The first edition of the American Handbook of Psychiatry (1959)1 did not include a single reference to childhood depression. The American Psychiatric Association's Diagnostic and Statistical ManualAl (1968)2 did not include childhood depression in its nosology. Although depression is usually thought of as an adult problem, children also become depressed. Depression is a major disease of childhood and may, in many cases, be a significant underlying cause of various societal and health-related problems. Teenage pregnancy, substance abuse by children and teens, eating disorders, such as bulimia or anorexia nervosa, suicide, serious accidents, and violent crimes may all be symptoms of, or be concomitant with, childhood depression. Depression is an identifiable, preventable, and treatable disease; however, debate continues as to whether children can be diagnosed as being depressed - not just moody or unhappy. The situation is complicated by the use of the term depression to refer to a symptom, a syndrome, or a diagnostic entity.
Childhood should be a time of learning, growing, and discovering life's opportunities and challenges. Childhood depression is particularly devastating because, if undiagnosed and untreated, the effects may eventually be seen in the form of drug abuse, poor performance in school, aggressive and inappropriate behavior, or,· most damaging of all, suicide or violent acts against self or others. Depression is characterized by symptoms of sadness, listlessness, and lack of energy that persist over several months. Depression in children is largely unrecognized and misunderstood by parents and professionals, even though estimates indicate that 10% of children in this country suffer from some form of depression before age 12.
Childhood depression is marked by a feeling of worthlessness, sadness, and the conviction that nothing one does makes a difference. These attitudes, once adopted, have a self-fulfilling outcome. Often, childhood depression is masked by apparent hyperactivity, aggression, feigned illnesses, or frequent absence from school. Although such behavior may be a sign of other illnesses, a child with depression will look sad periodically and may even verbalize depressing thoughts. Pediatricians are in a unique position to recognize signs of depression and prescribe interventions to prevent this illness from taking a chronic course.
The incidence of childhood depression is greater for certain high-risk populations, which include children of depressed parents or those with close relatives who suffer from depression. Other high-risk groups include:
* children of divorce
* siblings of children hospitalized for medical or psychiatric reasons
* children with hyperactivity or attention deficit disorders
* incarcerated adolescents
* mildly mentally retarded children
* pregnant teenagers and their siblings
* children of lower socioeconomic status
* children suffering from a chronic illness
Many believe that depression is the most widespread mental and emotional disorder. Because depression hurts the child, patients want help and can respond favorably to treatment. Early diagnosis and medical intervention can have a positive affect on childhood depression.
This article is based on the thesis that children and adolescents become depressed as adults do, but exhibit different clinical pictures at different ages and stages of their developmental growth.3 This thesis is based on the premise that many children and adolescents continue to be depressed as adults. Depression that occurs at early developmental stages should not be dismissed lightly. "Don't worry, he will grow out of it" is often the attitude of well-meaning health professionals, and even parents, but this opinion is inaccurate and potentially dangerous.
In 1946, Spitz and Wolf described institutionalized infants with syndromes of withdrawal, weight loss, insomnia, weeping, and developmental retardation. The health of some of these infants declined into stupor and death. Spitz and Wolf coined the term "anaclitic depression" to describe the symptoms noted. Spitz theorized that depression in institutionalized infants resulted from maternal separation of at least 3 months' duration and occurred when the infant was between 6 and 8 months of age. Bowlby5 studied the effect of separation from the mother on the infant and noted three predictable stages: protest, despair, and detachment. Bowlby used the term "mourning" rather than depression.
Cytryn and McKnew6 divided childhood depression into three categories: masked depression, acute depression, and chronic depression. They emphasized that masked depression can be evidenced by hyperactivity, aggressive behavior, psychosomatic illness, hypochondriasis, and delinquency, with periodic displays of overt depression.
SYMPTOMS OF DEPRESSION
Poznanski7 described the following behavioral symptoms associated with childhood depression.
Depressed affect. Depressed affect is a sine qua non of the clinical diagnosis of depression. Depressed affect may be present in children with schizophrenia or organic brain damage, or as a labile response to disappointment or frustration. Children with moderate to severe depression look distinctly unhappy. Smiles are fleeting and quickly replaced by a bland, frozen look.
The distinction between an unhappy child and a depressed child can be made, in part, by determining the duration of the child's downcast mood. Information about the duration of mood change should be sought from multiple sources, eg, teachers, parents, and child. It is difficult for parents to be objective about depression. Parents often gloss over the child's pathology because of guilt or because their relationship with the depressed child is strained and symptoms cannot be observed objectively.
