DEPRESSION IN CHILDREN AND ADOLESCENTS
Cynthia L. Boykin, PhD, clinical psychologist, Center for Disabilities and Development
Dennis C. Harper, PhD, ABPP, professor, Department of Pediatrics; interim director, Division of Developmental Disabilities, Center for Disabilities and Development
University of Iowa Hospitals and Clinics
Fall 2002

The National Institute of Mental Health (NIMH) estimates that up to 11% of young children and adolescents suffer from depression, with 50% of those having another psychiatric disorder. Of children treated for major depression, 66% to 70% will experience a relapse. In spite of its high incidence, depression remains one of the more difficult disorders for parents and health care providers to identify.

Identifying depression in children

Symptoms of depression vary depending upon developmental age. Children with limited verbal language may not be able to explain how they feel. This may result in acting out behaviors such as irritability, disobedience, or aggression. In addition, research shows that parents do not readily pick up on the symptoms of depression, and this can increase the length of time a child goes untreated. The child that acts out by picking fights at school, has frequent stomachaches, kicks the dog, and hits his siblings may be demonstrating depression just as much as the child who hides in the bedroom, doesn’t want to eat or play, and cries all the time.

The signs of depression in children and adolescents include:

• Lack of interest in friends and activities
• Absences from school; drop in academic performance
• Withdrawal from family or social activities; decreased communication
• Increased crying, irritability, anger, reckless behavior, or mood swings
• Increase in vague, nonspecific physical complaints; fatigue
• Talking about or attempting to run away
• Complaints of being bored; talk of feeling hopeless
• Sadness
• Difficulty concentrating and organizing thoughts
• Significant change in appetite or body weight
• Sleep difficulties: too much or too little
• Feelings of worthlessness
• Overwhelming, inappropriate guilt
• Recurrent thoughts of death or suicide
• Psychomotor agitation (constant movement) or retardation (loss of energy)
• Drug or alcohol abuse

Risk factors for depression in childhood

While research at this time does not clearly indicate a single biological, psychological, or social explanation for childhood depression, the Harvard Mental Health Letter (2-02) reports that a genetic predisposition toward childhood depression exists in about half of all cases. As young children, boys and girls appear to be equally at risk. In adolescence, however, girls are twice as likely to experience depression.

Risk factors for all children include:

• A family history of depression, especially if parents experienced it when they were young
• Abuse or neglect
• Chronic illness, such as diabetes or cancer
• Trauma, including experiencing a natural disaster
• Loss of a close friend, romantic partner, parent, or other loved one through death, distance, or break-up
• Attention, conduct, or learning disorder

Identifying depression in children

All children have times when they feel sad. Sometimes the reason is clear, such as when a child is dealing with the death of a pet or loved one. Clinical major depression refers to symptoms that are beyond what would be considered normal for the situation, and that interfere with functioning in various areas of the child's life. It generally lasts from 6 to 9 months if left untreated. If symptoms have persisted for more than two weeks, professional care should be sought.

In children age 3 and younger, the symptoms of depression may take the form of tantrums, feeding problems, and a decrease in playfulness and expressiveness.

For children between the ages of 3 and 5 years, depression may cause them to be more accident prone and to demonstrate more fears. They may over-apologize for minor mistakes because they feel guilty; or may express feelings of worthlessness because they think they are not living up to expectations.

Between the ages of 6 and 8 years, children with depression may have such symptoms as vague physical complaints such as muscle aches, stomachaches, or headaches. These children may become overly aggressive -- become overly timid, clinging to their parents. They may  withdraw from new situations or tasks they perceive as too difficult. By paying attention to when physical problems occur or what a child's fears are, parents may be able to discover important clues about the cause of their child's depression.

Older children between the ages of 9 and 12 may experience difficulty falling asleep at night as they worry about schoolwork, social relationships, their parents’ perceptions of them. Over time, such anxious thoughts can evolve into a recurring pattern of morbid thinking.

Adolescents who experience depression may be hypersensitive and overreact to minor problems or embarrassments. They may run away, or indulge in self-harming behaviors like reckless driving or abusing alcohol or drugs. They may be easily annoyed, uncommunicative, or anxious and hopeless. Despite the popular myths, all adolescents do not experience intense emotional fluctuations that verge on psychiatric disorder. If an adolescent exhibits extreme behavior or emotional turmoil, then assessment and treatment is appropriate.

Differential diagnoses. Conditions that produce symptoms similar to those of depression include dysthymia, a milder but more pervasive and long-standing depressed mood that may seem to be part of a child’s personality. Adjustment disorder, attention deficit disorder, and interpersonal conflicts may also cause symptoms that resemble those of depression. Bipolar disorder, a more severe form of mental illness, occurs in 20% to 30% of children with major depression sometime between their late teens and early twenties.

The good news: Treatment of childhood depression

Depression is considered to be one of the most easily and successfully treated mental illnesses. It is best treated by a combination of antidepressant medication and cognitive behavior therapy.

Medication. While the FDA has not approved any medications for treating depression in children and adolescents, the Harvard Mental Health Letter (February, 2002) reports that controlled studies have been made of the use of selective serotonin re-uptake inhibitors (SSRIs) such as Paxil, Prozac, and Zoloft. The studies found that these antidepressants were as effective in children as in adults, with 60% reporting improvement. Once the child feels better, it is recommended that the medication be continued for an additional 4 to 6 months to help prevent relapse. The use of the SSRIs should be considered to control severe symptoms, for such treatment can enable a child to benefit more fully from psychotherapy.

Cognitive behavior therapy. Cognitive behavior therapy is the most thoroughly tested form of psychotherapy for children. It focuses on changing a child's self-defeating thinking, re-interpreting life experiences, and replacing negative perceptions with healthier thought patterns. The behavioral aspect of this therapy involves keeping a log of activities and thoughts, and rehearsing new behaviors and problem-solving strategies.

References:

Depression in children, Part I (2-02, pp 1-3) and Part II (3-02, pp 1-4); Harvard Mental Health Newsletter.

Childhood depression, by Hammen, C and Rudolph, K; in Mash, EJ and Barkley RA, eds. Child Psychopathology (NY: Guilford, 1996), 153-195.

Depression in Children and Adolescents, National Institute of Mental Health, NIH Publication No. 00-4744 (Washington, DC: U.S. Government Printing Office, 2000).

National Institute of Mental Health Web site: http://www.nimh.nih.gov/index.shtml