INTRODUCTION:
The status of “depression in children” is, to say the least, curious. On the one hand, this question has been placed at the center of developmental, psychodynamic and psychopathological reflection since the early work of child psychoanalysts (M Klein, DW Winnicott …). On the other hand, the clinical reality of depression in children seems to have to be constantly reaffirmed as if its existence was not self-evident.
Is it possible to not treat “depression” in an adult psychiatry book?
Conversely, is it conceivable not to treat the question “psychosis” in a book of child psychiatry under the pretext that this question is also treated in adults? Finally, the “anaclitic depression” described by Spitz as early as 1946 in infants has not only been recognized, but has even served as an “experimental” model for some theoretical conceptions of adult depression (Widlöcher 1983).
However, the semiology and the circumstances of the occurrence of this “anaclitic depression” are so precise and particular that they may have prevented the differentiation (clinical and psychopathological) between deficiency and depression. Thus one could easily refer back to Klein’s “depressive position” and Spitz’s “anaclitic depression”: one is a theoretical model and the other a clinical state that lie at the two extremes of the depressive problem of Child, and which have served as a screen, in both senses of this term: projection screen, apt to receive the constructions of the theorists of childhood, but also screen masking in the eyes of the clinicians the depressive illness of which can suffer a child.
As early as 1971, at the Stockholm congress (congress of the European Union of Child Psychiatrists), figures on child depression appear to reinforce the weight of preliminary, descriptive or psychopathological studies.
From this date, if the clinical reality of depression is accepted in children, on the other hand, its semiology continues to be the subject of many debates centered on two questions: is this semiology specific to the child? Is depressive expression stable over the ages (both in different subjects and in the same subject)?
The International Diagnostic Classifications (ICD10) and the American Diagnostic Classifications (DSM IV) adopt this last point of view even if they recognize some peculiarities. The French classification (CFTMEA) retains the idea of a specificity. In reality, there seems to be a relative consensus on the semiology of the depressive episode proper, while questions remain about the semiology of “depressive illness”, “dysthymic disease”, “bipolar disease” and A fortiori of the “double depression” (association major depressive episode + dysthymia according to the criteria DSM IV) which begins to be described in children. In other words, this opposition leads one to wonder about the place that a possible depressive state lasting in the course of the development and the maturation of a child, and on the strategies of fighting against this depression through the mechanisms of defense . It is in this perspective that, from a strictly descriptive point of view, we have witnessed a multiplication and accumulation of symptoms as possible witnesses of a depressive illness: almost all the semiology of the child has thus The authors suggesting lists of particularly long symptoms. The problem of symptomatic specificity reappears today through the question of comorbidity, which is particularly important and heterogeneous. However, the clinical reality shows the relevance of some syndromic groupings in particular through the description of the major depressive episode as isolated DSM IV. A “translation” of this semiology into the child’s language, its particular expressive mode or the perceptions of the parents and the clinician, however, is necessary for abstract concepts such as “loss of self-esteem”, “anhedonia” “Self-depreciation”, take on a true clinical significance. This is at least the position taken by the recent consensus conference on depressive disorders in children.
SEMIOLOGICAL EXPRESSION OF DEPRESSION:
Depressive episode of the child:
Happily occurring after an event of loss or bereavement (separation of parents, death of a grandparent, sibling or parent) sometimes an event which, in the eyes of adults , To appear more innocuous (move, death of a familiar domestic animal, removal of a comrade …), this depressive episode is gradually established but the behavior of the child appears clearly modified compared to the previous situation.
Certainly the psychomotor slowdown and the motor inhibition can be seen, marked by a certain slowness, an aspect almost “small old”, a face not expressive, not very mobile and not very smiling. Sometimes the child is described as wise and even “too wise”, almost indifferent, subject to all that is proposed to him. But most often there is a certain instability or restlessness, especially when the child is asked for certain tasks or moments of attention: “he can not stay in place”, “he moves all the time”, “it is a True pile “,” it gets nervous for nothing “say the parents. These moments of agitation are frequently interspersed with moments of almost collapse or inertia: a child sitting on the sofa in front of the television but appearing “absent”, almost indifferent.
Irritability often takes the form of anger: “one can not tell anything to him”, “he is wicked, angry, nervous” or opposition “he refuses everything”, “he always says no”, ” Never agree “. If the lack of interest often results in the interruption of leisure or cultural activities (“he is not interested in anything”, “he can never be pleased”), it is sometimes directly expressed: “j ‘M’enuie’, ‘I’m sick of it’. Loss of self-esteem translates into words such as “I’m null,” “I’m good for nothing,” almost systematic.
