Depression in the School-Aged Child With Type 1 Diabetes: Implications for Pediatric Primary Care Providers

ARTICLE

Depression in the School-Aged Child With Type 1 Diabetes: Implications for Pediatric Primary Care Providers Caitlyn M. Alvar, MSN, RN, CPNP, Jennifer A. Coddington, DNP, MSN, RN, CPNP, Karen J. Foli, PhD, RN, FAAN, & Azza H. Ahmed, DNSc, RN, IBCLC, CPNP

ABSTRACT Depression is a common comorbid condition experienced by children with type 1 diabetes that, if undiagnosed, can lead to deterioration in glycemic control and other serious health complications. Although it is documented that children with type 1 diabetes experience high rates of depression, a comprehensive clinical guide does not exist to

help direct the pediatric provider on how to best care for these children. The purpose of this article is to synthesize current evidence to aid the pediatric primary care provider in the detection and management of depression in the school-aged child with type 1 diabetes. J Pediatr Health Care. (2017) -, ---.

KEY WORDS Caitlyn M. Alvar, Pediatric Nurse Practitioner, Purdue University School of Nursing, West Lafayette, IN. Jennifer A. Coddington, Clinical Associate Professor, Director of Pediatric Nurse Practitioner Master’s Program, Director of Practice and Outreach and Medical Director of North Central Nursing Clinics, Purdue University School of Nursing, West Lafayette, IN. Karen J. Foli, Associate Professor, Purdue University School of Nursing, West Lafayette, IN. Azza H. Ahmed, Associate Professor, Purdue University School of Nursing, West Lafayette, IN. Conflicts of interest: None to report. Correspondence: Jennifer A. Coddington, DNP, MSN, RN, CPNP, Purdue University School of Nursing, 502 N. University St., West Lafayette, IN 47907; e-mail: [email protected]. 0891-5245/$36.00 Copyright Q 2017 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedhc.2017.07.002

www.jpedhc.org

Depression, pediatric primary care providers, pediatrics, school-aged child, type 1 diabetes

Pediatric providers are aware of the common pathological complications and comorbid conditions associated with type 1 diabetes such as diabetic ketoacidosis, retinopathy, and neuropathy (Chiang, Kirkman, Laffel, & Peters, 2014). However, just as concerning as these physical ailments are the comorbid mental health disorders that many children with type 1 diabetes face including depression, anxiety, and disordered eating (Chiang et al., 2014). The rates of depression among this population are particularly alarming, with higher rates of depression noted in children with type 1 diabetes than among their peers without diabetes (Reynolds & Helgeson, 2011). Estimates vary regarding the exact number of children with type 1 diabetes who experience depressive symptoms; however, a recent systematic review showed a pooled prevalence of -/- 2017

1

30.04% (Buchberger et al., 2016). Unfortunately, a large number of these children are not properly diagnosed and treated, in part because of a lack of adequate screening (Silverstein et al., 2015). The school-age years, also known as middle childhood, occur between the ages of 5 and 11 years and represent a particularly vulnerable time for children with type 1 diabetes (Kleigman, Stanton, St. Geme, & Schor, 2015). Research and literature have historically focused heavily on the incidence of depression in adolescents with type 1 diabetes. However, recent guidelines and recommendations reflect the necessity of early screening and intervention in the prevention of the long-term complications associated with unrecognized depression in the schoolaged child with type 1 diabetes (Chiang et al., 2014; Delamater, de Wit, McDarby, Malik, & Acerini, 2014). Therefore, it is imperative that pediatric primary care providers caring for school-aged children with type 1 diabetes are aware of this common comorbidity. Providers must also be able to identify children who are at an increased risk for depression, implement proper screening techniques, and appropriately manage depression in this population. The purpose of this article is to synthesize current evidence to aid the pediatric primary care provider in the detection and management of depression in the school-aged child with type 1 diabetes.

BACKGROUND Type 1 Diabetes Recent statistics estimate that nearly 170,000 American youth are currently living with a diagnosis of type 1 diabetes (Pettitt et al., 2014). Although most often diagnosed in White children, the prevalence of this disease continues to increase across all racial groups (Hamman et al., 2014; Pettitt et al., 2014). Type 1 diabetes affects both pediatric and adult populations alike and can be diagnosed at any age. However, formerly known as juvenile-onset diabetes, type 1 diabetes is most often diagnosed in the school-aged child, with a mean age of onset of 8.1 years (Pettitt et al., 2014). This autoimmune disease causes destruction of pancreatic b cells, resulting in the body’s inability to produce insulin. Without insulin, the body is unable to transport glucose from the blood stream into the cells where it is necessary for cellular functions. As a result, individuals with type 1 diabetes require careful management of blood glucose levels and frequent administration of insulin via injection or insulin pump (Chiang et al., 2014). Poor control of type 1 diabetes is associated with both physical and psychiatric comorbidities (Chiang et al., 2014).

