Understanding Childhood Depression

Bhatia and Bhatia (2007) reported that at any given time, up to 15 percent of children and adolescents experience some symptoms of depression. Of this 15 percent of children and adolescents, 5 percent of those aged nine to 17 meet or exceed the requirements for major depressive disorder. According to Bhatia and Bhatia, childhood depression affects growth and development, academic performance, and friend and family relationships, and it can be fatal. Bhatia and Bhatia further explained that children who suffer from depression run a two- to fourfold risk of depression persisting into adulthood. Bhatia and Bhatia attributed this intensified risk of persistent depression to the fact that more than 70 percent of children who suffer from depressive disorders do not receive appropriate diagnosis and treatment.

Defining Childhood Depression

"The Harvard Mental Health Letter" (2002) posited that for a number of years, children who exhibited symptoms of what would be diagnosed as depression in adults struggled silently as they were labeled as shy, lazy, or disobedient. These symptoms of childhood depression were normally attributed to an adjustment disorder, attention deficit disorder, or conflicts with parents, teachers, siblings, and peers. "The Harvard Mental Health Letter" further explained that the symptom presentation of childhood depression is extensive and varied, making it a disorder that is not easily recognized. "The Harvard Mental Health Letter" described the following:

Depressed children may insist, heartbreakingly, that they are stupid and ugly, could never accomplish anything worthwhile, and will never be loved. . . . [However], a child who hits his baby sister, picks fights at school, or has frequent stomachaches or headaches may be as depressed as one who is obviously morose or withdrawn. And some typical symptoms of depression in adults . . . are much less common in children and adolescents. (p. 1)

Normal Sadness vs. Clinical Depression

In diagnosing childhood depression, Fassler and Dumas (1997) stressed a necessary distinction between good sadness and bad sadness. Fassler and Dumas described sadness as a normal and healthy emotion that often serves as a temporary response to some big changes in life. In contrast, depression is described as a debilitating disease that is intense, pervasive, and sustained over time. Fassler and Dumas emphasized that the negative feelings of sadness, while powerful, are too short-lived to be considered true symptoms of depression.

The most recent edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) stated that an individual has suffered a "major depressive episode" if certain symptoms persist for at least two weeks, including a loss of pleasure in previously enjoyable activities, a morose or irritable mood, difficulties sleeping or concentrating, and feelings of worthlessness. Fassler and Dumas (1997) contended that while similarities exist between the DSM-IV-TR criteria for adult depression and childhood depression, there are also major differences which must be taken into consideration. For example, Fassler and Dumas reported that depressed children normally do not experience their symptoms for two weeks straight, rather the symptoms of depressed children come and go frequently over a period of time. In effect, Fassler and Dumas contended that determining the extent to which a child's sad feelings and behavior interfere with his everyday experiences and normal development is crucial in the diagnosis of childhood depression.

Causes of Childhood Depression

Shapiro (1994) reported that all mental health professionals agree that depression is caused by multiple factors that interact with each other, some exerting more influence in certain situations and others having more influence at various times. In addition, Fassler and Dumas (1997) contended that the development of depression depends upon a wide range of risk factors, such as temperament, relationships with loved ones, how the child is parented, and various life experiences. In effect, no simple explanation exists.

Biological theories. Janzen and Saklofske (1991) reported that biological explanations of depression have investigated the roles of heredity, biochemical, hormonal, and brain factors. Shapiro (1994) asserted that although depression runs in families, it is not known whether it is inherited or comes from the family environment. In support of the heredity theory, Shapiro reported that adopted children are more likely to become depressed if their biological parents also suffered from depression. In addition, twins consistently exhibit a strong genetic tie to depression. Shapiro explained that if one identical twin is depressed, a 65 percent chance exists that the other one will be depressed, too.

Fassler and Dumas (1997) found that an increasing number of mental health professionals have come to believe that biochemical makeup plays a key role in causing depression. According to Fassler and Dumas, certain people are born with the type of brain chemistry that makes them depression prone. In contrast, some people may start out healthy but then experience a traumatic event that alters their brain chemistry and increases their vulnerability to depression. Fassler and Dumas explained that reduced availability of the neurotransmitters serotonin, norepinephrine, and dopamine can either serve as a catalyst for clinical depression or make a child more vulnerable to it when challenged by life's many stressors.

