Pediatric Annals

Clinical Aspects of Childhood Depression

Elizabeth B Weller, MD; Ronald A Weller, MD

Abstract

Despite earlier doubts about their occurrence in children, depressive episodes with signs and symptoms similar to those seen in adult depres' sion have been described by multiple authors. In the Diagnostic and Statistical Manudi, third edition (DSMIII) the criteria for a major depressive episode are the same for children and adults. These criteria require that there be a dysphoric mood or loss of interest or pleasure lasting at least 2 weeks, in addition, at least four of the following symptoms must be present: appetite disturbance, sleep disturbance, psychomotor agitation or retardation, loss of energy, feelings of worthlessness or guilt, diminished ability to think, and thoughts of suicide or death. Although the incidence of depression in prepubertal children is unknown, it is not a rare occurrence. Approximately 7% of pediatrie inpatients and 30% to 60% of child psychiatry outpatients1 fulfill DSM-III or similar criteria for depression. Without prompt recognition and effective treatment, such depressive episodes can last for months and lead to impaired school performance, poor peer and family relationships, and even suicide.

ASSESSMENT

Some special considerations must be made in assessing depression in children. Although depression in children has symptomatology similar to adults, its form of expression may be different and is related to the developmental level of the child. Thus, it is necessary to ask age relevant questions when interviewing a child. Detailed descriptions of age/stage relevant questions for depressive symptoms include decreased school performance, anhedonia (lack of feeling pleasure), social withdrawal, sleep and appetite disturbance, fatigue, somatic complaints, irritability, guilt, low self-esteem, depressed affect, morbid and/or suicidal ideas, and weeping.2

Nonverbal communication, particularly facial expressions, body posture, tone of voice, tempo of language, and level of activity, lake on increased meaning in children as verbal skills are not as well developed compared to adults. The varied cognitive and language skills children possess at different age levels can affect both the way children interpret questions and the responses they give. Therefore, both written and verbal questions should be asked using simple, concrete language.

Some depressed children present with problems suggestive of conduct disorder or other psychiatric disorders, but upon careful examination depressive symptomatology is apparent. Care must be taken to "unmask" these cases to ensure proper diagnosis. By analogy, a child with an obstructed colon may present with constipation, but this is only a symptom and not the primary diagnosis. Similarly, behavior problems occurring only as part of a depression should be considered symptoms of the depression, and not the primary diagnoses.

In children it is important to obtain information from a variety of sources before making a diagnosis. Parents, children, and teachers may all report symptoms of depression in a child. However, they may provide disparate information on the presence or severity of specific symptoms. When ratings of depression made by parents, teachers, and the children themselves were compared, parents' ratings of sadness or dysphoric mood were confirmed to a moderate degree by the child's self-ratings. There was, however, little consistency between parent and teacher ratings of behavior problems for depressed children.3 Regardless of the reasons for the inconsistencies, this study illustrates the benefits of gathering data from several sources. While it is important to use multiple informants, the child should be the primary source of information when making a diagnosis.

Finally, many children do not have a well-developed sense of time. Thus, questions of duration might best be answered by other informants. However, there is evidence that in the past children simply have not been questioned carefully enough to elicit this information.4 Perhaps more precise handling of questions related to duration and severity may provide more information…

Despite earlier doubts about their occurrence in children, depressive episodes with signs and symptoms similar to those seen in adult depres' sion have been described by multiple authors. In the Diagnostic and Statistical Manudi, third edition (DSMIII) the criteria for a major depressive episode are the same for children and adults. These criteria require that there be a dysphoric mood or loss of interest or pleasure lasting at least 2 weeks, in addition, at least four of the following symptoms must be present: appetite disturbance, sleep disturbance, psychomotor agitation or retardation, loss of energy, feelings of worthlessness or guilt, diminished ability to think, and thoughts of suicide or death. Although the incidence of depression in prepubertal children is unknown, it is not a rare occurrence. Approximately 7% of pediatrie inpatients and 30% to 60% of child psychiatry outpatients1 fulfill DSM-III or similar criteria for depression. Without prompt recognition and effective treatment, such depressive episodes can last for months and lead to impaired school performance, poor peer and family relationships, and even suicide.

ASSESSMENT

Some special considerations must be made in assessing depression in children. Although depression in children has symptomatology similar to adults, its form of expression may be different and is related to the developmental level of the child. Thus, it is necessary to ask age relevant questions when interviewing a child. Detailed descriptions of age/stage relevant questions for depressive symptoms include decreased school performance, anhedonia (lack of feeling pleasure), social withdrawal, sleep and appetite disturbance, fatigue, somatic complaints, irritability, guilt, low self-esteem, depressed affect, morbid and/or suicidal ideas, and weeping.2

Nonverbal communication, particularly facial expressions, body posture, tone of voice, tempo of language, and level of activity, lake on increased meaning in children as verbal skills are not as well developed compared to adults. The varied cognitive and language skills children possess at different age levels can affect both the way children interpret questions and the responses they give. Therefore, both written and verbal questions should be asked using simple, concrete language.

