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David Baxter PhD

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Ped Med: Depression tough to spot in youth
May 13, 2006
By Lidia Wasowicz

SAN FRANCISCO, CA, United States (UPI) -- When it comes to depression in the young, it pays to know when to get help.

However, with a disorder whose true colors run the gamut of an average adolescent's emotional and behavioral palette -- from angst to anguish to apathy to anxiety to anger to aggressiveness -- parents may find it difficult to draw the line between typical and troublesome teen turmoil.

The most consistent rule of thumb for reportable symptoms requires them to represent a change in the child's characteristic mood or behavior, last at least two weeks, interfere with school or home life and not be attributable to any other condition, doctors say.

There is, however, a distressingly large number of caveats, beginning with the warning signs themselves.

The formal diagnostic criteria do not specifically differentiate by age for major depressive disorder, yet children's expressions of the condition may not mirror the classic characteristics seen in adults.

For example, distraught adolescents often are irritable, angry and self-critical, in contrast to their grownup counterparts who tend to languish in languor and lethargy. Markers of youthful depression also may include:

For children 6 to 11:
  • Worry, anxiety, sadness, crying;
  • Deteriorating academic performance;
  • Sleep or appetite changes, nightmares;
  • Refusal to participate in school or activities;
  • Temper tantrums;
  • Hyperactivity or excessive fidgeting;
  • Disobedience or aggression;
  • Poor attention, concentration or organization;
  • Boredom, fatigue;
  • Low self-esteem;
  • Volatile moods;
  • Talk of dying;

For adolescents:
  • Declining school performance;
  • Bad mood, hopelessness, helplessness;
  • Truancy, theft, vandalism, running away, harassment;
  • Drug or tobacco abuse;
  • Abnormal eating/dieting habits;
  • Angry outbursts, rage;
  • Inability to cope with daily problems;
  • Nightmares, sleep disturbances;
  • Aches and pains, such as headaches and stomachaches;
  • Thoughts of or threats to harm self or others;
  • Sexual acting out;
  • Neglected hygiene or appearance.

If the above list looks suspiciously familiar to those familiar with attention-deficit/hyperactivity disorder, it should. Many of these behaviors and emotions also are used to distinguish ADHD as well as other mental conditions.

"Many symptoms of depression also present with other psychiatric disorders," noted Dr. David Fassler, a Burlington, Vt., child and adolescent psychiatrist, clinical associate professor of psychiatry at the University of Vermont and author of Help Me, I`m Sad: Recognizing, Treating, and Preventing Childhood and Adolescent Depression (Penguin, 1998).

"For example, irritability can be a sign of depression or anxiety or attention deficit or bipolar disorder or a reaction to a learning disability, so a proper diagnosis is critical," he said.

In a further entanglement, numerous conditions with overlapping characteristics often coexist, making the symptom sorting all the more tricky, even for professionals.

"The symptoms of the four most prevalent mental-health conditions (ADHD, anxiety, bipolar disorder and depression) are not always easy to tease apart, especially in children," who, in addition to other complicating factors, may not be capable of articulating their feelings, notes the Consumer Reports Medical Guide, an assessment by the non-profit advocacy group Consumers Union.

The task presents a particular challenge to primary-care providers, who lack specialized training but whose caseloads increasingly include children in psychological trouble.

Studies suggest 12 percent to 25 percent of these young patients have significant psychosocial problems, only a small fraction of which are properly identified and referred for treatment.

As many as two-thirds of depressed children also suffer from other oftentimes look-alike disorders. Untangling these so-called comorbidities hits a snag on the chicken-and-egg quandary: Which came first and is one the cause, effect, neither or both of the other?

Take the symbiotic relationship between sleep and mood. Extensive evidence exists of high rates of slumber disruptions in adolescents with mood irregularities, particularly major depressive disorder. The condition can drag a child down with a host of symptoms that can last seven months to nine months per single episode.

Conversely, studies show sleep-starved teens have more than their fill of moodiness. In a tit-for-tat, while stress and emotional arousal can disturb the slumber of troubled teens, sleepless nights can make them irritable and cranky.

A similar crossover with ADHD has led slumber specialists to urge parents and patients to exhaust non-drug sleep disturbance treatment options before turning to chemical alternatives.

In another study reflecting the complex relationship between co-existing conditions that can have an impact on treatment, neurologists found surgical correction of epilepsy that did not respond to medication resulted not only in fewer seizures but also in a more than 50 percent reduction in depression and anxiety disorders.

These are common among people with epilepsy, a neurological disease marked by recurrent convulsions.

The researchers are now studying why the treatment produced such a double dose of good results.

Even when unattached, depression can prove confounding by manifesting itself in strikingly dissimilar fashion in different individuals. Some depressed children may act withdrawn, sad, unable to enjoy activities they once found pleasurable while others become short-tempered, grouchy or disobedient.

A youngster in the dumps may pretend to be sick, refuse to attend class, cling to a parent or worry that mom or dad may die, while the older counterpart may sulk, cause trouble, show a short fuse and feel misunderstood, doctors say.

But so can children in the bloom of mental health. The natural metamorphosis of behaviors through the progressive stages of maturation can stump an observer trying to determine whether the youngster is suffering from a depressed state or simply going through a temporary phase of childhood.

Compounding the confusion, not every troubled child shows all or even most symptoms, which vary across types and over time.

"Everyone's depression is different," Fassler said. "Some children's grades drop, others sleep too much or not enough because signs and symptoms can be so varied."

And they can be interpreted in many different ways, contend critics convinced there's too much misreading of normal reactions as evidence of mental illness.

"It's easy to medicalize the kinds of emotional upheavals young people experience, so a child who is angry or sad can easily be diagnosed as having depression and be put on treatment," said Peter Goldenthal, a Wayne, Pa., pediatric and family psychologist, lecturer and author of Why Can't We Get Along?: Healing Adult Sibling Relationships (John Wiley, 2002). He specializes in children's emotional and behavioral problems.

To help teachers, coaches and others in routine contact with children sift through the oftentimes contrarian symptoms, the American Psychiatric Foundation, an arm of the American Psychiatric Association, has established a public education campaign called Typical or Troubled: Knowing More about Teen Mental Health.

"The program helps people who deal with kids determine, is this kid a typical moody teenager or a troubled, depressed and suicidal teenager," said Dr. William Narrow, associate director of diagnosis and classification in APA's research division.
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