Until relatively recently, depression in children and adolescents was considered so unlikely that there were no established diagnostic criteria in place in any formal classification system. Historically, children were thought to be unable to experience true depression, a disorder thought to be related to psychodynamics only associated with adult psychosocial development. Consequently, long-term studies about children’s depression and response to clinical interventions are virtually nonexistent. Treatments for children largely parallel established treatments for adults, with some modifications to make them more age appropriate.

Currently, depression in children and adolescents continues to be a highly controversial topic for a number of reasons: (a) recent government warnings about the use of antidepressants in young people possibly increasing their suicidal ideation and behavior (U.S. Food and Drug Administration, 2004), (b) questions about the efficacy of antidepressant medications in young people, (c) epidemiological evidence that depression is growing rapidly in prevalence in children and adolescents, and (d) the recognition that depression in children or adolescents serves as a major risk factor for adult depression as well as the onset of other comorbid conditions, especially anxiety disorders, in both adolescence and adulthood (Garber, Kriss, Koch, & Lindholm, 1988; Harrington, Fudge, Rutter, Pickles, & Hill, 1990; Kandel & Davies, 1986; Wolraich, 1996). Accordingly, making the diagnosis of depression in children and adolescents is vitally important in order to increase the chances for more affected children to get help.

In this post we explore the phenomenon of child and adolescent depression primarily from the standpoint of clinical intervention. Specifically, we consider ways in which hypnosis may be applied in treatment to teach specific skills, help reduce depressive symptoms, and encourage young people to apply these skills in the service of self-help.

DIAGNOSIS AND EPIDEMIOLOGY OF CHILDHOOD DEPRESSION

In the Diagnostic and Statistical Manual for Primary Care (DSM-PC), childhood depression is described in the following way.

Sadness, irritability, or a loss of interest in normally pleasurable activities is a common and normal response to disappointment, failure, or loss. Such mood changes only represent a problem if they persist more than a few days and if they represent intense distress or significantly impair the child’s ability to function or relate to others at home, school or play. … Children and adolescents may not present with sadness, but may report aches and pains, low energy, or moods such as apathy, irritability or even anxiety. (Wolraich, 1996, p. 153)

Depression is distinguished from bereavement, defined in the DSM-PC in the following way.

Bereavement is an intense grief response after a major loss (e.g. death of parent) and is usually a normal reaction involving mood and sleep or appetite changes. When bereavement symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness or suicidal ideation, major depressive disorder can be diagnosed. (p.153)

In the case of either depression or bereavement in which the symptoms may be similar, the child may require intervention.

The signs and symptoms most commonly associated with depression include sadness, apathy, loss of pleasure (anhedonia), agitation, sleep disturbance, appetite changes, decreased energy and fatigue, decreased concentration, low self-esteem, crying, social withdrawal, and irritability.

There is no one single characteristic that defines depression, nor is there one single cause. There are many risk factors, some biological, some social, and some psychological, that can influence the onset and course of depressive episodes. Risk factors for childhood depression include depressed parents, strong family history of depression, early onset of a diagnosable anxiety disorder, alcoholism, family and marital discord, substance abuse, early childhood losses, poor coping skills, lack of social support, uncertainty about sexual orientation, and a history of previous depressive episodes (Wolraich, 1996).

Depression is 1.5 to 3 times more common among first-degree biological relatives of persons with major depressive disorder than in the general population.

Depression is thought to occur in approximately 2% of children and 4 to 8% of adolescents (American Academy of Child and Adolescent Psychiatry, 1998), and major depressive disorder (MDD) appears to be twice as prevalent in adolescent girls as in adolescent boys (Emslie, Weinberg, Rush, Adams, & Rintelmann, 1990). Thus, the prevalence of MDD in children and adolescents is estimated to range from 2 to 8% (Birmaher et al., 1996a, 1996b). Based on a figure of approximately 38 million Americans currently between the ages of 6 and 15 years, 2 to 8% represents between three quarters of a million and 3.04 million young people who may meet the formal criteria for the diagnosis of MDD.