2

Volume -  Number -

Developmental Considerations and Challenges Developmental theorist Erik Erikson describes the central psychosocial conflicts associated with each stage of development (Berk, 2014). He asserts that children 5 to 11 years of age are tasked with accomplishing a sense of industry and are at risk of developing a sense of inferiority if they are unsuccessful (Berk, 2014). The school-aged child may develop self-confidence and a sense of industry through the acquisition of cognitive, athletic, and social skills (Chiang et al., 2014). Although these children should be encouraged to participate in school, athletic, and peer activities, the tasks of routine management and inadequate blood glucose control can adversely affect the child’s ability to learn and partake in the normal activities of childhood (Chiang et al., 2014). Each child is unique, and therefore, the level of involvement in diabetes self-management may vary. Children younger than 11 years old may participate in some diabetes care tasks such as blood glucose testing; however, management is typically parent dominated (Schilling, Knafl, & Grey, 2006). Jean Piaget describes children between the ages of 7 and 11 years as being in the concrete operational phase of cognitive development (Berk, 2014). Although children in this period of development are capable of logical thoughts and problem solving, abstract concepts may remain difficult for the child to comprehend (Berk, 2014). As the child enters the later school-age years, he or she may transition into the formal operational phase of development as he/she becomes more capable of abstract thought (Berk, 2014). These children may begin to understand the short-term and long-term benefits of adequate control and may become more involved in their diabetes management (Chiang et al., 2014). This period of transition often begins around the age of 11 years, and management tasks become more equally shared (Schilling et al., 2006). Tasks that require calculation or medical decision making, such as dosing insulin or calculating carbohydrates, often continue to require parental consultation (Schilling et al., 2006). Therefore, during this stage of development, it is recommended that management practices remain shared between the child and parent and that the parent maintains involvement in management decisions to prevent deterioration in control (Chiang et al., 2014). Depression The toll of managing a chronic illness and associated lifestyle changes are thought to be major contributors to the increased incidence of depression in children with type 1 diabetes. However, it has also been suggested that there may be a biological component, with increased metabolic abnormalities and systemic

Journal of Pediatric Health Care

inflammation noted in children with concurrent diagnoses of type 1 diabetes and depression (Hood et al., 2012). Although research The toll of efforts and screening recommendations have managing a chronic traditionally focused on illness and surveillance and detecassociated lifestyle tion of depression in the adolescent with type 1 changes are diabetes, careful monithought to be major toring and early intercontributors to the vention during the school-age years may increased serve to prevent longincidence of term complications. depression in Research indicates that children with type children with type 1 1 diabetes who experidiabetes. ence depressive symptoms during childhood are more likely to experience depression later in life (Johnson, Eiser, Young, Brierley, & Heller, 2013). Although the incidence of depression increases with age and the duration of diabetes, metabolic control significantly declines within the first 6 years of diagnosis (Hood et al., 2014; Khan, Rabbani, Afzal, & Adnan, 2013). Therefore, it has been suggested that appropriate intervention during critical times of transition, particularly after diagnosis and before adolescence, may help prevent such complications (Delamater et al., 2014). Symptoms of depression in children include sadness, irritability, fatigue, and loss of interest in activities (Maslow, Dunlap, & Chung, 2015). Children may also present with poor academic achievement, sleep disturbances, and changes in appetite (Maslow et al., 2015). Other behavior changes, such as acting out, may indicate a possible diagnosis of depression (Maslow et al., 2015). In some children, declining health may also be noted because of neglect of self-care activities (Maslow et al., 2015; Box 1). The severity of depression may be reflected in the degree to which the patient presents with depressive symptoms (Maslow et al., 2015).

BOX 1. Symptoms of depression in the schoolaged child  Sadness  Irritability  Fatigue  Loss of interest in activities  Poor academic achievement  Sleep disturbances  Changes in appetite  Acting out  Declining health Note. Data from Maslow, Dunlap, & Chung, 2015.

www.jpedhc.org

The developmental stages associated with the school-age years and the symptoms accompanying complications of type 1 diabetes may make it particularly difficult to diagnose depression in this population. Younger school-aged children may present with somatic complaints or nonspecific physical symptoms, and they may be unable to vocalize their feelings (Maslow et al., 2015). In the later school-age years, as the child begins to transition into adolescence, it may be difficult to discern whether changes in mood are reflective of depression or are part of the characteristic fluctuations in mood often seen during adolescence (Maslow et al., 2015). Symptoms of persistent hyperglycemia, including weight loss, fatigue, lethargy, abdominal discomfort, and altered school performance, may mimic symptoms of depression in the school-aged child (Roy & Roy, 2015). Therefore, it is crucial for the provider to consider persistent hyperglycemia as a possible underlying etiology for such symptoms. Consequences of Unrecognized Depression in Type 1 Diabetes The correlation between depression and poor glycemic control in children and adolescents with type 1 diabetes has been repeatedly confirmed in research (Buchberger et al., 2016). The American Diabetes Association (ADA) recommends that school-aged children with type 1 diabetes maintain a hemoglobin A1c (HbA1c) level of less than 7.5% (ADA, 2015a). However, many children with depression fail to meet this goal and experience higher HbA1c levels than their peers without depression (Buchberger et al., 2016; Corathers et al., 2013; Lawrence et al., 2006). This may be due to less frequent blood glucose monitoring, which is correlated with both high HbA1c levels and increased depressive symptoms (Corathers et al., 2013; Hood et al., 2006). Furthermore, Lawrence et al. (2006) found that the degree of depression positively correlated with HbA1c levels, noting increasing levels as the severity of depression increased. Poor glycemic control can lead to severe health complications requiring visits to the emergency department and hospitalization. The number of visits to the emergency department is higher among children with depression (Lawrence et al., 2006). In older children and adolescents, depressive symptoms correlate with an increased risk for hospitalizations for diabetes-related complications (Garrison, Katson, & Richardson, 2005; Lawrence et al., 2006; Stewart, Rao, Emslie, Klein, & White, 2005). The correlation between depression and increased hospitalizations was not observed in younger children (Garrison et al., 2005). The higher level of parental management of diabetes in the younger population may account for this difference (Garrison et al., 2005). This emphasizes the importance of supporting and supervising the school-aged child as he/she becomes increasingly autonomous in diabetes management. -/- 2017

