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Although childhood is often pictured as a happy
time of little responsibility, endless play, and
infinite enjoyment, in fact, many children can
develop depression during this period.
Depressive disorders occur in children of all
ages, but are much more prevalent with increasing
A child may suffer from diagnosable mood
disorders, including bipolar disorder and major
depression. Like depressed adults, depressed
children typically have feelings of hopelessness,
loss of interest in usual activities, fatigue,
insomnia, poor appetite, more distorted thinking
patterns and tendencies to blame themselves for
events, lower self esteem, self confidence and
perceptions of competence than their
non-depressed peers (Lewinsohn et al. , 1994
Koracs, 1996).
They also report episodes of sadness and crying,
feelings of apathy, withdrawal behaviours,
avoidance of eye contact, physical complaints,
and even aggressive behaviour. In some cases,
they may also experience suicidal thoughts or
even attempt suicide. Yet depression in children
may be associated with some distinctive features
as well, such as refusal to attend school,
academic problems, hyperactivity, may also
express exaggerated fears(such as that parents
may die), and clinging to parents. A depressed
child may also lack various skills, including
arithmetic, athletic and social skills
(Seroczynski, Cole, Maxwell, 1997) Childhood
depression may also be masked by behaviours that
do not appear directly related to depression
hence some experts believe that in children the
signs of depression are not directly seen because
other problems conceal the underlying behaviours,
for e.g. conduct disorders which can constitute
masked depression.
Depressive disorders increase in frequency with
increasing age, in the general population. Mood
disorders among preschool-age children are
extremely rare the rate of major depressive
disorder in preschoolers is estimated to be about
0.3 in the community and 0.9 in a clinic
setting. Among prepubertal school-age children
in the community, the point prevalence is
approximately 1 . Depression, in referred
samples of school-age children, is about the same
in boys as in girls, with some surveys indicating
a slightly increased rate among boys. Studies
confirm that many youngsters often feel sad. In
one study, about 10 to 12 of the 10 year olds
in a school district population were described by
parents ad teachers as often appearing miserable,
unhappy, tearful, or distressed. While probably
most of these children do not meet the criteria
for major depression, they may meet the criteria
for dysthymic disorder. A study by Kronenberger
Meyer, 1996 have neatly sketched out the symptoms
of depression at different developmental stages
during childhood, starting from birth till 18
years of age.
Clinical features of a major depressive disorder
in children
According to DSM-IV-TR diagnostic criteria for
major depressive episode, at least five symptoms
must be present for a period of two weeks, and
there must be a change from previous functioning.
Among the necessary symptoms is either a
depressed or irritable mood or a loss of interest
or pleasure. Other symptoms from which the other
four diagnostic criteria are drawn include a
childs failure to make expected weight gains,
daily insomnia or hypersomnia, psychomotor
agitation or retardation, daily fatigue or loss
of energy, feelings of worthlessness or
inappropriate guilt, diminished ability to think
or concentrate, and recurrent thoughts of
death. These symptoms must produce social or
academic impairment. To meet the diagnostic
criteria for major depressive disorder, the
symptoms cannot be the direct effects of a
substance or a general medical condition.
A diagnosis of major depressive disorder is not
made within 2 months of the loss of a loved one,
except when marked functional impairment, morbid
preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor
retardation is present. A major depressive
episode in a prepubertal child is likely to be
manifest by somatic complaints, psychomotor
agitation, and mood-congruent hallucinations.
Anhedonia is also frequent . Mood disorders tend
to be chronic if they begin early. Childhood
onset may be the most severe form of mood
disorder and tends to appear in families with a
high incidence of mood disorders and alcohol
abuse. The children are likely to have such
secondary complications as conduct disorder,
alcohol and other substance abuse, and antisocial
behavior. Functional impairment associated with
a depressive disorder in childhood extends to
practically all areas of a childs psychosocial
world school performance and behavior, peer
relationships, and family relationships all
suffer. Children with major depressive disorder
may have hallucinations and delusions.
Dysthymic Disorder this disorder in children
consists of a depressed or irritable mood for
most of the day, for more days than not, over a
period of at least 1 year. According to the
DSM-IV-TR diagnostic criteria, at least three of
the following symptoms must accompany the
depressed or irritable mood poor self-esteem,
pessimism or hopelessness, loss of interest,
social withdrawal, chronic fatigue, feelings of
guilt or brooding about the past, irritability or
excessive anger, decreased activity or
productivity, and poor concentration or memory.
