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Depression in childhood and adolescence

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Depression in Childhood and Adolescence is a mood disorder that affects children under the age of 18.

The symptoms of depression in childhood are similar to adult major depressive disorder, with the exception that children may also exhibit an extended and irritable mood, rather than sadness [1] Children under stress, who experience loss or who have attentional, learning, conduct, or anxiety disorders, are at a higher risk for depression. Child depression is often comorbid with other mental disorders, most commonly anxiety disorder and conduct disorder. Depression also tends to run in families.[2] Psychologists have developed different treatments to help assist children and adolescents suffering from depression. Throughout the emergence of this disorder, there have been multiple controversies that have surfaced, such as the legitimacy of the diagnosis, as well as the most effective assessment and treatment.

Base Rates and Prevalence

About eight percent of children and adolescents suffer from depression.[3] Research suggests that the prevalence for children suffering from depression in Western culture ranges from 1.9-3.4% in primary school children and from 3.2 to as high as 8.9% in adolescents.[4] Also, studies have reported that among children diagnosed with depression, there is a 70% rate of children experiencing depression again within five years.[4] Furthermore, 50% of children with depression will continue to have recurrence in adulthood.[5] While children show differences in rates of depression between gender before teenage years (after the age of fifteen) girls are about twice as likely to be diagnosed with depression than boys. However, in terms of recurrence and symptom severity, there is no gender difference.[6] This notion is thought to be from a model that asserts that girls carry more risk factors for depression before early adolescence, on average, than boys. These risk factors lead to depression with the occurrence of challenges that become more prevalent during early adolescence.[7]


Suicidal Intent

Depression in children and adolescents is associated with an increased risk of suicidal behaviors 3,9. This risk may rise, particularly among adolescent boys, if the depression is accompanied by conduct disorder and alcohol or other substance abuse 10. In 1997, suicide was the third leading cause of death in 10- to 24-year-olds 11. NIMH-supported researchers found that among adolescents who develop major depressive disorder, as many as 7 percent may commit suicide in the young adult years 3. Consequently, it is important for doctors and parents to take all threats of suicide seriously. NIMH researchers are developing and testing various interventions to prevent suicide in children and adolescents. Early diagnosis and treatment, accurate evaluation of suicidal thinking, and limiting young people's access to lethal agents-including firearms 12 and medications-may hold the greatest suicide prevention value.

Risk Factor

In childhood, boys and girls appear to be at equal risk for depressive disorders; but during adolescence, girls are twice as likely as boys to develop depression 4. Children who develop major depression are more likely to have a family history of the disorder, often a parent who experienced depression at an early age, than patients with adolescent- or adult-onset depression 21. Adolescents with depression are also likely to have a family history of depression, though the correlation is not as high as it is for children.[8]

Comorbidity

Research has shown that there is a high rate of comorbidity with depression in children and dysthymia [9] There is also a substantial comorbidity rate with depression in children and anxiety disorders, conduct disorder, and impaired social functioning.[1][9] Particularly, there is a large comorbidity rate with anxiety, ranging as low as 15.9% to as high as 75% [9][10] Conduct disorders also had a significant comorbidity with depression in children and adolescents, with a rate of 23% in one longitudinal study.[11] Beyond other clinical disorders, there is also an association between depression in childhood and poor psychosocial and academic outcomes as well as a higher risk for substance abuse and suicide.[1]

Diagnosis

According to the DSM-IV, children must exhibit either a depressed mood or a loss of interest or pleasure in normal activities. These activities may include school, extracurricular activities, or peer interactions. In terms of depressive moods in children, it can be expressed as being unusually irritable, which may be shown by “acting out,” behaving recklessly, or often reacting with anger or hostility. Children who do not have the cognitive or language development to properly express mood states can also exhibit their mood through physical complaints such as showing signs of sad facial expressions (frowning) and poor eye contact. A child must also exhibit four other symptoms in order to be clinically diagnosed.

