What are the mood disorders and what are their characteristics? - Chapter 7

What are the developments of mood disorders?

An important aspect of internalizing disorders are mood problems. Children and adolescents who have an unusually sad or euphoric mood, which  are extreme or persistent and interfere with functioning, can be diagnosed with a depressed or manic mood disorder. Nowadays there is increasing attention for mood disorders, for various reasons:

• Promising developments in the identification and treatment of mood disorders in adults.
• Better instruments have been developed to investigate mood disorders in young people.
• Improvements in diagnostic practices have encouraged research into mood disorders among young people.

It is difficult to distinguish between different sub-categories of mood disorders, because many people meet the criteria of more than one disorder.

What is the historical perspective?

For many years the orthodox psychoanalytic perspective has been dominant. According to this perspective, depression was the result of the functioning of the superego and adult ego. For example, because the superego punishes the ego, a certain type of depression occurs. Because the superego in children is not yet fully developed, depression could not occur in them. That is why this subject received little attention.

A second important perspective contributed to the controversy regarding the existence of childhood depression. The concept of masked depression meant that child depression did exist, but that the sad mood and other characteristics of depression were often not present in children. There might have been an underlying depression, but this was masked by other problems (depressive equivalents), such as hyperactivity or delinquency. The idea of ​​a masked depression was problematic because there were no clear guidelines for deciding whether or not a particular symptom was a sign of depression.

This perspective was nevertheless important, because it was at least recognized that depression could also be a major and common problem in children. Moreover, the central idea of masked depression is still really relevant in the terms that depression can exist in children and that this can be expressed in age-related forms that differ from depression in an adult.

The idea that depression and expression are expressed differently in children and adults has contributed to the evolution of a developmental psychopathology perspective. Initially, this perspective stated that behaviours that led to the diagnosis of depression were only temporary developmental phenomena that were common among children in certain age groups. As a result, a distinction was made between temporary periods of sadness, which could be a common phenomenon, and more long-term manifestations of sadness. There is also a distinction between depression as a symptom and depression as a syndrome. One or two depressive behaviours can be seen as typical of a developmental phase. Just think of children in puberty who can be very emotional and insecure. However, a cluster of problems of this kind that interfere with functioning is something that occurs in rather few children.

What is the DSM classification of mood disorders?

The diagnostic categories for mania and depression in the DSM are the same for children and adults . In a unipolar depression , one mood is experienced (often it is about depression). In bipolar depression , both mania and depression are experienced. The DSM describes four types of mood episodes, these are categories that describe depression.

Major depressive disorder is a major depressive episode disorder. Major depressive episode: a period of a depressed mood or reduced interest or pleasure in almost all activities. At least five symptoms must be present for at least two weeks. One of these symptoms must be the first or the second in the list. In addition, the symptoms must interfere with daily functioning. These symptoms are:

• Depressive mood (in children this can be an irritable mood
• Loss of interest or pleasure
• Changes in weight or appetite
• Sleep problems
• Restlessness or slow motion
• Tiredness or loss of energy
• Feelings of worthlessness or guilt
• Difficulty thinking, concentrating or deciding
• Thoughts about death or suicidal thoughts or behaviours

Persistent depressive disorder is a more chronic form of depression in which many symptoms of the major depressive disorder are present for a longer period of time. Symptoms can be less extreme. The depressed or irritated mood, along with two other of the symptoms listed below, must be present for a diagnosis for at least one year. Symptoms can be;

• Depressive or irritable mood
• Little appetite or binge-episodes
• Sleep problems
• Tiredness or low energy
• Low self-esteem
• Concentration problems or difficulty in making decisions
• Feelings of hopelessness

When both chronic and major depression both occur at the same time, this is referred to as double depression.

The fourth category is disruptive mood dysregulation disorder. This is a new disorder added to the DSM-IV. It involves symptoms of persistent irritation and outbursts. Anger is present almost every day most of the day in between the eruptions.

The empirical approach

Syndromes with depressive symptoms have also been established by empirical approaches. This finding is illustrated by the syndromes of the Achenbach instruments. The syndromes with depressive symptoms that often occur together also contain symptoms that are characteristic of anxiety and withdrawn behaviour. This study therefore finds no syndrome with only symptoms of depression.

