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Childhood depression is not easy to think about. For many years, children who showed signs of what would be called depression in adults suffered quietly while they were regarded as shy, lazy, or disobedient. The symptoms might be attributed to an adjustment disorder (a temporary response to recent stress), attention deficit disorder, or conflicts with their parents, teachers, classmates, and playmates.
The picture changes with age. Up to age three, the signs 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.
Depressed adolescents sometimes seem to be angry rather than sad -- uncommunicative, hypersensitive to criticism, and generally annoying to their parents and others. They may show their depression through delinquent behavior -- running away from home, reckless driving, stealing, drug and alcohol abuse. But some suffer depression in its full adult intensity, with anxiety, dread, guilt, and a sense of hopelessness. They may even suffer more than adults, because limited experience of the world causes them to overreact to minor humiliations and setbacks.
Bipolar (manic-depressive) disorder (See Harvard Mental Health Letter, April and May 2001) can also occur in children, although it is not common. Unlike adults, children and adolescents are generally not elated during the manic phase of the cycle. They are more likely to be angry, irritable, and restless, with paranoid thoughts. Adolescents may have delusions, hallucinations, and other symptoms that create a potential for confusion with schizophrenia.
At least 50% of depressed children and adolescents also have at least one other psychiatric disorder -- usually an anxiety disorder, conduct disorder, eating disorder, or (in teenagers) alcohol or drug dependence. About 30% of children diagnosed with attention deficit disorder (distractible, hyperactive, and impulsive) eventually turn out to have bipolar disorder. Tobacco addiction, which almost always begins with adolescent smoking, is sometimes the result of depression -- nicotine may have an antidepressant effect, and depressed people find it especially difficult to quit smoking.
Genetics of childhood depression
The genetic contribution to mood disorders is especially high when the symptoms first appear in childhood or adolescence. For children of a depressed parent, the risk of depression is much higher than average. According to one report, more than 50% of children with a parent who has a history of major depression have an episode of depression themselves by age 20. Identical twins are highly concordant (matched) for childhood depression, and even more concordant for childhood bipolar disorder. But fraternal twins are no more concordant than any other brothers or sisters. A family history of personality disorders, panic disorder, or alcoholism also raises the risk of early depression. The heritability (proportion of individual differences in susceptibility associated with genetic difference) of childhood depression is estimated at 50% or more.
Causes of adolescent depression are particularly easy to suggest. Teenagers may have trouble giving up childhood comforts and pleasures while trying to establish an adult identity. Hormonal changes subject them to sexual tensions and aggressive impulses they don't know how to cope with. They may feel the need to deny dependence on their parents while also living up to what they suppose to be their parents' expectations. All the while, they have the intellectual capacity for self-criticism without the experience needed to put minor failures into perspective. Homosexual adolescents may be at especially high risk because isolation, concealment, social stigma, and family misunderstanding often make sexual development more emotionally difficult.
But many of the family conditions suggested as causes could instead be the effects of a child's or a parent's depression, or even of genetic vulnerability. There is no reliable evidence for a single biological, psychological, or social explanation of childhood depression. Twin and adoption studies have not shown that a common family environment affects the chance that a child will become depressed. After adjusting for genetic predispositions, it does not seem to matter whether the father is present, how many children there are, or even whether there is serious family conflict. The rate of depression in adopted children is correlated with the rate in their biological rather than their adoptive parents.
We know more about the adult consequences and adult outcomes of childhood mood disorders, and what we know is not reassuring. The childhood problems usually persist in adult life. About 90% of people who have manic episodes in childhood will also have them in adulthood. Depressed children are also vulnerable to a variety of personality disorders. According to recent research, the odds of antisocial, histrionic, and borderline personality are increased four times in adolescents with depression or bipolar disorder, regardless of social class, family conflict, other psychiatric disorders, or a history of child abuse or neglect.
Depression in a teenager should not be dismissed as "just a stage." Adolescents are sometimes expected to have serious emotional problems -- to be lonely, confused, angry, rebellious, and despairing. But however it may sometimes seem to their parents, normal teenagers do not go through a period of emotional turmoil that resembles a psychiatric disorder. Studies show that most of them do not feel misunderstood or miserable most of the time. When an adolescent does show signs of severe depression, it should always be treated as soon as possible, especially since there is some evidence that each untreated depressive episode makes the next one more likely.
Reflection Exercise #6
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