Sally L. Eves, Ph.D.
A great deal of research has been focused on the identification and treatment of depression in adults. More recently, a large body of evidence suggests that depression as a clinical disorder also exists in childhood, and that, while it is generally similar to depression in adults, there are significant differences in depression in childhood that are worthy of distinction.
I would like to touch upon those distinctions that have become apparent to me in my work with depressed youth. A primary distinctions of childhood depression is its occurrence at an early point in the person’s life. The child’s developmental level at the onset of depression determines how depression is manifested. The younger the child, the less developed is his/her capacity to verbalize feeling states associated with depression. Therefore, as a child tends to demonstrate his/her appearance and behavior, reports of the child’s behavior by parents or teachers is an important component in diagnosing depression. Another distinction is that the unique needs of the child are important considerations in treatment.
Thus, the child needs to be viewed primarily as a child, and then as a child who is experiencing depression. This subtle but important distinction is an important key to tailoring individual treatment for maximum efficacy. Children are different from adults, and these differences need to be recognized in developing interventions. Thus, the characteristic playfulness and imaginativeness of the child are the innate avenues to therapeutic revelations. Games, stories, and play, the domain of childhood, are invaluable tools in the therapist-child relationship.
While research has shown that children do experience depression as a clinical disorder, it is important for us to translate these findings into our understanding of children. How can depression be recognized in children, and, once recognized, what can be done to help? Depression as a clinical disorder is differentiated from a transitory feeling of sadness or normal grief process largely by its pervasiveness, severity, and longevity of symptoms and its associated impairment in social, academic, or other areas of functioning.
The general features of childhood depression include depressed or irritable mood and anhedonia, or a lack of interest or pleasure (DSM-IV, American Psychiatric Association, 1994). Feelings of depression or irritability may be expressed in sad or angry facial expressions, and social withdrawal or opposition and noncompliant behaviors. Anhedonia may be expressed as boredom or a lack of motivation and diminished interest and participation in previously enjoyable activities, such as sports or hobbies (Kronenberger and Meter, 1996).
Cognitive symptoms include decreased ability to concentrate, often demonstrated in declining school performance. A depressive cognitive style has been identified by Beck (1976) and Seligman (1975) and found in depressed children, as in adults. Beck proposed that the depressed individual views the self, world, and future negatively, reflecting the hopelessness of depression. Seligman proposed a “learned helplessness” model, suggesting that by experiencing uncontrollable, adverse events, the depressed individual believes he/she has no control, feeling helpless and apathetic. Seligman et al. (1984) identified a depressive attributional style found in depressed children , as in adults, in which the depressed individual attributes negative life events to internal, stable, and global factors. For example, a depressed child would be likely to attribute failure on a test to his/her own deficiency (internal) that is unchangeable (stable) and will impact on his/her whole life forever (global).
Additional symptoms in depression include feelings of worthlessness or guilt, which may be demonstrated in the child’s low self-esteem, expectations of rejection, defensiveness, and risk-taking behaviors which set him/her up to be punished. Some children may express their pain in suicidal thoughts, plans or gestures, which need immediate professional attention. Somatic or physical complaints include fatigue and loss of energy, changes in appetite and sleep patterns, psychomotor agitation, a feeling of restlessness, or psychomotor retardation, a feeling of being slowed down (DSM-IV, 1994).
The origins of depression have been postulated to be biological, psychological, and environmental. Children have been found to be at greater risk for depression if a parent or relative has been diagnosed as depressed (Weissman et al., 1987). Environmental stressors in childhood include the loss of a loved one or friend, a sibling leaving home, loss of a pet, moving to a new school, parental fighting, and divorce (Seligman, 1998).
Treatment for depression in children includes psychotherapy in an individual, group, or family format. Medication may also be indicated upon evaluation by a physician. Psychotherapeutic approaches include cognitive-behavioral interventions, psychoeducational interventions such as social skills or relaxation training, and psychodynamic play therapy.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington , DC: Author. Beck, A.T. (1976). Cognitive therapy and emotional disorders. New York: International Universities Press.
Copeland, M.E. (1992). The depression workbook: A guide for living with depression and manic depression. Vermont: Peach Press.
Kronenberger, W.G. and Meyer, R.G. (1996). The child clinician’s handbook. Massachusetts: Allyn and Bacon.
Seligman, M. E. P. (1975). Helplessness: On depression, development and death. San Francisco: Freeman.
Seligman, M.E.P., Kaslow, N., Alloy, L., Peterson, C., Tannenbaum, R., and Abramson, L. (1984). Attributional style and depressive symptoms among children. Journal of Abnormal Psychology, 93, 235-238.
Seligman, M.E.P. (1998). Learned optimism: How to change your mind and your life. New York: Simon and Schuster.
Weissman, M.M., Gammon, G.D., John, K., Merikangas, K.R., Warner, W.V., Prusoff, B.A., and Sholomaskas, D. (1987). Children of depressed parents: Increased psychopathology and early onset of major depression.Archives of General Psychiatry, 44, 847-853.
The author wishes to acknowledge the following individuals for their support:Anne E. Fowler, Ph.D., Department of Psychology, Yale University, David V. Sheslow, Ph.D. , Alfred I. du Pont Hospital for Children Robert H. Wozniak, Ph.D., Bryn Mawr College Christopher T. Hyde, Ph.D., Child Mental Health, State of Delaware