Pediatric Primary Care Case Studies (53 page)

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Long-term consequences of child abuse and neglect fact sheet
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Young children and their drawings
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Kellogg, N., & Committee on Child Abuse and Neglect. (2005). The evaluation of sexual abuse in children.
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Chapter 14

The 14-Year-Old Who Looks Depressed

Ann M. Guthery

Often primary care providers have adolescents brought to their office with complaints of irritability, decline in school performance, oppositional defiant behavior, withdrawn behavior, and somatic complaints. Deciding whether these symptoms are indicators of depression or are reflective of normal developmental transitions can often be difficult. Determining the persistence, intensity, and impairment caused by these symptoms with regard to home, school, and peers is needed to make the diagnosis of depression.

Educational Objectives

1.   Identify symptoms of depression in adolescents.

2.   Discuss treatment options including medication management and therapy in setting up a treatment plan.

3.   Identify when a referral should be made.

   Case Presentation and Discussion

Tom Williams is a 14-year-old male who is brought in by his mother who is concerned about his decreased energy level, frequent headaches, and stomach pains. He often wants to sleep or be alone in his room. He loses his temper easily and at one point punched a hole in the wall after an argument with his father. He just started ninth grade and is struggling with the transition to high school. He used to play baseball, but recently has been ditching his old friends and hanging around with new friends that his mother believes are a bad influence. Since being with these new friends, he has been caught shoplifting cigarettes and one of the peers was suspended for bringing marijuana to school. His mother is worried that he is using drugs, but he denies that he has used any.

You observe during this interaction that Tom’s affect is flat and he is tearful as his mother tells you this information. He has dark circles under his eyes and states, “I just don’t feel good, I can never get to sleep so I’m tired all the time and everything in my life is bad.”

You ask his mother to wait in the waiting room so you can question Tom privately. After his mother leaves he tells you the following:

He has tried marijuana a few times because he wanted to see if it helped him to relax, but he often feels worse after he comes off the high, so has stopped using it. He states he
has felt sad for the last year; he often feels that no one likes him and that everyone judges him. His closest friend from the baseball team has a girlfriend whom he spends all his time with, so Tom has had to try and find other friends. He knows that the new friends are not considered the best behaved kids in school, but they at least cause some excitement in his life because he is always bored. He feels he can’t ever please his parents because he struggles with academics. He states his parents make him so angry that he feels like he wants to hit them when they are lecturing him for something he has done. He denies suicidal thoughts, but states he feels like he is in a hole and can’t crawl out of it. Every day is the same and nothing ever gets better.

In meeting with Tom’s mother, you find out that she and Tom’s father have been arguing and they have discussed a trial separation and possible divorce. Tom is an only child. His father is diagnosed with bipolar disorder.

What other things do you need to do to further assess this patient?

Before answering this, here is additional information you need to consider.

Description and Etiology of Depression in Children and Adolescents

Definition and Characteristics of Depression

A definition of childhood depression is difficult to find in literature because depression is usually described by symptoms. Depression in children and adolescents may be defined with the same criteria as for adults. It is based on negative cognitions such as hopelessness, negative view of the self, negative self-schema, negative attributions, loss of locus of control, and cognitive distortions. Depression is hard to diagnose in children because many also have comorbid diagnoses such as anxiety. Depression in children appears to be a syndrome with a combination of dysphoria (inappropriately or excessively sad mood) or anhedonia (loss of pleasure in response to previously enjoyed activities) as the two most significant symptoms.

Depression symptoms change with age. For example, in preschool children, decreased appetite, failure to gain weight, sad appearance, irritable mood, feeling bored, GI upset, sleep difficulties, and repetitive behaviors are the most common symptoms. They tend not to report depressed mood or hopelessness feelings (Hankin, 2006). In children ages 3–8 years, aggression and self-endangering behaviors are more common. Negative life events sometimes lead to depressive symptoms in early childhood while a negative explanatory style leads to depressive symptoms in later childhood and adolescence. Major depressive disorder in young people continues into adulthood across many studies (Hankin, 2006; Rice, Harold, & Tharper, 2002). Genetic and biological factors also have been found to contribute to the occurrence of depression in children.

Pathophysiology

Norepinephrine and serotonin are the two neurotransmitters most often implicated in mood disorders. People who are depressed have decreased sensitivity of
beta adrenergic receptors for both epinephrine and serotonin; these neurotransmitters are increased with use of antidepressants. In addition to the neurotransmitters, studies have shown that the following areas of the brain are involved with mood regulation: medial and orbital prefrontal cortex, anterior cingulated cortex, amygdale, nucleus accumbens, and hypothalamus (Sadock & Sadock, 2007).