3

At each visit, the primary care provider should review the child’s chart and gather a comprehensive history to identify any interim hospital admissions, emergency department visits, or other signs of inadequate management. Such indicators of poor glycemic control should serve as an indicator for a possible underlying diagnosis of depression. Timely detection and intervention by the primary care provider can help prevent further complications (Box 2). ASSESSMENT OF DEPRESSION Risk Factors Although depression can affect children from all backgrounds, a relationship with certain risk factors and depressive symptoms has been established. Socioeconomic factors, such as lower parental education, lower household income, and lack of private insurance increase the risk for depression in children with diabetes (Khan et al., 2013; Lawrence et al., 2006; Silverstein et al., 2015). Children with type 1 diabetes who are overweight or obese, especially those in low-income families, have also been noted to experience higher rates of depression (Lawrence et al., 2006; Silverstein et al., 2015). Females with type 1 diabetes are more likely to experience depression, particularly if they have other comorbid conditions or live in a single-parent home (Hood et al., 2006; Lawrence et al., 2006). Discrepancies have also been noted in the prevalence of depression across racial and ethnic groups, with higher rates of depression noted in races other than non-Hispanic White (Lawrence et al., 2006; Box 3). Depressive Symptom Screening Recommendations Frequency of screening Awareness of the high risk of microvascular complications among children with type 1 diabetes, such as retinopathy and nephropathy, has led to the implementation of routine screening and surveillance activities (Cameron, Northam, Ambler, & Daneman, 2007). The widespread use of universal screening protocols has proven successful in decreasing the prevalence of these complications (Cameron et al., 2007). Until recently, BOX 2. Consequences of undiagnosed depression in children with type 1 diabetes  Higher HbA1c levels  Less frequent blood glucose monitoring  Increased visits to emergency department  Increased hospitalizations Note. Data from Buchberger et al. (2016); Corathers et al. (2013); Garrison, Katson, & Richardson (2005); Hood et al. (2006); Lawrence et al. (2006); and Stewart, Rao, Emslie, Klein, & White (2005).

4

Volume -  Number -

BOX 3. Risk factors for depression in children with diabetes  Lower parental education  Lower household income  Lack of private insurance  Obesity/overweight  Female  Races other than non-Hispanic White Note. Data from Khan, Rabbani, Afzal, & Adnan (2013); Lawrence et al. (2006); and Silverstein et al. (2015).

screening for depressive symptoms was not included in the recommendations for routine surveillance across all ages. Although the American Academy of Pediatrics (AAP) suggests that annual screening for depressive symptoms should begin at 11 years of age, the high rates of depression within this unique population have led to the suggestion to include screening for depressive symptoms in routine monitoring for diabetes complications, beginning at the time of the initial diagnosis of diabetes (ADA, 2014; Buchberger et al., 2016; Cameron et al., 2007; Committee on Practice and Ambulatory Medicine & Bright Futures Periodicity Schedule Workgroup, 2016). The ADA’s most recent statement on the care of diabetes across the lifespan encourages providers to screen children for depressive symptoms every 3 months, beginning at the onset of the disease (Chiang et al., 2014). The nature of this disease necessitates that children are seen every 3 months to evaluate HbA1c levels and management practices and to monitor for any complications (Chiang et al., 2014). Because these appointments often do not occur in the primary care setting, providers may need to integrate screening into well-child visits, episodic visits, or other routine appointments. However, in very rural areas where the primary care provider has assumed responsibility for diabetes management, the provider should be diligent about incorporating routine screening into quarterly diabetes visits. Depression screening and diagnosis At this time, to our knowledge, no tool has been developed specifically to screen for depressive symptoms in children with type 1 diabetes, and there are presently no universal recommendations regarding the optimal tool for routine screening in school-aged children with type 1 diabetes in the primary care setting. Further research must be conducted to determine the most appropriate screening tool for this population. However, screening tools such as the Child Depression Inventory (CDI; Kovacs, 1992) and the Centers for Epidemiological Studies Depression Scale for Children (CES-DC; Weissman, Orvaschel, & Padian, 1980) are commonly used to screen for depressive symptoms in children with type 1 diabetes and may be effectively

