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Depression in School-aged Children: An Introduction      
1999-2000


James W. Drisko, Ph.D., L.I.C.S.W.

Smith College School for Social Work
Northampton, Massachusetts 01063


1.  What Depression is: 

What we often think of as depression is viewed by mental health professionals as a variety of Mood Disorders which share some features but have different qualities, duration and intensity. These are the 
Depressive episodes and disorders,  Dysthymic disorder and Bipolar and Cyclothymic disorders. 
The core symptoms are the same for persons of all ages. Ideas from the recent past about "masked depressions" or "depressive equivalents" have not been borne out by research. However, irritability may be substituted for depressive mood in children. (Somatic complaints and social withdrawal are also more common in depressed children (Kovacs. et al., 1994). Discrepancies between child's perceptions and that of parents and other adults (such as teachers) is common.

Depression is a potentially fatal disorder! Suicide risk is real, even for children. Statistics show a 1.5 in 100,000 risk for children ages 10 to 14. Suicide is the sixth leading cause of death for children 10-14. Although the incidence of suicide in pre-adolescents is low, thoughts (ideation) of suicide and death among depressed children are common. 

Childhood suicide attempts are often impulsive and reactive; in response to poor treatment, a bad day, or a desire to "get even." Remember that young children think differently than do adults. Death may not be understood as permanence. Suicidal behavior may reflect a wish to briefly join a dead relative in order to feel better or make amends. Identifying with the deceased family member may also be a factor as suicide risk is higher among children where there has been a suicide in the family (even if the child is "supposed" not to know about it) (Pfeffer).

The key types:

Many depressions come -- and then go. These are depressive episodes. Several symptoms must be present for two weeks and represent a change in the child's functioning.

Formal diagnosis of a Major Depressive Episode requires (from the DSM - IV) 

A) 5 (or more) symptoms to be present during the same two week period representing a change from previous functioning. Depressed mood and/or loss of interest or loss of pleasure must be present for the diagnosis. Depressed or irritable mood most of the day, every day evidence by reports or observations by others.

Marked diminished interest in all or most all activities, most of the day every day; Significant (more than 5% in a month) weight loss or weight gain (without dieting) OR decrease or increase in appetite nearly every day OR failure to gain expected weight in children); 
Insomnia or hypersomnia (sleeping too much) nearly every day; 
Observable psychomotor agitation or retardation nearly every day; 
Fatigue or loss of energy nearly every day; 
Feelings of worthlessness or excessive or inappropriate guilt nearly every day; 
Diminished ability to think or concentrate OR indecisiveness nearly everyday (by self report or observations of others); 
Recurrent thoughts about death (not just a fear of dying), recurrent suicidal ideation (thoughts) without a specific plan, or a specific plan or an attempt to commit suicide.

B) Symptoms do not meet the criteria for a Mixed Episode (that is includes manic features);

C) Symptoms cause clinically significant distress or impairment in social, occupational (school) or other important areas of functioning;

D) Symptoms are not directly due to substance use or general medical condition;

E) Symptoms are not better accounted for by bereavement (longer than 2 months or marked by impaired functioning).

Major Depressive Disorder has been a subject of considerable debate among mental health professionals. The main issue is to be sure that the depression is the primary disorder and not secondary (due to, reactive to) another disorder such as ADHD. learning disorders, conduct
disorder and even environmental stressors (an adjustment reaction). 

A single episode of major depression not due to schizoaffective or other psychotic disorder with no manic, mixed or hypomanic episode is a probably best viewed as a major depressive episode. But when major depressive episodes recur, a diagnosis of major depressive disorder is indicated.

The diagnosis of Major Depressive Disorder requires (after DSM-IV): 
Two or more major depressive episodes with an interval of at least 2 months between episodes (periods in which the criteria for major depressive episode are not met); 
These episodes are not due to schizoaffective or other psychotic disorder, and 
There has never been a manic, mixed or hypomanic episode

Severity, remission, course over time and seasonal pattern specifiers (data) are recorded with this diagnosis.

Dysthymic Disorder is of lesser severity than a major depressive episode or disorder but of longer duration. (Kovacs found the average duration of Dysthymia in children is 2 years.) Onset is often early and insidious. The course of Dysthymia is often chronic and progressive:
Superimposed (co-morbid) major depressive episodes can occur at any time but are more frequent as one gets older. Functioning in important areas of life is significantly impaired. 