Correlation between Adolescent Depression and Adulthood Obesity

According to a research done by Laura.P.Richardson et al., Major depression occurred in 7% of the cohort during early adolescence (11, 13, and 15 years of age) and 27% during late adolescence (18 and 21 years of age). At 26 years of age, 12% of study members were obese. After adjusting for each individual's baseline body mass index (calculated as the weight in kilograms divided by the square of height in meters), depressed late adolescent girls were at a greater than 2-fold increased risk for obesity in adulthood compared with their nondepressed female peers (relative risk, 2.32; 95% confidence interval, 1.29-3.83). A dose-response relationship between the number of episodes of depression during adolescence and risk for adult obesity was also observed in female subjects. The association was not observed for late adolescent boys or for early adolescent boys or girls.[12]

Correlation between Child Depression and Adolescent Cardiac Risks

Research suggests that any history of child depression influences the occurrence of adolescent cardiac risk factors, even if they no longer suffer from depression.[13]

Distinction from Major Depressive Disorder in Adults

While there are many similarities to adult depression, especially in expression of symptoms, there are many differences that create a distinction between the two diagnoses. Research has shown that when a child’s age is younger at diagnosis, typically there will be a more noticeable difference in expression of symptoms than from the classic signs in adult depression.[14] One major difference in the symptoms exhibited in adults and in children is that children have higher rates of internalization; therefore, symptoms of child depression are more difficult to recognize.[15] One major cause for this difference is that many of the neurobiological effects within the brain that have been shown in adults with depression are not fully developed until adulthood. So, neurologically, children and adolescents express depression differently.

Symptoms

[16] These symptoms must also not be accounted for by other disorders or explanations. Symptoms must be present in the child for at least two weeks, and there must be a change in functioning prior to the expression of symptoms. The symptoms are sometimes hard to recognize, as children often internalize their feelings and emotions more than adults.


Symptoms of Major Depressive Disorder Common to Adults, Children, and Adolescents 14 Persistent sad or irritable mood, Loss of interest in activities once enjoyed, Significant change in appetite or body weight, Difficulty sleeping or oversleeping, Psychomotor agitation or retardation, Loss of energy, Feelings of worthlessness or inappropriate guilt, Difficulty concentrating and decrease in attention, Recurrent thoughts of death or suicide, Five or more of these symptoms must persist for 2 or more weeks before a diagnosis of major depression is indicated, daily issues of insomnia or hypersomnia, fatigue, dissociation from peers and multiple absences from school, self-depreciation, Poor school performance.

Signs

Signs That May Be Associated with Depression in Children and Adolescents

Frequent vague, non-specific physical complaints such as headaches, muscle aches, stomachaches or tiredness, Frequent absences from school or poor performance in school, Talk of or efforts to run away from home, Outbursts of shouting, complaining, unexplained irritability, or crying, Being bored, Lack of interest in playing with friends, Alcohol or substance abuse, Social isolation, poor communication, Fear of death, Extreme sensitivity to rejection or failure, Increased irritability, anger, or hostility, Reckless behavior, Difficulty with relationships, While the recovery rate from a single episode of major depression in children and adolescents is quite high 15, episodes are likely to recur 16. In addition, youth with dysthymic disorder are at risk for developing major depression 17. Prompt identification and treatment of depression can reduce its duration and severity and associated functional impairment.

History

First, child abuse began to come into the awareness of professionals in the early 1980s. Therefore, it is possible that some of the young people identified with depressive disorders may have had a history of sexual abuse which was not disclosed. This raises the argument of what would the outcome have been in those young people who had been sexually abused had they made disclosures and had appropriate therapeutic intervention for this. It is well known that childhood sexual abuse is a significant factor in the histories of some adults presenting with depressive syndromes.

Second, when attention-deficit hyperactivity disorder (ADHD) was not recognised and hyperkinetic disorder was only rarely diagnosed. Some of the young people, especially those in the comorbid conduct disorder/major depressive disorder group, may have had undiagnosed and untreated ADHD. Certainly this was long before the use of psychostimulants on a wider basis in the UK and it is possible that some of these young people untreated may have been more vulnerable to development of depressive syndromes because of untreated attentional and other behavioural problems impacting on their self-esteem.

