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Depressed children, teenagers and adults all have feelings of "pervasive pessimism." This means they feel that everything is going to go wrong. Adults blame themselves for the problems. Children and early teenagers blame other people, especially their parents. This can make depression in youth seem very different from depression in adults. Depressed adults often feel guilty. Children and teenagers with depression usually feel more anger.
Depressions often begin discretely. Usually, a person can identify depression as beginning over a period of a few weeks. A happy child can become depressed at a certain age. Another child who was mildly depressed for years can have a time when the symptoms of depression become more intense.
Often, a child or adolescent tries to fight the depression. The efforts at fighting depression cause mood swings. The mood quickly changes if a child tries to behave happy, but then gives up. The mood then swings to depression or irritability.
A serious problem with depression is thoughts of suicide. Suicidal thoughts occur with three feelings. One is the feeling of helplessness, that there is no help for the problems. Second is the feeling of hopelessness, that things will never get better. The third is the feeling of being overwhelmed, that life seems so unbearable that it is not possible to go on. Often, a suicidal person won't look for help because of the feelings of helplessness and hopelessness. The person then commits suicide because he feels so overwhelmed.
Depression can become a lifelong problem. A person who has never experienced depression has a twenty percent chance of becoming depressed. If a person has one depression, he or she has a fifty percent chance of becoming depressed again. After each episode of depression, the chance of having another episode of depression increases even more.
Depression often runs in families. Depression seems to have a biological involvement. This means that although there are stressors causing a depression, there also may be biologic abnormalities in the brain that are a part of the depression.
Types of Childhood Depression
There are several different types of depressive disorders that can be diagnosed in children. Sometimes one type of depression is diagnosed at first, but later, after more information is obtained, another depression might be diagnosed. The prognosis, or future outlook, is different for the different types of depression.
The mildest form of depression is adjustment disorder with depressed mood. An adjustment disorder is a reaction to an identifiable stressor that occurs within three months after the stressor. The stressor is an event that could cause emotional upset in anyone. An adjustment disorder may result from physical or sexual abuse, a robbery at home, parents getting divorced, the first day of school, relocation of the family, or other stressors. An adjustment disorder impairs the child's school and social functioning.
The major symptom of adjustment disorder with depressed mood is, of course, depressed mood. The child looks sad, feels hopelessness, and may cry. It is important to identify properly the predominant mood. If a child is mostly anxious and not depressed, the diagnosis is adjustment disorder with anxious mood, which is a different adjustment disorder.
An adjustment disorder is not just a pattern of overreaction. Before the stressor, the child has normal mood and functioning. The depression is a result of the stressor. The adjustment reaction does not persist longer than six months. For example, a child who becomes depressed one month after a divorce could be diagnosed as having an adjustment disorder with depressed mood. If he continues to be depressed six months later, the diagnosis becomes another type of depressive disorder.
Another type of depression is dysthymic disorder, or dysthymia. Dysthymia is a mild to moderate level of depression that continues for a long time. In adults, dysthymia is diagnosed if it is present for more than two years. In children, mild to moderate depression has to be present for only one year to be diagnosed as
dysthymia.
Dysthymia involves symptoms of depression "more often than not." By "more often than not," it is meant that the child feels depressed more days than he does not feel depressed.
More often than not, children with dysthymia have either a noticeable increase or decrease in appetite. More often than not, they have insomnia, which is poor sleep, or hypersomnia, which is too much sleep. More often than not, they have low energy or fatigue. On some days, children with dysthymia appear to have good energy, but on most the days, they have low energy. They complain about concentration. They easily feel helpless or hopeless.
Dysthymic disorders are not severe enough to be diagnosed as major depressions. Dysthymic disorders do not include manic or hypomanic moods. This means that dysthymic children do not have times of excessively high energy or inappropriately euphoric mood. If this occurs, the illness is diagnosed as bipolar disorder or cyclothymic disorder. When children have psychotic symptoms, including beliefs that are not in touch with reality or disorganized thinking, they have a more serious problem than dysthymia.
To be diagnosed with dysthymic disorder, the child has to have these symptoms for at least a year. Usually, dysthymia persists for many, many years. This prolonged depression causes long term impairment in academic and social functioning. Dysthymia prevents children from reaching their potential as adults. Children with dysthymic disorder should be given treatment during childhood, because if the symptoms are reduced, they can develop normally.
Another problem with dysthymic disorder is that the chance of severe depression is increased. When a child is moderately depressed, it takes less stress to cause severe depression. Dysthymia and depression during childhood increase the chance of continuing dysthymia and depression in adulthood. By treating dysthymia in childhood, it may be possible to reduce the chance of depression during adult years.
