PCPs often first
to spot child depression
Specific symptoms require appropriate intervention
In 1998, the Collins* family was confronted with the fact that
their 12-year-old daughter Molly was suffering from depression.
Molly’s school nurse contacted her parents when she noticed self-inflicted
wounds on her arms and legs. The wounds weren’t the only thing
that was wrong: Molly also presented with classic depression symptoms,
including hopelessness, insomnia, concentration troubles, depressed
mood (which can present as irritability), relationship issues,
and suicidal ideation.
Fortunately, the family realized the severity of Molly’s disease
and immediately sought help. Despite still struggling with what
she calls an addiction to cutting herself, a comprehensive treatment
plan of medication and counseling, combined with the support of
her family, close friends and care providers, has allowed Molly
to acquire new tools to deal with her problems.
Until the latter half of the 20th century, many experts thought
that children such as Molly weren’t psychologically developed
enough to become depressed. Today, however, it is widely recognized
that age of onset for depression is decreasing while its rate
is increasing. Because there is significant morbidity and mortality
associated with adolescent depression, early diagnosis is key.
Children’s Hospital Boston psychiatrist Brigid
Vaughan, MD, now treats Molly’s depression. She says
that cases such as hers are common, and that the family pediatrician
is often the first clinician to become aware of the problem. “In
addition,” says Vaughan, “the primary care clinician is in a unique
position to be able to advise families regarding treatment needs.”
SIGNS
OF DEPRESSION IN CHILDREN
In young children, verbal communication
is less than accurate, so behavioral indicators like facial
expression, body posture, level of playfulness, and sleep
and appetite disturbances are more important.
School-age children are better able to
describe their feelings. Their parents should be able to
provide additional useful information about their behavior.
The depressed child may often appear sad or low, have frequent
somatic complaints like headaches and stomachaches, and/or
exhibit a decline in school performance. There also may
be psychomotor agitation, self-endangering behaviors or
even psychosis (usually in the form of auditory hallucinations).
Adolescents have been socialized to disguise
their feelings and they usually present with fewer somatic
complaints. They are more likely to have anhedonia, hypersomnia,
hopelessness and weight change than younger children. Teens
may use self-mutilation (e.g., cutting) to help deal with
their overwhelming emotions, and suicide attempts become
more dangerous.
Substance abuse may accompany with teen depression, so
primary care providers should ask in confidence about drug
and alcohol usage. Psychosis, when present, can take the
form of delusions, and hallucinations may also be present.
It is important to note that parents are not necessarily
good reporters of mood and suicidal thinking in teens—for
this reason, providers should develop good rapport with
adolescent patients and to talk with them about depression.
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Most important, says Vaughan, the care provider can lead the
patient to the specific intervention appropriate for his or her
symptoms. Low mood, low energy and high anxiety often respond
to medication or psychotherapy. For a child whose depression may
stem from relationship problems, consider group or individual
psychotherapy. Some other treatments to consider include psychosocial
interventions like supportive psychotherapy, psychoeducation and
manualized treatment (CBT or interpersonal). Family or school
interventions may also be appropriate. Patients with co-morbid
psychosis, bipolar disorder or substance abuse should see a psychopharmacologist.
Those with chronic or recurrent depression, lack of response to
the initial course of treatment, a history of recent suicide attempts
or a current suicidal ideation should immediately be referred
to a specialist.
“Pediatricians should familiarize themselves with mental health
services in their community and maintain working relationships
with at least a few therapists,” says Dr. Vaughan. “They should
also be aware of local mental health crisis intervention services
for situations involving patients at acute risk.”
After initiation of the appropriate of therapy, the primary care
provider’s main role is to help ensure adequate follow-up, as
well as possibly to prescribe psychotropic medication. With the
exception of severe cases of depression, the decision to medicate
should be deferred until after a trial of therapy. When starting
medication, it is prudent to refer for a consultation with a child
psychiatrist.
Pediatricians and other care providers who have ongoing contact
with patients and families can also help monitor the course and
outcome of specialist care. Dr. Vaughan recommends that providers
ask questions about psychotherapy, school, medication management
and general functioning during regular office visits. Do the specialist’s
impressions and treatment plan make sense to you? Is the family
involved in the therapy? Is the therapist using empirically proven
approaches such as cognitive-behavioral therapy? Are the patient
and family learning new coping strategies? Asking the child and
family about the therapist’s impressions and recommendations should
yield information that will prove useful to the overall care delivered
by primary care providers.
*Names have been altered to protect the patient’s identity.
It can be difficult to discern depression
in adolescent patients. Click
here for a printable self-screening tool to help teens recognize
potential depression and invite dialogue with care providers or
other trusted adults.
For information about Children’s Mood Disorders Center,
visit www.childrenshospital.org/psych
or visit these resources for physicians and patients:
