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Childhood Depression

Depression in children and adolescents is a state of sadness and the inability to enjoy previously favorite activities. While it may manifest similarly to major depressive disorder in adults, this illness in youth may present as increased irritability or self-destructive behavior.


Presentation

Depression in all ages is diagnosed by the same criteria as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The definition of a major depressive episode is a syndrome with manifestations that occur in the same 2-week span. At least 1 of the following symptoms must be present in this period:

Additionally, at least 4 of the following must be present:

  • Changes in appetite or difficulty with gaining age appropriate weight (in children)
  • Difficulty with sleeping
  • Difficulty with concentration or decision-making
  • Feeling worthless or inappropriately guilty
  • Energy loss or fatigue
  • Psychomotor agitation or retardation
  • Suicidal thoughts and/or ideations

In addition to the above signs, depressed individuals may exhibit atypical features or even catatonic features that must be assessed.

The overall clinical presentation should include poor performance academically, behaviorally, socially, and other key aspects as well.

When evaluating the patient, the clinician must distinguish a major depressive episode from other disorders such as seasonal mood disorder, schizoaffective disorder, schizophrenia, etc. Also, family history should be assessed as depression can be passed from one generation to the next [8].

Fatigue
  • Additionally, the patient may experience fatigue and/or difficulties with concentration, sleeping, and eating. Overall, children and adolescents with depression suffer from poor academic, social and family functioning.[symptoma.com]
  • “For the most part, children and teens experience fatigue and irritability and other physical complaints,” such as aches and pains, Serani said. Kids also may seem bored and withdrawn and experience loss of interest.[psychcentral.com]
  • […] child has enjoyed Negative point of view Frequent thoughts of death Expressions of hopelessness Suicidal intentions Alcohol or drug use Anger or irritability Physiological Changes Disrupted sleep patterns Serious loss of or increase in appetite Constant fatigue[bradleyhospital.org]
Pressured Speech
  • ., emergency departments, crisis hotlines). 8, 30 – 32 Parents and family members should be educated about behaviors that would warrant immediate follow-up, such as increased suicidal ideation, impulsivity, irritability, restlessness, pressured speech[aafp.org]
  • ., emergency departments, crisis hotlines). 8 , 30 – 32 Parents and family members should be educated about behaviors that would warrant immediate follow-up, such as increased suicidal ideation, impulsivity, irritability, restlessness, pressured speech[aafp.org]
Severe Pain
  • We report a case documenting successful use of duloxetine in a depressed girl child who also had severe pain and dissociative symptoms.[ncbi.nlm.nih.gov]
Motor Restlessness
  • restlessness Follow-up clinic visits Schedule (in addition to phone follow-up above) One month after starting medication Three months after starting medication Assess interim history Assess mood, Suicidality and adverse effects as above Titrate medication[fpnotebook.com]
Anger
  • High levels of depression in both groups of depressed children were associated with low levels of conflict and anger in family members.[ncbi.nlm.nih.gov]
  • Excessive anger and irritability can also be signs of depression. Our best advice is to be observant of your children all the time and to pay special attention to changes that persist or seem unnatural.[bradleyhospital.org]
  • Signs that may indicate depression in children: Change in personality, such as increased anger, irritability, moodiness, or whining; Change in appetite, usually a loss of appetite; Change in sleep patterns, such as difficulty failing asleep, staying asleep[ldaamerica.org]
Low Self-Esteem
  • Low self-esteem . Trouble focusing or making choices. School grades may drop . Not caring about what happens in the future. Aches and pains when nothing is really wrong. Frequent thoughts of death or suicide .[healthychildren.org]
  • Low self-esteem. Trouble with focusing or making choices. School grades may drop. Not caring about what happens in the future. Aches and pains when nothing is really wrong.[lfcsmo.org]
  • Or an absence of pleasure derived from relationships; Low self-esteem, frequently expressed through self-deprecating and negative talk; Indecisiveness; Difficulty with concentration (not to be confused with attention deficit disorder); Feelings of helplessness[ldaamerica.org]
  • Doctor Torres-Eaton shared with us that some of the signs that children might be suffering from true depression are irritability, having low self-esteem, and lack of interest in things that are normally fun for them.[choc.org]
Withdrawn
  • All kids have their ups and downs, but if your child is unusually irritable, sad or withdrawn for a prolonged period of time she may be showing signs of depression.[childmind.org]
  • Older adolescents and adults tend to become withdrawn. They may be quiet or become agitated, irritable, and angry; they may also look sad and talk about their sadness.[ldaamerica.org]
  • This might vary from child to child, but can manifest in things like: Feeling/looking sad, withdrawn, apathetic, or down Irritability and temper tantrums Saying negative things about themselves or the world Feeling worried or frightened, including having[telethonkids.org.au]
  • Having slowly become socially withdrawn, depressed children seem to lack the interest in things that used to excite them, and they become increasingly more irritable, tearful and sad.[nativeremedies.com]
Suicidal Ideation
  • It is crucial that if you notice signs of depression and/or suicidal ideation in your child have them evaluated by a doctor or mental health professional. -Meredith Beard, LMSW, KITM therapist[kidsinthemiddle.org]
  • Prevention of self-harm Since suicidal ideations and attempts are a major risk in depressed individuals, safety is a top priority.[symptoma.com]
  • . • Difficult to treat when suicidal ideations exist. 3.[slideshare.net]
  • The American Food and Drug Administration (FDA) has come to a similar conclusion stating that the use of antidepressants by children under 18 can cause suicide and/or suicide ideation.[australiacounselling.com.au]
  • Symptoms are not caused by bereavement (i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms[aafp.org]
Suicidal Depression
  • Depression is diagnosed when negative feelings, lack of interest in previous activities, and physical symptoms like fatigue and insomnia persist for at least 2 weeks.[childmind.org]
Clumsiness
  • When asked about it she said it was her father's harsh criticisms about her study behavior and the clumsiness in the up keep of her personal belongings which made her to manifest the anger and physical aggression of breaking the ruler into pieces.[ncbi.nlm.nih.gov]
Perseveration
  • This early stage is when any side-effects are at their greatest, so it's important to persevere with treatment, provided the side-effects are tolerable. If the first antidepressant doesn't suit the young person, a different one is worth trying.[netdoctor.co.uk]