Devaluation is often expressed through the expression of an immediate doubt about a question, a task demanded (drawing, play): “I do not know”, “I can not do it”, “I can not “. Special mention must be made of the expression “my parents do not like me” and to a lesser degree “they do not love me”, “my buddies do not like me” all expressions that express the feeling of loss of And which in general mask a feeling of devaluation and guilt. The conscious expression of the feeling of guilt readily takes the form of “I am bad”, “I am not nice with my parents” but can also express itself directly by “it’s my fault”.
Difficulty thinking, being attentive to work and concentrating often leads to escape, avoidance or refusal of school work, which is often referred to as “laziness” by parents but also by the child himself and leading to failure school. In some cases, the child spends long hours every night on his books and exercise books but is unable to learn and even memorize.
Appetite disorders can be observed, rather anorectic behavior in early childhood (sometimes causing weight stagnation) and bulimia or snacking behavior in the older child or pre-adolescent. Sleep is difficult to find with often opposition to bedtime, refusals that amplify the conflict with parents, can provoke punitive measures and accentuate the irritability of each other. The nightmares are part of the anxious component as well as the frequent fears, especially the fear of accidents in the parents. Belly stomach pain and fairly frequent headaches are at the junction of the anxious problem and the frequently associated depressive problem.
It is not unusual for ideas of death or suicide to be expressed in a letter written to the parents in which the child declares “that he is not loved and that he will die or that he will kill himself “. This letter or admission is often the reason for consultation.
When the depressed child is alone with the consultant, he repeats readily in front of the white sheet “I do not know”, “I can not do it”, “I can not”. The draft of a drawing is often accompanied by negative comments: “it is missed”, “it is not good”, “it is not beautiful”. There is an exacerbated sensitivity to imperfections or broken objects in the use of toys: “it’s broken” … And of course the theme of failure, inability to achieve drawing, task, play undertaken , Is in the foreground.
These findings with the child alone reinforce the interview data with the parents and this confirms the diagnostic probability.
Obviously, each of these signs alone is not necessarily indicative of the depressive episode, but their conjunction (five to six of these symptoms), their permanence in time and the net behavioral change they induce are very characteristic. It is not uncommon for this very typical symptomatic whole to be completely ignored (or denied?) Of the entourage, the parents themselves, and that the child thus remains whole semesters in this state of depressive suffering.
This lack of knowledge is serious because, in addition to the persistent suffering of the child, the symptoms can lead to a gradual maladjustment, especially in school, confirming in a second time the devaluation of the child (“j’suis nul”, “j’suis Good for nothing “,” I can not do it “) and often accentuating the lack of understanding between parent and child. In addition, these symptoms are often complicated by superimposed manifestations, such as anxious manifestations, exacerbated behavioral disturbances, behavioral or oppositional behavior. These manifestations can gradually place the child in the “depressive illness” which often resembles a redevelopment in the form of denial of depression.
Depressive illness: expression of depressive suffering or defense against the depressed position (denial of depression)?
In addition to the depressive episode, some children have a poorer or fuzzy symptomatology, but are more durable because they are often ignored or denied, primarily by parents. The manifestations of restlessness, instability, and irritability may gradually take the front of the scene, leading to paintings of a characteristic or behavioral character. This explains the very frequent “comorbidity” as described in the Anglo-Saxon literature. Thus, Angold and Costello perform a meta-analysis of epidemiological publications on child depression and on the frequency of comorbidity, ranging from 21 to 83% for conduct disorders and opposition, from 30 to 75 % For anxiety disorders and 0 to 57% for attention deficit disorder. The authors nevertheless conclude their article by this remark: “the mechanisms by which comorbidity appears remain, to this day, obscure!”
The main “complication” of the lasting depression lies in the impact of schooling. School failure and, to a lesser extent, school disinterest or disinvestment are very frequent: a long series of failures that contrast with a good level of efficiency, or more characteristically a sharp drop in academic achievement. Phobic behavior, particularly school phobia, may reflect the fear of being away from home or abandoning and covering a depressive state.
At the level of the body or the physical appearance, there is sometimes a permanent demeanor, a clochard aspect, as if the child was unable to invest positively his body and appearance. Very close are the children who constantly lose their personal belongings (clothes, keys, toys).
At the most, certain behaviors appear as direct witnesses of a feeling of guilt or a need for punishment, the at least temporal link of which with a depressive episode is evident: repeated wounds, dangerous attitudes, incessant punishments at school, etc. The appearance or reappearance of directly self-aggressive behavior is also possible.
We shall mention, without developing them, the suicide attempts of the child, and especially of the adolescent, emphasizing, however, that we must not establish too direct an equivalence between depression and attempted suicide.
