Diagnosis of childhood depression is problematic;
reference to antidepressant usage
Prior to 1970 childhood depression was not thought to be a clinical entity by psychiatrists (Cytryn, 2002). This was a result of an overzealous interpretation of Freud in that the punitive super-ego and the self-concept were not developed enough for a child to experience a psychiatric disorder (Rie, 1966).
Psychiatrists, DSM and the international classification of disease (ICD) committees now recognise childhood depression as a clinical pathology. A distinction should be drawn between general feelings of depression and a clinical diagnosis of depression. A depressed mood is one where there is a profound unhappiness and sense of dejection. Features of childhood depression include irritability, tearfulness, loss of appetite, poor concentration, and loss of energy and sleep disturbance. Although it is difficult to document because of the controversy about the definition of diagnostic criteria (Jimerson, 2002), the prevalence of major depressive disorder is approximately 1 percent in preschoolers, 2 percent in school-aged children and 5 to 8 percent in adolescents (Jellinek, 1998; Lewisohn et al, 1993).
Depression in childhood has been documented since Spitz (1946) recognised ‘anaclitic depression’ in 6 – 12 month olds that had been separated from their mothers. They displayed apathy, weight loss and withdrawal, which are all symptoms similar to those in DSM-III-R. Bowlby (1980) also demonstrated ‘protest-despair-detachment’ sequence in response to infant’s separation with their parents. However, whether these reactions are the same as depressive symptoms seen in adults remains a matter of controversy because they are common and ‘natural’ behaviours in young separated from their parents. Nonetheless, depression has been found in preschoolers (Luby et al., 2002) and children as young as six years old (Egger et al., 1999) using developmentally modified DSM-IV criteria.
Although childhood depression is not uncommon, clinicians often overlook it (Louters, 2004). This is not surprising when 46% of paediatricians lack confidence in their skills to recognise depression (Olsen et al., 2001). Diagnosis is problematic because adult concepts of depression are merely extended down onto children without any consideration for the differences between them (Rutter, 1986b). The DSM-III-R is consistent with this notion and the APA (1987 p.220) merely state that "Depression can start at any age, including infancy". Doubts exist over this comparability because symptoms spontaneously disappeared after a matter of weeks and so it is not clear whether these should be regarded as manifestations of depression as observed in adults (Rutter, 1986a). It also neglects developmental aspects and differences in language and cognitive functioning.
The nature of childhood, with the numerous and instant developmental changes does not fit with a depressive disorder which should be stable and uninfluenced by its environment (Arieti & Bemporad, 1978; Costello, 1980). However, because the onset occurs at such a critical period it may interfere with all aspects of the child’s functioning, it may place them at serious future risk and effect the way in which the disorder is experienced and manifested.
Although adults can express their symptoms with ease, children have a cognitive inability to express and label how they feel (Rutter, 1986a) and hence parents often mistake symptoms of the child being depressed as them being socially isolated. This also causes difficulty for accessing the mindset of the child. A process of translation between what the child says and what can be inferred must take place. With a lack of understanding, a minimisation of the depth of feeling that children experience occurs. The problem of diagnosis becomes even more difficult considering the child’s activity and general liveliness (Arieti & Bemporad, 1978).
Conversely, it could be thought that translation is not the problem. Instead, children are unable to contemplate one’s self worth due to an inability to self-reflect. Because of this cognitive inability, they are unable to experience depression but we are attributing to these children a much more complex psychological make up than is justified (Arieti & Bemporad, 1978).
Most children will exhibit symptoms of depression at some stage but 90% of the time, these disappear within the first year. They can be seen as a normal symptom of growing up and not a psychopathology (Lefkowitz & Burton, 1978). Common symptoms can have diagnostic significance if they occur with greater intensity and frequency (Costello, 1980). In addition, the available data of symptoms based on a function of age, is insufficient to judge normal and abnormal behaviour. Nevertheless, this does not lessen the problem; the expression of the disorder has not changed. Even if symptoms do fade away, they are recurrent and 35% of children will once again meet the criteria for a major depressive disorder within the first year of being alleviated. Depression can damage peer and family relationships, academic and social maturation and have the ability to cause suicidal tendencies, it is therefore important to lessen the duration and intensity of symptoms.
