Clinical Considerations

Many elements in the evaluation of depression in pediatric patients are similar to those in adult evaluations; however, important differences must be considered throughout every component of the evaluation (American Academy of Child and Adolescent Psychiatry 2009). The importance of the child's developmental level in assessing emotional and cognitive experiences of illness and the effect of the family on medical outcomes are two important factors that are discussed in Chapter 3, "The Pediatric Psychosomatic Medicine Assessment." In this chapter, we discuss other clinical considerations relevant to the evaluation and management of children and adolescents in the medical setting.

Table 6-2. DSM-IV-TR diagnostic criteria for a manic episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

(1) inflated self-esteem or grandiosity

(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3) more talkative than usual or pressure to keep talking

(4) flight of ideas or subjective experience that thoughts are racing

(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

(6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The symptoms do not meet criteria for a mixed episode.

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electrocon-vulsive therapy, light therapy) should not count toward a diagnosis of bipolar I disorder.

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