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From one PHASE to the next

Recognizing depression in your child and treating them with therapy and medication can prevent a lifelong downward spiral.

If your child can't seem to shake the blues, don't just chalk it up to growing pains. Those down-in-the-dumps feelings could be something more serious.

One in 33 children and one in eight adolescents suffer from depression, says the National Alliance for Mental Illness. Clinicians estimate that two to three percent of children may have severe clinical depression.

The majority of seriously depressed children go undiagnosed and untreated, leading to failures at school, substance abuse and suicide. Psychiatrists say early diagnosis is the key to preventing a lifelong downward spiral, but diagnosis is difficult.

"The biggest problem in identifying depression in children is that people don't accept that it happens and don't see it when it does. That includes many physicians," says Nada Stotland, a psychiatrist at Illinois Masonic Medical Center in Chicago.

Why don't we easily see, or accept, the reality of depression in children? Perhaps we too often tend to think of depression as an affliction of midlife, something that happens when marriages fail, when bills become overwhelming, when careers are less than what we'd hoped for. But psychiatrists are learning that depressed adults were most likely depressed as children and never treated.

The symptoms and signs of depression in children are often not immediately clear to parents. As a result, a depressed child with symptomatic or radically changing behavior may never be evaluated for depression by a doctor.

"Changed behaviors may be seen as a "stage,' " Stotland says. Even psychiatrists, who use a guide called the Diagnostic and Statistical Manual of Mental Disorders to make diagnoses, have trouble pinpointing depression in children.

The manual is meant to diagnose depression in adults, and depressed children don't always exhibit the same signs and symptoms listed in the manual.

Observing a child's behavior may be the only clue to depression, but if children are seen and not heard, symptoms may not catch anyone's attention. Humberto Nagera, a child psychiatrist and professor of psychiatry at the University of South Florida School of Medicine, says that children and adolescents can get depressed very easily.

"Like depressed adults, depressed children can be sad and gloomy. But depression in children often manifests itself as irritability and anger," says Paramjit Joshi, clinical services director of the division of child and adolescent psychiatry at the Johns Hopkins Children's Center. "Children with depression may have sleep problems. They may wake in the middle of the night. Younger children may revert to past behaviors they have outgrown, such as bed wetting, or be suddenly unable to do a task they have already mastered."

Depressed children, depressed adults

Depressed children grow up to be depressed and unsuccessful adults. A recent study in the Journal of the American Medical Association said that adults who had onset of depression as adolescents have higher rates of impaired functioning in work, social settings and family life. They also have higher suicide rates.

"As a kid I had no idea what was wrong with me," says James, a Tampa man in his 50s who didn't want his last name published. "I would sometimes feel down, real sad. At times I used to pull myself away and just watch the other kids and wonder why I was standing there, not joining."

James watches his 10-year-old son closely for patterns similar to those he experienced. Fortunately, none of the symptoms have surfaced.

"When I got depressed I wasn't any trouble," recounts James, who was diagnosed as an adult. "As long as I was quiet and no bother, it was unnoticed. I'd cry and didn't know why. It hasn't stopped; the depressed child is still there, just in a bigger body. There is the same sense of doom."

As an adolescent, James mixed his sense of doom and sadness with alcohol and began attributing what he then understood as depression to the effects of alcohol. But when he quit drinking as an adult, the depression was still there. He finally got treatment in his late 40s.

Joshi says that while children, like adults, are different, classic symptoms of depression _ sudden loss or increase in appetite, weight gain or loss, withdrawing from friends and activities, and an air of hopelessness and helplessness _ can also characterize childhood depression. She says that any five symptoms with an accompanying mood change can point to clinical depression, which she treats as an episodic and chronic biological disease.

"Some children may express wishes that they were never born, or wish to get hit by a car, or get sick and die," Joshi says. The doctor has just returned from Macedonia, where she evaluated the effects of violence and resulting depression in children and adolescents who were living in refugee camps during the Kosovo crisis.

Bipolar illness

Bipolar illness (manic depression), an inherited disease once thought to afflict only adults, is now recognized as often starting in children before puberty.

Jeremy Bray, 11, was diagnosed with bipolar disorder at age 9 during a stay at a children's psychiatric unit. He was hospitalized after a period of behavior that his mother, Cheryl Bray, said she could neither understand nor control. At age 6, Jeremy had been had been diagnosed with attention deficit hyperactivity disorder.

The medication Jeremy was given for ADHD probably caused manic episodes, during which he broke things, set fires and stole. The destructive behavior led to his bipolar diagnosis.

"Placing Jeremy in the hospital at age 9 was the hardest thing I have ever had to do. But it was also the best choice I could have made," says Bray, of Texas. "It took the treatment team three weeks to diagnose him and find the correct medication combination that worked for him."

Jeremy has childhood-onset bipolar disorder. He is a rapid cycler with many quickly occurring episodes between mania and depression. Seventeen months after his diagnosis, Jeremy was rehospitalized for medication adjustments after he experienced suicidal thoughts. When he hits his teens, Jeremy will probably need more medication adjustments, his mother says.

"As a parent searching for ways to help my child, I have discovered that if the diagnosis your child receives doesn't seem to fit, or if the treatment prescribed isn't working, don't stop searching for a better answer. A good doctor is willing to listen to you and to weigh any information."

Psychiatrists say childhood onset of bipolar illness is different from adult onset illness and may first become obvious because of a major depressive episode rather than mania, when the child is excitable and animated.

