Introduction: Why Depression is a problem.
Depression in children has long been an overlooked health problem. While it is fairly well known to the general public that clinical depression is common (sometimes referred to as "the common cold of mental illness"), affecting 10 to 15 % of the adult population at some point in life, it is not commonly known that depression in childhood is also a major health problem. In fact, depression in children is arguably more significant of an issue that is adult depression. For example, about 5% of children at any given time suffer from clinical depression; this naturally occurs during critical phases in child development, and not only can show itself with behaviors and feelings not commonly viewed as part of a "depression," but can interfere with the normal developmental processes of childhood.
Depression in children can, if untreated, affect school performance and learning, social interactions and development of normal peer relationships, self-esteem and life skill acquisition, parent-child relations and a child's sense of bonding and trust, can lead to substance abuse, disruptive behaviors, violence and aggression, legal troubles, and even suicide. According to the American Academy of Pediatrics, suicide is the 3rd leading cause of death among children and adolescents, just behind accidents and violence. Moreover, depressive thinking can become part of a child's developing personality, leaving long-term effects in place for the rest of a child's life.
Childhood depression is a serious problem that demands a serious treatment approach. However, one obstacle to eliminating depression in children is first to recognize it for what it is. Often children's behavioral problems are only brought to professional attention when they are obvious: they may cause classroom disruption, expulsion from school, school failure, or injury to themselves or others. These behaviors may be seen as symptoms of ADHD, Oppositional Defiant Disorder, "truancy," "delinquency," or other vague problems and never recognized to be manifestations of an underlying depressive disorder. It is important to determine if depression is a part of the overall behavioral picture, because many effective therapies and interventions are available today.
Diagnosis of Depression: What to look for.
Depression is a disorder that is defined by certain behaviors and thought patterns. Although the core troubles are the same for children as they are for adults, often the specific behaviors are different, and vary according to the age and developmental level of the child. Importantly, often a child or adolescent is unable to say that they are "depressed" or "sad." Rather, they may say that they are bored, angry, or are just not happy. As examples of how depressive behavior can be somewhat different in adults versus children, below is a list comparing the major symptoms of depression.
||Irritable, argumentative, aggressive, whining/crying
||Argumentative, aggressive, emotionally sensitive
|diminished interest/pleasure, inability to feel pleasure
||not as motivated or playful, not as curious and explorative, school work drops off, boredom
||Isolative, quits activities, shows no initiative, grades drop, boredom
|unintentional weight changes
||Fails to gain weight normally
||Difficulty falling asleep or staying asleep
||Difficulty falling asleep or staying asleep, stays up all night
|being slowed down or sped up
||Difficulty concentrating or sitting still, impulsivity, less active or interactive, hyperactive, disorganized
||Difficulty concentrating or sitting still, impulsivity, less active or interactive, disorganized
||Needs rests, naps, complains when is pushed to do things, plays "sick"
||Refuses to participate, lays around a lot, sleeps during day, acts "sick" a lot
|worthlessness and guilt
||Makes negative self-comments such as "You hate me" and "I'm stupid"
||Makes negative self comments such as "I'm fat" "I'm ugly" "Everybody hates me"
|poor concentration, can't make decisions
||Poor attention and concentration, easily distractible, disorganized
||Poor attention and concentration, easily distractible
|thoughts of death or suicide
||Talks about death, states "I wish I was never born" or "I wish I was dead"
||Obsesses on death and morbid topics, voices wishes to be dead or thinksabout/attempts suicide
|Psychosis: hearing things, seeing things, or paranoia
||Extreme fears for safety, seeing scary images, hearing monsters
||Suspiciousness, paranoia, seeing fearful images or hearing their name called
These problems must lead to significant difficulties in peer interaction, play and recreation, school performance, family interactions, or disturbance of normal development. They must last at least 2 weeks continually, must not be the result of drug or alcohol use, and not be due to bereavement or grief after a loss.
As seen in clinical practice and in some studies, the most common symptoms of depression reported in children and adolescents were sadness, inability to feel pleasure, irritability, fatigue, insomnia, lack of self-esteem, and social withdrawal. Children are as well somewhat more likely than adolescents to suffer from physical symptoms (e.g., stomach aches and headaches), hallucinations, agitation, and extreme fears. On the other hand, adolescents showed more despairing thoughts, weight changes, and excessive daytime sleepiness.
Prevalence: How common is depression?
