- *Chief, Child Psychiatry Service, Massachusetts General Hospital; Professor of Psychiatry and of Pediatrics, Harvard Medical School, Boston, MA.
- †Pediatric Consultation Liaison Service, Physician-in-Charge, Attention Deficit Hyperactivity Disorder Program, Division of Child and Adolescent Psychiatry, North Shore University Hospital-New York University School of Medicine, Manhasset, NY.
Vulnerability to psychiatric disorders, including depression, involves the interplay of genetic, biochemical, and psychosocial/environmental forces.
The “core” symptoms of depression are the same for children and adults, but the prevalence of certain symptoms can vary with age.
Evidence suggests that early-onset major depression is associated with especially high levels of psychiatric comorbidity, a protracted course, a poorer outcome, and a high probability of significant functional impairment.
Suicide risk factors are common to a wide range of distressed children and adolescents and are not specific to suicide.
There is no way to predict suicide among depressed children and adolescents, except in those who have made previous attempts.
Pediatricians are confronted daily with a wide array of psychosocial issues.Whether it’s the preschooler crying and complaining of stomach aches before leaving for child care, the young adolescent skipping school, or the older teenager abusing substances, pediatricians often are put in the difficult position of having to decide if problem behaviors and emotions are“ normal variations,” developmental transitions, temperamental manifestations, or primary symptoms of a serious psychiatric disorder. Mood disturbances and depressive states often represent a diagnostic dilemma to the primary care physician.
Sadness is common and is an appropriate response to loss (eg, death of a loved one), divorce, or separation. Although the initial sadness following loss may fade over time, children often revisit their sadness in later years. Normal adaptation involves a gradual acceptance of the loss and an incorporation of this reality into the child’s life experience. Some children will reconfigure the memory of the deceased through pictures or momentos in a process called memorialization. Other children (and adults) may carry on a silent dialogue with the deceased, trying to imagine how this person would have reacted at key times during the child’s life (eg, graduations, weddings). Sadness, when provoked by such losses, may provide an opportunity to experience and process deep feelings, review priorities and values, and gain an appreciation for, and learn from, past relationships. This process of attaching, loving, maturing, facing loss, and moving on to more sophisticated or new attachments gives life much of its meaning.
Mood variations related to changes in child care, school, peer relationships, the birth of a sibling, or loss from routine life events are all expected, and pediatricians commonly reassure parents that their child probably will adjust well over time. However, a small percentage of children and a greater number of adolescents experience more persistent and serious difficulties with their moods. Some mood disorders will be precipitated by a stressful event; others will arise spontaneously (in the past called“ endogenous depression”), probably rooted in genetics and neurotransmitter systems. Sometimes a depressed mood will initiate behaviors such as withdrawal, which then precipitates other losses (eg, loss of friends), and can be interpreted mistakenly as the cause rather than the consequence of the depression.
Finally, few children will experience dysphoric moods that are so persistent, recurrent, or pervasive as to become embedded into the child’s character. Components of depression, such as loss of self-esteem, victimization, and poor motivation, may become so ingrained that a child expects failure and stops trying. To avoid overwhelming anxiety, another set of failures, or criticism, a child may make a conscious or unconscious choice that repeats failure, which reaffirms a negative self-perception.
From a clinical perspective, childhood depression, regardless of etiology or associated conditions, is difficult to diagnose. It ranges from mild to severe and can lead to specific or broad dysfunction. In adolescence, it is associated with an increased risk of suicide and risk-taking behavior. Unfortunately, depression in many children is recognized only after prolonged and significant impairments in school and social functioning have occurred. Moreover, pressures of managed care are encouraging pediatricians to be more self-sufficient and limiting access to mental health consultation. Finally, greater demands on the pediatrician’s time usually translate into less time available to address mental health concerns.
Traditionally, depression was believed to be the reaction to the loss of an ambivalently loved object. In Mourning and Melancholia, Freud discussed the similarities between mourning in those who suffered the“ real” loss of a loved one and melancholia (depression). According to Freud, both conditions involve sadness, changes in sleep and eating patterns, emotional pain, and loss of interest in the outside world. Melancholia, however, is seen as a failure of mourning. Freud suggested that in melancholia, the mourning process is disrupted by unconscious anger and feelings of rage toward the lost person. Such rage evokes guilt and loss of self-esteem as part of a maladaptive solution to ambivalent feelings (love and anger) toward the lost person. Depression was thought to require adolescent or adult development because theoretically the capacity for guilt required more mature and abstract forms of thinking (specifically, a conscience). Children were believed to have “immature” or limited consciences.