Journal of Pediatric Health Care

implemented in the primary care setting. In addition to screening tools that screen exclusively for depressive symptoms, providers may also use broader developmental and emotional screening tools, such as the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997), to identify children who may be experiencing difficulties with mood (Table 1). If a positive screening result is obtained, a follow-up visit with the provider or a psychiatrist is indicated to complete a comprehensive psychiatric diagnostic evaluation (Birmaher, Brent, & American Academy of Child and Adolescent Psychiatry Work Group on Quality Issues, 2007). The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V; American Psychiatric Association [APA], 2013) can help guide the provider in the diagnosis of major depression. The CDI has been widely used to detect depressive symptoms in children and adolescents with diabetes and other chronic diseases and is frequently used in research regarding depression in children with type 1 diabetes (Buchberger et al., 2016; Hood et al., 2006). The CDI was developed specifically for use in schoolaged children and adolescents, requires a very low reading level, and provides optional parental and teacher report forms (Kovacs, 1992). An updated version of this tool, the CDI-2, has been published and is available for use (Multi-Health Systems Incorporated, 2017). The CDI has a per-use cost associated with it (Kovacs, 1992); however, the costs associated with screening via self-administered questionnaires are relatively low, and the prevention of depression-related complications may reduce long-term health care expenditure (Cameron et al., 2007). Corathers et al. (2013) developed a self-administered electronic version of the CDI and tested it in a population of adolescents with type 1 diabetes. This method of screening was well accepted by the patients and staff alike and was found to have clinically significant outcomes (Corathers et al., 2013). The CES-DC has also been used for the detection of depressive symptoms in children with type 1 diabetes and offers a more accessible screening option (Weissman et al., 1980). Although this tool has proven to have good psychometric properties when used in adolescents, it may not be as reliable or valid in younger children (Faulstich, Carey, Ruggiero, Enyart, & Gresham, 1986). The CES-DC is an adaptation of the Centers for Epidemiological Studies Depression Scale (CES-D), a tool developed to screen for depressive symptoms in the adult population, and it may be used in children ages 6 to 17 years (Radloff, 1977; Weissman et al., 1980). The SDQ may be used to conduct a broader evaluation of a child’s behaviors, emotions, and relationships (Goodman, 1997). The questionnaire is available online at no cost and may be used to evaluate children 4 through 16 years of age (Goodman, 1997; Youth in www.jpedhc.org

Mind, 2017). The questionnaire can be completed by a parent or teacher and, therefore, may provide important insight into the strengths and difficulties of the school-aged child, who may have difficulty accurately conveying information regarding his/her own emotions and behaviors (Goodman, 1997). The DSM-V (APA, 2013) criteria for major depression can be helpful in diagnosing this condition and differentiating it from other mental health disorders. When using the DSM-V, the provider must evaluate the patient for the presence of certain symptoms such as depressed mood, diminished interest or pleasure, significant weight loss, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished concentration or indecisiveness, or thoughts of death (APA, 2013). To receive a diagnosis of major depressive disorder, the patient must have experienced at least five of these symptoms within the past 2 weeks and at least one of the symptoms must be either depressed mood or loss of interest (APA, 2013). Providers must recognize that although the same diagnostic criteria may be applied to both the pediatric and adult population, certain symptoms may manifest differently in children. For example, rather than losing weight, children may fail to meet expected gains, or rather than presenting with a sad or depressed mood, the parent may report that the child has been more irritable (APA, 2013). Loss of interest may be seen when a child begins to make excuses to avoid a certain sport or activity that he/she once enjoyed, and poor concentration be evidenced by a drop in grades (APA, 2013). These symptoms must cause significant impairment in important areas of functioning, such as school or social interactions (APA, 2013). Additionally, the symptoms should not be attributed to the physiologic effects of a medication or medical disorder and should not be able to Providers must be attributed to another recognize that mental disorder. Finally, although the same the patient must have never had a manic or diagnostic criteria hypomanic episode in may be applied to the past that cannot be both the pediatric attributed to a medication or medical condiand adult tion (APA, 2013).

population, certain symptoms may manifest differently in children.

Screening for Suicidal Ideation High-risk individuals, including children with a diagnosis of depression, should be carefully and routinely assessed for suicidal ideation (Maslow et al., 2015). Evidence suggests that children with type 1 diabetes attempt suicide more frequently than their peers without diabetes (Butwicka, Frisen, Almqvist, Zethelius, & Lichtenstein, 2015). -/- 2017

5

TABLE 1. Screening tools for the school-aged child Tool

Ages

Number of items

Scoring

Criteria for positive screen

Accessibility

CDI

7–17 years 27 items; Each item receives score T-score of 56 or above signifies Proprietary 10-item short between 0 and 2 that depressive symptoms version available (0 = absence of symptoms; are above average for age 2 = definite symptoms) and gender CES-DC 6–17 years 20 items Each item receives score Score of 15 or greater indicates Accessible online between 0 and 3 (0 = do not possible depressive disorder at no cost: http://www. experience symptoms; psy-world.com/ 3 = experience symptoms CES-DC.htm frequently) SDQ 4–16 years 25 items Each item receives a score Varies by scoring method; Accessible online between 0 and 2 (0 = not true; scoring tools available at at no cost: http://www. 2 = certainly true) http://www.sdqinfo.com/ sdqinfo.com/ Note. CDI, The Child Depression Inventory; CES-DC, The Centers for Epidemiological Studies Depression Scale for Children; SDQ, Strengths and Difficulties Questionnaire. Data for CDI from Weissman, Orvaschel, & Padian (1980); data for CES-DC from Kovacs (1992); data for SDQ from Goodman (1997).

