Hysteria Overview in Relation to Childhood Depression

Jean Galica, M.A., LMFT

Jean Galica

Licensed Marriage & Family Therapist

Hysteria Overview in Relation to Childhood Depression

Introduction: Although the psychological clinical world no longer uses the term “hysteria” as a clinical diagnosis, it still generates a high level of scholarly interest. Hysteria was the catch-all term for most pathological disturbances (epidemic, mass, and pseudo), since the 1700’s. Many of hysteria’s traditional symptoms included fits, seizures, anxiety, personality disorders, etc., and today have been reclassified as organic illnesses, psychosis, chronic fatigue syndrome, and depression, just to name a few. Micale states a condition as complex as hysteria cannot be reduced to a single cause, but includes such influences as social, political, cultural, economic, and medical factors. Unfortunately, there is confusion over the ambiguous meaning of the word “hysteria” as it is used to describe distinct behavioral patterns, so one needs to study hysteria from an interdisciplinary orientation (Dowbiggin, 1995).

            In a pathological study of hysteria, one can find the etiology of neurosis which incorporates not only depression in a mild form, such as your everyday garden variety of depression that everyone experiences from time to time, to severe depressive disorders/psychoses. Until about 25-30 years ago, childhood depression was not even recognized or acknowledged as an illness and/or a forerunner of possible severe personality disorders. Although childhood and adult depression have many similarities and childhood depression is classified using the mood disorder categories in the DSM-IV adult diagnostic system, they do have differences and cannot be treated and diagnosed in the same manner. Childhood depression can be treated by either psychotherapy, pharmacology, or a combination of the two.

Historical Overview of Hysteria:  Scholars have remained down through the years fascinated by the phenomenon of hysteria due to its association to Freudian psychoanalysis. In the 1800’s, nervous conditions were called hysteria and colored by feminization, sexuality, excessive speech, hypochondria, excessive sensibility, nerves, and a lowness of spirit and/or disposition. Despite this variety of names, these nervous conditions were all structurally identical and in practice their names were interchangeable (Evans, 1991). Hence, the difficulty in defining hysteria lies in the absence of reliable symptoms.

            However, one of the marks of hysteria that still prevails today is excessive speech and especially speech about one’s bodily condition. Such people are still called “hypochondriacs.” While hypochondriacs, like all nervous disorders, originally had an endless parade of symptoms, only this particular attribute has survived to become the primary meaning of the term in current usage (Veith, 1965).

            In relation to nervous disorders, they are inextricably bound up with the female body and feminization of the male body. The female body represents the active principle of contagion and increasing the reproduction of persons with a nervous impairment. According to Godwin’s philosophy, femininity thereby could be considered a disease. The sought out goal was to stamp out this disease, thus the female body’s reproductive ability would disappear and by stamping out nervousness or hysteria, thus disease-free utopia would be obtained and people possibly could live forever (Godwin, 1985).

            However, today even though the word “hysteria” is no longer clinically used, we still have hysterias and women still tend to be the major focal point of them. An example of a modern-day hysteria focusing on women is chronic fatigue syndrome (CFS) per Elaine Showalter. CFS has been around since the early 1980’s. Showalter notes the longer an epidemic (hysteria) has been going, the more invested sufferers become in proving its authenticity.

            Showalter says, “CFS is not an organic disease but a psychoneurotic epidemic akin to the wave of hysteria diagnosed among women in the late 19th century.” She claims it is caused by the stressful, conflicted lives of American women in the late 20th century and exacerbated by fin de siècle anxiety. She goes on to state psychological disorders are still stigmatized as weakness or character and so patients want a biological explanation for their symptoms and can usually get them from their doctor. These epidemics get spread on the Internet, talk shows on TV/radio, and women’s magazines (Herbert, 1997).

