Depression in Childhood and Adolescence
James C. Harris
Depression is a pervasive emotional disorder manifested by negative mood, an inability to obtain pleasure in everyday activities, poor concentration, cognitive complaints of self-blame and worthlessness, reduced personal motivation, and physiologic changes in sleep and appetite. As a symptom or syndrome, depression is not synonymous with sadness or unhappiness. The mood is referred to as dysphoric and is one of despair. Irritability, deterioration in school performance, difficulty in peer relationships, and problems in conduct may be the presenting symptoms, which were sometimes referred to in the past as masked depression. Without early recognition and effective treatment, depressive episodes can last for months and lead to a continuing deterioration in school performance and already poor peer and family relationships. Adolescent suicide as a consequence of depression is an increasingly significant problem.
Because of children’s level of psychological development and the lack of universally accepted diagnostic criteria for depression in children, whether the preadolescent child can be depressed had been a subject of debate. In adolescence, depression often had been ignored and the symptoms attributed to adolescent turmoil. However, it is clear that diagnostic criteria originally developed for use with adults can be used to make the diagnosis in children and adolescents.
Although the same diagnostic criteria for a depressive episode are used for adults and children, as listed in Box 104.1, questions are asked of children based on their developmental level, and parent reports also are used in the diagnosis of children. This approach has led to the recognition of major depressive disorder in children and adolescents. However, the diagnostic lower limit for other forms of depressive subtypes is not established as clearly.
A distinction must be made between the more common reports of sadness seen in pediatric practice, which may be associated with somatic symptoms, unhappiness, bereavement, or demoralization, and a true major depressive disorder (i.e., a constellation of symptoms with a characteristic prognosis). How the child’s developmental level affects his presentation is ascertained through structured and semistructured interviews with the child and the parents, self-reports, and self-esteem
inventories. Interview information from both child and parents is essential to make a diagnosis.
inventories. Interview information from both child and parents is essential to make a diagnosis.
BOX 104.1 Diagnostic Criteria for Major Depressive Episode
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Symptoms that are clearly due to a general medical condition or mood-incongruent delusions or hallucinations should not be included.
Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
The symptoms do not meet criteria for a mixed episode (manic episode and depressive episode).
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The symptoms are not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
The symptoms are not better accounted for by bereavement (i.e., after the loss of a loved one); the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Footnote
Reprinted with permission from
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Text revision. Washington, DC: American Psychiatric Association, 2000.
EPIDEMIOLOGY
The earliest indication of depressive symptomatology can appear in a severely neglected infant. This nonorganic failure to thrive may represent a “reactive attachment disorder of infancy and early childhood” and is the result of a dysfunctional parent–child relationship. Information on prevalence is poorly documented, although failure to thrive with no specific etiology has been reported in up to 9% of infants in a rural area. For the preschool child, unhappy mood was reported in 4% to 8% of 3-year-old children in a behavioral survey; girls were affected more frequently than boys.
More than 40% of adolescents interviewed by a psychiatrist reported complaints of misery and sadness. Furthermore, 20% had feelings of self-depreciation, and 7% to 8% had suicidal thoughts. In prepuberty, depressive feelings are much less common. Symptoms were equally divided between boys and girls in prepuberty, but with the onset of puberty, the prevalence increased in girls. In one study, major depressive disorder was found to be rare in 10- to 11-year-old children, with a rate of 3 per 2,000. When the same group was assessed 4 years later, however, the rate had increased threefold, suggesting a potential role of physiologic changes at puberty in the onset of major depression.
Other authors have identified a prevalence of 1.8% of major depressive illness and a 2.5% prevalence of dysthymic disorder (discussed later in this chapter) in an epidemiologic population survey of 9-year-old children. In adolescence, those authors found a prevalence of 4.7% of major depression and 3.3% of dysthymic disorder, which is similar to the adult prevalence. A review of several studies suggested a rate of 3% to 8% overall in children and adolescents.
Prevalence rates are substantially higher in populations referred to pediatric hospitals or to child psychiatric inpatient and outpatient units. Consecutive admissions on a pediatric ward showed a 7% prevalence of depressive disorder and 38% prevalence of dysphoric moods in children 7 to 12 years old. A psychiatric outpatient study showed that one in nine prepubertal and one in four postpubertal young people seen for evaluation had depressive symptoms. Before puberty, symptoms were twice as frequent in boys, but after puberty, they were twice as frequent in girls.
During the 1980s and 1990s, depression in children was recognized with greater frequency; the greatest prevalence was found in the postpubertal years. Planning based on epidemiologic studies requires agreement on diagnostic criteria for both major depression and other depressive disorders. Achieving agreement is complicated by the recognition of subtypes of depression. Efforts are ongoing to validate assessment criteria and find biologic markers that will improve recognition.
