Patient Safety / Quality

Recognizing depression in children

Whether or not you learned about it in nursing school, children do suffer depression. In the United States, depression occurs in about 5% of children and adolescents. But because a depressed child’s symptoms may differ strikingly from an adult’s, the condition often goes unrecognized and untreated. With a better understanding of childhood depression, you can help families recognize and cope with the problem and find appropriate treatment.
Unlike the sad mood and energy loss typically seen in adults, depression tends to cause irritability, anger, and behavioral problems in children. They may lose interest in school and extracurricular activities, throw temper tantrums, and withdraw from friends and family. Younger children may experience somatic complaints, such as headache or stomachache. Teens may develop eating disorders, start drinking or using drugs, or engage in promiscuous sex.
To complicate matters, children generally don’t articulate their feelings as well as adults. What’s more, parents may be reluctant to seek diagnosis and treatment for a child, because of the stigma linked to mental illness or fear that their parenting ability may be questioned. To top it all off, primary healthcare providers may not routinely screen children for depression, and relatively few mental health professionals are trained specifically to work with children.

The added dangers of childhood depression
Seriously depressed children feel miserable and need help—reason enough for our concern. But unrecognized childhood depression poses added dangers. Throughout childhood, physical, emotional, social, and cognitive development occurs at a rapid rate; a bout of untreated depression may cause a major developmental setback. Academic performance may lag and the child may be unable to catch up. Also, lost friendships and withdrawal from activities can impair development of social skills, and interpersonal conflicts may cause family dysfunction.
Of course, the most serious concern is that the child may attempt or commit suicide. Many children younger than age 10 think about death; some make clumsy suicide attempts, such as jumping from high places or swallowing a handful of pills. Among children ages 10 to 18, suicide is the third leading cause of death.

Assessment
If a child shows troubling behavior changes, a logical starting place is a visit to the primary care provider, who can take a history, perform a physical examination, and order basic laboratory tests to rule out medical problems whose symptoms mimic those of depression.
The primary care provider also should screen for depression using a simple tool, such as the Children’s Depression Inventory or the Center for Epidemiological Studies Depression Scale for Children. In young children, initial evaluation should include suicide risk assessment. The practitioner should ask, “Are you thinking about hurting or killing yourself?” and take seriously any suicidal thoughts the child expresses.
Obviously, concerns about suicide influence the decision regarding immediate referral to a mental health professional. A child who’s severely depressed or at high risk for suicide must be referred to a specialist and may even need to be admitted to a hospital.Treatment
If evaluation suggests a child is suffering depression, the treatment plan ideally should include psychotherapy or psychosocial support from a mental health professional experienced in working with children. Antidepressant drug therapy should also be considered.
Cognitive-behavioral therapy has been used extensively—and successfully—with depressed adults and can be modified for use with children. Interpersonal therapy gives the child an opportunity to talk about troubling situations and to learn and practice the skills needed to foster positive relationships. After the death of a loved one, bereavement counseling might make sense if symptoms emerged after the loss. Family therapy, which focuses on family system functioning, could also be considered.
However, professional psycho­therapy for a child can be costly. Many insurance plans don’t cover the cost of psychotherapy, or the family may not have health insurance. Also, psychotherapists may be difficult to find; the few psychotherapists trained to work with children are clustered mainly in urban areas.
Whether or not psychotherapy is available and affordable, every depressed child should receive psycho­social support. The primary care provider should teach the family about depression and help them develop a plan for supportive care at home. Be sure to inform parents about available resources. (See Resources for battling childhood depression.)

Antidepressant drug therapy
Antidepressants, primarily selective serotonin reuptake inhibitors (SSRIs), may be used to treat depressed children and can be prescribed by the primary care provider or a specialist in child psychiatry. All antidepressant drugs can cause a small but statistically significant increased risk of suicidal thoughts or attempts in children and adolescents. However, nothing prohibits a practitioner from prescribing antidepressants for children. Currently, the only one approved for use in patients younger than age 18 is fluoxetine (Prozac).
In an extensive meta-analysis of rigorously conducted research studies measuring therapeutic effects and incidence of suicidal thoughts and suicide attempts in children receiving SSRIs, potential benefits clearly outweighed the risks. Nonetheless, practitioners must weigh potential benefits and risks for each individual child.
When antidepressant drug therapy is prescribed, the prescribing professional, the child, and family members must not view it as a magic pill that will make everything better right away. These drugs typically take 4 to 6 weeks to improve mood. In the meantime, the child may be at increased risk for suicidal thoughts, self-harming behaviors, or other impulsive behaviors. Inform parents that the child needs especially close supervision during this time. Provide the telephone number of a healthcare provider or therapist they can call 24 hours a day if they’re worried about changes in the child’s mood or behavior. The physician or nurse practitioner should contact the family at least once a week to monitor the child’s status.

Teaching parents
Instruct parents to lock up or discard potentially lethal items, such as weapons, poisons, or medications (both prescription and over-the-counter). Emphasize that depressed children need to know others care about them and that there are adults they can trust and talk to—especially if they seem to be feeling worse. Also inform parents that most people of any age who receive appropriate treatment for depression recover or show significant improvement.

Selected references
Bhatia S, Bhatia S. Childhood and adolescent depression. Am Fam Physician. 2007;75(1):73-80.
Bridge J, Iyengar S, Salary C, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007;297(15):1683-1696.
Garzon, D. Childhood depression: diagnosis and management in an era of black box warnings. Adv Nurse Pract. 2007;15(2):35-44.
Jeffery D, Sava D, Winters N. Depressive disorders. In: Cheng K, Meyers K, eds. Child and Adolescent Psychiatry: The Essentials. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005.
For a complete list of selected references, visit www.AmericanNurseToday.com.

Jean Nelson, PhD, RN, is a Clinical Assistant Professor at the University of Missouri-St. Louis College of Nursing in St. Louis.


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