Anhedonia. Having fun is an integral part of a child's life and a necessary component for learning and playing. Depressed patients are often unable to describe what they do for fun. Seemingly pleasureevoking activities (eg, a trip to Disney World) are perceived without anticipation or pleasure.
Lowered self-esteem. This area is difficult to explore, as children develop only an abstract idea of self-concept between the ages of 6 to 9. Patients are sensitive about their self-esteem and may try to hide the intensity of their emotions. Children will describe themselves in negative terms, such as stupid or not popular, or admit that friends call them derogatory nicknames. Depressed children disproportionately collect real or perceived rejections and derogatory nicknames, which further lowers self-esteem.
Pathological guilt. Guilt is a difficult area in which to obtain consistent and reliable information. The problem may be with the child's ability developmentally to discuss these feelings or may stem from effort on the child's part to make a good impression.
Social withdrawal. The depressed child has usually developed the capacity for interpersonal relationships and has been able to socialize prior to the onset of depression. Depressed children may directly state that they have friends but that the friends do not like them. They turn down opportunities to play with other children. In play behavior, depressed children repeatedly set themselves up to be rejected by other children. Mildly depressed children may long for social relationships and turn to a dog or cat for a substitute friend. More severely depressed children no longer care about having friends.
Impairment of school work« Depressed children have been able to perform in school prior to the depression and show varied ability in school function, depending on mood. Poor school performance stems from lack of interest in any activity and more importantly from difficulty in concentrating. The attention span of the depressed child is different from that of the hyperactive child, whose attention is distracted by external stimuli. Depressed children turn inward, preoccupied with their own worries and thoughts. They tune out the exterior world.
Complaints of fatigue. Complaints of fatigue are common among depressed children. The depressed child often states, "I feel tired in the afternoon." They report taking voluntary naps or feeling too tired to engage in activities children normally enjoy.
Psychomotor retardation. Clinicians have focused so extensively on hyperactive children that children are assumed to be either hyperactive or normal in motor activity. Depressed patients are often hypoactive, particularly in moderate or severe depression. Children may sit with a slumped posture and stare at the floor.
Retardation of speech and language is a common feature of depressed children. They answer questions in one-word or two-word sentences delivered in a monotone. Because of a decrease in verbalization, fantasy material is difficult to obtain.
Difficulty with vegetative functions. A large number of depressed children have difficulty sleeping. Children often report difficulty going to sleep and, more rarely, speak of insomnia in the middle of the night or early morning awakening. Generally, the child is more aware of sleep disturbance than the parents realize. Depressed children describe sleep problems with convincing accuracy. They need only to be asked, "Do you have trouble sleeping?"
Children are poor reporters of appetite reduction. Because not eating well brings parental disapproval, it is not surprising that the child does not talk about loss of appetite.
Morbid ideation or suicide attempts. Moderately to severely depressed children have morbid or suicidal thoughts. Morbid ideation may center around a real event, such as the death of a pet or grandparent. The difference between a normal grief reaction and morbid ideation is quantitative and qualitative. The theme of death recurs repetitively. Elaborate fantasies may be attached to a real event. Depressed children also may show morbid ideation without a precipitating event. Many depressed children plan suicide attempts and think about their plans actively over time. Straightforward questions about suicide plans yield rich information for the clinician.
Associated symptoms. Irritability is commonly described in depressed children by parents; children sometimes admit to feeling irritable. Weeping or wanting to cry is seen in childhood depression, occurring more often in the younger child (ie, 6 to 8 years of age). Children rarely report crying, but more readily describe episodes in which "they feel like crying." Somatic complaints without organic basis, such as stomach aches, leg pains, and headaches, are frequently described.
THE DEPRESSIVE SYNDROME
Poznanski8 reports that the diagnosis of a depressive syndrome in children can be made using the same criteria as are used with adults. Children generally express their feelings nonverbally and thus behaviors are substituted for adult verbal descriptions of uncomfortable feelings.
Five of the following types of behaviors must be present to diagnose a depressive syndrome: anhedonia, low self-esteem, impairment of school work, sleep difficulty, excessive fatigue, psychomotor retardation, social withdrawal, and morbid or suicidal ideation.
