Pediatric Annals

EDITORIAL 

Sad Children

Milton I Levine, MD

Abstract

Most modern pediatricians have a deep interest in the emotional life of the boys and girls under their care. Most parents today look to their pediatrician not only for the physical care of their children but usually for emotional and educational direction as well.

But unfortunately many of these same parents wait too long before turning to the child's physician with problems that may be either emotional or physical. What about the child who develops a poor appetite? What if the child has difficulty sleeping? What if there is a sudden lack of interest in schoolwork? What about a lack of energy or a lack of joy? These are only a few signs of childhood problems which may be due to physical or emotional causes.

All pediatricians in their routine questioning as to the child's development should definitely ask questions concerning such subjects as those listed above, and should delve more deeply to solve possible serious problems - one of the most serious of which is depression.

Often, a well trained pediatrician can capably direct the parents as to the causes and relief of the underlying difficulties. All children need to feel loved, admired, and wanted by their parents. This is basic for happiness and security."

I remember one sad 10-year-old girl who was constantly being criticized by her father for her low grades in schoolwork. One day she made an A in an important test and rushed home full of joy to show her parents. Her rather looked at the test result. There was no word of praise. "Well, it's about time," he scowled. Is it any wonder that the child was depressed? It was a simple task to direct this father, and it was interesting to watch his daughter improve scholastically and in every other way.

Through the years I have observed a fair number of cases of childhood depression. There were many causes - parental death, sibling rivalry, lack of acceptance by peers, parental divorce, and many others.

I recall vividly one 15-year-old boy. He was a brilliant student at a very selective high school in New York City, and stood at the top of his class. His rather, who chanced to be an habitual gambler, was very proud of his son and both enjoyed the times they could spend with one another. One Saturday he took the boy with him to the race track and proceeded to teach him the fine art of selecting a winning horse. He showed his son how to study the past races, how to rate the horses and jockeys, how to study the odds, how to place a bet and how much.

The boy entered into the spirit of the occasion. He watched his father piace a bet and watched him lose. Then suddenly the father suffered a heart attack, slumped over in his seat, and died in the grandstand before aid could arrive.

The teenager came home in a state of shock and in deep depression. Depressed for weeks, he could no longer study. He had only one thing on his mind - he would develop an intricate mathematical plan which, in his estimation, would surely select the horse which would either win, show, or place. You couldn't lose. There were no computers at that time or Tm sure he would have tried one.

I spoke to this boy on several occasions in an effort to make him realize that he was trying to prove to his deceased father that his teachings were not in vain. But the boy was obsessed with his plan and said he had to go…

Most modern pediatricians have a deep interest in the emotional life of the boys and girls under their care. Most parents today look to their pediatrician not only for the physical care of their children but usually for emotional and educational direction as well.

But unfortunately many of these same parents wait too long before turning to the child's physician with problems that may be either emotional or physical. What about the child who develops a poor appetite? What if the child has difficulty sleeping? What if there is a sudden lack of interest in schoolwork? What about a lack of energy or a lack of joy? These are only a few signs of childhood problems which may be due to physical or emotional causes.

All pediatricians in their routine questioning as to the child's development should definitely ask questions concerning such subjects as those listed above, and should delve more deeply to solve possible serious problems - one of the most serious of which is depression.

Often, a well trained pediatrician can capably direct the parents as to the causes and relief of the underlying difficulties. All children need to feel loved, admired, and wanted by their parents. This is basic for happiness and security."

I remember one sad 10-year-old girl who was constantly being criticized by her father for her low grades in schoolwork. One day she made an A in an important test and rushed home full of joy to show her parents. Her rather looked at the test result. There was no word of praise. "Well, it's about time," he scowled. Is it any wonder that the child was depressed? It was a simple task to direct this father, and it was interesting to watch his daughter improve scholastically and in every other way.

Through the years I have observed a fair number of cases of childhood depression. There were many causes - parental death, sibling rivalry, lack of acceptance by peers, parental divorce, and many others.

I recall vividly one 15-year-old boy. He was a brilliant student at a very selective high school in New York City, and stood at the top of his class. His rather, who chanced to be an habitual gambler, was very proud of his son and both enjoyed the times they could spend with one another. One Saturday he took the boy with him to the race track and proceeded to teach him the fine art of selecting a winning horse. He showed his son how to study the past races, how to rate the horses and jockeys, how to study the odds, how to place a bet and how much.

The boy entered into the spirit of the occasion. He watched his father piace a bet and watched him lose. Then suddenly the father suffered a heart attack, slumped over in his seat, and died in the grandstand before aid could arrive.

The teenager came home in a state of shock and in deep depression. Depressed for weeks, he could no longer study. He had only one thing on his mind - he would develop an intricate mathematical plan which, in his estimation, would surely select the horse which would either win, show, or place. You couldn't lose. There were no computers at that time or Tm sure he would have tried one.

I spoke to this boy on several occasions in an effort to make him realize that he was trying to prove to his deceased father that his teachings were not in vain. But the boy was obsessed with his plan and said he had to go to the race track. He would show me and everyone. 1 finally sent him to a psychiatrist who suggested that we give him the opportunity to try out his system.