Workup

Clinical evaluation includes the patient's personal and family history, a physical and psychiatric exam, and studies to exclude other etiologies such as infection, neurologic disorder, endocrine disorder, tumor, or another illness.

Laboratory tests

The patient's clinical presentation will guide the selection of tests which may include complete blood count (CBC) to ascertain the presence of infection or anemia. Further investigations such as serum electrolytes, creatinine, creatinine clearance, blood urea nitrogen (BUN), and urine osmolality may be necessary to determine if renal causes are responsible for the patient's symptoms. Another important consideration is performing thyroids functions tests to rule out a thyroid disorder.

Other

As expected, a full psychiatric assessment is essential. The survey known as the Children’s Depression Inventory can help the clinician understand the severity of the depression.

Additional studies may be indicated to help clarify the full clinical picture. For example, young individuals with present or past episodes of seizures should undergo electroencephalography (EEG).

Sinus Arrhythmia
  • Kennedy, James Atypical development of resting respiratory sinus arrhythmia in children at high risk for depression Developmental Psychobiology, 54, 556-567, 2012.[ppdm.wpic.pitt.edu]

Treatment

The therapeutic approach depends on the overall clinical presentation and factors such as the severity and chronicity of symptoms, patient's age, previous history of depression, past response to treatment, compliance, and others conditions as well.

Younger children may warrant psychotherapy initially and antidepressants in more severe cases. In adolescents, an effective regimen includes both psychotherapy and antidepressants. Furthermore, CBT ( Cognitive-based therapy) is very helpful as evidenced by numerous randomized clinical trials.

With regards to antidepressants, the most common choices for depressed children and adolescents are selective serotonin reuptake inhibitors (SSRIs) which include sertraline, fluoxetine, and paroxetine. In contrast, tricyclic antidepressants (TCAs) are not as effective in children and tend to cause more side effects. Note that medications such as TCAs require periodic monitoring of plasma levels to avoid toxicity.

Since depressive episodes are recurring, treatment should be continued for a year or more after recovery.

Patients should be assessed for suicidal thoughts and their risk for executing self-harm. Close monitoring and possibly even hospitalization may be required to protect suicidal patients or those without adequate home supervision [9].

Psychosocial support

A key component in the treatment of depressed individuals is the support provided by family, the physicians and mental health team, and school teachers. Regular individual and family psychotherapy sessions should be part of the patient's management. Also, parents or guardians must be included in treatment planning and supervision of the child. Additionally, social workers can find emotional and financial resources to fund the treatment of the children.

Important considerations

There were questions raised concerning the small risk of suicidal ideations and attempts associated with antidepressant use in the pediatric population. However, a reduced use of this medication has been linked to higher suicide rates. This controversy led to studies investigating the issue further, in which the results confirmed that antidepressants may increase suicidal thoughts and attempts. But since the benefits likely outweigh the risks, a vast majority of physicians will proceed with treatment under the condition that the medical team and family are vigilant and cautious about warning signs.