Assessment of depression can be problematic because it does not always display itself in a recognisable form. Lewisohn et al. (1993) found that at least 43% of children diagnosed with depression have at least one other behavioural problem that is not a symptom of depression. Behaviours such as aggression, hypochondrias, enuresis, psychosomatic illness (Cytryn, 2002), somatic complaints, delinquency and even attention deficit hyperactivity disorder have been thought to mask depression (Cantwell, 1983). If the child fulfils the criteria for a depressive disorder then other diagnostic features are stated as ancillary. It is thought that they are unable to tolerate the prolonged feelings of sadness and so move their attention onto other activities (Hammen & Compas, 1994).
Behaviours cited as masking depression cover the entire range of psychopathology, leading to difficulty in diagnosis. It is not clear how these behaviours are directly linked to, or whether a symptom is actually masking depression (Cantwell, 1983). The whole concept of masking depression is so loosely defined that it has lost all credibility in recent years (Cantwell, 1983), although not completely dismissed. This does not reduce the masking symptoms importance but merely abandons children that might have depression masked by other behaviours, an issue that must be considered further.
Immaturity of a child is a fact, but the way in which this immaturity is interpreted and made meaningful is the process of culture (Prout & James, 1997). Indeed, sociologists have argued that childhood has been lost in our culture (Postman, 1983) as children gain access to the world of adult concepts, resulting in a blurring of boundaries between what is considered childhood and adulthood. Childhood depression reflects this notion of little adults falling prey to internalised mental disorders resembling those of adults. The birth and the increasing popularity of diagnosing childhood depression reflect a wider socio-cultural process rather than any medical breakthrough (Timimi, 2004).
Childhood depression, often goes undiagnosed and neglected because society wants to maintain an idealised and romanticised view of childhood. We do not like to think of children experiencing depths of depression because "it is inherently disturbing" (Luby et al., 2002). As a result, parents and teachers often fail to notice and refer to clinicians, those with severe depression and suicidal tendencies (Rutter, 1986b). It is often years before a child’s depression is recognised and brought to the attention of a specialist. Even then, parents and clinicians are often reluctant to label the child as depressed because of the social stigma incurred.
Using the word ‘depression’ as a label, an entity or a diagnostic criterion has different meanings to different people. The notion has become very popular and is used to describe everything from mild sadness to a full psychotic episode. It is a convenient way to classify and blame something but it may not actually help. Helman (2004) contemplates; "They are behaving this way because they are depressed" and it leads to a circular argument "what does a depressed child do, they display these behaviours… is that child demonstrating them, yes. Well they are depressed". Timimi (2004) considers that psychiatrists are not so much interested in discovering the reasons behind depression, but more interested in creating a set of meanings to explain them. There is a need to understand why children are exhibiting certain forms of behaviour before medicating or providing a form of therapy.
There are serious consequences of putting any mental health label on a child; because once a diagnosis is made, it tends to stick for a long time. People tend to change the way they react to the child. This can be very damaging to a child’s self-concept, which in turn changes the child’s behaviour. With little requirement for a specific label, Timimi (2004) suggests that the label should be abandoned in favour of a multi-perspective approach.
The current DSM model might be applicable to adults but it is not clear whether it is appropriate to children, let alone infants. Important contexts of childhood depression are often reduced to consequences or co-morbidities. The medical model does not allow psychiatrists to work within these issues. Interventions should take a more context rich perspective that allows multiple viewpoints in a way that takes full account of the lived in situation of the child (Timimi, 2002). It should also be considered that if a depressed mood is common in children in a certain context, it is not necessarily indicative of a syndrome that needs pharmacological treatment.
It must be remembered that the DSM and ICD committees once diagnosed run away slaves as mentally ill, and thought that same sex attraction was a disease. This emphasises how psychological diagnosis is contextual and we should not accept concepts at face value. Diagnosis has a poor evidence base and has evolved from beliefs and values of Western culture. It cannot be assumed relevant or valid in our multi-cultural society of today and caution should especially be used when diagnosing those of ethnic minority populations (Timimi, 2004). All possible social and psychological factors that could be responsible for the child’s distress should be considered, and a comprehensive treatment plan including school, family and psychological treatment must be implicated.
