Mood disorders in preschool and primary school children

Catina FeresinDepartment of Medicine, University of Padua,

Italy

International Conference on Education for Development

Department of Educational SciencesUniversity Juraj Dobrila

Pula, april 2013

Introduction

In the last few years a number of researchers has pointed out that the seriousness of mood

disorders among preschool and primary school children is still underestimated when

compared to the seriousness of the same illness during adolescence and adulthood.

In spite of that, many pupils are not yet diagnosed and treated. Without any

treatment, this illness can lead to severe psychiatric problems in the future

adolescents and adults who have been affected during their childhood.

Principal purposes of this talk:

(1)-firstly, to describe types and main symptoms of mood disorders to help preschool and primary school teachers to clearly recognise them;

(2)-secondly, to describe treatments used today by clinicians to cope with mood disorders;

(3)-thirdly, to suggest a new study regarding close cooperation between clinicians and teachers to be held during the last two years of preschool;

(4)-finally, to suggest another research, about close cooperation between clinicians and teachers to be held during the last two years of primary school.

First aim of this talk(1)

To describe the principal types and symptoms of mood disorders among preschool and primary

school children.

There are two types of mood disorders

1-depressive disordersmajor depressive disorderdysthymic disorder2-bi-polar disordersbi-polar I disorder bi-polar II disorder

1-Depressive disorders

Major depressive disorder is a severe condition characterised by one or more major depressive episodes lasting at least two weeks.Dysthimyc disorder is a mild disorder, but is more persistent, in fact children are depressed for most of the day on most days and symptoms may continue for about one year.

2-Bi-polar disorders

Bi-polar disorder I is considered the classic form of manic depression, with full manic episodes followed by major depressive episodes.Bi-polar disorder II involves again major depressive episodes followed by hypo-manic instead of full manic episodes.

Main symptoms of mood disorders

-Sadness / Irritability-Loss of pleasure (anhedonia)-Difficulty in concentrating-Negative self-evaluation Guilt / Grandiose notion of self-Recurrent thoughts of death-Fatigue / Hyperactivity-Changes in appetite-Pain complaints without medical cause-Sleep disorders

Sadness / Irritability

Sadness is one of the most significant emotional-cognitive symptom among depressed children (usually, bi-polar

children often show more irritability than sadness). During major depressive episodes,

pupils perceive a deep sadness or cry without being able to understand the reason

for why they are behaving this way.

Teachers can observe this crucial symptom for a few weeks (at least two weeks

according to the criteria of DSM IV (A.P.A., 2000); and, if it disappears before two

weeks, it is not connected with depression (e.g. the pupil may have lost a good friend

or may have changed school).

Sadness in depressive disorders(primary school children)

Sadness in depressive disorders (preschoolers)

Irritability in bi-polar disorders (preschoolers)

Loss of pleasure/(anhedonia)

Depressed or bi-polar children during depressive episodes show a clear emotional-

cognitive symptom: they do not feel pleasure in anything, lose their normal desire

to play with classmates (i.e. they stop participating to games activities).

Difficulty in concentrating

Difficulty in concentrating is again an emotional-cognitive symptom. It is a simple

task for a trained teacher to notice if students cannot concentrate very much.

Indeed, depressed or bi-polar children during both depressive as manic episodes have their minds busy all day long, while attention is directed towards themselves,

negatively influencing their ability to concentrate on common activities at school.

Negative self-evaluation-Guilt / Grandiose notion of self

Negative self-evaluation is a cognitive-emotional symptom among children

suffering of depression or bi-polar disorder during depressive episodes.

Teachers are generally required to observe not only if negative self-evaluation affects

school performance, but also if it influences the perception of pupil's physical aspect and

his/her social ability to integrate with friends.

Guilt is also an emotional-cognitive symptom: depressed children feel guilty

more often compared to children who do not suffer from depression. In this case, teachers

are asked to notice whether these pupils blame themselves also for facts which are

not responsible for (i.e. separation between their parents).