In the 1960s it was hypothesized that children suffer“ masked depression.” Typical adult-like depressive symptoms were thought to be “hidden” by behaviors and symptoms such as hyperactivity, learning disabilities, and encopresis (Glaser, 1968). However, clinical reports dating back as early as the 1900s describe depressed children suffering from dysphoric moods, intense sadness, irritability, and suicidal thoughts that resemble more typical adult-like symptoms. Anthony (1975) argued that part of the difficulty in recognizing childhood depression was that children, although capable of experiencing depression and depressed affect, expressed their symptoms differently than adults. He proposed that children express symptoms in a manner consistent with their developmental level of symbolism, language, and thought and that they manifest more somatic complaints, self-esteem deficits, and sad facial expression than do depressed adults.
By the mid-1970s, research and epidemiologic studies began to support the existence of childhood depression and helped to clarify diagnostic criteria. The most current revision of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, DSM IV (1994), emphasizes that the “core” symptoms of depression are the same for children and adults, but that the prevalence of certain symptoms can vary with age. During the past two decades, epidemiologic studies using diagnostic criteria have studied the relationship of factors such as family history, genetics, and biochemistry with childhood depression. Most recently, the American Academy of Pediatrics (AAP), in collaboration with the American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP), has created a separate pediatric manual, the DSM-PC (Primary Care), which offers a developmental approach to the recognition and diagnosis of childhood mental disorders. The diagnostic system is based on a set of symptoms, which for childhood depression is age-specific. The DSM-PC notes characteristic symptoms of sadness in infancy, early and middle childhood, and adolescence. It describes a range from “normal variation” to “the problem” of sadness approaching a depressive disorder to major depression, using criteria drawn from DSM IV.
Epidemiologic studies have established that depression is a disabling disorder identifiable in all age groups. Estimates of the incidence and prevalence of major depression in children vary according to differences in sampling strategies (schools, households, clinic populations) and measurement techniques. Studies using questionnaires to elicit a self-report of the child’s intrapsychic feelings tend to find higher rates and may be more reflective of a high frequency of depressive symptoms in the child and adolescent population rather than the presence of the full clinical disorder. For example, Albert and Beck (1975), using self-report depression rating scales in community samples of nonreferred children (ages 11 through 15), reported rates of depressive disorders as high as 35%. In contrast, diagnostic interviews such as the Diagnostic Interview Schedule for Children (DISC; Costello, Costello, and Edelbrock, 1988) and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), which are based on strict research and DSM diagnostic criteria, report much lower rates of depression.
Before puberty, rates of depression are similar in boys and girls. After puberty, there is a 2:1 female preponderance, just as in adulthood. According to recent reports, rates of major depression are estimated to be 0.9% in preschool-age children, as high as 2.5% in school-age children, and between 4.7% and 6.1% in adolescents (comparable to a rate of 4.9% for the total adult populations ages 15 through 54) (Anderson and McGee, 1994; Blazer et al, 1994). Others have predicted that in a high school of 1,000 students, 74 cases of depression (lasting an average of 5.4 months) would be expected to occur over a 1-year period (including “first-time” depressives and those who had a history of depression and relapsed within 1 year after entry into the study).
Recent reports have suggested a possible secular increase in rates of depression, meaning that more individuals born recently are at greater risk for developing the disorder compared with individuals born earlier (Ryan et al, 1992). Successive birth cohorts also were found to have a younger age of onset for first major depression (Kovacs and Gatsonis, 1994).
Etiology and Pathogenesis
“(Environmental) influences do not really write like a pen upon the clear sheet of the child’s innocence, but they play upon, and are engaged in a sort of battle with, the instinctual forces with which the child is endowed.” (Emanuel Miller 1938).
Vulnerability to psychiatric disorders, including depression, involves the interplay of genetic, biochemical, and psychosocial/environmental forces.
