Download Depression in childhood and adolescence: clinical features

Jornal de Pediatria - Vol. 78, Nº5, 2002 359
0021-7557/02/78-05/359
Jornal de Pediatria
Copyright © 2002 by Sociedade Brasileira de Pediatria
REVIEW ARTICLE
Depression in childhood and adolescence:
clinical features
Saint-Clair Bahls*
Abstract
Objective: this study reviews clinical features, evolution, comorbidity and suicidal behavior in
childhood and adolescence depression. Its objective is to provide clear information on this common, severe
and not very easily recognized pathology.
Sources: literature searches were performed through Medline (1991-2000), with secondary-source
follow-up.
Summary of the findings: scientific concern about depression in childhood and adolescence is recent
and up to the 70’s depression was considered rare or inexistent in this period. Current diagnostic systems
define as basic features of depression in children and adolescents are the same ones found in adults for
major depression episodes; however, researches emphasize the significance of the developmental process
in the clinical manifestations, with predominant features in each phase.
Conclusions: nowadays, major depression in children and adolescents is understood to be a common,
disabling and recurrent disease, with a high level of morbidity and mortality. It is an important public health
problem.
J Pediatr (Rio J) 2002;78(5):359-66: depression, childhood and adolescence, clinical features.
Introduction
Depressive disorders consist of a group of pathologies
with a high and growing prevalence in the general population.
According to the World Health Organization, in the next
two decades there will be a dramatic change in health needs
of the world population, due to the fact that diseases like
depression and cardiopathies are substituting the traditional
problems of infectious diseases and malnutrition. The
damage caused by diseases measured by the Disability
Adjusted Life Years shows that major depression, the 4th
generative cause of overload in 1990, will be the 2nd cause
in 2020, only losing to cardiac diseases. 1,2 Meanwhile,
scientific interest in depression in children and adolescents
is relatively recent, until the 1970s it was believed that
depression in this age group was rare or even nonexistent. 3-9
The National Institute of Mental Health in the U.S. (NIHM)
officially recognized the existence of depression in children
and adolescents in 1975,10 and the research on depression
during these life phases has attracted a growing interest
during the last two decades.3,11,12
Many authors have called attention to the phenomena of
depression in children and adolescents that not only is it
now fully recognized, it seems to be more frequent and
happening earlier and earlier. 13-19 In the Los Angeles
Epidemiologic Catchment Area Project study, according to
Olsson and von Knorring,20 25% of adults with major
* Professor, Department of Psychology, Universidade Federal do Paraná.
Master’s Degree in Childhood and Adolescence Psychology.
Manuscript received Oct 08 2001. Accepted for publication Apr 24 2002.
359
360 Jornal de Pediatria - Vol. 78, Nº5, 2002
Depression in childhood and adolescence: clinical features - Bahls S-C7
depression report that the first episode of the disease occurred
before 18 years of age. In a recent review of the epidemiology
of depressive disorder in children and adolescents Bahls3
found that the prevalence-year for major depression in
children is 0.4 to 3.0%, and 3.3 to 12.4% in adolescents.
Major depression in childhood and adolescence is
considered to exhibit a pervasive and long-lasting nature,
affect multiple functions and cause significant psychosocial
damage. The objective of this article is to present a review
of depression in these age groups, emphasizing clinical
status, its evolution, comorbidities and relation to suicidal
behavior. For the purpose of this paper a search was done
using these key words: depression, childhood and
adolescence, clinical characteristics, in the period of 1991
to 2000, and a manual survey of bibliographic references.
Clinical status
Today depressive disorders in children and adolescents
and those in adults are understood as the same
phenomenological entities, a fact derived from studies
which show the same diagnostic criteria reliably applied to
these three age groups.7,8,13,21-23 According to the
Diagnostic and Statistical Manual of Mental Disorders24
(DSM-IV) the basic symptoms of a major depressive episode
(Table 1) are the same in adults, adolescents and children
even though there are data suggesting that the predominance
of characteristic symptoms can change with age, including
very common symptoms in children (somatic complaints,
irritability and social withdrawal) and symptoms less
commonly found in children (psychomotor retardation,
oversleeping and delusions). The International Classification
of Diseases25 (ICD-10) presently deals with depressive
disorders in the same way for all age groups, with only the
following specific citation “atypical presentations are
particularly common in depressive episodes in adolescence”,
but it does not supply more information.