In addition some symptoms can be analyzed as a defense against the “depressive position”. They are very diverse in nature. In reality, it is either the psychopathological evaluation during the clinical interview or by the projective tests or the psychogenetic reconstruction which make it possible to link them to the “depressive nucleus”.
The attitude of empathic understanding takes precedence over semiotic decryption. However, the risk of abuse of language can be highlighted. Some behaviors seem to be directly in the register of what Mr. Klein calls manic defenses as if to deny or defeat any depressive affect. One can cite here the extreme turbulence which can become a real instability, either motor or psychic with a logorrhea directly evoking the maniacal flight of ideas. These states raise the question of the existence of bipolar disease in children. Other behaviors appear as conducts of protest or protest against the state of suffering. Let us quote: conduct of opposition, sulkiness, anger or even rage; Aggressive manifestations (clastic crises, violence with other children) and even self-aggression; Behavioral problems, theft, runaway, delinquent conduct, drug abuse behavior.
In all, if the semiology of the depressive episode is fairly easy to detect, the same is not true of long-term depression, the diagnostic criteria of the most used classifications, in particular DSM IV, do not solve this difficulty . In 1992, a paper by Papazian et al showed the complexity of the concept of depression in children by comparing the results of a triple approach: free clinical interview, Poznanski scale DSM III. These authors isolated two types of depression, one included in a neurotic type personality structure and the other associated with personality disorders. The first often related to the loss of “a loved one or a domestic animal” typically appears as a “depressive episode”. Symptoms of sadness, fear of losing a parent, stomach or headache, fear of failure and feeling of being nil, being a burden on parents, sleeping problems dominate The clinical picture. On the other hand, children with personality disorders suffered from “a more lasting, dramatic history” and semiology was dominated by aggression, a sense of injustice, Not being loved, agitated, difficulty falling asleep. The concordance between clinical evaluation, CDRS-R and DSM III evaluation was low, perhaps even more with the DSM III criteria. This concordance was even less when it came to depressive states with personality disorders.
It is likely that the conclusions would be identical with the DSM IV criteria.
DIFFERENTIAL DIAGNOSIS:
“Depression” in children is more often undervalued than diagnosed by excess.
The first step is to integrate this diagnostic possibility into the “syndromic” hypotheses of the clinician. The diagnosis of depression, a fortiori of depressive episode, does not prejudge the underlying structural organization.
However, in the young child (before 5-6 years), a differential diagnosis must be evoked: the existence of pain, especially chronic pain. The clinical picture of the painful child has many similarities with that of depression. In addition, chronic pain and depressive reaction may associate with the same child. It is therefore necessary to envisage such a possibility, especially if the clinical situation of the child is suggestive of such a context.
When a painful condition is detected, it must be treated beforehand.
FREQUENCY EPIDEMIOLOGICAL:
Epidemiological surveys have recently increased to assess the frequency of child depression. All these surveys use either standardized interviews (in a categorical perspective: DISC and DISC-R, DICA, KSADS …) or evaluation scales (constructed from a dimensional perspective that quantifies and gives thresholds: CDI, CES -DC, DSRS, etc.) or refer to the classification criteria, in particular DSM IV. Of course, the frequency of depression in children in the general population (prevalence) depends on the definition and the assessment tool used.
Flemming et al. (1989) in children aged 6 to 11 years, respectively, estimate the incidence at 0.6% with high certainty (high scores on scales and interviews), 2.7% With average certainty, and 17% with poor diagnostic certainty.
However, the most recent studies (Mouren-Simeoni, Depressions in Children and Adolescents, Facts and Issues, Paris, ESP, 1997) using rigorous criteria all estimate this prevalence (major depressive episode) between 0.5 And 2-3% of the population (When the child is the informant himself, this prevalence is slightly higher than that observed when the parents are the informants.
In the clinical population (consultant and hospitalized children), the frequency is higher, reaching 20-25% of the population, often higher for boys than for girls (boys 39%, girls 18%: children 9-12 years ).
The prevalence in the general population is therefore significantly lower than in the adolescent (depressive prevalence of 3 to 7% for the major depressive episode in most surveys).
BECOMING ADOLESCENT AND ADULT:
The epidemiological data accumulate, which shows a significant evolutionary risk.
First of all, these manifestations are lasting: the depressive episode lasts on average 9 months, while the dysthymic state lasts for almost 4 years in a study by Kovacs et al (1977) on 112 depressed children aged 8 to 13 years . The pattern of recurrence is also high (47% recidivism at 1 year, 70% at 2 years on a population of 70 children and adolescents hospitalized for major depressive disorder followed for 1 to 5 years). The persistence of the disorders is a function of their age at diagnosis (the older the disorder, the longer the episode is) and the existence of “comorbidity” (in particular obsessive-compulsive disorder, opposition).