After initiation of pharmacologic treatment with selective serotonin reuptake inhibitors (SSRIs), patients must be monitored closely, especially during the first 9 days of treatment, when the risk for suicidal ideation is greatest (Southammakosane & Schmitz, 2015). The Ask Suicide-Screening Questions (ASQ) is a highly sensitive and specific screening tool that uses just four questions, allowing providers to quickly assess for suicidal ideation (Horowitz et al., 2012). These questions are accessible online at no cost and are aimed at determining whether the child has had any recent thoughts of being better off dead or wishing they were dead and also assess for any recent suicidal ideation or past suicide attempts (Horowitz et al., 2012; National Institute of Mental Health [NIMH], 2017). If the child answers yes to any of the four screening questions, a follow-up question regarding current suicidal ideation should follow (Horowitz et al., 2012). Although suicide prevention contracts were once commonly used, recent evidence indicates that safety plans may be safer and more effective (Maslow et al., 2015). A safety plan should be created for all patients immediately after the diagnosis of depression, regardless of whether they report suicidal ideation (Cheung, Kozloff, & Sacks, 2013). This plan should include recognizing possible warning signs, using self-coping skills, identifying those who may be a support and those who may assist in resolving a crisis, having the contact information for mental health professionals and local emergency services, ensuring a safe environment, and identifying a positive focus or a specific thing worth living for (Maslow et al., 2015). MANAGEMENT OF DEPRESSION The present lack of information regarding best practices for management of depression in this group calls for further research on the subject. However, general principles of management that are used in treating children and adolescents with depression may be transfer6

Volume -  Number -

able to this population. Initial management should begin with educating the child and family regarding the diagnosis and treatment options. Children and their families should be aware that depression, particularly in the child with type 1 diabetes, is often a recurring illness and will require long-term surveillance and management (Birmaher et al., 2007; Johnson et al., 2013). This information may be difficult for families to receive and may signify a loss as they come to realize that they are now faced with two chronic conditions that must be carefully monitored and managed. The treatment plan should be created in collaboration with the family with specific self-management goals and desired outcomes (Birmaher et al., 2007). These goals should focus not only on the improvement of depressive symptoms but also on functional outcomes (Cheung et al., 2013). For children with diabetes, these goals might include better glucose monitoring or improved glycemic control (Table 2). It is important to ensure that these goals are simple and achievable for the family to prevent undue frustration and the consequent abandonment of goals. The severity of the patient’s depressive symptoms, as well as the child’s age and temperament, should help guide the treatment plan. Although a more conservative approach may be effective in patients with mild depression, a more aggressive approach and consultation with a psychiatrist should be considered for patients with moderate and severe depression (Birmaher et al., 2007). Ongoing treatment of depression is often multifaceted and may consist of psychotherapy, pharmacotherapy, or further evaluation and management by a psychiatrist (Birmaher et al., 2007; Cheung et al., 2013). Family-Centered Management When providing care for the school-aged child with type 1 diabetes, family-centered care is essential. At this age, children are unable to independently make complex decisions regarding their health and well-being. Journal of Pediatric Health Care

TABLE 2. Developmentally appropriate management goals Diabetes self-management

Depression

Younger school-aged children  Perform blood glucose monitoring with parental guidance and notify parents of high and low readings Older school-aged children  Deliver insulin injections or insulin boluses under parental supervision  Perform daytime blood glucose monitoring  Increase frequency of blood glucose monitoring  Calculate carbohydrate intake with parental guidance  Identify coping skills  Recognize individuals who can provide support  Create a safety plan

Note. Data from Malsow, Dunlap, & Chung (2015) and Schilling, Knafl, & Grey (2006).

Therefore, the provider must recognize the significant role of the family when caring for these patients. Appropriate delivery of family-centered care can reduce health care costs; improve outcomes; and increase patient, family, and provider satisfaction (AAP, 2012). Familycentered care requires the provider to be respectful, flexible, honest, and supportive of the family during the planning and delivery of health care (AAP, 2012). Listening and collaboration are also key features of family-centered care (AAP, 2012). The provider should help identify the unique strengths of the family and families should be empowered to make informed decisions regarding the health of their child (AAP, 2012). Treatment plans must be individualized to the child and their family, to achieve treatment goals while maintaining quality of life (Chiang et al., When providing 2014). The school-aged child spends a considercare for the schoolable amount of time at aged child with type school, making it vital 1 diabetes, familythat the provider partner with the family in centered care is addressing any concerns essential. regarding the management of the patient’s diabetes or depression in this environment (Chiang et al., 2014). The importance of the parent or caregiver should not be underestimated, particularly when caring for children with type 1 diabetes. Hood et al. (2006) found that parent–youth agreement regarding the presence or absence of depressive symptoms was higher in this population compared with the general population. This was attributed to the high level of involvement necessary when caring for a child with a chronic illness www.jpedhc.org