Table 1 -
The majority of authors in the area of depressive
disorders in childhood and adolescence cite that
symptoms vary with age, emphasizing the importance of
the maturation process at the different developmental
stages of the symptoms and behaviors of depression,
with
one
predominant
symptomatological
characterization per age group. 8,16,19,26-28
Children
In preschool children (up to age 6 or 7) the most
common clinical manifestations are physical symptoms,
such as: pains (principally head and abdominal), fatigue and
dizziness. Goodyer4 cites that approximately 70% of the
cases of major depression in children present physical
complaints. The complaints of physical symptoms are
followed by anxiety (especially separation anxiety), phobias,
psychomotor agitation or hyperactivity, irritability, loss of
appetite with a failure to reach an adequate weight, and
sleep disorders. Some authors also cite, with less frequency,
the occurrence of enuresis and encopresis, sad facial
expressions, deficient communication skills, frequent crying,
repetitive movements and auto and heteroaggressiveness
through aggressive and destructive behavior. The pleasure
in playing or attending preschool diminishes or disappears
and the acquisition of age-appropriate social skills does not
occur naturally4,8,9,18,19,29 (Table 2). Although the majority
of authors affirm that in this period suicidal ideation or
attempts do not occur, Shafi and Shaffi8 emphasize that
self-destructive behavior in the form of severe and repeated
head bashing, biting oneself, swallowing dangerous objects
and a propensity for accidents could be the suicidal equivalent
in children that do not verbalize emotions. Meanwhile
suicidal ideation in this age group is considered a rare
occurrence, occurring only in special cases. North American
studies of preschool children with depression found that
often parents are also depressed and are involved in serious
social problems.19
Symptoms of major depressive episodes – DSM-IV
1. Depressed or irritable mood
2. Extremely diminished interest or pleasure
3. Significant weight loss or weight gain, or decreased or increased appetite
4. Insomnia or hypersomnia
5. Agitation or psychomotor retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think and concentrate, or indecisiveness
9. Recurrent thoughts of death, suicidal ideation, suicide attempt or plan
Depression in childhood and adolescence: clinical features - Bahls S-C
Table 2 - Depression symptoms in preschool children
1.
2.
3.
4.
5.
6.
7.
8.
9.
Pain (headache and stomachache)
Diminished pleasure in playing and going to school
Difficulty in acquiring age-appropriate social skills
Anxiety
Phobias
Agitation or hyperactivity
Irritability
Diminished appetite
Sleep disorders
In school-age children (between six or seven to twelve
years of age) a depressive mood can be verbalized and what
is often communicated is sadness, irritability or boredom.
They present a sad appearance, cry easily, have apathy,
fatigue, isolation, decline in or poor school performance,
which could result in school refusal, separation anxiety,
phobias and death wishes. They may also report weak
concentration, somatic complaints, weight loss, insomnia
and mood-congruent psychotic symptoms (depreciative
aural hallucinations and less frequently delusions of blame
or guilt). The decline in performance could be due to weak
concentration or interest, both characteristic of the state of
depression. It is common for the child not to have friends,
say that classmates do not like him/her or have an exclusive
and excessive attachment to animals.8,9,14,22,29,30 Inability
to enjoy oneself (anhedonia), poor relationship with peers
and low self-esteem, describing oneself as stupid, silly or
unpopular can also be present (Table 3). It is important to
emphasize that teachers are often the first to notice the
emerging modifications of depression in these children. In
a study on school efficiency in nine to ten year old children
with symptoms of depression, in one school in particular in
Recife, state of Pernambuco, Bandim et al.31 found that
there was a significant decrease in school performance in all
Jornal de Pediatria - Vol. 78, Nº5, 2002 361
areas, principally in Portuguese and Sciences, when
compared to children without depressive symptoms.