Taken together, family, twin, and adoption studies make a strong case for genetic influences operating in the transmission of major depression. Adoption studies document up to an eight-fold increase in depression and a fifteen-fold increase in suicide among the biological relatives of adoptees who have affective illness. Studies show that depression aggregates in families and that a family history of major depression is a significant risk factor for the development of depression in children. Not only do children of parents who have affective disorder experience up to a three-fold increased incidence of developing depression and have an earlier age of onset (<20 years), but they are also at increased risk for anxiety and disruptive disorders, and they tend to have illness of longer duration (Beardslee et al, 1993). Twin studies showing the concordance rates for major affective disorder to be higher in monozygotic than dizygotic twins (76% versus 19%) suggest a strong genetic component and inheritability. Despite strong associations of heritability, one third to one half of children develop depression in the absence of any family history of depressive illness.
Endocrine studies implicate several different neurotransmitter systems in depression, including the noradrenergic, serotonergic, cholinergic, and dopaminergic systems. Abnormal levels of these neurotransmitters (and their metabolites) in blood, cerebrospinal fluid, and urine as well as measures of platelet receptor functioning have been detected in depressed patients.
Although no laboratory findings are diagnostic of a depressive disorder, several other abnormalities have been associated. These include cortisol hypersecretion, dexamethasone nonsuppression, hyposecretion of growth hormone in response to an insulin challenge, hypersecretion of growth hormone during sleep, functional and structural brain imaging changes, and sleep electroencephalographic abnormalities. Further studies are necessary to establish the clinical usefulness of these preliminary findings.
Stressful events can precipitate depression in children who have no identifiable constitutional susceptibility, but they are more likely to precipitate depression in children who have an inherited vulnerability to depression. Studies of depressed adults and adolescents show significantly more stressful life events or losses in the year prior to the onset of depression (Brown and Harris, 1993).
Families of depressed youths have been characterized as having more conflict, rejection, and abuse and less communication, expression of affect, and support (McCauley and Myers, 1992). Low self-esteem and perceived worthlessness also play an important role in the development and perpetuation of depression (Hammen, 1988).
INFANTS AND TODDLERS
Infants and young children are “individuals of the moment” who have an undeveloped conceptualization of past and future. They are highly reactive to environmental disturbances or deprivations, such as separation, rejection, or punishment. Brief expressions of sadness manifested by crying, transient withdrawal, and anger are common. True depression in this age group is rare and difficult to define or detect.
Spitz described “anaclitic depression” in which infants who experienced prolonged separations from primary caretakers or who did not have adequate, consistent caretakers developed withdrawal and apathetic reactions that were believed to be analogous to the adult form of depression. Clinicians were left to infer depression from overt behaviors. For example, infants who suffer depression sometimes will demonstrate a lag or regression in their developmental milestones and exhibit“ nonorganic” failure to thrive, sleep disturbance, and persistent irritability and despondency that may not respond to extra efforts at soothing and engagement by caretakers. Toddlers may “lack spunk,” be too eager to please, be excessively whiny and clingy, and have problems with separation. Although these symptoms may apply to many children who are not depressed, when these symptoms are persistent and intense, they should alert the pediatrician to the possibility of an underlying mood problem.
School-age children begin to express feelings of sadness not only as a reaction to external disappointments, but in response to a sense of disappointment with themselves. At this age, children may incorporate ex-ternal events, such as parental separation, into a negative view of themselves and lose self-esteem (a prominent feature of depression). In addition, a high incidence of parental aggression, marital discord, and scapegoating or rejection has been reported in the families of depressed children.
Depressed children often manifest a loss of interest and pleasure in many usual childhood activities. Because a school-age child’s self-image is predicated partially on praise derived from achievements in school, skills, and social development, early depression-related failures in social, academic, and athletic arenas may begin a self-sustaining cycle of withdrawal, decreased productivity and skill, rejection, and ultimately a progressive lowering of self-esteem. Children who are depressed often describe themselves in negative terms, such as “I am bad, ugly, or stupid.” Some depressed children, trying desperately to compensate for feelings of poor self-worth, become preoccupied with attempting to please others. However, striving for academic excellence or behaving so as not to cause any trouble affords only temporary relief for their sense of failure; behind these struggles, depression persists. Such depressed children are harder to recognize because their solution of “being good” covers their distress. Thus, recognition depends on identifying other commonly presenting symptoms of childhood depression, such as a depressed appearance (sad face), somatic complaints (eg, stomach ache, headache, fatigue, and symptoms of pain), restlessness or agitation, phobias and nightmares, separation anxiety, and psychotic symptoms (eg, hallucinations).