There is still much doubt about the best definition and classification of depression in children and adolescents. One issue, for example, is determining development-dependent diagnostic criteria, because young people may experience depression differently at different moments in development. In addition, it may be better to classify depression in children dimensionally rather than categorically. Many researchers have chosen to look after children with symptoms of depression, no matter of whether or not they have a mood disorder according to the DSM. This is logical, because many children who do not meet the diagnostic criteria are still limited in their daily functioning and run the risk of developing problems in the future.

Epidemiology

MDD is the most diagnosed mood disorder among children and adolescents. Of the children with unipolar disorder, 80% suffer from MDD, 10% with dysthymia and 10% with double depression. Compared with prevalences at a certain point in time, lifetime prevalences (the amount of people who have been depressed at some point in their lives) show that episodes of clinical depression are fairly common. In addition, the seriousness of the problem becomes even clearer when looking at young people who have depressive symptoms but do not meet the diagnostic criteria. These young people are not included in the prevalence estimates, but do experience limitations in their academic, social and cognitive functioning and have a higher risk of developing disorders.

Age and gender

Depression is less common in young children than in adolescents. No gender differences are found in depression until the age of 12. In the few studies that did find a gender difference before this period, it seems that depression is more common among boys. In adolescence, depression is much more common in girls. The sex difference in MDD is likely to occur between the ages of 12 and 14.

Socio-economic, ethnic and cultural factors

A low socio-economic status is associated with a greater chance of depression. This is probably due to factors such as income, low-educated parents, chronic stress and racial or ethnic discrimination. Little research has been done into the racial and ethnic differences in depression. Corresponding prevalence rates are usually reported for different ethnic groups, with the exception of Latin American girls who are more likely to suffer from depression. In addition, African American boys are more often depressed compared to European peers and African American girls.

Comorbidity

Many depressed children and adolescents also experience other problems. About 40-70% of young people with MDD also meet the criteria of another disorder, and about 20-50% have 2 or more other disorders. It often concerns anxiety disorders, behavioural disorders, eating disorders and drug abuse.

Development of depression

Schwartz describes depression at various stages of development. Children up to two years old do not have the cognitive and verbal skills to reflect on themselves and to mention depressive thoughts. Due to cognitive and language skills, it is likely that depressed behaviour in this age group is manifested and experienced very differently from that in adults. The behaviour of small children who are separated from their parent(s) is similar to behaviour that is shown when there is a depression. These children (and also children of depressed mothers) have eating and sleeping problems, cry a lot, are irritable and look sad.

Depression is also difficult for children of preschool age. Many of the symptoms of later depression are noted in this age group. For this age period it is again difficult to determine how such behaviour is related to depression in older children and whether such behaviour is stable.

For middle childhood (6-12 years) there is more evidence that a pattern of depressive symptoms may be present. From the age of 9, children can verbally express feelings of hopelessness and low self-esteem. However, depressive symptoms in this age group may not yet form a separate syndrome but may be accompanied by symptoms associated with other disorders.

In early adolescence, the expression of depression is similar to the expression of depression in childhood. Later in adolescence, however, the symptoms begin to resemble the symptoms of depression in adults. This is probably related to shifts in biological, social and cognitive development.

There is a clear difference between pre- and post-pubertal depression. Family members of people with post-pubertal depression have a higher chance of a manic disorder, while delinquency and family conflicts are more common among family members of someone with a prepuberal depression. In addition, the continuity of MDD is greater among young people who only became depressed after puberty.

Depressive episodes of adolescents can last for a long time and tend to be recurring. The occurrence of depression before the age of sixteen is related to longer periods of depression than usual. Research has shown that young adults who were diagnosed with MDD or adaptive disorder with a depressive mood before the age of 19 were more likely to meet MDD diagnostic criteria. In addition, follow-up studies indicate that some adolescents with MDD develop bipolar disorder five years after the onset of depression.

What are the biological influences?

