Major Depression in Children and Adolescents: Hurting and Healing

1. Major Depression in Children and Adolescents:Hurting and Healing Adria Fredericks, M.Ed.

2. Learner Objectives Participants in this seminar will be able to: • Identify risk factors of major depression in children and adolescents • Describe age-related symptoms and possible dual diagnoses • Define various treatment methods • Act as referral agents to health care professionals and other sources of information

3. Glossary • Bipolar • A mood disorder in which debilitating depression on one pole becomes mania on the other • CBT (Cognitive Behavioral Therapy)• A treatment of choice for depression which deals with changing thoughts and behaviors, usually in adolescents • Comorbidity • Two disorders occurring at the same time, e.g. depression and panic disorder • Dysthymia • A chronic depression, not as serious, which can last for years, and at times develop into more serious episodes (double depression)

4. Glossary (continued) • Major depression • A critical mood disorder that affects vital signs, lasts at least two weeks, and can threaten the lives of its sufferers through suicide • Play therapy • A treatment of choice for depression in children who do not yet conceptualize well, which allows them to express through play • SSRI (Selective Serotonin Reuptake Inhibitor) • Anti-depressant drugs

5. Definition Major depression is an illness that can affect any age, sex, ethnic group or class • Feeling sad (sadness that won’t go away) • Feeling guilty • Eating and sleeping too little or too much • Loss of energy and interest • Lack of focus Characteristics include:

6. Definition (continued) Characteristics also include: • Feeling nervous, irritable, angry and unable to relax • Feeling badly about self • Thinking about hurting self • Thinking about death and suicide

7. Definition (continued) • In infants, major depression may look like apathy, withdrawal, and developmental delay or inability to reach developmental milestones • In children, major depression may look like the above plus be expressed through lingering somatic complaints (stomachaches, head- aches, etc.), while some children over-compensate by needing to achieve and please others • In adolescents, major depression may look like the above plus be expressed through acting out, eating disorders, substance abuse, cutting and suicide, which are comorbid

8. Prevalence • Major depression affects 1 percent of preschoolers, 2 percent of children and 5-8 percent of adolescents • The incidence of depression appears to be increasing, with onset occurring at earlier ages, along with a greater risk for developing other disorders • Boys and girls are equally at risk until adolescence, when depression in girls occurs with much greater frequency

9. Prevalence (continued) • Suicide is the most serious result of untreated major depression • The adolescent suicide rate has tripled since the 1970s, with twice as many attempts made by adolescent girls compared with boys, the latter having been four times more successful in completing the act • Completed suicides for children under 10 are rare, but do occur

10. How we identify the problem • In children, look for withdrawal from play, friends and family, changes in sleeping and eating patterns, and pay attention to physical symptoms, problems at school, increased emotional distress or agitation • In adolescents, look for withdrawal from activities, friends and family, and pay attention to changes in self-maintenance habits, problems at school, degree of anger and acting out, substance abuse and talk of death or suicide

11. Biological factors • Much research on some of the core symptoms of depression in adults reveals that little is known about the biological basis for depression in children and adolescents • Investigations have focused on the neuro- endocrine systems in the body, and the changes that occur in the interactions between the nervous and endocrine systems as the child becomes an adolescent, including stress factors and hormonal influences

12. School factors • Children and adolescents with major depression have reduced energy and difficulty focusing on tasks, may be tardy, absent and unable to deal with assignments • They may be overwhelmed by what is required of them, and may express anger and act out • Problems with peers and teachers may develop, and school can become a place of few successes and many failures

13. Family factors • Genetics and family dynamics seem to be two important contributors to major depression • Children and adolescents who have a depressed parent(s) are three times more likely to experience some form of depression, as well as other mental and physical disorders, than those who do not • Stress from loss, abuse, neglect or other trauma within families may significantly affect the moods and coping abilities of children and adolescents

14. Cultural factors In some cultures, depression may be expressed through somatic complaints rather than sadness or guilt • Latino and Mediterranean • “Nerves” or headaches • Asian • Imbalance or disturbance of “chi” (lifeforce or energy) • Middle Eastern • Problems of the heart • Native American • Heartbreak