            Even today, male symptoms are more readily taken seriously by medical personnel; whereby women’s symptoms are more likely to be written off as hysteria. However, the good news is that all the recent scientific breakthroughs are focusing a revolution. Clinical data now proves that our minds and bodies are inextricably linked—meaning every thought, feeling, and emotion is the result of chemical transmissions in individual nerve cells. So, consequently, depression is no different than a disease such as diabetes in that it is a specific biological malfunction that gives the patient specific symptoms regardless of its etiology.

            The statistics on psychiatric disorders are staggering. Thirteen percent of Americans suffer from a diagnosable mental illness, but one in one hundred will ever get help (Weisel, 1996). It is thought that the prevalent rate of depressive symptoms in elementary-age children is about 5.2 percent (Carson, 1995). This is not a matter to be taken lightly, especially when the percent of prevalence goes much higher in adolescence.

History of Childhood Depression:  Until about 40 or so years ago, childhood depression was not even recognized as a disorder let alone even a possibility. Freudian theory postulated that depression in adults was created by interpersonal loss during early stages of development. As a result, many psychoanalytically oriented therapists have claimed that children are not capable of experiencing sorrow or depression. Many psychoanalytic theories of depression require a specific symptom or developmental condition to be present or a specific developmental psychological milestone to be achieved in order for a diagnosis to be established. In other words, the symptom or condition is necessary, but it is not necessarily a sufficient reason to make a diagnosis (Newman/Garfinkel 1992).

            Theoretical approaches claiming that depression cannot exist in children appear to be based on circular reasoning. Certain attributes in adults have been designated to be central to depression and children use different and/or immature defenses and, consequently, do not conform to the central attribute model; therefore, it has been reasoned that children cannot be depressed. Other psychological and biological theories also contributed to the lack of recognition.

            Also, partly due to Freud’s legacy, the psychiatric profession had no official classification for children exhibiting behaviors and moods seen in adult depression. However, around 1950 Leon Cytryn, a pediatrician, noticed a frequency of sadness and withdrawal in pre-adolescent and early adolescent boys admitted to the hospital for surgical repair for cryptorchism (undescended testicles). As a result, he did a research project to explore the emotional adjustment of children with this specific condition. The results were that the boys with this condition, especially if surgery was delayed beyond eight years of age, almost half were seriously emotionally disturbed. Most had symptoms of sadness, poor self-esteem, social withdrawal, poor school performance, and a feeling of hopelessness (Cytryn, 1968).

            By the 1960’s, Cytryn had become a pediatric psychiatrist and he returned to a large pediatric university hospital. Through his work there, he again observed physically ill children appearing markedly depressed in accordance to criteria used at the time to diagnose adult depression. He continued to explore this phenomenon as it was thought that children did not suffer from depression.

            Simultaneously, Dr. Donald McKnew was also working with children who were in a mental hospital for a variety of reasons. Two diagnoses predominated and they were schizophrenia and conduct disorders.

            Both men were impressed by their observation that so many of these children were extremely sad, withdrawn, and lethargic with the expression of low self-esteem, hopelessness, and despair. However, they were aware that a diagnosis of childhood depression was not acceptable medically as medical teaching still insisted that children did not become depressed in a clinical sense.

            McKnew found very little cooperation from colleagues within the hospital to further his research and he eventually accepted a staff appointment at Children’s Hospital in Washington, D.C., where he met Cytryn. They collaborated in studying this subject which still continues today approximately forty years later. Gradually other clinicians became very interested and today childhood depression is a widely recognized condition. There are official criteria for diagnosing this disorder as well as a variety of drugs for use along with psychotherapy.

            One of the first individuals to classify childhood depression was Warren Weinberg, who with colleagues at the Washington University in St. Louis, drew up a set of criteria in the early 1970’s (Weinberg, 1973).

            In the early 1970’s Cytryn and McKnew also proposed a childhood depression classification for children from six to twelve years of age. According to their classification, there are three types of depression, acute, chronic, and masked. Acute and chronic types have similar features which include severe impairment of the child’s scholastic and social adjustment, sleep disturbances, feelings of despair, etc., just to name a few. The main difference between these two is the precipitating causes, whether it is the child’s adjustment before illness, length of the illness, and the family history.

