A Primer on Childhood and Adolescent Depression
July, 2008
Dr. Nadja Reilly
Depression: An Overview
One out of every four people is affected by mental illness (APA, 1994). Worldwide, unipolar depressive disorders alone lead to 12.15% of years lived with disability, and rank as the third leading contributor to the global burden of diseases (World Health Organization, 2003). Alarmingly, depression is the fourth most important cause of impairment in work and home life, and by the year 2020 it will be the second leading cause (Beardslee, 2002).
Sadly, these statistics are a reality not just among adults, but among children and adolescents, as well. The burden of suffering and the costs, emotionally and financially, frighteningly mirror those found among adults. In the United States, one in ten children and adolescents suffer from mental illnesses severe enough to cause some level of impairment. Yet, in any given year, only about one in five of these children will receive the specialty mental health services they need. Evidence compiled by the World Health Organization indicates that by the year 2020, childhood neuropsychiatric disorders will rise by over 50 percent, worldwide, to become one of the five most common causes of morbidity, mortality, and disability among children (Report of the Surgeon General’s Conference on Children’s Mental Health, 2000).
By the year 2020, neuropyschiatric disorders will become one of the most common causes of disability among children (World Health Organization).
Today’s schoolchildren are at a higher risk for depression than any previous generation. As many as 9% of children will experience a major depressive episode by the time they are 14 years old, and 20% will experience a major depressive episode before graduating from high school. Having suffered from depression as children, these young people are much more vulnerable to depression as adults (APA, 2006).
Child and adolescent depression has been studied extensively, and is associated with many negative outcomes, including substance abuse, academic problems, substance abuse, high-risk sexual behavior, physical health problems, impaired social relationships, and an increased risk of completed suicide (Horowitz & Garber, 2006).
There is significant hope as safe and effective treatments are available for the majority of cases of depression
While these are alarming statistics, there is significant hope in that safe and effective treatments are available for the majority of cases of depression. Treatments include medication, psychotherapy, family therapy, and group therapy. In particular, cognitive, behavioral, and interpersonal therapy can have significantly positive impacts on the treatment of depression Beardslee, 2002)
Depression is a disabling disorder in Children and Adolescents
- Depression is the leading cause of disability worldwide among persons age 5 and older.
- 7-14% experience an episode of depression before the age of 15.
- 60-80% of children and adolescents with depression are undiagnosed and untreated
- One in five adolescents in US considers suicide.
- Depression directly or indirectly results in 1700 teen suicides per year.
Symptoms of Depression
Use this chart to help clarify some of the common symptoms of depression.
|
Category |
Symptoms |
| Affective | Anxiety, depressed mood, irritable, morning depression worse than later in the day |
| Motivational | Loss of interest in activities, hopeless, helpless, suicidal thoughts or acts |
| Cognitive | Difficulty concentrating, worthlessness, guilt, low self-esteem, memory problems, difficulty with problem solving |
| Behavioral | Isolated, easily angered or agitated, oppositional, risk taking |
| Vegetative | Sleep problems, appetite change, weight change, energy loss, motor agitation |
| Somatic | Physical complaints, frequent stomachaches and headaches, body pains |
Childhood Depression
- Estimates reach 2%
- Male predominant
- Somatic complaints very common
- Commonly associated with high irritability and sadness
- High co-morbidity with disruptive behavior disorders
Some of the behavioral cues associated with childhood depression include:
- Looking sad
- Weeping or crying, tearful
- Withdrawn
- Refusal to eat
- Sleep problems
Poor school functioning - Slowed movements
- Monotone voice
- Extreme sensitivity to rejection or failure
- Describe themselves in negative terms such as “I’m dumb,” “I’m stupid” or “Nobody loves me.”
- Somatic symptoms are common, for example, complaints of stomach aches, head aches, or tiredness
- Anxiety about being separated from parents or caretakers
- Increased irritability and moodiness
- Loss of interest in activities
Adolescent Depression
- Estimates reach 15-20%
- Female predominant (2:1 ratio) after puberty (mostly noted between 15-18 years)
- Somatic complaints very common (example: headaches, stomachaches, muscle and joint pain)
- Increased sadness and lack of pleasure
- High co-occurrence with anxiety and substance abuse disorders
Some of the signs and symptoms associated with adolescent depression include:
- Reports of feeling overwhelmed
- Self-injurious behaviors (example: cutting, burning)
- Hopelessness (feeling like things will never change)
- Inability to concentrate
- Sense of responsibility for negative events
- Feeling “different”
- Poor-decision making
- Substance use
Suicide
Rates
- Between 1950’s and late 1970’s rate of suicide among young males more than tripled and doubled for young women.
- By 1980’s suicide by youth 15-24 = 17% of approximate 30,000 suicides in the US
- 1994 saw a peak at 13.6 suicides per 100,000 youth 15-24
- In 2002 rates declined to 9.9 per 100,000
- Cultural differences are noted in attempts and completed suicides
- Despite declines overall youth suicide rate remains more than 2 times what it had been prior to marked rise and currently constitutes almost 13% of all US suicides
Risk Factors
Risk factors are factors related to family history, past, or current situations that may play a role in the child’s emotional health. Having one of the risk factors does not mean a child will necessarily develop a mood disorder. Mental health professionals assess the number of risk factors, as well as how they impact the child’s current functioning, when evaluating a child for a mood disorder.