Prognosis

Depression in youth may lead to marked morbidity and mortality as this disease can be chronic and recurring. Furthermore, this young population is susceptible to difficulties in the school and social settings and are at high risk for poor outcomes such as substance abuse and suicide [7].

With regards to treatment, approximately 50% to 60% will experience success with their initial psychotherapy or medication. Of the remainder, those that fail a primary trial of antidepressants will tend to respond to other drugs and/or psychotherapy.

A major depressive episode may resolve spontaneously within 1 to 2 years [7]. However, this disease is characterized by elevated relapsing rates as 40% experience a recurrence within 2 years of remission and as many as 70% have a repeating episode within 5 years.

Etiology

The etiology of childhood depression is likely multifactorial in origin. The genetic and environmental interplay is complex as genetic factors account for as much as 40% variance while environmental factors and their interaction with genetics are responsible for 60% of variances [1] [2].

Epidemiology

Epidemiologic studies investigating depression in the pediatric population reported a rate of 2.8% in individuals younger than 13 and a rate of 5.6% in adolescents between 13 and 18 years of age.

In terms of patient demographics, both boys and girls have similar rates of depression. However, adolescent females have double the prevalence of their male counterparts. Additionally, childhood depression is more common in the indigenous population [3] as well as in children with long-term medical illness [4].

Sex distribution
Age distribution

Pathophysiology

The specific contributions of genetic and environmental factors to childhood depression are yet to be elucidated. Furthermore, the studies investigating the pathophysiology of this disease in children have yielded findings not observed in adults. In contrast to depressed adults, children with depression have not exhibited hypersecretion of cortisol [5]. Depressed children, however, have demonstrated serotonin dysregulation, which is associated with poor stress and emotional reactions, mood disorders and minimized impulse control.

Furthermore, studies suggest that pediatric depression is linked to an interruption in the motivation-and-reward neurologic pathway. Specifically, imaging studies show disruptions in key regions of the brain such as the prefrontal cortex, amygdala, and anterior cingulate which are known to regulate emotions, stress response, behavioral inhibition, and occurrence of symptoms of depression [6].

Prevention

There are measures that parents, caretakers, and teachers can undertake to help reduce the risk of depression in children and adolescents. Such efforts include providing support and resources to decrease stress and trauma. Additionally, cognitive behavioral prevention programs in the school, community or internet settings could be very helpful [10] [11]. In this modern age, there are creative technological methods that can also influence children and adolescents to think more positively and develop a good outlook on life and how to deal with difficult issues.

Since psychiatric conditions may coexist together, the clinician must assess the individual thoroughly and screen for attention deficit hyperactivity disorder (ADHD), anxiety, and others as well. Moreover, treatment of these could reduce the risk of depression.

Prevention of self-harm

Since suicidal ideations and attempts are a major risk in depressed individuals, safety is a top priority. The risk for self-harm and other behaviors such as substance use should be assessed during the frequent follow-up appointments. Parents should ensure adequate supervision and implement safety plans.

Management of the patients includes finding the correct medication and dose, addressing any present side effects, and encouraging compliance. Additionally, controlling the depression and preventing relapse is crucial as recurrence is incredibly likely.

Summary

Depression in the pediatric population is relatively common especially in children with comorbid psychiatric and developmental disorders. It is also observed in those who experienced trauma or medical illnesses. Childhood depression is associated with high recurrence rates and often continues into adulthood. It is believed that the cause of depression is likely multifactorial with environmental factors and genetics playing a key role.

The age-adjusted diagnostic criteria for depression in children is essentially the same as for adults. This illness manifests as a depressed or irritable mood and/or anhedonia. Additionally, the patient may experience fatigue and/or difficulties with concentration, sleeping, and eating. Overall, children and adolescents with depression suffer from poor academic, social and family functioning.

Early diagnosis and treatment are paramount. Therefore, as soon as parents, other adult caretakers, or teachers recognize the signs and symptoms, the young individual must undergo careful assessment by the appropriate professionals. This includes obtaining the patient's personal and family history, and performing a full psychiatric test among other possible relevant studies.

Once the diagnosis is established, the choice of treatment is based on the consideration of the severity of the illness, the patient's age, whether the patient has had previous episodes and/or treatments, the patient's and family's motivation for treatment, and other factors as well. Cognitive-based therapy (CBT) is the key component in the treatment of depressed youth. Additionally, antidepressants may also be used in certain cases.

Since the disease has a high chance of relapsing and there are increased incidences of suicides in such patients, it is pertinent that they attend frequent follow-up appointments and comply with therapy and treatment. Moreover, parents are often encouraged to utilize the available resources to help their children.

