Table of Contents
1. What is childhood depression?
(c) Myths about Teenage Depression
(e) Symptoms and Signs of Depression
2. Causes of Depression
3. Predictive Factors
4. Defenses against Depression
5. Risk Factors
6. Anxiety Disorders and Depression
7. Subtypes of Depression
(b) Bipolar Disorder
8. Related Issues
9. Treatments for Depression
(c) Alternate Medication
(d) Diet & Exercise
(b) Reasons for Suicide
(d) Warning Signs
(a) Appendix A: DSM-IV-TR Criteria for Major Depressive Episode
(b) Appendix B: DSM-IV-TR Criteria for Generalized Anxiety Disorder
(c) Appendix C: DSM-IV-TR Criteria for Dysthymic Disorder
1. What is childhood depression?
As adults, when we think back to our childhood, many of us remember this period in our lives as a ‘happy’ time, free from the stresses and worries that accompany adulthood. The reality of the matter is that many children do experience stress and anxiety, similar to that of adults and this can, and often does result in children and adolescents in particular, experiencing mild to severe depression. According to Gerali (2009), depression is one of the most common issues that adolescents deal with and it affects teenagers regardless of their race, ethnicity, gender or socioeconomic status.
It is quite normal for peoples’ mood to change during the course of a day, and many experience mood changes from hour to hour, but when those moods become completely overwhelming and all consuming or fluctuate wildly, they may be indicative of some kind of mood disorder (McIntosh & Livingston, 2008). A depressed child will show characteristics similar to those of adults but there tends to be more self-blame, self-criticism and a generally poorer self-concept among teenagers who are experiencing depression (Jaenicke, Hammen, Zupan, Hiroto, Gordon, Adrian, & Burge , 1987).
Symptoms of depression begin to increase around the time of puberty and are characterized by intense feelings of sadness and worthlessness, accompanied by a sense of futility resulting in withdrawal from social situations (Sue, Sue & Sue, 1997; Berk, 2000).
During the course of this paper, I will focus on defining teenage depression, isolating the causes and predictive factors in conjunction with certain risk factors. Anxiety as a correlate of depression will be highlighted and two of the more common manifestations of depression, dysthymia and bipolar disorder will be outlined. Coexisting issues and the course of treatment will be addressed; ending with insight into suicide in adolescents. The point of departure needs to be a working concept of depression as it pertains to adolescents.
Adolescence is defined as the period of development marked at the beginning by the onset of puberty and at the end by the attainment of physiological or psychological maturity. In Reber & Reber (2001), depression is defined in two categories: (1) Generally, a mood state characterized by a sense of inadequacy, a feeling of despondency, a decrease in activity or reactivity pessimism, sadness and related symptoms; (2) In Psychiatry, any of a number of mood disorders in which the above characteristics are extreme and intense.
Mood disorders are generally divide into two main categories: depressive disorders (the focus of this paper, often referred to as ‘unipolar’ disorders) and bipolar disorder. While mood disorders involve depression, or mania, or both; our focus will be on the depressive disorder comprised of the depressive pole of mood disorders. In Sue, Sue & Sue, (1997) the connectedness of mood disorders is charted and reproduced below:
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The DSM-IV lists three kinds of depression:
- Major Depressive Disorder, single episode (acute depression)
- Major Depressive Disorder, recurrent
- Dysthymic Disorder
(Cytryn & McKnew, 1996)
The most easily recognized mood disorder is major depressive disorder, single episode, defined by the absence of manic or hypomanic episodes before or during the disorder. We do now know that an occurrence of just one isolated depressive episode in a lifetime is rare (Angst & Priezig, 1996). Although dysthymic disorder shares some of the symptoms of major depressive disorder, it is milder in severity but persists relatively unchanged over long periods of time (Akiskal & Cassano, 1997).
Dysthymia will be discussed later, but sadly, most people who do experience dysthymia, eventually experience a major depressive episode (Klein, Lewinsohn & Seeley, 2001).
The prevalence of depressive disorders is on the increase. The World Health Organisation (WHO), noted that depression and suicide among adolescents (aged 15 to 19 years) has increased in ninety of the one hundred and thirty member countries (Gerali, 2009). According to the 2004 study by the National Survey on Drug Use and Health, some 10% of adolescents, aged 12 to 17 yeas had at least one major depressive episode (Rutledge, 2007). Gerali (2009) adds that as many as 1 in 8 American teenagers suffer from one or another form of depression.
