Abstract
During the past 20 years, depression has been recognized widely in children and adolescents. However, even with what is known today about depression, many children and adolescents remain undiagnosed. Early recognition is imperative to prevent further episodes that may continue into adulthood. Depression in children and adolescents affects social development, academic performance, and ultimately, success as an adult. This article describes risk factors for depression, diagnostic criteria, medications, psychosocial interventions, and implications for school nursing practice.
INTRODUCTION
At times, a child or adolescent may say he or she is depressed. He or she may have broken up with a boyfriend or girlfriend or may have lost an important game. This is usually just a case of the “blues” that soon will go away. However, it may be something else—Major Depressive Disorder (MDD). MDD is not a normal developmental occurrence that will pass in a short period of time (Cicchetti & Toth, 1998).
It was not until the 1970s that the diagnosis of depression in children and adolescents was widely accepted (Costello et al., 2002). Studies indicate that as many as 2.5% of children and 8.5% of adolescents experience depression (U.S. Department of Health and Human Services [USDHHS], 1999). During adolescence, gender differences begin to emerge, with the incidence of depression 50% greater in girls than in boys (Costello et al.). Rates of depression differ with ethnicity: 29% of American Indian, 22% of Hispanic, 18% of White, 17% of Asian American, and 15% of African American youths surveyed reported depressive symptoms (Saluja et al., 2004). It is imperative that this disorder be recognized and be treated as soon as possible. If depression remains untreated, it may continue on into adulthood. Kim-Cohen and colleagues (2003) found that 50% of adults with a mental health disorder usually had the disorder in childhood or adolescence. School nurses’ daily interactions with students provide an opportunity to recognize the signs of depression and to make appropriate referrals.
OVERVIEW OF THE PROBLEM
Depression is a mood disorder. There are two types of mood disorders—depressive disorder and bipolar disorder. Depressive disorder has two subtypes; MDD and Dysthymic Disorder (DD). The American Psychiatric Association (APA; 2002, p. 345) defines these conditions as follows:
Major Depressive Disorder (MDD) is characterized by one or more Major Depressive Episodes (i.e., at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression).
Dysthymic Disorder (DD) is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms that do not meet criteria for Major Depressive Disorder.
Bipolar I Disorder is characterized by one or more Manic or Mixed Episodes, usually accompanied by Major Depressive Episodes.
Bipolar II is characterized by one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode.
Genetic, biologic, developmental, cognitive, and experiential processes have all been associated with the development of depression. It is evident that genetics plays a role in depression, although researchers cannot clearly define what role it plays (Nemeroff, 1998). Studies show a familial component to depression. Having a parent with depression dramatically increases a child’s risk for the development of depression. It is not known whether inherited genes specifically cause depression, or whether inherited cognitive styles lead to depression (Costello et al., 2002).
Studies show a familial component to depression. Having a parent with depression dramatically increases a child’s risk for the development of depression.
The biological basis of depression is centered on the monoamine hypothesis. The hypothesis proposes that a deficiency of the monoamine neurotransmitters, norepinephrine, and/or seratonin in the brain is the underlying cause of depression (Hirschfield, 2000). Neurotransmitters are chemicals produced by nerve cells in the brain that send messages back and forth across the space between the neurons, referred to as the synapse (Nemeroff, 1998). The monoamine hypothesis was the focus in the development of the class of antidepressants known as the selective seratonin re-uptake inhibitors (SSRIs) (Hirschfield).
Hormonal abnormalities are believed to contribute to the development of depression. Dysregulation of the hypothalamic-pituitary-adrenal axis (HPA), the system that manages the body’s response to stress, has been shown to contribute to depression (Goodyear, Herbert, & Tamplin, 2003). When a physical or psychological threat to well-being is detected, the hypothalamus amplifies production of the corticotropin-releasing factor (CRF), which induces the pituitary gland to secrete ACTH. ACTH then instructs the adrenal gland to secrete cortisol. Hypersecretion of cortisol is a risk factor for the development of depression in male and female adolescents and adult women (Goodyear, Herbert, & Tamplin).
Cognitive theory postulates that negative self-perceptions make individuals vulnerable to depression. Depressed children and adolescents have cognitive distortions, negative attributions, hopelessness, and a tendency to blame outcomes on external forces beyond their control. When a child or adolescent is faced with a stressful event, it is the negative or dysfunctional interpretations made about these events that create and maintain a depressed mood (Asarnow, Jaycox, & Thompson, 2001). Table 1 describes common errors in the way a depressed individual perceives information.
