about Children and Depression
of Childhood Depression
of Depression in Children
Since 1980, criteria for diagnosing bipolar disorder
in adults have also been used to diagnose mania in children, with some
modifications to adjust for age. Similarly, to diagnose a child or adolescent
with bipolar disorder, there need be at least one period of mania that
is manifested by a distinct period of abnormally and persistently elevated,
expansive or irritable mood, lasting at least one week or any duration
if hospitalization is required.
In addition, during the period of mood
disturbance the children or adolescents may experience to a significant
degree at least three of the following symptoms (or four if their mood
is irritable): inflated self-esteem or grandiosity, decreased need for
sleep, pressured speech, flight of ideas or racing thoughts, distractibility,
increased goal directed activity, or excessive involvement activities with
the potential for painful consequences. For a diagnosis of bipolar disorder
these symptoms must also produce marked impairment in functioning and be
unaccounted for by other psychiatric disorders due to physiologic effects
of substances or medical conditions (American Psychiatric Association 1994).
Obstacles in identifying and diagnosing this disorder
in children and adolescents include the low base rate of the disorder,
the diversity in clinical presentation within and across episodes, the
symptomatic overlap of mania with other disorders commonly found in childhood,
such as attention deficit hyperactivity disorder (ADHD), and the constraints
placed upon symptom expression due to the developmental stage of the child
(Bowring and Kovacs 1992).
Developmental factors may confound the presentation
of symptoms; for example, normal behavior in children may sometimes resemble
hypo-manicactivity. Therefore, if not viewed within the context of normal
behavior, psycho pathology may not be recognized.
In young children it is difficult to identify
discrete episodes of mania or depression. The clinical presentation of
childhood bipolar disorder is variable but includes a waxing and waning
course, worsening disruptive behavior, moodiness, irritability, difficulty
sleeping, impulsivity, hyperactivity and decreased concentration.
Episodically they experience short attention span,
low frustration tolerance, explosive anger followed
by periods of guilt, depression and declining academic performance.
In adults the lifetime prevalence for bipolar
disorder, according to the Epidemiologic Catchment Area (ECA) survey, ranges
from 0.6 percent to 1.1 percent (Robins and colleagues). An Epidemiologic
study of adolescents in the United States reported consistent prevalence
rates. However, a significant number also reported experiencing a distinct
period of abnormal,
persistent, elevated, expansive or irritable
mood, although they did not fulfill criteria for bipolar I, bipolar II
or cyclothymia (Lewinsohn and colleagues).
This corresponds with survey
results of the membership of the National Depressive and Manic Depressive
Association (DMDA), which reported the onset of illness during childhood
or adolescence in 59 percent of
adult respondents (Lish and coworkers). At present,
large-scale epidemiologic studies on pre-pubertal children are not available.
However, studies have revealed descriptions of children and adolescents
likely to develop the disorder. Akiskal described the profile of a child
at risk to develop bipolar illnesses one who experienced emotions, whether
they be positive or negative, passionately and intensely and whose mood
and behavior was disregulated and disinhibited.
Predictors of bipolar outcome
in adolescents with major depression have been identified as a family history
of bipolar disorder, sudden onset of symptoms, delusions, psychomotor retardation
and hypersomnia, pharmacologically induced hypomania/mania (Akiskal and
coworkers; Strober and Carlson). Medical and psychiatric conditions may
mimic symptoms of bipolar disorder. Differential diagnoses to be considered
include: thyroid disorders, neuroligic disorders, substance abuse, ADHD,
conduct disorder, schizophrenia, as well as Axis II diagnoses.
Childhood-onset bipolar disorder
is commonly comon-bid with other psychiatric disorders, especially disruptive
disorders. The major symptomatic difference between ADHD or conduct disorder
and bipolar disorder is that disruptive disorders are chronic and may present
insidiously, whereas mania is episodic and reflects a change in functioning.
Disruptive disorders reflect aberrant attention and/or behavior while mania
is primarily characterized by abnormal mood and activity. In addition,
earlier age of onset is more commonly seen in ADHD.
It is important to recognize that children with
ADHD may also experience irritability or dysphoria due to demoralization
and decreased self-esteem, making the differential diagnosis with Bipolar
Disorder difficult. Furthermore, bipolar disorder may be superimposed on
ADHD. In these cases one would expect to see an increase in the intensity
or severity of symptoms.
Like bipolar disorder, conduct disorder frequently
emerges during adolescence. These children usually engage in high risk
behaviors with the potential for painful consequences seen in mania. However,
unlike the manic child, the conduct disorder child’s motives are more hurtful,
vindictive, antisocial. (Bowring and Kovacs; Weller and colleagues). Psychotic
are also significant in determining diagnosis.
These are not present indisruptive disorders, but may be present during
an acute bipolar episode or with thought disorders.
Manic symptoms are recognized as a barometer of
psycho pathology severity in children and adolescents and have been correlated
with greater psycho social impairment. In addition to the daily interference
in functioning and increased risk of suicide, long-term consequences of
symptoms include interference with the mastery of developmental tasks such
emotions, acquiring competencies, and establishing
and maintaining social relationships (Nottelmann and Jensen).
to the DMDA survey acknowledged the negative impact on their lives, reporting
problems with crime, substance abuse, self-injurious behavior or aggression
toward others, unstable relationships, gambling and financial difficulties
interruption in their education.