On the other hand, the risk of suicide can be reported (this risk would be eleven times higher in children with depressive disorder compared to children with a different type of mental disorder and onset of conduct disorders, Drug addictions are generally associated with pre-adolescence (11-13 years) and especially adolescence.
Depressive risk in adolescence and adulthood is more difficult to assess. A few catamnestic studies over many years have described the evolution of some cases. Penot on 17 children between the ages of 5 and 11 showed not only the diversity of the psychopathological structures underlying the depressive state but, in the case of persistence of this state, “the remarkably constant tendency to structure itself in a characteristic or psychopathic mode “. These clinical findings are already corroborated by the current epidemiological studies which show the frequent comorbidity associated or appearing (see above). Chess et al also followed, over a period of 18 to 22 years, six subjects who presented a depressive episode in childhood.
In the cases observed, the continuity between a childhood disorder and a depressive disorder of adolescence is evident especially for two of them who, as children, had presented major depressive episodes repeatedly.
The most recent epidemiological surveys are not always easy to interpret as the fate of depression in children is often confused with depression in adolescents. If the correlation between adolescent and adult depressive disorders seems to be strong enough, the correlation seems more debatable when considering only the prepubertal child. Thus the study by Harrington et al provides interesting information on the continuity of depression in adulthood. While depression in children and adolescents generally increases the risk of depression in adulthood, the correlation between major depressive episode in adulthood and depressive antecedent in childhood is much greater Strong when the depressive episode appeared after puberty. Only one out of five pre-pubertal children will have a major depressive episode (20%), whereas after puberty, eight out of thirteen post-pubic depressed children will develop a major depressive episode in adulthood (proportion: 60 %).
The same authors (Harrington et al., 1991) analyze the 18-year follow-up of a cohort of depressed children and adolescents (63 cases) compared to a matched control group (68 cases); 21% had behavioral problems associated with depressive syndrome. Children “depressed with behavioral disorders” had an evolution in adulthood characterized by a high risk of antisocial and delinquent behaviors and a lower risk of depressive development. On the other hand, the group of children “depressed without conduct disorders” presented a slightly higher risk of developing depression in adulthood.
From the same 18-year follow-up (60 depressed children and adolescents, 67 matched control children and adolescents), Harrington et al (1994) also studied the risk of a suicide attempt: 32% (19/60) Of depressed children and adolescents made at least one attempt at suicide, and 20% (12/60) made several attempts.
There are two suicide deaths in this population. In the so-called controls, 12% (8/67) attempted suicide with suicide.
Having attempted suicide in childhood or adolescence significantly increases the likelihood of a suicide attempt in adulthood, but this probability is more related to the existence of behavioral disorders Associated with the depression itself.
Finally, the problem of depressive continuity throughout the ages is fundamental. Indeed, subjects depressed in adulthood (20 cases on the whole cohort: 60 + 67) have a suicidal risk all the greater because they have already suffered from depression in childhood or childhood, Adolescence: of these 20 cases, 16 were in the depressed cohort and 13 had attempted suicide (13/16: 81%); Four were in the undepressed cohort, one made a suicide attempt (1/4: 25%). On the other hand, for people not depressed in adulthood (107/127), the risk of attempted suicide is no different from whether there was an infant or juvenile depression.
This indirectly demonstrates the importance of identifying and, if possible, treating depression of a child or adolescent, and not allowing them to settle into a lasting depressive illness (dysthymia).
However, in the last two studies of Harrington the cases of prepubertal children and those of adolescents are not distinguished.
In conclusion, if the continuity of a psychic suffering is evident from the depressed child to the adult, the depressive continuity properly so-called remains to be affirmed by more rigorous studies.
LIFE EVENTS AND FAMILY ENVIRONMENT:
It seems preferable to speak here of a context favoring rather than evoking a specific etiology. Indeed, the risk, already indicated, is to relate in a linear causality the events observed and the present behavior of the child. This attitude leads, for example, to baptize “depression” any manifestation secondary to a loss, the clinical symptomatology and the supposed cause forming a sort of globalizing, reductive … and sometimes false explanation.
However, some contexts, some traumatic circumstances, are found with great frequency in the histories of children who present the semiology described above. Among these factors we will isolate the loss situation and then the family context.