In both preschool as well as school-age children
depression can become clear through observation of the
themes of their fantasies, desires, dreams, games, with the
predominant subjects of failure, frustration, destruction,
injuries, losses or abandonment, blame, excessive selfcriticism and death.8
Adolescents
The manifestation of depression in adolescents (from
age 12) normally presents symptoms similar to those of
adults, but there can exist important phenomenological
characteristics that are typical of depressive disorder in this
phase of life. Depressed adolescents are not always sad;
they seem primarily irritated and unstable, and can have
emotional outbursts and anger in their behavior. According
to Kazdin and Marciano11 more than 80% of depressed
youths present irritable mood and also loss of energy,
apathy and marked lack of interest, psychomotor retardation,
feelings of hopelessness and guilt, sleep disorders, especially
oversleeping, appetite and weight changes, isolation and
difficulty concentrating. Other unique characteristics of
this group are poor school performance, low self-esteem,
suicidal ideation and attempts, and serious behavior
problems, especially abusive alcohol and drug
use.7,14,18,19,22,30,32 The development of abstract thought
around age 12 brings a clearer understanding of the
phenomenon of death, consequently, both suicidal ideas
and attempts, which are normally extremely fatal, reach a
greater dimension in depressed adolescents, and so,
adolescents are extremely vulnerable to them (Table 4). In
a study on the symptoms of major depression in adolescents
between the ages of fourteen and eighteen, in a community
sample in the Oregon Adolescent Depression Project, in the
US, Roberts et al.23 found the most prevalent symptoms to
be depressed mood, sleep disorders and difficulties in
Table 4 - Depression symptoms in adolescents
Table 3 - Depression symptoms in school age children
1. Sadness, irritability and/or dullness
2. Lack of ability to enjoy himself/herself
3. Sad appearance
4. Easy crying
5. Fatigue
6. Isolation with weak relationship with peers
7. Low self-esteem
8. Diminished or weak school performance
9. Separation anxiety
10. Phobias
11. Death desire or ideation
1. Irritability and instability
2. Depressed humor
3. Loss of energy
4. Lack of motivation and significant lack of interest
5. Psychomotor retardation
6. Feelings of hopelessness and/or guilt
7. Sleep disorders
8. Isolation
9. Difficulty in concentrating
10. Poor school performance
11. Low self-esteem
12. Suicidal ideas and attempts
13. Severe behavioral problems
362 Jornal de Pediatria - Vol. 78, Nº5, 2002
thinking (concentration problems and negative thinking)
and the most stable symptoms to be depressed mood and
anhedonia.
Some authors28,33 call attention to the difference between
the manifestation of depression in female and male
adolescents, emphasizing that girls report more subjective
symptoms such as feelings of sadness, emptiness, boredom,
anger and anxiety. Girls normally are also more concerned
with popularity, less satisfied with their appearance, more
self-conscious and have lower self-esteem, while boys
report more feelings of contempt, defiance and disdain, and
show conduct problems like: missing classes, running away
from home, physical violence, robberies and substance
abuse. They emphasize that alcohol abuse can be a strong
indicator of depression.
As guidance for physicians, the following should not be
considered normal, alerting to the probable presence of
depression during adolescence: states of irritability or longlasting and/or excessive depression, prolonged periods of
isolation from or hostility towards family and friends,
distancing oneself from school or a significant decline in
school performance, distancing oneself from group activities,
and behaviors such as substance abuse (alcohol and drugs),
physical violence, promiscuous sexual activity and running
away from home.28 An adolescent is normally the best
source of information as to his/her depressive suffering and
his/her schoolmates and friends most easily notice the
modifications caused by the pathology. Many authors
emphasize that parents and teachers are often not aware of
depression in their adolescent children and students.
Risk factors
The most important risk factor of depression in children
and adolescents is the presence of depression in one of the
parents, the existence of a family history of depression
increases the risk by at least three times, followed by
environmental stressors like physical and sexual abuse and
loss of a parent, sibling or close friend.8,14,34 In a longitudinal
study, involving 550 adolescent students between ages
eleven and seventeen, Garrison et al.,35 in the US, concluded
that at the start of adolescence, family environment is a
more important predictor of depressive symptoms than
stressful life events. Abou-Nazel et al.,36 in Egypt, in a
study with 1,561 adolescent students between ages eleven
and seventeen, found that low academic performance is a
marker for children at high risk of depression in this age
group. Nunes et al.37 in a study in Londrina, state of Paraná,
Brazil, evaluated the presence of psychiatric disorders in
the parents of individuals between ages seven and eighteen
and found a predominance of mood disorders, especially
major depression and dysthymia, confirming the importance
of the family factor in vulnerability to depression in childhood
and adolescents. Patten et al.38 in a community study in
California, US, with 5,531 adolescents between ages twelve
and seventeen with depressive symptoms, concluded that a
Depression in childhood and adolescence: clinical features - Bahls S-C
lack of the perception of support on the part of the parents
is highly related to the presence of depressive symptoms in
youths.
