Depression, It Occurs in Children

Ruth E. Imershein, MD RMOPUS Embassy LimaDepression, It Occurs in ChildrenDepressionDepression is an illness when the feelings are greater or more prolonged than warranted by any objective reason, plus they persist and interfere with an individual's ability to function.A state of being depressed, dejected, downcast, sad or gloomy.

FactsIt is a disorder of mood. Children under stress, who experience loss, or who have attentional, learning, conduct or anxiety disorders as well as certain chronic medical conditions are at a higher risk for depression. Earlier onset appears to be associated with more severe symptoms and with depression that extends into adulthoodDepression tends to run in families.

More FactsIncidence - 2.5% of children and up to 8.3% of adolescents in the U.S. Prevalence- 6% in a 6-month period of 9-17 year olds, with 4.9 percent having major depressionOnset can be in infancyIt can be a single episode, recurrent or chronic. Most often it is recurrent and chronic.

Why?The etiology of depression is unknownThese factors play a role in depression:Biological rhythmsBiogenic amines (neurotransmitters)Physical illness GeneticsPsychosocial factorsOther: Depressed parents, child abuse, gender, hormonal changes, poverty, alcoholism and substance abuse

Common Mood Disorders in ChildrenNormal MoodinessAdjustment DisordersWith depressed moodWith mixed emotions*DysthymiaMajor DepressionDouble DepressionBipolar Disorder or Manic Depressive Illness*Seasonal Affective Disorder (SAD)**not discussed here

Normal MoodinessMy child is so sensitive that the slightest thing can put him or her in a bad moodTemperament cannot be changes but its impact can be minimizedMy child has been so moody since my mother died, her best friend left, he moved to another schoolchildren go through a period of bereavement or grieving whenever they suffer a loss

Normal MoodinessMy teenager is no irritable and moody that I'm not sure that we will both survive her adolescenceNormal teens actually have very mild mood swingsMy daughter has PMS-like mood swings but they seem to come and go more than once a monthHormones are clearly associated with mood changes. Thyroid dysfunction causes depression. Fluctuating levels of female hormones during teen years is not uncommon until their menstrual cycles are predictableNormal MoodinessMy child never gets enough sleep; it's no wonder my child is so irritable all the timeChildren, even teenagers, need 8 to 9 hours of sleep or more. Chronic sleep deprivation is not normal just because most children suffer from it. It is unhealthy and associated with fatigue, sleepiness, decreased attention span, moodiness, irritability.

What Can a Parent Do?Patience, tolerance and a positive attitudeThe three Ls - love, limits, large muscleThe three Rs - respect for you, respect for your child, responsibility for his or her actionsEnlist the aid of the teachers To provide a basis of comparisonTo lessen the school loadTo notify you if the situation gets worseAdjustment Disorder with Depressed MoodThe development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within three months of the onset of the stressor(s) and lasting less than six months. The symptoms or behaviors are clinically significant as evidenced by either of the following:Marked distress that is in excess of what would be expected from exposure to the stressorSignificant impairment in social or occupational (academic) functioningHelping Children After a TraumaSeek help if child's behavior changes and problems persistAfter the initial trauma, check the National Center for Child Traumatic Stress website for age appropriate handouts for parents and teachers - Reactions and BehaviorsResponses Examples of what to do and say

DysthymiaA chronic low grade form of depression in which the symptoms are present for a year or twoYoung children don't necessarily recognize sadness or identify themselves as depressedChildren may cry more easily, or have a sad or expressionless faceChildren may not express a sense of sadness, but rather be more irritable

DysthymiaThe average duration of a dysthymic period in children and adolescents is about 4 years.Sometimes children are depressed for so long that they do not recognize their mood as out of the ordinary and thus may not complain of feeling depressed. Dysthymia - DSM CriteriaThe presence, while depressed, of two or more of the following symptoms:Poor appetite or overeatingInsomnia or hypersomnia (sleeping too much)Low energy or fatigueLow self esteem (negative self statements)Poor concentration or difficulty making decisionsFeelings of hopelessness

Associated SymptomsPhysical Symptoms such as headaches or stomachachesChange in interestsChange in friendshipsChange in school performance