Existence of loss or separation:
It is very common if not constant in the history of children depressed or depressed. The loss can be real and have lasting effects: death of one or more parents, a sibling, an adult close to the child (grandparent, nanny …), brutal and complete separation By the disappearance of one of the relatives (parental separation, departure of a brother …) or by remoteness of the child himself (hospitalization, nursing placement or institutional unprepared …).
The event is all the more traumatic as the child has a critical age (6 months to 4-5 years) and no permanent marker persists (change of frame, disappearance of siblings).
The separation may be temporary (illness, brief hospitalization, momentary absence from one of the parents), but it creates an anguish of abandonment that persists well beyond the normal situation. It is sometimes purely fantasmatic: a feeling of no longer being loved, of having lost the possibility of contact with a loved one. The loss can only be “interactive”: a parent who is no longer available psychically, monopolized by a conjugal conflict or a bereavement for example. Note that for the child, especially if he is young, the loss of a loved one, in particular a member of the siblings, is often redoubled by the “interactive loss” of the parent (s) who are themselves immersed In a mourning work or a real depressive state. These factors should be reconciled with the family context usually described.
However, the “loss” is sometimes more banal in appearance, at least for the adult.
The death of a domestic animal (especially the animal that was present at home since the birth of the child), a move, the loss or removal of a comrade.
Family environment:
Of the studies on the family environment, several points stand out regularly.
The frequency of a history of depression or associated pathology (alcoholism in parents, especially in the mother). Two mechanisms have been proposed to explain this frequency: a mechanism of identification with the depressed parent; A feeling that the mother is both inaccessible and unavailable and that at the same time the child is incapable of comforting, gratifying or satisfying it. The child is thus confronted with a double movement of frustration and guilt. It is conceivable in such a situation that aggressiveness can not find an external target for expression.
The frequency of parental default, especially maternal: poor parent-child contact, little or no emotional, verbal or educational stimulation. A parent is sometimes openly rejecting: devaluation, aggressiveness, hostility or total indifference towards the child, which can go as far as total rejection.
More rarely have other parental components been described, in particular an excessive educational severity which arouses in the child the constitution of a particularly severe and merciless superego.
Certain particular conditions favor the development of this ruthless superego and contribute to the development of a depressive state. Child victims of abuse often have depressive traits or depression. In a population of 56 children from 7 to 12 years of age, J Kaufman notes that 27% of children have a major depressive episode or dysthymia (DSM III-R criteria). Children who are victims of abuse often develop the feeling that if their parents beat them it is because they have done stupid things and are “bad guys”. In short, they feel guilty about the blows they receive.
On the other hand, in the case of the family environment or life events, apart from the harmful role of their cumulation, there does not appear to be any particular correlations between these events, their succession and the evolution of the ” Depressive episode.
PSYCHOPATHOLOGICAL ADVICE:
We can not take up the work of authors such as M Klein (the depressive position) or Winnicott (compassion or solicitude), which touches upon normal development and which concern children who are often younger.
From a psychopathological point of view, it seems necessary to differentiate in a very clear way two types of depression in the child: those that are consecutive to an early and massive deprivation, a deficiency: figures of the vacuum that alter the child ‘ Psychosomatic balance and obey the conditions of maturation and development; Those that are consecutive to absence, loss or secondary lack: the image of the missing object is internalized and it is this representation of the lost object that causes “depressive work”.
There is no psychopathological continuity from one state to another. On the contrary, these two states, which may be called a “figure of the void and the unrepresentable”, the other “the figure of the full of the missing object” seem to function as attractors organizing one and the other, Psychopathological complexes “with different logics.
We shall not dwell on the first, referring the reader to the theories of Spitz and Bowlby and the description of depression, or more precisely, of the affective deficiency in the infant.
Concerning depressive states related to the representation of the loss of the link to the object, the problem is not fundamentally different from what is observed in adults, on the express condition that the child, consciously or unconsciously Can imagine this lack. This indirectly raises the question of language, even if the child uses expressions of his own. That is why we have described these “words of the child”.
A theoretical question arises: the expression of guilt and the place of the superego in the development of the child.
The Kleinian theory situates almost at birth the emergence of the feeling of guilt and of the archaic superego. But Klein proposes more a psychodynamic interpretation than a semiological description: from this point of view, all the manifestations of the psychotic appearance of the young child can be analyzed as the expression of archaic anguish linked to an archaic guilt, The fear of a retaliation from an intransigent and archaic superego.
More traditionally in the Freudian perspective, at the end of the Oedipal period, the internalization of the parental imagos and the organization of the superego open the way to neurotic guilt. The occurrence of a loss in the child’s environment returns the latter to the inevitable ambivalence of his feelings, arouses his guilt and leads to a depressive spiral. This is particularly so, for example, in the case of the death of a member of the sibling group in which the surviving child considers himself guilty, wicked or in the event of a serious illness of a close relative, especially if the disease mobilizes attention and care parents.
