Childhood depression: causes, symptoms, and treatment approaches

Childhood Depression

Major depressive disorder, or MDD, may affect up to twenty percent of the adult population. The recognition of depression as a serious and common mental disorder has been vital in the identification and treatment of depression in adults. Leaps and bounds have been made in the field of depression research. The widespread recognition of the many possible causes of depression, including chemical imbalances with genetic or medical origins as well as traumatic life events, has made it possible for those suffering from depression to openly seek treatment options and discuss their depression without necessarily feeling the same overwhelming shame and isolation that were inevitable in generations past. Depression is more likely to be identified in an affected individual by family members, physicians, or others because of the public information that is available for professionals and the common people. Research is constantly revealing new treatment options, identifying causal factors, and overall quickly improving the outlook for depressed adult individuals.

Unfortunately, there exist a significant number of individuals suffering from depression that are not benefiting from the research developments, educational campaigns, and treatment options that have changed the outlook for so many others. Childhood depression has been an under-recognized disorder. However, ignoring childhood depression does not make this problem disappear. For many years, it was believed that young children simply do not have the mental or emotional capacity to become affected by depression. Symptoms which would have been telltale of this disorder in an adult have been dismissed as shy or rebellious behavior, or completely misdiagnosed as another disorder, such as a learning disability. Parents, teachers, and others involved with children remain uneducated about childhood depression. Researchers may be reluctant to focus on the difficult topic of childhood depression. Children continue to suffer with major depressive disorder, even while revolutionary findings are eliminating the need for suffering among adults with major depressive disorder.

The need for further research in the area of childhood depression is therefore blatantly obvious. The well-being of children relies on the dedication of adults to researching and developing solutions to problems. Major depressive disorder is indeed a childhood problem. The purpose of the proposed research at hand is to study some of the important primary issues which must be addressed when studying depressive disorders in children.

The primary focus of the proposed study are the factors which may directly cause childhood major depressive disorder, or which may cause children to be predisposed to depression. In order to understand depression in children, it is necessary to know the origins of this disorder. Treatment options can be opened up to include specifically formulated counseling and/or medication -- or even prevention -- if the exact causes of depression can be properly identified. "Education is key in the management of childhood depression. Both the patient and the family should understand the difference between clinical depression and the typical growing pains of development: although most children experience periods of loneliness, rebellion, and confusion, depressed children feel this way all or most of the time....Education may also diminish the feelings of blame and guilt often felt by the child or parents...depression does not simply result from the influence of a particular environment and is not preventable." (Louder 2004)

An important aspect of the present study is to review literature that is currently available from research conducted on childhood depression. Unfortunately, while a great deal of the MDD research conducted which has focused on adults is invaluable to this subject, it is necessary to filter out a lot of information that is not transferable from depressed adults to depressed children. Information taken from studies on adult MDD may actually be detrimental if not properly filtered because it will give researchers inaccurate expectations of how children may respond to causal factors and treatments alike. Therefore information will be collected from studies which have specifically focused on childhood depression. This literature will help to identify a wide spectrum of causal factors, as well as some correlating factors, and a quick survey of treatment options. However, the focus of the review of literature will be on the direct causal factors and factors which will predisposition children to major depressive disorder.

In order for childhood depression to be properly diagnosed and treated, the predispositioning and causal factors must be understood. The literature review will show that these factors are an integral part of how and why depression manifests in children. Further original research will be conducted to identify how widespread the lack of knowledge regarding the causes and symptoms of childhood depression may be. Additionally, the proposed research will identify further causal factors and symptoms that may be correlated to childhood depression which may not have been thoroughly covered by the material in the review of literature. From this research, further clarity may be drawn on the causal and predispositioning factors of childhood depression, as well as the ways in which depression may manifest itself in children and the lasting effects this may have on the affected child.

This study is intended to help provide guidelines for future research and development in the field of child depression and MDD. The literature review and findings from the original survey research that will be conducted are delimited by the fact that they are not being performed for the purpose of gathering conclusive evidence. The proposed research and survey will give an overview of the current state of academic knowledge on this subject, as well as an overview of the experiences of individuals who have experienced childhood depression first- or second-hand. Further clinical research will be necessary in order to provide more definitive results.