Genetic influences

Genetic influences probably play a role in depression in children and adolescents. For example, twin-, adoption- and family studies have shown that there is a heredity component to the disorder. The genetic contribution may be greater for depression in adolescence than for depression in prepubescent children. The heredity of depression also points to the importance of environmental influences and the complex interaction between genes and environment. For example, the genes that affect early anxiety increase exposure to environmental influences that contribute to depression.

What exactly is inherited? Research suggests that genetic factors influence through factors such as temperament, cognitive style and stress reactivity. Extreme depressive symptoms may arise as a result of the presence of these genetic factors and stressful living conditions.

Neurochemistry and the functioning of the brain

Research has shown that the effectiveness of antidepressants in adults depends on the levels of or susceptibility to certain neurotransmitters of individuals. That is why a lot of research is being done on the role of neurotransmitters, such as norepinephrine, serotonin and acetylcholine, in the development of depression.

In addition, research shows that a dysregulation of the neuroendocrine system, which includes the hypothalamus and pituitary gland, can contribute to the development of depression in adults. Examples of neuroendocrine factors investigated in relation to depression are the dysregulation of the stress hormone cortisol and of growth hormones produced by the pituitary gland. These neuroendocrine systems are also regulated by neurotransmitters.

Our understanding of the neurobiology of depression in children and adolescents is still quite limited. There are probably neurobiological differences between depression in adults and depression in children. For example, sleeping problems are associated with depression. Specific EEG patterns during sleep are strong biological indicators of MDD in adults. However, this does not apply to children. These patterns are only reported in older adolescents. Converting the findings for adults to children is therefore not sufficient.

A second example between neurobiological differences between depression in children and adults concerns the role of the stress hormone cortisol. Adults with MDD produce extremely high levels of cortisol in response to stress. However, this does not happen with young children. The amount of excreted cortisol in severely depressed adolescents is more similar to the pattern of cortisol excretion in adults though.

Finally, research shows that depressed adults suffer from anatomical and functional abnormalities in the prefrontal cortex, amygdala and other areas of the brain. Little research has been done on this in children, but there is some evidence that depressed adolescents and children of depressed mothers exhibit structural and functional abnormalities in the same brain areas. Differences in the biological indicators of depression suggest that childhood, adolescence, and adulthood disorder is different. However, these differences may also be a representation of developmental differences in the same disorder.

Temperament

Temperament has a genetic or biological origin but is also influenced by the environment. Research has shown that there is a connection between aspects of temperament and the development of depression. Evidence has been found for the role of negative affectivity (the tendency to experience negative emotions, to be vigilant and to be sensitive to negative stimuli) and positive activity (energetic, social behaviour, sensitivity to reward cues) in the development of childhood depression and adolescents. The contribution of these temperament characteristics takes place in interaction with environmental influences. For example, the relationship between temperament and depression is bigger for children with strict parents who discipline inconsistently. Positive temperament characteristics can provide protection against the contribution of parental rejection to depression. With regard to the development of depression, the relationship between the child's temperament and upbringing (and other environmental influences, such as relationships with peers) is probably reciprocal.

What are the social psychological influences?

Separation and property loss

A psychological explanation for depression that is often mentioned is that it is caused by separation, loss or rejection. Psychoanalytic explanations of depression emphasize object loss. The loss can be real (for example, the death of a parent) or symbolic. Identification with and ambivalent feelings toward the lost, beloved object cause the individual to direct hostile feelings about the object to himself. Some psychodynamic writers emphasize the loss of self-esteem and feelings of helplessness due to object loss. They, however, minimize the importance of aggression that is focused on themselves.

Behavioural statements use the ideas of separation and loss by emphasizing the role of inadequate positive reinforcement in the development of depression. Loss or separation of an object of importance leads to a decrease in the positive reinforcement of the child. However, it is also recognized that inadequate ratification may also be the result of other factors, such as insufficient skills to obtain desired rewards. For example, small children who are separated from their parents develop an anaclitic depression . This is initially a period of protest, characterized by crying, asking for their parents and restlessness. Then there is a period of depressed and withdrawn behaviour. After a few weeks it’ll gradually get better.

