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Depressive disorders in children
Until recently it was widely believed that depressive disorders were rare in
young people. Young children were thought to be incapable of experiencing
many of the phenomena that are characteristic of depressive disorders
in adults. Affective disturbance in adolescents was often dismissed as
adolescent ''turmoil''. Over the past 20 years, however, there has been a
substantial change in the ways in which mood disturbance among the
young has been conceptualized. The use of structured personal interviews
has shown that depressive syndromes resembling adult depressive disorders
can and do occur among both prepubertal children and adolescents. Indeed, clinical research in the United Kingdom has suggested that as many as one in four referrals to child psychiatrists suffer from a depressive disorder. Depression may be becoming more prevalent among young
people.
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Diagnosis of Depressive Disorder
Defining the boundaries between extremes of normal behaviour and psychopathology is a dilemma that pervades all of psychiatry. It is especially problematic to establish the limits of depressive disorder in young people,
because of the cognitive and physical changes that take place during this
time. Adolescents tend to feel things particularly deeply, and marked mood
swings are common during the teens. It can be difficult to distinguish
these intense emotional reactions from depressive disorders. By contrast,
young children do not find it easy to describe how they are feeling, and
often confuse emotions such as anger and sadness.
Children usually give a better account of symptoms related to internal
experience, whereas parents are likely to be better informants on overt
behavioural difficulties. Accounts from children and parents are usually
supplemented by information from other sources, particularly teachers and
direct observations.
Probably the best single indicator of whether or not a young person has
a serious depressive disorder is the duration of the problem. Polysymptomatic
depressive states that persist for more than 6 weeks usually require
intervention. |
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AETIOLOGY
The aetiology of child and adolescent depressive disorders is likely to be
multifactorial, including both genetic and environmental factors. Genetic
factors account for a substantial amount of the variance in liability to
bipolar illness in adults, but probably play a less substantial, though still
significant, part in unipolar depressive conditions. Interest in the genetics
of depressive disorders arising in young people has been stimulated by data
from several sources. First, it seems that, among adult samples, earlier age
of onset is associated with an increased familial loading for depression.
Second, the children of depressed parents have greater than expected rates
of depression. Third, there are high rates of affective disorders among
the first-degree relatives of depressed child probands. Moreover, there
is some specificity in this linkage, to the extent that the risk applies mainly to
affective disturbances as opposed to non-affective disorders. |
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Recovery from the Index Episode
Although the risk of recurrence of juvenile depression is high, it is important
to know that the prognosis for the index episode is quite good. The available
data suggest that themajority of children with major depression will recover
within 2 years.
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COURSE AND OUTCOME
By comparison with non-depressed subjects, young people diagnosed as
depressed are more likely to have subsequent episodes of depression. Thus
studies of children meeting DSM-III criteria for depression have shown
that depression in childhood often recurs. For example, Kovacs et al [28]
found that about 70% of child patients with a major depressive disorder had
another episode within 5 years.
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InitialManagement
The initial management of depressed young people depends greatly on
the nature of the problems identified during the assessment procedure.
The assessment may indicate that the reaction of the child is appropriate
for the situation. In such a case, and if the depression is mild, a sensible
approach can consist of regular meetings, sympathetic discussions with the
child and the parents, and encouraging support. These simple interventions,
especially if combined with measures to alleviate stress, are often
followed by an improvement in mood. In other cases, particularly those with
severe depression or suicidal thinking, a more focused form of treatment is
indicated. |
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