At the psychopathological level, there is a gradient ranging from a typical depressive state to more neurotic manifestations in the form of repeated failures or punishments to personality pathologies dominated by cleavage.
Initially, the neurotic dynamics is prevalent but evolution will depend on the recognition or not of the depressive suffering. If the latter is recognized particularly by parents (which does not necessarily imply a request for care), the picture of depression can be organized or even fixed (for example, identification with the figure of a parent, A depressed grandparent). If the depressive suffering is unknown, the progressive organization of the personality may then take place around the denial of affects and emotions with a gradual accumulation of deviant behaviors called comorbidity in the DSM nosography: instability or hyperactivity, Attention, opposition behavior, academic failure, consumption of products, etc. At the nosographic level, this “comorbid” pathology eventually dominated the clinical picture. From a psychodynamic point of view, the development of the personality is organized around the cleavage leading to so-called “boundary” pathologies.
In the totality of this dynamics of guilt, if the Oedipal superego threatens the child with a withdrawal of love and esteem as the “punishment” of an accomplished, thoughtful or fantasized fault, the archaic superego threatens the young child A withdrawal of shoring, a collapse and an implacable reply commanded by the law of the Talion. Under these conditions, anything that feeds fantasies and aggressive fantasies can undergo severe repression especially if an event of reality comes to give them a semblance of confirmation. When the child is under the pressure of his oedipal superego, he will seek to “repair” his real or imaginary fault by the means of sublimation. When the young child undergoes the pressure of the archaic superego, he has no alternative but to increase his persecutory vigilance, to project his aggressive impulses on the outside and to increase his fear of retaliation. We are confronted here with two opposing figures of depression depending on whether or not the “depressive position” has been elaborated. From a structural point of view, this divide separates what would be on one side the “neurotic depressions” and on the other the “depressions” that one might call “prenormal” in the genetic developmental sense, or ” Prepsychotics “in the economic-dynamic sense.
PRESSIVE AND / OR BIPOLAR DISEASE IN CHILDREN AND ORGANIC RESEARCH:
Bipolar disorder:
The debate over the existence of a manic-depressive illness in childhood has been a lot of ink since the first publications of Campbell, then Anthony and Scott. The latter, on the basis of the semiology described by Kraepelin, define ten criteria for the recognition of a manic-depressive psychosis in a child; They do a review of clinical cases published in the literature and find that none of the children before adolescence meets more than seven criteria; Only three cases meet more than five criteria.
The concept of “emotional psychosis” proposed by Harms had certainly opened up the semiological perspective recognizing the possibility of symptomatic expressions specific to the child, but had somewhat confused the nosographic limits. Under the expression of serious babies, Harms described children from three to five years of age, presenting moments of abnormal sadness, without a smile, a little expressive face, seemingly uninterested, with at other moments agitation , Moments of aggressiveness, clowning behavior without apparent cause. These moments follow one another.
It is on the basis of similar clinical cases that, since 1973, Penot proposes a theoretical interpretation in terms of denial of the depressive position with all secondary remodeling in the long term, particularly in a characteristic or psychopathic mode.
The French classification of mental disorders for children and adolescents retains the term “dysthymic psychosis” for these children. Forms that strictly meet the defined criteria are rare among all early psychoses.
In the context of manic-depressive illness, the existence of monopolar and bipolar form has been described in both children and adults. Thus, Tomasson and Kuperman describe the case of a boy who, from the age of seven, presented alternating episodes of withdrawal and episodes of agitation, aggressiveness and “clowning”, Particularly in the classroom. These episodes occurred suddenly. In adolescence, mood reversals, especially under antidepressant therapy, became more frequent, leading to a “mixed state”. The authors note the importance of psychiatric history in the family. The mother and two maternal aunts have a manic-depressive illness; The paternal grandmother had “major affective disorder”, the father of organic personality disorder.
In a depressive episode of the grandchild, Carlson and Strober define the criteria that must evoke a depressive episode in the context of a manic-depressive illness: a rapid onset of symptoms with a clear psychomotor slowdown and a congruent mood of psychotic manifestations; Family history; The reversal of the mood induced by the antidepressant treatment.
Although rare, these cases need attention, on the one hand so as not to confuse them with psychotic disorders, and on the other hand because of the effectiveness of lithium treatment.
However, all authors agree on the frequent and almost permanent “comorbidity” especially with conduct disorders. Moreover, almost all publications include in their study the case of young adolescents (11-13 years), therefore of individuals already engaged in the physiological pubertal process. For all authors, it is obvious that the diagnosis of bipolar disease becomes easier in adolescence.