Cyclothymic Disorder the only difference in
the DSM-IV-TR diagnostic criteria for child
cyclothymic disorder is that a period of 1 year
of numerous mood swings is necessary instead of
the adult criterion of 2 years
One of the most striking aspects of major
depression in childhood is the likelihood of
coexisting disorders. Anxiety symptoms are found
among almost all depressed children. At least 50
of children who were chronic school refusers also
met the criteria for depressive disorder. Other
childhood disorders that are likely to co-occur
with depression are ADHD, oppositional defiant
disorder, and conduct disorder. Children seen in
diagnostic centers for learning problems and
children with chronic illnesses also have high
rates of depression. Childhood depression,
according to a study, rarely occurs by itself.
Depressed children typically experience other
psychological disorders, especially anxiety
disorder , conduct or oppositional defiant
disorders and even eating disorders ( Hammer
Compas, 1994).
A study conducted by Angold Costello in 1993
have proven that childhood depression increases
the chances that a child will develop another
psychological disorder by at least 20 fold.
Childrens moods are especially vulnerable to the
influences of severe social stressors, such as
chronic family discord, abuse and neglect, and
academic failure. Most young children with major
depressive disorder have histories of abuse or
neglect. Not only do environmental factors
bring on symptoms of depression in children,
according to Hammen,1992, depression tends to
run in families. This means that many depressed
children also have depressed parents. Again a
childs attributional style (where they blame
themselves for events) is an important
vulnerability factor, just as it is in adult
depression. Considerable evidence indicates
that the mood disorders in children are the same
fundamental diseases experienced by adults.
  • Molecular Genetic Studies Two genes have been
    identified as incurring vulnerability for
    depressive disorder. The first one, the MAOA
    gene, and the second is the Serotonin transporter
    gene (5-HTT).
  • Familiality Mood disorders in children,
    adolescents, and adult patients tend to cluster
    in the same families. An increased incidence of
    mood disorders is generally found among children
    of parents with mood disorders and relatives of
    children with mood disorders having one
    depressed parent probably doubles the risk for
    the offspring. Having two depressed parents
    probably quadruples the risk of a child having a
    mood disorder before age 18 compared with the
    risk for children with two unaffected parents.
  • 3. Biological Factors Studies of prepubertal
    major depressive disorder have revealed a
    variety of biological abnormalities. For e.g. ,
    prepubertal children in an episode of depressive
    disorder secrete significantly more growth
    hormone during sleep than do normal children and
    those with non-depressed mental disorders. These
    children also secrete significantly less growth
    hormone in response to insulin-induced
    hypoglycemia than do non-depressed patients.

Sleep studies shows either no change or changes
characteristic of adults with major depressive
disorder reduced REM periods and an increased
number of REM periods. Hence these studies are
quite inconclusive. Other biological factors
might also make children vulnerable to
psychological problems like depression. These
factors include biological changes in the neonate
as a result of alcohol intake by the mother
during pregnancy. One recent study by
M.J.OConnor (2001) revealed that children
exposed to alcohol use in utero, has shown a
continuity between alcohol use by the mother and
infant negative affect and early childhood
depression symptoms. 4. Magnetic Resonance
Imaging MRI scans in more than 100
psychiatrically hospitalized children with mood
disturbances report a low frontal lobe volume
and a high ventricular volume. 5. Learning
Factors Learning of maladaptive behaviors
appears to be important in childhood depressive
disorders. There are likely to be learning or
cultural factors in the expression of
depression. A recent article by Stewart, Kenard,
et al. (2004) reported that depression symptoms
and hopelessness were higher in Hong Kong than in
the United States.
