Childhood & Adolescent Depression
Criteria for depression
Mood d/os occur in infants, children & adolescents; ds made by same criteria use to ds mood d/os in adults, w/ minor modifications that take into account different developmental levels observed in kids
- Major depressive episode – represent a change from functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure
o Depressed mood ® irritability
o Markedly diminished interest or pleasure (anhedonia)
o Physical symptoms
§ Significant wt loss or gain – failure to gain wt as should
§ Insomnia (classic) or hypersomnia nearly every day
- Terminal insomnia – wake early in morning & can’t go back to sleep
- Middle insomnia – waking in middle of night & has trouble falling back to sleep
- Initial insomnia – trouble falling asleep
§ Psychomotor agitation or retardation nearly every day
§ Fatigue or loss of energy nearly every day
§ Feelings of worthlessness or excessive/inappropriate guilt
§ Diminished ability to think or concentrate or indecisiveness nearly every day
§ Recurrent thoughts of death (not just fear of dying), suicidal ideation w/o specific plan, or suicide attempt or a specific plan for committing suicide
Etiology
- Genetic model
o Twin studies
§ Concordance for affective (mood) d/o in monozygotic twins = 76%, compared w/19% in dizygotic twins
§ When monozygotic twins are reared apart, concordance rate drops to 67%
o Family studies
o Adoption studies
- Biochemical factors – NE & 5-HT (‘chemical imbalance’)
- Role of environment – can trigger episode, especially in those predisposed
o Loss or stress
o Marital discord
o Parental affective d/o
o Neglect/abuse
- Psychological factors
o Psychodynamic model – ‘anger turned inward;’ failure in development
o Life stress model – not predictive, but may be factor
o Cognitive distortion model
§ “Bad things always happen to me, & they always will”
§ Assuming blame/guilt
§ Stuck in present (situation won’t ever change)
o Learned helplessness model
Epidemiology
- Reported prevalence of depression in kids varies widely
- THE YOUNGER THE PT, THE LESS LIKELY THEY’LL BE DEPRESSED
o Depression in preschoolers = 0.3%
o Depression in pre-pubertal kids = 1.8%
o Depression in 14-16 yr-olds = 4.7%
- Clinic samples
o Of kids attending psychiatric o/pt clinic = 28%
o Of those evaluated in educational diagnostic center = 53%
o Of general pediatric medical inpts = 7%
o Of pediatric neurology inpts = 40%
Clinical presentation – developmental level & depressive symptoms
- Infancy
o Anaclitic depression
o Failure to thrive (non-organic) – can be fatal
o Caretaker problems & life events
§ Parental depression
§ Rejection
§ Abuse – neglect (physical & psychological)
- Pre-school child (2-6 y) – looks very sad; limited verbal communication; appears “slowed down”
o Symptoms
§ Severe separation anxieties (tantrums)
§ Hyperactivity
§ Somatization – ‘tummy aches’
§ Social withdrawal – weepiness
o Caretaker problems & life events
§ Parental depression
§ Abuse/neglect
§ Separation – death, hospitalization, divorce
- School-aged child – verbal repertoire makes them more accessible to be listened to & understood; can tell how they feel, but not good w/time
o Symptoms
§ Depression similar to adult picture
§ School refusal or poor performance
§ Psychosomatic symptoms – headaches, abdominal pain
§ Aggression
§ Hyperactivity
§ Isolating behavior
§ Suicidal thoughts – 1st grp to discuss
- Running into risk
- Jumping from high place
- Hanging themselves
- Caretaker problems & life events
§ Caretaker depression
§ Abuse
§ Illness or death of parent
§ Parental discord or divorce
§ Chronic illness
- Adolescence
o Symptoms
§ Running away from home, truancy – impulsive behaviors
§ Drug or EtOH abuse – which came 1st: depression or substance abuse
§ Anorexia – not anorexia nervosa – no distorted image
§ Psychosomatic symptoms – malaise, fatigue
o Caretaker problems & life events
§ Parental depression
§ Parental divorce
§ Parent death
§ Peer death, especially suicide
§ Chronic illness
Differential ds
- Pre-schooler – evaluate for organic “failure to thrive”
- School-age child – ADHD, anxiety d/o – OCD
- Adolescent – all organic causes that may precipitate affective-type symptoms should be considered & excluded, including substance & EtOH abuse; anorexia nervosa & other eating d/os; AIDS; bipolar d/o
o Kids w/depression have risk for developing bipolar d/o
Assessment & tx
- Before initiating tx for depressed child, perform a complete physical exam & lab tests to rule out medical conditions that mimic depression
- Psychotherapy
o Cognitive therapy for teens
o Play-type therapy for younger kids
- Pharmacotherapy – tricyclic antidepressants
- Focus on child’s environment
Prognosis
- Pretty good for treating episode, but lifetime risk for recurrence is
Tags: Aggression, Anaclitic depression, hyperactivity, Initial insomnia, Middle insomnia, Psychomotor agitation, separation anxieties, Social withdrawal, suicide, Terminal insomnia