Bi-polar children, during manic or hypo-manic episodes, often suffer of grandiose

notion of self, showing an increased level of talking and feeling euphoric: teachers are able to observe clearly this cognitive and emotional symptom, especially when it

follows a period of negative self-evaluation.

Recurrent thoughts of death and suicidal ideation

Recurrent thoughts of death and the idea of committing suicide without a specific plan is an emotional-cognitive symptom (although not very common) among primary school

children suffering of depression or bi-polar disorder during depressive episodes

Fatigue/Hyperactivity

Teachers can easily observe if pupils are tired during classes: fatigue is a very

common physical symptom among children suffering of depression or bi-polar disorder

during depressive episodes.Children who suffer of hyperactivity show an increased energy. This symptom is very

frequent during manic and hypo-manic episodes in bi-polar children.

Changes in appetite

A decrease/increase in appetite may cause an unbalanced growth of child's body

causing possible serious physical disorders.

A decrease in appetite is considered a physical symptom and is usually connected with depressive disorder or bi-polar disorder

(during depressive episodes).

Pain complaints without medical cause

Pain complaints are considered symptomatic when there is no objective illness. This

physical symptom is usually connected with major depressive disorder and its severity is

given by the intensity of pain and the frequency of occurrence.

Sleep disorders

This physical symptom is divided into insomnia, if child sleeps less than his/her necessity and hypersomnia, when child

sleeps longer than his/her necessity (he/she often has difficulty getting up in the

morning).

Among preschool and primary school children, nightmares during REM sleep are very common and often disturb the quality of sleep; on the contrary, night terrors (i.e. restless leg, sleepwalking) are a common findings in children affected by bi-polar disorders and occur during deep sleep.

The teacher may notice this symptom when pupil loses concentration and takes short

naps on his/her desk.

Second aim of this talk(2)

To describe the principal therapies used by clinicians to treat mood disorders among preschool and

primary school children.

Principal therapies to treat mood disorders

-Play therapy (preschoolers)-Verbal therapy (primary school children) -Antidepressants (primary school children) -Parent Child Interaction Therapy (P.C.I.T.) and Emotion Development Therapy (E.D.) combined (preschoolers).

Play therapy

Play therapy is a common therapy for very young children. The psychologist makes use

of techniques engaging the child in recreational activities, observing the child while he/she is playing with a variety of

toys, expressing in this way his/her unpleasant feelings which cannot be

communicated verbally.

Play therapy

Verbal therapy

Verbal therapy is very helpful for primary school children, but not for very young

children who haven't developed the verbal level to correctly express their feelings, lacking the linguistic sophistication to

describe any kind of emotional experience.

Antidepressants

There is a common concern regarding antidepressant pills in preschoolers: indeed,

clinicians are against this treatment for children that young (see Luby, 2009).

Regarding primary school children, medication, such as antidepressants, may be

used only in severe cases of depression, (Bailly, 2006). Clinicians prefer to make use

of mood stabilizers instead of antidepressants in cases of bi-polar disorder I, because some antidepressants can induce manic episodes (see Kowatch et al., 2005

for an accurate review).

Antidepressants pills

Parent Child Interaction Therapy (P.C.I.T.) and Emotion Development

Therapy (E.D.)

Recently, a parent-child psychotherapy has been developed for the treatment of

preschool depression: it combines two different therapies, such as Parent Child

Interaction Therapy and Emotion Development Therapy.

The former (P.C.I.T.) comes from the common knowledge that the child is not an independent entity at this early age and the

caregiver is a fundamental part of the child’s psychological world and plays a key role in

the therapy.

The latter (E.D.) is designed to enhance the child emotional developmental capacities through the use of emotional education.

Parent Child Interaction Therapy-Emotion Development (P.C.I.T.-E.D.) combines the

use of emotional education by enhancing the caregiver’s capacity to serve as an effective

external emotion regulator for the child.

By using this therapy, the clinician hopes that children will learn to handle depressive symptoms and parents will reinforce those lessons. All this is based on the hypothesis that depressed children will be less reactive

to positive stimuli and more reactive to negative stimuli than healthy children.