(Hood et al., 2006). Therefore, it is important to further explore any discrepancies between the parental and patient report, because this may be an indicator of more significant problems in family functioning (Hood et al., 2006). Psychosocial Support Education, supportive management, and monitoring should be considered as first-line treatment for patients with mild depression (Birmaher et al., 2007; Cheung et al., 2013; Maslow et al., 2015). This may involve weekly or biweekly appointments during which the provider assesses the patient’s depression, provides education regarding depression, encourages self-care behaviors, and collaborates with the patient and family to establish self-management goals (Birmaher et al., 2007; Cheung et al., 2013; Maslow et al., 2015). If improvements are not seen within 6 to 8 weeks, psychotherapy and/or pharmacologic treatment should be considered (Cheung et al., 2013). Psychotherapy may be used as monotherapy or in tandem with pharmacologic treatment and has proven to be effective in the treatment of mild to moderate depression (Birmaher et al., 2007). Psychotherapy, including practices such as cognitive behavioral therapy or interpersonal therapy, can play an important role in the management of depression (Birmaher et al., 2007). This often requires collaboration and coordination with a social worker, psychologist, or other therapist trained in these treatment modalities (Cheung et al., 2013). Therefore, it is important for providers to establish connections with mental health resources in the practice area (Cheung et al., 2013). Peer support can also play an important role in the treatment of depression (Cheung et al., 2013). During the school-age years, peer support and approval become increasingly important to the child, who is becoming more acutely aware that his/her illness makes him/her different from classmates and friends (Chiang et al., 2014). Therefore, providers should take note of services available for the school-aged child with diabetes including peer groups, camps, and educational resources that may provide psychological benefits. Coping skills training, group diabetes education, and diabetes camps have been shown to improve both psychological outcomes and reduce depressive symptoms in schoolaged children with type 1 diabetes (Bultas, Schmuke, Moran, & Taylor, 2015; Grey et al., 2009). Pharmacologic Management Pharmacotherapy, including the use of SSRIs, may be indicated for school-aged children with major depressive disorder and may be used in conjunction with psychotherapy (Birmaher et al., 2007; Cheung et al., 2013). The use of pharmacologic treatment may be considered for patients who have not responded to psychotherapy alone and those with more complicated or severe -/- 2017

7

depression (Birmaher et al., 2007). The U.S. Food and Drug Administration (FDA) has approved only one medication, fluoxetine, for the treatment of depression in the school-aged child (Southammakosane & Schmitz, 2015). However, other SSRIs have been approved by the FDA for the treatment of depression in older individuals and for the treatment of obsessive–compulsive disorder (Southammakosane & Schmitz, 2015; Table 3). Patients and their families should also be informed that although effects may be noted in as little as 1 to 2 weeks, it may take up to 4 to 8 weeks for the full effects of the medication to be seen (Southammakosane & Schmitz, 2015). The potential hazards of pharmacotherapy should not be underestimated. Because of the increased risk of suicide among children treated with antidepressants, a black box warning accompanies these medications (FDA, 2004). Before initiation of pharmacotherapy, patients and families should also be thoroughly educated regarding commonly experienced adverse effects such as headaches, gastrointestinal upset, and sleep disturbances, and possible severe adverse effects such suicidal ideation (Birmaher et al., 2007; Southammakosane & Schmitz, 2015). Referral In certain cases, referral to a psychiatrist may be indicated, particularly in situations where the patient has moderate or severe depression, is very young, is actively suicidal, or has failed to respond to pharmacologic interventions (Cheung et al., 2013; Maslow et al., 2015; Southammakosane & Schmitz, 2015). Before referral, consultation with a psychiatrist should be attempted, because this may be useful in developing an appropriate management plan (Maslow et al., 2015). The provider’s experience in caring for patients with mental health conditions, the family’s preferences, and the severity of symptoms should be carefully considered before referral (Cheung et al., 2013). It is also important to consider the current shortage of child psychiatrists in the United States (Basco, Rimsza, Hotaling, Sigrest, & Simon, 2013). This poses a barrier to accessing mental health services, particularly in rural areas (Basco et al., 2013). Therefore, it is imperative that pediatric primary care providers are knowledgeable

regarding the treatment of depression in the schoolaged child and are prepared to manage this chronic health condition. Should the patient be referred for management by a psychiatrist, the primary care provider must remain involved in the patient’s psychological care and assist in the coordination of services (Maslow et al., 2015). Follow-up After the initial diagnosis or positive screening result and the initiation of treatment, patients should be monitored every 1 to 2 weeks for 6 to 8 weeks (Cheung et al., 2013). If pharmacologic treatment is initiated, follow-up should occur 1 to 2 weeks after the initiation of pharmacotherapy to confirm adherence and understanding of the treatment regimen; the patient should be routinely monitored for treatment efficacy and adverse effects (Cheung et al., 2013; Southammakosane & Schmitz, 2015). If necessary, dosages may be titrated every 3 to 4 weeks as tolerated by the patient (Southammakosane & Schmitz, 2015). Should the patient reach the maximum dosage without achievement of desired effects, secondline therapy may be considered (Southammakosane & Schmitz, 2015). However, after failure of a second medication, referral to a child psychiatrist is necessary (Southammakosane & Schmitz, 2015). Once an effective treatment regimen has been established and depressive symptoms have resolved, the patient should continue treatment for 6 to 12 months and should be monitored every 3 months (Southammakosane & Schmitz, 2015). Once the decision to stop pharmacologic treatment has been made, the patient should be tapered off the medication over the course of 1 to 2 months, because abrupt discontinuation of treatment can lead to adverse reactions (Southammakosane & Schmitz, 2015). Children, especially those with type 1 diabetes, are at a high risk for recurrent depression (Birmaher et al., 2007; Johnson et al., 2013). Therefore, it is important that providers continue close monitoring, resume quarterly screenings, and encourage caregivers to inform them if symptoms return. While adapting to this new diagnosis, careful management of the patient’s diabetes also remains a priority to prevent further complications. During follow-up visits, glycemic control, self-management practices,

TABLE 3. Use of SSRIs in the pharmacologic management of depression in the school-aged child Medication

Age

First-line treatment Fluoxetine 8 years or older Second-line treatment Sertraline 6 years or older Escitalopram 12 years or older

FDA-approved indication

Initial dose

Titration

Target dose

Maximum dose

Depression

5 mg

5 mg

10–20 mg

40 mg

OCD Depression

12.5 mg 5 mg

25 mg 5 mg

50–100 mg 10–20 mg

200 mg 20 mg

Note. FDA, U.S. Food and Drug Administration; OCD, obsessive-compulsive disorder; SSRI, selective serotonin reuptake inhibitor. Data from Lexi-Comp Inc. (2017); Maslow, Dunlap, & Chung (2015); and Southammakosane & Schmitz (2015).

