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Childhood Depression: Matter of Life or Death

Because some depressed children appear happy, depression in children can be difficult to diagnose. But many depressed children become suicidal, making diagnosis crucial.
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Childhood is not a universally happy time, and for 3% to 8% of kids, depression will be part of the growing-up experience. Fortunately, children who experience depression usually respond to treatment, and that treatment can mean the difference between life and death, say experts.

While it is easy to blame childhood depression on 21st century life -- too much stress, too little "quality time" for families, too much exposure to violence, too little extended family, and too many children of divorce -- the reality is that depression has probably been stalking children for generations. For example, the 19th century American poet Henry Wadsworth Longfellow in the often-quoted poem The Children's Hour writes of "Grave Alice," who is accompanied by "laughing Allegra and Edith with golden hair." Readers of any era are led to believe that "Grave Alice" is not a happy-go-lucky child.

Experts tell WebMD that childhood depression is nothing new, but what is "new" is the realization that depressed children have a significant risk of suicide and that depressed children, even children with bipolar depression -- characterized by mood swings from "mania" to depression, do meet a set of defined criteria.

Childhood Depression: How Do You Know?

Joan Luby, MD, associate professor of psychiatry at Washington University at St. Louis School of Medicine, tells WebMD that even in preschool children "depression is pretty definable" and does follow criteria found in the DSM-IV, the psychiatry manual that describes the symptoms of mental illness. But those criteria, says Luby, "have to be translated" in a way that can be applied to children.

For example, very young children will know that something is wrong but may not be able to express the problem. In those cases, Luby says that a valid diagnosis can be "obtained by interviewing parents, by observing the child, and by the use of puppet interviews." The child, she says, can be encouraged to talk about feelings with the use of the puppet. Meanwhile, the parent interviews and observations can provide what Luby says is the most specific symptom of early childhood depression: anhedonia, which is the inability to experience joy or pleasure. She says that when she studied 174 children, "anhedonia never occurred in children who were not depressed."

The problem, however, is that while clinically depressed adults rarely appear happy, depressed children often appear happy, says child psychiatrist David Fassler, MD. He tells WebMD, "Children present in a lot of different ways. Sometimes kids are just like classically depressed adults -- they are withdrawn, sad, tearful, and have trouble sleeping. Other times they are irritable, can't sit still, and have trouble concentrating. And sometimes they 'look' happy." Fassler is a spokesman for the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.

Luby agrees and notes that children are "inherently joyful and often don't appear obviously sad." Also, their sadness is not constant, she adds. Sadness is often interrupted by normal mood periods, so it can be missed. Thus, rather than attempting to measure sadness, she measures the lack of pleasure by having parents interact in games and scenarios that "are specifically designed to elicit joy." Luby says, too, that the most reliable gauge of childhood depression is "parent reports."

Michael Naylor, MD, director of the division of child and adolescent psychiatry at the University of Illinois at Chicago, says, too, that depressed children are less likely to lose their appetites and sleep disturbances are more likely to have difficulty falling asleep, rather than waking in the middle of the night.

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