15. Cultural factors (continued) Cultural ideals and stereotypical gender roles also add stress to what may already be very stressful situations at home and in school

16. National legal safeguards IDEA (Individuals with Disabilities Act) stipulates that alternative placements (to full inclusion in a regular public school classroom) must be made available to students with disabilities, including • Regular classrooms with support personnel • Special teachers • Special classrooms • Special schools • Day treatment/hospitals • Homebound education • Special classes in detention centers and prisons

17. National legal safeguards(continued) • Section 504 protects against discrimination in programs that receive federal funds from the U.S. Department of Education • ADA (Americans with Disabilities Act) extends protection against discrimination to the state and local levels whether or not they receive federal funds

18. Legal Safeguards in Pennsylvania • Chapter 14 of Title 22 of the PA Code delineates the rights of children with disabilities (and their families) to qualify for public special education so that they can participate fully in their communities • Chapter 15 of Title 22 of the PA Code provides a non-discrimination policy for children with disabilities (and their families) that adheres to Section 504 of the IDEA

19. Legal Safeguards in Pennsylvania(continued) Contact: • OCR (Office for Civil Rights) • OSERS (Office of Special Education and Rehabilitative Services) • Commonwealth of PA - Department of Education/Instruction

20. What can you do? • Refer families to their primary care physicians to rule out other medical conditions that may be creating depressive symptoms • Refer families to specialists (psychiatrists, psychologists, counselors) who can better screen for and treat major depression • Create a stable, secure atmosphere for children/adolescents in which they feel safe

21. What can you do?(continued) • Encourage children and adolescents to talk to someone about their feelings, and to express themselves through art, music and writing • Know what’s available and share the information • Be compassionate

22. What to avoid • Being judgemental/critical • Having unrealistic expectations • Being inflexible • Taking behavior personally

23. Treatment Medication • SSRIs (Selective Serotonin Reuptake Inhibitors) are the most effective drugs currently used to treat children and adolescents with major depression • At this time, the only recommended SSRIs are Fluoxetine (Prozac) and Sertraline (Zoloft)

24. Treatment (continued) Therapy • Play therapy is appropriate for children • For adolescents, CBT (Cognitive-Behavioral Therapy) has been shown to be the most effective therapy for changing negative thought patterns and behavior

25. Case study of a child Please refer to the Study Guide to read about Annie, a small girl with a big problem

26. Case study of an adolescent Please refer to the Study Guide to read about David F., a depressed adolescent on a dangerous path

27. Information for parents Please refer to the Parent Brochure

28. Where you can get more help • NAMI PA (National Alliance on Mental Illness of Pennsylvania) Helpline (800) 223-0500 www.namipa.org • NIMH (National Institutes of Mental Health) Helpline (301) 443-4513 www,nimh.gov • NMHA (National Mental Health Association) Helpline (800) 969-6642 www,nmha.org Please refer to the Study Guide for a more comprehensive list

29. References • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C., American Psychiatric Association. 1994 (pp. 339-345). • Ramchandani. (2004). Treatment of major depressive disorders in children and adolescents [Electronic version]. BMJ, 328, 3-4. • Sarafolean, M. (2000). Depression in school-age children and adolescents: characteristics, assessment and prevention [Electronic version]. HealthyPlace.com, Depression Community, 1-4.

30. References(continued) • National Alliance on Mental Illness (2007). Understanding major depression and recovery (Brochure). Duckworth, K., M.D.: Author. • Surgeon General (2006). Depression and suicide in children and adolescents [Electronic version]. Mental Health: A report of the Surgeon General, chapter 3, section 5. For a complete list of references, please refer to the Study Guide

31. Contact information Adria Fredericks, M.Ed. The Center for Counseling Arts 1901 East Carson Street Pittsburgh, PA 15203 Phone: (412) 431-8552 Fax: (412) 431-8561 Email: aaf20@pitt.edu