Whether there is actually a link between loss and depression is doubted, partly because many studies have methodological problems embedded in their research. It is nowadays stated that an early loss cannot, in itself, lead to depression. A loss can, however, cause a chain reaction in which there are accumulating adverse circumstances that increase the risk of depression. Research has shown that a loss can have indirect effects on the development of depression, for example through the degree of warmth within the family.

Cognitive behavioural perspectives

Many cognitive behavioural perspectives emphasize the influence of interpersonal skills, cognitive distortions, self-image, ideas about control, self-regulation and stress on the development of depression. The way in which depressed people are seen by themselves and others contributes to the development and maintenance of depression. A combination of low activity and poor interpersonal skills could play a role in depression. Interpersonal theories of depression emphasize a transactional relationship: depressed children contribute to and respond to problematic relationships. They exhibit deficits in social functioning, have negative interpersonal expectations and perceptions and are considered less positive by others.

There are various cognitions that are related to depression, such as learned helplessness. As a result of previous experiences, some individuals feel that they have little control over their environment. This learned helplessness is associated with depressive symptoms. Separation can lead to a special form of learned helplessness: the child tries in vain to bring the parent back, so that the child thinks that personal actions and positive outcomes are independent of each other.

The theory of learned helplessness emphasizes the attribution style of an individual: the way he or she thinks about activities and outcomes. Depressed people have an attribution style, blaming themselves (internally) for negative events and they see these events as stable over time (stable) and applicable in different situations (globally). The opposite attribution style (external, unstable and specific) can also be characteristic of depressed people.

In the hopelessness theory, a revision of the learned helplessness theory, more emphasis is placed on the interaction between stressful living conditions and cognitive style. A person's attribution style moderates the relationship between negative life events and hopelessness. Hopelessness then leads to depression. See also Figure 7.3 on page 155. According to this theory, a child with a negative attribution style and many negative life events is more likely to develop depression. A combination of a lot of stress and a positive attribution style reduces the risk of depression. Studies have confirmed that depressed children suffer from hopelessness and wrong attribution styles.

Beck assumes that depression is due to a negative image of himself, others and the future. Depressed people, according to Beck, have errors in their way of thinking, as a result of which they use mild, nasty events to blame themselves. In this way they convince themselves that they are failures. Although the findings are inconsistent, some studies do indeed indicate that there is cognitive distortion in depressed people . Depressed people tend to make everything worse than it is (catastrophizing), generalize annoying events (overgeneralizing) , attract everything personally (personalizing) and selectively look at negative events.

More research needs to be done on the nature of the relationship between depression and cognitive influences, such as attribution style or hopelessness. It is unclear whether these cognitions play a causal role or are related to depression in another way (for example, that they are a consequence of depression). Nevertheless, problematic cognitions form a central part of cognitive behavioural therapy. These procedures are called cognitive restructuring .

Depression of parents

Children and adolescents with a depressed parent have an increased risk of developing depression, but also of other psychological problems such as phobias and alcohol addiction. In addition, children of parents with another disorder or chronic physical illness may have an increased risk of developing depression. There may be various mechanisms that make a connection between parent and child depression, including shared heredity. In addition, there are various non-biological ways in which parental depression can affect. These will be discussed below. It is important to remember that influences between parent and child are probably reciprocal.

Depressed parents can transfer their cognitive styles to their child through modelling. In addition, maladaptive cognitions can influence the way in which depressed parents raise their children. For example, depressed parents can show aggressive or withdrawn behaviour. In addition, they are mainly concerned with their own problems, so that they pay little attention to their child. They may also be less tolerant of certain behaviours of the child. Families with a depressed parent sometimes live in unfavourable and stressful circumstances (for example in socio-economic terms), which aggravates the parent's depression. Finally, a parent's depression is associated with an unsafe parent-child attachment, which increases the risk of developing a child's depression.

The effects of parental depression on children vary with the child's age and gender. In addition, not all children with a depressed parent experience adverse outcomes. For example, stability in the family offers protection against the influence of parental depression.

