Assessment and Treatment of Mood Disorders in Children and Adolescents

"Assessment and Treatment of Mood Disorders in Children and Adolescents” was presented at the Minnesota Psychological Association Friday Forum series on November 6, 2015.  Dr. Leffler focused on the following three areas: enhancing diagnostic skills related to mood disorders in youth, utilizing assessment strategies for identifying mood disorders in youth, and applying treatment techniques for youth with mood disorders.

Pediatric mood disorders, which include depression and bipolar spectrum disorder, are among the more severe childhood disorders. These disorders have been found to result in significant impairments in numerous areas including interpersonal interactions, communication patterns, academic and employment functioning, family engagement, and suicide.

Enhancing diagnostic skills related to mood disorders in youth.  Accurate diagnosis of mood disorders in children and adolescents is crucial to aiding in directing the most effective treatment interventions.  Accurate diagnosis can be hindered by comorbidity in diagnosing mental illness in children (Caron & Rutter, 1991). Mood disorders in children and adolescents can be particularly complex due to variations and overlap in symptom presentation and development (Mash & Barkley, 2007). It is crucial that the assessment process includes evaluating functioning and symptom presentation throughout the development of the individual, from a nomothetic and ideographic approach in all the systems the individual is a part of (Leffler, Riebel, & Hughes, 2014).

Utilizing assessment strategies for identifying mood disorders in youth.  Structured and semi-structured clinical interviews can be integrated into diagnostic assessments within the time allotted for these initial appointments (Leffler et al., 2014).  Information from these interviews along with narrow or broad-band measures can assist in diagnostic clarity.  Results from these techniques can be integrated with a biopsychosocial history to facilitate conceptualization of the client.  For example regarding bipolar disorder, knowing the base rate of the illness in your practice setting, the client’s family history of bipolar disorder and scores on a parent checklist provides a considerable amount of information about the degree of risk of bipolar disorder in a specific case (Youngstrom & Youngstrom, 2005). Regarding informants and scores on rating scales, parent report should always be included in the differential diagnosis of mania in children and adolescents. Teacher report on the Achenbach Child Behavior Checklist (CBCL) was found not to add incremental information about bipolar diagnoses, and low scores on the CBCL can be decisive in most settings in ruling out bipolar (Youngstrom & Youngstrom, 2005).  However, high scores on the CBCL Externalizing scale should trigger more thorough assessment.

Examples of narrow band measures for depression that were reviewed include the Children’s Depression Inventory (ages 7-17), the Reynolds Child Depression Scale (ages 8-12), the Reynolds Adolescent Depression Scale (ages 13-18), the Center for Epidemiological Studies Depression Scale for Children (ages 12-18), the Center for Epidemiological Studies Depression Scale (ages 14 and older), and the PHQ-9M (ages 11-17).  Narrow band measures of mania included the General Behavior Inventory (ages 11-17), the Parent General Behavior Inventory (ages 5-17), the Parent Young Mania Rating Scale (ages 11-17), and the Mood Disorder Questionnaire (ages 12-17).  Non-proprietary measures are also available and include those listed on the American Psychiatric Association Diagnostic and Statistical Manual fifth edition (DSM 5) assessment webpage (http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures).  These include the PROMIS Emotional Distress—Depression—Parent Item Bank,

The Affective Reactivity Index (ARI) and adaptations of the Altman Self-Rating Mania Scale (ASRM). Versions for youth and parents are available.  Broad-band measures that were reviewed include the Behavior Assessment System for Children (BASC-2), the Child Behavior Checklist (CBCL), the Conner’s Comprehensive Rating Scales (CBRS), the Conner’s Rating Scales –Revised (CRS-R), and the Devereux Scales of Mental Disorders.

Applying treatment techniques for youth with mood disorders. Treatment interventions that are well-established and probably efficacious were reviewed for depression and bipolar disorder.  Well–established therapies for depression in children include cognitive behavioral therapy (CBT) provided in individual or group settings along with parent involvement.  Treatments for adolescents with depression include CBT offered in a group therapy format, and interpersonal psychotherapy (IPT) provided in an individual format.  Additionally, CBT with adolescents and parents and IPT- adolescents (IPT-A) are probably efficacious interventions (David-Ferndon, & Kaslow, 2008).  Probably efficacious treatments for child and adolescents with bipolar disorder include Family psychoeducation plus skill building (i.e., Multi-Family Psychoeducational Psychotherapy, Family-Focused Treatment) and cognitive-behavioral therapy (CBT; Fristad, MacPherson, 2014). Overall treatment approaches for depression and bipolar include cognitive behavioral therapy, interpersonal psychotherapy, and family based strategies.   Additionally, mindfulness and health and wellness techniques were reviewed.  A two-week integrated partial hospitalization program (PHP) for youth with mood disorders and their families was discussed.  Mayo Clinic’s Child and Adolescent Integrated Mood Program (CAIMP) integrates a family-based approach to treating complex mood disorders in a PHP setting.  Preliminary results of CAIMP suggest decreased inpatient psychiatric readmission for patients, decreased levels of youth depression, and improved functioning.

Jarrod M. Leffler, Ph.D., L.P., ABPP, is a diplomate of the American Board of Professional Psychology in the specialty of Clinical Child and Adolescent Psychology (ABCCAP).  He is the director of the Child and Adolescent Integrated Mood Program (CAIMP), the co-director of the Pediatric Mood Disorder Program, and director of the Pediatric Transitions Program (PTP). He is an Associate Professor, and faculty member of the Mayo Clinic Clinical Child Psychology Fellowship (Department of Psychiatry and Psychology) and Mayo Clinic Graduate School (Rochester, MN).  His research program focuses on the assessment and treatment of mood disorders in children and adolescents; clinical program development, implementation and evaluation; biological mechanisms of identifying mood disorders; and training of mental health professionals.  Dr. Leffler received his Doctorate in Psychology from Saint Louis University and completed his internship at Harvard Medical School and Children’s Hospital Boston before completing his Post-Doctoral Fellowship at The Ohio State University in Child and Adolescent Mood Disorders.

References

Caron C., & Rutter, M. (1991). Comorbidity in child psychopathology: concepts, issues and research strategies. Journal of Child Psychology and Psychiatry, 32(7): 1063-80.

David-Ferndon, C., & Kaslow, N.J., (2008).  Evidence-based psychosocial treatments for child and adolescent depression. Journal of Clinical Child Adolescent Psychology, 37(1): 62-104.

Fristad, M.A., & MacPherson, H.A. (2014). Evidence-based psychosocial treatments for child and adolescent bipolar spectrum disorders. Journal of Clinical Child and Adolescent Psychology, 43(3): 339-55.

Leffler, J.M., Riebel, J., & Hughes, H.M. (2014). A Review of Child and Adolescent Diagnostic Interviews for Clinical Practitioners. Assessment, 22(6): 690-703.

Mash, E.J., & Barkley, R. (2007).  Assessment of Childhood Disorders, Fourth Edition Eric J. Mash, Russell Barkley Editors. The Guilford Press: New York, NY.

Youngstrom, E.A., & Youngstrom, J.K. (2005). Evidence-based assessment of pediatric bipolar disorder, Part II: Incorporating information from behavior checklists. Journal of the American Academy Child Adolescent Psychiatry, 44(8): 823-8.

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