Clinical
Corner Ð Children and Depression
This fact sheet, prepared by the National Institute of Mental Health
(NIMH), the lead Federal agency for research on mental disorders, summarizes
some of the latest scientific findings on child and adolescent depression and
lists resources where families and physicians can obtain more information.
Depressive disorders, which include major depressive disorder (unipolar
depression), dysthymic disorder (chronic, mild depression), and bipolar
disorder (manic-depression), can have far reaching effects on the functioning
and adjustment of young people. Among both children and adolescents, depressive
disorders confer an increased risk for illness and interpersonal and
psychosocial difficulties that persist long after the depressive episode is
resolved; in adolescents there is also an increased risk for substance abuse
and suicidal behavior. Unfortunately, these disorders often go unrecognized by
families and physicians alike. Signs of depressive disorders in young people
often are viewed as normal mood swings typical of a particular developmental
stage. In addition, health care professionals may be reluctant to prematurely
"label" a young person with a mental illness diagnosis. Yet early
diagnosis and treatment of depressive disorders are critical to healthy
emotional, social, and behavioral development.
Although the scientific literature on treatment of children and
adolescents with depression is far less extensive than that concerning adults,
a number of studies-mostly conducted in the last four to five years-have
confirmed the short-term efficacy and safety of treatments for depression in
youth.
Given the challenging nature of the problem, it is usually advisable to
involve a therapist or psychologist with experience diagnosing children in the
evaluation, diagnosis, and treatment of a child or adolescent in whom
depression is suspected.
A number of studies have reported that up to 2.5 percent of children and
up to 8.3 percent of adolescents in the U.S. suffer from depression. A
NIMH-sponsored study of 9- to 17-year-olds estimates that the prevalence of any
depression is more than 6 percent in a 6-month period, with 4.9 percent having
major depression. In addition, research indicates that depression onset is
occurring earlier in life today than in past decades. A recently published
longitudinal prospective study found that early-onset depression often
persists, recurs, and continues into adulthood, and indicates that depression
in youth may also predict more severe illness in adult life. Depression in
young people often co-occurs with other mental disorders, most commonly
anxiety, disruptive behavior, or substance abuse disorders, and with physical
illnesses, such as diabetes.
Suicide
Depression in children and adolescents is associated with an increased
risk of suicidal behaviors. This risk may rise, particularly among adolescent
boys, if the depression is accompanied by conduct disorder and alcohol or other
substance abuse. In 1997, suicide was the third leading cause of death in 10 to
24 year-olds. NIMH-supported researchers found that among adolescents who
develop major depressive disorder, as many as 7 percent may commit suicide in
the young adult years. Consequently, it is important for therapists and parents
to take all threats of suicide seriously. Early diagnosis and treatment,
accurate evaluation of suicidal thinking, and limiting young people's access to
lethal agents-including firearms and medications-may hold the greatest suicide
prevention value.
The diagnostic criteria and key defining features of major depressive
disorder in children and adolescents are the same as they are for adults.
However, recognition and diagnosis of the disorder may be more difficult in
youth for several reasons. The way symptoms are expressed varies with the
developmental stage of the youngster. In addition, children and young
adolescents with depression may have difficulty in properly identifying and
describing their internal emotional or mood states. For example, instead of
communicating how bad they feel, they may act out and be irritable toward
others, which may be interpreted simply as misbehavior or disobedience.
Research has found that parents are even less likely to identify major depression
in their adolescents than are the adolescents themselves.
Symptoms of Major Depressive Disorder Common to Adults, Children and
Adolescents
Five or more of these symptoms must persist for 2 or more weeks before a
diagnosis of major depression is indicated.
Signs that may be associated with Depression in Children and Adolescents
While the recovery rate from a single episode of major depression in children
and adolescents is quite high, episodes are likely to recur. In addition, youth
with dysthymic disorder are at risk for developing major depression.
Prompt identification and treatment of depression can reduce its
duration and severity and associated functional impairment.
In childhood, boys and girls appear to be at equal risk for depressive
disorders; but during adolescence, girls are twice as likely as boys to develop
depression. 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.
Other Risk Factors Include:
Treatment for depressive disorders in children and adolescents often
involves short-term psychotherapy, medication, or the combination, and targeted
interventions involving the home or school environment.
Psychotherapy
Recent research shows that certain types of short-term psychotherapy,
particularly cognitive-behavioral therapy (CBT), can help relieve depression in
children and adolescents. CBT is based on the premise that people with
depression have cognitive distortions in their views of themselves, the world,
and the future. CBT, designed to be a time-limited therapy, focuses on changing
these distortions. An NIMH-supported study that compared different types of
psychotherapy for major depression in adolescents found that CBT led to
remission in nearly 65 percent of cases, a higher rate than either supportive
therapy or family therapy. CBT also resulted in a more rapid treatment
response. Another specific psychotherapy, interpersonal therapy (IPT), focuses
on working through disturbed personal relationships that may contribute to
depression.
