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Characteristics of child and adolescent depression
In many ways, the symptoms are similar to those of
adult depression. In the DSM-IV, the criteria for
childhood and adult Major Depression are the same.
Children may not have the vocabulary to talk about
such feelings and so may express their feelings through
behavior. Younger individuals with depression are
more likely to show phobias, separation anxiety disorder,
somatic complaints and behavior problems. With psychotic
depression, children are more likely to report hallucinations.
Older adolescents and adults with psychotic depression
are more likely to have delusions. (Delusions require
more advanced cognitive functioning than simple hallucinations)
One might observe the following external signs in
a depressed child or adolescent.
1.Preschool or young elementary age: The child might
look serious or vaguely sick. He might be less bouncy
or spontaneous. While other children would become
tearful or irritable when frustrated, this child
may show these states spontaneously. He may say negative
things about himself and may be self-destructive.
2.Older elementary school through adolescence: The
adolescent may present with academic decline, disruptive
behavior, and problems with friends. Sometimes one
can also see aggressive behavior, irritability and
suicidal talk. The parent may say that the adolescent
hates himself and everything else.
Causes of Depression
How much is due to heredity and how much to environmental
issues? Things associated with childhood depression
include inconsistent parenting, stressful life experiences,
and a negative way of viewing the world. Childhood
depression is also associated with a family history
of mood disorders and with the existence of other
psychiatric conditions If the relative has had childhood
or recurrent depression, the child is at even higher
risk of developing depression. There are different
theories on the causes of depression. Some feel that
children inherit a predisposition to depression and
anxiety but that environmental triggers are necessary
to elicit the first episode of Major Depression.
When depressed adults are asked about their childhood
experiences, they are more likely to report neglect,
abuse rejection and parental conflict.
Consequences and Associated Conditions
Many children with depression have one or more other
major psychiatric diagnoses. Anxiety Disorder, Substance
Abuse, and ADHD are frequently associated with childhood
depression. ADHD might be present before the first
episode of depression and can complicate the treatment
of both conditions. Substance abuse often starts
after the first episode of depression, although this
can vary in different individuals. The other conditions
may persist even after the major depressive episode
passes, and can render the individual more vulnerable
to a recurrent depression. Children with depression
accompanied by ADHD or Conduct Disorder are more
likely to have adult criminal records and suicide
attempts than individuals with depression alone.
Depression is associated with school and interpersonal
problems. It is also correlated with increased incidence
of suicidal behavior, violent thoughts, alcohol,
early pregnancy, tobacco and drug abuse.
Depression can lead to an increased chance of suicide
attempts and successful suicides. Since 1950, the
adolescent suicide rate has risen four fold 12% of
the total adolescent mortality in 1993 was due to
suicide. Suicide is not always associated with MDD.
Usually those who attempt suicide have more than
one problem. One should be especially vigilant with
those who have a relative who committed suicide or
who are exposed to family violence.
Family Issues
Depressed children often
have depressed or stressed parents. Can the stress
of coping with a depressed child lead to parental
rejection or is it the poor parenting that leads
to the child's depression? The answer may be different
in different cases. A depressed, hyperactive child
may be hard to raise. Some parents have more coping
skills than others. A child may learn to give up
because parents have not modeled good ways of coping
with stressful situations.. Some suggest that parental
patterns of irritability, and withdrawal lead to
low self-esteem in the child and that this predisposes
the child to depression. Some suggest that a genetically
vulnerable child is more likely to develop depression
when exposed to family stress.
Diagnosis
It usually takes more time to diagnose Major Depression
in a child than it does to diagnose an adult. The
diagnostic process should include interviews of parents
and the child. I try to include both parents, even
if the child is only living with one parent. Parents
are more likely to report outward signs of depression.