            Children with chronic depression do not always have a known precipitating cause, their illness usually lasts longer and there is a history of marginal, social, and emotional adjustment, previous depressive episodes, and depressive illness in close family members.

            Children with acute type of depression seem to fall ill as a response to some traumatic event in their lives or the lives of those close to them.

            In children with masked depression, the illness is often associated with so-called acting-out behavior. The individual tries to relieve or act out an emotional problem by committing anti-social acts.

            The APA, American Psychiatric Association, classifies three kinds of depression in the current edition of the DSM-IV. They are as follows: (1) Major depressive disorder, single episode (equivalent to Cytryn/McKnew’s classification of acute depression); (2) major depressive disorder, recurrent; and (3) dysthymic disorder (both two and three are equivalent to Cytryn/McKnew’s classification of chronic depression). There is no equivalent classification for masked depression.

            According to Cytryn and McKnew, masked depression reaction has proved to be a very difficult and controversial clinical entity. Acting-out behavior, if it is predominant and the depression seems secondary, the child would now be diagnosed with a conduct disorder with depressive features. However, if the depression is the primary diagnosis, then the acting-out behaviors will become an integral part of the depressive picture rather than diagnosed as a mask.

            There are several reasons why childhood depression has gone unrecognized for so long. One main explanation is co-morbidity; previously children have tended to be categorized in a single psychiatric category, depression may have remained undetected due to reliance upon questionable traditional systems of classification, sometimes crucial information is not obtainable from the mother but from the child (Kolvin, 1991), and often depressed children are the “nicest” boys and girls on the block or the best behaved in school (Cytryn, 1996). Many times depressed individuals, children and adults alike, are very uncomplaining and eager to help due to poor self-esteem and deep-seated conflict over handling hostile/angry feelings. Many such individuals avoid or even suppress such feelings at any cost.

Definition of Childhood Depression:  Depression itself is common to all mankind. It is marked by sadness, feelings of worthlessness, and feelings that nothing one can do really matters. Depression can be quite appropriate in many circumstances, such as the death of a loved one, personal losses, loss of friends, major life changes, such as a move or school/job change, just to name a few.

            A person may feel down for days, weeks, or even in some instances due to the severity of the event months and it still be normal, part of the grieving process. However, eventually the depression becomes inappropriate and it can then develop into a mental illness.

            According to Dr. Sam Goldstein, a child psychologist, childhood depression cannot just be defined as unhappy, but it is an exaggeration of unhappiness. Things to look for are the number of problems, severity, intensity, tendency to go on and on, and the child usually is very resistant to doing anything.

            The hallmark of one or both of the following emotions, sadness, an overwhelming sadness, or an inability to find pleasure, boredom, is found in almost all depressed children. Two other very common emotions found in depressed children are hopelessness (a sense of nothing is going to work or get better so why even try) and a sense of guilt (“I must be a bad child” or this is my entire fault) or it even entails a sense of anger.

            In the area of cognitions, a key factor is the locus of control, meaning whether we believe we control the world internally versus an outside force controlling our world which would be external. Most people feel they control their world internally. If one believes there is an external force controlling their world, they do not accept responsibility, they cannot accept accomplishments, and they tend to devalue their accomplishments. The depressive person in this aspect tends to look over their shoulder at the past and devalue their accomplishments and their anxiety is expressed by looking ahead at what is coming down the road and worry about it. Hence, their self-esteem is low. A healthy child needs at least one island of success, if not more, in one of the following areas: Home, school, church, sports, etc. They also feel/believe that nobody loves them.