Dysthymia has only depressive features, is of lesser severity than depression, but of lengthy duration -- more days than not for over 1 year for children. (This criteria for children is shorter than the adult duration requirement of 2 years for the Dysthymia diagnosis.)

Dysthymic disorder criteria are:

A) Depressed mood for most of the day, more days than not, by subjective account or by observations of others, for at least 1 year (2 years for adults). 

B) Presence, while depressed of 2 or more of the following symptoms:
Poor appetite 
insomnia or hypersomnia 
low-energy or fatigue 
low self-esteem 
poor concentration or difficulty making decisions 
feelings of hopelessness

C) During the 1 year period, the child has never been without these symptoms for more than 2 months at a time.

D) No major depressive episode has been present during the 1 year period (though a previous major depressive episode -- fully in remission -- does not reject dysthymic disorder diagnosis).

E) There has never been a manic, mixed or hypomanic episode

F & G) The Dysthymia is not due to a psychotic disorder, substance abuse or a general medical condition, and 

H) The symptoms cause clinically significant distress or impairment of functioning in social, occupational (school) or other important areas of functioning. 

Age of onset is specified as well. Early onset is correlated with first degree relatives who have depressive disorders. 

Bipolar disorders include both a depressive component and a manic, mixed or hypomanic (elevated, expansive or irritable mood for at least 4 days) phase.  

Mania is extremely rare in childhood -- which may only indicate it is under-diagnosed. Reviews of patient charts indicate the diagnosis was often warranted by recorded symptoms (Carlson & Cantwell, 1982). 

There is some evidence that explosive disorders in adolescence are correlated with first degree relatives having bipolar disorder -- and is responsive to lithium and other psychopharmacological treatment. 

The diagnosis of Bipolar I Disorder requires:

The presence of one or more manic episodes with or without past depressive episodes, Not due to schizoaffective or other psychotic disorder.

The disorder is called a mixed disorder where both manic and depressive features are present or where both manic and depressed episodes have occurred. 

Specifiers describing the course of the cycling over time, its rapidity and any seasonal variation are also documented.

Bipolar II Disorder requires presence of history of one or more major depressive episodes and one hypomanic episode, but no history of a manic or mixed episode, along with the usual rule outs for medical conditions, drug or substance use, or other mental health conditions and which cause significant impairment in functioning. 

An organization on Bipolar Disorders in Childhood (BPkids) offers excellent information for families, educators and clinicians.

MHsource.com offers a fine overview of the early signs of bipolar disorder in children and adolescents. 

Cyclothymic disorders have both hypomanic and depressive components, but differ in severity and in duration. Specifically, over the past 2 years, there have been numerous episodes of hypomanic symptoms and numerous periods of depressive symptoms which do not meet the criteria for major depressive episodes. Note that the depressive episodes are not severe enough to warrant a diagnosis of major depressive episode. Again, the usual rule outs for medical conditions, drug or substance use, or other mental health conditions apply as does the requirement that symptoms cause significant impairment in functioning. 

2.Prevalence of Depression among Children Over a lifetime, adult rates in general community samples for major depressive disorder range from 5 to 12% for males and from 10 to 25% for females. At a given point in time from 5 to 9% of community samples warranted a diagnosis of major depressive disorder, and from 2 to 3% of males. 

Major depressive disorders are less common in prepubertal children than in adults, but are underdiagnosed (Kovacs, et al., 1994; Rutter, et al., 1986).

Females are 2 to 3 times more likely to suffer dysthymic disorder than are males. Lifetime risk is at about 6% for dysthymic disorder in the general population, and roughly 3% for point in time samples. There appears to be no correlation for either major depressive disorder or Dysthymia with race, ethnicity, education, income or marital status.

Cyclothymic disorders have a lifetime prevalence of 0.4 % to 1% and prevalence in clinical samples of from 3% to 5%.

Risk of future episodes increase as one has more of them: Having a single episode of depression is linked to a 50 to 60% likelihood of having a second depressive episode. Individuals with two episodes have a 70% likelihood of a third, and those with three episodes a 90% of having a fourth.