As stated above, in general about 5% of children and adolescents nationally could be diagnosed with depression at any given time. Further studies have shown that this number changes as children age: about 1% of preschoolers, 2% of school-age children, and 5% of adolescents are affected. About 25 to 50% of all children and adolescents in psychiatric treatment are seen for depression and its related problems. Childhood depression appears to be more common in boys than in girls (about a 5 to 1 ratio, boys to girls) until adolescence, when it becomes more common for girls than boys (2 to 1 ratio, girls to boys).
Children who have biologic relatives that suffer from depression, anxiety disorders, and substance abuse disorders have a biologic tendency towards depression, and are more likely to develop clinical depression than children that do not have biologic relatives with these disorders.
Comorbidity/Risk factors: What else to look for.
Unfortunately depression in children and adolescents does not always show up alone: there frequently are one or more problems associated with the depression, making it important for the doctor to discover and treat. If not, the undiscovered and untreated problems will likely interfere with the depression treatment and complicate the picture.
Frequent illnesses that accompany depression include anxiety, phobias, obsessive compulsive disorder, ADHD, substance abuse, oppositional defiant disorder, learning disorders, and delinquent behaviors.
Course of Illness: Will the depression come back again?
For the majority of children, the answer is Yes. However, it is not known when depression may recur or how severely. Depression that remains untreated on average may last 9 months and take 9 more months to fully resolve. With treatment, the length of the depressive episode is much shorter, and the child will recover more quickly. This results in less disruption to the child's life and quicker return to normal function at home, with friends and family, at school, and in the normal course of development. It is believed that treatment of depression as well can serve to reduce the likelihood of depression recurring; or if depression does return, treatment delays the return of symptoms and reduces the severity of symptoms overall. From a statistical point of view, about 70% of children and adolescents will have another episode of depression within 5 years of the first one. Fortunately, if the child and his family sought treatment the first time, they are very educated about depression and its signs, and so can be on the lookout for the earliest, most subtle changes associated with a returning depression and can immediately seek help and early treatment.
Treatments: What can be done.
Successful treatment of childhood and adolescent depression has proven to require interventions on several strategic fronts:
- thorough and accurate diagnostic evaluation of the child. As depression in childhood is commonly confounded by multiple disorders, it is vital to the treatments success that all disorders be discovered and addressed. Many of these disorders can be helped with appropriate use of medications, such as mood stabilizers, antianxiety medications, antidepressants, and stimulants. Also, individual therapy is often beneficial for the patient, and can specifically help with issues of family conflict, self-esteem, relaxation strategies, mood and anger control, and better communication.
- evaluation of the school environment and its impact on the current situation. Very frequently school and peer issues can lead to and/or perpetuate an environment in which the child's depression can take root and grow. It is important, therefore, that assessment of the school be done so that modifications to the demands placed on the child may be appropriately completed so as to best create an environment that fosters recovery while not unduly affecting the educational process. This usually involves the interaction of the school counselor, principal, psychologist, teachers, and parents. Some interventions include psychoeducational testing, speech and occupational therapy, in-school counseling, curriculum modification, resource classes, behavioral modification systems, ARD meetings, self-contained classrooms, and alternative placements.
- evaluation of the home/parental environment and its impact on the current situation. Home life can also contribute to the development and/or continuance of a child's or adolescent's depression. Like school modification and intervention, family and home modification may be necessary to best create an environment that fosters recovery while minimizing the disruption to the family and child's lives. Family therapy and couples therapy are often very useful in this regard, and can address issues of parental roles, parental modeling, interfamily conflict, better communication, behavioral reward systems, and defining family members' roles and responsibilities.
- Education (also known as psychoeducation) about childhood depression and its associated illnesses, and nature and expectable course of the disorder(s), the importance and limitations of specific treatment modalities.
Support: Where to look for help.
There are several convenient sources of information and support, many of which can be found on the internet or in your community's libraries. Below are several good internet starting points. Additionally, your physician, nurse, pastor or counselor can be good sources of information.
- American Academy of Child and Adolescent Psychiatry: Information is provided as a public service to aid in the understanding and treatment of the developmental, behavioral, and mental disorders which affect an estimated 7 to 12 million children and adolescents at any given time in the United States. You will find information on child and adolescent psychiatry, fact sheets for parents and caregivers, current research, practice guidelines, managed care information, awards and fellowship descriptions, meeting information, and much more.
- Mental Health Net: the most comprehensive source of online mental health information, news and resources.
- Online Psych: Online Psych gives you a variety of interactive tests, quizzes, and surveys to challenge, inform, intrigue, and educate you. You'll find everything from online screening tests for mental health issues to fun surveys about relationships.
- Knowledge Exchange Network: The Center for Mental Health Services (CMHS) Knowledge Exchange Network (KEN) provides information about mental health