Like Billy, the boy you read about at the beginning of this chapter, around 2 percent of children and 8 percent of adolescents currently experience a major depressive disorder (Mash & Wolfe, 2012). As many as 20 percent of adolescents experience at least one depressive episode during their teen years. In addition, many clinicians believe that children may experience bipolar disorder.

As with anxiety disorders, very young children lack some of the cognitive skills that help produce clinical depression, thus accounting for the low rate of depression among the very young (Hankin et al., 2008). For example, in order to experience the sense of hopelessness typically found in depressed adults, children must be able to hold expectations about the future, a skill rarely in full bloom before the age of 7.

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Nevertheless, if life situations or biological predispositions are significant enough, even very young children sometimes have severe downward turns of mood (Tang et al., 2014; Swearer et al., 2011). Depression in the young may be triggered by negative life events (particularly losses), major changes, rejection, or ongoing abuse. Childhood depression is commonly characterized by such symptoms as headaches, stomach pain, irritability, and a disinterest in toys and games (Schulte & Petermann, 2011).

Clinical depression is much more common among teenagers than among young children. Adolescence is, under the best of circumstances, a difficult and confusing time, marked by angst, hormonal and bodily changes, mood changes, complex relationships, and new explorations (see MindTech below). For some teens, these “normal” upsets of adolescence cross the line into clinical depression. As you read in Chapter 9, suicidal thoughts and attempts are particularly common among adolescents—one in eight teens persistently thinks about suicide each year—and depression is the leading cause of such thoughts and attempts (Nock et al., 2013; Spirito & Esposito-Smythers, 2008).

Interestingly, while there is no difference between the rates of depression in boys and girls before the age of 13, girls are twice as likely as boys to be depressed by the age of 16 (Naninck et al., 2011; Merikangas et al., 2010; Hankin et al., 2008). Why this gender shift? Several factors have been suggested, including hormonal changes, the fact that females increasingly experience more stressors than males, and the tendency of girls to become more emotionally invested than boys in social and intimate relationships as they mature. One explanation also focuses on teenage girls’ growing dissatisfaction with their bodies. Whereas boys tend to like the increase in muscle mass and other body changes that accompany puberty, girls often detest the increases in body fat and weight gain that they experience during puberty and beyond. Raised in a society that values and demands extreme thinness as the aesthetic female ideal, many adolescent girls feel imprisoned by their own bodies, have low self-esteem, and become depressed (Stice et al., 2000). Many also develop eating disorders, as you saw in Chapter 11.

For years, it was generally believed that childhood and teenage depression would respond well to the same treatments that have been of help to depressed adults—cognitive-behavioral therapy, interpersonal approaches, and antidepressant drugs—and, in fact, many studies have indicated the effectiveness of such approaches (Straub et al., 2014; Vela et al., 2011). Some recent studies and events over the past several years, however, have raised questions about these approaches for teenagers.

In one development, the National Institute of Mental Health recently sponsored a massive six-year study called the Treatments for Adolescents with Depression Study (TADS), which compared the effectiveness of cognitive-behavioral therapy alone, antidepressant therapy alone, cognitive-behavioral and antidepressant therapy combined, and placebo therapy for teenage depression (TADS, 2010, 2007, 2004). Three major surprises emerged from this highly regarded study. First, neither antidepressants alone nor cognitive-behavioral therapy alone was as effective for teenage depression as was a combination of antidepressants and cognitive-behavioral therapy. Second, antidepressants alone tended to be more helpful to depressed teens than cognitive-behavioral therapy alone. And third, cognitive-behavioral therapy alone was barely more helpful than placebo therapy. Many researchers believe that certain peculiarities in the participant population of the TADS study may have been responsible for the poor showing of cognitive-behavioral therapy. However, other clinical theorists believe that the TADS study is a definitive research undertaking and that many depressed teens may in fact respond less well to cognitive-behavioral therapy than adults do.

