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Educating the Depressed Child
Clinical depression in children (like clinical depression in adults) involves persistent sadness, discouragement, loss of self-worth, and loss of interest in usual activities. To be diagnosed with clinical depression (or a major depressive episode), depressive states must affect children for lengthy periods of time. Childhood depression can also range from mild to moderate. Signs of depression can manifest in varying degrees. It is important that caretakers and teachers not misinterpret depression as a personal weakness or a character flaw. As the National Alliance on Mental Illness explains children and adolescents dealing with depression “cannot simply ‘snap out of it.’”
Definitions from Various Sources
National Alliance on Mental Illness-Depression is a brain disorder (mental illness) that affects the whole person-it affects the way one feels, thinks, and acts.
American Academy of Child and Adolescent Psychiatry- Depression is defined as an illness when the feelings of depression persist and interfere with a child or adolescent’s ability to function.
National Institute on Mental Health- When a person has depression, it interferes with his or her daily life and routine, such as going to work or school, taking care of children, and relationships with family and friends.
Criteria for Major Depressive Episodes in Children, and Adolescents
A. Symptoms do not meet the criteria for mixed bipolar disorder.
B. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. Symptoms are not caused by the direct physiologic effects of a substance (e.g., drug of abuse, medication) or a general medical condition (e.g., hypothyroidism).
D. Symptoms are not caused by bereavement-i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
E. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is (1) depressed mood or (2) loss of interest or pleasure.
(1) Depressed mood most of the day, nearly every day, as indicated by subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)
(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation made by others).
(3) Significant weight loss when not dieting, or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day
(4) Insomnia or hypersomnia nearly every day
(5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feeling of restlessness or being slowed down)
(6) Fatigue or loss of energy nearly every day
(7) Feeling of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (by subjective account or as observed by others)
(9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Adapted with from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed. rev. Washington, D.C.: American Psychiatric Association, 2000:356,
Prevalence Rates
-About 2% of school-age children (i.e. children 6-12 years of age) appear to have major depression at any one time. National Alliance on Mental Illness 2003
-With puberty, the rate of depression increase to about 4% major depression overall. National Alliance on Mental Illness 2003
- In 2004, 9.0 percent of adolescents aged 12 to 17 (an estimated 2.2 million adolescents) experienced at least one major depressive episode (MDE) in the past year National Survey on Drug Use and Health
- Among adolescents aged 12 to 17 who reported having experienced an MDE in the past year, less than half (40.3 percent) received treatment for depression during that time National Survey on Drug Use and Health
-With adolescence, girls, for the first time, have a higher rate of depression than boys. This greater risk for depression in women persists for the rest of life. National Alliance on Mental Illness 2003
-Overall, approximately 20% of youth will have one or more episodes of major depression by the time they become adults. National Alliance on Mental Illness 2003
-Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15-44.
Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27
Treatments
Because development and behavior varies from child to child it is important that a child who is suspected of being depressed is examined by his/her physician to rule out physical symptoms. Pediatricians may then recommend a consultation with a psychiatrist or psychotherapist. Based on studies conducted by the CDC and NIMH (a division of NIH), it has been concluded that the most effective treatment method for depressive episodes is a combination of psychotherapy and medication. In the Treatment for Adolescents with Depression Study conducted by NIMH research conducted at 13 sites nationwide, show that 71 percent responded to the combination of fluoxetine (Prozac) and CBT (cognitive behavior therapy). The other three treatment groups, of participants between the ages of 12 and 17, also showed improvement, with a 60.6 percent response to fluoxetine-only treatment, and 43.2 percent response from those receiving only CBT. The response rate was 34.8 percent for a group that received a placebo. There are four classes of anti-depressants prescribed to depressed children: Selective Seratonin Reuptake Inhibitors or SSRIs (Prozac), Atypical Antidepressant Medication (Wellbutrin), Monoamine Oxidase Inhibitors or MAOIs (Parnate or Nardil) and Trycyclic Antidepressants (not as commonly used because of a high risk of overdose, marketed as Elavil or Norapramin) Children taking anti-depressants should be carefully monitored to ensure they are responding positively to their medication. The FDA has warned that anti-depressants can cause suicidal ideations in children and adolescents. There is typically a one to three week gap from when a child starts taking a medication and when he/she senses relief from his/her symptoms.
Suggested Interventions from the Classroom
-teach coping skills -get students physically active -celebrate successes
-encourage journaling -monitor nutrition -track support over time
-teach social skills/emotional intelligence -increase student control over environment
-avoid point systems and token economies
Prognosis
Undiagnosed and untreated depression can be fatal for students. One in 10 children/youth with major depression will attempt suicide (World Health Organization).Most depression sufferers typically endure more than one major depressive episode over their lifetimes. It is important that support systems are established for individuals with depression so they can easily reach out for help should they need it.