Childhood Depression

Childhood depression is a very real but sometimes elusive illness that affects the young today. We take a look at what it actually means and how unity and support in the family can help fight its hold over a child.

At the recently concluded Asia Pacific Suicide Prevention Convention 2006, we learnt a few startling facts about children and suicide. For example, in a worldwide survey, 7.3% to 38% of the children surveyed demonstrated suicide ideation, which is the idea of wanting to kill themselves. In Singapore, close to 4.7% of children entertain this morbid thought. While the figure may be alarming, there is no need to panic as it is actually not uncommon to think about suicide.

Ask anyone in the street if he had thought about suicide before and the answer will most probably be a `yes'. Thinking about something as serious as killing oneself and actually doing it are two different matters. Out of all childhood suicides, approximately 23.5% are associated with mental illness such as depression, schizophrenia and others. Seeing the numbers and understanding that depression is one of the key causes that drive our young to suicide. It is time we understand a little more about this elusive illness called "Childhood Depression".

The Definition of Childhood Depression

In a 2004 article published by the American Academy of Child and Adolescent Psychiatry http://www.aacap.org/publications/factsfam/depressd.htm , childhood depression is defined as "an illness when the feelings of depression persist and interfere with a child or adolescent's ability to function."

Feelings of depression are represented in the forms of mood, physical, mental and behavioural changes in a child. Dr Ken Ung, Senior Consultant Child, Adolescent & Adult Psychiatrist & Psychotherapist at Adam Road Hospital describes the signs of childhood depression as persistent "irritability or loss of interest, loss of appetite and weight, poor sleep , lethargy, headache, stomach pain, loss of concentration, preoccupation with self-harm or suicide, refusal to go to school, increased temper tantrums and antisocial behaviours such as smoking, drinking and running away from home. Any combination of these changes that lasts for more than two weeks could spell a child falling into depression and warrants a closer look.

Many of the symtoms listed are actually applicable to both adults and children but there are telling differences. Age, in a non-categorical way, does make a difference in the presentation of depressive behaviour. "We don't tend to categorize (childhood depression) in terms of age groups," says Dr Ung, " but we can generally say that adolescent depression tends to look more like adult type depression , whereas, childhood depression can be more `a typical' perhaps manifesting in bodily pains and behaviour changes. The closer the age of a child to adulthood - the more we can expect to see an adult-type depression.

Types of childhood depression

There is no clear categorization of childhood depression. According to Dr Ung, "Typing depression is notoriously difficult and fashions come and go. We now tend to type it according to severity i.e. mild, moderate and severe. Sometimes, we use the term `reactive' depression to denote the type that is due to a reaction to some stress (such as the sudden passing of a loved one). Although very rare in children, `psychotic' depression refers to the presence of psychotic symptoms, which are symptoms that show that the person has lost touch with reality, i.e. hearing voices, believing irrational, bizarre or incredible thoughts."

Another childhood psychiatry expert, Dr Sharon Chan of Sharon Chan Child Guidance Clinic, who has been practicing child psychiatry since 1988 concurs, "I am not sure that there is such a categorization (of childhood depression).. because the entity is still controversial, it follows adult depression patterns (sic) - chronic, single episode or recurrent, adjustment disorder, bipolar etc."

Bipolar disorder, also known as manic-depression, is a type of mood disorder marked by extreme changes in mood, energy levels and behaviour. Symptoms can begin in early childhood but more typically emerge in adolescence or adulthood. Children with bipolar disorder usually alternate rapidly between extremely high moods (mania) and low moods (depression). These rapid mood shifts can produce irritability with periods of wellness between episodes, or the young person may feel both extremes at the same time. Parents who have children with the disorder often describe them as unpredictable, alternating between aggressive or silly and withdrawn.

Stages of childhood depression

According to a Harvard Medical School Publication, " The picture changes with age. Up to age three, the signs (of childhood depression) may include feeding problems, tantrums, and lack of playfulness and emotional expressiveness. AT ages 3-5, depressed children may be accident-prone and subject to phobias. Even before age 5, they may show signs of self-reproach by apologizing unnecessarily for minor mistakes and transgressions like spilling food or forgetting to put clothes away. Children of early school age (6-8) sometimes show depression with vague physical complaints and aggressive behavior. They may cling to their parents and avoid new people and challenges. At ages 9-12, some common symptoms are morbid thoughts and lying awake worrying about schoolwork. By then, children have enough intellectual capacity and social understanding to think about reasons for their depression , and they may blame themselves for disappointing their parents."

