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(Solved) Depression in children and adolescents Depression is a relatively common presentation and needs to be recognised in children and adolescents. Wendy...


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Depression in children and adolescents
Depression is a relatively common presentation and needs to be recognised in children
and adolescents.
Wendy Vogel, MB BCh, MMed, FCPsych (SA)
Head, Clinical Unit, Division of Child and Adolescent Psychiatry, Red Cross War Memorial Children’s Hospital, Rondebosch, Cape Town
Dr Wendy Vogel is a child and adolescent psychiatrist who trained at the University of the Witwatersrand, Johannesburg. She is currently head of the
clinical unit, Division of Child and Adolescent Psychiatry, Red Cross War Memorial Children’s Hospital.
Correspondence to: W Vogel ([email protected]) ‘Depressive disorders are often familial
recurrent illnesses associated with increased
psychosocial morbidity and mortality. Early
identification and treatment may reduce
the impact of depression on the family,
social, and academic functioning ... and may
reduce the risk of suicide, substance abuse
and persistence of depressive disorders into
adulthood. Evidence supported treatment
interventions have emerged in psychotherapy
and medication treatment of childhood
depressive disorders that can guide clinicians
to improve outcomes in this population.’1
This article aims to highlight current best
practice in the management of major
depression in children and adolescents.
Mood changes with feelings of sadness,
misery and unhappiness are common
after disappointments or stressful life
events, and usually the child or adolescent
adapts. A persistent change in mood with
deterioration in functioning is the central
feature of depression.
A study by Kleintjes et al. suggested a
prevalence rate of 8% for depression in
children and adolescents in the Western
Cape.2 International estimates suggest a prevalence rate of 1 - 2% in children (aged
6 - 12 years) and 4 - 8% in adolescents
(aged 13 - 18 years). Importantly, during
childhood boys and girls are equally
affected, while during adolescence girls are
twice as likely to be depressed as boys.3 When a child or
adolescent presents
with a first episode of
depression, a diagnosis
of bipolar mood disorder
cannot be excluded.
Clinical presentation The clinical picture is similar to that seen
in adults but differences may be attributed
to the child’s physical, emotional, cognitive
and social development. Typically, there is a
minimum of a 2-week period of a changed
mood, when the child or adolescent may
appear depressed (Table 1).
Younger children under the age of 6 years
may present with apathy and food refusal. They may be miserable, cry a great deal
and rock. The picture in adolescents closely
resembles that seen in adults. Adolescents
may present with melancholia, behavioural
problems suggestive of a conduct disorder
and suicide attempts. They also may have an
atypical presentation with increased sleep
patterns (hypersomnia) and weight gain. It
is important to diagnose a true depression
in adolescence as opposed to a fluctuating
mood, which is typically seen in adolescents
experiencing hormonal changes. Substance
misuse in adolescence should also be
considered. There must be a change from
the previous level of functioning, with
impairment in friendships and school
performance and other related activities.
Although psychotic symptoms are rare
in younger children, they may present
in adolescence. Psychotic depression is
associated with a family history of bipolar
disorder and psychotic depression. It has
a poorer longer-term prognosis, with an
increased risk of bipolar disorder and
treatment resistance.
Dysthymia is a chronic condition lasting
for at least a year. The features are similar
to those seen in a major depression but less Table 1. Symptoms of depression
• • • • • • • • • • • • • Mood is sad or unhappy, with very little spontaneity
Irritability with nagging, whining and angry outbursts (may be mistaken for ‘naughtiness’)
Loss of interest in usual activities with energy level changes, which may be increased or decreased
Changes in appetite accompanied by weight changes, or ‘fussy’ eating
Changes in sleep pattern
Capacity to have fun is reduced, the child complains of boredom
Self-esteem may be low
There may be social withdrawal such as refusing to visit friends
They may talk less and may express the wish to be dead, with suicidal attempts or ideation
They may express guilt and feelings of hopelessness
Poor concentration associated with depression may be mistaken for attention deficit hyperactivity disorder (ADHD)
They may present with physical complaints such as a headache or sore tummy and somatise
High levels of anxiety may predate the onset of depression 114 CME April 2012 Vol.30 No.4 Depression in children and adolescents
severe. Some children and adolescents may
have a ‘double depression’ – a combination
of a major depressive episode together with
a chronic mood disorder (dysthymia). Major depression in
children and adolescents
may have a self-limiting
course, but there is a
high risk of recurrence.
