Depression in childhood and adolescence

Depression is a state of low mood and aversion to activity. It may be a normal reaction to occurring life events or circumstances, a symptom of a medical condition, a side effect of drugs or medical treatments, or a symptom of certain psychiatric syndromes, such as the mood disorders major depressive disorder and dysthymia. Depression in childhood and adolescence is similar to adult major depressive disorder, although young sufferers may exhibit increased irritability or aggressive and self-destructive behavior, rather than the all-encompassing sadness associated with adult forms of depression.^[1] Children who are under stress, experience loss, or have attention, learning, behavioral, or anxiety disorders are at a higher risk for depression. Childhood depression is often co-morbid with mental disorders outside of other mood disorders; most commonly anxiety disorder and conduct disorder. Depression also tends to run in families.^[2] Psychologists have developed different treatments to assist children and adolescents suffering from depression, though the legitimacy of the diagnosis of childhood depression as a psychiatric disorder, as well as the efficacy of various methods of assessment and treatment, remains controversial.

Base rates and prevalence

About 8% of children and adolescents suffer from depression.^[3] Research suggests that the prevalence of young depression sufferers in Western cultures ranges from 1.9% to 3.4% among primary school children and 3.2% to 8.9% among adolescents.^[4] Studies have also found that among children diagnosed with a depressive episode, there is a 70% rate of recurrence within five years.^[4] Furthermore, 50% of children with depression will have a recurrence at least once during their adulthood.^[5] While there is no gender difference in depression rates up until age 15, after that age the rate among women doubles compared to men. However, in terms of recurrence rates and symptom severity, there is no gender difference.^[6] In an attempt to explain these findings, one theory asserts that pre-adolescent women, on average, have more risk factors for depression than men. These risk factors then combine with the typical stresses and challenges of adolescent development to trigger the onset of depression.^[7]

Suicidal Intent

Like their adult counterparts, children and adolescent depression sufferers are at an increased risk of attempting or committing suicide.^[8] Suicide is the third leading cause of death among 15-19 year olds.^[9] Adolescent males may be at an even higher risk of suicidal behavior if they also present with a conduct disorder.^[10] In the 1990s, the National Institute of Mental Health (NIMH) found that up to 7% of adolescents who develop major depressive disorder may commit suicide as young adults.^[11] Such statistics demonstrate the importance of interventions by family and friends, as well as the importance of early diagnosis and treatment by medical staff, to prevent suicide among depressed or at-risk youth.

Risk factor

In childhood, boys and girls appear to be at equal risk for depressive disorders; during adolescence, however, girls are twice as likely as boys to develop depression. Before adolescence rates of depression are about the same in girls and boys, it is not until between the ages of 11-13 that is begins to change.Young girls around this age, physically, go through more changes than young boys which put that a higher risk for depression and hormonal imbalance. The gender gap in depression between adolescent men and women is mostly due to young women's lower levels of positive thinking, need for approval, and self-focusing negative conditions.^[12] Frequent exposure to victimization or bullying was related to high risks of depression, ideation and suicide attempts compare to those not involved in bullying.^[13] Nicotine dependence is also associated with depression, anxiety, and poor dieting, mostly in young men.^[14] Although causal direction has not been established, involvement in any sex or drug use is cause for concern.^[15] 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. 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.^[16][17]

Co-morbidity

Research has shown that there is a high rate of co-morbidity with depression in children with dysthymia.^[18] There is also a substantial co-morbidity rate with depression in children and anxiety disorder, conduct disorder, and impaired social functioning.^[1][18] Particularly, there is a high co-morbidity rate with anxiety, ranging from 15.9% to 75%.^[18][19] Conduct disorders also have a significant co-morbidity with depression in children and adolescents, with a rate of 23% in one longitudinal study.^[20] Beyond other clinical disorders, there is also an association between depression in childhood and poor psycho-social 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. Depressive moods in children can be expressed as being unusually irritable, which may be displayed 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 sad facial expressions (frowning) and poor eye contact. A child must also exhibit four other symptoms in order to be clinically diagnosed. However, according to the Omnigraphics Health References Series: Depression Sourcebook, Third Edition,^[21] a more calculated evaluation must be given by a medical or mental health professional such as a physiologist or psychiatrist. Following the bases of symptoms, signs include, but are not limited to, an unusual change in sleep habits (for example, trouble sleeping or overly indulged sleeping hours); a significant amount of weight gain/loss by lack or excessive eating; experiencing aches/pains for no apparent reason that can found; and an inability to concentrate on tasks or activities. If these symptoms are present for a period of two weeks or longer, it is safe to make the assumption that the child, or anybody else for that matter, is falling into major depression.