According to Demitri F. Papolos, associate professor of psychiatry at the Albert Einstein College of Medicine in New York, bipolar disorder in children rarely occurs by itself. It is often accompanied by clusters of symptoms that may be diagnosed as attention deficit or obsessive-compulsive disorder. Papolos, author of the forthcoming The Bipolar Child, says that 50 to 80 percent of those children with bipolar also have attention deficit. Some treatments for attention deficit, such as Ritalin, can escalate bipolar symptoms, so it is important, says Papolos, to address the bipolar disorder before attention deficit.

He adds that, in retrospect, many parents say their children diagnosed with bipolar disorder were different from infancy. They were overresponsive to sensory stimulation, had sleep disturbances, experienced night terrors and later experienced hyperactivity with high levels of anxiety. These children were also easily frustrated and had difficulty controlling their anger.

How to spot symptoms

In its patient publications on childhood depression, the American Medical Association suggests that parents watch for preoccupation, fears or phobias, frequent crying, an inability to concentrate on tasks, loss of interest in play, rocking of the head or body, or saying things such as "No one likes me . . . I'm ugly . . . I'm stupid."

If a child talks of suicide, such talk should not be dismissed. Suicide is the leading cause of death among adolescents. Because depression often runs in families, children's symptoms are often easily recognized by others in the family who may be in treatment for depression.

It is often those children in families in which no one else is suffering symptoms who risk having their depression go undetected. Joshi says, however, that pediatricians are "increasingly savvy" about recognizing depression in children and may be the first to spot symptoms.

Treating childhood depression

Among the newest depression medications widely prescribed for children are "serotonin selective reuptake inhibitors," often referred to as SSRIs. This class of drugs includes Prozac, which is approved by the Food and Drug Administration for patients older than 18 but has been increasingly prescribed for children since the early 1990s.

Negara says it is likely that a psychiatrist will prescribe a Prozac-like drug for children rather than an older class of drugs called "tricyclic anti-depressants," drugs that Negara says have some "nasty" side effects.

"Prozac is also used for compulsive-obsessive disorder in children, and it's very effective," Negara says.

There are some controversies about prescribing SSRIs for children, however. Jerry L. Rushton, a pediatrician at the University of North Carolina, Chapel Hill, says that more than 500,000 prescriptions for SSRIs are written for adolescents and children every year, and that the drugs are increasingly being incorporated into primary care practice.

The drugs have an anecdotally good, even if clinically unproven, track record in treating children. Rushton says that in a survey of 600 family doctors, 72 percent said they prescribed SSRIs for patients younger than 18 but felt they had not received adequate training in treating childhood depression. Sixteen percent said they were uncomfortable caring for depressed children.

Rushton says SSRIs should be used for children with caution and careful monitoring, because there are unanswered dose questions. They should not replace other therapies, such as individual counseling and family therapy.

Papolos says that the first line of pharmacological treatment for bipolar kids is to stabilize their moods, treat sleep disturbances and relieve psychotic symptoms. Mood stabilizing drugs being used for children include lithium, Depakote and Tegretol. For treating psychotic symptoms, Risperdal, Mellaril, Trilafon, Klonopin and Ativan.

"The medication isn't a cure; it is an adjustment," Cheryl Bray says about her son Jeremy's progress. "We still have to continue with behavioral modification, and he still cycles, but not to the severe degree he did before hospitalization. I know that puberty is going to play havoc with his medication levels, but I am prepared for that, I think."

_ Randolph Fillmore is a freelance writer based in Temple Terrace.

Gender and depression

Boys and girls may not be created equal when it comes to depression.

By age 18, young women are much more likely to be depressed than young men the same age. Between the ages of 11 and 15, rates of depression soar for girls while the rates for boys stay about the same.

A recent study of San Francisco teens suggests that increased depression in girls comes from their tendency to worry about life and love, and to focus on negative emotional issues. Study psychologists Susan Nolen-Hoeksema and Joan S. Girgus say that excessive rumination over problems is probably a gender difference that contributes to variations in male and female depression.

Their survey of 615 sixth, eighth and 10th graders found gender played a part in how much boys and girls worried. Girls, they found, worried more about their appearance, friends, personal problems, romantic relationships, family problems, being liked and being safe.

"Girls may feel less in control of their environments than boys from a very early age," Girgus says. "This sense of uncontrollability contributes to rumination. In essence, girls are frantically trying to understand what's going on around them in their lives and their own emotional distress, and this is manifested as rumination."

_ RANDOLPH FILLMORE

Look for symptoms

Here are the warning sings of childhood depression:

Persistent sadness and hopelessness

Withdrawal from friends and activities once enjoyed

Increased irritability or agitation

Missed school or poor performance

Changes in eating and sleeping habits

Indecision, lack of concentration or forgetfulness

Poor self-esteem or guilt

Frequent physical complaints, such as headaches or stomachaches

Drug and/or alcohol abuse

Recurring thoughts of death or suicide

For more information

Oct. is the 9th annual National Depression Screening Day, held during Mental Illness Awareness Week. Designed to call attention to depression on a national level, and to educate public about symptoms and treatments, free depression screenings are offered on college campuses across the country. To find out where screening will be available in your area call the National Locator Line at (800) 573-4433.

The National Alliance for Mental Illness brochure "Teenage Depression" is available by calling (800) 950-6264.

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