3.  Causes (Etiology):

Just as with adult depression, the causes of childhood depression is probably due to multiple factors. Biological factors are now a key focus (partly due to the effectiveness of medication as treatment) and the hard sciences focus of brain research. Advocacy groups have also promoted the idea of depression (and all mental disorders) as "brain disorders."  Surely they are brains disorders in part, but they also have psychological and social aspects that warrant attention, too -- and exacerbate or relieve suffering.

One documented factor is heredity. Heredity studies have repeatedly demonstrated higher rates of mood disorders among first-degree adult relatives of depressed children. Both Bipolar Disorder and Major Depressive Disorder run in families, though there is stronger evidence for the genetic inheritance of Bipolar Disorder. Major depressive disorder is 1 1/2 to 3 times more likely for first degree biological relatives of persons with the disorder. Dysthymia is more common in first degree relatives, but by how much is unclear. Cyclothymia is more frequent in persons with first-degree relaives having major depressive disorder or bipolar disorder. Early onset of depression appears correlated with genetic factors. (However, some very recent research suggests Temperamental variation is also hereditary/biological.

Biological factors lead one advocacy group to call mood disorders "brain disorders." There are biological correlates of depression.. For instance, REM sleep abnormalities (such as decreased REM latencies, earlier onset of REM sleep) have been found in some depressed children.  Some groups, particularly NAMI, emphasize the neurobiological perspective.  They offer a handout entitled:  Neurobiological Brain Disorders:  Does my Child Have One?   Prenatal malnutrition may also be correlated to the later development of major affective disorder

Cognitive models advance the view that our thinking is a factor in depression. That it, depressed patients (at any age) have distorted thinking which leads to (or perhaps sustains and exacerbates) their depression. For example, Beck points out that depressives have a negative view of the self, of the environment and the of future. (Few would disagree!) Clearly altering these self-,messages is an important part of therapy for depression. 

Human Development models suggest that early separations from parents or caregivers and/or their outright loss (to death, divorce, placement) may play a role in of depression. Greater incidence of early separation(s) and loss(es) are found in the histories of depressed children compared to the population in general. Human Environment risk factors are clearly associated with depression. Poor parental caregiving, emotional unavailability (which may be due to parental depression or other mood disorder) or poor abuse and/or neglect by the caregivers are all clearly associated with childhood mood disorders. There is a strong correlation between depressed mothers and depressed infants (Tronick,
et al)

4.  Onset and Course:

Major depressive disorders can begin at any age. However, the average age of onset is the mid-20's. Recent epidemiological data suggest that age of onset is decreasing for those born recently. 

Dysthymia is often first evident in children. Before age 21, dsthymia is specified as "early onset." Persons with early onset are more likely to have later major depressive episodes.

Cyclothymic disorders usually begin in adolescence or early adulthood.  However, manic phases may be hard for adults to identify, and may be briefer than is true for adults.  Thus under-identification is very likely.

People may have a single episode of depression and no others. Others may have recurrent depressions separated by many years. Others have clusters of depressive episodes. Frequency of depressive episodes may increase with age, and periods of remission are generally longer early in the course of the disorder. 

5.  Treatments

Research on adults has found a combination of medication and psychotherapy is the most effective treatment for depression (though simply talking to another caring person had a very positive effect!) The medication generate quick symptomatic relief, and the psychotherapy addresses issues of social supports, behaviors and thoughts which may ameliorate or sustain the depressive symptoms. 

Sadly, there are no parallel studies for children. We must assume these results are roughly applicable, though how to include family is not well defined. There is also little evidence older tricyclic anti-depressant medications are effective with children. 

Cognitive behavioral and interpersonal therapies are both proven effective on changing depressive behavior and thoughts.  Cognitive therapies appear to be the best when we emphasize cognitive distortions, while interpersonal therapies appear the best at the interpersonal aspects.  (Maybe both should be used jointly!)

A study by Rushton and colleagues examined how pediatricians and family physicians treat depression.  Watchful waiting was used often by both groups.  Family physicians used medication more than did pediatricians.  SSRi's were most common:  77% of medications prescribed by family physicians and 53% prescribed by pediatricians.  Note well:  most of the physicians reported inadequate training in factors influencing childhood depression.  It is wise to get a psychiatric evaluation when medication is indicated! 