Third, although antidepressants were in use by child and adolescent psychiatrists when the diagnosis was major depressive disorder, they may not always have been used in young people with major depressive disorder with comorbid conduct disorder because of the risks of overdose in such a population. Tricyclic antidepressants were the predominant antidepressants used at that time in this population. With the advent of selective serotonin reuptake inhibitors, child and adolescent psychiatrists probably began prescribing more anti-depressants in the comorbid conduct disorder/major depressive group because of the lower risk of serious harm in overdose. This raises the possibility that more effective treatment of these young people might also have an impact on their outcomes in adult life. [17]

Treatment

There are multiple treatments that can be effective in treating children diagnosed with depression. Psychotherapy and medications are commonly used treatment options. In some research, adolescents showed a preference for psychotherapy rather than antidepressant medication for treatment.[18] For adolescents, cognitive behavioral therapy and interpersonal therapy have been empirically supported as effective treatment options.[1] The use of antidepressant medication in children is often seen as a last resort; however, studies have shown that a combination of psychotherapy and medication is the most effective treatment. [19] Pediatric massage therapy may have an immediate impact on a child's emotional state at the time of the massage, but sustained effects on depression have not been identified.[20]

Treatment programs have been developed that help reduce the symptoms of depression. These treatments focus on immediate symptom reduction by concentrating on teaching children skills pertaining to primary and secondary control. While much research is still needed to confirm this treatment program’s efficacy, it has shown to be effective in children with mild or moderate depressive symptoms in a study. [21]

Talk Therapy

There are 3 common types of talk therapy. These can assist people to live more fully and have a better life.[22]

Cognitive therapy

Cognitive therapy helps you to change harmful ways of thinking and it assists you to have a more positive way to see things which you tend to see negatively.

Situation: You call a friend, but he says he is busy and wants to talk to you later. Your first thought will be like maybe you made him angry and you feel anxious and worried. You will be overwhelmed with a flood of negative thinking after a while.

Therapy: Talk therapy can help you focus on your reaction to your friend’s behavior. Thinking of other reasons for his actions enhance you to see the event in a more positive and accurate way. For instance, perhaps what he said has nothing to do with you or maybe he was having a bad day. Perhaps he was late for an appointment. [23]

Behavioural therapy

Behavioral therapy helps you change harmful ways of acting and to get control over behavior which is causing problems.

Situation: You were robbed and now you are scared of being alone in public. You can’t go anywhere alone and you are starting to miss days at work and school.

Therapy: Talk therapy can help you to face your fears. Discussing your problems with a trusted person can help to overcome those fears and take control of your life.

Interpersonal therapy

Interpersonal therapy helps you learn to relate better with others and focus on how to express your feelings and develop better people skills.

Situation: You and your father are not getting along. He doesn’t approve of your significant partner, or your group of friends. You feel that he is trying to run your life.

Therapy: Talk therapy can help you see your father's point of view. Perhaps he feels you don’t spend time with him anymore. Finding new ways of talking to your father helps you both feel better.

Family Therapy

The principles of group dynamics are highly relevant to family therapists who must not only work with individuals, but with entire family systems (Nichols & Schwartz, Family Therapy: Concepts and Methods. Fourth Edition. Allyn & Bacon 1998)

Two concepts that influence family therapy were:

(a) the distinction between the process and content of group discussions, and

(b) role theory.

Therapists realized that have to understand not just what the group members said, but how these ideas were communicated (process). Therapists can help families improve the way they relate and thus enhance their own capacity to deal with the content of their problems by focusing on the process of their discussions. Virginia Satir expanded on the concept of how individuals behave and communicate in groups by describing several family roles that can serve to stabilize expected characteristic behavior patterns in a family. For instance, if one child is considered as a "rebel child," a sibling may take on the role of the "good child" to alleviate some of the stress in the family. This concept of role reciprocity is helpful to understanding family dynamics because of the complementary nature of roles makes behaviors more resistant to change. [24]

Controversies

Throughout the development and research of this disorder, controversies over the legitimacy of depression in childhood and adolescence as a diagnosis, the proper measurement and validity of scales to diagnose, and the safety of particular treatments, have surfaced among psychology.

Legitimacy as a Diagnosis

In early research of depression in children, there was argument as to whether or not children could clinically fit the criteria for Major Depressive Disorder.[25] However, since the 1970s, it has been accepted among the psychological community that depression in children can be clinically significant [25] The more pertinent controversy in psychology today centers around the clinical significance of subthreshold mood disorders. This controversy stems from the current debate as to what the definition of the specific criteria for a clinically significant depressed mood is in relevance to the cognitive and behavioral symptoms. Some psychologists argue as to whether the effects of mood disorders in children and adolescents that exist but do not fully meet the criteria for depression have severe enough risks. Children in this area of severity, they argue, should receive some sort of treatment since the effects could still be severe.[5] However, since there has yet to be enough research or scientific evidence to support that children that fall within the area just shy of a clinical diagnosis require treatment, other psychologists are hesitant to support the dispensation of treatment.