Psychological theories. Shapiro (1994) reported that Sigmund Freud was one of the first to identify object-loss, the loss of a love object, as a cause of depression. According to Fassler and Dumas (1997), many traditional psychoanalysts view depression as anger turned inward against the self, a theory which originated with Freud's work. Shapiro explained that when the child loses his parent because the parent is either physically absent or emotionally unavailable, the child feels angry. However, according to Fassler and Dumas, the angry child may find it impossible to confront someone who is viewed as all-caring. In effect, the child blames himself for being unlovable and turns his anger inward, becoming withdrawn and depressed.

In addition, Janzen and Saklofske (1991) contended that psychological descriptions have correlated depression with the loss of loved ones, conflicts in the parent-child relationship, and threats to self-esteem. Janzen and Saklofske further explained that the ways in which children interpret and structure everyday experiences and the belief they have about their capacity to control and shape their world may also have a profound effect on the state of mind of the child. Fassler and Dumas (1997) added that a preponderance of research links depression in adults to events that occurred in their childhoods.

Cognitive and behavioral theories. Shapiro (1994) believed that depressed children think differently about themselves and the world than non-depressed children do. Shapiro compared the depressed child's thought processes to the "cognitive triad" emphasized by psychiatrist Aaron Beck. The cognitive triad of depression is defined as "a negative view of oneself, the world, and the future" (Shapiro, 1994, p. 25). In addition, Fassler and Dumas (1997) reported that children can actually learn to be depressed by observing the environment. Shapiro described this phenomenon as "learned helplessness," stating that "Children who are depressed . . . view themselves as the cause of everything, so they take total responsibility and view the situation as unchanging" (p. 26). Shapiro further explained that these learned belief systems originate within the child's family.

Fassler and Dumas (1997) reported that children can also become depressed if they receive too much negative, or not enough positive, reinforcement. Shapiro (1994) added that behaviorists believe that the symptoms of depression result from difficulties in interacting with other people. In effect, depressed people experience a paucity of positive feedback from others, because they lack the social skills to elicit such feedback. Furthermore, Shapiro reported that depressed children tend to have impaired relationships with their mothers and peers and are often rated as less popular and less socially competent.

Family systems theory. Fassler and Dumas (1997) reported that most family systems therapists believe that childhood depression is caused by a dynamic, or pattern of relationships, that occurs within the family. Shapiro (1994) added that while the nature of the presenting symptom is important in itself, it is also a signal that the child and the other family members feel overwhelmed and distanced from meaningful interpersonal contact. Fassler and Dumas also contended that when children grow up in families where emotions are not openly expressed, and where keeping family secrets is the norm, depression may result.

Vulnerable Children

Fassler and Dumas (1997) explained that the reasons why some children become depressed only define the problem retrospectively, that is, after the depression has appeared. In effect, parents and therapists must take into consideration risk factors, which provide information prospectively, that is, before depression develops. Such risk factors signal when a "healthy child is at risk for depression in the future, whether weeks, months, or years away" (p. 16).

Major Risk Factors

Bhatia and Bhatia (2007) reported that risk factors for child depressive disorder include biomedical and psychosocial factors, such as chronic illness, gender, hormonal changes, family history, childhood neglect or abuse, and general stressors. Fassler and Dumas (1997) believed that by understanding the risk factors for depression, parents can more accurately determine if their child is vulnerable, stay alert to warning signs and symptoms, and multiply the chances of recognizing problems early on. Fassler and Dumas further contended that if the child has not yet developed depression, preventative steps can be taken to help offset the problem before it begins.

Gender. Fassler and Dumas (1997) reported that among young children, boys are more likely to be depressed than girls. Fassler and Dumas further explained that when young boys become depressed, they become disruptive, fight and argue with peers and siblings, disobey teachers and parents, and break rules. In contrast, Fassler and Dumas added that young girls who become depressed are more likely to become withdrawn and quiet, making it more difficult to detect a problem. In effect, boys are more likely to be referred to the school counselor, which may explain why more young boys than girls are considered depressed.

Previous depression. Wagner and Ambrosini (2001) reported that depression in children is a serious disorder with high recurrence rates and continuity into adulthood. Fassler and Dumas (1997) found the following:

Fully 44 percent of children who developed depression before age eighteen experienced another episode by the time they turned twenty-four. Other studies have shown recurrence rates of as high as 50 percent - which leads us to believe that the greatest predictor of depression is a previous episode of depression [italics added]. (p. 19)

Fassler and Dumas emphasized that when depression is diagnosed early, and when it is treated effectively, the risk of recurrence can be significantly reduced. In addition, Fassler and Dumas stated that through treatment, children can also learn to identify the feelings or thoughts that may signal an oncoming depression.