The first goal of this therapy is to enhance the child’s capacity to identify emotions in self and other people;

the second goal is to teach the child to develop healthy emotions;

the third goal is to enhance the child's capacity of experiencing positive affect at high intensity as well as the capacity to recover from negative affect.

During a single session, the therapist observes the interaction between the child

and the caregiver through a one-way mirror. The setting contains also a microphone and

an earbud allowing a more effective interaction (see Luby, 2009).

Third aim of this talk(3)

First research proposal:Parent-child therapy should

include a teacher when caregiver shows affective disorders.

It is well known that depression runs in families: children affected by depressive

disorders often have a parent affected by the same illness. The two relevant causes of

depression in children are:

1) living with a depressed parent;

2) inheriting depressive traits from him or her.

Very recently, Feresin, Mocinić and Tatković (2013) suggested to include in a

PCIT-ED session the teacher who is affectively close to both the child and the

parent/caregiver.

The teacher has to interact with the caregiver in order to help him/her to

participate effectively in the treatment.

At the beginning of the program, the teacher educates himself attending specific classes, reading scientific papers and books about

mood disorders in children. Then the teacher is trained by the psychologist to help the

caregiver to participate more actively in the treatment (in the meantime, the caregiver

requires an individual psychotherapy).

To receive a direct and more objective confirmation of the validity of the change brought to PCIT-ED (i.e. the presence of a teacher) a further research is needed which directly studies preschoolers' brain by using a functional Magnetic Resonance Imaging

(fMRI).

Functional magnetic resonance imaging

Functional magnetic resonance imaging is an MRI procedure that measures brain

activity by detecting associated changes in blood flow. This technique relies on the fact

that cerebral blood flow and neuronal activation are coupled. When an area of the

brain is in use, blood flow to that region also increases.

fMRI apparatus

The procedure is similar to MRI but uses the change in magnetization between oxygen-

rich and oxygen-poor blood as its basic measure.

The resulting brain activation can be presented graphically by color-coding the

strength of activation across the brain or the specific region studied. The technique can

localize activity to within millimeters.

For example, this brain scan represents the activation of the amygdalae during a

specific emotional task (reddish spots).

Nowadays, researchers are starting to study brain functions in depressed preschoolers by

means of fMRI.

A paper by Gaffrey and colleagues has indicated that depressed preschoolers

exhibited a significant positive relationship between depression severity and amygdalae activity when viewing facial expressions of

negative affect (Gaffrey et al., 2011).

According to Feresin, Mocinić and Tatković (2013) another experiment is needed for

studying the activation of depressed preschoolers'amigdalae in response to facial

expression of negative affect.

The new experiment must compare two experimental conditions: a first condition in

which the teacher is present during the therapy (P.C.I.T.-E.D.) and a second

condition in which the teacher is absent.

Then, reproducing Gaffrey's results, the activation of the amygdalae can be

compared with the degree of depression, when children are viewing facial expressions of negative affect.

If the idea of combining teacher and caregiver is correct, a slight positive statistic correlation or no correlation at all should be

found between the severity of depression and the activity of amygdala, in the

condition in which the teacher is present.

This hypothetical result should mean that the child is learning how to deal with negative emotions to fight depression.

Fourth aim of this talk(4)

Second research proposal:A three steps precocious

prevention program to be held at primary schools as a possible way

to fight mood disorders.

Primary schools are generally doing a limited job for precociously identifying

children affected by mood disorders.Possibly, it is a result of the failure to

recognise prevention as a crucial mental health service.

According to Mocinić and Feresin (2012), a program on a large scale should be

developed and applied during the last two years of primary schools, when the children' knowledge of mother tongue is comparable

to adolescents and when the pupils can easily follow a written test.

All children should be screened for possible mood disorders, just as they are screened for

visual acuity or other health problems.

Many valid tests can be used to collect data for identifying children who might suffer of mood disorders; the most famous of them are: The Child Behaviour Checklist and The Children's Depression Inventory (Achenbach, 1991; Kovacs, 1992).