Diagnosis Controversy

In order to diagnose a child with depression, different screening measures and reports have been developed to help clinicians make a proper decision and treatments have been developed. However, the accuracy and effectiveness of certain measures that help psychologists diagnose children have come into question.[26] Also, in terms of treatment, questions about the safety and effectiveness of the antidepressant medication have surfaced in the psychology community [27]

Measurement Reliability

When reviewing dimensional child self-report checklists, the actual effectiveness of this measure has been criticized. Despite the fact that literature has documented strong psychometric properties, other studies have shown a poor specificity at the top end of scales, resulting in most children with high scores not meeting the diagnostic criteria for depression.[5] Another issue with reliability of measurement for diagnosis occurs in parent, teacher, and child reports. One study, which observed the similarities between child self-report and parent reports on the child's symptoms of depression, acknowledged that on more subjective symptom reports measures the agreement was not significant enough to be considered reliable.[26] Also, in terms of the use of self-report measures to diagnose depression in children and adolescents, two scales have an error of misclassifying twenty-five percent of children in both the depressed and controlled samples.[28] As with other self-report measures, a large concern in the use of these is how accurate the information collected from these reports are. The main controversy is caused by uncertainty about how the data from these multiple informants can or should be combined to determine whether a child can be diagnosed with depression.[5]

Treatment Issues

The controversy of the use of antidepressants began in 2003 when Great Britain's Department of Health stated that, based on data collected by the Medicines and Healthcare products Regulatory Agency that paroxetine (a form of antidepressants) should not be used on patients under the age of 18.[27] Since then, the US' Food and Drug Administration (FDA) has issued a warning describing the increased risk of adverse effects for antidepressants used as treatment for those under the age of 18 [27] The main concerns of the use of antidepressants in children is whether the risks outweigh the benefits of the treatment. In order to decide this, studies often look at the adverse effects caused by the medication in comparison to the overall symptom improvement.[27] While multiple studies have shown an improvement or efficacy rate of over fifty percent, the concern of severe side effects, such as suicidal ideation or suicidal attempts, worsening of symptoms, or increase in hostility are still concerns when using antidepressants.[27] However, an analysis of multiple studies argue that while the risk of suicidal ideation or attempt is present, the benefits significantly outweigh the risk [29] As of now it is recommended that, because of the variability of these studies, if antidepressants are chosen as a method of treatment for children or adolescents, that the clinician monitor closely for adverse symptoms, since there is still no definitive answer on the safety and overall efficacy [27][29]