Family history. Fassler and Dumas (1997) reported that children with a depressed parent are twice as likely to become depressed as children whose parents aren't depressed. Fassler and Dumas further explained that if both parents suffer from depression, the child's risk quadruples. In addition, Fassler and Dumas stated that research has confirmed that children whose biological parents suffer from depression are at a higher risk even if the children are adopted at birth and raised by parents who have never been depressed.

Stressful life events. According to Fassler and Dumas (1997), stressful life events have cumulative and interactive effects on children who exhibit a predisposition to depression. Fassler and Dumas posited that stressors that interfere with the child's sense of security and his belief that the world around him is relatively stable and secure are more influential than other stressors. Fassler and Dumas further explained that without the solid foundation which is established by stability and security, it is difficult for the child to develop the self-esteem, confidence, and resilience he needs to cope with the struggles of everyday life.

Child abuse and unstable caregiving. Fassler and Dumas (1997) reported that repeated physical, sexual, or emotional abuse puts children at high risk for depression because it prevents them from developing positive self-esteem and self-worth. In addition, ongoing abuse can make a child unable to tolerate any frustration. Fassler and Dumas contended that the issue of child abuse is further complicated by the fact that young children need consistent and predictable relationships with all of the caregivers in their lives. This need for consistent relationships is frequently downplayed, as a growing percentage of at-home mothers use some form of supplemental child care. Fassler and Dumas stated, "When children are pulled in and out of various child care settings, it hinders the development of trust, self-esteem, and coping skills" (p. 29). In effect, multiple or disrupted relationships with caregivers make children more vulnerable to depression.

Problems between Mom and Dad. Fassler and Dumas (1997) posited that children who live in homes in which there is persistent tension between the parents are at a higher risk for depression than children in less troubled environments. Fassler and Dumas further explained that it doesn't matter if the children are actually at the center of the disputes; one way or another, kids tend to blame themselves. In addition, Fassler and Dumas reported that children who are involved in a family divorce endure several injuries, including the loss of the intact family the child has come to know and the changed relationship with the noncustodial parent.

Drug and alcohol abuse. Substance abuse raises a child's risk for depression in several ways. Fassler and Dumas (1997) reported that parents who abuse drug and alcohol are incapable of engaging in consistent relationships with their children. In addition, these parents are also more likely to abuse their children and cause emotional damage. Fassler and Dumas further explained that drugs and alcohol may also disguise depression in children, especially teenagers, who are "abusing these substances not merely to 'get high' but as a way of dulling painful emotions and helping themselves feel normal again" (p. 31). In effect, the underlying cause of children's substance abuse may well be depression. Diagnosis of Childhood Depression

According to the DSM-IV-TR, the diagnosis of major depressive disorder requires at least one episode in which the child has had five or more of the following symptoms, including one of the first two, for a minimum of two weeks: (1) depressed or irritable mood; (2) markedly diminished interest or pleasure in activities; (3) weight or appetite loss or gain; (4) insomnia or hypersomnia; (5) psychomotor agitation or retardation; (6) fatigue or loss of energy; (7) feelings of worthlessness or excessive guilt; (8) decreased ability to think, concentrate, or make decisions; and (9) recurrent thoughts of death or suicide or a suicide attempt or plan.

Symptoms of Childhood Depression

Chrisman, Egger, Compton, Curry, and Goldston (2006) summarized the DSM-IV-TR criteria, stating that in depression, children may report feeling "sad, unhappy, bored or disinterested in usual activities, angry or irritable, or may appear sad and tearful" (p. 111). In addition, Luby et al. (2002) proposed developmentally modified DSM-IV-TR criteria for the diagnosis of depression in preschool children, stating that the prominent symptoms of childhood depression are sad or irritable mood, anhedonia, low energy, eating and sleeping problems, and low self esteem. In effect, Luby et al. encouraged a reduction in the duration requirement for persistence of depressed or irritable mood in children, stating that it must be "present but not necessarily persistently present over a two-week period" (p.111).

Depression in Infants

According to Shapiro (1994), babies who are depressed show the following symptoms: (1) they are lethargic, fussy, and unresponsive; (2) they withdraw from their mother and do not look at her; (3) they rarely smile and turn away from other adults; (4) they do not sleep or eat well; (5) they show little or no curiosity in things around them; (6) they are slow to sit or crawl; and (7) they do not grow at the rate expected for their age.