Depressed children and adolescents have cognitive distortions, negative attributions, hopelessness, and a tendency to blame outcomes on external forces beyond their control. When a child or adolescent is faced with a stressful event, it is the negative or dysfunctional interpretations made about these events that create and maintain a depressed mood.
Factors that increase a child’s risk of depression include stressful life events, family size, minority status, and physical and sexual abuse. Having a parent or sibling with MDD significantly increases the risk of depression (Costello et al., 2002). The school environment, where academic competence is stressed, may be a contributing factor for students who are not able to achieve academic success (Cicchetti & Toth, 1998). Bullying also has been noted as a risk factor in the development of depression for both those who are bullied and those who bully. The incidence of depression is higher among victims of indirect (social isolation) bullying (van der Wal, de Wit, & Hirasing, 2003).
Factors that increase a child’s risk of depression include stressful life events, family size, minority status, and physical and sexual abuse.
Children and adolescents with chronic medical conditions are at higher risk for depression. The incidence of depression in children with diabetes is 20% (Grey, Whittemore, & Tamborlane, 2002). Female diabetic adolescents have been found to have an incidence of depression that is nine times that of male adolescents (Kovacs, Obrosky, Goldston, & Drash, 1997). Depressed children and adolescents with asthma (Galil, 2000) and diabetes (Grey, Whittemore, & Tamborlane) are less compliant with medical management. The use of steroids in asthma (Andrews et al., 1991), inflammatory bowel diseases, Crohn’s disease, and ulcerative colitis also increases the incidence of depression (Szigethy et al., 2004). Children and adolescents with epilepsy are at risk for depression, but the danger often goes unrecognized (Plioplys, 2003). In addition, migraine headaches have been noted to precede depression (Lagges & Dunn, 2003).
Bullying also has been noted as a risk factor in the development of depression for both those who are bullied and those who bully. The incidence of depression is higher among victims of indirect (social isolation) bullying.
Immigrant children and adolescents may be at increased risk for depression, especially if they were exposed to violence prior to and during the immigration process (Jaycox et al., 2002). As young immigrants adjust to the culture of their new environment, new stressors occur, such as language conflicts, acculturation differences with family members, and pressure to conform to ethno-cultural norms. These new stressors increase the risk of depression (Romero & Roberts, 2003).
Diagnostic Assessment
Table 2 summarizes the diagnostic criteria for MDD. Although the key defining characteristics of MDD in children and adolescents are the same as those in adults, there may be some different symptoms. Children and adolescents tend to exhibit more irritability. They are frequently indecisive and have problems concentrating (APA, 2002, p. 354). Although children and adolescents often do not display psychotic features when depressed, when such symptoms do occur, auditory hallucinations are more common than delusions. Somatic symptoms, such as stomachaches and headaches, are more common in children and adolescents than in adults. The increase in somatic complaints may be higher in younger children due to their inability to express themselves (Ryan, 2001). Besides the typical symptoms of depression, such as sadness and/or irritability, preschool children also show a lack of pleasure in activities and play. Significantly more destructive and/or suicidal play themes are displayed in the depressed preschool population (Luby et al., 2003).
Comorbidity
Approximately two thirds of children and adolescents who experience depression are afflicted with another mental health disorder (Angold & Costello, 1993). Anxiety disorders are 8.2% more likely in depressed children and adolescents than in nondepressed youth (Costello et al., 2002). DD frequently occurs with depression in children and adolescents. With DD, they experience 1 year (at least 2 years for adults) of depressed mood more often than not, in addition to exhibiting depressive symptoms that are outside the realm of MDD. Individuals with DD are often self-critical and view themselves as noninteresting and incapable (APA, 2002, pp. 376–377). As compared with MDD, DD has a more prolonged course, with the average length of an episode being 4 years. MDD generally will appear 2–3 years after the onset of DD (Cicchetti & Toth, 1998). Early identification and treatment of DD is critical to the prevention of recurrent depressive disorder. Studies have suggested that anxiety may precede depression in children and adolescents. It has been found that depression generally precedes substance abuse and panic disorder, but frequently follows the onset of other disorders. Other comorbid conditions in youth are conduct and oppositional disorders, attention deficit/hyperactivity disorder, and substance abuse (Costello et al.).
Approximately two thirds of children and adolescents who experience depression are afflicted with another mental health disorder.
Complications
The effects of MDD in adolescence can carry on into adulthood. Depression is associated with poorer global functioning, poor relationships with family, a smaller social network, greater major and minor adversity, lesser life satisfaction, and greater utilization of mental health services (Lewinsohn, Rohde, Seeley, Klein, & Gotlib, 2003).
