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Introduction
 Appear in children of all ages.
 Mood disorders among children &
Adolescents have been increasingly
diagnosed & treated with variety of
modalities.
 Depressive disorders & Bipolar I disorders
are generally episodic, onset may be
insidious.
 Co-morbidity is also common in children.

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 Epidemiology
 Mood disorders increase with increasing age.
 Mood disorders in pre-school age is extremely
rare (0.3% in community & 0.9% in clinical
setting).
 In School age – 2% in community.
 In Adolescents -5% in community.
 In Hospitalized children & Adolescents about
20% of children & 40% Adolescents are
depressed.
 In school age children –Dysthymic disorder is
0.5 times more prevalent.
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 In adolescents dysthymic disorder is less
common than major depressive disorder.
 The prevalence rate is about 3.3% for
dysthymic disorder & 5% for depressive
disorder.
 The lifetime rate of Bipolar I Disorder is 0.6% in
community study of Adolescents.
 Depression is more common in boys than girls
among school age children.

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 Etiology
1) Genetic Factors:-
 Increased incidence is found if parents are
having Mood disorders.
 Having one Depressed parent double the risk
for offspring.
 Studied of twins & adopted studies support this
hypothesis.

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2) Biological factors:-
 Depressed children secrete more GH during
sleep.
 Dysregulation of central serotonergic or
noradrenergic systems.
 Children with mood Disorder showed a low
frontal lobe volume & a high ventricular
volume.
 Downward shift of thyroid hormone contribute
to depression.

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3) Other Organic factors:-
 Major depressive disorder sometime follows
head injuries, viral infections & cerebral
diseases.
 Metabolic abnormalities affecting monoamine
neurotransmitters & cartisol metabolism may
also lead to mood disorders.

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4) Environmental factors:-
 Predisposing or vulnerability factors- early parental loss
& separation.
 Disturbance in infant-mother relationships.

 Precipitating factors- threatening life events.

 Children live in families characterized by high level of

expressed emotions lead to Bipolar Disorder.

5) Social factors:-
 Social events like- parental marital status, number of
siblings, family’s socioeconomic status, parental
separation, divorce, marital functioning plays much role
in causing depressive disorder in children.
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Clinical features:-
 Major depressive episode:-
 Onset is insidious, may occur after
hyperactivity, SAD & IDS.
 According to DSM-IV five symptoms must be
present for a period of 2 weeks & must be
change in previous functioning.
 Depressed or irritable mood. Loss of interest or
pleasure.

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 Other symptoms from which the other four diagnostic
criteria are drawn are-

 Failure to make expected weight gains & loss of

appetite.
 Daily insomnia or hypersomnia.
 Psychomotor agitation or retardation.
 Sudden or gradual marked lowering of mood & daily
fatigue or loss of energy.
 Retardation of movement, speech, occasionally
agitation & pressure of talk.
 Thought of unworthiness, guilt, hopelessness about
future, desire of death, suicidal behavior may present.
 Delusions & Hallucinations are usually absent. 10
 In Hypomanic episode:-
 Elevation of mood with excitement & pressure of
speech.
 Irritability is prominent features.
 The teenager will be unduly energetic & requires
less sleep then usual.
 Disinhibited behavior may lead to financial
extravagance or sexual misdemeanors.
 Youngsters may have inflated ideas of his own
capacities that may reach a delusion levels.
 Hallucinations may occur but rare.
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 Bipolar I Disorder:-
 According to DSM-IV the diagnostic criteria for
manic episode are same for children
adolescents & adults.
 It includes elevated, expansive or irritable mood
that lasts for 1 week or any duration if
hospitalization is required.
 At least 3 of the following symptoms- Decreased
need for sleep, pressure of talk, racing of
thoughts, distractibility, increase in goal directed
activities & excessive involvement in pleasurable
activities.
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 Delusions & Hallucinations are of adolescents
may involve grandiose notions about their
power, worth, knowledge, family &
relationships.
 Persecutory delusions & flight of ideas are
common.
 Gross impairment in reality testing is common
in adolescents manic episode.

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 Assessment:-
 Full assessment is required with special
attention on family history & possible PPT
events.
 In MSE consider carefully suicidal behavior.
 Organic diseases should be excluded.
 ADHD, Anxiety disorders, Schizophrenia &
Substance Abuse should be ruled out.
 School performance & interpersonal
relationships should be assessed to determine
youth’s functional impairment & educational
needs.
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 Management
 Primary Prevention:-
 Primary prevention measures include family
teaching, referral & risk reduction.
 Family teaching about prevalence, causes &
early identification of mood disorders in children
& adolescents.
 Impact of family environment on mental health.
 Risk reduction is by referring for genetic
Counselling.

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 Secondary Prevention:-
 When in a community any child found to have
mood disorders CHN can make referral for
adequate treatment, plan for treatment, find
out cyclical ups & down.
 CHN can explain the therapeutic & toxic
effects of mood stabilizers & antidepressants
on child.

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Treatment:-
 Hospitalization

 Pharmacotherapy

 Psychotherapy

 ECT

 Nursing Management
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 Hospitalization:-
 It is done for safety & to initiate treatment.

 It is also done when there is co-existing

substance abuse & dependence.
 Treatment:-

-Acute Depressive Phase-

 Medication- SSRI 1st choice of treatment.

 ECT

 Counseling & Supportive psychotherapy

 Securing the safety of the patient.

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 Acute Hypomanic Phase:-
 Haloperidol up to 5 mg/kg body wt/day in 3
divided doses. Clonazapin also can be given.
 Counseling & Supportive psychotherapy.
 Securing the safety of the patient.
 Chronic Phase:-
 In teenagers with recurrent attack of acute
disorder Lithium Carbonate is usually an
effective treatment.