            The affect of depressed children is usually occasioned by a flat intonation of voice and they appear unhappy, they are not just acting unhappy. Some of these symptoms will be exhibited, although not necessarily all of them, change in sleep patterns, whether it be more or less sleep; appetite change (usually the appetite is decreased, but sometimes it involves an increase in the appetite); appear agitated; and the hallmark of depression in both adults and children is a lack of ability to concentrate.

            When assessing the severity of the child’s depressed mood, one should look at the number of times a day the child loses their temper, number of times a day they may verbalize they are unhappy, the length of how long the symptoms last is important, how many episodes there are in a day or week, and note how many major mood changes there are in a week (three to five a week is cause for concern). However, according to Goldstein, just looking at the physical symptoms of the child and his/her behaviors is not enough. Goldstein feels it is crucial to get inside the child’s head and become aware of their thoughts and feelings as well. Four key messages the child can give you are: (1) Lack of pleasure; (2) feelings of being unloved, (3) low mood, sadness; and (4) feelings of guilt.

            Depressed children routinely, although this may vary by sex, age, and environment, refuse to go to school, they have anxiety (worry) about school, they have more negative thoughts than the average child about self, family, and the world, and they do not self-evaluate very well (Goldstein 1994).

            The depressive process in children manifests itself at several different levels. The deepest level is the unconscious, which can be acted out in dreams or the way the child reacts to a part of a movie, television program, a book, or through fantasy. One of the really popular specifically designed tests to “tap” into the unconscious is the TAT, Thematic Appreciation Test, which is a series of pictures in which the child tells a story about what they see in the pictures and thereby reveals worries and concerns. Another popular test used is the Rorschach, the series of ink blots. Common depressive themes that tend to emerge from these two tests include mistreatment, criticism, abandonment, injury, death, and suicide.

            Another way a depressive process may show itself is through verbal expression, includes talking or writing spontaneously in response to questions in which the child reveals that they may feel hopeless, helpless, worthless, unattractive, unloved, or guilty. They may even express suicidal ideation.

            Another way a depressive process may make itself known is through mood and behavior, and this would be observed. Signs include a sad facial expression and posture, crying, slow movement, emotional reactions, disturbances in their sleep and appetite, school failure, physical complaints, or even irritability.

            When depressive symptoms begin to fade, the signs under mood and behavior are the first to go as they are on the conscious level. Usually depressive symptoms expressed on the verbal level go next as they are at a deeper preconscious level. The unconscious material is the last to disappear, as this is material at the deepest level, and at this point the depression itself has been alleviated, if not obliterated. Thus, the disappearance of symptoms in depression follows a hierarchical order known since the time of Freud (Cytryn, 1996).

            Since depressive feelings are very emotionally painful, children as well as adults try to avoid experiencing and expressing those feelings. One of the most effective types of defense mechanisms is sublimation, in which the individual gets up and does something active about the depression in hopes of alleviating the depression. An example might be a person who loses their job, instead of moping around the house and blaming others, they choose to get up and look for another job, update their resume, go on interviews, ask their friends for job leads, etc.

            However, one of the most primitive and potentially dangerous defense mechanisms is denial. In this scenario, the child may simply refuse to acknowledge thoughts or feelings that are too painful. An example of this might be a diabetic person who refuses to take their medication because they refuse to acknowledge they have a serious physical illness.

            Other destructive defense mechanisms include projection, in which something undesirable that the person cannot accept about themselves is projected or attributed to another person; acting out, in which the person suppresses their depression by engaging in anti-social behavior; dissociation of affect, in which the individual unconsciously represses their depressive feelings while retaining the memory of the event that evoked those feelings; reaction formation, in which the person talks or behaves contrary to the way they really feel; and introjections, which is the opposite of projection. This is the individual who feels everything is their fault and they turn natural dislike and hatred inward. All these defense mechanisms can be used at the previously discussed three levels of the depressive process, the unconscious, verbal, and mood and behavior.