The most serious consequence of depression is suicide. In 2000, suicide was the third leading cause of death for youth 10–24 (Anderson, 2002). In 2003, 8.5% of teens attempted suicide (Grunbaum et al., 2004). Risk factors for suicide include depression, drug use, prior suicide attempts, and sexual orientation (Gould, Greenberg, Velting, & Shaffer, 2003). Male youth complete suicide five and a half times more than female youth, but female youth attempt more frequently (Anderson). Hispanic girls have the highest rate of attempted suicide (15%) compared with White girls (10.3%) and Black girls (9%). Black boys have the highest rate of attempted suicide (7.7%), compared with Hispanic boys (6.1%) and White boys (3.7%) (Grunbaum et al.). A recent study found that less than one third of suicide victims received any psychological counseling (Perkis et al., 2003). Only one third of teens who were at risk for suicide would seek help. If help was sought, it was usually from a friend with similar risk factors and maladaptive coping strategies who either would keep the confidence or would not take it seriously (Gould et al., 2004).
MANAGEMENT
The most common forms of treatment for depression in children and adolescents are short-term psychotherapy, medication, or the two in combination. Cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and family therapy are the most common forms of psychosocial therapies (Asarnow et al., 2001).
CBT is based on the premise that depressed individuals have cognitive distortions of themselves, the world, and the future (Beck, 1976). CBT assists in identifying negative or dysfunctional interpretations of events and substituting these with positive thought patterns. CBT techniques show promise in the prevention of depression in children and adolescents (Asarnow et al., 2001).
The most common forms of treatment for depression in children and adolescents are short-term psychotherapy, medication, or the two in combination.
Interpersonal therapy (IPT) focuses on working through disturbed personal relationships that may contribute to depression. The focus of IPT is on improving current functioning and interpersonal relationships. IPT-A, adapted for adolescents, addresses five interpersonal problem areas: interpersonal role disputes, role transition, interpersonal deficits, grief, and single-parent families. The IPT-A intervention can be learned and can be delivered by social workers and psychologists who work in school-based health clinics (Mufson et al., 2004).
Family therapy focuses on altering family interactions. Therapists focus on improving the presenting problem and relationship patterns associated with the problem (Asarnow et al., 2001). Family therapy appears to be more effective for younger children with depression (Cottrell, 2003).
Numerous studies have been conducted on the efficacy of CBT, IPT, and family therapy, showing 40–50% of participants failing to respond significantly. There is a need to develop effective treatment strategies (Asarnow et al., 2001). Costello and others (2002) state the urgent need to create and to test age-appropriate psychotherapeutic interventions for depressed prepubertal children.
Treating children and adolescents with medication for depression is controversial. Tricyclic antidepressants, such as imipramine and desipramine, have been effective in adults, but have shown little effect in the pediatric population (Costello et al., 2002). Selective serotonin reuptake inhibitors (SSRIs) have shown promise in the treatment of depression in children and adolescents. Fluoxetine (Prozac) is the only SSRI approved by the FDA for the treatment of depression in children and adolescents, although other unapproved SSRIs have been used with this population. A recent study has shown that fluoxetine was 60% more effective than placebo was, although the combination of CBT and fluoxetine was superior (March et al., 2004).
In recent years, there has been concern about the use of SSRIs and an increased incidence of suicide and suicidal ideation. On October 15, 2004, the U.S. Food and Drug Administration (USFDA) directed all manufacturers of antidepressants to revise their labeling to include a boxed warning and expanded warning statements that alert health care providers to an increased risk of suicide and suicidal ideation. Studies of children and adolescents being treated with these drugs showed an increase of suicide-related thought and activity from 2% in the placebo group to 4% in the treatment group (USFDA, 2004). However, the USFDA has not recommended that these products be contraindicated for use in the pediatric population. SSRIs have shown positive results in six clinical trials, but five unpublished trials had less favorable results. The benefits and the risks of drug use need to be weighed, so clinicians can find a balance between the risk of suicidal activity and the risk of doing nothing (Brent, 2004).
Due to stigma, those who are depressed fear that disclosure may have an impact on their ability to get health care and to make friends (Roeloffs et al., 2003). Beliefs about the etiology of depression also affect help-seeking behaviors. Those who believe that depression is within their personal control are less likely to seek help and more likely to disparage those who are depressed (Halter, 2004). Parents who have this belief may not seek help for their children.
