CHAPTER 1
BENARD DREYER, MD
CHILD AND ADOLESCENT DEPRESSION
What Is Childhood and Adolescent Depression?
Common Signs and Symptoms in Infants and Preschoolers
• Apathy
• Withdrawal from caregivers
• Delay or regression in developmental milestones
• Failure to thrive without organic cause
• Excessive crying
• Dysregulation
• Irritability
Common Signs and Symptoms in School-Aged Children
• Low self-esteem
• Excessive guilt
• Somatic complaints, such as headaches and stomachaches
• Anxiety, such as school phobia or excessive separation anxiety
• Irritability
• Sadness
• Isolation
• Anger
• Bullying
• Fighting
• Fluctuating moods
• Sleep disturbance
• Academic decline
Common Signs and Symptoms in Adolescents
Signs and symptoms of depression in adolescents are similar to those in adults and, according to the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV- TR), include
• Depressed or irritable mood
• Loss of interest or pleasure in activities
• Feelings of worthlessness or excessive guilt
• Low energy/fatigue; psychomotor retardation
• Insomnia or hypersomnia; appetite and weight changes
• Poor concentration
• Thoughts of death or suicide
Cases of adolescent depression are complex. Although genetic factors are important, the onset of a depressive episode may be precipitated by difficult or stressful life experiences, such as family, school, or peer relationship problems. Sexual or physical abuse also is a risk factor.
Why Is It Important to Include Childhood and Adolescent Depression in History, Observation, and Surveillance?
Major depression in children and adolescents is a relatively common disorder. Major depressive disorder is estimated to occur in 1% of preschoolers and 2% of school-aged children. Evidence also indicates that the prevalence is increasing, with onset at earlier ages. Studies also show that 4% to 6% of adolescents may experience depression at any one time, with lifetime prevalence rates by late adolescence of 20% to 25%.
Depression in prepubertal children occurs equally in males and females. Adolescents are different, with depressive disorders after puberty occurring in twice as many females as males.
Depression is related to serious morbidity and mortality. Depressed children and adolescents frequently have comorbid mental disorders, such as
• Anxiety disorders
• Attention-deficit/hyperactivity disorder
• Disruptive disorders, including conduct disorder and oppositional defiant disorder (see the "Disruptive Behavior Disorders" chapter for more information on these disorders)
• Eating disorders
Depressed adolescents are at higher risk of alcohol and substance abuse. Generally depression precedes the onset of alcohol and substance abuse by 4 to 5 years, so identification of depression may provide an opportunity for prevention. Depressed adolescents also experience significant impairment in school functioning and in interpersonal relationships.
Adolescents who are depressed also are at increased risk of suicide ideation, suicide attempts, and completed suicides. Studies show that 85% of depressed teenagers report suicidal ideation and 32% attempt suicide. Approximately 60% of adolescents who commit suicide have a depressive disorder. Depression in prepubertal children has a lower rate of suicide (0.8 per 100,000).
Suicide is the third leading cause of death in youth aged 15 to 19. More than 1,600 youth (aged 15 to 19) committed suicide in 2000. Suicide is the fourth leading cause of death in youth aged 10 to 14. In this age group, 5 times as many males as females completed a suicide attempt.
Depression among adolescents is likely to continue and may lead to other mental disorders. Studies indicate that 20% to 40% of adolescents with a major depressive episode go on to develop bipolar disorder within 5 years.
Moreover, depression in adolescents is likely to continue into adulthood. Approximately 70% will have another episode of depression in 5 years. Teenagers with depression are 4 times as likely as others to have depression as adults.
Depression is underdiagnosed. Studies show that only 50% of adolescents with depression are diagnosed.
Should You Screen for Depression?
In 2007 the American Academy of Pediatrics endorsed the Guidelines for Adolescent Depression in Primary Care, which recommend primary clinicians assess for depression in adolescents at high risk and those presenting with emotional problems.
The US Preventive Services Task Force (USPSTF), in 2009, recommended screening "adolescents (12-18 years of age) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up." There was insufficient evidence for the USPSTF to recommend screening children (aged 7-11).
In 2010 the American Academy of Pediatrics released a supplement to Pediatrics, Enhancing Pediatric Mental Health Care: Report from the American Academy of Pediatrics Task Force on Mental Health and Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit, which provides pediatric health care practitioners guidance on how to select appropriate assessment, screening, and surveillance instruments (available at: http://pediatrics.aappublications.org/conten/vol125/ supplement_3).