Some depressed children present with problems suggestive of conduct disorder or other psychiatric disorders, but upon careful examination depressive symptomatology is apparent. Care must be taken to "unmask" these cases to ensure proper diagnosis. By analogy, a child with an obstructed colon may present with constipation, but this is only a symptom and not the primary diagnosis. Similarly, behavior problems occurring only as part of a depression should be considered symptoms of the depression, and not the primary diagnoses.

In children it is important to obtain information from a variety of sources before making a diagnosis. Parents, children, and teachers may all report symptoms of depression in a child. However, they may provide disparate information on the presence or severity of specific symptoms. When ratings of depression made by parents, teachers, and the children themselves were compared, parents' ratings of sadness or dysphoric mood were confirmed to a moderate degree by the child's self-ratings. There was, however, little consistency between parent and teacher ratings of behavior problems for depressed children.3 Regardless of the reasons for the inconsistencies, this study illustrates the benefits of gathering data from several sources. While it is important to use multiple informants, the child should be the primary source of information when making a diagnosis.

Finally, many children do not have a well-developed sense of time. Thus, questions of duration might best be answered by other informants. However, there is evidence that in the past children simply have not been questioned carefully enough to elicit this information.4 Perhaps more precise handling of questions related to duration and severity may provide more information than previously thought.

METHODS OF ASSESSMENT

Methods of assessment, usually administered by a child psychiatrist include diagnostic interviews, selfreport inventories, projective testing, peer ratings, and use of biological markers. These methods vary in their use of children, parents, or significant others as informants. There are also differences in their use of subjective and objective criteria. While numerous techniques to assess childhood depression exist, only limited psychometric data are available for most of them.

Diagnostic Interviews

Diagnostic interviews may be structured or semistructured. Structured interviews provide the advantages of a defined interview framework for inexperienced clinicians and more standardized data collection for research purposes. Semi-structured interviews may be less cumbersome in clinical use. Choice of a diagnostic interview will depend on the purpose of the interview and who will perform it. In studies to date at least six different systematic interviews have been used to diagnose childhood depression. 5

1. The Kiddie-SADS (K-SADS) is based upon the Schedule for Affective Disorders and Schizophrenia for Adults. It is designed for children aged 6 to 16. Data are gathered from the parent and the child.

2. The Interview Schedule for Children (ISC) is designed for children 8 to 13 years of age. Data are obtained only from the child. However, the interview may also be administered to parents by altering the nature of the questions.

3. The Bellevue Index of Depression (BID) is designed for children aged 6 to 12 and can be administered separately to the child, parents, and others who know the child.

4. The Children's Depression Rating Scale (CESlS-R) follows the format of the Hamilton Rating Scale for depression in adults. The measure is completed by the clinician after interviewing the child and others who observe his or her daily behavior (eg, parents, nursing staff).

5. The Diagnostic Interview for Children and Adolescents (DICA) is designed for children ages 6 to 17 with separate forms provided for the child and parents.

6. The Child Assessment Scale (CAS) was designed for children ages 7 to 12, but has been used with children as young as age 5.

Self-Report Inventories

There are three main self-report scales forchildhood depression: The Childhood Depression Inventory (CDl); the Short Children's Depression Inventory (SCDI) ; and the Children's Depression Scale (CDS). 5 The most widely used is the CDI. 6 It is patterned after the Beck Depression Inventory. It consists of 27 items, with three choices for every response, to assess the presence or absence and the severity of symptoms. Reliability appears high (0.86) but factor analysis indicates that the CDI is a single-factor test. It has been administered to children 7 to 17 years old, including both psychiatric patients and normal controls. These normative studies have established cutoff levels for severity of depression.

There are several problems in using self-report measures to assess childhood depression. Children may engage in "impression management." If the instruments face validity is high (ie, the child can readily recognize which is the "healthy" response and which is the "sick" response) children may not accurately report depressive symptomatology. For example, if the child has an interest in remaining out of the home environment he or she may choose to acknowledge symptoms. Another child with comparable symptoms might deny them if he or she wishes to return home. Another potential problem is that incompletely developed language and cognitive skills in children may affect their ability to comprehend the questions asked. Also, cognitive functioning may be hampered by depressive pathology, thus lowering the child's ability to interpret questions and respond accurately.

Projective Techniques

Protective techniques have traditionally been used to measure unconsciously repressed or consciously suppressed material. Thus, they might be most helpful in diagnosing "masked" or denied depression. Unfortunately, projective testing is time-consuming and may not always provide diagnostic information beyond that obtained in a thorough dinical interview. Themes indicative of depression observed in the Rorschach, Thematic Apperception Test, and Children's Apperception Test include: feelings of mistreatment, blame or criticism, abandonment, injury, and suicide. Drawing tests such as the Bender-Gestalt, House-Tree-Person, and Draw-A-Person have characteristics traditionally associated with depression. These include low placement of the figures, placement of figures on the left side of the paper, small figures, figures slanting downward, and the increased or decreased intensity of line. However, there have been few controlled studies to validate or repudiate these constructs.