Correlation between adolescent depression and adulthood obesity

According to research conducted 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 non-depressed 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.^[22]

Correlation between child depression and adolescent cardiac risks

According to research by RM Carney et al., any history of child depression influences the occurrence of adolescent cardiac risk factors, even if individuals no longer suffer from depression. They are much more likely to develop heart disease as adults.^[23]

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 from the classic signs in adult depression.^[24] One major difference between 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.^[25] One major cause of this difference is that many of the neurobiological effects in the brain of adults with depression are not fully developed until adulthood. Therefore, in a neurological sense, children and adolescents express depression differently.

History

Professionals first became aware of child abuse in the early 1980s, so 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 question of what the outcome would have been in those young people if they had disclosed the abuse and received appropriate therapeutic interventions. It is well-known that childhood sexual abuse is a significant factor in the history of some adults with depressive syndromes.

In the past, attention deficit hyperactivity disorder (ADHD) was not recognized, and hyperkinetic disorder was only rarely diagnosed. Some young people, especially those with co-morbid conduct disorder and major depressive disorder, may have had undiagnosed and untreated ADHD. Before the use of psycho-stimulants, some young people may have been more vulnerable to development of depressive syndromes because of untreated attentional and other behavioural problems which reduce their self-esteem.

Although antidepressants were used by child and adolescent psychiatrists to treat major depressive disorder, they may not always have been used in young people with a comorbid conduct disorder because of the risks of overdose in such a population. Tricyclic antidepressant were the predominant antidepressants used at that time in this population. With the advent of selective serotonin re-uptake inhibitors (SSRIs), child and adolescent psychiatrists probably began prescribing more anti-depressants in the co-morbid 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 improve their outcomes in adult life.^[26]

Assessments

Among the psychological assessments for identifying whether or not children and adolescents are experiencing depression and/or depressive symptoms is the Children's Depression Inventory.^[27] In early 2016, the USPSTF released an updated recommendation for the screening of adolescents ages 12 to 18 years for major depressive disorder (MDD). Appropriate treatment and follow-up should be provided for adolescents who screen positive.^[28]

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.^[29] 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.^[30] Pediatric massage therapy may have an immediate effect on a child's emotional state at the time of the massage, but sustained effects on depression have not been identified.^[31]

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, one study showed it to be effective in children with mild or moderate depressive symptoms.^[32]

Talk therapy

There are three common types of talk therapy. These can assist people to live more fully and have a better life.^[33] Men are encouraged to open up more emotionally and communicate their personal distress, while women are encouraged to be assertive of their own strengths^[34]

Cognitive therapy

Cognitive therapy aims to change harmful ways of thinking and reframe negative thoughts in a more positive way.

Behavioral therapy

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

Interpersonal therapy

Interpersonal therapy helps one learn to relate better with others, express feelings, and develop better social skills.

Psychotherapy

Psychotherapy teaches coping skills while allowing the teens or children to explore feelings and events in a safe environment.^[35]

Family therapy

The principles of group dynamics are relevant to family therapists who must not only work with individuals, but with entire family systems.^[36] Two key concepts that influence family therapy are the distinction between the process and content of group discussions, and role theory.

Therapists strive to understand not just what the group members say, but how these ideas are 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 to be 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 in understanding family dynamics because the complementary nature of roles makes behaviors more resistant to change.^[37]

Controversies

Throughout the development and research of this disorder, controversies have emerged 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.

Legitimacy as a diagnosis

In early research of depression in children, there was debate as to whether or not children could clinically fit the criteria for Major Depressive Disorder.^[38] However, since the 1970s, it has been accepted among the psychological community that depression in children can be clinically significant.^[38] The more pertinent controversy in psychology today centers around the clinical significance of sub-threshold mood disorders. This controversy stems from the debate regarding the definition of the specific criteria for a clinically significant depressed mood in relation to the cognitive and behavioral symptoms. Some psychologists argue that the effects of mood disorders in children and adolescents that exist (but do not fully meet the criteria for depression) do not 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. However, the accuracy and effectiveness of certain measures that help psychologists diagnose children have come into question.^[39] Questions have also surfaced about the safety and effectiveness of antidepressant medications.^[40]

Measurement reliability

The effectiveness of dimensional child self-report checklists has been criticized. Although 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.^[39] Two self-report scales demonstrated an erroneous classification of 25 percent of children in both the depressed and controlled samples.^[41] A large concern in the use of self-report scales is the accuracy of the information collected. 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 over 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, paroxetine (an antidepressant) should not be used on patients under the age of 18.^[40] Since then, the United States Food and Drug Administration (FDA) has issued a warning describing the increased risk of adverse effects of antidepressants used as treatment in those under the age of 18.^[40] The main concern 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.^[40] While multiple studies have shown an improvement or efficacy rate of over 50 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.^[40] However, an analysis of multiple studies argues that while the risk of suicidal ideation or attempt is present, the benefits significantly outweigh the risks.^[42] Due to the variability of these studies, it is currently recommended that if antidepressants are chosen as a method of treatment for children or adolescents, the clinician monitor closely for adverse symptoms, since there is still no definitive answer on the safety and overall efficacy.^[40][42]

References