Evolution
On average, major depression in childhood increases
around age nine and in adolescence between ages thirteen
and nineteen. The first depressive episode usually lasts
between approximately five and nine months. In terms of
recovery, the majority of authors cite the article written by
Kovacs et al.,39 in which 74% or cases presented significant
improvement within a year, and 92% recovered in a period
of two years.5,6,8,11,15,20,22 Authors are unanimous in
affirming that after recovery there normally remains some
degree of psychosocial damage; and the earlier the
appearance of the pathology, the greater the harm is likely
to be, which was confirmed by the Rohde et al. study40 with
1,507 community adolescents in which they concluded that
the early appearance of major depression is one of the most
harmful forms of the disease and causes a more severe
impact than in adults.
The risk of recurrence of major depression in childhood
and adolescence is more frequent a few months after the
first episode, with variable rates, between 33 and 80% in
five years, according to review articles. 13,22,29 In
longitudinal studies16,39 in the US and England, rates of
recurrence between 60 and 74% were found. Children and
adolescents with depression possess a high risk of recurrence
which extends through adulthood, representing a high
vulnerability to depressive disorders.
The following factors are predictive of recurrence: early
onset, numerous previous episodes, the severity of the
episode, presence of psychotic symptoms, presence of
stressors, comorbidity (especially dysthymia) and not
following treatment.19 Some authors consider the appearance
of a depressive episode in childhood and adolescence as
predictive of bipolar disorder in the future, meanwhile there
remains a lack of clear evidence regarding this
relationship.13,20,41
Comorbidity
Depressed children and adolescents normally present
high rates of comorbidity with other psychiatric disorders,
found more commonly than in depressed adults. The most
common comorbidities in children are anxiety disorder
(especially separation anxiety), conduct disorder, or
oppositional defiance disorder and attention deficit disorder,
and in adolescents, substance-related disorders and eating
disorders.5,12,16,22,24,27,40,42
Goodyer and Cooper26 emphasize that depressive
disorders in children and adolescents present 40%
comorbidity with anxiety disorders and 15% with conduct
disorders. Birmaher et al.13 describe major depression in
Depression in childhood and adolescence: clinical features - Bahls S-C
adolescence as normally presenting an index of 40 to 70%
psychiatric comorbidity, at least 20 to 50% of which have
two or more comorbidities; and they emphasize that conduct
disorders could persist after the depressive episode ends.
Kazdin and Marciano11 cite that depressed youths, in
community studies, present average rates of comorbidity
between 40 and 50% for at least one other psychiatric
diagnosis, and can reach up to 80%. Martin and Cohen43
and Scivoletto et al.7 cite that 20% of depressed adolescents
also present alcohol and drug abuse.
Kashani et al.,44 in a community study of adolescents in
the US, found the following rates of comorbidity among
those with a diagnosis of major depression: 100% for
dysthymia; 75% for anxiety disorders; 50% for oppositional
defiant disorder; 35% for conduct disorder and 25% for
substance abuse. Roberts et al.23 in the US, in a community
survey of 1,710 adolescents, found between sufferers of
major depression the rate of 66% with a history of another
mental disorder, and 34% with a previous depressive episode.
Garrison et al.45 in the US, in a longitudinal epidemiological
study with 3,283 participants between ages twelve and
fourteen, researching dysthymia and major depression,
found a high rate of comorbidity, in which 58% of those
diagnosed with dysthymia also had major depression
characterized by the presence of double depression. Also in
the US, Kessler and Walters16 in an investigation of a
population of 1,769 individuals between ages fifteen and
twenty, which took part in the National Comorbidity Survey,
found that 76.6% of those with major depression and 69.3%
of those with dysthymia presented at least one other
psychiatric disorder during their lives, and concluded that
comorbidity for depression, in this age group, is more of a
rule than an exception.
