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Depression in Children and Adolescents

In children and adolescents, the most frequently diagnosed mood disorders are major depressive disorder, dysthymic disorder, and bipolar disorder.

Major depressive disorder is a serious condition characterized by one or more major depressive episodes. In children and adolescents, an episode lasts on average from 7 to 9 months (Birmaher et al., 1996a, 1996b) and has many clinical features similar to those in adults. Depressed children are sad, they lose interest in activities that used to please them, and they criticize themselves and feel that others criticize them. They feel unloved, pessimistic, or even hopeless about the future; they think that life is not worth living, and thoughts of suicide may be present. Depressed children and adolescents are often irritable, and their irritability may lead to aggressive behavior. They are indecisive, have problems concentrating, and may lack energy or motivation; they may neglect their appearance and hygiene; and their normal sleep patterns are disturbed (DSM-IV).

Despite some similarities, childhood depression differs in important ways from adult depression. Psychotic features do not occur as often in depressed children and adolescents, and when they occur, auditory hallucinations are more common than delusions (Ryan et al., 1987; Birmaher et al., 1996a, 1996b). Associated anxiety symptoms, such as fears of separation or reluctance to meet people, and somatic symptoms, such as general aches and pains, stomachaches, and headaches, are more common in depressed children and adolescents than in adults with depression (Kolvin et al., 1991; Birmaher et al., 1996a, 1996b).

Dysthymic disorder is a mood disorder like major depressive disorder, but it has fewer symptoms and is more chronic. Because of its persistent nature, the disorder is especially likely to interfere with normal adjustment. The onset of dysthymic disorder (also called dysthymia) is usually in childhood or adolescence (Akiskal, 1983; Klein et al., 1997). The child or adolescent is depressed for most of the day, on most days, and symptoms continue for several years. The average duration of a dysthymic period in children and adolescents is about 4 years (Kovacs et al., 1997a).

Sometimes children are depressed for so long that they do not recognize their mood as out of the ordinary and thus may not complain of feeling depressed. Seventy percent of children and adolescents with dysthymia eventually experience an episode of major depression6 (Kovacs et al., 1994). When a combination of major depression and dysthymia occurs, the condition is referred to as double depression.

Bipolar disorder
is a mood disorder in which episodes of mania alternate with episodes of depression. Frequently, the condition begins in adolescence. The first manifestation of bipolar illness is usually a depressive episode. The first manic features may not occur for months or even years thereafter, or may occur either during the first depressive illness or later, after a symptom-free period (Strober et al., 1995).

The clinical problems of mania are very different from those of depression. Adolescents with mania or hypomania feel energetic, confident, and special; they usually have difficulty sleeping but do not tire; and they talk a great deal, often speaking very rapidly or loudly. They may complain that their thoughts are racing. They may do schoolwork quickly and creatively but in a disorganized, chaotic fashion. When manic, adolescents may have exaggerated or even delusional ideas about their capabilities and importance, may become overconfident, and may be“fresh” and uninhibited with others; they start numerous projects that they do not finish and may engage in reckless or risky behavior, such as fast driving or unsafe sex. Sexual preoccupations are increased and may be associated with promiscuous behavior.

Cognitive Factors
For over two decades there has been considerable interest in the relationship between a particular “mindset” or approach to perceiving external events and a predisposition to depression. The mindset in question is known as a pessimistic“attribution bias” (Abramson et al., 1978; Beck, 1987; Hops et al., 1990). A person with this mindset is one who readily assumes personal blame for negative events (“All the problems in the family are my fault”), who expects that one negative experience is part of a pattern of many other negative events (“Everything I do is wrong”), and who believes that a currently negative situation will endure permanently (“Nothing I do is going to make anything better”). Such pessimistic individuals take a characteristically negative view of positive events (i.e., that they are a result of someone else’s effort, that they are isolated events, and that they are unlikely to recur). Individuals with this mindset react more passively, helplessly, and ineffectively to negative events than those without a pessimistic mindset (Seligman, 1975).

There is uncertainty over whether this mindset precedes depression (and represents a permanent style of thinking as part of an individual’s personality), is a manifestation of depression that is only present when the patient is depressed, and/or is a consequence or“scar” of a previous, perhaps unnoticed, depressive episode (Lewinsohn et al., 1981). This pessimistic mode of thinking does not occur in children under age 5, which could be one of the reasons why depression and suicide are rare in early childhood (Rholes et al., 1980; Rotenberg, 1982).


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