The child may be more aware of inward signs. Sometimes
a parent's report is skewed by the parent's own agenda,
so school and other outside reports are useful. (with
written permission) Generally, there should be a
recent physical. Although this is usually done by
the primary care physician, the psychiatrist may
do a screening neurological and relevant parts of
a physical exam. The psychiatrist will ask about
the developmental history and about the existence
of other psychiatric conditions.
Treatment
There is no cookbook technique. Treatment must be
tailored to the needs and schedule of the child and
his family. Generally, with mild to moderate depression,
one first tries psychotherapy and then adds an antidepressant
if the therapy has not produced enough improvement.
If it is a severe depression, or there is serious
acting out, one may start medication at the beginning
of the treatment.
Psychotherapy
A variety of psychotherapeutic techniques have been
shown to be effective. There is some suggestion that
cognitive-behavioral therapy may work faster. Cognitive
therapy helps the individual examine and correct
negative thought patterns and erroneous negative
assumptions about himself. Behaviorally, it encourages
the individual to use positive coping behaviors instead
of giving up or avoiding situations. After therapy
is over, children may benefit from scheduled or "as-needed" booster
sessions.
Many feel that family therapy can speed recovery
and help prevent relapse. There are different styles
of family therapy.
Medication
Most studies suggest that the older, tricyclic antidepressant
medications (Amitryptiline, Imipramine Desipramine)
are no better than placebo in the treatment of depression.
Still, many of us have seen individual children and
adolescents who have responded well. Tricyclic antidepressants
can be an effective treatment for ADHD. Since there
is a small risk of heart rhythm changes, in children
on these medications, we usually follow EKGs. The
usefulness of blood tricyclic levels is being debated.
SSRIs (Selective Serotonin Reuptake Inhibitors--Prozac,
Zoloft etc.) have brightened the outlook for the
medication treatment of child and adolescent depression.
The side effects are not as annoying as those of
the older medications. These medications are somewhat
less toxic in overdosage. Fluoxetine (Prozac) has
been approved by the FDA for the treatment of depression
in children 8 and up. There is special concern about
using paroxetine (Paxil) or venlafzxine (Effexor)
with depressed children and adolescents. As compared
to adults, adolescents are a bit more likely to become
agitated or to develop a mania while they are taking
an SSRI. These medications can decrease libido in
both adolescents and adult. I warn parents about
the symptoms of mania, especially if there is a family
history of Bipolar Disorder. If the child has had
a manic episode in the past, one might want to consider
a mood stabilizer such as Lithium, or Depakote.
Follow Up and Other Considerations
Some individuals have only one episode of depression,
but often depression becomes a recurrent condition.
Thus, one should educate the child and family about
the early warning symptoms of depression so that
they can get right back in to the doctor. It is also
useful to discuss the child's particular "early
warning signs" with the primary care doctor.
Sometimes I schedule booster sessions in advance
and other times, leave the door open for the child
or family to schedule one or two sessions.
The decision about when to stop antidepressant medication
can be complex. If the depressive episodes are recurrent
or severe, one may consider longer term maintenance
pharmacotherapy. If the depression was milder, the
family wishes the child to be off medications, or
there are side effects, one may consider stopping
the medication several months or a year after the
symptoms are gone. If there have been several recurrences,
one might then talk to the patient and family about
longer term maintenance. Exercise, a balanced diet
(at least three meals per day) and a regular sleep
schedule are desirable. If there is a seasonal component,
a light box or light visor may be helpful.
If there are residual social skills problems, a social
skills group through the school or other agency can
help. Scouts and church youth groups can be enormously
helpful. If parents and child consent, I will sometimes
involve a scout leader or clergy.
One must treat comorbid psychiatric disorders such
as anxiety and ADHD. Since a young person who has
had a depression is more vulnerable to drug abuse,
one should start out early with preventative measures.
The primary care doctor can be a partner in monitoring
for relapse, substance abuse and social skills problems
during and after the psychiatric treatment.
Courtesy
of : Carol E. Watkins. MD (Pyschiatrist) in the U.S.A.
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