With such doubts about being able to accurately diagnose childhood depression there are serious reservations as to whether children should be medicated. However, the routine course of action is a preliminary prescription of antidepressants. Because of acceptance of childhood depression, there has been a sharp rise in the use of antidepressants during the 1990s. Currently, there are over 50,000 children and adolescents taking antidepressants in the UK (Boseley, 2003), some as young as two years old (Zito et al., 2002). It is thought by several psychiatrists that the threshold for depression is set too low and psychiatrists are unjustifiably overmedicating children.
Evidence for the effectiveness of antidepressants in children is scarce. Emslie et al (1999) conducted a very influential study claiming that Selective Serotonin Reuptake Inhibitors (SSRI’s) have beneficial effects for children with depression. Yet, this study had a 38% drop out rate across all conditions raising doubt over its reliability and conclusions. Emslie et al. (2002) conducted a follow up study, which showed there was no statistical difference between Flouxetine and placebo. The treatment for adolescents with depression (TADS) study is another dominant study, which found that Flouxetine is beneficial, but like many other experiments, it was funded by pharmaceutical companies and lacked patient blinding and controls that exaggerated the benefits of Flouxetine. These studies also excluded severely depressed children due to the ethical considerations of not providing an active antidepressant.
There are a number of studies that demonstrate there are no beneficial effects of antidepressants over placebo (Stark et al., 1999; Ambrosini et al., 1999; Hazell et al., 1995; 2002). It is also argued that there is a significant lack of research focusing on treatments specific to childhood depression (Hammen et al., 1999) and those that do show that children respond significantly less to antidepressants than adults. Drugs companies argue that the antidepressants were not developed for children and the consequential affects of prescribing them are not their responsibility. However, these same companies have conducted their own independent research and have not disclosed their findings. This leaves much concern with clinicians and the public as to their effects. Considering these findings, clinicians still prescribe antidepressants regularly to children.
With the issue of their effectiveness aside, antidepressants have caused deep concern about their potentially fatal side effects. The most serious of which include cardio-toxicity, provoking suicidal tendencies and consequences on the developing brain regarding growth, intelligence and non-symptomatic behaviours (Stark et al., 1999-). In addition, Pharmacotherapy alone increases the chances of a relapse (Hollon et al., 1991). More specifically, a group of antidepressants known as Tricyclics produce adverse reactions due to their muscarinic effects. Withdrawal from the drug Effexor has been seen to cause psychosis. It is probable that many clinicians are not fully aware of these side effects. If they are, any problems arising from mistaken diagnosis are protected through doctor-patient confidentialities and privacy laws.
Due to these concerns, the government has recommended that the SSRI, Seroxat and Venlafaxine should never be prescribed to children and adolescents. The US food and drug administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA) also warn that antidepressants pose a risk that is not worth the benefits. Because of the lack of knowledge about antidepressants effects, every prescription made is essentially a "Government backed experiment" (Timimi, 2002). The ethical considerations of medicating children with unknown effects are vast and it is surprising that they are not discontinued until essential research is concluded. Many psychiatrists note that it has been a long time since they administered antidepressants, and since then they have become considerably more successful in their treatment courses. The use of cognitive behavioural therapy and family therapy, among others, deals with the underlying problem instead of merely suppressing the symptoms.
Antidepressants cannot be seen as a cure to depression, they merely control the symptoms. Although many agree that they should only be used as a last resort and should never used on their own (Beardslee et al., 2003), due to the economics of health care, a lack of resources often means offering drugs is the only course of action available to them (Pelton, 2004).
An urgent, open and honest debate is needed about the validity of the diagnostic system currently in place because of the concern over increasingly inappropriate medicalisation of childhood problems. There is a worry that by increasing the number of prescriptions being made, he bycantly ily TministrationIf they are,on (TADS) study diagnosed with depression have at least one other behavioural problemchildhood depression will follow the medication epidemic seen in ADHD diagnosis. There is a need for clinical intervention for the worst cases but essentially, population health interventions should take priority. School based, public health and social policies will be more effective at preventing depression, rather than having more clinicians treating, which does not solve the problem, but merely copes with it.
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