What Should a Parent Do?Learn the symptoms of depression - it often begins insidiouslyTake action when you notice these symptomsDon't deny the problem or make excusesPrevent excessive stress - even though it doesn't cause depression, it can worsen the conditionRecognize the signs of suicidal behavior and intervene immediatelyTreatment OptionsTherapyIndividual, group or family therapyCognitive therapyBehavior therapyInterpersonal TherapyMedications usually antidepressants, most commonly SSRIsAlso consider a change in school situation or modification of the current school program

Major Depressive Disorder - MDDPopulation studies show that at any point in time 10 to 15 percent of children and adolescents have some symptoms of depression.In children and adolescents, an episode lasts on average from 7 to 9 months.Once a young person has experienced a major depression, he or she is at risk of developing another depression within the next 5 years.

Major Depressive Disorder DSM CriteriaFive or more of the following symptoms have been present during the same 2 week period AND represent a change from previous functioning; At least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasureSymptoms should be present most of the day, nearly every day

MDD - Criteria1. Depressed (or in children irritable) mood2. Markedly diminished interest or pleasure in all, or almost all, activities Change in participation, communication. Increased social isolation. 3. Significant weight loss or weight gain4. Insomnia or sleeping too much5. Motor agitation or retardation observable by others6. Fatigue or loss of energy7. Feelings of worthlessness, excessive or inappropriate guilt8. Diminished ability to think, concentrate, make decisions9. Recurrent thoughts of death, suicidal ideation with or without plan

MDD Associated SymptomsCrying spells or tearfulnessFrequent absences from school or poor performance in school Frequent complaints of physical illnesses such as headaches and stomachaches Frequent bouts of physical illnesses that don't get better with treatmentExtreme sensitivity to rejection or failureMore Associated FeaturesEmotional outburstsPoor social relationships or change in friendshipsAlcohol or Substance abuseReckless behavior single person car accidents Reluctance to meet new people or try new thingsFears of separationPsychotic features can occur, but are more likely to be auditory hallucinations than delusions

What Should a Parent Do?Listen to your childAccept, do not argue about his or her feelingsHelp your child copeGet your child professional assistanceMake it easy to get to therapyEncourage compliance with treatmentCollaborate with the professionals involved in your childs care both at school and in treatmentRemind your child that you love him or herTreatment OptionsEarly diagnosis is importantRecognize that depression is a treatable illness that requires professional helpA combination of individual psychotherapy, family therapy and medications is probably bestResourcesThe American Academy of Child and Adolescent Psychiatry Facts for Families (http://aacap.org)Madison Institute of Medicine booklets on Depression, etc http://www.miminc.org/ Depression and Bipolar Support Alliance (DBSA) - http://www.dbsalliance.org/site/PageServer?pagename=home

More Resources books for ParentsLonely, Sad and Angry: How to Help Your Unhappy Child (Paperback) by Barbara IngersollHelp Me, I'm Sad: Recognizing, Treating, and Preventing Childhood and Adolescent Depression by David Frassler and Lynne DumasTalking to Depression: Simple Ways to Connect When Someone in Your Life is Depressed by Claudia Strauss

More Resources books for childrenFeeling Better-A Kids Book About Therapy by Rachel RashkinThe Boy Who Didnt Want to be Sad by Robert GoldblattDepression is the Pits, But Im Getting Better-A guide for Adolescents by E. Jane GarlandBeyond the Blues: A Workbook to Help Teens Overcome Depression (Paperback) by Lisa SchabWhen Nothing Matters Anymore: A Survival Guide for Depressed Teens (Paperback) by Bev CobainMore Books for ChildrenDont Feed the Monster on Tuesdays! The Childrens Self Esteem Book by Adolph MoserTales of a Fourth Grade Nothing by Judy BlumeBeezus and Ramona by Beverly Cleary

Yet More Resources online orderingMagination Press self help books for kids and adults by the American Psychological Association http://www.apa.org/pubs/magination/

ChildsWork/ChildsPlay resources for parents, teachers and professionals: http://childswork.com/

Courage to Change more resources available online: http://couragetochange.com/

Creative Therapy Store - http://portal.creativetherapystore.com/

Classroom TipsSchool Behavior.com All sorts of resources about all sorts of common mental health problems and learning difficulties in children