Relationships with peers

Problems in relationships with peers contributes to the development and maintenance of depression. A person's status within a group is related to adjustment problems such as depression. Research shows, for example, that rejection or exclusion by peers increases the risk of depression in girls. Problems in relationships with peers can both contribute to and be a consequence of depression.

How do you assess and treat depression?

The assessment of depression contains different strategies, assesses different characteristics and contains information from different informants. Because various factors can contribute to the development of depression, it is important to make an assessment of both the child and the social environment.

Self-reporting tools are used the most, among other things because many of the characteristics of depression are subjective, such as feelings of worthlessness. Many self-reporting tools have been reformulated so that parents and other adults can also complete the questionnaire. Usually the coherence between the child's and parents' responses is low, suggesting that the information from different informants provides insight into different aspects of the child's problems. In addition to self-reporting, use can be made of interviews and observations.

Pharmacological treatment

Depressed children and adolescents are often prescribed antidepressants. However, pharmacological treatment is controversial because its effectiveness and safety is unclear. Initially, tricyclic antidepressants were prescribed, but they were found to be ineffective and had many side effects. Today, selective serotonin reuptake inhibitors (selective serotonin reuptake inhibitors; SSRIs) are prescribed. SSRIs prevent the reuptake of serotonin, which gives the brain more serotonin. These antidepressants have far fewer side effects.

The use of such medication is based on limited research, which does not provide clear evidence of its effectiveness in children or adolescents. In addition, little is known about its effects in the long term. For example, some scientists think that SSRIs increase the chance of suicidal behaviour.

Combined treatment

Research shows that a combination of SSRIs and cognitive behavioural therapy (CBT) is most effective in treating depression than just SSRIs or CBT alone. After a follow-up period, however, there were no longer any differences between the three study conditions. Moreover, the remission (no longer meeting the diagnostic criteria) was low and many young people still had severe depressive symptoms. An advantage of the combined treatment is that the treatment reduces the chance of suicidal behaviour compared to young people who only get the SSRIs.

Psychosocial treatment

When developing psychosocial interventions, it seems reasonable to rely on interventions that are effective in treating depression in adults. However, this must be done with caution, as there are major differences between the lives of children and adults. For example, children have daily contact with their parents, who may contribute to the depressive symptoms. In addition, young people have to deal with the negative effects of problematic relationships with peers. Adults, on the other hand, can avoid family and social contacts. Treatments for childhood depression are probably the most effective when taking into account relevant developmental experiences.

Most psychological treatments for depression are derived from a cognitive behavioural perspective. Cognitive behavioural therapy (CBT) confronts and changes the maladaptive cognitions of the child. In addition, it focuses on goals, such as increasing social problem-solving skills.

Interpersonal psychotherapy for adolescents is based on the assumption that depression is inextricably linked to the interpersonal relationships of the individual. The therapist helps the adolescent understand interpersonal issues such as separation from parents, romantic relationships, interpersonal deficits, peer pressure, and mourning. Research shows that interpersonal psychotherapy is effective in treating depression in adolescents.

CBT and interpersonal psychotherapy are promising in the treatment of depression in children and adolescents. However, the research findings are moderate, especially for the more severely depressed young people, young people with comorbid disorders and younger children. The long-term effectiveness of the treatments is also moderate.

Prevention of depression

There are various universal prevention programs for depression. Most prevention programs are implemented in schools and emphasize cognitive behavioural procedures. These programs appear to be reasonably effective in the short term, but this effect disappears in the long term. Possibly because programs have to be more intensive and longer to properly be implemented. In addition, more emphasis must be placed on reducing risk factors and increasing protective factors in the child's environment.

Different universal programs are more effective for young people with moderate to many depressive symptoms, which indicates the value of indicated prevention programs. This approach is promising.

What is bipolar disorder?

