Essay on "Mental Disorder Major Depressive Disorder in Children"

Essay 10 pages (4992 words) Sources: 10

[EXCERPT] . . . .

Mental Disorder

Major Depressive Disorder in Children and Adolescents

Research on childhood and adolescent mood disorders has advanced significantly in recent years. It is now no longer common to find those who say that depression is an adult mental disorder alone. While there is not much debate about the definition and diagnosis of childhood depression, there are questions still to be answered regarding the best treatment outcome for children and adolescents who display symptoms of depression. This paper will outline a view of Major Depressive Disorder (MDD) as it relates to children, starting with a discussion of the diagnostic criteria for defining its symptoms. Then it will limit itself to synthesizing the research on childhood depression and treatment intervention styles from a cognitive standpoint. The cognitive perspective is probably the one most used in research, understanding and treating children who suffer from MDD. It is often in treatment combined with behavioral elements to improve treatment success. Finally, some of the ethical issues involved in working with depressed children will be thought out.

Diagnostic Criteria and Definition

The DSM-IV-TR lists Major Depressive Disorder (MDD) under the heading of mood disorders (American Psychiatric Association, 2000). There is no reason for not accepting this manual's definition and diagnostic criteria as a guideline. Important for the DSM-IV-TR's definition of MDD is an understanding of Major Depressive Episodes (MDE). The manual characterizes an MDE as "a period of at least two weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities" (APA, 2000, p. 349). However, the prolonged period of downturned mood must be accompanied by at least four additional symptoms, such as appetite or weight change, sleep disruption, decreased energy, feelings of worthlessness or guilt, difficulty thinking and concentrating, or suicidal thoughts and intentions. Such symptoms, combined, must persist most of the day, all day, for at least two consecutive weeks. Further, they must show serious distress or social impairment of functioning. It is important to note that according to the manual, the childhood and adolescent symptoms for a MDE are considered the same as the adult symptoms (APA, 2000, p. 353).

To properly diagnose MDD, the psychotherapist must interpret symptoms. These may include somatic complaints, reports of hostility or irritability, statements about loss of interest and care for anything, or reports about appetite loss. In addition, many physical symptoms may suggest MDD, such as brooding, tearfulness, worry, abdominal pains, headaches, and even panic attacks. The therapist can read facial features and body language to determine the symptoms. Insomnia or over-sleeping may be noted. There might be increased agitation (pacing, tapping) or increased slowing of motor and speech functions. Heightened fatigue is typical. Loss of intimate relations or less satisfying social interactions are common. The therapist may notice the patient taking more responsibility for events, thus blaming themselves and attributing greater defect to the self than is natural. Along with these potential diagnostic symptoms, the person may be distractible, lacking memory or concentration, as well as wishing to be dead. A combination of four of these, or related symptoms, in addition to the general joyless loss of interest in life are good cause for considering a diagnosis of MDD.

Many of the additional factors that have been identified for diagnosing MDD are not that relevant for children. Individuals with chronic or severe medical conditions are at higher risk for developing MDD. There is an average onset in the mid-20s, but this age is decreasing in the younger population and it is important to realize that MDD can begin at any age. After one single episode, there is a 60% chance of having another. The more episodes someone has, the more likely they are to experience other episodes, as well as to develop a Manic Episode. While difficult to predict, MDD in a young person can evolve into Bipolar Disorder.

The diagnosis of MDD should not be made, however, if the MDE is linked together with a recurring pattern that includes Manic Episodes. The episode or episodes must occur without a history of Manic, Mixed, or Hypomanic Episodes in order to be properly considered constitutive of Major Depressive Disorder. In addition, the MDE(s) can be confused with Schizoaffective Disorder, so care must be taken to analyze clearly the difference. Further, the occurrence of Substance-Induced Mood Disorder or of Mood Disorder Due to a General Medical Condition cannot be part of the diagnosis of Major Depressive Disorder.