Peer Ratings

Peer ratings have the advantage of assessing a large range of behaviors across a variety of settings. One peer nomination scale designed specifically to assess childhood depression is the Peer Nomination Inventory for Depression (PNID).7 PNID score predicts performance at school, self-concept, teacher rating of work skills and social behavior, peer ratings of happiness and popularity, locus of control, and other measures. While the PNID may prove useful for researchers, it may be of less practical value for practitioners who typically do not have access to a child's peer group.

Biological Markers

Several biological markers have been associated with depression in adults. In children, cortisol secretion, urinary catecholamine metabolites, sleep EEG changes, and growth hormone secretion have been studied as potential markers of depression.8 However, the dexamethasone suppression test (DST)1 which assesses the ability of dexamethasone to suppress endogenous cortisol secretion, has probably been the most widely studied. In endogenously depressed adults, dexamethasone does not suppress cortisol secretion in 40% to 60%. Early studies in depressed children have found that similar findings may hold true for children. The percentage of nondepressed children who show suppression has been reported at 89% for normal controls, conduct disorder inpatients, and dysphoric (but not depressed) outpatients. Reports of sensitivity, the percentage of depressed children who feil to suppress, range from 13% in depressed outpatients to 79% in depressed inpatients.9

SUICIDE

Suicide deserves special mention in relation to childhood depression. Just as depressive disorders were previously unrecognized, childhood suicide or suicidal thoughts have probably been underreported in the past. This may be due to denial on the part of the child or hesitancy on the part of adults to inquire as to suicidal ideation in children. As a result, suicide has not been recognized as a potential cause of death in children until recently. For example, in 1974. there were no reports of completed suicides among children 12 and younger in the United Kingdom during the previous 7-year period.10 However, in 1980 Pfeffer and associates reported that 33% of 39 children, ages 6 to 12 years, seen in a psychiatric outpatient clinic had suicidal ideation or had made suicidal threats and/or attempts.11 Methods included jumping from high places, hanging, running in front of cars, stabbing, and pill ingestion. Potential suicide cannot be ignored but should be carefully evaluated in each depressed child.

SUMMARY

Currently, major depressive episodes in children can be diagnosed using criteria similar to those for adult depression. Although symptoms appear similar to those seen in adult depression, differences in cognitive and language functioning compared to adults must be taken into account when assessing children. Recognition of depression and its presentation in children is essential in making an accurate diagnosis. Increased interest and improved methods of assessment and treatment should result in better care for depressed children and their families.

REFERENCES

1. Kashani JH, Hussain A, Shektm WO, cr at: Current perspectives on childhood depression: An overview. Am } Piydumrj 1981; 138(2):14M53.

2. Ponnanskt EO: The clinical phenomenology uf childhood depression. Am J Onhoptyduatry 1982; 52(2):308-313.

3. Leon GR, Kendall PC. Garber J. Depics&on in thilthen: Parent, wachei arid child perspectives. J Abnorm CttU Psydal i960; 8(2):221-235.

4. Reich W, Herjank B, Welner Z. et si: Development of a structured interview for children: Agreement of diagnosis comparing child and patent interviews. J Abnorm Child Psydnl 1982; 10(4): 125-336.

5. Voller EB, WtI 1er RA. friscad MA: Assessment and treatment uf childhood depression, in Weller EB. Weller RA (eds): Current Perspectives on Major Depressive Disorders in Chädren. Washinxton, OC. American Psychiainc Association Press, I9S4,

6. Kisses M: Ran UK scale to assess depression in school-aged children. ACM Pafdnpsyàvaa I9B1-, 46:305-315.

7. LeftowitiMM. Tesmy EP: Assessment of childhood depression. J CimnJr Clin PrçW 1980; 48:43-50

8. PiiÎR-Antkh j; Psvchobkilngy of prepubcrral major depression, in Weiler EB, "Ätller RA (eds); CUrrent Perspectives un Mufoi DepieuKe Disorders m Children. Washington, DC. American Psythiatric Association Press, 1984.

9. Weller EB, Weller RA, Fristad MA. et ah Dexamethasone suppression test in ptepuhertal depressed children. Am ; Psychiatry 1985; ?1:?70-?72.

10. Schaffer D. Suicide in childhood and early adolescence, j Chad Piyctvi Prtduom 1974; 15:275-291.

11. Ptefler CR. Cunte HR, Rute h it R, et al: Suicidal behavior in latency-age children. ) Am Acad Child rVJuorrv iggo- I9:70}-710.

10.3928/0090-4481-19861201-05

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