Base rates and prevalence
About 8% of children and adolescents suffer from depression.
This year, 51 percent of students (teens) who visited a counseling
center reported having anxiety, followed by depression (41 percent),
relationship concerns (34 percent) and suicidal ideation (20.5 percent).
Many students reported experiencing multiple conditions at once.
Research suggests that the prevalence of young depression sufferers in
Western cultures ranges from 1.9% to 3.4% among primary school children
and 3.2% to 8.9% among adolescents.
Studies have also found that among children diagnosed with a depressive
episode, there is a 70% rate of recurrence within five years. Furthermore, 50% of children with depression will have a recurrence at least once during their adulthood.
While there is no gender difference in depression rates up until age
15, after that age the rate among women doubles compared to men.
However, in terms of recurrence rates and symptom severity, there is no
gender difference.
In an attempt to explain these findings, one theory asserts that
preadolescent women, on average, have more risk factors for depression
than men. These risk factors then combine with the typical stresses and
challenges of adolescent development to trigger the onset of depression.
Suicidal intent
Like
their adult counterparts, children and adolescent depression sufferers
are at an increased risk of attempting or committing suicide. Suicide is the third leading cause of death among 15-19 year olds. Adolescent males may be at an even higher risk of suicidal behavior if they also present with a conduct disorder. In the 1990s, the National Institute of Mental Health (NIMH) found that up to 7% of adolescents who develop major depressive disorder may commit suicide as young adults.
Such statistics demonstrate the importance of interventions by family
and friends, as well as the importance of early diagnosis and treatment
by medical staff, to prevent suicide among depressed or at-risk youth.
However, some data showed an opposite conclusion. Most depression
symptoms are reported more frequently by females; such as sadness
(reported by 85.1% of women and 54.3% of men), and crying (approximately
63.4% of women and 42.9% of men). Women have a higher probability to
experience depression than men, with the prevalences of 19.2% and 13.5%
respectively.
Risk factor
In
childhood, boys and girls appear to be at equal risk for depressive
disorders; during adolescence, however, girls are twice as likely as
boys to develop depression. Before adolescence rates of depression are
about the same in girls and boys, it is not until between the ages of
11-13 that is begins to change. Young girls around this age, physically,
go through more changes than young boys which put that a higher risk
for depression and hormonal imbalance. The gender gap in depression
between adolescent men and women is mostly due to young women's lower
levels of positive thinking, need for approval, and self-focusing
negative conditions.
Frequent exposure to victimization or bullying was related to high
risks of depression, ideation and suicide attempts compare to those not
involved in bullying. Nicotine dependence is also associated with depression, anxiety, and poor dieting, mostly in young men. Although causal direction has not been established, involvement in any sex or drug use is cause for concern.
Children who develop major depression are more likely to have a family
history of the disorder (often a parent who experienced depression at an
early age) than patients with adolescent- or adult-onset depression.
Adolescents with depression are also likely to have a family history of
depression, though the correlation is not as high as it is for children.
Comorbidity
Research has shown that there is a high rate of comorbidity with depression in children with dysthymia.
There is also a substantial comorbidity rate with depression in
children with anxiety disorder, conduct disorder, and impaired social
functioning. Particularly, there is a high comorbidity rate with anxiety, ranging from 15.9% to 75%.
Conduct disorders also have a significant comorbidity with depression
in children and adolescents, with a rate of 23% in one longitudinal
study.
Beyond other clinical disorders, there is also an association between
depression in childhood and poor psychosocial and academic outcomes, as
well as a higher risk for substance abuse and suicide.
The prevalence of psychiatric comorbidities during adolescence may vary by race and ethnicity.
Diagnosis
According to the DSM-IV,
children must exhibit either a depressed mood or a loss of interest or
pleasure in normal activities. These activities may include school,
extracurricular activities, or peer interactions. Depressive moods in
children can be expressed as being unusually irritable, which may be
displayed by "acting out," behaving recklessly, or often reacting with
anger or hostility. Children who do not have the cognitive or language
development to properly express mood states can also exhibit their mood
through physical complaints such as showing sad facial expressions
(frowning) and poor eye contact. A child must also exhibit four other
symptoms in order to be clinically diagnosed. However, according to the
Omnigraphics Health References Series: Depression Sourcebook, Third Edition,
a more calculated evaluation must be given by a medical or mental
health professional such as a physiologist or psychiatrist. Following
the bases of symptoms, signs include, but are not limited to, an unusual
change in sleep habits (for example, trouble sleeping or overly
indulged sleeping hours); a significant amount of weight gain/loss by
lack or excessive eating; experiencing aches/pains for no apparent
reason that can found; and an inability to concentrate on tasks or
activities. If these symptoms are present for a period of two weeks or
longer, it is safe to make the assumption that the child, or anybody
else for that matter, is falling into major depression.