As adolescents strive to develop their own identities and travel beyond the intimate setting of their family to a world filled with friends, expectations, and romantic relationships, many will acknowledge feelings of sadness. Parents also may experience the child’s growing up as growing away. Thus, there is an expected undercurrent of sadness in both parents and adolescents resulting from appropriate separation. This sadness commonly is manifested by tension, but it also may precipitate depressed mood of varying degrees. For adolescents, social acceptance by and conformity with peers becomes a bridge between dependence on parents and their own emerging identity. Adolescents also are susceptible to episodes of sadness following loss (eg, breakup with boyfriend or girlfriend) that sometimes can be accompanied by suicidal ideation. The typical adolescent can experience rapid mood shifts, contempt for authority, disrespect for parents, grandiose self-confidence, defiance, changing ideas or beliefs, and indifference. These shifting states make it especially difficult to differentiate between “normal” and pathologic states in this age group.
Developmentally, a sociocognitive maturation also occurs during puberty that permits more mature feelings of despair, self-hate, blame, and hopelessness, as well as the means to act on those feelings in the form of suicide. Compared with younger children, depressed adolescents have more apparent diminished interest or pleasure, hypersomnia, feelings of hopelessness, and weight change. They also are more likely to seek alternative forms of pleasure and stimulation via drug abuse. Further, adolescents suffering from depression may withdraw when they experience difficulty adjusting to peer and social groups. They may appear shy,“ bored,” and unmotivated, and they often are scapegoated or ridiculed at school.
Depression is diagnosed by using very specific criteria evolved from epidemiologic studies. The DSM IV diagnosis of major depression requires at least 2 weeks of predominantly depressed, bored, or irritable mood and an additional four or more depressive symptoms (eg, sleep disturbance, decreased interest and pleasure, guilt, hopelessness) that together cause significant distress or impaired functioning (Table 1⇓ ). The DSM-PC classifies depressive behaviors that occur during childhood and adolescence into four categories: sadness variation (normal), bereavement, thoughts of death variation/problem, and depressive disorder.
One of the most confusing problems in children is not only differentiating normal mood variation from depressive states, but distinguishing depression from other disorders that include depressive symptoms.
Adjustment disorders are manifested by depressive symptoms (not enough to fulfill criteria for depression) and precipitated by maladaption to common forms of psychosocial stress (eg, loss of a loved one, family conflict, failure or rejection at school). Adjustment disorders do not predict later dysfunction; they have a good short-term prognosis, with a median episode length of 7 months and a 97% recovery rate (Kovacs et al, 1994).
Bereavement resembles an adjustment disorder in that it is associated with a stressful event. “Normal” bereavement is the reaction to the loss of a loved one. For children, it can lead to a temporary impairment in school and social functioning. The reaction to the loss can be so intense that it fulfills criteria for major depression, but bereavement is not considered a disorder unless these symptoms persist for more than 2 months and cause significant impairment or dysfunction. Uncomplicated bereavement gradually diminishes with time, and previous levels of functioning are restored. Nevertheless, most children will continue to “work through the sadness” by revisiting it months to years later.
SEPARATION ANXIETY DISORDER
Children who have separation anxiety experience severe distress when separated from parental figures. Separation anxiety can be associated with certain depressive symptoms such as sadness, excessive worrying, somatic complaints, and apathy. For many of these children, the depressive symptoms arise only in the context of separation and are absent once the situation is resolved. However, up to 69% of children who have separation anxiety also have a concomitant depressive illness.
Dysthymic disorder is manifested by a depressed or irritable mood for most of the day, for more days than not, for at least 1 year. Unlike major depression, dysthymia is milder, requiring only two of the following symptoms: appetite and sleep disturbance, poor energy, poor concentration, and hopelessness. However, because of the chronic nature of the disorder, it can interfere with a child’s peer relations, attachments to caretakers, and development of social skills. Children who have dysthymia are also at increased risk for the development of subsequent mood disorders.
Depressive symptoms and mood swings can be difficult to differentiate from evolving manic-depressive disorder. Many “manic-depressives to be” exhibit predominantly depressive symptoms during childhood, then develop full-blown mania in adolescence or adulthood. Wozniak et al (1995) found that children who have bipolar disorder have a developmentally different presentation from adults. The majority of children presented with irritable rather than euphoric mood, a chronic rather than episodic course, and a mixed presentation that included simultaneous symptoms of depression and mania. Those children who had a family history of bipolarity and depression coupled with attention deficit hyperactivity disorder (ADHD), conduct disorder, or substance abuse were at higher risk for developing bipolar disorder (Carlson and Weintraub, 1993).