Clinical Diagnosis of Childhood Depression:  In infancy the child has only a limited number of defense mechanisms and is not psychologically equipped to develop a depressive disorder as we know it in adults, but when stress for the infant is overwhelming and of long duration, the infant may develop a primitive depressive state characterized by a sad face, withdrawal, failure to interact, and may even refuse food. On into toddlerhood and the preschooler, the conscience of the child is far less developed, so feelings of guilt and lowered self-esteem will be far less severe, and seldom would a clearly delineated depressive syndrome be seen but rather a variety of behavioral deviations.

            By the time the child is five to six years old, a diagnosis of a specific depressive disorder and a clinical diagnosis of childhood depression could be made. By the time the child is eight, there is far less denial of symptoms in the child, etc., and it becomes far easier to make the correct diagnosis. The majority of case studies done on children in regards to depression have been done on the elementary-age child and specifically children from nine to thirteen.

            For a clinical diagnosis of a major depression, which the average length in a child is approximately seven months, the child would need to demonstrate five of the nine symptoms in a two-week period (Goldstein, 1994): (1) Anhedonia, lack of pleasure; (2) sad/depressed mood; (3) change in appetite; (4) change in sleep patterns; (5) suicidal ideation; (6) fatigue; (7) poor concentration; (8) low self-esteem; and (9) feelings of guilt.

            Dysthymia is another type of depression, a minor depression, which is a sense of unhappiness and must be present for at least one year. It would include two to three symptoms of the above-mentioned symptoms for a major depression.

            The types of depression that have been described thus far are really unipolar, which means the mood deviates toward the depression end of the continuum and does not swing toward mania. This is the common type of depression found in children. However, the association of major depression and mania, known as bipolar I disorder, is extremely rare in children, while the bipolar II disorder, which is a combination of major depression and hypomania is more frequent and often preceded by an episode of major depression. Statistics on the prevalence of this disorder in children are unavailable, but one study reports that 31 percent of children treated for an episode of major depression disorder will develop a bipolar episode within several years (Cytryn/McKnew, 1996).

            In diagnosing depression in children, there has been much discussion as to who the information should come from, the child, the parent, school authorities, or other important figures in the child’s life. In all the case studies that were read, they all bore out the fact that there is a disparity between the material gathered from the child and from other people. The disparity seems to be unique to depression and depressive disorders in children and is seldom seen in other conditions.

            In the Newcastle Child Depression Project, the extent of the similarities and discrepancies in the reporting of depressive symptoms by children and their mothers was examined. The parent-child agreement was not very impressive in regards to the more subjective symptoms. However, the study bore out the fact that due to (1) the conceptual limitations of some prepubertal children; (2) the provision of accurate chronology of themselves by children is poor; and (3) adolescents may be reluctant to let others know their inner feelings, information should definitely be obtained from parents, teachers, or other important figures in the lives of the children in addition to interviewing the child and directly observing the child clinically.

            The results of the project of who should be interviewed fell into five different categories: (1) Agreement about the presence or absence of symptoms; (2) symptoms with good agreement between child and parent as to occurrence; (3) symptoms reported more often by the child; (4) symptoms reported more often by the parents; and (5) symptoms reported equally commonly by parents and children.

            In the first category, agreement about the presence or absence of symptoms, the range of agreement extended from 40 to 86 percent with the majority falling between 60 to 70 percent. The nine symptoms with the highest rate of overall percentage agreement were psychomotor retardation, obsessionality, loss of appetite, suicide attempts, suicidal ideation, loss of interest, anhedonia, weeping, and initial insomnia. Most of these symptoms are observable with the exception of anhedonia and suicidal ideation. However, the overall agreement reflected agreement on the absence of symptoms versus the presence of symptoms.

            The second category, symptoms with good agreement between the child and the parent as to occurrence, only one-fifth of the symptoms studied showed rates of agreement of occurrence over 40 percent, with only loss of appetite and loss of interest having a percentage agreement over 50 percent. Most of the symptoms, loss of appetite, loss of interest, initial insomnia, reactivity of mood, anhedonia, irritability, changed school attitude, weeping, social withdrawal, and anger, are objectively observable.