Those with dysthymia usually do not feel happy. Even when dysthymic children do well in school, they do not feel happy. It may take something special for them to feel happy. For example, children without depression say that being with friends or playing with special toys makes them happy. Dysthymic children might remember feeling happy at Disney World or on Christmas, but may not remember feeling happy at other times.
Sheree had a severe type of depression called major depression. Although major depression is a serious diagnosis, it is a common problem. Major depression involves physical symptoms as well as psychological symptoms. Major depression is a definite worsening from previous level of functioning. Such a serious depression has to be present for at least two weeks to be diagnosed as major depression. Like Sheree, children and teenagers with major depression may have felt happy and had good school and social functioning before becoming seriously depressed. With major depression, children and teenagers feel unhappy, often isolate themselves from friends, and do not function very well in the school environment.
The difference between dysthymic disorder and major depression is that dysthymic disorder involves depression "more days than not," while major depression involves depression "most days, most of the time." Functioning is more impaired with major depression than dysthymia. For example, a child with dysthymic disorder feels happy only on holidays or at Disney World, but can still go to school every day and make "A's." If the same child develops major depression, he feels even more unhappy and he may become suicidal. With major depression, concentration becomes poor and grades often decline to "C's" and "D's." This worsening impairment in functioning is a sign that the dysthymia is slipping into major depression.
Children and adolescents with major depression have depressed or irritable mood most of the day, nearly every day. They have diminished interest or pleasure in almost all activities. It seems that nothing makes them happy. There are often changes in appetite so there might be a five percent weight gain or weight loss. Weight loss, which bothered Sheree, is common with major depression. There also may be insomnia or hypersomnia. Some children with major depression sleep longer. Some may take naps when they didn't take naps before. Other children, like Sheree, lose sleep at night.
Major depression results in changes in activity level. Some people who suffer from major depression have psychomotor retardation or agitation. In other words, major depression can slow some people to the point that they even walk in "slow motion." Others may have a higher level of activity, although the activity may not be purposeful. Major depression causes fatigue or loss of energy. Children with major depression sometimes complain about feeling tired or not being able to do things.
With major depression, some people feel a sense of quilt or worthlessness. They feel that something is wrong with themselves or they are not as good as other kids. Some feel indecisive and have a hard time making decisions. Their concentration is usually lower causing a definite decline in school functioning.
Major depressions often cause children and adolescents to have persistent thoughts of death. Many think of suicide, and some even make suicide attempts. Because of the risk of suicide, major depression should definitely be treated.
To diagnose major depression, it is not necessary to have all these symptoms. Still, many symptoms will occur in a child with major depression.
Major depression can involve psychotic symptoms. For example, Sheree had some hallucinations of hearing her name called. However, major depression is not diagnosed if the child has an ongoing severe psychotic illness. For example, a child with schizophrenia, schizophreniform disorder, or delusional disorder is not diagnosed as having major depression.
Unfortunately, major depression does not have the best prognosis. Ninety percent of those with major depression get better with treatment. After their first depression, a person has about a fifty percent of becoming seriously depressed again. Because it is so severe, the treatment for major depression often involves both medication and psychotherapy.
Often, a depressed child or adolescent does not have all the symptoms necessary for the diagnosis of a specific type of depression. The depression may be one that is somewhere in between adjustment disorder, dysthymia and major depression. When this happens, the depression is called, "depression, not otherwise specified." (It is also called "atypical depression," but some research psychiatrists regard atypical depression as a special type of severe depression that includes some anxiety symptoms.) Depression, not otherwise specified, may be used as an initial diagnosis because there may not be enough data and observation to confirm the diagnosis of another type of depression.
One way of thinking about atypical depression (or depression, not otherwise specified) is that it is a depression that doesn't exactly fit the other patterns of depression. For example, a mild depression that is not due to an identifiable stressor is not an adjustment disorder. A mild depression that continues for six months, but has not been going on for a year is not a dysthymic disorder. This depression could be diagnosed as atypical depression. Another example is a moderate depression or even severe depression that is brief, lasting a month or less. This also may be diagnosed as an atypical depression if it does not include enough of the symptoms of major depression.
Evaluation of Depression
The first step in helping a child or teenager with depression is to understand the depression. During a psychiatric evaluation for depression, information about current problems and past development is collected. The parent usually gives this information for their child. The child's mental status is then examined. Symptoms such as mood, hallucinations, and false beliefs are checked. The data obtained through the psychiatric evaluation is needed to make a correct diagnosis.
The medical history, physical examination, and laboratory testing are important in the evaluation. The medical examination can show if there are physical problems that cause depression. For example, thyroid problems can cause depression. A child who does not have enough thyroid hormone (hypothyroid) may gain weight, be sluggish, and have poor concentration. The appropriate treatment for low thyroid hormone is to take thyroid hormone medication. If a depression in a child is caused by a thyroid problem, treatment for depression such as psychotherapy and antidepressant medication will not help.
