Principal Authors: Boris Birmaher, M.D., David A. Brent, M.D., and R. Scott Benson, M.D. This Summary was developed by the Work Group on Quality Issues: William Bernet, M.D., Chair, and John E. Dunne, M.D., former Chair, Maureen Adair, M.D., Valerie Arnold, M.D., R. Scott Benson, M.D., Oscar Bukstein, M.D., Joan Kinlan, M.D., Jon McClellan, M.D., and David Rue, M.D. AACAP Staff: Elizabeth Sloan, L.P.C.

This summary and the full text of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders is available to Academy members on the World Wide Web (www.aacap.org) and appears in the 1998 supplement to the JAACAP. The full text of these parameters was reviewed at the 1997 Annual Meeting of the American Academy of Child and Adolescent Psychiatry. Both the full text and this Summary were approved by AACAP Council on May 28, 1998. Reprint requests to AACAP Publications Department, 3615 Wisconsin Ave., N.W., Washington, DC 20016. [XXXX] © 1998 by the American Academy of Child and Adolescent Psychiatry.

ABSTRACT

This summary provides an overview of the assessment and treatment recommendations contained in the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. Depressive disorders in children and adolescents are marked by core symptoms similar to those seen in adults, although symptom expression varies greatly with developmental stage. These disorders are common, chronic, and recurrent, and are associated with comorbid psychiatric conditions and poor outcome that can be alleviated by early identification and treatment. Opinions differ regarding treatment planning and duration of treatment required. Development of a treatment relationship with the patient and family is crucial for a successful outcome. Psychotherapy is an appropriate treatment for all children and adolescents with depressive disorders. Antidepressants may prove useful in some cases and are especially recommended for those patients with psychosis, bipolar depression, and severe depression. Continuation treatment is necessary in all patients after the acute phase; long-term maintenance is required in some. Early detection and intervention is effective in ameliorating the poor psychosocial outcome. Key words: children and adolescents, depression, dysthymia, antidepressants, psychotherapy, practice parameters, and practice guidelines.

These guidelines offer the clinician direction in diagnosing and treating major depressive disorder (MDD) and dysthymic disorder (DD) in children and adolescents. Recommendations are based on extensive review of the scientific literature and clinical consensus among experts in the subject. The literature review, including references, and the rationale for specific recommendations are contained in the complete document (American Academy of Child and Adolescent Psychiatry, 1998). MDD and DD are common disorders occurring in approximately 2% of children and 4% to 8% of adolescents. Early, aggressive treatment is required because these recurrent disorders are frequently accompanied by poor psychosocial outcome, comorbid conditions, and high risk of suicide and substance abuse. The prevalence of depression increases during adolescence, possibly due to biological (e.g., sexual maturation), environmental (e.g., increased social and academic expectations, more chance of exposure to negative events), and psychological (e.g., increased autonomy and abstract thinking) factors. Adolescent girls appear to have more risk factors for depression than boys. Studies in adults and youth have suggested that each successive generation since 1940 is at greater risk for developing a depressive disorder, and that these disorders are being recognized at successively younger ages.

CLINICAL PRESENTATION

Every child can be sad occasionally. However, to be diagnosed with MDD or DD, a child must meet the diagnostic criteria of the DSM-IV. Symptoms should not be attributable only to substance abuse, use of medications, other psychiatric illnesses, bereavement, or medical illness. The clinical picture of MDD and DD in children and adolescents varies considerably across different developmental stages and diverse ethnic groups. For example, children usually show more anxiety symptoms, somatic complaints, auditory hallucinations, temper tantrums, and behavioral problems. In middle and late childhood, children may begin to report the cognitive components of their dysphoric mood and low self-esteem, guilt, and hopelessness. The normative push for autonomy may complicate the presentation of symptoms in depressed adolescents, who manifest more sleep and appetite disturbances, delusions, suicidal ideation and attempts, and impairment of functioning than younger children, but fewer neurovegetative symptoms and perhaps more irritability than adults with MDD. It is important to assess for symptom clusters that define the subtypes of depression (e.g., seasonality, atypical symptoms, psychosis, or hypomania) in order to develop appropriate treatment strategies. Manic and depressive symptoms may be mixed (the so called "mixed state"), a common presentation of bipolar disorder. The differential diagnosis of psychotic depression includes bipolar disorder, substance abuse, schizophrenia, dissociative states, and trauma-related "hallucinations." Most youth with MDD have other psychiatric disorders, with many having 2 or more comorbid diagnoses. The most frequent comorbid diagnoses are dysthymia (the so-called "double depression"), anxiety disorders, disruptive behavior disorders, and substance use disorders. Separation anxiety disorder is a common comorbidity in younger children. Personality disorders, especially borderline personality disorder, are frequently reported, although some of the personality symptoms may be secondary to the mood disorder. The family relationships of depressed youth frequently are characterized by conflict, maltreatment, rejection, and problems with communication, with little expression of positive affect and support. Parents of depressed children may themselves be depressed or suffer from other psychiatric or medical illnesses that reduce effectiveness of parenting. On the other hand, parenting role problems may be secondary to interaction with a depressed, irritable, or oppositional child. There is evidence that early adverse experiences (e.g., parental death or separation) raise the risk for depression or anxiety in adulthood. The effect of parental loss through separation or death may be aggravated by parental discord associated with the separation and/or by the social and economic sequelae of family disruption.