A number of depression screening tools for children and adolescents have been evaluated. Some of the more widely used assessments and tools are highlighted below.
Beck Depression Inventory (BDI), Beck Depression Inventory for Primary Care (BDI-PC), Center for Epidemiological Studies-Depression Scale (CES-D), and Center for Epidemiological Studies-Depression Scale for Children (CES-DC)
The Agency for Healthcare Research and Quality conducted a systematic evidence review of these depression screening tools in children and adolescents.
The review indicated that
• These tools perform reasonably well in community adolescent populations.
• They have sensitivities that range from 75% to 100% and specificities from 49% to 90%.
• The positive predictive values of these tests are low due to the lower specificity and the low prevalence of depression in these populations (most of the patients identified are not depressed).
• The CES-D, while not validated for children younger than 12 years, has been used in several studies involving children as young as 10 years.
Similar evidence regarding operating characteristics of depression screening tools is available in a recent review by Sharp and Lipsky.
The Patient Health Questionnaire for Adolescents (PHQ-A) and the Patient Health Questionnaire (PHQ- 9) Quick Depression Assessment
These screening tools
• Have sensitivities of 73% and specificities of 94% to 98% for the diagnosis of major depressive disorder in adolescents
• Have not been validated in preadolescent children
• Have positive predictive values of 40% to 60% depending on the prevalence of depression in the adolescent population being screened (this is due to the higher specificity of these screening tests, at the expense of a somewhat lower sensitivity).
An advantage of the PHQ-A is that it also assesses dysthymic disorder and other common mental health problems of adolescents. The advantage of the PHQ-9 is that it is very short (9 questions).
Children's Depression Inventory (CDI), Child Depression Scale (CDS), Children's Self-Report Rating Scale (CSRS), Depression Self-Rating Scale (DSRS), and Reynolds Adolescent Depression Scale (RADS)
These screening tools for depression in children and adolescents have been tested only in referred populations, and their use in primary care populations as general screening tools is untested.
Pediatric Symptom Checklist and the Child Behavior Checklist (CBCL)
These general behavioral symptom checklists are good for highlighting psychosocial issues but are not appropriate for identifying the specific diagnosis of depression.
How Should You Perform a Depression Screening?
Although screening for depression in preadolescent children is not specifically recommended in Bright Futures, a behavioral and psychosocial assessment is recommended at every visit. Some specific signs and symptoms of depression in children may be different from those in adolescents, but some overlap exists and you may wish to ask many of the same questions noted here for adolescents.
Perform a Preliminary Assessment Using HEADSS
At every health supervision visit with an adolescent, take a thorough psychosocial history based on the HEADSS method of interviewing. This method has recently been expanded to HEEADSSS (or HE2ADS3).
This assessment includes questions related to the following HE2ADS3 psychosocial domains. Sample question topics are listed. For a complete list, see Goldenring and Rosen.
Home: Who lives with the teen? What are relationships like at home? Recent moves or running away?
Education/Employment: School/grade performance — any recent changes? Suspension, termination, dropping out?
Eating: Likes and dislikes about one's body? Any recent changes in your weight or appetite? Worries about weight?
Activities: With peers and family? Church, clubs, sports activities? History of arrests, acting out, crime?
Drugs: Use of tobacco, alcohol, or drugs by peers, by teen, by family members?
Sexuality: Orientation? Degree and types of sexual experience and acts? Number of partners? Sexually transmitted infections, contraception, pregnancy/ abortion?
Suicide/Depression:
• Feeling sad
• Sleep disorders (insomnia or hypersomnia)
• Feelings of boredom, helplessness, or hopelessness
• Emotional outbursts and impulsive behavior
• Withdrawal/isolation from peers and family
• Psychosomatic symptoms
• Decreased affect on interview
• Preoccupation with death (music, art, media)
• Suicidal ideation
• History of past suicide attempt, depression, or psychological counseling
• History of depression, bipolar disorder, or suicide in family or peers
Safety: History of accidents, physical or sexual abuse, or bullying? Violence in home, school, or neighborhood? Access to firearms?
To help you with your HEADSS/HE2ADS3 assessment, you also may want to use the Guidelines for Adolescent Preventive Services (GAPS) self-report questionnaires.
These instruments, developed by the American Medical Association, are available for younger and middleolder adolescents in both English and Spanish.17,18 Have adolescents fill out the GAPS form before you talk with them.
Take Additional Steps if Needed
Consider an adolescent at high risk of depression if the HEADSS/HE2ADS3 interview reveals any of the following:
• Any positive answers in the suicide/depression domain
• Poor or absent relationships with peers or family members
• History of acting out or antisocial behavior
• Recent deterioration in school performance
• Changes in appetite/weight
• Alcohol or substance abuse
• Recurrent serious accidents
• History of sexual or physical abuse
• Comorbid disorders, such as ADHD, anxiety disorders, conduct disorder, or oppositional defiant disorder
If you determine that an adolescent is at high risk on the basis of HEADSS/HE2ADS3 interviews, GAPS questionnaires, or comorbid mental disorders, consider using a standardized screening tool to assess adolescent symptoms of depression.
What Should You Do With an Abnormal Result?
Interview all adolescents who have a positive screen for depression.
Assess them for depressive symptoms and functional impairment based on the DSM-IV-TR criteria for major depressive disorder, dysthymia, and depression not otherwise specified.
Assess for comorbid conditions, both medical and psychiatric.
Perform a safety assessment for suicide risk.
• Does the adolescent now have suicidal thoughts or plans?
• Have prior attempts occurred?
• Does the plan or previous attempt have significant lethality or efforts to avoid detection?
• Has the adolescent been exposed to suicide attempt/ completion by peers or family members?
• Does the adolescent have alcohol or substance abuse problems?
• Does the adolescent have a conduct disorder or patterns of aggressive/impulsive behavior?
• Does the family show significant family psychopathology, violence, substance abuse, or disruption?
• Does the adolescent have the means available (especially firearms and toxic medications)?
Meet with the adolescent's family members or caregivers.
Discuss a referral to a mental health professional. Make an immediate referral to a mental health provider or emergency services if severe depression, psychotic, or suicidal ideation/risk is evident.
Educate adolescents and their family about depression and treatment options.
• Stress that depression is treatable.
• Briefly discuss treatment options, such as watchful waiting for mild depression, psychotherapy (cognitive behavioral therapy or interpersonal therapy), and medication (selective serotonin reuptake inhibitors).
• Encourage families to remove firearms and toxic substances from the house, especially if any suicidal ideation is present.
Provide information about print or online resources that may be helpful to adolescents and their families.
Schedule a follow-up visit in 1 to 2 weeks.
What Results Should You Document?
Document HEADSS/HE2ADS3 assessment, scores of depression screening tools, referrals discussed or made, and follow-up plans.
Resources
Scales and Tools
A number of good standardized screening tools exist for adolescent depression.
Beck Depression Inventory-II (BDI-II)
• 21-question, self-report questionnaire
• Updated version of Beck Depression Inventory; based on DSM-IV-TR criteria
• Appropriate for middle-older adolescents
• Available in Spanish
Must be purchased from http://www.musc.edu/dfm/ RCMAR/Beck.html
Center for Epidemiological Studies Depression Scale (CES-D)
• 20-question, self-report questionnaire developed for adults
• Appropriate for middle-older adolescents
• Available in Spanish
Available free from http://www.hepfi.org/nnac/pdf/ sample_cesd.pdf
Center for Epidemiological Studies Depression Scale for Children (CES-DC)
• 20-question, self-report questionnaire similar to the CES-D
• Appropriate for younger adolescents
• Available free from http://www.brightfutures.org/ mentalhealth/pdf/professionals/bridges/ces_dc.pdf
Patient Health Questionnaire Adolescent Version (PHQ-A)
• 83-question, self-report questionnaire that screens for major depressive disorder, dysthymia, minor depressive disorder, anxiety disorders, drug abuse or dependence, nicotine dependence, and eating disorders
• First 16 questions focus on depression and mood and could be used without rest of questionnaire
• Moderately complex scoring schema
Patient Health Questionnaire Quick Depression Screen (PHQ-9)
• 9-question, self-report questionnaire that screens for major depressive disorder and other depressive disorder
• Does not screen for dysthymia
• Easy to score
• Available in Spanish
Available for review at http://www.mapi-trust.org/ questionnaires/66
Other depression screening tools
• Children's Depression Inventory (CDI)
• Reynolds Adolescent Depression Scale (RADS)