In addition, cultural views affect stigma. For example, in Asian cultures, mental illness reflects poorly on family lineage, thereby affecting other family members’ marriage and economic prospects (Ng, 1996). Accordingly, only 3% of Asians would seek help from a physician, as compared with 13% of Whites (Zang, Snowden, & Sue, 1998). African Americans tend to rely on themselves and their spirituality in dealing with depression before deciding to see a health care professional, usually their general practitioner (USDHHS, 2001). Diala and colleagues (2004) found that African Americans have a more positive attitude toward seeking mental health care than Whites have. Lack of culturally competent mental health care may deter individuals from different cultures from seeking treatment for mental illness (Choi, 2002).
Social stigma and poor coverage or lack of health insurance contribute to the large numbers of depressed individuals who do not seek treatment.
Unfortunately, children with depression frequently are undiagnosed (Costello et al., 2002). A shortage of specialized child psychiatrists has given the responsibility for mental health care management to primary health care providers who are often unable to identify and to treat mental health disorders (Costello et al.). Social stigma (Roeloffs et al., 2003) and poor coverage or lack of health insurance contribute to the large numbers of depressed individuals who do not seek treatment. Health care coverage is a major factor in children and adolescents not receiving mental health care. Private health care plans often have limits on coverage for mental health services, such as a limited number of outpatient visits, inpatient stays, and higher copays than for medical diagnoses (U.S. Government Accountability Office, [USGAO], 2000). With limits on mental health care coverage, primary care health providers and pediatricians are expanding their roles to treat mental health disorders in children and adolescents (Williams et al., 2004). Twenty-five percent of youth who are covered by public health insurance have restricted eligibility. Sadly, there are reports of parents who have had to place their children with severe mental health disorders in the child welfare or juvenile justice systems to obtain needed mental health services (USGAO, 2003).
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
The high incidence of depression in children and adolescents gives school nurses the responsibility to be aware of the signs of depression and to know the resources available in their communities. Frequently, students with emotional problems will see the nurse with somatic complaints. The school nurse has many opportunities to assess a student’s physical and emotional health. The school nurse is available to all students who are experiencing stress and emotional problems and is supportive and nonjudgmental. Even though many states permit minors to consent to mental health treatment, school nurses should follow school district policies and their own judgment regarding when to alert staff members and parents. In the event that a student threatens suicide, the threat must be taken seriously and an appropriate referral made immediately (Cohn, Gelfman, & Schwab, 2001).
The high incidence of depression in children and adolescents gives school nurses the responsibility to be aware of the signs of depression and to know the resources available in their communities.
The 2000 Surgeon General’s Conference on the mental health of children identified “Educating the public about mental health and illness in children” as a key concern (U.S. Public Health Service [USPHS], 2000). Therefore, the first intervention must be self-education, followed by education of the school community. Advanced practice mental health nurses may be of great assistance in helping school nurses and other personnel by providing interpretation and guidance regarding unusual student behavior (Hootman, Houck, & King, 2003).
One goal of education should be removing the stigma surrounding mental health disorders. Stigma may prevent children and families from obtaining needed mental health services (USPHS, 2000). Children with mental illness also may be stigmatized by the cruelty of their classmates. The school nurse can play a pivotal role in reducing this type of behavior through education. Those who have greater knowledge about mental health disorders are less likely to stigmatize (Corrigan et al., 2001). The expression of depressive symptoms varies in different cultures (Choi, 2002); therefore, it is essential that school nurses have knowledge of how these expressions vary and cultural beliefs about mental illness.
An educational program, described by Hootman and colleagues (2002), can be used as an educational model to enhance nurses’ skills. It includes the need to connect in meaningful ways to establish relationships with at-risk youth, therapeutic communication skills, and the importance of being proactive in assessing students with depression and suicidal ideation. School nurses who were part of a program that developed and implemented practice improvement projects focused on identification and prevention in students with “preclinical cases.” The school nurses who participated in the program stated that increased knowledge of mental health assessment and interaction processes improved their skills. As schools recognize the growing need for mental health services, some are establishing school-based mental health clinics where students can be referred (Hootman et al., 2003).
Children with mental illness also may be stigmatized by the cruelty of their classmates. The school nurse can play a pivotal role in reducing this type of behavior through education.
CONCLUSION
Depression in children and adolescents is a serious concern. Too often depression goes undiagnosed and untreated. Its effects can be seen into adulthood with poor psychosocial functioning and a decrease in life satisfaction (Lewinsohn et al., 2003). The most serious consequence of depression is suicide. School nurses are in an optimal position to identify those students who are at risk for depression. Daily interaction with students provides the opportunity to assess for depressive symptoms. Finally, school nurses are the key to educating the community about depression in children and adolescents. Educating the community about youth depression is vital in reducing the stigma of mental illness and alerting the community about the need for services to treat mental health problems.