Depression in Children and Youth

Prevalence of depression

Depression is a common illness. About 2% of children and 4% to 8% of adolescents are affected by major depressive disorder. Depression in childhood affects as many boys as girls, but twice as many girls during adolescence.¹

The Canadian Community Health Survey (CCHS)—one of the few national studies of mental health in Canada—found rates of depression in children and youth new to Canada are generally lower than in their Canadian-born peers.²

However, it is important to remember that immigrant children are not all alike. Studies have shown that refugee children, for example, have higher rates of psychological distress, including depression, than immigrant children in general.³ Rates of onset of depression among refugees and voluntary migrants appear to equalize over time.⁴

Etiology of depression

The causes of depression involve biological, psychological and social factors. Many of the factors that jeopardize the mental health of all children also affect immigrant children.

General risk factors for depression in youth—as well as more specific factors that can affect the mental health of young newcomers—are summarized below.^5-10

Risk factors for depression in children and adolescents

Biomedical factors

• Female sex
• Older adolescent age
• Parent/family history of depression
• Comorbid chronic illness (e.g., diabetes, anxiety disorder, ADHD)
• Past history of depression
• Comorbid learning disorders
• Genetics (presence of specific serotonin-transporter gene variants)
• Certain medications (e.g., prednisone, isotretinoin [Accutane])
• Substance use

Psychosocial factors

• Family or peer conflict (e.g., bullying)
• Childhood neglect or abuse (physical, emotional, sexual)
• Poverty*
• Recent loss (e.g., death of a loved one, breakup of romantic relationship)
• Academic difficulties or school failure
• Parents’ lack of education
• Discrimination and social exclusion
• Poor home–school relationships (e.g., presence of conflict)
• Poor quality neighbourhoods (e.g., high conflict, low community support)

Migration-specific factors

• Country of origin
• Region of resettlement
• Resettlement stress
• Prejudice
• Parents’ limited linguistic fluency

* During their first 10 years in Canada, about one-third of immigrant families live in officially defined poverty.

Source: Adapted from Childhood and Adolescent Depression, American Family Physician 2007;75(1). Copyright © 2007 American Academy of Family Physicians. All Rights Reserved.

Poverty is a risk factor for depression in children and adolescents, and immigrants are more likely than non-immigrants to live in poverty. However, immigrant children new to Canada may be less affected by poverty than their non-immigrant peers because of protective factors.¹¹  Protective and mental-health enhancing factors include:

• Household factors:
  • Family stability: For example, poor immigrant families are much less likely to be single-parent families than poor families in the general population.
  • Family size: Many immigrant children from China are only children. Although being an only child is often assumed to be detrimental for mental health, research suggests it can be protective.
  • Parenting style: Parenting style is a non-specific factor supporting overall mental health. Parents from certain cultural groups may practice the authoritarian parenting they received as children. Although harsh or authoritarian parenting may be a cultural practice, evidence suggests it is not adaptive.
• The child’s world beyond the family: Factors include good quality neighbourhoods, good home–school relations, school outreach programs, recreational facilities, and the presence of a sizeable community of the same ethnicity.
• Socioeconomic and political conditions: Employment opportunities for parents, language programs for parents, creating positive role models in schools, professions, politics and media.

How depression presents

Although the diagnostic criteria for depression in children and adolescents are similar to those for adults,¹² symptom presentation can differ. For example, young children may not be able to describe their mood and instead present with physical complaints, a sad facial expression or poor eye contact.⁷ Children and adolescents may be irritable rather than in a depressed mood.

In your assessment, consider the role of culture. For example, poor eye contact may be a symptom of emotional problems among children coming from cultures that stress individual autonomy, but a mark of respect in cultures that stress deference.  Symptoms of depression are probably more similar than different across cultures, but culture affects which symptoms individuals choose to emphasize, as well as the idioms they use to describe distress.

The American Psychiatric Association’s DSM-IV describes some common idioms associated with depression.

The presentation of depressive symptoms can also be influenced by cultural background and may include somatic complaints that are unusual to the clinician. For example, a number of studies have reported a higher rate of somatic symptoms in Asian patients with depression.^13-15 In a study of Asian Canadians, participants described poor mental health as “not being physically fit” or “not eating and sleeping properly”.¹⁴

However, patients who present with somatic complaints may have additional symptoms that they are reluctant to discuss. It is important for clinicians to be aware of this when discussing depression with patients and their families.

Culture also affects how intensely people express themselves. Clinicians may hear stories of considerable suffering told with a restraint that makes them less credible. On the other hand, symptoms can be reported so dramatically that they seem exaggerated. Before overlooking seemingly very mild-sounding reports or dismissing what sounds exaggerated, be sensitive to the effects of culture on expressive style.

Along with language difficulties, the problem of discussing depression with patients and their families can be compounded by cultural barriers to eliciting and interpreting symptoms. Newcomers to Canada whose English or French is limited may have difficulty describing their symptoms to health professionals.¹⁴

Diagnostic criteria for depression

The diagnostic criteria for a major depressive episode in a child or adolescent are persistent change in mood—depressed or irritable mood and/or loss of interest—plus additional symptoms.¹²

Diagnostic criteria for a major depressive episode in children and adolescents (DSM-IV-TR)

Persistent change in mood—either¹ depressed or irritable mood and/or² loss of interest—plus four or more of the following symptoms present for 2 weeks:

• Diminished interest in daily activities, such as peer play or school activities.
• Significant weight loss or gain. Children may fail to make expected weight gain.
• Insomnia or hypersomnia.
• Psychomotor agitation or retardation; hyperactive behaviour may occur in children.
• Fatigue, loss of energy.
• Feelings of worthlessness or excessive guilt.
• Inability to concentrate, which may manifest as poor performance in school.
• Recurrent thoughts of death, suicidal ideation or a suicide attempt.

Symptoms must be present for 2 weeks, represent a change from previous functioning, and produce impairment in relationships or performance of activities.¹² Additionally, symptoms attributable to another cause, such as substance use (e.g., medications, drugs), medical illness or bereavement, should be ruled out. However, the presence of medical illness or medication use does not necessarily mean there is not comorbid depression.

Screening tools for depression

A number of instruments can be used to screen and track depressive symptoms, including the Beck Depression Inventory and the Children’s Depression Inventory (both self-reporting measures) and the Children’s Depression Rating Scale (an interviewer-administered measure). Several have been adapted for use in ethnic minority youth.¹⁵ Such instruments may be used as an adjunct to, but are not substitutes for, a culturally sensitive assessment.

Self-reported and interviewer-administered measures may be helpful supplementary tools for screening and monitoring symptoms. However, they are not diagnostic instruments.

Addressing suicidality and safety

The most serious sequela of depression is suicide. Identifying and monitoring suicide risk are key tasks for the physician. Of children and adolescents with major depressive disorder, two-thirds have suicidal thoughts and one-third attempt suicide.¹ Suicide is rare before puberty.

Although data on suicide rates in immigrant and refugee youth are limited, certain populations may be at increased risk. For example, a study in Afghan youth—two-thirds of whom had experienced war trauma—found almost 25% had thoughts of suicide and 16% had attempted suicide.¹⁶

A number of factors may increase the risk of suicidal behaviour, as summarized below.^1,17 Identifying safety risks associated with non-evidence-based treatments (e.g. chiropractic manipulation, herbal medicines) is also important.

Factors that may increase the risk of suicidal behaviour

Personal

• Sex (risk of attempt is higher in girls; completion is higher in boys)
• History of suicide attempts
• Mood disorders
• Comorbid psychiatric disorders
• Impulsivity and aggression
• Exposure to negative events (e.g., physical or sexual abuse, violence, suicide)
• Self-harming behaviour (e.g., cutting)
• Recent shame (e.g., school failure)
• Recent disclosure of homosexual orientation
• Recent loss
• Recent police arrest, pending court hearing
• Social isolation, including peer conflict (bullying)

Family

• Poor parent–child communication
• Family history of suicidality

Environmental

• Availability of lethal means

Treatment

Discussing depression with newcomers

To discuss depression with children and families new to Canada, health professionals need to identify and address potential cultural barriers. In particular, clinicians should be mindful of the stigma associated with mental health issues, which can be substantial in some communities.¹⁶ For example, mental health issues may be misperceived as bringing shame, not only to the individual affected but to the entire family.

Health care professionals should also explore the reasons why patients and their families perceive a mental health condition as stigmatizing. For example, families may be concerned that a mental health condition is heritable and will, therefore, make their child a less attractive marriage prospect later in life. Language can be another barrier.¹⁶

Confidentiality is an important consideration when discussing depression with newcomers. Clinicians can play an essential role in educating patients about their rights, especially by explaining that:

• Confidentiality is maintained unless there is a need to disclose a life-threatening injury (to self or others).
• A child’s personal health information cannot be released outside the health care system (e.g., to schools or extended family members) without the consent of the parents.

Interpreter services are not always available or trusted by families. Alternatives to professional interpreters must be chosen with care. The use of siblings as interpreters is discouraged. When available, interpreters must be used appropriately. 

