Child And Adolescent Depression

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Clinical depression as seen in children and adolescents is characterized by depressed mood and/or loss of interest in activities as well as related symptoms such as difficulties with sleep, appetite changes, a sense of hopelessness, decreased energy, increased aches and pains, loss of self-esteem, difficulties with concentration, and thoughts of death and dying, sometimes with active suicidal plans. In some cases, young people do not complain of depressed mood or loss of interest in activities but instead have extreme irritability along with other symptoms. Most children, just like adults, have brief periods of depressed or irritable mood. Clinical depression (Major Depression) requires that several symptoms occur at the same time; persist for most of the day, nearly every day for a period of at least 2 weeks; and be associated with significant impairment in the child's ability to function. When clinical depression is causing impairment, parents and teachers may notice loss of interest in activities, increased arguments with others, decreased school attendance or performance, and loss of friends. Thus, many children may have brief periods of time (a few days) when they feel down in the dumps, typically after a disappointment. parents and caretakers need to worry about clinical depression when many symptoms occur at the same time, persist over a period of a week or more, and are associated with a decline in school or family functioning and social participation.

significant depression has been observed in young children, but depression appears to become more of a problem for children as they move into the adolescent years. At any point in time about 1 to 2% of children meet the criteria previously outlined for clinical depression; this rate increases to 4 to 8% of adolescents, and some research studies indicate that 25% of adolescents will have experienced a significant depression by the time they turn 18. Although rates of depression increase during adolescence for both boys and girls, gender differences begin to emerge between ages 13 and 15, with more girls than boys reporting depressive symptoms.

Periods of clinical depression can last for many months in some young people and can interfere significantly with a child's ability to keep up in school and remain active with friends. They can also be recurrent: As many as 40% of children and adolescents experience a second episode of depression within 2 years. Finally, depression is associated with substantial negative changes and risks both during and after the episode; these include difficulties in school and interpersonal relationships, increased risk of tobacco and substance abuse, suicide attempts, and completed suicide.

Although the cause of depression is not yet determined, it is thought that depression is most likely to occur when a number of risk factors come together. Biological vulnerability is one of these factors: Children whose parents have had significant depression are at a markedly increased risk for depression as well as other behavioral and emotional problems. Children may inherit a genetic risk for depression or temperamental qualities such as sensitivity to negative emotions, or they may learn depressive coping styles from their parents. Both adults and young people who are depressed share a depressive or negative way of thinking that leads them to view themselves, the world, and their future in a negative way. This is frequently described as seeing the cup as half empty, while others can look at the same situation and see the cup as half full. Many times depressed individuals come to see all failures as due to their own inherent faults but any success as pure chance or a fluke. This is called negative attributional or explanatory style. It is widely believed that depression affects a vulnerable person (based on biological, cognitive, or a combination of factors) when he or she is faced with stressful life events. For young people these events frequently include parental separation or divorce, geographic moves, loss of a friendship or romance, or exposure to abuse or neglect. Antidotes for depression include increased social support and social activity and learning skills needed to manage stress.

Efforts to both prevent the onset of depression in at-risk young people and treat depression in children and adolescents have been promising. A series of studies have de scribed the use of school-based, small group programs geared to increase problem-solving skills, decrease negative or depressive thinking patterns, and increase social supports in youths at risk for depression. Risk is typically determined based on the presence of a parent who is struggling with depression or a child's report of initial signs of depressive symptoms.

Two structured psychotherapeutic approaches have also shown promise in the treatment of youths who are clinically depressed. Cognitive-behavioral therapy (CBT) is a 12- to 16-week individual treatment approach that focuses on teaching how to identify and then challenge (change) negative thought patterns as well as how to increase participation in pleasant events and improve stress management and social support. CBT has been effective in reducing the negative thinking patterns of depressed youths. Interpersonal psychotherapy (IPT), another brief treatment (12-16 weeks), also has initial outcome data suggesting positive treatment effects. IPT stresses the importance of the youth's social relationships and sees depression as occurring when a young person is in the midst of a change in social role (i.e., the adolescent transition) or does not have the social skills or social support to maintain a sense of well-being. Initial studies of this approach indicate success in improving overall social function, which may in turn lead to a decrease in depressed mood. Finally, initial studies suggest that medication also plays an important role in the treatment of depression. Although carefully controlled studies are few, there is some evidence to suggest that the selective serontonin reuptake inhibitors, such as Prozac, are effective in reducing symptoms of depression, especially symptoms of sleep and appetite disturbance and the tendency to be caught up in recurrent worries and negative thoughts. At this time the recommended treatment approach for clinical depression in children and adolescents is psychotherapy with pharmacotherapy as an additional component when indicated, such as when sleep or appetite disturbance or recurrent worry is present or when the depressed mood is so severe that it interferes with psycho-therapeutic efforts.

Elizabeth McCauley

Cindy Smith

University of Washington See also: Antidepressant Medication; Gender Roles

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