In bipolar disorder , there is both mania and depressive symptoms. Mania is described as a period of an abnormally euphoric or irritable mood. A euphoric mood occurs when someone is bursting with self-confidence, talks a lot, is very distractible and has exaggerated feelings of physical and mental well-being. To meet the diagnostic criteria for a manic episode, mania and at least three of the following symptoms must be present:

• Increased self-esteem
• Less need for sleep
• Talk more than usual
• Racing thoughts
• Derivability
• Increased targeted activity or motor unrest
• Excessively enjoyable activities that can lead to negative outcomes (for example, spending a lot of money)

Of bipolar I disorder occurs when someone has experienced manic episodes and usually has a history of MDD, while there is bipolar II disorder where a person has had one or more hypomanic episodes (less severe form of mania) and usually has a history of MDD. A cyclothymic disorder involves chronic, but mild, mood swings that do not meet the MDD or mania criteria. The diagnosis of other specified or unspecified bipolar and related disorders applies to individuals who do not meet all the criteria for other bipolar disorders but experience many of the symptoms. With unspecified bipolar and related disorder, unlike with other specified bipolar and related disorder, the reasons for not meeting the full criteria are not stated. Many children receive these diagnoses.

Although the diagnostic criteria are almost the same for children and adults, it is doubted whether bipolar disorders beginning with childhood or adulthood should be regarded as the same or different disorders. Manic children exhibit different symptoms than adults with bipolar disorder. This is specified more in the DSM-IV than in earlier versions. For example, in adults there is often a cyclic disorder with an acute onset of individual episodes of mania and or depression, in which they often function relatively well in the periods between episodes. Young people, on the other hand, often have very short episodes, many mood changes, mixed moods and chronic problems with regulating moods. In addition, a euphoric mood is considered an important characteristic of mania or bipolar disorder in adults, while an irritable mood is more common in young people.

The patterns of comorbidity also differ between children and adults with bipolar disorder. The comorbidity of bipolar disorder and ADHD is high. In addition, mania in adolescents is associated with antisocial behaviour, truancy, poor school performance and drug abuse. Manic episodes often also have psychotic features in adolescence. Finally, a bipolar disorder may initially manifest itself as a depression, with mood changes only occurring later.

A distinction must be made between manic symptoms and normal behaviour. Examples of manic behaviour compared to the normal behaviour of the child are:

• Elated mood - Manic behaviour: a nine-year-old girl who dances through the house and sings "I'm high, over the mountain high". A seven-year-old boy who is always sent to the director because he is always giggling and doing crazy things in class, while no one else did this. Normal behaviour: a very enthusiastic child when the family went to Disneyland on Christmas morning.
• Grandiose behaviours - Manic behaviours: an eight-year-old girl sets up a paper flower shop in the classroom and gets angry and refused to do schoolwork when the teacher asked. A boy of seven years steals a car. He knows you can't steal, but he didn't think he's doing anything wrong. He thinks the police are coming to play with him. Normal behaviour: a seven-year-old boy pretends to be a fireman, instructs others and saves lives. While playing he doesn't really call the fire department. The game is age appropriate.
• Hypersexual behaviour - Manic behaviour: an eight-year-old boy imitates a rock star, turns his hips and rubs his crotch during an interview. A nine-year-old boy publicly showed a picture of a naked woman and said this is his future wife. Normal behaviour: a boy of seven plays doctor with a friend of the same age.

The behavioural assessment should take into account the child's age and level of development, the context in which the behaviour is displayed and the extent to which the behaviour interferes with the child's performance.

Manic symptoms that occur in young people with bipolar disorder are a euphoric mood (without any apparent reason), an irritable mood, unrealistic optimism, tantrums or oppositional behaviour, mood swings, less need for sleep, more energy than normal, hyperactivity, excessive self-confidence, rapid changes in conversation topic ( flight of ideas), fast speech, easily distractible, poor judgment, impulsive behaviour, hallucinations and delusions. In addition, manic youngsters in conversations continuously and randomly switch topics, because they think of many things at the same time.

Epidemiology of bipolar disorders

Due to differences in definitions and methodological differences between studies, it is difficult to give an accurate estimate of the prevalence of manic symptoms and bipolar disorders. Bipolar disorder is relatively rare in childhood and adolescence, but nowadays appears to be more common than in the past. The disorder appears to occur more often after puberty than before. There is no gender difference in the prevalence of bipolar disorders.