For this study, the definition of major depressive disorder will be based on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, which outlines the criteria for a diagnosis of MDD. (Louters 2004) Major depressive disorder cannot be diagnosed without five or more of the listed symptoms being present during a two-week period. These symptoms must occur every day or nearly every day, and they include the following:

1. Decreased concentration, indecisiveness

2. Depressed or irritable mood

3. Diminished pleasure or interest in activities

4. Failure to make expected weight gains

5. Fatigue

6. Feelings of guilt or worthlessness

7. Insomnia or hypersomnia

8. Morbid thoughts, suicidal ideation or attempt

9. Psychomotor retardation or agitation.

However, the term childhood depression may be used herein without there being an official, clinical diagnosis for the individual or individuals in question.

Literature Review.

An introduction to childhood depression including causal risk factors, symptoms, and research was presented by Lauren Louters in the Journal of the American Academy of Physicians Assistants article, "Don't overlook childhood depression: an effective approach to childhood depression requires that you maintain a high index of suspicion and understand the disorder's full spectrum of manifestations." (2004) Louters acknowledges that in the past, the possibility of diagnosis for mood disorders such as MDD in children was not considered. "Although children once were thought to lack the emotional and cognitive ability to experience depressive symptoms, we now know that a range of mood disorders, including major depressive disorder (MDD), can affect children and adolescents." (Louders 2004) Despite the recognition of psychologists that this mood disorder does affect children, it is still not as widely recognized as adult depression.

Mood disorders such as depression can be very difficult to recognize and diagnose in children, presenting some difficulties that are not factors for adults. One difficulty is that there are issues such as the child's stage of development; the presentation of depression may be very different depending on the stage of development and other factors. Often times, depression is mistaken for other conditions in children, or comorbid conditions may further complicate diagnosis by masking or altering the symptoms of depression. Children also generally do not have the same amount of integration into the norms of social behavior as adults. "The spectrum of normalcy among children may also be a factor: a socially withdrawn 6-year-old may be depressed or may be just shy, while an adolescent's troublesome behavior may be related to clinical depression or to the challenges of growing up." (Louders 2004) There is still no objective test for mood disorders, including depression.

A number of possible symptoms, including an irritable mood, a loss of interest in activities that once brought pleasure, fatigue, disinterest in food, abnormal sleeping patterns, thoughts about suicide or attempts to commit suicide, and a number of other possible symptoms, must be taken into consideration when recognizing depression in children. "Psychiatric disorders other than MDD -- such as bereavement, adjustment disorder with depressed mood, bipolar disorder, and substance-induced mood disorder -- should also be considered. Alcohol and marijuana use can cause depressive symptoms, as can drugs such as systemic corticosteroids, oral contraceptives, benzodiazepines, barbiturates, stimulants, and anticonvulsants." (Louders 2004) However, the detection of just one symptom does not give cause to diagnose depression, nor does the detection of several symptoms guarantee the presence of depression. Children may also be exhibiting symptoms, however these symptoms are undetectable because they are being hidden or missed by adults for other reasons. Many times, even physicians do not obtain information regarding a child's condition and history from the child, but rather the physician will have parents recount the information to them; this lack of personal interaction with the child may contribute to the inability to detect symptoms. It is important for all involved adults to be aware of the child's mental state. Based on age, there are several key symptoms or manifestations of major depressive disorder that should serve as warning signs if observed:

Age 0-3: Feeding problems, temper tantrums, lack of playfulness, muted emotional expression

Age 3-5: Phobias, enuresis, encopresis, being accident-prone, being overly apologetic for minor infractions

Age 6-8: Vague somatic complaints (such as chronic abdominal pain and headaches), aggressive behavior, resistance to new experiences and people

Age 9-12: Excessively morbid thoughts, worry about homework, self-blame

Adolescence: Anger, irritable mood, moodiness, uncommunicativeness, hypersensitivity to criticism, anhedonia, hypersomnia, delinquency, preoccupation with body image

Major depressive disorder appears to become more common as children age, though perhaps it simply becomes easier to identify and therefore more commonly diagnosed as children grow older. For preschool-age children, the prevalence of major depressive disorder is reported to be 0.3%, and for school-age children, the prevalence of MDD is between four and eight percent. However, adolescents are reported to have a similar rate of major depressive disorder as adults do, which is between fifteen and twenty percent. During childhood both males and females exhibit similar rates of depression, while female adolescents and adults have nearly twice the rate of depression as do males. The differences between male and female depression rates is just one indicator that research must be conducted separately on childhood depression than adult depression for accurate results. (Louders 2004)