When asked for his opinion on this analysis, Dr Ung says, " I think that this is a good guide by and large. Nevertheless, this is merely a guide and should not ne taken as set in stone. For example, a 12 year old boy may show signs of depression by aggressive behaviour and phusical complaints."

For Dr Chan, "Depression before the age of six is very rare. In fact, I do not think that there is general agreement that it exists. In a young child, the common emotional condition is anxiety, not so much depression. From six years onwards, I would agree with the given description."

Children under stress, who experience loss , or who have attention , learning , conduct or anxiety disorders are at a higher risk for depression. Depression also tends to run in families.

Lena's experience

Lena (not her real name) is a 17 year-old student who recently suffered a relapse and fell into depression once more. Lena has been troubled by depression since the age of 12. Once again, she has no appetite for food, is feeling listless and confused, lost a lot of weight and is isolating herself from others.

Lena's mother, 49 year old clerical staff Sonia (not her real name), recounts her daughter's experience with depression, " It all started after Lena's father passed away. At first , nothing seemed wrong. SHe was very sad but she did not shed a tear at his funeral. It was a year after that she started to miss him badly. This was compounded by being bullied in school and stressed by schoolwork. Always a quiet child, Lena became even more withdrawn. She had trouble sleeping, would cry for no reason, refused to eat and talked about hurting herself."

Seeing her daughter's condition, Sonia brought Lena to a Polyclinic which referred them to a psychiatrist at a hospital. Lena was given antidepressants and started having regular therapy sessions with psychiatrists and counsellors. She tried to follow their advice of not thinking negatively, to focus on developing her interests and to make a timetable for each day. Everyday was a struggle but she managed to recover with time.

"She said she liked the counselling sessions where she could talk to someone about her feelings and problems." say Sonia of Lena's reaction to treatment. "Slowly, she got better to the point that she was more cheerful and could laugh and giggle like a normal young girl. She even enrolled in yoga classes that helped her gained fitness and to relax."

For Sonia, being supportive of Lena through the down times and being sensitive to her needs are her priorities. "I told her that her health is more important than studies. When I'm at work, I try to call her and talk to her whenever I can. She will tell me things like, " Mummy, I'm useless and I don't know what to do," and I will try to encourage her to look on the bright side, not to think too much..etc.. I have to try to give her lots of love, my full support and attention."

Treatment

What most doctors agree on is that medication should not be used unnecessarily on children and that when used, it should be accompanied with the right counselling and therapy. " It's interesting that recent studies have not been able to prove that antidepressants work in children. This could be because children are not mini adults and what works for adults may not work for kids," says Dr Ung.

There is also little research of how antidepressants work on children and prescription drugs may increase the risk of self-harm for some vulnerable ones. However, Dr Ung adds, "To keep a perspective on things, the increase of antidepressants prescriptions is small, probably around 2% in affected children given inactive medications (placebos) to about 4% of those on active medication."

Counselling, it seems , plays the key role in helping children recover from depression. "A good counsellor will try to get information from parents, child and school and will try his or her best to co-ordinate the counselling to incorporate all these parties. Cognitive-behavioural therapy is one of the commonest forms of counselling techniques used nowadays - it seeks to change the negative thoughts of the child to more realistic and positive ones and also t help the child make action/behavioural changes that will help lift the mood," adds the psychiatrist.

Cyber Help
With the computer-savvy generation of today, some children or teens may choose to express their thoughts and feelings in cyber space. http://www.depnet.com is a community website launced in March to provide information and counselling services for depression. A `diary' services allows members to post daily updates on their mental and emotional experiences while a `letterbox' service provides them with an opportunity to ask questions to a panel of experts. Most importantly, a service like this seeks to educate the public on the existence of depression and encourage those who are depressed to seek help. Following examples, depressed children may be inspired by a strong sense of community to step out of a possible state of isolation. Adults too, can visit to gather more information and advice before deciding how best to seek help.

Understanding is Key.

"Sometimes, depressed children are mistakenly labelled as lazy, stubborn or difficult," says Dr Chan. This is largely due to a lack of knowledge and understanding on the adults' part. Children, unlike adults are dependent on their families and guardians to identify their troubles and seek help.

Dr Ung adds," One common misconception is that the child is mad. This is totally not so. Another is that the child is `weak'. Some famous people who are strong of character and have suffered depression include Abraham Lincoln. Another misconception is that it is incurable or that the child is `bad'. Depression is a very treatable condition and the change of behaviour from depression should not be mistaken for `badness'.