Help them set realistic goals with reasonably sized projects

Understanding the Child s Mindset

Learn about the child s problem Seek to understand Not all brains are wired the same We see only part of what is going on in a child s life Remember that some of the difficult child/adolescent behaviour is simply normal

Keep it Positive
Enjoy the child Use positive reinforcement when possible Threats may change behaviour but does not motivate towards a good attitude Avoid the resentment treadmill Don t be a nasty cop

Keeping it Positive
Avoid nagging, lecturing, arguing and offering unscheduled or spontaneous advice Minimize arguments with the no-fault approach Keep your relational bank account in the positive Positive help for deficits at the moment is needed

Keep it Calm
Pick your fights Give transition warnings Watch the stress speedometer Just stop is the key for the overwhelmed person and for you Stay calm

Treatment Objectives for Depression and Suicide

Alleviate the person s isolation by recommending to stay with family and friends Facilitate removal of weapons or other means of suicide attempt environment Facilitate the appropriate expression of anger Validate the person s experience of the crisis or their ambivalence Refer for medication evaluation

Treatment Objectives for Depression and Suicide (Continued)

Educate the person re the impact of lack of sleep on effective coping Identify the irrational negative beliefs Do not verbally or nonverbally express shock or horror Do emphasize how much they have upset other people Do not offer moral edicts of suicide

Treatment Objectives for Depression and Suicide (Continued)

Explore with the person what they hoped to accomplish by suicide Identify life issues Discuss the fact that suicide is a permanent solution Review resources and relationships Be reassuring and supportive Facilitate improved problem solving and coping

Treatment Objectives for Depression and Suicide (Continued)

Facilitate development of self-care program:
Daily structure Inclusion of pleasurable activities Resources and support system Identify potential crisis situations Identify warning signs Regular aerobic and good nutrition Depression and suicide risk relapse potential red flag when there is an impending crisis

Treatment Objectives for Depression and Suicide (Continued)

A pervasive negative outlook that they cannot manage day to day activities A belief that they lack control over their life and blame other people and situations Taking the position that they are doing fine and do not need the help of other poeple, resources. Impulsive behaviours

Depression and Suicide Risk Relapse

Potential red flag when there is an impending Crisis:
Isolation and withdrawal continues Physical symptoms: sleep disturbance, fatigue, headaches Inability to maintain their daily schedule Person is often confused and irritated Breaking relations and associations Energy level is dimished Lack of sleep and poor sleep patterns

Depression and Suicide Risk Relapse (Continued)

Expresses dissatisfaction in life The person begins to miss therapy appointments Person takes on a victim role Having thoughts of death of a death wish Gets their life in order by making a will, giving things away Feel overwhelmed and unable to cope Pattern of self destructive patterns

Thank You!
Sources: Martin L. Kutscher. (2005) Kids in the syndrome mix of ADHD, LD, Asperger s, tourette s, Bipolar and more! The one step guide for parents and other professionals Sharon L. Johnson. (1997) 123 s therapist s guide to clinical intervention, the 123 s of treatment planning. San Diego: Academic Press