Mania and agitated depression commonly coexist with and often are confused with ADHD (Wozniak et al, 1995). Each of these conditions may present with motor hyperactivity and impaired concentration. However, children who have predominant mood disorder usually do not manifest the same elements of impulsivity. A careful history that reveals a normal attention span prior to the onset of illness may be less suggestive of ADHD and more suggestive of poor concentration attributable to preoccupation with sad feelings.
Depression and poor physical health are strongly associated, making the role of depression in medically ill children and adolescents of special interest to both pediatricians and mental health professionals. In particular, chronic or prolonged illness involves a severe degree of loss (eg, loss of function, loss of school time/friends, loss of the parents’ hope for a well child) and consequent profound elements of sadness and grieving for both the child and parents. Although many children overcome the challenges of having a chronic illness, most experience acute sadness and disturbances in self-esteem and peer relationships while adapting to a loss of function, change in body image, and disruptive and unpleasant treatments. For these children, finding opportunities for functioning and building self-esteem may promote future emotional well-being. Others who experience more seriously debilitating conditions and/or illness-specific risk factors, such as poverty, parental dysfunction, divorce, and abuse, may develop depressive disorders that require psychiatric intervention.
Although the prevalence of depression in general pediatric settings approximates the rates reported in nonreferred community samples (0.6% using diagnostic interview DISC, Costello et al, 1988), higher rates of depression (up to 7%) have been reported in general pediatric inpatient settings (Kashani et al, 1981). The prevalence of major depression also has been shown to increase significantly in chronically ill populations. For example, 17% of children and adolescents (ages 6 through 17) diagnosed with cancer and 24% of adults who have type 1 diabetes meet criteria for major depression.
Often the presentation of depression in medically ill children is confusing, and the differential diagnosis must be pursued along both organic and psychiatric lines. Certain medical conditions, alcohol and drug abuse, and prescription drug side effects can present as or mimic depression (Table 2⇓ ). In general, an initial physical examination and screening laboratory tests (complete blood count with differential, electrolytes, blood urea nitrogen, creatinine, liver function tests, thyroid function tests) are necessary to evaluate potential organic etiologies. Treatment focuses on correction of any underlying abnormality or illness and adjustment or removal of any precipitating causal agent.
Comorbidity is a term used to describe the coexistence or simultaneous presence of more than one disorder affecting a single individual. The onset of depression in children and adolescents is believed to have especially high levels of psychiatric comorbidity. Kovacs et al (1984) reported that up to 70% of depressed children met criteria for another major psychiatric diagnosis. In a recent review, comorbidity with conduct and oppositional defiant disorder ranged from 21% to 83%; comorbidity with anxiety disorders ranged from 30% to 75%; and comorbidity with ADHD ranged from 0 to 57.1% (Angold and Costello, 1993). Depressive comorbidity has a generally deleterious effect, influencing recurrence, duration of the depressive episode, suicide attempts or behaviors, functional outcome, response to treatment, and utilization of mental health services.
Disease Course and Outcome
Much of what is known about the natural history of depression in children comes from a major, longitudinal study by Kovacs et al (1984), who found that the average duration of a major depressive episode was 32 weeks, with 92% of children recovering within 18 months. However, the cumulative probability of having a recurrent major depressive episode was 72% within 5 years after the onset of the first episode. The evidence suggests that early-onset major depression is associated with a protracted course, a poorer outcome, and a high probability of significant functional impairment. Prepubertal-onset depression not only is more severe and resistant to treatment, but it is associated with a 31.7% risk of developing future bipolarity or manic symptomatology.
Although suicide by children and adolescents is rare on a community level, it accounts for up to 12% of deaths (second only to accidents and homicide) nationally. Suicide is rare in prepubertal children, but there is a precipitous rise in prevalence after puberty and through adolescence. Further, the rate of both suicide attempts and completions has been increasing steadily over the past three decades.
A recent estimate of the adolescent suicide rate is 11.2 per 100,000, a four-fold increase since 1950 (Brent et al, 1988). Nearly one fourth (24.1%) of 9th- through 12th-grade students nationwide report having seriously considered attempting suicide, 17.7% acknowledged more serious intent by making a specific suicidal plan, and 8.7% attempted suicide, with 2.8% suffering an injury requiring medical attention (Morbidity and Mortality Weekly Report, 1996). In the past decade, teenagers have surpassed adults in the ratio of suicide attempts to completed suicides and have accounted for more than 12% of the nation’s suicide attempts.