We could not find any prevalence data for other forms of depressed mood/sadness in children and teenagers that we believe to be far more common than MDD. When we consider the additional diagnostic categories into which children with sadness and depressed mood problems fall (see below), we believe it is conservative to estimate that there are likely anywhere from 7 to 10 million children with significant symptoms of depression and depressed mood.

In one telling study, Garland et al. (2001) employed the Diagnostic Interview Schedule for Children (Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000), which they administered to 1,618 randomly selected youth ages 6 to 18 years. These children and adolescents were active in at least one of these five public sectors of care: alcohol and drug services, child welfare, juvenile justice, mental health, and public school services for youths with serious emotional disturbances (in San Diego, California). Major depression was identified in 8.9%, 4.7%, 4.7%, 5.7%, and 7.9% of children in these groups, respectively, or overall in 5.1% of respondents. Not surprisingly, the less severe (but more chronic) diagnosis of dysthymia was identified in only 0.5% of respondents.

One might reasonably predict that the severity of dysthymia would preclude either an identification of an affected child or an involvement in services provided in any of these sectors, suggesting an underdiagnosis. Furthermore, missing from these kinds of data, further suggesting an underdiagnosis, are all those children with other forms of depression and depressed mood (discussed further below), as well as all categories of individuals who may have contact in other sectors (e.g., private or other community medical/mental health care) and those who have gone unidentified and untreated. Particularly when we understand the accelerating prevalence of problems that children encounter that may best be characterized diagnostically as an adjustment disorder with depressed mood, it is not unreasonable to consider that, as with the adult population, sadness and depression in children and youth are of large and still growing proportions.

ASSESSING CHILDREN’S DEPRESSION

Like most, if not all, of what we do in clinical health care, the clinical diagnosis of depression should begin with an understanding of what signs and symptoms (including parental concerns or “complaints”) should lead one to consider the possibility of depression as either a primary or secondary cause of the presenting concerns. For children and youth, this requires a recognition that while so-called classical signs of depression in adults may appear in children (making diagnosis easier), the “typical” vegetative signs of low energy, hypersomnolence, and sad mood are less likely to be evident in children and more likely in adolescents (Wolraich, 1996). Instead, virtually any—especially “new”—behavior or behavioral concern may be a sign or symptom of an as-yet-unidentified or undiagnosed depression. These will vary according to age.

In school-aged children ages 6 to 12, recurrent and/or persistent somatic complaints, such as chronic or recurrent headaches or recurrent abdominal pain, may be the first indication that the clinician should begin to consider and inquire about depressed mood and related feelings. Clinicians must trust their own clinical judgment and intuition when first noticing and then thinking about kids being sad. This means being confident, comfortable, and willing to make time to ask them directly to talk about sad feelings, as well as to consider the use of various formal screening tools and/or inventories to support or confirm one’s clinical perspectives. These include the Child Depression Inventory (CDI; Kovacs, 1985), the Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996), the Achenbach Child Behavioral Checklist—parent (CBCL) and the Achenbach Youth Self Report (YSR; Achenbach, 1991), and the Pediatric Symptom Checklist (Jellinek et al., 1988). We utilize these assessment instruments as adjuncts to clinical evaluation, specifically to facilitate the evolution of our therapeutic communication and alliance, and not solely as “diagnostic instruments.” They are regarded as clinically reliable only if they confirm the clinical suspicion or further inform the clinical impression of depression. They may be particularly helpful diagnostically if the child’s presentation, at first glance, doesn’t seem like depression, yet on deeper consideration makes a clinician think depression might be there, such as when the patient presents with anxiety or “hyperactivity” (e.g., impulsivity and inattention).

If the CDI or other inventories reflect a “normal” result, then the patient may indeed not be depressed, or the patient is depressed but coping well enough to not “look” depressed, or he or she has figured out how to deceptively appear to “look okay” on the inventory. In our opinion, therefore, one should never rely only on such inventories to arrive at a diagnosis of depression. If one clinically suspects significant depression but an inventory does not support the “official diagnosis,” one should nonetheless proceed to provide appropriate supportive and therapeutic intervention (Birmaher, Brent & Benson, 1998).