And so we saw to it that he received $100 to implement his mathematical scheme. The boy tried his system and at the end of a frustrating afternoon came home empty-handed. He had vindicated his father in accepting that his father was not inadequate. The teenager immediately broke out of his depression and with intensity once again become an honor student at the school.

This issue of Pediatrie Annuls deals with our present knowledge of childhood depression. The authors have all had considerable experience in this area.

The first paper is on the "Clinical Aspects of Childhood Depression" and has been contributed by Dr. Elizabeth B. Weller, Professor of Psychiatry and Director of Child Psychiatry, Ohio State University, Columbus, Ohio; and Dr. Ronald Weiler, Professor of Psychiatry, Director of Education and Training and Director of Inpatient Services, also at the Ohio State University.

The authors present a very clear clinical assessment of depressed children. Not only do they note the questions a pediatrician should ask on history taking, but also what nonverbal considerations to assess, such as the child's facial expression, body posture; and tone of voice.

Also considered are various methods of assessment including diagnostic tests (usually administered by a clinical psychologist), and a number of self-report inventories such as child depression tests. Projective techniques are discussed, including the Rorschach test, several apperception tests, and certain drawing tests such as the Draw-A-Person test. Peer ratings are discussed and special attention is given to the subject of suicide.

The second article deals with "Childhood Sibling Loss: A Family Tragedy," and has been written by Dr. George H. Pollock, President of the Institute for Psychoanalysis in Chicago.

This is a very sensitive analysis of the effect on a child of the death of a sibling. Not only is the loss of a sibling a tragedy to the child, but also he or she is exposed to a devastated household with a grieving mother and fether. How do children react to this destructive situation?

Dr. Fbllock, who has studied this subject for many years, notes the difficulty also of "replacement children" bom after the death of a sibling, often named after the dead child and being constantly compared to this child. In so many cases of sibling loss, the grief is continued by anniversaries, keepsake memories, and trips to the cemetery.

The author notes that the degree of loss varies with the age of the child and his or her gender. Also, he points out that there are other kinds of sibling loss besides death, such as prolonged hospitalization, split custody after divorce, and family break-up during stress periods in war or disaster. This is a most interesting article.

The following contribution, of special importance to pediatricians, deals with "Treatment Issues in Childhood Depression" and is contributed by Dr. Leon Cytryn and Dr. Donald H. McKnew, both from the Laboratory of Developmental Psychology, National Institute of Mental Health, Bethesda, Maryland.

This is an important paper for it deals with therapy from all angles. The present concept, they contend at the outset, is that the cause of depression is due to lack of self esteem, negative view of the past and present, and hopeless outlook for the future.

Dr. Cytryn and Dr. McKnew recommend working with the families and advise on methods of parent counseling. They then discuss building up the child emotionally through empathy, building up the child's self esteem, and encouraging the child to express all negative feelings and thoughts. They next consider antidepressant drugs such as those so often used in treating adults. Most of these drugs have not been adequately studied in children. Good results, however, -have been obtained in the treatment of minor depression in children through the use of imipramine, but the authors emphasize that the improvement is gradual and becomes significant after 3 or 4 weeks of treatment.

The fourth article discusses the "Hospitalization of Young People" and is authored by Dr. Sherman C. Feinstein and Dr. Victor Uribe. Dr. Feinstein is Director of Child Psychiatry Research at the Michael Reese Hospital, and Professor of Psychiatry, Pritzker School of Medicine, University of Chicago. Dr. Uribe is Assistant Professor of Psychiatry at Northwestern University, Chicago.

Doctors Feinstein and Uribe open their discussion by stating that hospitalization should not be advised before other efforts at treatment of emotional disorders have been attempted and found ineffective. They emphasize the strong impact hospitalization has not only on the young patient but on the family as well. But once the decision to hospitalize has been made, the decision must also be made as to the treatment program and whether short-term or long' term treatment is necessary. The short-term program is often effective, using a combination of psychopharmacology and psychotherapy. After the hospital stay, treatment can be continued on an outpatient basis.

Most children in depression can usually be treated successfully without hospitalization, but those teenagers in deep depression who may contemplate or attempt suicide should certainly be hospitalized.

The final paper in this symposium deals with a subject that has interested many of us - the question of "Biological Factors in Prepubertal Major Depression." Is the condition due to some physiological abnormality in the bodies of such patients or could it be of genetic origin?

The article is written by one of the primary workers in the field, Dr. Joachim Puig-Antich, Professor of Psychiatry and Chief of Child and Adolescent Psychiatry at the Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania.

Dr. Puig-Antich brings out certain important facts at the outset of his paper. He points out that children and adolescents with major depressive disorders come from biological families with high rates of mental illness among their adult relatives. He also notes that if both parents have suffered from a mental disorder the morbid risk for their children is quadrupled. Is this a genetic condition or is there some familial biological dysfunction?

This question is carefully discussed and some interesting facts are stated, such as the fact that during an episode of a major depression, prepubertal children secrete significantly more growth hormone during sleep than normal children or those with non-depressive emotional disorders.

He presents many scientific studies to date, with the realization that there is great potential in future studies. This is an interesting scientific article and concludes with an excellent bibliography.

10.3928/0090-4481-19861201-04

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