Patient Information

Depression affects not just adults but children and adolescents as well. In fact, approximately 5% of the young population suffer from depression at any given time. Children that are susceptible to depression are those who suffer a loss, or experience stress, illness or trauma. Additionally, individuals who have psychiatric, developmental, or attention disorders are prone to developing depression. Furthermore, a family history also increases the risk.

What are the signs of depression?

Children and adolescents with depression often feel sad and experience difficulty functioning academically, behaviorally, and socially. Sometimes a child does not look sad but can exhibit depression in other ways. Examples of childhood depression may include a child who previously enjoyed playing with friends but now has withdrawn socially; or a child who misses school days, can not concentrate, and is doing poorly in school; or a child who is behaving badly and causing trouble at school and home. Of course, depression should always be suspected when an individual expresses interest in suicide. The following are symptoms of depression:

  • Feelings of sadness; crying
  • Low interest in hobbies and activities and the inability to find satisfaction and joy in favorite activities
  • Low self-esteem and feeling of low self-worth
  • Feeling sensitive to rejection
  • Feelings of guilt
  • Feelings of hopelessness
  • Feeling angry and irritable
  • Difficulty with relationships and social situations
  • Social isolation
  • Fatigue and low energy
  • Poor concentration
  • Poor school attendance or poor academic performance
  • Sleep changes
  • Eating difficulties or poor weight gain for age
  • Complaints of headaches and upset stomachs
  • Thoughts or attempts to run away from home
  • Thoughts or attempts of suicide or self-harm
  • Substance abuse

How is childhood depression diagnosed?

As soon as the signs and symptoms are recognized, the parents must promptly seek care and treatment for the child. The clinician will perform full personal and family evaluation and gain a complete understanding of the patient's symptoms. Sometimes, blood tests will be performed to rule out other causes of the patient's symptoms.

How is the childhood depression treated?

The earlier the treatment, the better for the depressed individual. Some of the most effective ways of treatment are cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). Additionally, family therapy is also very helpful for the children as well as the parents.

There are cases where therapy is not sufficient by itself. Therefore, antidepressants are added as well.

What is the prognosis?

Childhood depression has a high recurrence rate that parents and caretakers should be aware of. Hence close and frequent follow-up appointments with the medical team are absolutely essential.

It is important to remember that children and adolescents with depression are at increased risk of suicidal thoughts and attempts. Therefore, they require supervision. The mental health professional and the parents can formulate safety plans to ensure this. Also, parents should watch out for self-destructive behaviors such as substance abuse.

What can the family do?

Treating a child will require a team effort as family and friends can provide major support for the depressed child or adolescent. For example, attending family therapy session, staying up to date on follow-up appointments, and showing love and compassion are all crucial. Also, parents can attend support groups and draw encouragement from others who are also dealing with similar situations.

References

Article

  1. Thapar A, McGuffin P. Genetic influences on life events in childhood. Psychol Med. 1996;26(4):813-820.
  2. Thapar A, Rice F. Twin studies in pediatric depression. Child Adolesc Psychiatr Clin N Am. 2006;15(4):869-881,viii.
  3. Pumariega AJ, Roth EM, Rogers KM. Depression in immigrant and minority children and youth. In: Rey JM, Birmaher B, eds. Treating child and adolescent depression. Baltimore, MD: Lippincott Williams & Wilkins; 2009:321-331.
  4. Pinquart M, Shen Y. Depressive symptoms in children and adolescents with chronic physical illness: an updated meta-analysis. J Pediatr Psychol. 2011; 36(4):375-384.
  5. Rao U, Dahl RE, Ryan ND, et al. The relationship between longitudinal clinical course and sleep and cortisol changes in adolescent depression. Biol Psychiatry. 1996;40(6):474-484.
  6. Rosenberg DR, Mirza Y, Russell A, et al. Reduced anterior cingulate glutamatergic concentrations in childhood OCD and major depression versus healthy controls. Journal of the American Academy of Child and Adolescent Psychiatry. 2004; 43(9):1146-1153.
  7. Birmaher B, Brent D, AACAP Work Group on Quality Issues, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007; 46(11):1 503-1526.
  8. Wickramaratne PJ, Greenwald S, Weissman MM. Psychiatric disorders in the relatives of probands with prepubertal- onset or adolescent-onset major depression. J Am Acad Child Adolesc Psychiatry. 2000; 39(11):1396-405.
  9. Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry. 1996; 35(11):1427-39.
  10. Merry SN, Hetrick SE, Cox GR, et al. Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database Syst Rev. 2011;(12):CD003380.
  11. Christensen H, Pallister E, Smale S, et al. Community-based prevention programs for anxiety and depression in youth: a systematic review. J Prim Prev. 2010; 31(3):139-170.

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Last updated: 2019-07-11 21:09