Major Depressive Disorder is known to occur in children of almost every age. The DSM-IV-TR states that "the core symptoms of a Major Depressive Episode are the same for children and adolescents, although there are data that suggest that the prominence of characteristic symptoms may change with age" (APA, 2000, pp. 353-54). It gives some indications of childhood symptoms of depression, which are similar to the adult symptoms, and associated disorders:

Certain symptoms such as somatic complaints, irritability, and social withdrawal are particularly common in children, whereas psycho-motor retardation, hypersomnia, and delusions are less common in prepuberty than in adolescence and adulthood. In prepubertal children, Major Depressive Episodes occur more frequently in conjunction with other mental disorders (especially Disruptive Behavior Disorders, Attention-Deficit Disorders, and Anxiety Disorders) than in isolation. In adolescents, Major Depressive Episodes are frequently associated with Disruptive Behavior Disorders, Attention-Deficit Disorders, Anxiety Disorders, Substance-Related Disorders, and Eating Disorders. (APA, 2000, p. 354)

Elsewhere the manual says that its symptoms in children may come across as irritable rather than as sad. Significantly, it warns that MDD symptoms of crankiness should be differentiated from a "spoiled child" pattern of frustrated irritability. Furthermore, symptoms such as distractibility or difficulty paying attention can reflect in the child's suddenly poor performance at school. This would be a significant potential indicator of childhood depression, especially if it distresses the child seriously. A child with MDD may exhibit separation anxiety as well.

What seems important in trying to give a diagnosis to children is to pay close attention to their behavior. Often a child cannot express just what he or she is feeling in a verbal way. Rather he or she will act out in frustration. Children under 9-years-old express distress through behavioral problems and acting out (Schwartz, Gladstone, & Kaslow, 1998). They may be fidgety and restless in session, or, the opposite, motionlessness. Children communicate through somatic symptoms (headaches, etc.) more than adolescents (Birmaher et al., 1996), and the depressed child may miss school or visit the nurse more than other children. Assessment should gather from many sources. Friedburg & McClure (2002) speak of self-report measures, interviews, observer ratings, peer nominations, and projective techniques. There is a Children's Depression Inventory (CDI) that is a tool in long and short versions. It can be completed by children or adolescents before sessions and can be used to monitor changes. Another self report rating to assess symptoms is the Revised Children's Depression Rating Scale (CDRS-R) which includes parent, sibling, and teacher forms and has been normed on 9- to 16-year-olds.

Research on Childhood and Adolescent Depression

The research on childhood depression is vast. After referencing some developmental studies, this paper will pass on to specifically cognitive research on childhood MDD. Although quite rare in young children, the incidence of MDD rises in adolescence, along with suicidal ideation associated with depression (Myers, McCauley, Calderon, & Treder, 1991). This adolescent increase in depressive disorder is double for girls than for boys (Birmaher et al., 1996). It is not clear whether this is the case before adolescence. In children, major depressive disorder can impair social and academic performance (Emslie et al., 1994), can increase risk for substance abuse and other psychopathologies (Kovacs, 2003), and can lead to successful suicide or suicidal attempts (Rao et al., 1993). At least one longitudinal study has shown a high prevalence of persistence and recurrence once diagnosis has been given (Fleming, Boyle, & Offord, 1993). This is troubling because it means that once one has had an MDE episode in childhood, it is likely to continue into or recur in adulthood. Length of depressive episodes seems determined by age of onset, where the earlier the age the longer the episode (McCauley & Myers, 1992).

From a developmental standpoint, research has been done on the various stages of the development of Major Depressive Disorder. The focus has been on a change in symptoms and behavior across time. A study done by Birmaher, Brent, & Benson (1998) suggests that young children show symptoms of anxiety, somatic complaints, temper tantrums, behavioral problems of various kinds, and even auditory hallucinations. Later in childhood, depressed youth report experience more related to cognition, such as distorted thinking, self-blame and negative attributions, low self-esteem, guilt feelings, and hopelessness. This makes sense in terms of the cognitive development of the individual. It is not till adolescence that these researchers saw a greater prevalence of sleep and appetite disorders, delusions, and suicidal thoughts and attempts.

Other research has been done to clarify depression in childhood. Emslie, Kennard, & Kowatch (1994) give a broad depiction… READ MORE

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