Good treatment will involve collaboration with teachers -- if only as information sources about the child's functioning. 

6.  What Teachers Can Do

Identifying the depressed child is the first crucial step. It is the most difficult step! This may be done via listening to the child's complaints directly. However, children may not verbalize feelings, so direct observation of behavior, and especially changes in functioning which seem to connect with sad or irritable affect are key. Parents complain that teachers do not do this enough. Use a list of depressive symptoms as a guide (such as the one in this handout). Remember, changes from prior functioning are key for major depressive episodes, but ongoing diminished or impaired functioning characterize dysthymia.

When you have the concern, use a screening tool. One is the symptom checklist for depression (provided later in the handout). These can help guide you and clarify if you are "on target" although some symptoms will be evident only outside of school or will require subjective reports
from the child directly (which you may, or may not, obtain). The DSM-IV criteria can serve as a screening tool -- or use the broader tool available for depression screening from the National Mental Health Association.  This tool can be used to build depression awareness as well.

Document changes in behavior as possible. Write up some notes or keep a tally of when symptoms are present. (Yes - this is well be above and beyond the usual "above and beyond" work for a teacher! Some do it for particular purposes.)

Talk with parents and express your concern. Parents complain they do not get enough information about early warning symptoms of emotional problems from teachers. We also know some do get these early warnings and do not appreciate them as they are intended! Parents will have access to information and observations teachers do not. Collaboration is imperative. 

Consult with, or refer to, your school psychologist, social worker or counselor. Most school systems make consultation with guidance, counseling and social work staff a resource to explore and clarify your concerns. Diagnosis of depression (or its variants) is complex, collaboration is useful. 

School systems should develop a policy or approach to screening children in classrooms. Many will be the kids who "fade into the woodwork" -- they need your attention to be identified and helped. There are annual depression screening days for adults -- maybe there should be one for kids, too!

Have a Depression Awareness day! Many cities and towns are taking this simple and direct form of action to alert parents about depression in children. This can be as simple as sending home a flyer on depression or a simple depression symptom checklist. You can find a symptom checklist for general use online online from the National Mental Health Association which they cite as from Dubuque, S.E.  (1996).  A Parent's Survival Guide to Childhood Depression.  King of Prussia, PA: The Center for Applied Psychology, Inc.


Remember your concern for children is always helpful in the long run even if not appreciated in the moment. You can be an important part of depression treatment -- aiding the well being and development of the children we care for!


7.  Prevention! 

There is growing evidence that preventive efforts can reduce the severity and duration of depressive episodes.  Prevention seeks to educate and support families to improve communication and reduce depressive symptoms.  It will also make parents attentive to how they might exacerbate or reduce their child's difficulties.  

The New York Times (Tuesday, October 10, Science Times section, final page) also reports exercise is effective at reducing depressive symptoms (though the exercise was done in a group and the group dynamic may also have been a curative influence). 


References and Resources

Carlson, T. (1998). Depression in the young: What we can do to help them. Benline Press. ISBN: 0964244357 A starting point only.

Essau C., Petermann, F., Ahmoi Easau, C. (1999). Depressive disorders in children and adolescents: Epidemiology, risk factors, and treatment.  Northvale, NJ: Aaronson. ISBN: 076570188X 

Miller, J. (1999). The childhood depression sourcebook. Lowell House Publishing. ISBN: 0737300019 

Shafii, M., & Shafii, S. (Eds.). (1991). Clinical guide to depression in children and adolescents. Washington, DC: American Psychiatric Press. ISBN: 0880483563 

Stark, K. (1990). Childhood depression: School-based intervention. New York: Guilford Press. ISBN: 0-89862-236-0

Zero to Three / National Center for Clinical Infant Programs. Diagnostic Classification: 0 to 3. Arlington, VA: Author

On the Web:


An overview of depression and treatments.

NAMI gives a medically-oriented consumer (parent) viewpoint. Also a strong advocacy organization you may wish to join and work with.

A fine overview of childhood bipolar disorder is offered by mhsource.com

 

October, 1999, updated October, 2000.

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