Fact sheets can facilitate discussions about depression with children and families new to Canada:

• The British Columbia Partners for Mental Health and Addictions Information have a number of culturally sensitive fact sheets in multiple languages, including one on depression. Fact sheets on other mental health issues translated into a number of languages, many specific to children and youth, are also available.
• The Children’s Hospital of Eastern Ontario has a comprehensive fact sheet on mental health issues in children and youth (English only).
• The Offord Centre for Child Studies has fact sheets in a number of languages on mental health issues in children and youth, though not for depression specifically.

Newcomers may ask about or be unaware of how to access after-hours care. Health care providers should offer printed contact information to newcomer families for local hospital emergency and after-hours services.

Treatment approaches

When treating a paediatric patient with depression, the first decision is whether they are at acute risk of harm and if hospitalization is necessary to ensure safety. This decision should be based primarily on level of functioning and safety to self and others.¹ These factors, in turn, can be influenced by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, adherence to treatment, parental psychopathology and family functioning.¹

An uncomplicated or brief depressive episode in children and adolescents may be addressed through education, supportive psychotherapy, and case management (related to environmental stressors in the family and at school).¹

Children and youth with more severe depression may require more specific types of psychotherapy and pharmacological treatment.¹ Cognitive behavioural therapy (CBT) and interpersonal psychotherapy for adolescents (IPT-A) are nonpharmacological interventions shown to be effective in adolescents with depression.¹ However, language is a major barrier to their use with immigrant and refugee populations.

Research studies—including the Treatment for Adolescent Depression Study (TADS)¹⁸ and the Treatment of SSRI-resistant Depression in Adolescents (TORDIA)¹⁹ —confirm that antidepressant medication is effective in treating depression among youth. TADS—one of the largest studies of antidepressant use in youth—showed that patients treated with CBT and fluoxetine or fluoxetine alone had significantly greater improvements in depressive symptoms compared with patients treated with CBT alone or those who received placebo.¹⁸ However, patients treated with fluoxetine were more likely to experience a suicidal event (suicidal ideation or behaviour, not completed suicide) compared with those treated with combination therapy or CBT alone. The AACAP practice parameter on depressive disorders provides a more in-depth discussion of these issues.¹

Of note, Health Canada has not approved the use of antidepressants in children and adolescents younger than 18 years. In the United States, fluoxetine has been approved for the treatment of depression under 18 years of age by the Federal Drug Administration (FDA). Escitalopram has also been approved for treatment of adolescent depression by the FDA.

Family dynamics—which may include discord, lack of support and a controlling or authoritarian relationship—should also be evaluated to assist in diagnosis and treatment.²⁰  For example, authoritarian parenting and restraint in expressing warmth are preferred patterns in some cultures. Yet research suggests that once in Canada, such traditional patterns may no longer be as functional as they were in the family’s home country.^5,6 Effective interventions may help address some parenting issues; telephone support, for example, has been found to be an effective social intervention for immigrant mothers new to Canada.²¹  Additional considerations for caregivers are maintaining a healthy lifestyle (e.g., adequate sleep, exercise, social activities, pursuit of enjoyable activities, decreasing stress) and, if present, treating mental illness (such as depression, PTSD). Every assessment of a child should also include an assessment for family violence or abuse of any kind.¹

Ongoing monitoring and maintenance treatment

Ongoing monitoring and maintenance treatment are important to avoid recurrence, particularly in those who have had a severe, recurrent and/or chronic disorder. The maintenance phase in a youth with major depressive disorder may last one year or longer. The main goal is to foster healthy growth and development.¹

For further information, clinicians may want to consult:

• Clinical practice guidelines developed by the American Academy of Child and Adolescent Psychiatry on topics including assessment, depression, psychotropic medications and suicidal behaviours.
• GLAD-PC guidelines for adolescent depression in primary care.

Comorbidities and when to refer

Depressed youth should also be screened for potential comorbid psychiatric illnesses, such as anxiety disorders, substance use, PTSD, ADHD and learning disorders.  When present, comorbid mental illness increases both functional impairment and suicide risk among affected adolescents.¹⁷ Treatment of young patients with depression should therefore include the management of comorbid conditions,¹ which may necessitate referral to a specialist.

Referral to a child and adolescent psychiatrist should be considered in the following circumstances:

• Moderate-to-severe depression severity
• Presence of psychotic features
• Presence of comorbid psychiatric illness (described above)
• Poor or incomplete response to treatment
• Worsening depressive or other (e.g., suicidal) symptoms, or the development of significant adverse events following treatment initiation
• Presence of acute safety risks (e.g., suicidality, homicidality) necessitating hospitalization.