Adolescent males are more likely to complete suicide (ratio of 4:1 boys to girls) because they use more lethal means, but the rate of attempts is substantially higher in females, who as a group, tend to use less lethal means. Methods and lethality are directly related to availability. Firearms constitute the method used most frequently in completed suicides (ages 15 through 24), followed by hanging. Alarmingly, the trend in recent years has been toward increased use of firearms and decreased use of drug ingestion for both males and females (MMWR, 1988).
Even though completed suicide in young children is rare, some studies show that suicidal ideas, threats, and attempts are relatively common. In one school-age (6 through 12 years old) community sample, 8.9% of the children expressed suicidal ideas and 3% had made threats or mild attempts.
The relationship between psychiatric illness and completed suicide has been examined in a retrospective review. Although more than 90% of those who committed suicide have been found retrospectively to meet criteria for at least one major psychiatric diagnosis (52% met criteria for major depression), only 46% had sought treatment from a mental health professional (Shaffer et al, 1996). Thus, more than 50% of completed suicides are not detectable by mental health or pediatric personnel because the individuals never seek treatment. Among the 46% who did present for treatment, only 10% had been prescribed antidepressants or enrolled in substance abuse programs, suggesting that assessing the presence or severity of suicidal potential even in those who have been evaluated in treatment remains difficult and frustrating.
Suicide can be the final common pathway of many psychiatric and social problems. Suicide victims are reported to have had higher rates of conduct disorder (28.4%), bipolar disorder (17.9%), and substance abuse (27.3%) (Brent et al, 1993). They also were more likely to have experienced interpersonal problems with parents and to have family histories of depression, substance abuse, and suicidal behavior (Brent et al, 1994). Among children younger than 14 years of age admitted to a psychiatric inpatient unit for suicide attempts, up to 80% had experienced some type of loss (death of a parent, sibling, or grandparent or loss of a possession), and two thirds had either witnessed physical violence between parents or had been physically abused themselves. In addition, suicidal victims tended to have impulsive-dramatic and avoidant-dependent personality disorders and high levels of aggression.
Shaffer and Gould (1987) also have found significant associations between suicide and major depression, prior suicide attempts, substance abuse, antisocial behavior, and family history of suicide in suicide victims younger than age 20. Their study has identified many teenagers who committed suicide shortly after a disciplinary crisis, rejection, or humiliation (being ridiculed or teased or failing at some event). These authors propose that these common stresses may lead quickly to suicidal behavior, reducing the opportunity for preventive interventions. Other factors, such as poor social adjustment (eg, school failure, legal problems, conduct problems), chronic medical conditions (eg, diabetes), and anxiety about homosexuality have been associated with suicidal impulses and behavior (for a review, see Shaffer et al, 1988).
EXPOSURE TO SUICIDE
It is estimated that each year 60,000 children will experience a relative’s death by suicide. It is well known throughout history that clusters of suicide and suicidal behavior can occur. Although it has been shown that children and adolescents exposed to the suicide of a parent, sibling, or friend are more likely to develop depression, anxiety, and posttraumatic stress disorder and to experience significant impairments in social adjustment, academic competence, and spare-time activities, such exposure does not appear to increase the risk of suicidal behavior (Brent et al, 1996; Pfeffer et al, 1997). The highest risk of imitative suicide behavior may be among those other than close friends or family of the victim. However, other studies have found an association between adolescent suicide and having had parents or adult relatives with suicidal tendencies. Further investigation will be needed to understand the characteristics and underlying motivations of those who engage in imitative suicidal behavior.
Suicide: Developmental Considerations
Anxiety about death or dying is a common concern among most healthy young children and usually arises in the context of a death in the family. However, suicidal preoccupation and attempts are rare before puberty. Particularly young children may be protected against their own suicidal impulses by their lack of technical and cognitive ability to accomplish their own self-destruction.
One common misconception is that suicidal intent requires a cognitive understanding that death is final. Although young children (up to 9 years) may not yet have evolved an understanding of death as an irreversible event, they can be considered suicidal if they intend or act to cause self-harm or death. Many children who are giving death more serious consideration may express a verbal wish to die or enact self-destructive themes through their play. Such behavior in preschool children often is associated with significant punishment or disappointment, family disruption or discord, and physical or sexual abuse.
