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From: MHM Journal - Volume 6, Issue1

The first thing I was told in my paediatrics rotation at medical school was that “you need to remember children are not small adults.” In many ways this is a very accurate statement. In children, the physiological responses to illness and injury are indeed often quite different from those of adults. Children also have far fewer reserves available and as a result, they can’t compensate nearly as well as adults can. Whilst it’s important to bear in mind the physical differences between children and adults, it’s also important to remember that although children are not small adults, they most definitely are little people. What I mean by this is that whilst they exhibit physical and psychological differences, they also experience many of the positive and negative emotions that any adult does. The biggest issue when dealing with ‘feelings’ in children, is that very often, they’re not equipped to deal with them. Frequently they exhibit their struggles in a manner which is difficult for adults to understand. Children lack the vocabulary of adults and therefore can have serious problems with verbalising what their feeling.

OUR CASE STUDY

Juan (not his real name) is a six-year-old boy. He started grade 1 at the beginning of 2018 at a local private school. He is an only child.

JUAN’S BACKGROUND

Juan’s parents have been experiencing difficulties in their marriage recently. His mother previously suffered from anxiety and depression for which she has received treatment.

JUAN’S DIFFICULTIES

Juan has always been quite a serious little boy. He is a helpful child who’s generally not disobedient or easily irritated.

On his first day of grade 1, the other kids in his class made fun of his name, which they said, “sounded funny!” They have decided to call him John which he doesn’t like very much but he is too scared to say anything.

At the end of Juan’s first term in grade 1, his parents attended a parent- teacher conference, where Juan’s teacher informed them of the following:•

  • Juan was initially a very quiet, helpful boy who did well with his school work.
  • Over the last few weeks, the teacher noticed he tends to isolate himself from his class mates.
  • He gets irritated quickly and has been involved in a few physical altercations with other children.
  • His school work is messy and he frequently doesn’t complete his school tasks. He ‘daydreams’ in class and must constantly be reminded to continue with his work.
  • He often appears tired and disinterested in what is happening around him.

Juan’s mother noticed that over the same time-span, he’s been very withdrawn at home. He has become very picky with his food and refuses to brush his teeth, bath or comb his hair unless nagged to do so. He tends to be very sensitive to perceived criticism.

DIAGNOSIS

From the information provided, we can see there are several features in this case which are concerning and causing a negative impact on Juan’s ability to function in academic, social and home environments. The DSM 5 provides full diagnostic criteria for the diagnosis of a major depressive episode. Some important features to watch out for in children would include:

  1. Family history of depression
  2. A persistently low or irritable mood
  3. Diminished interest in activities, particularly those which they previously enjoyed
  4. Changes in appetite or weight
  5. Appearing tired and lethargic
  6. Changes in sleeping patterns
  7. Difficulties with focus and concentration
  8. Decrease in self-care
  9. Talking about death or suicide

HOW CAN CHILDHOOD DEPRESSION BE MANAGED?

Childhood depression is very serious and can potentially lead to negative outcomes and multiple physical and psychological comorbidities. As such, the evaluation and referral of children with suspected depression is paramount.It’s important to ascertain that the child is safe, contained and doesn’t pose a threat to themselves or others.A thorough history and physical examination are essential. This includes interviews with both parents and the child.Bear in mind that children may not be able to verbalise what they’re experiencing. Somatic symptoms such as headaches, stomach-aches and other body pains should be taken seriously. A medical cause for these symptoms should ideally be excluded.

MEDICAL TREATMENTS:

The judicious use of SSRI’s in combination with psychological therapies is supported by the NICE guidelines CG28.The administration of these medications should be commenced at low doses, titrated slowly to effect and should be monitored against the emergence of side effects.Careful psychoeducation should be undertaken as regards the increased risk of suicidality in children, adolescents and young adults. They should initially be monitored weekly until improvement is seen or appropriate referral is warranted. A treatment time of at least 4-6 weeks in combination with psychotherapy is recommended to assess response to treatment. If no response is noted, then referral to a specialist is suggested.The use of Benzodiazepines is not indicated in the management of depression in children and adolescents.

PSYCHOLOGICAL MANAGEMENT

The use of medications such as SSRI’s are only indicated if used in conjunction with psychotherapy.Psychotherapy in the context of children and adolescents can include:

  • Individual psychotherapy
  • Parent counselling
  • Family therapy
  • Group therapy

Different approaches are used by different therapists, although there are controversies which exist regarding the various types of therapies.It may also be appropriate to consider an educational psychology assessment, occupational therapy and many other allied approaches as part of an overall management strategy.

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