Depression in children and adolescents can impair social, family, educational, and work functioning and can result in an elevated risk of recurrent episodes, increased suicidal risks, and/or lead to the development of bipolar disorder (Purper- Ouakil et al., 2002). Depression in childhood can produce a variety of adverse consequences, including violence and use of addictive substances.
In a study of 603 predominantly Hispanic children, aged 10–14 years, Ferguson et al. (2009) reported that depression, along with the influence of delinquent peers, antisocial personality, and parents or guardians who employ psychosocial abuse in intimate relations, increases the risk for youth violence.
Based on a longitudinal investigation of 1,545 adolescent twins in Finland, Sihvola et al. (2008) discovered that onset of depression at age 14 increased the risk of smoking, use of smokeless tobacco, frequent use of illicit drugs, fre- quent consumption of alcohol and recurring intoxication 3 years later. As noted previously, comorbid disorders worsen the prognosis for depressed children and adolescents.
Children and adolescents may continue to show adverse effects after recovering from MDD (Son and Kirchner,2000). They may continue to experience difficulties in relationships, have low self-esteem, participate in risky behaviors, and suffer dis- ruption in their overall functioning (Birmaher et al.,1996). Primary care providers should assess for MDDs as well as their sequelae throughout the individual’s life (Son and Kirchner,2000).
Case Study
The following case study describes a girl with depression. Melissa is a 12-year-old Caucasian female, who lives with her mother in an upper middle class suburb. Her parents were divorced 2 years ago. She has two older siblings, a 19-year-old sister who is a freshman in college and a 17-year-old brother, who is a junior in high school. Her mother is an attorney at a large law firm. Her father is also an attorney.
She has visitation with her father on alternate weekends, as well as one dinner per week. Her father rarely exercises his midweek dinner visits and typically picks Melissa up on Saturday at noon, rather than Friday night. He lives in an adjoining suburb.
Melissa’s school performance decreased dramatically in fifth grade. Prior to that time, she had been a superior student, performing at the 95th percentile or higher in all academic areas and was placed in the gifted program for both reading and math.
In fifth grade, homework completion became a problem and her performance on tests significantly decreased. She was eventually removed from the gifted program.
In sixth grade, she completed homework only half the time, despite two conferences between the school and her parents.
Melissa had participated in figure skating since she was 4 years old and she had been identified as having a special talent. She took private lessons 4 days per week and was also on the synchronized skating team. In addition, she competed in local, regional, and national competitions. Through figure skating, she had a number of friends, although she also had friends at school. Melissa also participated in compet- itive gymnastics, although she did not experience as much success in this endeavor.
Coaches described her as energetic, hard working, friendly, and “sweet.” In the past year, she had become increasingly irritable, easily frustrated, and short-tempered.
This behavior was also noted at school and home. In particular, she and her mother began to have almost daily conflict. Most of her old friends avoided her and stopped calling her. Melissa began to associate with a new peer group, consisting primarily of outcasts and/or children with behavior problems. Her parents suspected drugs, but disagreed whether she should be evaluated. They consulted the school social worker, who spoke with Melissa. It was the social worker’s perception that the problems stemmed from the divorce. Melissa’s father questioned whether depression was a possibility, but the social worker related that adjustment disorder was more likely, because Melissa was not having appetite or sleep problems.
When she was found intoxicated by her mother 6 weeks later, she was referred to a clinical psychologist for an evaluation. She was interviewed and adminis- tered the Personality Assessment Inventory – Adolescent and the Rorschach Inkblot Test and diagnosed with depression. The psychologist explained to the parents that the absence of appetite and sleep issues was not that atypical for depres- sion in adolescents. She was subsequently referred to a psychiatrist and placed on an antidepressant medication (Zoloft) and began individual counseling. Melissa also had some conjoint sessions with her parents. Her depression responded to treatment and there was a noticeable change in behavior, particularly increased moti- vation regarding school work and decreased irritability and anger. She continues in therapy.
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Chapter 9
Eating Disorders
Eating disorders cause substantial morbidity and mortality in children, adolescents, and adults.
Individuals with AN refuse to keep a minimally normal body weight. They fear gaining weight and have a severely disturbed perception of their body shape or size.
Postmenarcheal females with AN are amenorrheic. Persons with the disorder main- tain a body weight that is below minimally normal standards for age and height.