In relation to depression in childhood and adolescence,
we know that the probability of comorbidities increases
with the severity of the state of depression; in addition, its
presence normally indicates a more severe evolution and a
poorer prognosis.3,8,22
Suicide
Child and adolescent suicide is a particularly dramatic
and severe manifestation, and is the most relevant fact in the
clinical status of depression. Today there is a tendency
among authors to call a suicide attempt deliberate selfharm.17,46,47
Suicidal behavior among youths has apparently been on
the rise in the last decades, and adolescence is calling
attention to itself as the period most related to death due to
violent causes.17,38,41,46,48,49 In a study in England and
Wales with individuals between ages fourteen and twentyfour, according to Scivoletto et al.,7 a 78% rise in suicide
rates between 1980 and 1990 was found. Today suicide is
the second cause of death among youths from ages fifteen
to twenty-four in the US, according to the National Center
for Health Statistics49 from 1986, as well as in England,
Jornal de Pediatria - Vol. 78, Nº5, 2002 363
according to the study Office of Population Census and
Surveys42 from 1990; and the suicide index in the general
population for this age group is 0.01%. 47
In relation to age, suicidal ideation is common in schoolage children and in adolescents, however attempts are rare
in children. Suicide attempts and ideation increase with age,
becoming common after puberty. Of high-school students
4% presented one suicide attempt in the previous twelve
months and 8% had already had one previous suicide
attempt in their life, according to the United States Youth
Risk Survey14 of 1990. And the indices of suicide ideation
are even higher; community surveys found rates of 12 to
25% in primary school students and more than 25% in high
school students.14
Weismann et al.41 in the US, in a research follow-up
study in a period between ten and fifteen years with depressed
adolescents, found a suicide attempt rate of 50.7% and
7.7% for suicides. In Brazil, Feijó et al.48 in an investigation
of self-destructive behavior in adolescents in the range of
thirteen to twenty years of age, accompanied suicide attempts
attended at the Emergency Room of the Hospital de Clínicas
de Porto Alegre-RS daily during a period of four months
and found the following results: 88% were caused by
overdose, 84.4% of the cases occurred in girls, 47% had
already had a previous suicide attempt and 28% presented
a diagnosis of major depression. Mirand and Queiroz50
researching on suicide ideation and suicide attempts in a
sample of 875 medical students in Belo Horizonte, state of
Minas Gerais, Brazil, obtained rates of 37% for suicide
ideation and 2.3% for suicide attempts.
Approximately 80% of adolescent suicide attempts were
through overdoses, followed by cutting wrists. Close to
65% of suicides are committed with guns, followed by
hanging, jumps and overdoses. Shafii and Shafii8 cite a
study in Louisville, US, in which 57% of the adolescent
suicides were with guns, emphasizing that 82% of the cases
had never had specialized help. The majority of adolescent
victims commit suicide impulsively and are often found
intoxicated (alcohol and drugs) at the time of death. Suicide
is three to four times more common in boys as it is in girls,
while suicide attempts are two to five time more common in
girls.7,14,22,28,47,51,52
The following are considered risk factors for suicidal
behavior in childhood and adolescence: age, presence of
previous attempts, family history of psychiatric disorders
(especially with suicide attempt and/or suicide), absence of
family support, presence of a gun in the house, serious and/
or chronic physical disease, presence of depression and
comorbidity with other conduct disorders, and substance
abuse. The risk of suicidal behavior in depressed adolescents
is three times higher in the presence of these
comorbidities.22,29,46,48,50,52 A previous suicide attempt is
the best predictor, so we calculate that 25% of adolescents
who attempt suicide and 25 to 40% of youths who commit
suicide have already had at least one previous suicide
attempt. It is estimated that up to 11% of adolescents who
364 Jornal de Pediatria - Vol. 78, Nº5, 2002
attempt suicide through overdose will commit suicide in the
following years.47 The feeling of hopelessness is strongly
associated with suicidal behavior and predicts future
attempts.7,21,49,53 It is known that at least 50% of adolescents
who commit suicide made threats or attempts in the past,
and the risk of repeating an attempt is greater in the first
three months after a suicide attempt.14
Precipitators of suicidal behavior in this age group are:
losses, interpersonal crises with family or friends,
psychosocial stressors, physical and sexual abuse, legal or
disciplinary problems and exposure to the suicide of friends,
relatives or even through the media.7,14,22,47,51,53 Knowing
the risk factors associated with triggering factors provide
the clinician with a necessary and useful indication of those
statuses that need urgent specialist referral.
Conclusions
The study of depressive disorders in childhood and
adolescence has already shown that their presence is
sufficiently common and serious to deserve clinicians and
researchers’ attention. Especially if we consider the
possibility suggested by modern epidemiological studies of
their growing prevalence and earlier onset. The clinical
manifestations of depression in children, adolescents and
adults are essentially the same, to such an extent that the
principal systems of classification of mental disorders use
the same diagnostic criteria in these three life phases. There
exists, however, a need to emphasize the relevance of
unique characteristics of each phase of pediatric
development, which model the clinical manifestations of
depression, with predominant symptomalogical groups in
the different age groups.