In a recent review, Carlson questions the “prepubescent mania”. She notes that in the prepubescent child, mood disorders are always associated with conduct disorders, and that the latter rarely take the form of episodic acute attacks; They are generally sustainable.
In reality these purely phenomenological findings want to ignore an analysis of the “symptom” in psychopathological development, especially the symptoms of agitation, opposition, anger or irritability. These behaviors generally reflect discomfort and are most often a response to an interaction, one of the most frequent characteristics of which is to ignore or deny the child’s pain and suffering. One of the symptomatic sets most characteristic of adult mania, the acceleration of the course of thought, logorrhea, play on words, counterpoises and cocks to the donkey, are rarely described in prepubescent children. The author of the present lines has no personal clinical experience of such a case and has only rarely found in the literature a description that can approximate it.
The present situation in which clinical cases of children with “dysthymic disorders and associated conduct disorders” are accumulated to prove the existence of a bipolar disease in the continuity of the child to the adult appears More as a theoretical and dogmatic issue than as a clinical reality.
This short paragraph can be concluded by observing that a manic depressive disease in its monopolar form and even more in its typical bipolar form can be recognized and isolated in children from the age of 6-7 years. However, these forms are very rare; The diagnosis, which is always difficult, requires rigorous criteria, among which the indisputable family history, a long evolutionary follow-up, and the sharp and sudden moments of reversal of mood that are the most important element. The expressions of “affective psychosis” or “dysthymia” with less rigorous diagnostic criteria certainly have the advantage of drawing the attention of the clinician to the predominantly thymic semiology of certain early childhood psychoses, Beyond manic-depressive illness. The long-term evolution of these “dysthymic psychoses” seems to be carried out in a different way, that of a pathology of character or conduct (psychopathies).
Organic research:
Organic, biochemical, neuroendocrine, electroencephalographic and genetic research have multiplied in recent years, largely taking up the hypotheses formulated and the work undertaken in the context of adult depression.
This research gives the child results which are not always consistent with what is observed in adults. This is also true for adolescence.
Thus, Puig-Antioch finds in the child the same modifications as in the adult with regard to the plasma concentration of cortisol during the dexamethasone brake test. Similarly, the response of growth hormone (GH) secretion to insulin-induced hypoglycemia appears to be attenuated in depressed children. In contrast, MR Garcia, J Puig-Antich et al found no difference in thyroid stimulating hormone response to thyrotropin releasing hormone (HRT) stimulation between a group of prepubertal children with major depression And a control group.
The nocturnal secretion of melatonin appears to have a higher peak in major depressed children (8 to 17 years) than in control subjects. This peak elevation is only found in isolated major depressive episodes and is not found when psychotic manifestations are associated with mood disorder. De Bellis, Ryan et al study the nocturnal levels of ACTH (adrenocorticotrophic hormone), cortisol, GH, and prolactin in 38 children with major depression compared to 28 matched control cases. Although plasma ACTH concentrations did not appear to be different in depressed patients compared to controls, in contrast, depressed hospitalized children had significantly lower ACTH levels, whereas they were significantly higher in depressed, non-hospitalized children. Similarly, the peak secretion of cortisol in the first 4 hours of sleep was lower in depressed than in controls, while the mean plasma cortisol concentration over the whole night was not different in the two groups.
The peak of the first 4 hours of sleep and the average plasma concentration of GH are not different in the two groups, but when comparing the depressed girls to the female controls, only the GH peak is lower in the first groups, There is no difference for prolactin.
The authors conclude that factors such as age, sex, and life events with stress (hospitalization) can significantly alter the psychobiological profile of major depressed children and that there are likely to be several subtypes of profiles depending on the age- (Future bipolar or unipolar).
Electroencephalographic recordings, as in adults, are the subject of numerous studies. The results in children are very often different and / or contradictory to those observed in adults. Thus, Emslie et al found on nighttime electroencephalogram (EEG) of children hospitalized with major depressive episodes (DSM Ill-R) similar but not identical to those seen in depressed adults. In particular, there is a decrease in paradoxical sleep latency in depressed children compared to controls. However, compared to the control group, these changes appear to be less significant than observed in adults.
To conclude, it seems to us that this research is still fragmentary and does not allow the development of an organic model that responds to a coherent and explanatory theory of depression in children.
READY TEA:
We will be extremely brief, only identifying the main thrusts of treatment.
Prevention is obviously an essential approach: prevention at the level of the mother-child relationship, avoiding breaks through guidance work, social prevention through adequate staffing, training and awareness of Crèches, pediatric services, institutions, institutional prevention by repeating the harmful role of breaks in nursing placements when they are not indispensable or inevitable, and so on.