            In the third category, symptoms reported more often by the child, there were 52 symptoms studied. The ten symptoms reported twice as often by children were self-denigration, feeling unloved, guilt, feelings of emptiness, sense of failure, compulsions, morning fatigue, psychomotor retardation, fears and phobias, and quality of mood. The six symptoms reported three times more often by children were déjà vu, self-dislike, general anxiety, obsessions, suicidal ideation, and suicide attempts. Less than one-third of the symptoms in this category were observable.

            In the fourth category, symptoms reported more often by parents, there were only four symptoms ranging from 32 to 57 percent greater reporting by the parent. The four symptoms more often reported by parents were hypersomnia, increased appetite, anhedonia, and exaggerated illness behavior.

            The fifth category, symptoms reported equally, was a variable group and included objective symptoms such as a separation anxiety, hypochondria, and anger, as well as the more subjective experience of nightmares.

            The conclusion drawn from these results is that children, even very young ones, should be asked directly about their feelings as well as being assessed. This point is well made by the fact that only a few symptoms, usually objective, were reported in excess by parents, whereas over 50 percent of symptoms, usually all subjective, were reported in greater numbers by children. Rates of agreement between parents and children regarding the presence of symptoms were low and were highest, although only moderate agreement, for objective behavioral symptoms.

            Prepubertal children in general agreed better with their parents about a wide range of symptoms than did adolescents. These findings are in accord with evidence that as children grow older, parents are less reliable in reporting psychiatric symptoms their children display and the children themselves become far more reliable. Prepubertal children displayed a poor performance of agreement with parents concerning the duration of an illness, which probably reflects a poorer ability to express things chronologically.

            Research suggests that parents’ accounts should never be discounted, but they should be seen as complementary. There is also evidence to suggest that parents rarely report the presence of disorders that are not present according to the children themselves except on the occasion where a diagnosis of conduct disorder is particularly disadvantageous. Consequently, if parents indicate that their child is depressed, the clinician should view that seriously, (Barrett, et al., 1991).

            Various diagnostic tests have been developed to help gain complete information about a child’s depressive symptoms as well as other aspects of their behavior, thinking, and mood. The most widely used questionnaires are CAS, (Child Assessment Scale), DICA, (Diagnostic Inventory for Children and Adolescents), ISA, (Interview Schedule for Children), and Kiddie-SADS, (child version, Schedule of Affective Disorders and Schizophrenia). Kiddie-SADS is probably one of the more prominent tests used in the assessment of childhood depression as well as schizophrenia and a whole host of affective disorders.

Causes of Childhood Depression:  There are many factors or a combination of factors that can cause childhood depression. Some of the greatest contributors to childhood depression are marital discord, lower socio-economic status, depressed parents (especially if both parents are depressed or have other affective disorders), separation from loved persons and/or places, loss of a strong attachment (especially in the death of a parent), depression and rejection factors, physical stressors (disability or prolonged illnesses and/or hospitalizations), biochemical factors (neurotransmitters, receptors, synaptic transmission), and genetics.

            Childhood depression may be the result of social or biological factors or both. Social factors include either the loss or rejection of a loved one. Rejection does not necessarily mean that the child is ignored or even pushed out of the loved one’s life, but it can mean that someone is simply failing to give the child the warm attention and love that is needed for their best development. One the contrary, a family who is abnormally close to one another and fearful of the world outside can foster depression in a child. Families who set goals too high for their children can foster depression within their children. The depression can also be associated with a physiological disability suffered by the child or even a loved one.

            However, research seems to bear out the fact that underlying all of these causes of childhood depression, there is likely to be a disorder or predisposition in the child’s biological make-up—something that is inherited and in return makes the child predisposed to depression.

Children at Risk for Childhood Depression:  Children most at risk for major depression or depressive illnesses are children whose parents have a major affective illness. The risk involves both genetic and psychosocial factors and “is among the largest risk factors for depression across the life span” (Mrazek, 1994).