Correlation between adolescent depression and adulthood obesity
According
to research conducted by Laura P. Richardson et al., major depression
occurred in 7% of the cohort during early adolescence (11, 13, and 15
years of age) and 27% during late adolescence (18 and 21 years of age).
At 26 years of age, 12% of study members were obese. After adjusting for
each individual's baseline body mass index (calculated as the weight in
kilograms divided by the square of height in meters), depressed late
adolescent girls were at a greater than 2-fold increased risk for
obesity in adulthood compared with their non-depressed female peers
(relative risk, 2.32; 95% confidence interval, 1.29-3.83). A
dose-response relationship between the number of episodes of depression
during adolescence, and risk for adult obesity was also observed in
female subjects. The association was not observed for late adolescent
boys or for early adolescent boys or girls.
Correlation between child depression and adolescent cardiac risks
According
to research by RM Carney et al., any history of child depression
influences the occurrence of adolescent cardiac risk factors, even if
individuals no longer suffer from depression. They are much more likely
to develop heart disease as adults.
Distinction from major depressive disorder in adults
While
there are many similarities to adult depression, especially in
expression of symptoms, there are many differences that create a
distinction between the two diagnoses. Research has shown that when a
child’s age is younger at diagnosis, typically there will be a more
noticeable difference in expression of symptoms from the classic signs
in adult depression.
One major difference between the symptoms exhibited in adults and in
children is that children have higher rates of internalization;
therefore, symptoms of child depression are more difficult to recognize.
One major cause of this difference is that many of the neurobiological
effects in the brain of adults with depression are not fully developed
until adulthood. Therefore, in a neurological sense, children and
adolescents express depression differently.
History
Professionals
first became aware of child abuse in the early 1980s, so it is possible
that some of the young people identified with depressive disorders may
have had a history of sexual abuse, which was not disclosed. This raises
the question of what the outcome would have been in those young people
if they had disclosed the abuse and received appropriate therapeutic
interventions. It is well-known that childhood sexual abuse is a
significant factor in the history of some adults with depressive
syndromes.
In the past, attention deficit hyperactivity disorder (ADHD) was not recognized, and hyperkinetic disorder
was only rarely diagnosed. Some young people, especially those with
comorbid conduct disorder and major depressive disorder, may have had
undiagnosed and untreated ADHD. Before the use of psycho-stimulants,
some young people may have been more vulnerable to development of
depressive syndromes because of untreated attentional and other
behavioural problems which reduce their self-esteem.
Although antidepressants
were used by child and adolescent psychiatrists to treat major
depressive disorder, they may not always have been used in young people
with a comorbid conduct disorder because of the risks of overdose in
such a population. Tricyclic antidepressant were the predominant antidepressants used at that time in this population. With the advent of selective serotonin re-uptake inhibitors
(SSRIs), child and adolescent psychiatrists probably began prescribing
more anti-depressants in the comorbid conduct disorder/major depressive
group because of the lower risk of serious harm in overdose. This raises
the possibility that more effective treatment of these young people
might also improve their outcomes in adult life.
Assessments
Among
the psychological assessments for identifying whether or not children
and adolescents are experiencing depression or depressive symptoms is
the Children's Depression Inventory.
In early 2016, the USPSTF released an updated recommendation for the
screening of adolescents ages 12 to 18 years for major depressive
disorder (MDD). Appropriate treatment and follow-up should be provided
for adolescents who screen positive.
Treatment
There are multiple treatments that can be effective in treating children diagnosed with depression. Psychotherapy
and medications are commonly used treatment options. In some research,
adolescents showed a preference for psychotherapy rather than
antidepressant medication for treatment. For adolescents, cognitive behavioral therapy and interpersonal therapy have been empirically supported as effective treatment options.
The use of antidepressant medication in children is often seen as a
last resort; however, studies have shown that a combination of
psychotherapy and medication is the most effective treatment. Pediatric massage therapy
may have an immediate effect on a child's emotional state at the time
of the massage, but sustained effects on depression have not been
identified.
Treatment programs have been developed that help reduce the
symptoms of depression. These treatments focus on immediate symptom
reduction by concentrating on teaching children skills pertaining to
primary and secondary control. While much research is still needed to
confirm this treatment program’s efficacy, one study showed it to be
effective in children with mild or moderate depressive symptoms.
Talk therapy
There are three common types of talk therapy. These can assist people to live more fully and have a better life.
Men are encouraged to open up more emotionally and communicate their
personal distress, while women are encouraged to be assertive of their
own strengths.