Shapiro (1994) reported that depression in babies is rare, but when it occurs, it has long-lasting consequences. Shapiro further explained that infant depression reflects a disturbance in the infant-caregiver relationship. Shafii and Shafii (1992) concurred, stating that depression in infants is closely related to the disorders of attachment and mothering, child neglect, maternal deprivation, parental psychopathology, and placement of infants in institutions. Shafii and Shafii further delineated infant depression into the categories of anaclitic depression, hospitalism, and failure to thrive.

Anaclitic depression. Shafii and Shafii (1992) defined anaclitic depression as "partial emotional deprivation in infants" (p. 13). According to Shafii and Shafii, infants who have a good relationship with their mothers during the first six months of life will develop anaclitic depression if they are deprived of their mothers for an unbroken period of three months. Shafii and Shafii further explained that infants suffering from anaclitic depression experience a significant decline in intellectual development. In effect, Shafii and Shafii contended that if the separation between mother and infant continues in excess of one year, the infant's intelligence will deteriorate to the moderate-to-severe retardation range.

Hospitalism. Shafii and Shafii (1992) reported that if total emotional deprivation continues for more than five months, the infant will show " . . . the symptoms of increasingly serious deterioration, which appears to be, in part at least, irreversible" (p. 15). This phenomenon is referred to as hospitalism. Like anaclitic depression, Shafii and Shafii described hospitalism as a manifestation of infantile depression and maternal deprivation in its most severe form. Specifically, Shafii and Shafii attributed hospitalism to maternal depression, parental immaturity, family disharmony, drug and alcohol abuse, child abuse, and emotional neglect.

Failure to thrive. Shafii and Shafii (1992) reported that failure to thrive frequently occurs in multiple-problem families, families prone to child abuse and neglect, and lower socioeconomic families. According to Shafii and Shafii, most infants suffering from failure to thrive maintain a weight that is below the third percentile but gain weight rapidly after hospital admission or environmental changes in maternal care. In addition, Shafii and Shafii reported that one of the most striking clinical features of infants suffering from failure to thrive is apathy. In effect, these infants appear to be joyless and lifeless.

Depression in Toddlers

According to Shapiro (1994) depressed toddlers show the following symptoms: (1) they are angry, aggressive, and irritable; (2) they fight with other children; (3) they are cranky and throw temper tantrums; (4) they either cannot sit still or withdraw into a corner; (5) they have trouble sleeping or have nightmares; (6) they have difficulty following rules and making friends; and (7) they isolate themselves and avoid group situations.

Shapiro (1994) reported that toddlers express their depression through their behavior, which reflects their own unhappiness as well as tensions within the family. In effect, toddlers act out their depression. Shapiro further explained that depressed toddlers do not feel good about themselves and have a negative view of the world; as a result, even play is not fun for them. In addition, Shafii and Shafii (1992) reported that depressed toddlers are at a high risk for regression, developmental arrest, behavior continuity-discontinuity, and transformation of behavior.

Depression in School-Aged Children

According to Shapiro (1994), depressed children show the following symptoms: (1) persistent unhappiness, (2) a negative self-image, (3) loss of interest in activities previously enjoyed, (4) change in sleeping habits, (5) change in eating habits, (6) difficulty concentrating, (7) irritability, (8) unexplained physical symptoms, and (9) talk of death or suicide.

Shapiro (1994) explained that school-aged children express their depression by changes in their moods and behaviors, which reflect their own discontent as well as stresses within the family. Additionally, Shapiro reported that most school-aged children can still have some fun when they are depressed and can also laugh while they watch cartoons or have a lively conversation. In effect, if a school-aged child never laughs, that is a sign of severe depression. Shapiro also stressed the physical symptoms of depression, stating that "just as some children act out their feelings - acting bad or mad - rather than saying that they feel sad, others express their feelings through bodily symptoms" (p. 58).

Depression in Adolescents

According to Shapiro (1994), depressed adolescents show the following symptoms: (1) a change in school performance; (2) inability to concentrate; (3) irritability or anger; (4) persistent unhappiness; (4) a change in eating and sleeping habits; (5) withdrawal from people and activities; (6) excessive guilt or anxiety; (7) physical complaints; (8) aggressive, impulsive, or risk-taking behaviors; and (9) thoughts or talk of death and suicide.

Shapiro (1994) posited that even though adolescents seem more like adults than children because of their physical maturity, troubled teenagers are more similar to depressed children than to adults - their depression shows in their behavior. Shapiro further explained that depressed adolescents may feel the same way on the inside but rarely tell others, particularly their parents, how they feel. As a consequence, depressed adolescents reveal their unhappiness in more covert and self-destructive ways. Shapiro concluded by stating that the challenge "is to see beneath the annoying, offensive behavior to connect with a sad, unhappy child whose behavior signals a cry for help" (p. 69).

