5.2.4 Affective Disorders

Affective disorders, also known as mood disorders, are common mental health conditions in children and adolescents that involve disturbances in mood or emotion. This includes conditions such as depression and bipolar disorder.

Depression

Prevalence/Incidence:

The 12-month point prevalence of depression in children and adolescents is 1% before puberty and 3% after puberty. There is no gender difference before puberty, but it becomes more prevalent in females afterwards.
20% of children with depression will later manifest bipolar disorder.

Aetiology:

The stress vulnerability model is valuable in comprehending the emergence of depression. This model suggests that an individual’s susceptibility (genetic factors, hormonal influences, and early family experiences) interacts with social stressors (such as financial hardship and family conflict) to trigger depression during periods of life stress.

Presentation:

Symptoms of depression in children and adolescents include persistent sadness, irritability, low energy, feelings of worthlessness or guilt, and changes in appetite and sleep patterns. Symptoms of bipolar disorder include mood swings, high energy, impulsivity, and changes in sleep and appetite patterns (American Psychiatric Association, 2013).

50-80% meet the criteria for additional non-depressive disorders such as separation anxiety, OCD, ADHD, eating disorder, and other anxiety disorders.

Behaviours:

Affective disorders can be associated with a range of behaviours, including self-harm, substance abuse, and school refusal. Children and adolescents with depression may engage in self-harm as a way to cope with overwhelming emotions. They may also turn to drugs or alcohol to numb their feelings. School refusal is also common, as children and adolescents with affective disorders may struggle with anxiety or lack of motivation (Masi et al., 2016).

Treatment:

Treatment for depression in children and adolescents typically involves a combination of medication and psychotherapy. Psychotherapy can help children and adolescents develop coping skills and improve their emotional regulation. Family therapy may also be recommended to help improve communication and reduce conflict within the family (NIMH, 2021).

Treatment Level	Intervention
Mild Depression (Tier 1 or 2)	Up to 4 weeks of ‘watchful waiting’ with family contact. If symptoms persist, offer 2-3 months of individual non-directive supportive therapy, group CBT, or guided self-help. If unresponsive, refer for Tiers 2/3 review and treat as moderate to severe depression.
Moderate to Severe Depression	Offer individual CBT, IPT, or family therapy for at least 3 months as first-line treatment. If unresponsive after 4-6 sessions, multidisciplinary review and consider alternative/additional psychological therapy and pharmacotherapy. If unresponsive after a further six sessions, a comprehensive multidisciplinary review and consider alternative psychotherapy, including child psychotherapy. Consider inpatient treatment if the child/young person is at high risk of suicide, serious self-harm, and self-neglect, or when the required intensity of treatment (or supervision) is not available elsewhere, or for intensive assessment.
Medication	Limited evidence that SSRIs increase the risk of suicidal ideation and/or behaviour and discontinuation of treatment due to adverse events. First line: Fluoxetine (10mg daily, increase to 20mg after 1 week if necessary). Second line: Sertraline or Citalopram. TCAs, venlafaxine, and St John’s wort are not recommended. Continue medication for at least 6 months after remission, then phase out over 6-12 weeks.

Bipolar Disorder

Prevalence/Incidence:

Bipolar disorder is uncommon in children before puberty, with a prevalence of around 1% in teenagers. Genetic factors play a significant role, as there is a fourfold increased risk of mood disorders in children whose parents have bipolar disorder.

Aetiology:

The aetiology of bipolar disorder in child and adolescent patients is multifactorial, involving a complex interplay of genetic, biological, and environmental factors. Genetic predisposition plays a significant role, with a higher risk of developing the disorder observed in children of parents with bipolar disorder. Neurobiological factors, such as neurotransmitter imbalances and brain structure abnormalities, also contribute to the development of the disorder. Additionally, environmental factors like exposure to stressful life events, trauma, and family dysfunction can trigger or exacerbate the onset of bipolar disorder in vulnerable individuals.