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A second development in recent years has been the discovery that antidepressant drugs may be very dangerous for some depressed children and teenagers. Throughout the 1990s, most psychiatrists believed that second-generation antidepressants were safe and effective for children and adolescents, and they prescribed them readily (Cooper et al., 2014). However, as you read in Chapter 9, the U.S. Food and Drug Administration (FDA) concluded in 2004, based on a number of clinical reports, that the drugs may produce a real, though small, increase in the risk of suicidal behavior for certain children and adolescents, especially during the first few months of treatment. Thus, the FDA ordered that all antidepressant containers carry “black box” warnings stating that the drugs “increase the risk of suicidal thinking and behavior in children.”

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Arguments about the wisdom of this FDA order have since ensued. Although most clinicians agree that the drugs may increase the risk of suicidal thoughts and attempts in as many as 2 to 4 percent of young patients, some have noted that the overall risk of suicide may actually be reduced for the vast majority of children who take the drugs (Isacsson & Rich, 2014; Vela et al., 2011). They point out, for example, that suicides among children and teenagers decreased by 30 percent in the decade leading up to 2004, as the number of antidepressant prescriptions provided to children and teenagers were soaring.

While the findings of the TADS study and questions about antidepressant drug safety continue to be sorted out, these two developments serve to highlight once again the importance of research, particularly in the treatment realm. We are reminded that treatments that work for individuals of a certain age, gender, race, or ethnic background may be ineffective or even dangerous for other groups of people.

For decades, bipolar disorder was thought to be exclusively an adult disorder, and that its earliest age of onset is the late teens (APA, 2013). However, since the mid-1990s, clinical theorists have done an about-face, and a rapidly growing number of them now believe that many children display bipolar disorder. A review of national diagnostic trends from 1994 through 2003 found that the number of children—often very young children—and adolescents diagnosed and treated for bipolar disorder in United States increased 40-fold, from 25 such diagnoses per 100,000 individuals in 1994 to 1,000 per 100,000 individuals in 2003 (Moreno et al., 2007). Correspondingly, as you can see in Figure 17-2, the number of private office visits for children with bipolar disorders increased from 20,000 in 1994 to 800,000 in 2003. Furthermore most clinical observers agree that the number of children and adolescents diagnosed with bipolar disorder has continued to rise sharply since 2003 (Mash & Wolfe, 2012).

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Most theorists believe that these numbers reflect not an increase in the prevalence of bipolar disorders among children but rather a new diagnostic trend. The question is whether this trend is accurate. In a national survey of adults with bipolar disorders, 33 percent of the respondents recalled that their symptoms actually began before they reached 15 years of age, and another 27 percent said their symptoms first appeared between the ages of 15 and 19 (Hirschfeld et al., 2003). Such responses indicate that bipolar disorders among children and teenagers have indeed been around for years but were overlooked by diagnosticians and therapists.

Some clinical theorists, however, distrust the accuracy of such retrospective reports and believe that the diagnosis of bipolar disorder is currently being overapplied to children and adolescents (Paris, 2014; Mash & Wolfe, 2012). They suggest that the label has become a clinical catchall that is being applied to almost every explosive, aggressive child. In fact, symptoms of rage and aggression, along with depression, dominate the clinical picture of most children who have received a bipolar diagnosis over the past two decades (Roy et al., 2013; Diler et al., 2010). The children may not even manifest the symptoms of mania or the mood swings that characterize adult bipolar disorder. Moreover, two-thirds of the children and adolescents who receive a bipolar diagnosis are boys, while adult men and women have bipolar disorder in equal numbers.

The DSM-5 task force concluded that the childhood bipolar label has in fact been overapplied over the past two decades. To help rectify this, DSM-5 now includes a new category, disruptive mood dysregulation disorder, which is used to describe children with patterns of severe rage (see Table 17-2). It is expected that more such children will receive this diagnosis in the coming years and that the number of childhood bipolar disorder diagnoses will decrease correspondingly.

This issue is particularly important because the rise in diagnoses of bipolar disorder has been accompanied by an increase in the number of children who are prescribed adult medications (Toteja et al., 2014; Chang et al., 2010; Grier et al., 2010). Around one-half of children in treatment for bipolar disorder receive an antipsychotic drug; one-third receive an antibipolar, or mood-stabilizing, drug; and many others receive antidepressant or stimulant drugs. Yet relatively few of these drugs have been tested on and approved specifically for use with children.

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