References

  1. ^ a b c d Birmaher, B., Ryan, N.D., Williamson, D.E. Brent, D.A., Kaufman, J., Dahl, R.E., Perel, J. & Nelson, B. (1996). Childhood and adolescent depression: A review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 35(11), 1427-1439.
  2. ^ American Academy of Child & Adolescent Psychiatry. The Depressed Child, “Facts for Families,” No. 4 (5/08)
  3. ^ Eapen, Valsamma. (2012). Strategies and challenges in the management of adolescent depression. Current Opinion in Psychiatry, 25(1), 7-13.
  4. ^ a b Kovacs, M., Feinberg, T.L., Crousenovak, M.A., Paulauskas, S.L., & Finkelstein, R. (1984). Depressive-disorders in childhood. 1. A longitudinal prospective-study of characteristics and recovery. Archives of General Psychiatry, 41(3), 229-237.
  5. ^ a b c d Kessler, R.C., Avenevoli, S., & Merikangas, K.R. (2001). Mood disorders in children and adolescents: An epidemiological perspective. Biological Psychiatry, 49(12), 1002-1014.
  6. ^ Hankin, B.L., Abramson, L.Y., Moffitt, T.E., Siilva, P.A., McGee, R. Angell, K.E. (1998) Development of depression from preadolescence to young adulthood: Emerging gender differences in a 10-year longitudinal study. Journal of Abnormal Psychology, 107(1), 128-1140.
  7. ^ Nolen-hoeksema, S. & Girgus, J.S. (1994). The emergence of gender differences in depression during adolescence. Psychological Bulletin, 115(3), 424-443.
  8. ^ "A Fact Sheet". National Institute of Mental Health.
  9. ^ a b c Angold, A., & Costello, E.J. (1993) Depressive comorbidity in children and adolescents: Empirical, theoretical, and methodological issues. The American Journal of Psychiatry, 150(12), 1779-1791.
  10. ^ Brady, E.U., & Kendall, P.C. (1992) Comorbidity of anxiety and depression in children and adolescents. Psychological Bulletin, 111(2), 244-255.
  11. ^ Kovacs, M., Paulauskas, S., Gatsonis, C., & Richards, C. (1988). Depressive-disorders in childhood. 3. A longitudinal-study of co-morbidity with and risk for conduct disorders. Journal of Affective Disorders, 15(3), 205-217.
  12. ^ Hynes, J. (2002). "Follow-up of childhood depression: historical factors". The British Journal of Psychiatry. 181: 166–167. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  13. ^ http://www.sciencedaily.com/releases/2013/03/130315202640.htm
  14. ^ Kaufman, J., Martin, A., King, R.A., & Charney, D. (2001). Are child-, adolescent-, and adult-onset depression one and the same disorder? Biological Psychiatry, 49(12), 980-1001.
  15. ^ Zahn-Waxler, C., Klimes-Dougan, B., & Slattery, M.J. (2000). Internalizing problems of childhood and adolescence: Prospects, pitfalls, and progress in understanding the development of anxiety and depression. Development and Psychopathology, 12(3), 443-466.
  16. ^ American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  17. ^ Hynes, J (2002). "Follow-up of childhood depression: historical factors". British journal of psychiatry. 181: 166–167. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  18. ^ Bradley, K.L., McGrath, P.J., Brannen, C.L., & Bagnell, A.L. (2010). Adolescents’ attitudes and opinions about depression treatment. Community Mental Health Journal, 46(3), 242-251.
  19. ^ Chakraburtty, Amal. "Depression in Children". WebMD. WebMD, LLC. Retrieved 15 September 2011.
  20. ^ Jorm AF, Allen NB, O'Donnell CP, Parslow RA, Purcell R, Morgan AJ (2006). "Effectiveness of complementary and self-help treatments for depression in children and adolescents". Med. J. Aust. 185 (7): 368–72. PMID 17014404. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  21. ^ Weisz, J.R., Thurber, C.A., Sweeney, L., Proffitt, V.D., & LeGagnoux, G.L. (1997). Brief treatment of mild-to-moderate child depression using primary and secondary control enhancement training. Journal of Consulting and Clinical Psychology, 65(4), 703-707.
  22. ^ "An overview of talk therapy".
  23. ^ "An overview of talk therapy".
  24. ^ "Family therapy historical overview".
  25. ^ a b Chambers, W.J., Puigantich, J., Tabrizi, M., & Davies, M. (1982) Psychotic symptoms in prepubertal major depressive disorder. Archives of General Psychiatry, 39(8), 921-927.
  26. ^ a b Barret, M.L., Berney, T.P., Bhate, S., Famuyiwa, O.O., Fundudis, T., Kolvin, I., & Tyrer, S. (1991). Diagnosing childhood depression - who should be interviewed - parent or child - the Newcastle-child-depression-project. British Journal of Psychiatry, 159(11), 22-27.
  27. ^ a b c d e f Cheung, A.H., Emslie, G.J., & Mayes, T.L. (2005) review of the efficacy and safety and antidepressants in youth depression. Journal of Child Psychology and Psychiatry, 46(7), 735-754.
  28. ^ Fundudis, T., Berney, T.P., Kolvin, I., Famuyiwa, O.O., Barrett, L., Bhate, S., & Tyrer, S.P. (1991). Reliability and validity of 2 self-rating scales in the assessment of childhood depression. British Journal of Psychology, 159(11), 36-40.
  29. ^ a b Bridge, J.A., Iyengar, S., Salary, C.B., Barbe, R.P., Birmaher, B., Pincus, H.A., Ren, L., & Brent, D.A. (2007). Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: A meta-analysis of randomized controlled trials. Jama-Journal of the American Medical Association, 297(15), 1683-1696.
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