Risk factors As with many psychiatric disorders, major
depression is thought to be caused by the
interaction of genetic and environmental
factors. Risk factors may be divided into
those that:
pre-dispose or increase the vulnerability to
depression, such as
• family history of depressive disorder
• low levels of parental warmth and high
levels of family conflict
• parental mental health problems
• early or chronic adversity such as abuse,
poverty or social disadvantage
• temperamental or personality characteristics, such as children who are anxious or
self-critical
• precipitate a depressive episode, e.g.
stress-ful life events such as losses,
failures or disappointments
• maintain depression, such as persistent
adversity, e.g. family or peer problems.4 Co-morbid conditions Up to 40 - 90% of children and adolescents
who are depressed have other psychiatric
disorders, with up to 50% having two or more
co-morbidities.1 The following conditions
occur commonly with depression: dysthymia, autism spectrum disorders, anxiety,
disruptive disorders, ADHD, and substance
abuse. These conditions may predate or occur
with the depression. Co-morbid conditions
are important to identify, as they may require
a different intervention. They may also
contribute to treatment-resistant depression. Differential diagnoses Many psychiatric and medical disorders
may mimic depression.1 Anxiety, a chronic
low mood such as is seen in dysthymia and poor concentration and irritability
as part of ADHD may mimic a depressed
mood. Children with an autism spectrum
condition may appear withdrawn and have
a flat affect, which may be confused with
depression. Substance misuse may lead to
dysphoria and mimic depression.
Medical disorders such as hypothyroidism
and anaemia, and patients on medications
such as stimulants, corticosteroids and
contraceptives, may present with symptoms
similar to depression.1
When a child or adolescent presents with
a first episode of depression, a diagnosis of
bipolar mood disorder cannot be excluded.
A careful assessment for a manic or
hypomanic episode needs to be made. A high
family loading of bipolar mood disorder,
the presence of psychosis or medicationinduced hypomania should raise the index
of suspicion for the possibility of a bipolar
mood disorder. Clinical course Major depression in children and
adolescents may have a self-limiting course,
but there is a high risk of recurrence. A
number of factors contribute to a poorer
long-term outcome. This includes a severe
mood disorder, a family history of mood
disorders, psychotic episodes and exposure
to ongoing negative life events.5 • • • • • • • • school feel sad .... are you ever bullied or
do you ever feel sad?’
Ask about specific core symptoms of
depression, such as low mood and
irritability, as listed.
Ask about functioning at home and at
school.
Exclude a physical illness such as
hypothyroidism.
A short mood and feelings questionnaire
(MFQ) may be helpful as part of the
assessment, and also to monitor ongoing
care.6
A mood diary and mood timeline may
help to assess the course of the mood and
triggers.
A detailed developmental and family
history will elicit further risk and
protective factors.
Where possible and appropriate,
additional information may be obtained
from other people who know the child
well, such as the class teacher. Obtain
permission from the child and carers
before obtaining collateral information.
Determine the level of care. If the
depression is mild, it may be managed
on an outpatient basis by the general
practitioner or primary care nurse. A Assessment for depression • Always try to see the child or adolescent
alone. They may have difficulty
verbalising their feelings or may deny
that they feel depressed. Parents/carers
may give valuable information about
changes in level of functioning and other
symptoms, but they may not always be
aware of e.g. recent stressors or sleep
pattern changes.
• Explore ongoing stressors (such as
being a carer or living in a child-headed
household). Also consider abuse or
bullying and co-morbid anxiety.