In addition, a number of studies have indicated
that childrens exposure to early traumatic
events can increase their risk for the
development of depression. Children who have
experienced past stressful events are susceptible
to states of depression that make them vulnerable
to suicidal thinking under stress (Silberg,
Pickles, et al., 1999). Intense or persistent
sensitization of the central nervous system in
response to severe stress might induce
hyperreactivity and alteration of the
neurotransmitter system, leaving these children
vulnerable to later depression ( Heim Nemeroff,
2001). Children who are exposed to negative
parental behavior or negative emotional states
may develop depressed affect themselves
(Herman-Stahl Peterson, 1999). For e.g.,
childhood depression has been found to be more
common in divorced families (Palosaari
Laippala, 1996). Another important line of
research in childhood depression involves the
cognitive-behavioral perspective. Considerable
evidence has accumulated that depressive symptoms
are positively correlated with the tendency to
attribute positive events to external, specific,
and unstable causes and negative events to
internal, global, and stable causes ( Hinshaw,
1992) with fatalistic thinking (Roberts,
Chen, 2000) and with feelings of helplessness (
Kistner, Ziegert, et al.,2001).
6. Social Factors Despite a lack of definitive
evidence, given the stress-diathesis hypotheses
of depression, genetic vulnerability in
combination with a variety of social factors,
including level of family conflict, abuse or
neglect, conflict, family socioeconomic status,
parental separation or divorce, may play a
significant role in the emergence of depressive
disorders in children.
Differential Diagnosis.
Anxiety symptoms and conduct-disordered behavior
can coexist with depressive disorders and
frequently can pose problems in differentiating
those disorders from non depressed emotional and
conduct disorders. Of particular importance is
the distinction between agitated depressive or
manic episodes and ADHD, in which the persistent
excessive activity and restlessness can cause
confusion. Prepubertal children show an
inability to sit still and frequent temper
tantrums, which are common symptoms of
depression. Sometimes the correct diagnosis
becomes evident only after remission of the
depressive episode. If a child has no difficulty
concentrating, is not hyperactive when recovered
from a depressive episode, and is in a drug-free
state, ADHD probably is not present.
Course And Prognosis.
The course and prognosis of mood disorders in
children depends on the age of onset, episode
severity, and the presence of comorbid disorders.
In most cases, the younger the age of onset,
recurrent episodes, and comorbid disorders
predict a poorer prognosis. The mean length of an
episode of major depression in children is about
9 months the cumulative probability of
recurrence is about 40 by 2 years and 70 by 5
years. Reportedly, depressed children who live in
families with high levels of chronic conflict are
more likely to have relapses. Clinical
characteristics of the depressive episode that
suggest the highest risk of developing bipolar I
disorder include delusionality and psychomotor
retardation in addition to a family history of
bipolar illness. Depressive disorders are
associated with short-term and long-term peer
relationship difficulties and complications, poor
academic achievement, and persistently poor
self-esteem. Dysthymic disorder has an even
more protracted recovery than major depression
the mean episode length is about 4 years.
Hospitalization Safety is the most immediate
consideration in evaluating a child with major
depression, and determining whether
hospitalization is indicated to keep the child
safe becomes the first decision point. Children
who are depressed and express suicidal thoughts
or behaviors are in need of an extended
evaluation in the hospital to provide maximal
protection against the patients own
self-destructive impulses and behavior.
Pharmacotherapy Pharmacologic agents from
among the selective serotonin reuptake
inhibitors( SSRIs) are widely accepted as
first-line pharmacological intervention for
moderate to severe depressive disorders in
children. The demonstrated efficacy of fluoxetine
(Prozac), citalopram (Celexa), and
sertraline(Zoloft) compared with placebo in
treatment of major depression in children.
Research on the effectiveness of antidepressant
medications with children is both limited (
Emslie Mayes, 2001)and contradictory at best,
and some studies have found them to be only
moderately helpful ( Wagner Ambrosini, 2001).
Psychotherapy Cognitive-behavioral therapy is
widely recognized as an efficacious intervention
for the treatment of moderately severe depression
in children. This kind of therapy aims to
challenge maladaptive beliefs and enhance problem
solving abilities and social competence. Other
treatments also include relaxation techniques
which have been proved to be quite helpful in
treating mild to moderate depression. Social
skills interventions are helpful too, modeling
and role-playing techniques can also be useful in
fostering good problem solving skills. An
important facet of psychological therapy with
children, whether for depression or any other
disorder, is providing a supportive emotional
environment in which they can learn more adaptive
coping strategies and effective emotional
expression. The predominant approach for treating
depression in children over the past few years
has been the combined use of medication and
psychotherapy ( Skaer, Robison et al.,2000).