- Depression · Family history of suicide
- Parental psychopathology
- Hopelessness; pessimism
- Recent losses
- Stressful life events
- Social isolation
- Exposure to violence and/or trauma
- Conduct disorder in males
- Panic disorder in females
- Physical/emotional/ sexual abuse
- Drug/alcohol abuse
- Aggressive/impulsive behavior
- Firearm availability
- Diminished family cohesion
- Long term, sustained parent-child conflict
- Lack of parental support
- Suicide contagion
- Same sex sexual orientation (same sex sexual orientation in and of itself is not problematic, it is the alienation and/or rejection an adolescent may experience as a result that is problematic.)
Gender Differences
Among boys, a previous suicide attempt increases the risk of a second suicide attempt by over 30 fold. Boys who are depressed are 12 times as likely to attempt suicide and those with disruptive behavior are 2 times as likely to attempt suicide.
Girls who have experienced major depression are 12 times as likely to attempt suicide. Girls who have had a previous suicide attempt are 3 times as likely to have a second suicide attempt.
Warning Signs
Warning signs are different from risk factors in that these are behaviors that one is likely to see shortly before a suicide gesture or attempt. When warning signs are evident, immediate help should be sought.
- preoccupation with death related topics
- talking about suicide
- erratic behavior changes
- giving away special things
- taking excessive risks
- increased drug/alcohol use
- decreased interest in usual activities
- increased isolation
- getting weapons
How to tell if depression is a passing change (non-clinical temporary mood distrubance) or true disturbance (dysthymia or major depression)
- How long have the symptoms lasted? (2 weeks time frame)
- How severe is the change in behavior and mood? (able to respond to distraction or intervention)
- How many areas of functioning are impaired? (impaired across family, school, peers)
Diagnostic Differences
| Major Depression | Dysthymia |
| Dysphoric mood | Dysphoric mood |
| Symptoms severe | Symptoms mild-moderate |
| Impaired functioning common | Impaired functioning less common |
| Possible psychosis | No psychosis |
| Symptoms present every day | Symptoms usually fluctuating |
| Symptoms present every day for 2 weeks | Symptoms on and off for one year |
Treatment of Depression
- Psychotherapy
- Individual therapy (example: cognitive behavioral therapy)
- Parent guidance
- Family therapy
- Group therapy
- Pharmacological Treatment
- Selective serotonin reuptake inhibitors (SSRI’s)
- Mood stabilizers
- Anti-psychotics (While not a common occurrence, at times children and adolescents may present with hallucinations and/or delusions as part of the symptom cluster associated with their major depressive episode. This is diagnosed as Major Depressive Episode with Psychotic Features. When this occurs, anti-psychotic medication is used to treat the hallucinations and/or delusions.)
Outcomes
Those with adolescent depression 2 to 3 times as likely to experience anxiety or depressive disorder in adulthood.
A majority of adolescents will experience at least 1 recurrence within 2 years of treatment termination.
There are poorer outcomes associated with a presence of:
– Double depression
– Maternal depressive symptoms
– Family discord
– Hopelessness
– High cognitive distortion
– More severe depressive symptoms at intake
Protective Factors
- Each youth’s unique talents, strengths, interests, and future potential
- Resilience and coping skills
- Families described as emotionally involved and supportive
- Student connectedness to school
- Child’s connection to at least one adult
- Range of social skills
Negative Thinking Patterns
- Depressed individuals have more negative beliefs about themselves, the world, and their future
- Low self-esteem, negative automatic thoughts, pessimism, hopelessness, low belief about one’s self-efficacy are related to depression
- The link between negative thinking patterns and depression increases from middle childhood to early adolescence
A New Way to Think!
Because children and adolescents tend to have more negative beliefs about themselves, their world, and their future, it is important to teach them ways to combat these negative thinking patterns. Ways to do this include:
- Help children and adolescents recognize that our beliefs about stress and adversity affect how we feel, and consequently, how we behave
- Teach children and adolescents to become calm and focused prior to responding to perceived negative situations. For example, if a child fails a test, due to negative thinking and hopelessness, he might respond with “What’s the use, nothing will change, I am going to fail this class and will have to repeat the grade!” Parents and teachers may help by providing other ways of responding, such as: “Ok, let’s take three deep breaths and calm down, then let’s think about this situation. You failed this test, does that absolutely mean you will fail the class? Might there be another opportunity to increase your grade? How else can we solve this problem?”
- Develop an awareness of common thinking traps or errors (for example: the words “always” and “never” are good cues in helping adults determine whether a child is having negative thoughts. Examples might be “I’ll never have any friends!” or “I always fail at math, so what’s the use?”
- Help increase a sense of control. Children with negative thinking patterns tend to restrict their range of options. Assist them by helping them with problem solving and figuring out new ways to respond to challenging situations.