In an analogous way, changes in mood—for example, sad mood—must be understood and responded to with an appreciation of the child’s history and environment, and especially from the perspectives of frequency and interference with ability to function. Thus, we are not invested in the “requirement” of a precise label of a diagnostic category of “depression” or “depressed mood,” particularly if numbers of symptoms don’t fit published categories or scores on inventories don’t add up to a diagnosis. If a child’s distress from persistent sad mood (i.e., beyond a few days) interferes with normal function (e.g., not going to school or participating in sports or clubs), then the child deserves assistance toward relief of suffering and may well appropriately benefit from our intervention. As such, the discussion that follows regarding approaching depression with hypnosis applies equally well to those others suffering from their sadness.

EMPLOYING HYPNOSIS IN CLINICAL INTERVENTIONS

Research to support the use of hypnosis and self-hypnosis in the treatment of depression is lacking in general, and relevant research in children and adolescents is practically absent. We searched both the Medline and PsychInfo databases for depression and hypnosis. Our search revealed studies primarily directed at the treatment of another illness with changes in mood reported only as a secondary outcome, if at all.

One such study was conducted in the United Kingdom and involved 200 subjects with irritable bowel syndrome (Gonsalkorale, Miller, Afzal, & Whorwell, 2003). Based on survey results one year following “gut-directed hypnotherapy,” the subjects reported an improvement in depression scores. Interestingly, this finding was not linked to their level of improvement in irritable bowel symptoms. This suggests that the role of hypnosis in the improvement of depression is not simply secondary to an improvement in symptoms of the targeted illness.

One study we found specifically related to children used hypnosis and acupuncture in the treatment of chronic pain (Zeltzer et al., 2002). Of the 23 children enrolled in the study, none met criteria for depression prior to treatment, and this remained unchanged at follow-up. Certainly, the dearth of research suggests a need for prospective trials of hypnosis and self-hypnosis in the treatment of depression, especially in children and adolescents.

Despite the lack of research on the clinical applications of hypnosis in treating depressed children, the literature of hypnosis in general and hypnotic theory in particular may provide some valuable insights regarding the development of depression. In a theoretical article, Kaffman (1981) discussed the presence of “monoideism” in depression and the hypnotic influence of repetitive negative thoughts. In keeping with the important naturalistic concept of “finding the hypnosis in the encounter” (Sugarman, 1997), the initial therapeutic goal may be to elevate awareness of these “unconscious scripts” (i.e., beliefs and attitudes), examine their inaccuracies, and offer alternative therapeutic suggestions. This is a key aspect of cognitive-behavioral therapy, empirically a well-supported means of intervention for depression (Brent et al., 1997; Reinecke, Ryan, & DuBois, 1998). How hypnosis may be integrated with cognitive-behavioral therapies for depression has been addressed at length by Yapko (1992, 2001).

From a hypnotic perspective, and in practical consideration of helping young people to manage sad feelings, it is probably not as important or necessary to discern the precise diagnostic category of their depression as it is to honor and assure the patients’ awareness of depressed feelings and/or awareness of the manifestations of their depression (e.g., anxiety, somatic complaints, or “acting out”). Addressing children’s understanding and formulation of the reasons they are feeling that way (i.e., their attributions about its meaning), discussing their expectations and motivations for “getting well again,” and, most importantly, assessing if they have the energy and other resources to do the emotional and hypnotic work necessary to feel better are all vital parts of the early phase of treatment. They all influence the clinical response to treatment in general and thus may serve as possible targets for the hypnotic intervention. They are particularly important in helping the clinician to decide whether, if, and when the patient might also be treated with medication to facilitate sufficient functionality to be able to work clinically. We believe the same kind of thinking is applicable whether the medication being considered is an antidepressant, anxiolytic, and/or analgesic.