Depression (Children)

Children's Depression Inventory, 2nd Edition:

• A high CDI 2 score is not necessarily diagnostic of a depressive disorder because a high score "could conceivably reflect the effects of a medical illness or the side effects of a medical illness or the side effects of certain medications, or an acute emotional condition with significant functional impairment, which would not meet psychiatric diagnostic criteria. A high CDI 2 score also can indicate emotional difficulties other than depression (e.g., some anxiety or personality disorders tend to have depressive features, and certain symptoms such as sleep disturbance or fatigue are common to various disorders). In other words, while a high score undoubtedly reflects that the respondent is feeling depressed, it does not by itself confirm the presence of a disorder." 

Child & Adolescent Mental Health (Jess P. Shatkin)

• Young children with depression exhibit more symptoms of anxiety (e.g., phobias, separation anxiety, somatic complaints). Depressed children, unlike depressed adults, may not be entirely consumed by depression, "may still be able to enjoy numerous activities, engage with peers effectively, and complete their work relatively well at all times, while demonstrating severe discomfort and behavior problems at other times." 
• Etiology. About "one third of the risk for developing depression is genetically inherited and two thirds of the risk is environmental." 
• Epidemiology. Depression affects 1 percent of preschool children, 2 percent of school-age prepubescent children, and 4-8 percent of adolescents. Male to female ratio: 1:1 during childhood, 1:2 by mid adolescence, and between 1:1.5 and 1:3 for adults. Dysthymic disorder (chronic, low-grade depression) affects .6-1.7 percent of prepubescent children and 1.6-8 percent of adolescents. 
• Clinical course. Clinically referred children and adolescents typically have depression between 7-9 months, while those in the community typically have it 1-2 months. About 90 percent of MDD episodes remit within 1-2 years of onset (remission refers to a 2-week to 2-month period with only one or few clinically significant symptoms). About 50 percent of children and adolescents who have an MDE will experience a second episode after remission. "Factors likely to predict relapse include lack of treatment adherence and increased negative life events." Between 20-40% of children and adolescents who have a MDE will later be diagnosed with bipolar disorder. 
• Diagnosis. Five SIG E CAPSS symptoms for at least two weeks: Sadness. Interest loss. Guilt/worthless feelings. Energy loss. Concentration loss. Appetite change (usually declined, occasionally increased). Psychomotor agitation (unintentional and purposeless motions) or retardation (slowing down of thoughts and movements). Sleep change. Suicide/death preoccupation. DSM-5 criteria mostly similar for adults and children/adolescents with these differences: in place of depressed mood, children may experience an irritable mood (which can be expressed as temper tantrums and oppositional behavior); in place of a significant weight loss, children may simply fail to make expected weight gains. 
• Diagnosis of Dysthymic Disorder (aka persistent depressive disorder): depressed or irritable mood on most days for at least one year (for children and adolescents) in addition to two or more symptoms (changes in appetite, insomnia or hypersomnia, fatigue, poor self-esteem, difficulty with concentration, hopelessness). 
• Diagnosis of Disruptive Mood Dysregulation Disorder (DMDD). DMDD is intended to provide a diagnosis for children with symptoms of (a) chronic and severe irritability and (b) frequent temper outbursts). These children were being given a diagnosis of bipolar disorder even though most individuals with bipolar disorder exhibit clear symptoms of euphoria or elation when in a manic state, not just irritability. These children often exhibit symptoms of other disorders -- ADHD, ODD, CD, anxiety, PTSD. Most of these children not not grow up to have bipolar disorder. 
• Differential diagnosis (the process of differentiating between two or more conditions which share similar signs or symptoms). Disorders to rule out when considering depression: ADHD, anxiety disorders, ODD, learning disorders, substance use disorders, eating disorders, personality disorders. Medical conditions which must be ruled out: HIV, anemia, hypothyroidism, seizure disorders, chronic fatigue syndrome, diabetes. Also, stimulants, antipsychotics, corticosteroids should be ruled out. Before considering depression, clinician should order a complete blood count (to rule out anemia) a thyroid-stimulating hormone and free T4 (to rule out hypothyroidism), and a urine drug toxicology screen to rule out drug abuse. 
• Treatments. Those mildly affected (and not suicidal) should first be given psychotherapy, while those severely affected should receive both psychotherapy and medication. Effectively treating mothers with MDD has been showed to lead to reductions in anxiety, depression, and disruptive behavior in their children. // CBT has been shown to be more effective than a wait-list condition and non-CBT psychotherapy. CBT benefits 62% of treated patients versus 36% in placebo groups (p. 223). Most studies also find CBT to be more effective than relaxation training, family therapy, and supportive therapy. Studies find that CBT patients have a high rate of relapse, suggesting the need for continued treatment. Young children benefit the most from the behavioral parts of CBT, while children increasingly benefit from the cognitive parts as they age. 
• Treatments (2). Depressed children benefit more from combined treatments of CBT and medication than from CBT alone or medication alone. Medication is more effective than CBT in the short-run, but the two treatments are equally effective in the long run (after 36 weeks). Medication is usually a selective serotonin reuptake inhibitor (SSRI) (usually fluoxetine or escitalopram).