It is necessary to emphasize that depressive disorder has
a heterogeneous presentation from childhood, requiring
careful diagnostic evaluation by professionals involved
with children and adolescents. Whether in relationship to
the symptomatology or to the evolution, the existence of
comorbid psychiatric pathologies brings a special
complication to the study of pediatric depressions, as the
coexistence of multiple diagnoses is more of the rule than
the exception. Especially in these periods, it is necessary to
consider the importance of using many sources of
information (parents, teachers, friends) and establishing a
clinical investigation.
In adolescents, there is today an understanding that
major depression is common, debilitating and repeatable,
involving a high degree of morbidity and mortality especially
through suicide, which is one of the principal preoccupations
of public health.3,14,22,29,38 We call attention to the fact that
a vast majority of depressed children and adolescents do not
wish to be identified and even less referred to treatment. In
a study by Goodyer and Cooper26 in England, none of the
adolescents identified as having major depression had been
referred to treatment or was being treated.
Depression in childhood and adolescence: clinical features - Bahls S-C
In conclusion, depression in childhood and adolescence
becomes particularly important when the question of suicidal
behavior is considered. There even exist reports of suicidal
behavior and suicide in preschool children, 8 and its
occurrence in adolescence is rising. We estimate that
depression is responsible for the majority of suicides in
youths, reaching values close to 10% in cases of major
depression. Today we know, in a relatively sure way, the
risk factors as well as the triggering factors of suicidal
behavior in children and adolescents, which permit better
strategies of addressing the problem. And if we continue to
consider depression, due to its usually satisfactory
therapeutic result, as the principal preventable cause of
suicide, there is much to be done, protecting and impeding
innumerable potential victims of suicidal behavior caused
by depressive disease.
References
1. Bahls S-C. Depressão: uma breve revisão dos fundamentos
biológicos e cognitivos. Interação 1999;3:49-60.
2. Murray CJL, Lopez AD. The global burden of disease and injury
series. The global burden of disease (Summary). Cambridge:
Harvard University Press; 1996.
3. Bahls, SC. Epidemiology of depressive symptoms in adolescents
of a public school in Curitiba, Brazil. Rev Bras Psiquiatr 2002;
24(2):63-7.
4. Goodyer IM. Physical symptoms and depressive disorder in
childhood and adolescence. J Psychosom Res 1996;41(5):405-8.
5. Kent L, Vostanis P, Feehan C. Detection of Major and Minor
Depression in Children and Adolescents: Evaluation of the Mood
and Feelings Questionnaire. J Child Psychol Psychiatry 1997;
38(5):565-73.
6. Larsson B, Melin L, Breitholtz E, Andersson G. Short-term
stability of depressive symptoms and suicide attempts in Swedish
adolescents. Acta Psychiatr Scand 1991;83:385-90.
7. Scivoletto S, Nicastri S, Zilberman ML. Transtorno depressivo
na adolescência: diagnóstico e tratamento. RBM 1994;51(9):
1211-28.
8. Shafii M, Shafii SL. Clinical Manifestations and Developmental
Psychopathology of Depression. In: Shafii M, Shafii SL, editores.
Clinical Guide to Depression in Children and Adolescents.
Washington: American Psychiatric Press; 1992.p.3-42.
9. Souza PR. Depressão endógena em criança de oito anos - CASE
REPORT. Revista da Associação Brasileira de Psiquiatria
1984;6(21):67-9.
10. Bhatara VS. Early Detection of Adolescent Mood Disorders. S D
J Med 1992;45(3):75-8.
11. Kazdin AE, Marciano PL. Childhood and adolescent depression.
In: Mash E, Barkley R, editores. Treatment of Childhood
Disorders. 2nd ed. New York: The Guilford Press; 1998.
12. Olsson G, von Knorring A-L. Depression among Swedish
adolescents measured by the self-rating scale Center for
Epidemiology Studies – Depression Child (CES-DC). Eur Child
Adolesc Psychiatry 1997;6:81-7.
Depression in childhood and adolescence: clinical features - Bahls S-C
13. Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J,
Dahl RE, et al. Childhood and Adolescent Depression: A Review
of the Past 10 Years. Part I. J Am Acad Child Adolesc Psychiatry
1996;35(11):1427-39.