In the case of a depressive child, the therapeutic approach may concern the child or his environment, but it is significantly different on the one hand depending on whether one is confronted with depressive episodes of reaction or depressive illness, And on the other hand depending on the ability of parents to accept the idea that their child may be depressed.
Recognition of depression and empathic identification with child suffering:
When it is a depressive episode and all the more so as it appears to be reactionary (to a mourning, a move, a loss or something else …), the simple recognition of this depression can have therapeutic value: the doctor Depression “and the possible suffering of the child, parents are sensitive to it and often find answers themselves in the form of better attention, an understanding of transient behavioral or academic difficulties, and so on. The therapeutic value of this recognition is, in fact, all the greater as the parents do not feel accused, implicated both by the consultant and their own child. In these cases, the enunciation of the diagnosis, some therapeutic consultations, a few relational arrangements rapidly evolve and then disappear the symptoms.
Depressive illness and denial of depressive suffering:
The therapeutic attitude must be different when the child is enrolled in a “depressive illness” as described above, especially if the symptoms of struggle and denial of depression (instability, anger, aggressiveness, deviant behavior Etc.) are at the forefront and even more so when the dynamics of family relationships are dominated by certain forms of denial: denial of the child’s suffering, its needs, and the obvious underlying conflictuality. Under these conditions, positive changes can not be expected simply because of the diagnostic statement. Sometimes even this can lead to a parental reaction of pathological designation of the child.
In cases where depression threatens the psychodynamic organization of the child, the use of psychotherapeutic and / or environmental approaches is necessary.
Relational therapies:
The establishment of psychotherapy is, of course, fundamental insofar as the child himself, and especially his family circle, accepts it and appears capable of sufficient stability to bring the treatment to an end. The psychotherapeutic technique itself depends on the age of the child, the therapist, local conditions; Analytical therapy, psychodrama psychotherapy of analytical inspiration or support.
Helping parents is all the more important when the child is young. Coupled mother-child therapy is particularly dynamic in small children (2 to 6 years) as in the mother itself (narcissistic restoration).
Interventions on the environment:
Parental, simple transient removal, anguish of abandonment more fantasmatic than real, etc.
These interventions are intended either to restore a more satisfactory mother-child bond (parental guidance, couple-mother-child hospitalizations for brief periods), or to establish a new link because they can not intervene on the previous foster care placement: specialized foster care For young children, boarding schools for older children, etc. Between the two are part-time care (day hospital, psychiatric day-school) when the severity of the behavioral disorders or the massiveness of the depression prevents any maintenance in the usual teaching system.
Medication treatments:
Toxic antidepressants (imipramine: 10 mg / d 2 to 4 years, 30 mg / d 4 to 8 years, 50 to 75 mg / day between 8 And 15 years, clomipramine: 0.5 to 2mg / kg / d) can temporarily improve the most pronounced depressive behaviors (sadness, abasement, prostration but also opposition, emotional lability).
But their effect is often transient, an escape after a few weeks of use is usually observed.
The most recent publications remain very reserved on the efficacy of antidepressants in children. The vast majority of randomized, placebo-controlled double-blind studies do not demonstrate demonstrated efficacy of tricyclic antidepressants versus placebo. However, these studies present numerous methodological defects (small sample size, insufficient follow-up time rarely exceeding 4 to 6 weeks, measurement instrument not always adequate or validated, etc.).
A recent study by Emslie et al (2003) compares the effect of fluoxetine versus the efficacy of fluoxetine versus fluoxetine Placebo in 96 subjects aged 7 to 17 years (48 children 12 years and younger and 48 adolescents 13 years and older, 48 placebo-controlled subjects versus 48 fluoxetine subjects). This study concludes that the effect of fluoxetine is greater than that of placebo in the major depressive episode but notes that complete remission of symptoms is rare.
The current rule is that prescribing antidepressants in children with severe clinical forms resistant to psychotherapeutic and relational therapies and to living arrangements is reserved. Nevertheless, the use of these treatments should not be neglected in these severe forms by using a correct dose and controlled dosage.
Lithium carbonate (lithium levels between 0.60 and 1.2 mEq / L with weekly and monthly monitoring) has made some improvements in the manic-depressive psychoses of adolescence. In childhood, the results are mediocre or inconstant, especially in states of psychomotor instability. Unwanted side effects appear to be common.
Again, controlled studies and prolonged follow-up are sorely lacking. Other thymoregulators (carbamézapine, valpromide) are beginning to be used, but on a case-by-case basis.
