from CHAPTER 2

What Is Childhood Depression, Really?

Depression is painful.
—John Preston, You Can Beat Depression

Childhood Depression

Thirty years ago, it was common belief that only the most "mentally disordered" children experienced depression. This perception changed some in the 1980s. However, the greatest theoretical shift occurred in the mid-1990s with advances in brain imaging technology. Suddenly, researchers could see changes in brain function among depressed individuals. Shortly thereafter, clinical depression became more commonly thought of as a medical disease rather than a condition of weak will. More specifically, it was defined as a brain disorder in which "the neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly." Just like other diseases, such as diabetes or heart disease, depression has many different types and levels of severity. Just as any adult could experience depression, so could any child. The causes of depression are complex and unique for each child.

The National Institute of Mental Health estimates that 2.5 percent of all children and 8.3 percent of all adolescents will experience some form of clinical depression. Some estimates suggest as many as one in eleven children may experience some form of clinical depression before the age of fourteen.

The National Institute of Mental Health has also sponsored research indicating that without proper treatment, childhood depression tends to repeat throughout childhood and into adolescence and adulthood, with each successive episode becoming more severe.4 Depression in children has also been linked to eventual cigarette smoking, substance abuse, academic difficulties, physical and health problems, and suicidal behaviors. This is why intervention and relapse prevention is so important for children who have already experienced even a mild form of depression or exhibit depressive symptoms even though not diagnosed with clinical depression.

Symptoms of Clinical Depression

To date, no specific set of clinical criteria exists that exclusively describes childhood depression. Clinicians rely on the criteria outlined for diagnosing adults found in the American Psychiatric Association's fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

The DSM-IV lists nine criteria for a major depressive episode. Simplified, they are

• feeling depressed, sad, or melancholy most of the day, nearly every day
• the inability to experience pleasure or excitement even when doing activities that used to be pleasurable
• serious weight loss or weight gain in a short period of time
• sleeping too much, too little, or not well
• sluggish or jittery movements that are noticed by other people
• feeling tired and experiencing low motivation or loss of energy nearly every day
• feeling guilty a lot, feeling worthless, feeling inadequate
• having trouble thinking clearly, being unable to concentrate or make decisions
• feeling helpless and hopeless, having thoughts of death or suicide or having a plan for suicide

An adult must have at least five of these nine symptoms during a two-week period in order to be diagnosed with major depression. The symptoms must also be preventing a person from functioning well in daily life.

The only comment found in the DSM-IV about children is that "in children the depressed mood can be an irritable mood." In other words, a child may have angry outbursts or frequent temper tantrums.

David G. Fassler, M.D., and Lynne Dumas, in their book "Help Me, I'm Sad," outline specific symptoms for diagnosing clinical depression in children according to age group, from infancy to adolescence. They list a total of forty-six symptoms of clinical depression for children. This illustrates the complexity of diagnosing childhood depression and the incompleteness of the DSM-IV.

If you are concerned that your child is clinically depressed, don't try to diagnose her yourself. Take her to her primary care physician and also a licensed mental health professional. Some organizations that can assist you in locating a physician or other professional are listed in the "Resources" section of this book.

+ + +

Signs and Symptoms of Depression in Children

Diagnosing children with clinical depression can be a difficult task for physicians and mental health professionals. Part of the process is to gather information from parents, teachers, and if possible, friends.

Below is a list of signs and symptoms of depression in children. It is a composite of many lists found in many childhood depression books. The list is divided into four categories: physical, emotional, cognitive (thinking style), and behavioral. Childhood depression may be experienced in one area or several.

Physical:

• significant weight loss or weight gain
• appetite changes: eating too much or too little food
• physical complaints: stomachaches, headaches, and so on
• sleeping too little, too much, or not well; frequent nightmares
• tired all the time; loss of energy; exhaustion

Emotional:

• depressed, sad, or tearful mood
• moodiness; mood swings; easily angered
• anxious, nervous, fearful; worries a lot
• feels guilty a lot; hates self
• feels helpless to change negative situations
• feels hopeless about the future
• seems overly sensitive to criticism or correction

Cognitive:

• thoughts of running away
• suicidal thoughts; thoughts of death or death-related themes
• self-defeating or self-hating thoughts
• helpless and hopeless thoughts
• mostly negative thoughts about most situations (pessimism)
• many thoughts that create excessive or irrational guilt

Behavioral:

• slipping grades
• loss of playfulness or zest for life
• easily discouraged or frustrated
• increased whininess or aggressiveness
• loss of interest in usual pleasurable activities or hobbies
• social isolation; withdrawal
• difficulty concentrating; can't make choices
• can't finish projects
• lets life happen rather than helping to shape its direction
• overactivity; restlessness
• quiet, monotone, one-word answers to questions
• developmentally "going backward," such as soiling pants at age six
• self-injurious behaviors, such as head-banging and cutting oneself
• talking, writing, singing, or drawing about death or suicide
• habitually listening to music with death- or suicide-related themes
• habitually reading books, reading comics, or playing videos with death- or suicide-related themes

Exhibiting a few of these does not necessarily mean your child has clinical depression. She may be experiencing normal sadness, other medical problems, a situational problem, or something else that indicates a different diagnosis or no diagnosis at all. That is why, if you have concerns, you should not attempt to diagnose your child yourself but instead get a more thorough assessment by a qualified professional. If your child is talking about death or suicide, it is vital that you seek professional help immediately.

As stated before, a good place to start the process of assessment is with your child's primary care physician. A physician can evaluate for any medical problems that might be causing depressive symptoms. (Page 14 of chapter 1 discusses several medical conditions that mimic depressive symptoms.) In addition, a primary care physician usually has a list of psychologists, psychiatrists, or licensed master's-degree-level therapists and can often facilitate a referral if needed.

If a thorough assessment by a physician and/or clinician rules out clinical depression, it is not time to relax and go on with life as usual. Depression prevention is needed. From a prevention viewpoint, these signs and symptoms are also target areas for preventive interventions.

¬2003. All rights reserved. Reprinted from Raising Depression Free Children by Kathleen Panula Hockey. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, without the written permission of the publisher. Publisher: Hazelden, Center City, Minnesota, 55012-0176.