Toolan9 suggests that depression is a reaction to loss, either of a person or a state of well-being, with feelings of diminished self-esteem and helplessness. The result of any loss will depend on the individual's ability to tolerate pain and discomfort, be it physical or mental, and the developmental stage at which such loss occurs. The younger the child, the more serious the consequence. Infants may become fixated in psychosocial development or even regress. Psychosocial impairment hinders intellectual growth. The ability to form adequate new relationships may be significantly impaired, which will interfere with the child's ability to identify with significant figures in his or her life. Such disturbances in the process of identification will adversely affect the development of a conscience, a sense of self, and the whole personality structure.
When loss takes place during latency and early adolescence, the patient will exhibit hostility and anger toward the person whom he feels has betrayed and deserted him. This leads to serious acting out and delinquency, which may temporarily ward off painful feelings of helplessness and impotence. These defenses are not successful and lead to further conflict with parents, who become increasingly antagonistic toward the child who desperately needs their love and support. Some children inhibit the expression of anger toward their parents and turn such feelings against themselves. These children consider themselves to be evil, and this self-image may lead to the acting out so commonly seen in depressed children. Acting out behavior reinforces the child's poor self-image, further lowering self-esteem and increasing feelings of helplessness and depression.
The biochemical theory of depression should also be considered in terms of how it relates to treatment with antidepressant drugs and lithium. A current theory is that the alteration of catecholamine and serotonin formation may lead to depression. This has led to the supposition that subnormal catecholamine function is associated with depression. Such functioning can be improved by prolonging catecholamine synaptic action with tricyclics, which prevent catecholamine reuptake, or with monamine oxidase which inhibits catecholamine breakdown. Both groups of medications affect serotonin in a similar fashion. Lithium absorbed within cells increases the quantities of catecholamine and serotonin.
FAMILY HISTORY INFLUENCES
Kim Puig-Antich10 studied first- and second-degree adult relatives of prepubertal children with major depression, children with nonaffective psychiatric disorders, and normal children. Compared with normal controls, prepubertal children with major depressive disorder had significantly higher familial rates of psychiatric disorders in both first- and seconddegree relatives, especially major depressive disorder, alcoholism, and anxiety diagnoses. Relatives of children in the nonaffective psychiatric control group had low rates of alcoholism, high rates of anxiety disorder diagnoses, and intermediate rates of major depressive disorder. These findings suggest that the prepubertal onset of major depression may be especially likely in families with a high aggregation of affective disorders and a high prevalence of alcoholism. Also, a proportion of children without affective disorder but with separation anxiety disorders are at risk for the development of affective illness later in life.
A common denominator of most risk factors is the experience of loss. Types of loss include the following.
Bereavement. Children feel devastated by grief, guilt, panic, and anger. The loss of a parent creates profound psychological reactions, including denial, attachment to the lost parent, fantasies of the parent's return, and resolves to join the parent in death.
Separation. Separation occurs as the result of divorce and marital dissolution. Damage seems greater in "coming and going" situations when the loved one drops in and out of a child's life than in the final separation that death brings.
Loss of familiarity. Normal growth and psychosocial change encompass loss. Depression can be a normal part of the growth process because growing and developing require the experience of loss. Loss of components of childhood is often particularly devastating, for teenagers, the loss of the comfort of dependence and the simplicity of being a child is often overwhelming. Loss of socioeconomic status, poverty, and societal disasters, including war, the threat of nuclear war, and terrorism, have links with depression.
Self-esteem. Depreciation, rejection, and inability to live up to high parental expectations can cause significant loss of self-esteem and trigger depression. Rejection is exhibited in the form of blunt statements stressing the child's inadequacy. Parents are often unaware of their own rejecting behavior. Self-esteem crises occur when teenagers are rejected or not allowed autonomy and trust. The experience of control over personal destiny is all- important.
Normalcy. Depression may result from illness or injury that sets a child apart from peers, temporarily or permanently. Patients with physical illness or chronic impairment, such as diabetes and epilepsy, may become depressed, as they feel an inner turmoil about the disorder that separates them from peers. Conflicts with parents about treatment routines and acceptable activities occur. Chronic illness also impedes a child's emancipation from the family.
Loss of goals through achievement. Often, the child who wins a long-sought prize, makes the team, or finally meets a challenge becomes depressed. Mastery and victory experiences may seem hollow.
Limited internal resources. Children who feel helpless, hopeless, and depressed experience an inability to cope with problems. Such children have not learned effective coping or compensatory strategies and are thus more vulnerable. Several family variables are well known to be strongly associated with children's mental illness, including depression, severe marital discord, low socioeconomic status, overcrowding or large family size, father's criminality, psychiatric disorder of the mother, and care via a local authority (eg, foster care).