Presentation:

The presentation of bipolar disorder in children and adolescents will vary based on the current phase of the disorder. Depressive episodes, refer to the symptoms of depression in young individuals. When experiencing hypomania or mania, a child may appear overly active, require less sleep, exude excessive self-confidence, display grandiosity, and challenge authority. These individuals often exhibit irritability, rapid speech, and racing thoughts, and may engage in aggressive or violent behaviour. Poor concentration can negatively impact their academic performance. Additionally, they may demonstrate overspending, sexual disinhibition, and engage in risky activities. The presence of psychotic symptoms is also possible, as are mixed affective states.

Comorbidity:

• ADHD (70%)
• Substance abuse (40%)
• ODD (40%)
• Anxiety disorders (30%)
• Tourette’s syndrome (8%)
• Bulimia nervosa (3%).

Treatment:

Management Aspect	Child & Adolescent Bipolar Disorder
Acute Mania	NICE recommends Aripiprazole for up to 12 weeks for moderate to severe manic episodes in individuals aged 13+ with bipolar I disorder. Follow other adult treatment recommendations (starting at lower doses). Medication monitoring as per guidelines. Avoid routine use of valproate in girls of childbearing age.
Depression	Monitor and support if mild. Offer psychological therapy (e.g., CBT, IPT) for at least 3 months if moderate to severe. Consider medication as per adult guidance (with dose reduction) if the episode is severe.
Long Term	Consider an atypical antipsychotic with less weight gain and no increase in prolactin levels. For females, consider lithium; for males, consider valproate or lithium as a second-line.
Psychological Interventions	Psychoeducation and relapse prevention and support for individuals and family. CBT IPT Family therapy

An Understanding of How Affective Disorders Relate to Behaviour (e.g. Self-harm, Refusal to Attend School etc.) and Contexts (e.g. Pre-school Behaviours)

In children, affective disorders can manifest in various ways, and some common symptoms include:

• Feelings of sadness, hopelessness, or worthlessness
• Irritability, anger, or hostility
• Changes in appetite or sleep patterns
• Difficulty concentrating or making decisions
• Fatigue or loss of energy
• Thoughts of death or suicide

These symptoms can lead to a range of behaviours that can be challenging for children and their caregivers. For example, children with affective disorders may engage in self-harm, such as cutting or burning themselves, as a way of coping with their emotional distress. They may also refuse to attend school, avoid social situations, and have difficulty with daily tasks such as bathing and eating.

The behaviours associated with affective disorders in children can also be influenced by the context in which they occur. For example, preschool-aged children with affective disorders may exhibit behaviours that are different from those seen in older children or adults. Young children may have difficulty expressing their emotions and may exhibit behaviours such as tantrums, separation anxiety, and clinging to caregivers.

Environmental factors can also play a role in the relationship between affective disorders and behaviours in children. For example, children who experience stressful or traumatic events, such as abuse or neglect, are at higher risk for developing affective disorders, and their behaviours may be shaped by these experiences.

Overall, affective disorders in children can have a significant impact on their behaviours and functioning in various contexts. Understanding the symptoms and behaviours associated with affective disorders in children can help caregivers provide appropriate support and treatment to help them manage their condition and improve their quality of life.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.
2. Masi, G., Millepiedi, S., Mucci, M., Bertini, N., Milantoni, L., & Pfanner, C. (2016). Suicide ideation and behavior among children and adolescents with mood disorders: A systematic review of the literature. European Psychiatry, 33, 1-13.
3. National Institute of Mental Health. (2021). Mood disorders. Retrieved from http://www.nimh.nih.gov/health/topics/mood-disorders/index.shtml
4. Thapar, A., Collishaw, S., Pine, D. S., & Thapar, A. K. (2012). Depression in adolescence. The Lancet, 379(9820), 1056-1067.
5. Uher, R., & McGuffin, P. (2010). The moderation by the serotonin transporter gene of environmental adversity in the aetiology of mental illness: review and methodological analysis. Molecular Psychiatry, 15(1), 18-36.