Many adolescents become fascinated by death and may even experiment with these ideas by wearing black clothing and showing an interest in satanic worship in their selection of music and symbolic jewelry. Others may write about death in poetry or journals. Finding temporary identifies in philosophical beliefs, cults, musical bands, or religion is commonly part of evolving an identity, separating from the familiar comforts of home, and developing a sense of autonomy. Particularly distressed teens may become preoccupied with these “death themes” well beyond the point of“ normal” experimentation. Some even may verbalize a strong wish to die or make nonlethal attempts, most commonly as a means of gaining attention or asking for help. According to the DSM PC, “the motivation for most attempts appears to be a wish to gain attention and/or help, escape a difficult situation, or express anger or love.” Adolescents who attempt suicide are likely to have suffered stressful events and have fewer personal resources to help them cope with their environment. The greater prevalence of depression, substance abuse, and stressful life events such as having to make college and career choices all contribute to the potential hopeless/helpless feelings underlying teenage suicidal behavior.
Evaluation and Treatment
The identification of mood disturbance in children and adolescents is complex, demanding a careful assessment of medical, psychological, and social functioning. Primary care clinicians play a major role in both recognizing mood problems and allocating treatment and services. Much depends on interviewing the child or adolescent about his or her mood state, a task that requires support and judgment.
Hospitalization may be necessary to ensure the safety of children at imminent risk of suicide. Indications of imminent risk include an identified suicidal plan with access to lethal means, a history of recent or recurrent suicide attempts, and the presence of judgment-impairing conditions such as severe depression, psychotic symptoms, or substance abuse. In addition, hospitalizing a child may temporarily remove him or her from an environment that is overwhelmingly stressful and disorganized.
Regardless of the need for hospitalization, any suicidal child should be referred for a psychiatric consultation. Most pediatricians do not have the training or experience to assess suicidal risk. Beyond awareness of risk factors, suicide evaluation requires establishing rapport with the adolescent and making a detailed review of any plan or attempt (intrapsychic risk and rescue). Psychotherapy can help a child work through feelings of loss, hopelessness, anger, and guilt, which tend to be common motivators of suicidal impulses. Psychopharmacologic treatment, although not specific to suicide, may help treat underlying symptoms (depressed mood, impulsivity, disorganization) that contribute to the suicidal impulses. Treatment of families also may be indicated when stress within the family is believed to influence the child’s behavior. In general, when dealing with a suicidal child or adolescent, collaboration between all professionals involved with a particular child (eg, school psychologist/counselor, pediatrician, therapist) is essential to stabilize the child at home, in school, and in the community.
A comprehensive assessment requires exploring a child’s level of functioning in areas such as family, friends, ans school; screening for symptoms of depression; and ruling out additional diagnoses (eg, attentional problems, anxiety, substance abuse, learning disabilities) and contributing sources of stress (eg, divorce, parent-child conflict, neglect, abuse). Findings on medical history, physical examination, and indicated laboratory tests may reveal medication reactions, neurologic disorders, nutritional disturbances, endocrine abnormalities, and malignancies that can present with mood symptoms similar to those of depression (Table 2⇑ ). Obviously, this extensive evaluation process can be time-consuming in a busy office practice. In an attempt to focus interviewing efforts, Hack and Jellinek (1998) have suggested questions that clinicians can use to help facilitate the identification of childhood psychosocial dysfunction, emotional problems, and suicidal risk. (For a subset of these questions pertaining to depression and suicidal risk, see Table 3⇓ .)
Increasingly, pediatricians are being asked to assume the management of difficult psychosocial issues and psychiatric problems in their office practices. Therefore, they have learned to function in a complicated and multifaceted role as diagnostician, provider of medical treatment, monitor of emotional well-being, educator/supporter of families, and gatekeeper to mental health services. Because pediatricians gain familiarity with children and families by seeing them longitudinally, they often can work in collaboration with child psychiatrists,“ co-managing” patients largely in a primary care setting. Pediatricians can be essential in encouraging more specialized treatment, tracking progress, and suggesting key interventions in the child’s world of family, activities, sports, peer relationships, and school (Jellinek, 1994).