The laboratory studies include a serum profile, a complete blood count, and an electrocardiogram (EKG). These tests help to make sure that there are no physical illness that cause symptoms of depression. The laboratory tests also show if there are going to be problems with using medication for depression. These tests help to find problems with the liver and kidney that can cause a lack of energy or interfere with the breakdown of medication. An EKG is done before prescribing antidepressant medication to children to check for heart problems.
Part of the evaluation may include the use of check lists. An example of a helpful checklist is the Child Behavior Check List by Thomas Achenbach, Ph.D. This check list has over a hundred questions, and the answers can be tabulated into several scales. The scales help differentiate between problems with depression, anxiety, hyperactivity, and conduct. Answers to individual questions show what specific symptoms are present.
Psychological testing helps with the understanding of a child with depression. Psychological testing can be used to quantify (evaluate as a number) the symptoms of depression. Tests like the Beck Depression Inventory can be used to see if treatment is helpful. If treatment is working, the number that indicates the intensity of depression decreases. Projective psychological tests can help find the underlying or unconscious causes of depression. Examples of projective tests include the Thematic Apperception Test and the Rorschach. In the Thematic Apperception Test, the child is shown picture cards and asked to make up stories about the people shown in the cards. The stories reflect the unconscious thoughts and feelings that cause the depression. With the Rorschach test, the child describes what he sees on ink blot test. This ink block test shows if the thinking is organized and can help determine if psychosis is present. Psychological testing supplements the psychiatric examination in gathering information that can be used in diagnosis and treatment planning.
Psychotherapy
Children and adolescents with depression are helped with two basic classes of treatment, psychotherapy and medications. Psychotherapy includes many different kinds of talking strategies. When given outside a hospital program (called "out-patient" treatment), psychotherapy is usually scheduled from twice per week to every other week. Psychotherapy can be done with an individual, a family, or in a group.
There are several useful types of individual psychotherapy. Psychodynamic psychotherapy has a goal of improving insight. This psychotherapy involves understanding the child's play, fantasies, dreams, and unconscious thoughts and feelings. Supportive psychotherapy involves talking to the child about realistic problems. The child learns to make better decisions by examining alternatives in solving problems and choosing the best course of action. The child also can learn better social skills.
Cognitive therapy is a special type of psychotherapy designed specifically to help depression. Depressed people usually have repeating negative thoughts. An example of a repeating negative thought is, "I'm worthless," or "this will never get better," or "I'd be better off if I were dead." These thoughts repeat in an obsessional way. To understand this, consider that when something is memorized, it is said repeatedly until it is remembered. Repetition of the thought makes the memory become stronger. In the same way, a feeling that repeats frequently also becomes stronger.
Cognitive psychotherapy is a method of "reprogramming" thoughts and feelings in the brain. Since negative thoughts become stronger by repetition, it is possible to make positive thoughts stronger by repeating them. During cognitive psychotherapy, the child is taught to respond to repeating negative thoughts by replacing them with positive thoughts. Positive thoughts are mentally repeated in the same way as memorization. This makes it easier, even automatic, to think positive thoughts instead of negative thoughts.
For example, a child thinks his mother hates him because she does not give him what he wants. We can help by asking the child to think, "Mother shows me she loves me by taking care of me." Sheree thought that no boy would ever like her again. The positive thought response was, "Other boys will like me, since one already did." Sheree also could remind herself of the likable traits in her personality. She was taught to write down the positive thoughts and practice thinking them repeatedly.
Family psychotherapy is vitally important in the treatment of depressed children and teenagers. Often, stressful problems in the family are at the root of the depression. Also, parents find raising a child with depression can be very difficult. The parents feel helpless and hopeless, not knowing what to do.
Family psychotherapy can address these problems. Family therapy can help uncover difficult problems and assist the family in resolving them. With family therapy, the parents can be taught special strategies that can make it easier to care for a depressed child. These strategies include teaching the parents how to help their child with cognitive therapy techniques. The parents can help the child develop positive thoughts to deal with depressing negative thoughts that may be occurring.
Suicide Prevention
Depression causes serious risk of suicide in children and adolescents. Family psychotherapy helps to address the issue of managing suicidal children at home. Parents should get rid of guns, knives, and other objects that can be used in suicide attempts. It is especially important to make sure there are no firearms in the home, since shooting is probably the most successful method of committing suicide. In suicide attempts, boys shoot themselves more often than girls. Girls usually prefer to take overdoses. Because of guns, boys have a higher chance of fatality when they attempt suicide.
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