14. Brent DA. Depression and Suicide in Children and Adolescents.
Pediatr Rev 1993;14(10):380-8.
15. Garrison CZ, Addy CL, Jackson KL, McKeown RE, Waller JL.
Incidence of major depressive disorder and dysthymia in young
adolescents. J Am Acad Child Adolesc Psychiatry 1997;36(4):
458-65.
16. Kessler RC, Walters EE. Epidemiology of DSM-III-R Major
Depression and Minor Depression among Adolescents and Young
Adults in the National Comorbidity Survey. Depress Anxiety
1998;7:3-14.
17. Prosser J, McArdle P. The changing mental health of children
and adolescents: evidence for a deterioration? Psychol Med
1996;26:715-25.
18. Ryan ND, Williamson DE, Iyengar S, Orvaschel H, Reich T,
Dahl RE, et al. A Secular Increase in Child and Adolescent Onset
Affective Disorder. J. Am Acad Child Adolesc Psychiatry
1992;31(4):600-5.
19. Versiani M, Reis R, Figueira I. Diagnóstico do transtorno
depressivo na infância e adolescência. J Bras Psiquiatria 2000;
49(10-12):367-82.
20. Olsson G, von Knorring A-L. Adolescent depression: prevalence
in Swedish high-school students. Acta Psychiatr Scand 1999;
99:324-31.
21. Feijó RB, Saueressig M, Salazar C, Chaves MLF. Mental health
screening by self-report questionnaire among community
adolescents in southern Brazil. J Adolesc Health 1997;20:232-7.
22. Pataki CS, Carlson GA. Childhood and Adolescent Depression:
A Review. Harv Rev Psychiatry 1995;3(3):140-51.
23. Roberts RE, Lewinsohn PM, Seeley JR. Symptoms of DSM-IIIR Major Depression in Adolescence: Evidence from an
Epidemiological Survey. J Am Acad Child Adolesc Psychiatry
1995;34(12):1608-17.
24. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. DSM-IV. 4th ed. Washington, DC:
American Psychiatric Association; 1994.
25. Organização Mundial da Saúde. Classificação de Transtornos
Mentais e de Comportamento da CID-10. Descrições Clínicas e
Diretrizes Diagnósticas. Porto Alegre: Artes Médicas; 1993.
26. Goodyer I, Cooper PJ. A Community Study of Depression in
Adolescent Girls II: The Clinical Features of Identified Disorder.
Br J Psychiatry 1993;163:374-80.
27. Nolen-Hoeksema S, Girgus JS. The Emergence of Gender
Differences in Depression During Adolescence. Psychol Bull
1994;115(3): 424-43.
28. Sadler LS. Depression in Adolescents. Context, Manifestations,
and Clinical Management. Nurs Clin North Am 1991;26(3):
559-72.
29. Mirza KAH, Michael A. Major depression in children and
adolescents. Br J Hosp Med 1996;55(1-2):57-61.
30. Kashani JH, Rosenberg T, Reid J. Developmental perspectives in
child and adolescent depressive symptoms in a community
sample. Am J Psychiatry 1989;146:871-5.
31. Bandim JM, Roazzi A, Doménech E. Rendimento escolar em
crianças com sintomas depressivos. J Bras Psiquiatria 1998;
47(7):353-60.
32. Bahls S-C. Medicamentos Antidepressivos e Insônia. Revista
Temas: Teoria e Prática do Psiquiatra 2001;31 [in press].
Jornal de Pediatria - Vol. 78, Nº5, 2002 365
33. Baron P, Campbell TL. Gender differences in the expression of
depressive symptoms in middle adolescents: an extension of
early findings. Adolescence 1993;28(112):903-11.
34. Lewinsohn PM, Rohde P, Seeley JR, Klein DN, Gotlib IH.
Natural course of adolescent major depressive disorder in a
community sample: predictors of recurrence in young adults. Am
J Psychiatry 2000;157(10):1584-91.
35. Garrison CZ, Jackson KL, Marsteller F, McKeown R, Addy C.
A longitudinal study of depressive symptomatology in young
adolescents. J Am Acad Child Adolesc Psychiatry 1990;
29(4):581-5.