Treatment of Childhood Depression

Chrisman, Egger, Compton, Curry, and Goldston (2006) reported that the clinical guideline on the treatment of depression in children and adolescents recommends that children and adolescents suffering from moderate to severe depression should be offered, as a first line of treatment, a specific psychotherapy. Chrisman et al. emphasized that antidepressant medication should not be offered to children or adolescents with moderate to severe depression except in combination with a concurrent psychotherapy and should not be offered at all to children with mild depression.

Psychotherapy

Shapiro (1994) reported that there are 230 different types of psychotherapy for children. Shapiro clarified that most parents pursue a treatment that fits closest to their values and their own view of what is wrong. In addition, Shapiro noted that the choice of treatment is also affected by the resources of the community in which the child lives and by the pediatrician's referral sources.

Psychodynamic therapy. Clarizio (1994) posited that the psychodynamic approach to therapy encompasses three goals: (1) the establishment of a therapeutic relationship and support of the child, (2) the development of insight, and (3) the healthy acceptance of loss. Clarizio explained that individual treatment is based on the child's age, intelligence, level of ego development, ego defenses, as well as on parental attitudes and available facilities. Shapiro (1994) reported that verbal expression, gestures, games, and play are employed in an effort to externalize that feelings of the depressed child. Additionally, Shapiro speculated that for depressed children in particular, this type of therapy encourages active involvement.

Cognitive therapy. Clarizio (1994) stated that in cognitive therapy, depressed children are taught to recognize and correct distortions in thinking and the beliefs that follow. Clarizio found the following:

Depressed children are taught to identify and remedy distortions . . . through the use of several techniques, including recognizing the relationship between cognition, affect, and behavior; monitoring negative thoughts; examining the evidence for and against these thoughts; substituting more realistic interpretations for negative ones; and identifying and changing dysfunctional beliefs. (p. 150)

In summary, Shapiro (1994) stated that cognitive therapy helps people discriminate what they can control from what they can't. In effect, they learn to understand and accept what they cannot control and create strategies for dealing with what they can.

Behavior therapy. Verduyn (2000) reported that behavior therapy teaches depressed children how to modify troubling symptoms and learn more adaptive behavior. In addition, Verduyn explained that behavior therapists are concerned with changing behavior or eliminating symptoms, not with understanding underlying causes. Verduyn stated that behavior therapists are likely to use conditioning techniques, such as giving rewards to encourage positive behaviors and using penalties to eliminate negative behaviors. Shapiro (1994) added that through the use of social skills training, the depressed child's self-confidence increases and their depressive symptoms decrease.

The Role of Medication

Shapiro (1994) posited that medication is an important adjunctive treatment used in combination with all kinds of psychotherapy. Shapiro reported that tricyclic antidepressants, such as Prozac, Wellbutrin, and Zoloft, are normally the first drugs used to treat depression in children, simply because they have the longest track record. However, Scahill, Hamrin, and Pachler (2005) stated that selective serotonin reuptake inhibitors (SSRIs) have all but replaced tricyclic antidepressants in the treatment of childhood depression.

Scahill, Hamrin, and Pachler (2005) reported that in October of 2004, the federal Food and Drug Administration (FDA) issued a warning on the use of SSRIs in pediatric patients. The agency expressed concern that SSRIs increase levels of depression, suicidal thoughts and behaviors, hyperactivity, irritability, and impulsiveness. Additionally, Scahill, Hamrin, and Pachler posited that SSRI treatment is associated with behavioral activation, self-harm, and suicidal ideation. In summary, Shapiro (1994) stated that the appropriate use of any medication in children and adolescents requires "careful diagnostic assessment, evaluation of co-occurring conditions, and diligent monitoring, especially within the first weeks of treatment" (p. 112). Conclusion

Fassler and Dumas (1998) stated that there is much parents and others concerned about the health of today's youth can do in a preventative way to decrease the likelihood and incidence of depression in children. In addition, Fassler and Dumas stressed the need to do whatever necessary to educate Americans about depression and to eliminate the stigma that still surrounds this very common condition. Fassler and Dumas concluded by stating, "Today, almost no child or adult need suffer from depression. If detected early and diagnosed accurately, depression can be effectively treated - and, finally, overcome" (p. 192).

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