            Hyperactive or ADHD children seem to be at a high risk for depression. They often rank low in self-esteem and feel worthless and helpless, they are unable to control their lives, and they are often isolated from their peers. The relationship of ADHD to depression in children is not fully clarified, but two likely possibilities are: (1) Hyperactive children develop a secondary reactive depression in response to the many hardships incurred by their illness and (2) hyperactivity and depression have a parallel etiology and co-exist in the same child as autonomous entities (McClellan, 1990).

            The majority of studies report a higher rate of depressive symptoms in women than men, with an average ratio of two to one. However, during childhood the incidence of depression or a depressive disorder of any type are equally distributed among boys and girls. The rates for depression gradually increase for females during adolescence.

            Other groups at risk for depression are economically deprived children, chronically ill and handicapped children, and the mentally retarded.

            Goldstein also stated that research indicates boys who are more at risk for developing depression are as follows: (1) As infants had more health problems; (2) at age five, more dependent on their mother, and (3) at age nine they were more unpopular, lived in a family with remarriage, early marital discord in the family, and a history of anxiety. Factors making girls more at risk were as follows: (1) Raised by older parents; (2) raised in a large family; (3) at age nine were more anxious and unpopular; (4) lower role within the family; and (5) more stressful family events.

Treatment of Childhood Depression:  The goal of psychological therapy is to help the child reach the highest level of functioning possible in addition to alleviating mental pain and anguish. Psychotherapy for a child with depression involves working with the family, parent counseling and therapy for the parent if they have a depressive illness, and individual therapy with the child. Many times in cases of childhood depression, family and parental treatment may not suffice and individual therapy for the child is indicated. The specific goals in such circumstances differ little from those of adults, but the crucial aspect is the development of a close, empathetic, and trusting relationship between the child and the therapist. There is a general feeling among many therapists that a close trusting relationship accounts for most successes in psychotherapy with children. The therapist needs to accept the child in totality without criticism or judgment. If and when appropriate, the therapist needs to express approval for the child, the therapist needs to convey to the child that he/she values the child as a person regardless of the child’s shortcomings and that they have high hopes about the child’s ability to overcome their difficulties and become a well-functioning child. The child also needs to be able to ventilate all their negative feelings and thoughts. A therapist may also discuss with the child troubling situations and try to get the child to see what they can do about it and, if possible, help the child to understand the basis of their feelings and conflicts.

            The goals of therapy with children are all basically the same regardless of their age, but the techniques employed have to be tailored to the child’s chronological age and cognitive and emotional readiness. Children as young as five or six many times can verbalize their difficulties with a minimum of nonverbal activities, but many younger children do predominantly need nonverbal activities such as play therapy which can incorporate sand tray work, games, art, etc. Play is the language of younger children while older children usually can verbalize more directly. The level of interpretation must also be adjusted to the age and cognitive level of the child.

            Most depressed children who are reared by caring parents/caregivers respond favorably to psychotherapy. One of the major factors responsible for this success is the maturational push children experience, which, in effect, makes it easier for a child to change and mature then an adult.

            Although since the 1960’s and especially since the 1970’s, psychopharmacological treatment has increased rapidly with children and adolescents and been effective with many depressive disorders, the results do not confirm the effectiveness of antidepressant drugs in ameliorating depression in either children or adolescents. There is no published evidence of the superiority of drugs over a placebo in the treatment of childhood depression (Cytryn, 1996).

            Although the prevailing thought in depressive orders is that a combination of psychotherapy and psychopharmacology is the most effective treatment, I would gather from the studies and materials I have read that this is not necessarily true in relation to childhood depression. The trend among clinicians is to continue to treat children with antidepressants, but I believe there has to be much more study and more concrete evidence in regards to the efficacy before it should be so readily embarked upon in the treatment of childhood depression.



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