Comorbidities

Depression commonly occurs with other mental disorders including anxiety, conduct/oppositional defiant disorders, and attention deficit hyperactivity disorder (ADHD). Eating disorders and substance abuse are associated with depression in adolescents (Hankin, 2006). In examining comorbid conditions in adolescents, Rice et al. (2002) found that chemical dependency could be a form of depression.

Mesquita and Gilliam (1994) reported that both attention deficit disorder and depression can result in difficulty with concentration, psychomotor agitation, and engagement in self-endangering behaviors. Social withdrawal, guilt, weeping, and dysphoria are key to depression. Thus, it is clear that depressed children are suffering and that their emotional and social well-being and academic progress are at risk.

Depression in Children and Their Families

Depressed children may have a depressed parent. In addition, they may have received hard power-assertive discipline, a rigid and inflexible family structure, and internalized aggression. A family interaction of low conflict and aggression and maternal aversiveness was seen in both depression and conduct disorders. Environmental stressors seem to be less correlated with depression.

Theories of Depression

According to Sadock and Sadock (2007), the causal basis for mood disorders is not known, but many theories have been proposed. These theories have been divided according to biological, genetic, and psychosocial factors, as well as cognitive theories.

Biological

It is important to understand that brain chemistry may affect perception and thinking, which in turn could impact mood. One hypothesis is that mood disorders are associated with heterogeneous dysregulation of the biogenic amines; in particular, depleted levels of serotonin and norepinephrine are most often implicated in mood disorders. The pathology for depression seems to occur in the limbic system, the basal ganglia, and the hypothalamus.

Genetic

Genetic factors for depression have been shown in first-degree relatives. Sadock and Sadock (2007) cited a review of genetic studies showing that children have
a 25% higher chance of developing a mood disorder if they have one parent with a mood disorder. If both parents have a mood disorder, then children have a 50–75% chance of developing a mood disorder. Key findings from a review of studies by Rice, Harold, and Tharper (2002) showed an increased familial risk, and that recurrent prepubescent major depressive disorder may be more familial than previously thought.

Psychosocial

Psychosocial factors related to depression include life events and environmental stressors such as early loss and abandonment affecting children’s mood. Children who have experienced these stressors can show symptoms of internalized hostility, ambivalence, and loss of self-esteem. These factors can all affect thinking and perception, which, in turn, may be related to depressed feelings.

Cognitive Theories

The cognitive theory of depression has been widely studied. According to this theory, depression results from a negative cognitive set (i.e., a tendency to erroneously view the self, future, and one’s experience in a negative manner). Basically, the model reveals that a loss of social reinforcement and disruption of close interpersonal relationships mediate the development and maintenance of depression symptoms; the less interpersonal competence one has, the greater the negative impacts on others and the poorer interpersonal problem-solving performance will be.

Stress and Coping

It is important to understand potential resources for coping because they may be spiritual in nature or they may function in place of spiritual resources for the child. People learn modes of coping from their membership group. Coping involves modification of the stressful situation, modification of the meaning of the problem in order to reduce stress, and then management of the stress symptoms. It includes specific behaviors that vary depending on the problem and the social role one is dealing with. However, coping has its limits. As Pearlin et al. (1981) explained, individuals, faced with an array of problems and hardships as they move through life, do not choose between coping and supports, but use both in an effort to avoid, eliminate, or reduce distress.

Epidemiology of Depression

Prevalence rates vary across studies, which use a variety of measures to identify depression. Twenty-eight percent of the students nationwide completing the Youth Behavior Survey (Centers for Disease Control and Prevention [CDC], 2008) reported feeling so sad or hopeless every day for two or more weeks that they changed their activities; 14.5% reported considering suicide, 11.3% had made a suicide plan, and 6.9% had attempted suicide. In an assessment of children with chronic emotional, behavioral, or developmental problems completed
in 2001, 43.5% had depression or anxiety problems (CDC, 2005). Hankin (2006), in his review of many adolescent depression studies, notes that between 20% and 50% of adolescents report subsyndrome levels of depression. Generally, studies of individuals with clinically diagnosed major depression report prevalence rates of about 14% for 15 to 18 year olds and about 16.6% for 18 to 29 year olds. In childhood, rates are more like 1% to 3%.