Among the causal factors listed by Louders are both genetic and psychosocial factors. Having a family history of depression, especially if there is a first-degree relative that has suffered from major depressive disorder, indicates that a child is predispositioned to depression. Also identified as factors that may cause or predisposition a child to depression are problems with peers, serious or chronic illness, and having had isolated depressive episodes in the past. Factors that will be explored in greater detail throughout this literature review are among the following list of risk factors:

1. Academic difficulties

2. Family dysfunction or caregiver-child conflict

3. Family history of mood disorders, personality disorders, panic

4. disorder, or alcoholism

5. History of anxiety disorders, attention deficit hyperactivity disorder, or learning disabilities

6. Low self-esteem, self-consciousness, poor body image

7. Low socioeconomic status

8. Negative style of coping with stress or interpreting events

9. Severe life events such as death of a loved one or abuse

10. Uncertainty regarding sexual orientation (Louders 2004)

Children with depression have been proven to have similar psychobiological results as adults with depression. In dexamethasone suppression testing, which is the most commonly studies psychobiological parameter related to childhood MDD, children with depression have been shown to have twice the rate of non-suppression of the chemical than do non-depressed children. (Louders 2004) This is the same ratio of suppression vs. non-suppression as found in adults. However, the research that has been conducted for other psychobiological parameters, such as hormonal and chemical balances, have given contradictory results and require further research to determine if there is a correlation. MRI and magnetic resonance spectroscopy studies have shown particular brain abnormalities among depressed adults. However, these areas of research have not been applied to child patients, despite the very important correlation between biological factors and depression.

Denise Gaughan, et al. reported in the article "Psychiatric hospitalizations among children and youths with human immunodeficiency virus infection," in the 2004 edition of Pediatrics, on the effects of illness on depression and psychiatric illness in children. Their report specializes in the issue of pediatric HIV infections, but has implications for illnesses of all sorts. HIV is not unique in its prospects for fatality, though its social stigma does have certain unique aspects. Nonetheless, it seems fair to extrapolate from some of their results to other illnesses.

Gaughan and his colleagues begin their report by recalling that HIV is known to have some psychiatric manifestations, but continue to suggest that few studies have been performed on psychiatric effects requiring hospitalization. They found that among a little over 1800 HIV-infected children, only thirty-two had been hospitalized for psychiatric problems. However, this was a significantly higher percentage than among non-infected children. Most importantly for the subject at hand is the fact that half of these were hospitalized for depression.

All children had been diagnosed with HIV after being infected during their mother's pregnancy. However, not all children were aware of their status. Not surprisingly, children who knew that they were infected with HIV had a significantly higher rate of depression and psychiatric hospitalization. Children who had experience significant life trauma (such as being shuffled through the foster-care systems or losing their family members to AIDS) also had increased rates of depression. However, of the 1021 uninfected "control" subjects who had been born to infected mothers no child was hospitalized with depression. Life experiences, apart from the illness, were otherwise very similar. This shows that the illness was a primary cause of depression.

Gaughan and his colleagues thus concluded that having a serious illness like HIV and being aware of the poor future outlook for people with such a disease is a major cause for depression. Significant life events in the life of ill children are also especially devastating. Applying this research to the topic at hand, one assumes that most major illnesses can be just as emotionally devastating.

A series of medical conditions are common causes of depressive symptoms:

1. Addison's disease

2. Anemia

3. Asthma

4. Diabetes

5. Electrolyte abnormality

6. Epilepsy

7. Hyperkalemia

8. Hyperthyroidism

9. Hypokalemia

10. Lead intoxication

11. Mononucleosis

12. Postconcussion syndrome

13. Systemic lupus erythematosus

14. Vitamin [B.sub.12] deficiency

15. Wilson's disease (Louters 2004)

Other mental disorders may also contribute to childhood depression, as well as being correlating factors. Various academic difficulties have been noted as a manifestations, warning signs, and causal factors of depression among children. Lori A. Manas-Lammers discusses a related issue in the article " The challenge of childhood depression and ADHD: depression in patients who have ADHD is common but may be hard to spot," from The Journal of the American Academy of Physicians Assistants. (2002) It is estimated that up to seven percent of school-aged children suffer from attention deficit hyperactivity disorder, or ADHD. Additionally, it is believed that thirty percent of children with ADHD also suffer from major depressive disorder. When these problems are compounded, the level of impairment is greatly increased in cognitive, social, and psychological areas in comparison to the effects that either ADHD or MDD would have alone. In severe depression cases such as these, early diagnosis and regular treatment is vital.

The symptoms of ADHD and MDD may appear to be very similar. If a child has been diagnosed with depression or with ADHD, if the other disorder is also present, it is likely that it may be assumed that the symptoms are caused by the already diagnosed disorder alone. " For example, poor concentration is common to both conditions but has different causes. In MDD, poor concentration may be due to loss of interest in usual activities, but the rapid shifting among activities that indicates poor concentration in ADHD is not typical of major depression." (Manas-Lammers 2002) Additionally, children with ADHD often suffer from temporary periods of unhappiness that may mimic depression. Demoralization due to the consequences of ADHD difficulties is normal and can usually be worked through without taking extreme treatment measures. Demoralization will be resolved simply by treating the ADHD. However, an ADHD suffering child that also has MDD will have persistent depression, and a negative self-image can lead to the belief that all negative outcomes are personal failures. Daily occurrence of depression-like symptoms are a serious indicator that MDD might be present. Children with both ADHD and MDD must be treated for both disorders.

Manas-Lammers (2002) discusses a significant issue in diagnosis of MDD and other emotional or mental disorders in children. Parents, as mentioned previously, may be unaware of the manifestations -- or unaware of the significance of these symptoms -- of depression in children. Physicians and other professionals must be aware of any instances of a parent's description of symptoms and history not matching the child's self-report. Accurate diagnosis is most likely when a team approach is taken, where the reports of the child is taken into account along with the reports of parents, teachers, and mental health specialists. All possible causes of the symptoms reported by any source should be considered; before the conclusion is made that MDD is the underlying cause, an attempt should be made to isolate and rule out other factors such as ADHD medication or temporary life situations.

The following are among the psychiatric causes of depressive symptoms:

1. Adjustment disorder with

2. depressed mood

3. Anxiety disorder

4. Attention deficit hyperactivity disorder

5. Bereavement

6. Bipolar disorder

7. Substance-induced mood disorder (Louters 2004)

Temporary life situations can cause temporary depressive states of mind in children. However, an event which may seem temporary can in fact have lasting effects on the mental health of children. Erin Verkler discusses the possibility of divorce as a factor which will predisposition children to major depressive disorder in the article "Divorce-proof your kids: cut their risk of depression, anxiety, and substance abuse." (2003) "Children of divorce are at high risk for depression and anxiety, acting out, and substance abuse problems." (Verkler 2003) Many professionals suggest that families become involved in programs that will help children learn skills and cope with the change in the family. An event such as divorce can trigger MDD, and this childhood depression can last throughout adolescence and into adulthood.

Just as family situations can predispose children to depression, peer relationships and situations can be a causal factor in major depressive disorder among children. In the article "Anxious solitude and peer exclusion: a diathesis-stress model of internalizing trajectories in childhood" from the journal of Child Development (2003), peer exclusion is identified as a risk factor for childhood depression. In a study of kindergarten students, the combination of individual vulnerability and interpersonal adversity was found to be a strong indicator that the child is predisposed to depression. A child that is likely to be teased, bullied, or excluded by their peers has a much higher likelihood of becoming depressed. This could be a correlative factor because personality traits which make some students particularly vulnerable to being teased or being strongly affected by the teasing could in themselves be indicators of MDD. The bullying or other peer relation problems also may be the actual trigger. There are many important specific and general issues that must be addressed regarding peer relations in children and the impact of these factors on childhood depression and overall mental and emotional well-being of the individual.

Situations such as a family divorce in the home, or peer relation difficulties at school, are traumatic events or situations that are very close to the child and happen directly to them. However, trauma can be induced by larger events that may not have a personal connection to the child. Wanda Fremont discusses one of these very frightening and large factors in the article "Childhood reactions to terrorism-induced trauma: a review of the past 10 years," from the Journal of the American Academy of Child and Adolescent Psychiatry (2004). According to Fremont, the effects that national terrorism events have on a child mentally are very similar to the effects that a natural disaster may have on a child, which has been documented as a factor which will predispose children to depression. However, Fremont is also clear that the subject of terrorism-induced trauma and childhood depression is an under-researched topic. "To develop a proactive and strategic response to these reactions, policy makers and clinicians alike must understand the psychological effects of terrorism on children. Unfortunately, little clinical information and research exist on this topic....Further research is needed to identify children at risk and to determine the long-term impact on children's development." (Fremont 2004) This area has been given significantly more attention in the past decade, and specifically since the events of the Oklahoma City Bombing and the Terrorist attacks of September 11th there has been an increased amount of attention in this area.