Some young people have manic symptoms, but do not meet the criteria for bipolar disorder. However, young people with these subsyndromal symptoms do experience limitations in their functioning. This indicates a bipolar spectrum instead of a categorical distinction. A bipolar spectrum is a continuum that ranges from normal emotion regulation problems to subsyndromal symptoms to mild and more severe forms of the disorder.

Developmental progress and prognosis of bipolar disorders

A depressive disorder can be an early stage of bipolar disorder. The chance of a transition from MDD to bipolar disorder is possibly greater in children who already had depression at a young age. Many young people with bipolar disorders or symptoms continues to experience symptoms and experience functional limitations, at least until early adulthood.

Risk factors of bipolar disorders

Genetic and neurobiological factors play a role in the development of bipolar disorders. However, there is also increasing evidence that there is a genetic diathesis, with environmental experiences making a major contribution to the development of bipolar disorder.

Assessment and treatment of bipolar disorders

Various methods and informants can also be used for the assessment of bipolar disorders.

When treating bipolar disorder, attention must be paid to both the disorder itself and the comorbid problems and the involvement of the family. In order to guarantee the safety of the child, it may be necessary to include the young person in the discussion of his treatment. The most commonly used treatment for bipolar disorder is pharmacotherapy, which usually consists of mood stabilizers. The depressive aspects of the disorder are sometimes treated with SSRIs. However, antidepressants can destabilize mood or induce a manic episode as well, especially in the beginning..

In addition, individual and family therapy is often recommended. Many treatment programs include cognitive behavioural techniques. Some programs focus on dialectical behavioural therapy, with the focus on emotional dysregulation and psychoeducation and including cognitive behavioural strategies. In addition, it contains mindfulness techniques to gain more control over thoughts and emotions. Other forms of support for the family, including websites such as the 'Child and Adolescent Bipolar Foundation' site, are also highly needed.

How do you recognise suicidal behaviour?

Not every child who is suicidal is depressed. Compared to adults, suicide is relatively rare among young people. Moreover, it is less common among prepubescent children than among adolescents. Men commit suicide more often than women. In addition, suicide is more common among white youth than in other ethnic groups, with the exception of native Americans.

Suicidal behaviour includes not only suicide itself, but also suicidal thoughts and suicide attempts. It is difficult to determine the prevalence of suicidal behaviour, among other things because many suicide attempts go unnoticed and because suicide is sometimes wrongly treated as an accident.

Although young men die more often as a result of suicide, suicidal thoughts and suicide attempts are more common among women. Young people are vulnerable to suicide due to limited problem-solving and self-regulatory skills and limited skills to deal with stressful circumstances. Some experience circumstances that they feel unable to control. They often do not understand that negative situations can change and feel like there is only one way out.

Suicidal behaviour is not only related to depression, but also to other disorders, such as bipolar disorder, drug abuse and behavioural disorder. Although depression is an important risk factor, its presence is neither necessary nor sufficient for suicidal behaviour. There are different risk factors for suicidal behaviour, such as various child characteristics (for example biological factors, psychological disorders or aggression), different family factors (for example abuse or little parental supervision), a family history of suicidal behaviour, being bullied, high levels of stress at school, social relationships and socio-cultural influences. There is also concern about 'contamination' (imitation of suicidal behaviour) as a result of news reports regarding suicide by young people. The sexual orientation of young people, in interaction with other risk factors, can also form a risk factor for suicidal behaviour.

There are two types of universal prevention programs:

• Suicide awareness and education programs: focus on raising awareness and knowledge about suicidal behaviour and encouraging young people to seek help. It is unclear how effective these programs are.
• Screening programs: focus on identifying young people at high risk of suicidal behaviour and refer them for treatment. The success of this approach depends on the availability of screening instruments that are both sensitive (capable of identifying young people at high risk of suicidal behaviour) and selective (identifies few to no young people who do not have an increased risk of suicidal behaviour). The timing of the screening, for example just before exams start, can influence the accuracy of the screening. There is no clear evidence that screening programs reduce suicidal behaviour.

Selective or targeted suicide prevention programs target young people who do not yet display suicidal behaviour, but who are vulnerable to it. Such a program can, for example, target young people who have lost a family member to suicide.