Children and younger adolescents who develop AN may fail to reach expected weight gains and therefore may not lose weight. Persons with the condition can be classified as having a restricting type, e.g., the persons lose weight by dieting, fasting, or excessive exercise, or binge eating (BE)/purging type, e.g., the individual regularly participates in BE or purging or both.
Individuals with AN who are severely underweight may suffer symptoms of depression such as depressed mood, social withdrawal, irritability, inability to sleep, and reduced libido (American Psychiatric Association, DSM-IV-TR). Many of the symptoms of depression are due to the physiological effects of starvation.
Persons with AN regularly engage in obsessive–compulsive behaviors, which may or may not be associated with food (American Psychiatric Association, DSM- IV-TR). They may collect recipes and hoard food. Their obsessions and compulsions associated with food may be triggered or worsened by malnutrition. Persons with AN who do not have food-related obsessions and compulsions may meet the criteria for obsessive–compulsive disorder.
People with the disorder often are concerned about eating in public (American Psychiatric Association, DSM-IV-TR). They may feel ineffective and have a strong desire to control their environment. They often exhibit inflexibility in thinking and have reduced social spontaneity. Moreover, they are perfectionistic and have very limited initiative and emotional expression.
Persons with AN often also have a personality disorder. Compared to those with the restricting type, those persons with AN who have the BE/purging type often experience problems with impulse control, are more likely to have a substance disorder, be sexually active, have more suicide attempts, and have a borderline personality disorder.
Persons with BN engage in BE and use inappropriate compensatory methods to prevent weight gain (American Psychiatric Association, DSM-IV-TR). Individuals
171 M.L. Goldstein, S. Morewitz, Chronic Disorders in Children and Adolescents,
DOI 10.1007/978-1-4419-9764-7_9,C Springer Science+Business Media, LLC 2011
with BN excessively emphasize body shape and weight and base their self- evaluations on body shape and weight. BE refers to eating in a specific period of time an amount of food that is much more than a majority of people would eat in a similar situation. Their BE and inappropriate compensatory methods occur at least two times a week for 3 months.
Individuals with BN can be classified as having a purging type, e.g., the individ- ual regularly participates in self-induced vomiting or misuses laxatives, diuretics, or enemas or nonpurging type, e.g., the person engages in other inappropriate compen- satory activities, such as fasting or excessive exercise, but does not regularly engage in purging behaviors.
Those with BN may have normal weight, but some may be slightly overweight or underweight (American Psychiatric Association, DSM-IV-TR). BN is not prevalent among obese individuals. Between BE episodes, the persons often limit their total caloric intake and select low-calorie and low-fat foods or foods that they think will trigger their BE episodes.
Persons with BN have an increased likelihood of depressive symptoms or mood disorders, particularly dysthymic disorder and major depressive disorder (American Psychiatric Association, DSM-IV-TR). The disturbance of mood often starts at the same time that BN develops or after the disorder emerges. Individuals with BN also frequently develop anxiety symptoms or anxiety disorders. Following effective ther- apy for BN, the individuals’ mood and anxiety disorders are controlled. About 30%
of persons with BN have a lifetime prevalence of substance abuse or dependence.
These persons are particularly at risk for abusing alcohol or stimulants. Persons begin to use stimulants as a way to control their appetite and weight.
Among women, the lifetime prevalence of BN is about 1–3%, whereas males have a lifetime prevalence that is one-tenth of that in females (American Psychiatric Association, DSM-IV-TR). The disorder often starts in late adolescence or early adulthood.
Persons with binge eating disorder (BED) lose control of their eating but do not engage in compensatory behaviors, such as purging that are typical of persons with BN (American Psychiatric Association, DSM-IV-TR; Bak-Sosnowska,2009).
Individuals with the condition may eat quickly, eat until feeling uncomfortably full, and eat large quantities of food when not hungry. They may eat alone because they feel embarrassed about how much they are eating and may feel disgust, guilt, or depressed after eating too much. BE episodes occur at least 2 days per week for at least 6 months. Persons with the disorder report that their eating behaviors or weight disrupts their social, family, and occupational functioning. Some persons with the disorder report that feeling depressed or anxious triggers their BE episodes. Other people are not able to pinpoint any specific trigger but instead report general feelings of tension that are reduced by BE.
In samples obtained from weight control programs, the prevalence of BED varies from about 15 to 50%. Females are about 1.5 times more likely to have BED than males. The disorder often begins in late adolescence or in early adulthood and develops soon after dieting-related weight loss.