2025 – PAGE 438 – PSYCHIATRY AND SOME SOCIAL ISSUES

DEPRESSION

To meet the DSM-5 criteria for a major depressive episode, the child must have five of the following symptoms for at least two weeks, with at least one symptom being either depressed mood or loss of interest or pleasure: depressed or irritable mood, diminished interest or pleasure in almost all activities, change in appetite or weight, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, impaired thinking or concentration, and suicidal ideation or behavior. Major depression is defined as a history of at least one or more major depressive episodes in the absence of manic or hypomanic episodes. Functional impairment can affect school, relationships with parents and peers, and daily activities. First-line treatment for moderate to severe depression is a combination of pharmacotherapy (an SSRI such as fluoxetine) and psychotherapy (cognitive behavioral therapy or interpersonal therapy). For the boards, consider depression if a child’s behavior starts to change and interfere with routine life activities (like school). For the exam, pick depression over drug abuse unless something specifically suggests substance abuse. The younger the child, the more severe the depression. Keep in mind the differential is wide and should be explored, including hypothyroidism, nutritional deficiencies, infections, rheumatologic diseases, and drugs.

OPPOSITIONAL DEFIANT DISORDER

Oppositional defiant disorder is characterized by a persistent pattern of negative, defiant, and hostile behavior toward authority figures. Symptoms may include frequent temper loss, argumentativeness, defiance, deliberate annoyance of others, and vindictiveness. Treatment involves behavior therapy, parent management training, and sometimes medications for irritability or coexisting conditions like ADHD.

CONDUCT DISORDER

Conduct disorder involves a repetitive and persistent pattern of behavior that violates societal norms and the rights of others (not just authority figures). Symptoms include aggressive behavior, destruction of property, deceitfulness or theft, and serious rule violations (e.g., truancy, running away). Treatment includes behavioral therapy, family therapy, and medications for coexisting conditions. Consider a second-generation antipsychotic for severe aggression/irritability that affects psychosocial functioning or interferes with first-line therapy.

DIVORCE

Children respond differently to divorce depending on how old they are at the time (like death).

• 5 YEARS OLD OR LESS: Regresses to the most recent milestone.
• 6–9 YEARS OLD: Crying, guilt, fantasies about reunion, fear of rejection.
• 9–12 YEARS OLD: Mourns the loss of a safe family structure. They may be angry at one or both parents.
• TEENS: Act out. Depression. They may isolate themselves and act indifferent. They may have suicidal ideation.

ADOPTION

Adopted children need a medical home to fully address all of their health and developmental needs. Pediatricians play an important role with families by identifying the adopted child’s needs and providing emotional support to the family through the adoption process. Important consideration is made to evaluate environmental, nutritional, developmental, infectious disease, and mental health risks. Internationally adopted children should be screened for for Hepatitis A, Hepatitis B, Hepatitis C, TB, syphilis, HIV, intestinal parasites, and bacterial enteric infection. Children from endemic areas should also be screened for tissue parasites, lymphatic filariasis, and Chagas.

PEARLS: Children may struggle with identity development and feelings abandonment. Internationally adopted children almost always present with developmental delay in at least 1 area and nearly 50% have global developmental delay.