8

Volume -  Number -

Journal of Pediatric Health Care

and other components of diabetes care should be carefully assessed. Common symptoms of hypoglycemia and hyperglycemia, including headache, abdominal pain, fatigue, and lethargy, may mimic those symptoms associated with depression or adverse effects of SSRIs and may make it difficult for caregivers to determine the nature of these complaints (ADA, 2015b; Roy & Roy, 2015). Careful and consistent monitoring of blood glucose levels may be useful in discerning the cause of these symptoms. CONCLUSION The primary care provider has the opportunity to play an important role in the detection and management of depression in the school-aged child with type 1 diabetes. Early detection is key to prevent deterioration in glycemic control and further complications. The pediatric primary care provider needs to be aware of risk factors, warning signs, appropriate screening techniques, and management practices for depression in this population. Because evidence is still needed, providers should continue to advocate for further research on this subject. By remaining vigilant in these practices, providers can help prevent the negative consequences associated with depression in the school-aged child with type 1 diabetes and support quality of life for these children. REFERENCES American Academy of Pediatrics. (2012). Patient-and familycentered care and the pediatrician’s role. Pediatrics, 129, 394. American Diabetes Association. (2014). Executive summary: Standards of medical care in diabetes— 2014. Diabetes Care, 37(S1), S5-S13. American Diabetes Association. (2015a). Children and adolescents. Diabetes Care, 38(Suppl. 1), S70-S76. American Diabetes Association. (2015b). Hypoglycemia. Arlington, VA: Author. Retrieved from http://www.diabetes.org/living-withdiabetes/treatment-and-care/blood-glucose-control/hypo glycemia-low-blood.html?referrer=https://www.google.com/ American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Basco, W., Rimsza, M., Hotaling, A., Sigrest, T., & Simon, F. (2013). Pediatrician workforce policy statement. Pediatrics, 132, 390-397. Berk, L. (2014). Development through the lifespan (6th ed.). Boston, MA: Pearson. Birmaher, B., Brent, D., & American Academy of Child and Adolescent Psychiatry Work Group on Quality Issues. (2007). Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 46(11), 1503-1526. Buchberger, B., Huppertz, H., Krabbe, L., Lux, B., Mattivi, J., & Siafarikas, A. (2016). Symptoms of depression and anxiety in youth with type 1 diabetes: A systematic review and meta-analysis. Psychoneuroendocrinology, 70, 70-84. Bultas, M., Schmuke, A., Moran, V., & Taylor, J. (2015). Psychosocial outcomes of participating in pediatric diabetes camp. Public Health Nursing, 33(4), 295-302. n, L., Almqvist, C., Zethelius, B., & Lichtenstein, P. Butwicka, A., Frise (2015). Risks of psychiatric disorders and suicide attempts in children and adolescents with type 1 diabetes: A populationbased cohort study. Diabetes Care, 38(3), 453-459.