Psychiatric treatment for major depression in children and adolescents incorporates a biopsychosocial approach and may include psychotherapy, medication, and evaluation of the child’s living situation and educational needs. The amount and type(s) of treatment offered to a particular child or family is guided by the severity of the child’s symptoms and dysfunction. Comprehensive treatment requires acute management of symptoms and maintenance treatments aimed at recovery and prevention of relapse. Psychosocial treatments believed to be effective for depression are psychodynamic, cognitive-behavioral, and family therapies. Although there are very few controlled studies of psychotherapeutic interventions, preliminary findings suggest that the cognitive-behavioral approach is most effective in reducing symptoms (Brent, 1995).
Research in the area of psychopharmacological interventions in children and adolescents is scarce and evolving. Despite their usefulness in adults, tricyclic antidepressants are no more effective than placebo for the treatment of major depression in children and adolescents, and their use is limited by anticholinergic and cardiac side effects. Preliminary findings suggest that the selective serotonin reuptake inhibitors may be more effective in children and have a more favorable side effect profile (Simeon et al, 1990). Lithium can be used to enhance response to antidepressant treatmentt (Ryan et al, 1988) and in depressed adolescents who have a family history of bipolar disorder (Strober et al, 1990). Monoamine oxidase inhibitors and atypical antidepressants, while known to be effective in adults, require further investigation to determine their effectiveness in childhood depression. (For a review of psychopharmacologic treatment of child and adolescent depression, see Kye and Ryan, 1995.) In general, psychosocial therapies (interpersonal or cognitive-behavioral) and antidepressant medication used in combination are believed to have additive effects and may decrease the likelihood of relapse.
Suicidal risk factors are common to a wide range of distressed children and adolescents and are not specific to suicide. For example, family discord, divorce, substance abuse, and depression affect many children and adolescents, few of whom will attempt, and even fewer of whom will complete, suicide. There is no way to predict suicide among depressed adolescents, except in those who have made previous attempts. Attempts of escalating lethality are particularly ominous. The best form of prevention available to pediatricians is to provide thorough, sensitive primary care to all children.
The severity of suicidal impulses and lethal potential is a continuum ranging from thoughts and threats to self-mutilation, attempts, and gestures. Although it is virtually impossible to predict which children will attempt or commit suicide, many suicidal individuals do seek some form of medical treatment. In particular suicide attempters who present to emergency departments are the most readily identifiable children at risk and have the greatest potential for preventive action. However, because many children and adolescents will not volunteer information concerning suicide or ask directly for help, the only form of prevention is to recognize distress and attempt to resolve or treat any underlying disorders. Because suicide is often an impulsive act, pediatricians should inquire routinely about restricting access to lethal methods (eg, guns, medications, household toxic agents) and ask their seriously distressed, depressed patients directly about suicidal thoughts and intent.
Pediatricians and Suicide Prevention
Suicide prevention, on a public health level, requires the combined efforts of health providers and the school community. There has been no evidence that specific interventions or suicide prevention curricula can predict or prevent suicide, and there is the chance that they even may increase risk by heightening awareness (Shaffer et al, 1988). Therefore, pediatricians should target high-risk groups for intervention, attempt to limit access to lethal means, and provide broad psychosocial care to all youths in their practices. If there is a suicide, the pediatrician may be asked to provide“ post-incident intervention” and consultation to schools. By virtue of his or her special expertise and position in the community, the pediatrician can become a valuable member of the crisis team (for a review, see Adler and Jellinek, 1990).
Pediatricians face the challenge of recognizing, assessing, and managing an increasing number of depressed and suicidal children and adolescents. This challenge is complicated by the private nature of depressive and suicidal feelings. Although an awareness of family psychiatric history can be helpful in identifying those at higher risk, much depends on listening to the parent’s concerns and interviewing the child or adolescent. Recognition and treatment of initial and recurrent depressive disorders can have broad clinical implications for school performance, use of substances, and risk-taking behavior. Efforts to ease the child’s suffering and lift the depression can be particularly gratifying. A recently treated 10-year-old recommended the following to others facing depression:
Don’t beat yourself up.
Don’t store up your feelings, share them.
Don’t get anxious over every little thing.
Be kind to yourself.
Ongoing research in genetics, biochemical markers, screening questionnaires, and treatment approaches will facilitate the primary care pediatrician’s efforts to identify and treat depressed and suicidal children.
The authors wish to thank Drs Steven Ablon and Sabina Hack for their thoughtful suggestions and Lori Flick, RD, for her dedication and support throughout the preparation of this manuscript
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