Thorough evaluation and treatment are essential.
A biopsychosocial approach to intervention that incorporates psycho education
and school intervention is warranted. Psycho education should incorporate
child, adolescent and parent. They should be informed of symptoms of manic
and depressive episodes and supported in the exploration and identification
of symptoms of the index episode and of future symptoms indicative of a
recurrence. The physician should discuss treatment options that include
medication and psychotherapy.
While adolescents are treated with the same pharmacologic
agents as adults, it appears that adolescents with bipolar disorder tend
to have more mixed or rapid cycling presentations; these have been associated
with poor response to lithium. Furthermore, questions remain regarding
the efficacy of pharmacologic treatment and how long treatment should be
maintained in the child and adolescent population. Advocates of long-term
treatment acknowledge the serious consequences and course of illness; others
favor discontinuing medication after the patient is stable, since the long-term
effects of pharmacologic intervention remain unknown and non compliant
adolescents may contribute to their own refractoriness.
of the most common responses to hearing that a child has
depression is, “But what does he/she have to be depressed about?”
This statement reveals two major misconceptions. One is the lack of
understanding about clinical depression. It is not the same as the”blues” or “down” moods that everyone has from time to time, which
may actually be caused by unhappiness with one’s job, home life or
other factors. Clinical depression may resemble these emotional
dips, but it is much more pervasive, long-lasting, and life threatening.
It is not necessarily caused by an event or state of affairs in a child’s
life. The other misconception is that childhood is a carefree,
trouble free period in our lives. How many people can say that they
didn’t worry about peer acceptance, grades, or parental
expectations? Adults often forget that children are powerless and
have no control over their own lives. This can be a frightening and
frustrating state of affairs to live through day after day.
As with adult depression, diagnosis of
depression in children is not as clear-cut as
it is for other ailments. There is no test that
can be given which will positively say that
an individual has depression, much less
pinpoint the cause(s). The medical
community still knows relatively little about
the brain, how it works, and what makes it
malfunction. In fact, anti-depressant
properties of certain medications were
discovered by accident in the 1950s while
seeking a cure for tuberculosis.
We do know that certain children have risk factors in their lives which
could predispose them to depression or could “trigger” depression.
Among these are a family history of mental illness or suicide, abuse
(physical, emotional or sexual), chronic illness and the loss of a
parent at an early age to death, divorce or abandonment. However,
some infants exhibit depressive symptoms at an early age before
most of these factors come into play, so there is an argument to be
made for depression being wholly chemical in some children. Each
child’s depression is individual, and causes will be different for each
one. The depression could be wholly chemical, wholly due to
psychological factors, or a combination of the two. More important
than the cause is identifying the illness and treating it.
of Depression in Children
sadness and/or irritability.
Low self-esteem or feelings or worthlessness. A child may
make such statements as, “I’m bad. I’m stupid. No one likes
Loss of interest in previously enjoyed activities.
Change in appetite (either increase or decrease).
Change in sleep patterns (either increase or decrease).
Headaches, stomachaches or other physical pains that seem
to have no cause.
Changes in activity level. The child either becomes more
lethargic or more hyperactive.
Recurring thoughts of death or suicide.
Overall, the most important factor is change. Any change in a child’s
behavior that seems to have no external or physical cause should be
looked at. A low mood which results from a loss (death of a loved
one, moving, changing schools) which lasts more than a few weeks
should be considered possible depression and checked out.
parents of any child who is in immediate danger of harming himself
or others should consider hospitalization. This is a tough choice
for parents to make, but it must be emphasized that children do commit
Once a child has been diagnosed with either major depression or
dysthymia, both psychotherapy and medication could be options.
More and more, doctors are realizing that chemical imbalances often
account for mental illness, but at the same time, the importance of
psychotherapy cannot be discounted. If a child’s depression has
been caused wholly or in part by psychological factors, medication
may relieve the depression, but the underlying cause will not be
“cured” by medication alone. Therapy can help the child deal with his
past in a healthy manner, and also in learning ways to cope with the very difficult process of growing up.
Antidepressant medication for children is a controversial topic.
Currently no medications have FDA approval for use with children,
although most of the major drug companies have submitted data.
There are no long-term studies that show what kind of impact this
medication will have on a child’s development. There has also been
some question as to whether the older tricyclic antidepressants are
effective with children.
But keep in mind that it is almost a certainty
that depression will have negative long-term effects on the child and
his family. From my own experience, I am positive that my growing
up with depression had negative effects on the development of my
personality. For instance, even with my successful treatment with
antidepressants, it’s very hard for me to shake the crippling shyness I
grew up with. The decision of whether to treat a child with medication
is wholly individual, depending on the severity of the child’s
depression and what toll it will take on the child’s life without
successful treatment. Parents should educate themselves as much
as possible in order to make an informed decision.