Children not immune to deadly depression

Doctors now know even the very young can be suicidal

The Ottawa Citizen, Sharon Kirkey, Tuesday June 13, 2000

Children don't get depressed. That used to be the thinking. Years ago, child psychiatrists never thought to even ask about suicidal thoughts or behaviour in children, because "depression" was an adult word.

Today, doctors are seeing depressed children as young as three.

"They show it in strange ways," says Dr. Philip Cheifetz, a child psychiatrist and assistant professor of psychiatry at the University of Ottawa. "They show it in their anger, in their feistiness and sulkiness," he says, in irritability and a lack of interest in the world around them.

On Friday, Marc Allaire found his son dead in a small wooden cabin near the family's Buckingham home. Philip, who would have been 12 years old today, had hanged himself.

Lately, Philip had been plagued by a series of bad marks and risked failing the school year, Mr. Allaire said. "It became a big part of conversations."

Always a perfectionist, Mr. Allaire said, his son could not do things halfway.

"It was everything or nothing at all," he said. "He would get discouraged pretty easily. I guess he wanted to send a message that he could no longer deal with things."

Not only is it well recognized in psychiatry today that depression can strike in childhood, "we know that some little children will report -- if you ask them -- suicidal ideas," Dr. Cheifetz says.

Not three-year-olds, he stressed. But "there are kids of 10 and 11 who, because of various reasons, either because they've heard about (suicide), or they know about a suicide in their family, will say, 'Yes, I've thought about death. I've thought about killing myself.' "

It's extremely rare for a child under 12 to take his or her own life. But it does occur, Dr. Cheifetz says, "and when it does, it's a terrible tragedy." A child's suicide can tear a family apart. "The guilt begins to settle like a stone in the hearts of parents. They feel awful. And they need to be relieved of that."

Psychiatrists say major depression is being diagnosed at earlier and earlier ages, for reasons that aren't clear, but a phenomenon they say is real and not due to better detection alone.

And a major depressive episode is the No. 1 risk for suicide, says Dr. Robert Milin, clinical director of the Regional Children's Mental Health Centre at the Royal Ottawa Hospital's child and adolescent program.

Depending on the study, the incidence of major depression in adolescence ranges from o.4 per cent to as high as 8.3 per cent. "Even if you look at half a per cent," Dr. Milin says, "you're looking at a very significant number."

In the Vancouver suburb of Abbotsford, a crisis team is struggling to cope with a recent rash of teen suicides. Five teenagers have killed themselves since April; two of the deaths occurred within 48 hours of each other. Officials say there's nothing to indicate that any of the deaths, including the deaths of two girls in the past two weeks, are related.

Two years ago, four people between 16 and 21 committed suicide in West Carleton in the space of 24 months, leaving the community in shock and trying to find ways to deal with and prevent suicide.

The statistics have been cited so often we risk growing numb to them: Suicide is one of the leading causes of death for teens, claiming 20 out of every 100,000 boys and five out of every 100,000 girls.

But that it can claim a life as young as 11 makes it difficult to imagine how someone so young could be full of such despair.

Dr. Cheifetz is part of a team of psychiatrists who, over the past five years, have completed 30 "psychological autopsies" on area teens and young adults who have committed suicide. The researchers spend time with the parents and family, exploring the "psychiatric dimension, the psychosocial life of the child and what happened that would cause this (suicide)." The goal is to identify characteristics that are common in youth who have committed suicide compared to those who have made serious or minor attempts, to better identify those most at risk of killing themselves.

What does depression look like in a child?

"The child is serious. He's not a happy child. He's not a child who is spontaneous and wants to have fun," Dr. Cheifetz, former clinical director of the Royal Ottawa Hospital, says. They're often nihilistic, he says. "They're philosophers. They ruminate and they ruminate with melancholy."

One of the hallmarks of depression in children is sadness and lack of joy, though some children may be more irritable than sad, says Dr. Milin, of the Children's Mental Health Centre. Other symptoms include poor concentration, decreased energy, and social withdrawal.

A family history of depression can be a risk factor. Children of depressed parents face a 15- to 45-per-cent risk of becoming depressed themselves at some point in life. But genetics alone doesn't explain it. Conflict between parents, a sickness or death of a close family member all can leave a child feeling vulnerable. So can problems at school, or problems socializing with other children. The child's whole functioning "kind of deteriorates," Dr. Milin says.

"Can it all be explained by one factor? Probably not," he says. But he says "western society and the stress we place on what you have to do now, family changes and the way families are structured" can all contribute to childhood depression.

Dr. Milin says most children don't fully grasp the meaning of death and dying until about age eight, so at 11, "they're really not that far down the line."

Children can express when things aren't going well, even throw a temper tantrum and say, "I'm going to kill myself." But an outburst like that is fleeting, a momentary impulsive act for a child to get his or her own way. It differs from the child who turns to his mother or father at the dinner table and says, " 'My life is terrible, I'm feeling unbelievably bad, l don't know what to do,' " Dr. Milin says.

When a child of 11 or 12 becomes seriously suicidal, "there's been something going on for a long time in that child, something that has made this child despairing that people have not known about, that has not been communicated," Dr. Cheifetz adds. "You sometimes have to ask about (suicidal thinking). You sometimes have to really pursue it. Sometimes it's the only way."

But Dr. Cheifetz is troubled by what he says is a common experience for depressed youth. "Somebody sees them, and then both they and their therapist lose interest. Because they put away that problem. It's not there any more." But while some studies have found that many depressive episodes in adolescents will spontaneously remit, the risk of recurrence is substantial. "If you have one episode that's even brief, there's a higher chance that you will get another one later on," Dr. Milin says.

Doctors are increasingly prescribing anti-depressants to teens and pre-teens. According to reports, more than half a million children under 18 in the U.S. are now taking an antidepressant. Questions are being raised about whether we're overmedicating children with drugs like Prozac and its newer cousins for conditions that aren't bona fide clinical depression. But Dr. Milin will report at a conference on pediatric health in Ottawa this week that a study has found a "statistically significant improvement" in children and teens taking fluoxetine -- the generic version of Prozac -- for major depression.

Parents who suspects a child is depressed should contact their family doctor or pediatrician, as well as the school or school counsellor, unless it's an acute situation, and in that case the child should be taken to a hospital emergency room.

Parents and children need to recognize that depression is like any other illness, Dr. Cheifetz says. "It can occur in anybody, and it should be treated as a serious thing, not 'Pull up your socks, you'll get over this.' "

"The trouble is that people feel ashamed," he says. Suicide "often splits the family up. The turbulence is terrible, it's considerable and it goes on for a long time. "It's a tragedy because you lose a life and it has a ripple effect on everybody around them."

Copyright 2000 Ottawa Citizen