CLINICAL MANIFESTATIONS AND COMPLICATIONS
Depression presents as a biopsychosocial illness. It is a disorder of mood, with symptoms related to neuroendocrine and autonomic dysfunction, along with specific cognitive problems
in self-perception. Problems in falling asleep and remaining asleep, anorexia and weight loss, abdominal pain, chest pain, headache, and constipation are associated somatic symptoms. Depression in the parent or child may lead to increased office visits and increased hospitalization for the diagnostic evaluations of ill-defined complaints. How the child presents is influenced by the parent–child relationship; in making the diagnosis, the words that the child has learned to use to describe emotional states must be considered. If the child does not recognize the bodily experience of his or her feelings, his or her vague complaints of not feeling good may be misunderstood. An emotionally healthy child is active, feels good, and has fun in his or her activities.
in self-perception. Problems in falling asleep and remaining asleep, anorexia and weight loss, abdominal pain, chest pain, headache, and constipation are associated somatic symptoms. Depression in the parent or child may lead to increased office visits and increased hospitalization for the diagnostic evaluations of ill-defined complaints. How the child presents is influenced by the parent–child relationship; in making the diagnosis, the words that the child has learned to use to describe emotional states must be considered. If the child does not recognize the bodily experience of his or her feelings, his or her vague complaints of not feeling good may be misunderstood. An emotionally healthy child is active, feels good, and has fun in his or her activities.
The child also may have learned to use physical complaints to get attention when experiencing depressed feelings in a household in which emotional expression is discouraged, or the child may have modeled his or her symptoms on a parent’s complaints. These patterns may continue in adulthood, so they are best dealt with directly in childhood. Somatic symptoms and vague complaints may be the child’s way of expressing the dysphoric feelings associated with grief and minor or major depression.
Complaints of sleep and eating problems are characteristic of depression. In addition, studies of hospitalized children have found headache, fatigue, muscle pain, recurrent vomiting, and abdominal pain to be physical symptoms associated with depression; gastrointestinal symptoms were found to be the most characteristic. Separation anxiety symptoms often accompany depressive symptoms and are classically associated with physical complaints on school mornings. Abdominal pain often is associated with separation anxiety, which may accompany depression. Chest pain also is associated with depression. In one study, 13 of 100 children seen in a cardiac clinic had depressive symptoms; their chest pain had no associated cardiac diagnosis in this population.
Children with severe burns, trauma, or chronic illness are another group at risk for depressive symptoms. Restricted physical activity, sensory isolation, repeated treatment intervention, and sudden and severe loss of health may be factors in their apathy, regression, and withdrawal. Children with chronic handicaps also may be symptomatic. Twenty of 100 handicapped children reporting for orthopedic hospitalization had depressive symptoms.
Although the focus is generally on the child’s complaint, attention also must be paid to the parents’ problems. In one study, children with recurrent abdominal pain were not different from a control group in their degree of depressive symptomatology; however, 25% of the mothers were mildly to moderately depressed.
DIAGNOSIS
Ordinarily, the parents request help for their distressed or dysfunctional child. Depression can present as a symptom, syndrome, or disorder. As a symptom, it is the expected emotional response to stressful situations; as a syndrome or disorder, it represents an abnormally persistent dysphoric mood. It is essential to differentiate between transient mood changes, which may be normal reactions to stressors, and the despair, irritability, and loss of interest and pleasure that signify depression.
Depression involves not only dysphoria but also changes in self-perception. Those aspects of depression that involve self-blame and worthlessness become evident as the child matures. Thoughts of guilt, helplessness, and hopelessness about the future follow a developmental course, so diagnostic criteria for depression may need to be modified for younger children and children who are mentally retarded. At 4 or 5 years, children are aware of others being proud or ashamed of them, but it is not until approximately age 8 that they talk meaningfully about being proud or ashamed of themselves. By age 5 or 6 years, the child begins to distinguish accidental from intentional behavior, although earlier in life, bad outcomes are perceived as unintended. Similarly, 5- to 7-year-old children perceive that sadness comes from external events rather than internal feeling states. By approximately age 10 years, the child understands that a personal problem involves psychological distress as well as external stressors. Self-awareness with increased self-consciousness, as well as anxiety about the future, develops in adolescence.
Age and sex are important factors in evaluation. In younger children, assessment is more difficult because of their difficulty in describing their emotions. Younger children do not divorce mood from the context of their experience. Even in adolescence, however, parents and teachers often fail to recognize depression although young people report it. An interview with both the child and parents is essential.
From a diagnostic perspective, the current classification of psychiatric diagnoses lists several emotional disturbances of increasing severity. These range from uncomplicated bereavement and adjustment reaction with depressed or anxious mood to dysthymic disorder and major depression. An adjustment disorder with depressive symptoms following either acute or chronic stress is the most common diagnosis; the next most common is dysthymic disorder. In dysthymic disorder, symptoms have less intensity, are of shorter duration, and occur intermittently, in contrast to a major depressive disorder, which is accompanied by more severe physical symptoms, alterations in perception, and cognitive status. A description of symptom characteristics of a major depressive disorder follows.
Depressed Mood
Depressed mood can be expressed both verbally and nonverbally. Because young children vary in their ability to talk about their depressive symptoms, other informants are needed. For preschool children, teacher and parent reports are particularly important. Irritability and changes in activity, perhaps as a reaction to their dysphoric mood, are seen in preschool children. For these younger children, symptoms vary more with the environmental setting than they do in older children. A parent report helps to distinguish changes in behavior but does not necessarily include the child’s specific concerns. The child must be asked specifically about how he feels. The first step is to establish what words the child uses to describe the bad feeling inside (e.g., down, bored, blue, empty, real sad). Nonverbally, a sad expression with downcast eyes and sagging lips is easily recognized; however, changes in facial expression often are more subtle. Adolescents can appropriately label feelings, but they may be guarded in talking about them. They may distort their reports, perhaps because they lack the adult sense of time, and it seems to them that these feelings will never go away. Teenagers may try to hide their feelings from themselves and from adults.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