Continuing psychotherapy for several months after remission of symptoms
may help patients and families consolidate the skills learned during the acute
phase of depression, cope with the after-effects of the depression, effectively
address environmental stressors, and understand how the young person's thoughts
and behaviors could contribute to a relapse.
Medication
Research clearly demonstrates that antidepressant medications,
especially when combined with psychotherapy, can be very effective treatments
for depressive disorders in adults. Using medication to treat mental illness in
children and adolescents, however, has caused controversy. Many doctors have
been understandably reluctant to treat young people with psychotropic
medications because, until fairly recently, little evidence was available about
the safety and efficacy of these drugs in youth. In the last few years,
however, researchers have been able to conduct randomized, placebo-controlled
studies with children and adolescents. Some of the newer antidepressant
medications, specifically the selective serotonin reuptake inhibitors (SSRIs),
have been shown to be safe and effective for the short-term treatment of severe
and persistent depression in young people.
Medication as a first-line course of treatment should be considered for
children and adolescents with severe symptoms that would prevent effective
psychotherapy, those who are unable to undergo psychotherapy, those with
psychosis, and those with chronic or recurrent episodes. Following remission of
symptoms, continuation treatment with medication and/or psychotherapy for at
least several months may be recommended by the psychiatrist, given the high
risk of relapse and recurrence of depression. Discontinuation of medications,
as appropriate, should be done gradually over 6 weeks or longer.
It is very important for parents to understand their child's depression
and the treatments that may be prescribed. Physicians can help by talking with
parents about their questions or concerns, reinforcing that depression in youth
is not uncommon, and reassuring them that appropriate treatment with
psychotherapy, medication, or the combination can lead to improved functioning
at school, with peers, and at home with family. In addition, referring the
youth and family to a mental health professional and to the information
resources listed at the back of this publication can help to enhance recovery.
Although rare in young children, bipolar disorder-also known as
manic-depressive illness-can appear in both children and adolescents. Bipolar
disorder, which involves unusual shifts in mood, energy, and functioning, may
begin with either manic, depressive, or mixed manic and depressive symptoms. It
is more likely to affect the children of parents who have the disorder.
Existing evidence indicates that bipolar disorder beginning in childhood
or early adolescence may be a different, possibly more severe form of the
illness than older adolescent and adult-onset bipolar disorder. When the illness
begins before or soon after puberty, it is often characterized by a continuous,
rapid-cycling, irritable, and mixed symptom state that may co-occur with
disruptive behavior disorders, particularly attention deficit hyperactivity
disorder (ADHD) or conduct disorder (CD), or may have features of these
disorders as initial symptoms. In contrast, later adolescent- or adult-onset
bipolar disorder tends to begin suddenly, often with a classic manic episode,
and to have a more episodic pattern with relatively stable periods between
episodes. There is also less co-occurring ADHD or CD among those with later
onset illness.
Bipolar Disorder: Manic Symptoms
A child or adolescent who appears to be depressed and exhibits ADHD-like
symptoms that are very severe, with excessive temper outbursts and mood
changes, should be evaluated by a psychiatrist or psychologist with experience
in bipolar disorder, particularly if there is a family history of the illness.
This evaluation is especially important since psychostimulant medications,
often prescribed for ADHD, may worsen manic symptoms. There is also limited
evidence suggesting that some of the symptoms of ADHD may be a forerunner of
full-blown mania.
The essential treatment of bipolar disorder in adults involves the use
of appropriate doses of mood stabilizing medications, typically lithium and/or
valproate, which are often very effective for controlling mania and preventing
recurrences of manic and depressive episodes.
Bipolar Disorder: A Warning
About Antidepressants and Psychostimulants
Using antidepressant medication to treat depression in a person who has
bipolar disorder may induce manic symptoms if it is taken without a mood
stabilizer, such as lithium or valproate. In addition, using psychostimulant
medications to treat ADHD or ADHD-like symptoms in a child or adolescent with
bipolar disorder may worsen manic symptoms. While it can be hard to determine
which young patients will become manic, there is a greater likelihood among
children and adolescents who have a family history of bipolar disorder.
Dysthymic Disorder (Or Dysthymia)
This less severe yet typically more chronic form of depression is
diagnosed when depressed mood persists for at least one year in children or
adolescents and is accompanied by at least two other symptoms of major
depression. Dysthymia is associated with an increased risk for developing major
depressive disorder, bipolar disorder, and substance abuse. Treatment of
dysthymia may prevent the deterioration to more severe illness.
National Institute of Mental Health
Office of Communications and Public Liaison
Information Resources and Inquiries Branch
6001 Executive Boulevard, Rm. 8184, MSC 9663
Bethesda, MD 20892-9663
(301) 443-4513
Mental Health FAX 4U: (301) 443-5158
E-mail: nimhinfo@nih.gov
NIMH home page: www.nimh.nih.gov
American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Avenue, N.W.
Washington, DC 20016
(202) 966-7300
www.aacap.org
National Mental Health Association
1021 Prince Street
Alexandria, VA 22314
(800) 969-NMHA (-6642)
www.nmha.org
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Source:National
Institute of Mental Health