Times of risk: Childhood depression, a great unknown

Childhood depression, a great unknown: how to recognize it?, how to detect it?, what to do?, how to treat it?

EIt is a well-established fact that when parents and teachers encounter emotional or behavioral problems in childhood, depression is the last thing they think of. In the adult mind, childhood is a world of happiness and carefree living… adult life is for problems and difficulties.

A professor of mine used to say that “The adult, who has lost all real memory of what he was during his childhood, believes himself to be the only victim of life.”. A profound truth. Adults certainly find it difficult, and often frustrating, to accept that a child might be depressed. They always feel a sense of guilt that makes them reluctant to admit it, especially mothers. The reality is quite the opposite. Children place all their trust in their parents and teachers, and in difficult times for which they lack sufficient cognitive skills, they feel helpless, defenseless, and, why not, frustrated by an idealized adult who is incapable of connecting with their emotions.

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If you are a teenager and wish to self-assess your mood, you can do so using the Beck Depression Inventory:

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Symptoms of childhood depression

As is logical, the most frequent symptoms, although sometimes difficult to interpret, are those related to mood or state of mind. It is common for these symptoms to be denied by the patient and even masked in recreational settings. Therefore, it is important to be aware of any changes, however subtle, in:

• • Moments of sadness or crying in unusual situations.

• • Irritability in response to minor frustrations.

• • Self-deprecating phrases (“I’m stupid”…)

• • Diffuse discomfort, disinterest and indifference towards objects or activities that previously showed interest, social withdrawal.

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If you are a minor, or the parent of a child who you believe may be suffering from an emotional disorder, you can assess the symptoms with the Kovacs Inventory, an excellent tool for evaluating these types of symptoms.

It is not surprising that the symptoms that first become evident are the referring to the intellectual sphere which will obviously affect academic performance. Both teachers and parents are often surprised when they cannot find a reasonable explanation for the school changes that have taken place. It could be:

• • Attention and concentration problems. These symptoms, more often than we might think, can lead to false positives for Attention Deficit Hyperactivity Disorder (ADHD). Parents are often quicker to accept the possibility of ADHD than a depressive syndrome.

• • Cognitive slowing.

• • Impoverishment of imagination (fantasy) and spontaneity.

• • Failures in memory processes (both in fixation and recall memory).

I also know activity will be affectedIt can be expressed as:

• • Hyperactivity

• • Asthenia, fatigability.

• • Rejection of team games.

• • Reduction of spontaneous inertia.

• • Slowed task execution.

Psychosomatic symptoms are very common, some being more specific to childhood, such as enuresis and encopresis, and others more relevant in puberty and adolescence: sleep disorders, loss of appetite or, conversely, hyperphagia, and headaches.

From this semiology it is easy to see that not only will family life be affected, but also the school environment, as well as the social environment.

Depressive symptoms according to age.

Nissen differentiated the clinical presentation depending on the age of the patients and distinguished between psychic symptoms and psychosomatic symptoms.

Table 1: Depression and academic performance. NISSEN CLASSIFICATION

	Psychological symptoms	Psychosomatic symptoms
preschool age	Difficulty playing, hyperactivity	Cries and screams, encopresisinsomnia, appetite disorders
School age	Irritability, insecurity, difficulty playing, need for physical contact	Bedwetting, night anxiety, masturbation, crying and screaming
Adolescence	Rumination, suicide attempts, feelings of inferiority, dejection	Headaches

We observed that virtually all symptoms will have a negative impact on academic performance. It is very important to have in mind  The possibility of a depressive disorder, however surprising it may seem, should not be overlooked. Not every decline in academic performance, not every episode of aggression, not every instance of restlessness or attention difficulties is ADHD. This warning may seem redundant, but experience has taught me that we can easily misdiagnose ADHD.

Masked depressions

The 1980s saw the beginning of the marketing of new antidepressant molecules, with the resulting commercial pressure on each brand. Over time, widespread scientific fraud was exposed in more than one laboratory.

However, this boom meant that the clinical field of anxiety disorders and depression, in particular, acquired the same relevance that, for example, the diagnosis of ADHD has today.

Hence the focus of attention on a subtype of “depression without depression” or masked or somatized depressionThis facilitates a better semiological understanding of the clinical entity and optimizes therapeutic interventions. Nissen, a German child psychiatrist, was the first to provide a clinical description of its most relevant expression in childhood. Table 2.

Childhood depression and suicide risk

If it's already difficult to accept that a child can become depressed, anticipating the possibility of a suicide attempt in a child would be, for most adults, an oxymoron, a radical contradiction. It's impossible to contemplate the joy and vitality of childhood and infer the possibility that a child might think about "disappearing, about fleeing" from a situation that is subjectively unbearable to them—which is, ultimately, suicide. Table 1 outlines some of the characteristics of suicide in childhood.

Table 2. Symptoms of childhood depression

Clinical semiology in depression Infant
Sadness, frequent crying spells or urge to cry, Hopelessness Decreased interest in activities or inability to enjoy activities that were previously favorites Persistent boredom or low energy Withdrawal from friends or family. Low self-esteem and guilt. Increased irritability, anger, or hostility Relationship problems Frequent complaints of physical ailments such as headaches or stomach aches Frequent absences from school or poor performance in school Poor concentration; significant change in eating and/or sleeping patterns; talking about running away from home or attempting to do so. Anxiety
Extracted from Cincinnati Children's

Recommendations

• • It is very important to always keep this clinical eventuality in mind when evaluating school failure, especially in students who usually do well and experience a sudden change in performance and motivation.

• • Depressive symptoms are more common in female students.

• • If there is suspicion that a student may be depressed, it is recommended that the guidance team carry out some screening methods with the aim of preventing complications or the condition from becoming entrenched. If depression is suspected with reasonable grounds, the child would be referred to child mental health services.

• • We should always have in mind that there are at-risk students:
    1. 1. Consumption of toxins and medications.
    1. 1. Family environment: unemployment, financial difficulties, illness in one of the parents…
    1. 1.  Poor peer relationships or difficulty establishing satisfactory social relationships.
    1. 1.  Bullying and rejection by peers are very common issues that adults often downplay. Children and adolescents place great importance on their relationships with their peers and suffer when these relationships deteriorate.
    1. 1. Attitudes of some teachers who tend to minimize psychological semiology in students, considering it as something capricious or fleeting.