1. Pediatric Depression- can we get them early? Ayesha Mian M.D. National Health Symposium The Aga Khan University

2. Objectives At the end of the session participants will be able to –Recognize signs and symptoms of pediatric depression –Appreciate the burden of depression in children with chronic illness –Appreciate the need for early recognition of depression in the pediatric population

3. Do children get depressed?

4. Depressed Children- Oxymoron Historic Denial Lack of training Shame/Stigma Overlap of symptoms Mistaken for normal development Safety of drug therapy Societal pressures/ economic burden

6. Depression in Children

7. WHY? Biological Psychosocial

8. Depression in Children Point prevalence- 2% children and 8% adolescents meet criteria for MDD. 1 in 5 teens have experienced depression at some point Boys: Girls = 1:1 Boys : Girls = 1:2 (Adolescence) > 50% kids will have recurrence within 7 yrs. –Family Hx; stressful life events

9. Depression in Children Episode lasts 6-9 months During an episode children –Do less well in school –Have impaired relationships with frds & family –Internalize their feelings –Have increased risk of suicide

10. Depression in Children Signs that a child should be evaluated –Feeling persistently sad or blue –Talking about suicide or ‘better off dead’ –Increased irritability –Marked deterioration in school/home functioning –Persistent physical complaints/visits to nurse –Failure to engage in prev. pleasurable activities –Abusing substances

11. Depression in Children Early-onset depression often persists, recurs, and continues into adulthood. Depression in youth may also predict more severe illness in adult life. Depression in young people often co- occurs with other mental disorders, –most commonly anxiety, disruptive behavior, or substance abuse disorders, and with physical illnesses, such as diabetes.

12. Objectives At the end of the session participants will be able to –Recognize signs and symptoms of pediatric depression –Appreciate the burden of depression in children with chronic illness –Appreciate the need for early recognition of depression in the pediatric population

13. Depression and Chronic Illness In a study from China –17.6% youth with DM type 1 reported depressive symptoms –DM self management was lower –Depressive Sxs associated with family annual income, school attendance, peer relationship and parent-child relationship –Mean HBA1c was 9.68% –Guo J et al. J Clin Nurs. 2013 Jan;22(1-2):69-79. Diabetes self-management, depressive symptoms, quality of life and metabolic control in youth with type 1 diabetes in China.

14. Depression and Chronic Illness The presence of parental depressive symptoms influences both youth depression and poor metabolic control through problematic parenting practices such as low involvement and monitoring. Eckshtain D et al. J Pediatr Psychol. 2010 May;35(4):426-35. The effects of parental depression and parenting practices on depressive symptoms and metabolic control in urban youth with insulin dependent diabetes.

15. Depression and Chronic Illness Youth who have high levels of depressive symptoms in adolescence tend to continue to have such symptoms in early adulthood. Insabella G. Pediatr Diabetes. 2007 Aug;8(4):228-34.The transition to young adulthood in youth with type 1 diabetes on intensive treatment.

16. Depression and Chronic Illness Co-morbid depression and Asthma in children has been shown to be associated with heightened inflammation.

17. Obesity Obese children more likely to have –Activity restrictions, internalizing problems, externalizing problems, grade repetition, school problems and missed school days –ADHD, conduct do, depression, learning disability, DD, bone/joint problems, asthma, allergies, HA, metabolic issues and ear infections all more common. –Halfon N. Et al. Acad Pediatr. 2013 Jan-Feb;13(1):6-13. doi: 10.1016/j.acap.2012.10.007. Epub 2012 Nov 30. Associations between obesity and comorbid mental health, developmental, and physical health conditions in a nationally representative sample of US children aged 10 to 17.

18. Objectives At the end of the session participants will be able to –Recognize signs and symptoms of pediatric depression –Appreciate the burden of depression in children with chronic illness –Appreciate the need for early recognition of depression in the pediatric population

19. Kindling "kindling effect", or "kindling-sensitization hypothesis." According to this hypothesis, initial depressive episodes create changes in the brain's chemistry that make it more likely that future episodes of depression will develop “It suggests that the neurobiology of affective disorder is a moving target and changes as a function of the longitudinal course of illness” (Post, 1992, p. 1005).

20. Kindling At least 60% of individuals who have had one depressive episode will have an- other, 70% of individuals who have had two depressive episodes will have a third, and 90% of individuals with three episodes will have a fourth episode (American Psychiatric Association, 2000; Solomon et al., 2000).

21. Kindling Such thinking is poignantly captured by Kraepelin’s (1921) classic observation about a patient who became depressed “... after the death first of her husband, next of her dog, and then of her dove” (p. 179). Can we capture them early to mute the ‘kindling effect’???

22. Treatment Bio-Psycho-Social Model –Medications –Therapy- CBT, Play therapy, Parent Management Training –Social- school, exercise, hobbies, role modeling