• Ask nonspecific general questions, such
as ‘Other than your headache/tummy
ache, is anything else worrying you?’ or
‘How is school going?’ and ‘Are there any
difficulties there?’ Other questions such
as ‘Sometimes children who are bullied at April 2012 Vol.30 No.4 CME 115 Depression in children and adolescents Table 2. Factors increasing the risk of suicide
• • • • • • • • • • Increased age
Sex – males tend to complete suicide more frequently than females
Presence of hopelessness
Previous history of suicide attempts
Completed suicide in a family member
Presence of psychosis
Access to lethal weapons, with limited social support
History of aggression and impulsivity
Exposure to negative life events
Substance abuse moderate or severe depression may
need a referral to a child and adolescent
psychiatric service for further outpatient
or even inpatient admission. The level
of severity of the depression, risk factors
for suicide and family/environmental
support should all be kept in mind before
considering admission.
• Always assess suicidal behaviour, selfharm or harm to others. Not all selfharming behaviour has suicidal intent.
Adolescents who engage in repetitive selfharming such as cutting may be doing
so to relieve negative affect and not with
suicidal intent. It is crucial to evaluate risk
and protective factors such as a supportive
family1 (Table 2). The potential for homicidal behaviour
should also be assessed. For both suicidal
and homicidal behaviour it is important
to restrict access to lethal weapons such as
guns. Always assess for negative life events,
as these may contribute to the maintenance
of the depressive episode. Treatment All children and adolescents should be
offered
psycho-education,
supportive
management and involvement of the
family and school where possible. Psychoeducation involves education about
the symptoms, causes and different
treatment options for depression. Written
information, websites and information
about local support groups should be given
to the family. Supportive treatment includes
active listening and reflection, restoration
of hope, problem solving and coping skills.
Encouragement for ongoing treatment is
offered as part of the treatment package.1
Schedule activities and encourage small
new tasks that are enjoyable and rewarding.
Encourage a healthy diet and exercise.
Two forms of psychotherapy have some
evidence to suggest their efficacy, namely
cognitive-behavioural therapy (CBT) and
interpersonal therapy (IPT).
• CBT is the most frequently used, either
individually or in a group. CBT starts
with psycho-education and includes
self-monitoring, e.g. diary keeping,
challenging cognitive distortions and
activity scheduling. Psycho-education,
supportive therapy and some CBT
principles may be managed at primary
care level when the depression is believed
to be mild or moderately severe.
• IPT addresses problem relationship areas,
such as role conflict, transitions or losses.3 116 CME April 2012 Vol.30 No.4 Current evidence suggests that mild to
moderate depression with mild psychosocial
impairment and the absence of clinically
significant psychosis or suicidality responds
to psychological therapy without medication.
If the depression persists beyond 4 - 6 weeks
or is severe, antidepressant medication may
be required. Current evidence suggests that
the selective serotonin re-uptake inhibitor
(SSRI) fluoxetine is the treatment of choice
for adolescents between the ages of 13 and 18
years. It should be used extremely cautiously
in children younger than this as there is no
clear evidence for its use in such cases. As
with all medication, the dose should be low
(sometimes starting as low as 5 mg) and
increased to a therapeutic dose of 20 mg,
which may be increased up to 40 mg in older
adolescents. Always check the response with
the adolescent and parent or carer. Start low
and go slow and give adequate doses for long
periods. Continue for 6 months to 1 year
after remission. Always check outcomes
with the child and adolescent. Concerns
have been raised about an increased risk of
suicide in adolescents taking antidepressant
medication. While there may be a subgroup
of adolescents (particularly those who
are agitated and suicidal) who show an
increased risk of suicidal ideation after the
use of SSRIs, the consensus seems to be
that the benefits of treatment with an SSRI
outweigh the risks1 (Table 3).