Psychotherapy is the most significant treatment approach for depressed children and adolescents. Medication is of value in some cases, primarily in those older children and adolescents who exhibit overt depressive symptomatology. Authorities believe that even when medication is of help, it should be used in conjunction with psychotherapy and not as the only therapy.
Anaclitic infants require neither psychotherapy nor medication but reunion with the mother or mother surrogate as rapidly as possible. Depressed children require intensive psychotherapy, not shortterm crisis-oriented help. These patients also require competently trained therapists. As a rule, the average physician, pediatrician, teacher, guidance counselor, or mental health worker is not capable of providing highly skilled technical assistance. Therapy requires an individual well trained in child development, child psychiatry, and child psychology, who, in addition, has knowledge of psychopharmacology. The shortage of competent therapists is one of the reasons why many clinics depend largely on medication.
Children who act out, in particular those engaged in serious delinquency, require residential placement when acting out cannot be curtailed. Hospitalization is required when the child is suicidal or in immediate, life- threatening situations. Hospitalization is also helpful to observe and evaluate children with somatic symptoms masking depression, such as nonspecific headache or abdominal distress.
Infants come to the attention of pediatricians because of eating and sleeping difficulties, persistent crying, and colic, family history will often reveal that one of the parents, more often the mother, is profoundly depressed. Efforts must be directed toward resolving the mother's depression, not only for her own sake, but for that of the child, who will exhibit depression as he or she grows older.
Wallerstein11 has found that the effect of divorce depends greatly on the age of the child. Many children regress to earlier modes of behavior. Efforts must be directed toward helping parents anticipate the child's reactions. Children experience guilt over the break-up of the parents' marriage, feeling somehow responsible for the situation. Brief, expressive therapy may enable the child to rid himself of such feelings and see the situation more realistically. At other times, the child's guilt becomes internalized and intensive therapy will be required.
The field of child and adolescent affective disorders is relatively new and very challenging for research and clinical practice. A definite clinical entity of depression exists in significant numbers of children and adolescents. Signs and symptoms are different from those seen in adults and vary with different age levels. The syndrome must be recognized as early as possible to prevent a chronic illness from developing. Depression can cause serious difficulty in academic life because of its effects on concentration. Depression can affect relations with peers and, if acting out behavior ensues, can lead to serious delinquent behavior, sexual promiscuity, pregnancy, and substance abuse. Depression can also lead to suicide. Depression is often the common denominator in delinquency, promiscuity, teen pregnancy, to say nothing of alcohol and drug abuse. Adolescents often find substances on the street to "medicate" their own depression. When depression in children and adolescents is not properly identified, evaluated, and treated, it can lead to lifelong depression, antisocial behavior, and substance abuse. When depressed children receive appropriate therapy, the results can be rewarding. As one patient commented, "Every day was cloudy and gray. It always rained. Now I see some sun coming out."
1. Arieti S, ed. American Handbook of Psichiatri. 1st ed. New York, NY: Basic Books; 1959; vol 2.
2. American Psychiatric Association. Diagnostic and Statistical Maraud of Mental Disorders. 2nd ed. Washington, DC; American Psychiatric Association; 1968.
3. Toolan, JM, Depression in children and adolescents. Am ) Orthopsychiatry. 1962b;32:404-4l5.
4. Spitz R. Wolf KM. Anaclitic depression: an inquiry into the genesis of psychiatric conditions in early childhood. Psychoaruii Study Child. 1946:2:313-341.
5. Bowlby, J. Childhood mourning and its implications for psychiatry. Am J Ps-vcniarrv. 1960;18:481-498.
6. Cytryn L, McKnew DH. Proposed classification of childhood depression. Am ) Psychiatry 1972:129:149.
7. Pcnnanski EO. The clinical phenomenology of childhood depression. Am J Orthopsychiatry. I982;52(2):308-313.
8. Pomanski EO. Diagnostic criteria of childhood depression. Am ) Psychiatry. 1985:142(10).l 168-1 173.
9. Toolan, JM. Depression and suicide. In: S. Ariete, ed. American Handbook of Psychiatry. 2nd ed. New York, New York: Basic Books: 1974.
10. Puig-Antich J. Goes D. Daves M. Kaplan T, et al. A controlled family history study of prepubertal major depressive disorder. Aren Gen Psychiatry. 1989;46(5):406-4I8.
11. Wallerstein, HS. Kelly J. Sumtfng the Breakup: How Children and Parents Cope uitn Diwrce. New York. NY; Basic Books; 1980.