www.jpedhc.org

Cameron, F., Northam, E., Ambler, G., & Daneman, D. (2007). Routine psychological screening in youth with type 1 diabetes and their parents: A notion whose time has come? Diabetes Care, 30(10), 2716-2724. Cheung, A. H., Kozloff, N., & Sacks, D. (2013). Pediatric depression: An evidence-based update on treatment interventions. Current Psychiatry Reports, 15(8), 1-8. Chiang, J., Kirkman, M., Laffel, L., & Peters, A. (2014). Type 1 diabetes through the life span: A position statement of the American Diabetes Association. Diabetes Care, 37(7), 2034-2054. Committee on Practice and Ambulatory Medicine & Bright Futures Periodicity Schedule Workgroup. (2016). 2016 Recommendations for Preventive Pediatric Health Care. Pediatrics, 137, 1. Corathers, S. D., Kichler, J., Jones, N. H. Y., Houchen, A., Jolly, M., Morwessel, N., ., Hood, K. K. (2013). Improving depression screening for adolescents with type 1 diabetes. Pediatrics, 132, 1395-1402. Delamater, A., de Wit, M., McDarby, V., Malik, J., & Acerini, C. (2014). Psychological care of children and adolescents with type 1 diabetes. Pediatric Diabetes, 15(S20), 232-244. Faulstich, M., Carey, M., Ruggiero, L., Enyart, P., & Gresham, F. (1986). Assessment of depression in childhood and adolescence: An evaluation of the Center for Epidemiological Studies Depression Scale for Children (CES-DC). American Journal of Psychiatry, 143, 1024-1027. Garrison, M. M., Katon, W. J., & Richardson, L. P. (2005). The impact of psychiatric comorbidities on readmissions for diabetes in youth. Diabetes Care, 28(9), 2150-2154. Goodman, R. (1997). The strengths and difficulties questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38(5), 581-586. Grey, M., Whittemore, R., Jaser, S., Ambrosino, J., Lindemann, E., Liberti, L., ., Dziura, J. (2009). Effects of coping skills training in school-age children with type 1 diabetes. Research in Nursing & Health, 32(4), 405-418. Hamman, R., Bell, R., Dabelea, D., D’Agostino, R., Dolan, L., Imperatore, G., ., Saydah, S. (2014). The SEARCH for diabetes in youth study: Rationale, findings, and future directions. Diabetes Care, 37(12), 3336-3344. Hood, K., Beavers, D., Yi-Frazier, J., Bell, R., Dabelea, D., Mckeown, R., & Lawrence, J. (2014). Psychosocial burden and glycemic control during the first 6 years of diabetes: Results from the SEARCH for Diabetes in Youth study. Journal of Adolescent Health, 55, 498-504. Hood, K., Huestis, S., Maher, A., Butler, D., Volkening, L., & Laffel, L. (2006). Depressive symptoms in children and adolescents with type 1 diabetes association with diabetes-specific characteristics. Diabetes Care, 29, 1389. Hood, K., Lawrence, J., Anderson, A., Bell, R., Dabelea, D., Daniels, S., ., Dolan, L. (2012). Metabolic and inflammatory links to depression in youth with diabetes. Diabetes Care, 35, 2443-2446. Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., ., Pao, M. (2012). Ask suicide-screening questions (ASQ): A brief instrument for the pediatric emergency department. Archives of Pediatrics & Adolescent Medicine, 166, 1170-1176. Johnson, B., Eiser, C., Young, V., Brierley, S., & Heller, S. (2013). Prevalence of depression among young people with Type 1 diabetes: A systematic review. Diabetic Medicine, 30, 199-208. Khan, W., Rabbani, M., Afzal, E., & Adnan, M. (2013). Psychological screening in children with diabetes mellitus type-I at the children’s hospital and the Institute of Child Health, Multan. Journal of Pakistan Medical Association, 63, 1520-1522. Kleigman, R., Stanton, B., St. Geme, J., & Schor, N. (2015). Nelson Textbook of Pediatrics (20th ed.). Philadelphia: W. B. Saunders. Kovacs, M. (1992). Children’s depression inventory manual. North Tonawanda, NY: Multi-Health Systems, Inc.

-/- 2017

9

Lawrence, J., Standiford, D., Loots, B., Klingensmith, G., Williams, D., Ruggiero, A., ., McKeown, R. (2006). Prevalence and correlates of depressed mood among youth with diabetes: The SEARCH for diabetes in youth study. Pediatrics, 117, 1348-1358. Lexi-Comp Inc. (2017). Pediatric and neonatal Lexi-Drugs. Hudson, OH: Author. Maslow, G., Dunlap, K., & Chung, R. (2015). Depression and suicide in children and adolescents. Pediatrics in Review, 36(7), 299-308. Multi-Health Systems Incorporated. (2017). Children’s Depression Inventory 2. Cheektowaga, NY: Author. Retrieved from http:// www.mhs.com/product.aspx?gr=edu&id=overview&prod=cdi2 National Institute of Mental Health. (2017). Ask Suicide-Screening Questions (ASQ). Bethesda, MD: Author. Retrieved from https://www. nimh.nih.gov/news/science-news/ask-suicide-screening-questionsasq.shtml Pettitt, D., Talton, J., Dabelea, D., Divers, J., Imperatore, G., Lawrence, J., ., Hamman, R. (2014). Prevalence of diabetes in U.S. youth in 2009: The SEARCH for diabetes in youth study. Diabetes Care, 37, 402-408. Radloff, L. (1977). The CES-D scale a self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401. Reynolds, K., & Helgeson, V. (2011). Children with diabetes compared to peers: Depressed? Distressed? Annals of Behavioral Medicine, 42, 29-41. Roy, S. M., & Roy, V. (2015). Type 1 diabetes mellitus. In F. Domino, R. Baldor, J. Golding & M. Stephens (Eds.), 5-minute clinical

10

Volume -  Number -

consult standard 2016 (24th ed.). Philadelphia: Lippincott Williams & Wilkins. Schilling, L., Knafl, K., & Grey, M. (2006). Changing patterns of selfmanagement in youth with type I diabetes. Journal of Pediatric Nursing, 21(6), 412-424. Silverstein, J., Cheng, P., Ruedy, K., Kollman, C., Beck, R., Georgeann, K., ., Tamborlane, W. (2015). Depressive symptoms in youth with type 1 or type 2 diabetes: Results of the pediatric diabetes consortium screening assessment of depression in diabetes study. Diabetes Care, 38, 2341-2343. Southammakosane, C., & Schmitz, K. (2015). Pediatric psychopharmacology for treatment of ADHD, depression, and anxiety. Pediatrics, 136, 351-359. Stewart, S., Rao, U., Emslie, G., Klein, D., & White, P. (2005). Depressive symptoms predict hospitalization for adolescents with type 1 diabetes mellitus. Pediatrics, 115, 1315-1319. U.S. Food and Drug Administration. (2004, October 15). FDA launches a multi-pronged strategy to strengthen safeguards for children treated with antidepressant medications. FDA News. Weissman, M., Orvaschel, H., & Padian, N. (1980). Children’s symptom and social functioning self report scales: Comparison of mothers’ and children’s reports. Journal of Nervous Mental Disorders, 168, 736-740. Youth in Mind. (2017). Information for researchers and professionals about the strengths and difficulties questionnaires. Retrieved from http://www.sdqinfo.com/

Journal of Pediatric Health Care