Depression is believed to affect as many as 1 in 3 people at some stage of their life (Stoppard, 2006). A depressed mood is significantly prevalent during the adolescent years, with severe depressive symptoms being recorded in 10% of adolescent boys and 40% of adolescent girls (Petersen, Compas, Brooks-Gunn, Stemmler, Ey, & Grant, 1993). The gender distribution of depression is believed to be approximately equal up to the age of puberty, but becomes more prevalent in girls thereafter (Hankin, Abramson, Moffitt, Silva, MCGee, & Angell, 1998). While the research of Petersen et al, (1993), place the ratio at 1:4 for boy vs. girl prevalence, other studies have placed this ratio as high as 1:2 (Weissman, Leaf, Holzer, Myers, & Tischler, 1984). In developing countries, rates of depression seem to be similar for males and females and occasionally they are higher for males (Culbertson, 1997).
Estimates of prevalence in Sue, Sue & Sue, (1997), suggest that 44 million Americans suffer from symptoms of depression; with estimates of childhood depression ranging from 27 to 52% of the clinical population (Winnett, Bornstein, Cogsuell, & Paris, 1987). Birmaher, Ryan, Williamson, Brent, & Kaufman, (1996) purport that around 15 to 20% of teenagers have had a major depressive episode; and 2 to 8% of American youth are chronically depressed, gloomy and self-critical for a number of months or years. According to the Mood Disorders Society of Canada, between 7, 9% and 8, 6% of the Canadian Population will suffer from depression during the course of their lives (McIntosh & Livingston, 2008). According to The Depression and Anxiety Support Group and The Mental Health Information Centre, there are no available statistics on the prevalence of adolescent depression in South Africa (McLean, 2003).
It is important to note the research of Geller & Del Belo in Preston, O’Neal & Talaga (2009), as they imply that serious depressive episodes in adolescence can indicate the onset of severe and recurrent unipolar depression (35% of cases), or bipolar disorder (48% of cases). Sadly, up to 15% of adolescents who suffer with major depression will ultimately commit suicide (Marcus, 2010; Sainsbury, 1982). Studies by Whybrow, Akiskal & McKinney (1984), indicated that between 50 and 67% of all suicides were related to a primary mood disorder. Another sobering point here is the fact that the rate of suicide in America has increased by 200% in the last decade; with suicide causing more deaths annually among teenagers than cardiovascular disease or cancer (Goldberg in Cooper, 1996).
Parents, teachers and some professionals, have strange ideas about teenage depression, with regards to adolescent depression. Before we continue to the various theories of why children become depressed, let’s look at some myths and try to dispel them first.
(c) Myths about Teenage Depression
Some common misconceptions about teenage depression exist. We look at each individually below:
-It’s just a part of adolescence.
As a parent you may have heard yourself or others comment that teenagers ride a rollercoaster of emotions during adolescence and as such they are always on some extreme high or down-in-the-dumps emotionally. It is common to see teens expressing moodiness during the period of hormonal imbalance, eminent during adolescence; and as such, this moodiness may mask the underlying depression that the teen is experiencing. Later in the course of this paper, specific symptoms and signs to be aware of will be presented.
-It’s a part of culturally induced angst.
This myth suggests that kids are conditioned by the common culture to be depressed, angry and apathetic; as such, they are simply manifesting the conditioned behaviour. It is a relief to acknowledge that depression is not a disorder that teens do, or would want to, emulate. Depression is not manifest as a response to cultural conditioning and should not be viewed as such.
-Adolescents exaggerate; it’s not as bad as it seems.
This myth has the potential to minimize the severity of the feelings of depression of the teenager. It is acknowledged that they can exaggerate and often display attention-seeking behaviours, but to minimize the severity of the feelings of pain is extremely dangerous. Try to refrain from the ‘let’s wait and see what they feel like tomorrow’ syndrome, it is important to view the expressed pain and angst of the child as a serious matter. Your child may be ‘playing up’, but rather err on the side of caution rather than ignorance.