After the screening is completed, a diagnosis can be started by a trained clinician who is able to interpret the results of the previous

mentioned tests. A precise diagnosis of depression is a

complex task, extremely difficult for even highly skilled clinicians. It requires a careful examination of physical, mental, emotional, environmental, and cultural factors related

to the child.

At the end of the process, a treatment plan is traditionally coordinated by a school

psychologist who uses a verbal therapy helping the depressed child to change

his/her distorted view of himself/herself and improving his/her social skills.

Traditionally, teachers are not expected to diagnose depression in children: usually, the

major role of educators is to detect the symptoms of depression, to keep notes and

make appropriate referrals to school psychologists.

However, quite recently, Vulić-Prtorić suggested a more close collaboration

between educators and clinicians (Vulić-Prtorić, 2007): school psychologists may ask teachers to collaborate with them during the treatment itself: for instance, educators can participate to therapy, giving the pupil an

emotional support.

Teachers may also understand depressed pupils with patience and encouragement, making them talking, listening to them carefully, without underestimate their

feelings, but offering them a real hope of solving depression.

Clinicians and teachers can provide a supportive environment not only during the therapy but also during classes: teachers can invite school psychologists to join collective

activities inside the classroom, helping depressed children to develop positive relationships with peers and to enhance

optimistic feelings.

According to Mocinić et al. (2012), during the phase of test assignment, mentioned in a

previous slide, teachers can help school psychologists to allot the tests to the entire

class.

It is understood, that many children continue to attend school during the time they are being assessed for depression; therefore,

they will benefit from a close collaboration between their educators and the school

psychologist.

Mocinić et al. (2012) claimed that bringing together educators and clinicians may be a

good practise to fight depression during childhood.

This is because a multidisciplinary team, who organises regular meetings, will be able to sustain the child to solve mood disorders before he/she shall become an adolescent.

Conclusion

The three steps program, the presence of the teacher when the caregiver is depressed and the use of fMRI apparatus are probably very expensive from an economic point of view.

However, the cost of depression for future adolescents, adults and society is even more expensive than organising these researches and applying these programs during the last two years of preschool and primary schools.

Selected references:

ACHENBACH T.M. (1991). Child Behavior Checklist/4-18. Manual for the Teacher's Report Form Profile, Department of Psychiatry, University of Vermont, Burlington, USA.

AMERICAN PSYCHIATRIC ASSOCIATION (2000). DSM IV-TR: Diagnostic and statistical manual of mental disorders (4th ed., Text revision). Washington, DC, USA.

BAILLY D. (2006). Safety of selective serotonin re-uptake inhibitor antidepressants in children and adolescents. Press Med., 35, 1507-1515.

FERESIN C., MOCINIĆ S., TATKOVIĆ N. (2013). Should Parent-Child Therapy include teachers to treat depressed preschoolers when caregiver shows affective disorders? Školski vjesnik-Journal for Education and School Issues, 62 (1), 75-84.

GAFFREY M.S., LUBY J.L., BELDEN A.C., HIRSHBERG J.S., BARCH D.M. (2011). Association between depression severity and amygdala reactivity during sad face viewing in depressed preschoolers: an fMRI study. Journal of Affective Disorders, 129 (1-3), 364-70.

KOVACS M. (1992). Children's Depression Inventory (CDI). New York: Multi-health Systems, Inc.

KOWATCH R. A., FRISTAD M., BIRMAHER B., DINEEN WAGNER K., FINDLING R. L., HELLANDER M., and THE WORKGROUP MEMBERS. (2005). Treatment Guidelines for Children and Adolescents With Bipolar Disorder. Journal Am. Acad. Child Adolesc. Psychiatry , 44 (3), 213-235.

LUBY J.L. (2009). Early Childhood Depression. American Journal of Psychiatry, 166, 974-979.

MOCINIĆ S., FERESIN C. (2012). The importance of collaboration between teachers and school psychologist for helping children to cope with mood disorders. Occasional papers in education and lifelong learning (OPELL): An international Journal, 6 (1-2), 98-108.

VULIĆ-PRTORIĆ A. (2007). Depresivnost u djece i adolescenata, Naklada Slap, Jastrebarsko.

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