Mood disorders in preschool and primary school children

1. Mood disorders in preschool and primary school children Catina Feresin Department of Medicine, University of Padua, Italy International Conference on Education for Development Department of Educational Sciences University Juraj Dobrila Pula, april 2013

2. IntroductionIn 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.

3. 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.

4. 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;

5. (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.

6. First aim of this talk(1)To describe the principal types and symptoms of mood disorders among preschool and primary school children.

7. There are two types of mood disorders1-depressive disordersmajor depressive disorderdysthymic disorder2-bi-polar disordersbi-polar I disorder bi-polar II disorder

8. 1-Depressive disordersMajor 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.

9. 2-Bi-polar disordersBi-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.

10. 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

11. Sadness / IrritabilitySadness 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.

12. 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).

13. Sadness in depressive disorders(primary school children)

14. Sadness in depressive disorders (preschoolers)

15. Irritability in bi-polar disorders (preschoolers)

16. 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).

17. Difficulty in concentratingDifficulty 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.

18. 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.

19. Negative self-evaluation-Guilt / Grandiose notion of selfNegative self-evaluation is a cognitive-emotional symptom among children suffering of depression or bi-polar disorder during depressive episodes.

20. 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.

21. 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).

22. 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.

23. Recurrent thoughts of death and suicidal ideationRecurrent 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

24. Fatigue/HyperactivityTeachers 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.

25. Changes in appetiteA 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).

26. Pain complaints without medical causePain 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.

27. Sleep disordersThis 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).

28. 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.

29. The teacher may notice this symptom when pupil loses concentration and takes short naps on his/her desk.

30. Second aim of this talk(2)To describe the principal therapies used by clinicians to treat mood disorders among preschool and primary school children.

31. 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).

32. Play therapyPlay 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.

33. Play therapy

34. Verbal therapyVerbal 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.

35. AntidepressantsThere is a common concern regarding antidepressant pills in preschoolers: indeed, clinicians are against this treatment for children that young (see Luby, 2009).

36. 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).

37. Antidepressants pills

38. 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.

39. 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.

40. 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.

41. 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.

42. 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.

43. 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).

44. Third aim of this talk(3)First research proposal:Parent-child therapy should include a teacher when caregiver shows affective disorders.

45. 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.

46. 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.

47. 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).

48. 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).

49. Functional magnetic resonance imagingFunctional 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.

50. fMRI apparatus