-My child would tell me if she was depressed.
Sadly, many adolescents will endure severe depression without communicating with the care-giver. It may well be that your child does not have the vocabulary to correctly express their feelings; this is particularly relevant for males, as their emotional vocabulary develops at a slower rate than girls. Alternatively, they may not feel ‘safe’ to tell the parent, for fear of radical interventions or the ‘brush-off’ by the parent. It is common for teenagers to suffer in silence.
-My child is just a loner.
On the one hand, teenagers who isolate themselves from their peers can be manifesting symptoms of depression, but on the other hand, teenagers who are part of a social network can also experience severe depression. To ignore the warning signs of depression (discussed later), would be negligent of the parent.
-Depression can be resolved with tough love.
Depression is not a voluntary act; teens do not ‘choose’ to be depressed, they simply are. The idea of tough love is founded on the premise that the child has the ability to will themselves out of the depression; this is totally erroneous thinking and the tough love stance can unfortunately back-fire terribly, pushing the child over-the-edge emotionally, resulting in attempted or completed suicide.
-Antidepressants are harmful.
The idea of not treating depression is a far more risky practice than the potential side effects of antidepressant medication. While we acknowledge that side effects can cause discomfort for the user, not all patients experience the side effects, or the same degree of intensity. It is of value to note here that children and adolescents do not necessarily experience the same benefits from antidepressant medication as their adult counterparts (Hazell, O’Connell, Heathcote, Robertson & Henry, 1995).
Having focused on the myths that surround teenagers and depression, we now focus in on the theories for the development of depression.
There is no single reason for a child developing depression and no single theory has the potential to answer our questions about a child’s depression. The exact cause of depression has eluded scientists for over fifty years, but current knowledge on depression suggests the interplay of biology, psychology and environment as interactive causal factors. What causes one child to become depressed while another seems immune from depression? A number of theories exist as to the potential reasons to answer this question. We briefly discuss each theory here.
The biological theory focuses on brain chemistry. McIntosh & Livingston (2008) suggest that the chemistry of the brain can change, becoming imbalanced, leading to the production of too much or too little of certain chemicals in the brain, which results in depression. Depression is believed to stem from a problem with the neurotransmitters in the brain. While scientists have identified over twenty different neurotransmitters in the brain, three specific neurotransmitters have been isolated as components involved in depression, namely: serotonin, norepinephrine and dopamine. The amount released, the amount present at any given time and the amount of neurotransmitter taken back into the sending cells can lead to the imbalance in chemistry previously mentioned.
Serotonin seems to increase the overall arousal of the brain and the body and results in improved mood (Banich, 2004). Lower levels of serotonin activity has been observed to produce aggression, suicide, overeating and excessive sexual behaviour (Owens, Mulchahey, Stout, & Plotsky, 1997), while heightened levels in the brain are associated with depression (LeDoux, 1996).
Other studies into brain chemistry have suggested a deficit in activity of the prefrontal cortex (Mohanty & Heller, 2002), and the research of Videbach (2000) purports that depression is associated with a reduction in cerebral blood flow and metabolism in the prefrontal cortex, anterior congulate gyrus and the basal ganglia. Increasingly, there is a move towards the belief that certain people are born with a specific brain chemistry that makes them prone to experiencing depression (Rutledge, 2007).
This theory looks at the causal effect of the child’s environment, the events that happened to the child that may have caused the depression. This could include divorce of the parents; this ideology has its roots in psychoanalytic theory. Freud focused on ‘losses of a loved object such as a parent or a pet.
In addition, the child turns the anger generated from loss, inwards. In ability to express the anger at the object or person, causes the child to express the anger inwardly, resulting in him becoming sad and eventually depressed. The child may be unable to achieve a self-important goal and as such this frustration leads to depression.
Finally, an inability to successfully separate from the parents can lead to feelings of inadequacy and a poor self-image, leading to insecurities and eventually depression.
Too much negative reinforcement and not enough positive reinforcement can make a child depressed. Also, this theory suggests that a child can ‘learn’ to be depressed by observing the depressed behaviour of others or events that occur around him.
If parents manifest depressive symptoms when they are disappointed or frustrated, the child will learn to mimic this behaviour and behave accordingly when they are responding to stressors in their life.