Adolescents and children with severe
depression with high levels of co-morbidity
and psychosocial stressors should be
referred to specialist child and adolescent
psychiatry services. There is limited evidence
for specific relapse prevention strategies, but
recognition of stressors and early symptom
identification with early reassessment
and treatment (either psychological or
medication or both) seem beneficial.4 Once
medication has led to remission it should be
continued for at least 6 months, possibly up
to 12 months. Maintenance treatment may
continue for a further year. There are no clear
guidelines as to the duration of maintenance
treatment, and consultation with a child and
adolescent psychiatrist may help to make a
decision. Except for fluoxetine, which has a
long half-life, medication should be slowly
tapered off.1 Monitor for recurrence of
depression. Depression in children and adolescents
can dramatically improve the lives of those
affected by this disorder. Table 3. Side-effects of SSRIs
Common side-effects:
• • • • • • • Headaches
Gastrointestinal symptoms such as stomach ache and diarrhoea
Sleep changes such as sedation or insomnia
Sweating
Sexual side-effects
Tremor
Diastolic hypertension References, websites and recommended books
available at www.cmej.org.za Uncommon side-effects:
• • • • • Activation with increased impulsivity, irritability, agitation and silliness
Bipolar switching
Suicidality
Serotonin syndrome
Bleeding Any therapeutic intervention should involve
the family, mainly the parents/carers. While
there is little empirical evidence for the
use of formal family therapy, the parents
will always be involved in the child’s care
and treatment plan and be able to monitor
improvement, provide support and be part
of a safety plan. Prevention There is limited evidence to show the
effectiveness of primary preventive
programmes. Targeting at-risk populations
and children with dysthymia and anxiety
produced modest results.1 It is also important to identify and treat
any pre-existing depression in mothers
(and presumably fathers) of such children.
Looking at lifestyle changes (such as regular
sleep, exercise, coping plan for stress such as
meditation, exercise and social activities) may
also contribute to prevention of depression.
In summary, if left untreated, depression
in children and adolescents may be a
debilitating condition that has an impact
on their well-being and development.
Although there is still much that is
unknown about the treatment, it is clear
that early recognition and intervention In a nutshell
• Depression occurs in children and
adolescents.
• The sex ratios are equal in children, but
twice as many females as males develop
depression in adolescence.
• Symptoms of depression are similar
to those in adulthood and include low
mood, sleep and appetite changes,
activity level changes, irritability and
ADHD-like symptoms.
• A decline in school performance and
interest in usually pleasurable activities
occurs.
• Mild to moderate depression responds
to supportive therapy, CBT or IPT.
• Severe depression requires the use of
medication, and fluoxetine is the SSRI
of choice.
• Assess for suicide risk and protective
factors.
• Monitor regularly and if responsive
to treatment continue for at least 6
months. SINGLE SUTURE Farmyard antibiotics linked to superbugs
Dosing livestock with antibiotics can be bad for farmers’ health. A strain of MRSA that
causes skin infections and sepsis in farm workers evolved its resistance to antibiotics
inside farm animals. The ST398 strain of MRSA first appeared in 2003 and is prevalent
in USA livestock. Humans who pick it up from animals can become dangerously ill, but
it cannot yet spread from human to human.
A team led by Paul Keim of the Translational Genomics Research Institute in Phoenix,
Arizona, sequenced the genomes of 88 closely related strains of Staphylococcus aureus,
the bug that can become MRSA. Their findings suggest that ST398 was originally a
harmless strain living in humans, which migrated into livestock where it acquired
antibiotic resistance.
For some time microbiologists have been concerned that giving large amounts of
antibiotics to livestock can promote antibiotic resistance. Keim’s study provides a
powerful example, says Ross Fitzgerald of the University of Edinburgh, UK.
Earlier this year the USA Food and Drug Administration announced new restrictions
on using preventive antibiotics in livestock, but the rules cover a small subset of drugs
constituting just 0.2% of antibiotics used on farms. As a result they are not expected to
do much good.
New Scientist, 22 February 2012. April 2012 Vol.30 No.4 CME 117 Copyright of CME: South Africa's Continuing Medical Education Journal is the property of Health & Medical
Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without
the copyright holder's express written permission. However, users may print, download, or email articles for
individual use.

 


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