Depression in Children and Adolescents ?
Q.Major depression in the pediatric population is readily diagnosable using DSM-IV criteria, i.e. the criteria sets work. Nevertheless, there are clear age-related differences between children, adolescents and adults in depressive symptoms and associated features. For example, adolescents are more likely to complain of feeling sad without looking sad, whereas younger children and adults also look sad when depressed. Irritability also seems to be a much more prominent symptom in pediatric than in adult depression. Excluding somatic symptoms (in smaller children) and sleep rhythm disturbances (in adolescents), vegetative symptoms may be somewhat less common in young persons than in adults.
A.Like other disorders, major depression is commonly comorbid with other internalizing and externalizing disorders. The anxiety disorders often precede MDD, especially in younger children. Subtle anxiety symptoms sometimes remain when depressive symptoms resolve, and may form the nidus for a recurrent depressive episode. Conduct disorder and substance abuse may pose a significant problem in depressed adolescents. Comorbid disruptive behaviors may signal comorbid bipolarity in a substantial number of depressed acting out youth. Conversely, while ADHD and hypomania overlap symptomaticallyand most if not all children with bipolar disturbances meet DSM criteria for ADHDfew children with ADHD are bipolar. Absent thought disorder symptoms and/or clear mania, our practice is to treat ADHD symptoms first and only then to target residual affective symptoms are representing bipolarity. Finally, learning problemswhether due to failure to acquire skills due to affective illness and/or to comorbid neurocognitive impairmentsare not uncommon in youth with internalizing psychopathology. If impediments to successful learning are not addressed, school-related demoralization will confound the outcome of treatment for MDD. Whats the take home message? When a depressive episode strongly resembles major depression in adults; cross multiple contexts, including home, school and peers; is associated with anxiety disorders; shows a seasonal pattern; and occurs in the context of a strongly positive family history for affective and/or anxiety disorders, it is probable that the youngsters major depressive disorder is continuous with if not identical to adult major depression. However, at our current level of understanding, it is not possible to know whether pediatric MDD (or even more, bipolarity) is the same disorder, an etiopathogenically distinct disorder or simply an otherwise unconnected risk factor for adult MDD. Before venturing on to treatment, it is important to address suicide as a possible outcome of pediatric affective illness. While the population prevalence of suicide in the context of depression is unknown, affective illness (especially bipolar disorder) is a principal risk factor for suicide attempts, and even more, for completed suicide. Other risk factors include coincident post-traumatic symptomatology, including borderline personality disorder; conduct disorder and substance abuse or dependence; and ongoing psychosocial adversity. When these factors are present, and the youngster shows signs or symptoms of aggression toward self or others, safety becomes the primary consideration. Once safety is assured, suicidality should bias the treatment toward multi-modality therapy, probably including family-based interventions, that target not only depressive symptoms but accompanying comorbidities as well. Treatment begins with psychoeducation, the goals of which include: (1) defining the nature and natural history of the disorder; (2) differentiating psychosocial from pharmacological treatments and their targets; (3) defining the symptoms for which the family and school can assume responsibility; (4) discussing the indications, risks and potential benefits of medication and psychosocial treatments; and (5), helping children and families come to terms with what will in all likelihood be a chronic recurring problem.
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