Cognitive therapy
Cognitive therapy
aims to change harmful ways of thinking and reframe negative thoughts
in a more positive way. Aims of cognitive therapy include various steps
of patient learning. They learn to monitor their negative thoughts, to
become aware of the link between their thoughts, the affect their
thoughts have on them & their behavior, to become aware of and
change the negative, depressive thoughts which affect their health and
state of mind
Behavioral therapy
Behavioral therapy helps change harmful ways of acting and gain control over behavior which is causing problems.
Interpersonal therapy
Interpersonal therapy helps one learn to relate better with others, express feelings, and develop better social skills.
Psychotherapy
Psychotherapy teaches coping skills while allowing the teens or children to explore feelings and events in a safe environment.
Family therapy
The principles of group dynamics are relevant to family therapists who must not only work with individuals, but with entire family systems.
Two key concepts that influence family therapy are the distinction
between the process and content of group discussions, and role theory.
Therapists strive to understand not just what the group members
say, but how these ideas are communicated (process). Therapists can help
families improve the way they relate and thus enhance their own
capacity to deal with the content of their problems by focusing on the
process of their discussions. Virginia Satir expanded on the concept of
how individuals behave and communicate in groups by describing several
family roles that can serve to stabilize expected characteristic
behavior patterns in a family. For instance, if one child is considered
to be a "rebel child", a sibling may take on the role of the "good
child" to alleviate some of the stress in the family. This concept of
role reciprocity is helpful in understanding family dynamics because the
complementary nature of roles makes behaviors more resistant to change.
Controversies
Throughout
the development and research of this disorder, controversies have
emerged over the legitimacy of depression in childhood and adolescence
as a diagnosis, the proper measurement and validity of scales to
diagnose, and the safety of particular treatments.
Legitimacy as a diagnosis
In
early research of depression in children, there was debate as to
whether or not children could clinically fit the criteria for major depressive disorder.
However, since the 1970s, it has been accepted among the psychological
community that depression in children can be clinically significant.
The more pertinent controversy in psychology today centers around the
clinical significance of subthreshold mood disorders. This controversy
stems from the debate regarding the definition of the specific criteria
for a clinically significant depressed mood in relation to the cognitive
and behavioral symptoms. Some psychologists argue that the effects of
mood disorders in children and adolescents that exist (but do not fully
meet the criteria for depression) do not have severe enough risks. Children in this area of severity, they argue, should receive some sort of treatment since the effects could still be severe.
However, since there has yet to be enough research or scientific
evidence to support that children that fall within the area just shy of a
clinical diagnosis require treatment, other psychologists are hesitant
to support the dispensation of treatment.
Diagnosis controversy
In
order to diagnose a child with depression, different screening measures
and reports have been developed to help clinicians make a proper
decision. However, the accuracy and effectiveness of certain measures
that help psychologists diagnose children have come into question. Questions have also surfaced about the safety and effectiveness of antidepressant medications.
Measurement reliability
The
effectiveness of dimensional child self-report checklists has been
criticized. Although literature has documented strong psychometric
properties, other studies have shown a poor specificity at the top end
of scales, resulting in most children with high scores not meeting the
diagnostic criteria for depression.
Another issue with reliability of measurement for diagnosis occurs in
parent, teacher, and child reports. One study, which observed the
similarities between child self-report and parent reports on the child's
symptoms of depression, acknowledged that on more subjective symptom
reports measures, the agreement was not significant enough to be
considered reliable.
Two self-report scales demonstrated an erroneous classification of 25%
of children in both the depressed and controlled samples.
A large concern in the use of self-report scales is the accuracy of the
information collected. The main controversy is caused by uncertainty
about how the data from these multiple informants can or should be
combined to determine whether a child can be diagnosed with depression.
Treatment issues
The controversy over the use of antidepressants
began in 2003 when Great Britain's Department of Health stated that,
based on data collected by the Medicines and Healthcare products
Regulatory Agency, paroxetine (an antidepressant) should not be used on patients under the age of 18. Since then, the United States Food and Drug Administration
(FDA) has issued a warning describing the increased risk of adverse
effects of antidepressants used as treatment in those under the age of
18. The main concern is whether the risks outweigh the benefits of the
treatment. In order to decide this, studies often look at the adverse
effects caused by the medication in comparison to the overall symptom
improvement.
While multiple studies have shown an improvement or efficacy rate of
over 50%, the concern of severe side effects – such as suicidal ideation
or suicidal attempts, worsening of symptoms, or increase in hostility –
are still concerns when using antidepressants.
However, an analysis of multiple studies argues that while the risk of
suicidal ideation or attempt is present, the benefits significantly
outweigh the risks.
Due to the variability of these studies, it is currently recommended
that if antidepressants are chosen as a method of treatment for children
or adolescents, the clinician monitor closely for adverse symptoms,
since there is still no definitive answer on the safety and overall
efficacy.