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 ECT:-
 If there is no improved with medication ECT
can be used.
 Severely depressive stupor & severe motor
and verbal retardation are also indication for
ECT.
 ECT is less effective in younger age group
than adults.

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 Psychotherapy
 Cognitive behavioral therapy is now widely
recognized as an efficacious intervention for the
treatment of moderately severe depression in
children & adolescents.
 CBT aims to challenge maladaptive belief and
enhance problem solving abilities & social
competence.
 Other ‘active’ treatment including relaxation
techniques are also helpful.

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Counselling or Supportive Psychotherapy
 Although it may be difficult to conduct interview
with a very depressed & mute or unduly excited,
over active teenager, every effort should be
made to form a relationship.
 Brief & frequent sessions are indicated.
 The development of a trusting relationship also
reduces the risk of suicide.
 The family as well as teenager should included in
therapy.
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 Tertiary Prevention:-
 It includes rehabilitation of young people with in
the family & community.
 Prevention of relapses by providing adequate
home environment.
 Focus on compliance.
 Importance of regular follow ups.

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 Course & Prognosis
 The course & prognosis of mood disorders in
children and adolescents depends on the age of
onset, the severity of the episode and the
presence of co-morbid disorder; a young age of
onset & multiple disorder predicts a poor
prognosis.
 The mean length of an episode major depression
in children & adolescents is about 9 months.
 The mean length of dysthymic disorder is 4 yrs.
 The risk of suicide represents 12% mortalities in
the adolescents age group 24
Differential Diagnosis

 Schizophrenia
 Substance-induced mood disorders
 Anxiety symptoms & Conduct disordered
behavior
 ADHD

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 Nursing Management:-
 Nursing Diagnoses for Depressive behavior:-
 Risk for self directed violence r/t delusional
feeling, low self esteem.
 Impaired social interaction r/t depressive feelings
 Altered sleep pattern r/t feeling of helplessness,
hopelessness.
 Low self esteem r/t dysfunctional family system
& negative feedback.

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 Nursing interventions
 Risk for self directed violence r/t delusional feeling,
low self esteem.
 Provide safe environment.
 Young people should be kept on supervision.
 A written contract with the adolescents outlining the
adolescent’s agreement not to involve in suicide
behavior should be taken.
 Opportunity should be provided to these people to
explore relationships and feeling.
 They need to discuss their conflict & develop
realistic expectations with strategies to meet them.
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 Impaired social interaction r/t depressive feelings
 A trusting relationship should be established.
 One to one relationship should be established.
 Care is implemented by staying with young people
both physically & emotionally when they say ‘leave me
alone’.
 Group situation should be provided.
 Small tasks are provided to complete.
 Support & encouragement are necessary to give them
confidence that they can meet realistic expectations.
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 Altered sleep pattern r/t feeling of
helplessness, hopelessness.
 To induce sleep common method like milky
drinks, bedtime stories, warm beds, dark & quite
rooms can be used.
 The aim of nursing must be caring in safe
environment which than promotes sleep.
 Encouraging activity during day may create
physical tiredness & promote sleep during night.
 They are encouraged to adjust to normal sleep
pattern by performing daily tasks & retire at a
reasonable hour.
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 Low self esteem r/t dysfunctional family system
& negative feedback.
 Ensure that goals are realistic.
 Convey unconditional acceptance & positive
regard.
 Offer recognition for successful endeavors &
positive reinforcement for attempts made.
 Undesirable behavior must be limited by removing
the opportunity to flit from task to task.

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 Nursing Diagnoses for Manic behavior:-
 Risk for violence self or others directed r/t hostility,
disordered thought.
 Altered social interaction r/t disease condition.
 Altered nutrition less than body required r/t refusal
or inability to sit still.
 Altered sleep pattern r/t restlessness & disturbed
thought process.

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 Nursing interventions

 Risk for violence self or others directed r/t hostility,

disordered thought.
 Maintain low level of stimuli in client’s environment.
 Maintain constant supervision.
 Ensure that all sharp objects, glass or mirrored
items, belts, ties etc are removed from client’s room.
 Maintain & convey a calm attitude to client.
 Offer tranquilizing medication. If client refuses use
of mechanical restraints.
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 Altered social interaction r/t disease condition.
condition
 Recognize that manipulative behaviors help to
reduce feelings of insecurity by increasing feelings
of power.
 Set limit on manipulative behaviors. Explain what
is expected & the consequences if limits are
violated.
 Ignore attempts by client to argue, bargain or
charm his/her way out of limit setting.
 Help the client to identify positive aspects about
self, recognize accomplishment & feel good about
them. 33
 Altered nutrition less than body required r/t
refusal or inability to sit still.
 Provide high protein, high calorie, nutritious finger
foods & drinks that can be consumed on the run.
 Maintain accurate record of intake, output & wt.
 Provide favorite foods.
 Supplements diet with vitamins & minerals.
 Walk & sit with client while he/she eats.

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 Bibliography:-
 Nobert Rego, When your child is depressed, “Times of
India” 2007, Sept;2(col4).
 Graham P., Turk J. & Verhulst C., Child Psychiatry, III,
Oxford Univ Press, 2000.
 Sadock J. B. & Sadock A. V., Synopsis of Psychiatry,
IX, Philadelphia, Lippincott W & W, 2003.
 Cheng K. & Myers K. M., Child & Adolescents
Psychiatry, Philadelphia, Lippincott W & W, 2002.
 Schultz J. M. & Dark S. L., Manual of Psychiatric
Nursing Care, III, Little Browns & company, 1996.
 W.R. Teresa, Child & Adolescent Psychiatric Nursing,
1st ed, Melbourne, Blackwell Scientific Pub,1983.
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