36. Abou-Nazel MW, Fahmy SI, Younis IA, El-Din AGS, Fatah
MA, Mokhtar S, et al. A Study of Depression among Alexandria
Preparatory School Adolescents. J Egypt Public Health Assoc
1991;66(5-6):649-74.
37. Nunes SOV, Dario J, Paulucci I. Avaliação familiar de distúrbios
mentais em depressões infanto-juvenis. J Bras Psiquiatria 1992;
41(8):411-5.
38. Patten CA, Gillin JC, Farkas AJ, Gilpin EA, Berry CC, Pierce JP.
Depressive Symptoms in California Adolescents: Family Structure
and Parental Support. J Adolesc Health 1997;20:271-8.
39. Kovacs M, Feinberg TL, Crouse-Novak MA, Paulauskas SL,
Finkelstein R. Depressive disorders in childhood: I. A longitudinal
prospective study of characteristics and recovery. Arch Gen
Psychiatry 1984;41:229-37.
40. Rohde P, Lewinsohn PM, Seeley JR. Are adolescents changed by
an episode of major depression? J Am Acad Child Adolesc
Psychiatry 1994;33(9):1289-98.
41. Weissman MM, Wolk S, Goldstein RB, Moreau D, Adams P,
Greenwald S, et al. Adolescentes deprimidos: como ficam quando
adultos. Jama Brasil 1999;3(9):2429-35.
42. Harrington R, Bredenkamp D, Groothues C, Rutter M, Fudge H,
Pickles A. Adult Outcomes of Childhood and Adolescent
Depression. III Links with Suicidal Behaviors. J Child Psychol
Psychiatry 1994;35(7):1309-19.
43. Martin A, Cohen DJ. Adolescent Depression: Window of
(Missed?) Opportunity. Editorial. Am J Psychiatry 2000;157(10):
1549-51.
44. Kashani JH, Carlson GA, Beck NC, Hoeper EW, Corcoran CM,
McAllister JA, et al. Depression, depressive symptoms, and
depressed mood among a community sample of adolescents. Am
J Psychiatry 1987;144:931-4.
45. Garrison CZ, Waller JL, Cuffe SP, McKeown RE, Addy CL,
Jackson KL. Major Depressive Disorder and Dysthymia in
Young Adolescents. Am J Epidemiol 1992;135(7):792-802.
46. Gunnell DJ. The epidemiology of suicide. International Review
of Psychiatry 2000;12(1):21-6.
47. Hurry J. Deliberate self-harm in children and adolescents.
International Review of Psychiatry 2000;12(1):31-6.
48. Feijó RB, Salazar CC, Bozko MP, Bozko MP, Candiago RH,
Ávila S, et al. O adolescente com tentativa de suicídio:
características de uma amostra de 13 a 20 anos atendida em
emergência médica. J Bras Psiquiatria 1996;45(11):657-64.
49. Lamb J, Pusker KR School-based Adolescent Mental Health
Project Survey of Depression, Suicidal Ideation, and Anger. J
Child Adolesc Psychiatr Ment Health Nurs. 1991;4(3):101-4.
50. Miranda PSC, Queiroz EA. Pensamento suicida e tentativa de
suicídio entre estudantes de medicina. Rev ABP-APAL 1991;
13(4):157-60.
51. Feijó RB, Raupp APG, John AB. Eventos estressores de vida e
sua relação com tentativas de suicídio em adolescentes. J Bras
Psiquiatria 1999;48(4):151-57.
366 Jornal de Pediatria - Vol. 78, Nº5, 2002
52. Lippi JRS, Pereira IM, Soares KVS, Camargos Jr. W. Suicídio na
infância e adolescência. J Bras Psiquiatria 1990;39(4):167-74.
53. Pfeffer CR. Relationship Between Depression and Suicidal
Behavior. In: Shafii M, Shafii SL, editores. Clinical Guide to
Depression in Children and Adolescents. Washington: American
Psychiatric Press; 1992.p.115-26.
54. Culp AM, Clyman MM, Culp RE. Adolescent depressed mood,
reports of suicide attempts, and asking for help. Adolescence
1995;30(120):827-37.
Depression in childhood and adolescence: clinical features - Bahls S-C
Corresponding author:
Dr. Saint-Clair Bahls
Rua Carneiro Lobo, 570 - conj. 1403 - Batel
CEP 80240-240 – Curitiba, PR, Brazil
Tel./Fax: +55 41 242.6132
E-mail: [email protected]