Selected resources

• British Columbia Partners for Mental Health and Addictions Information. Self-help resources, including fact sheets, workbooks, 'vision' articles and personal stories. Several resources are available in French and other languages.
• Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics 2007;120(5):e1313-26.
• Mental Health Commission of Canada, Centre for Addiction and Mental Health. 2009. Improving mental health services for immigrant, refugee, ethno-cultural and racialized groups: Issues and options for service improvement.
• Kelty Mental Health Resource Centre. Families, together: Supporting the mental well-being of children and youth [video and discussion guide].  Several resources are available in French and other languages.
• KidsHelpPhone  provides children and teens with anonymous, confidential, professional counselling, resources, referrals and information in English and French, through technologically-based communications media.

References

1. Birmaher B, Brent D; AACAP Work Group on Quality Issues, et al. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 2007;46(11):1503-26.
2. Ali, Jennifer. Mental health of Canada’s immigrants. Statistics Canada. Supplement to Health Reports. 2002;13:Catalogue 82-003.
3. Bronstein I, Montgomery P. Psychological distress in refugee children: A systematic review. Clin Child and Fam Psychol Rev 2011;14(1):44-56.
4. Rasmussen A, Crager M, Baser RE, et al. Onset of post traumatic stress disorder and major depression among refugees and voluntary migrants to the United States. J Trauma Stress 2012;25(6):705-12.
5. Beiser M, Hamilton H, Rummens JA, et al. Predictors of emotional problems and physical aggression among children of Hong Kong Chinese, mainland Chinese and Filipino immigrants to Canada. Soc Psychiatry Psychiatr Epidemiol 2010;45(10):1011-21.
6. Beiser M, Zilber N, Simich L, et al. Regional effects on the mental health of immigrant children: Results from the New Canadian Children and Youth Study (NCCYS). Health Place 2011;17(3):822-9.
7. Bhatia SK, Bhatia SC. Childhood and adolescent depression. Am Fam Physician 2007;75(1):73-80.
8. Korczak DJ, Goldstein BI. Childhood onset major depressive disorder: Course of illness and psychiatric comorbidity in a community sample. J Pediatr 2009;155(1):118-23.
9. Oxman-Martinez J, Rummens AJ, Moreau J, et al. Perceived ethnic discrimination and social exclusion: Newcomer immigrant children in Canada. Am J Orthopsychiatry 2012;82(3):376-88.
10. Zisook S, Lesser I, Steward JW, et al. Effect of age at onset on the course of major depressive disorder. Am J Psychiatry 2007;164(1):1539-46.
11. Beiser M, Hou F, Hyman I, et al. Poverty, family process, and the mental health of immigrant children in Canada. Am J Public Health 2002;92(2):220-7.
12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn., 2000, DSM-IV-TR. Washington, DC: American Psychiatric Association, 2000.
13. Hoge EA, Tamrakar SM, Christian KM, et al. Cross-cultural differences in somatic presentation in patients with generalized anxiety disorder. J Nerv Ment Dis 2006;194(12):962-6.
14. Li HZ, Browne AJ. Defining mental illness and accessing mental health services: Perspectives of Asian Canadians. Can J Commun Ment Health 2000;19(1):143-59.
15. Stewart SM, Simmons A, Habibpour E. Treatment of culturally diverse children and adolescents with depression. J Child Adolesc Psychopharmacol 2012;22(1):72-9.
16. Mental Health Commission of Canada, Centre for Addiction and Mental Health. 2009. Improving mental health services for immigrant, refugee, ethno-cultural and racialized groups: Issues and options for service improvement.
17. American Academy of Child and Adolescent Psychiatry, Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry 2001;40(7 Suppl):24S-51S.
18. March JS, Silva S, Petrycki S, et al. The Treatment for Adolescents with Depression Study (TADS): Long-term effectiveness and safety outcomes. Arch Gen Psychiatry 2007;64(10):1132-43.
19. National Institute of Mental Health. Treatment of SSRI-resistant Depression in Adolescents (TORDIA). Ongoing study.
20. Josephson AM; AACAP Work Group on Quality Issues. Practice parameter for the assessment of the family. J Am Acad Child Adolesc Psychiatry 2007;46(7):922-37.
21. Stewart M, Simich L, Beiser M, et al. Impacts of a social support intervention for Somali and Sudanese refugees in Canada. Ethnicity and Inequalities in Health and Social Care 2011;4(4):186-99.