Depression Among Chronically ill Children

By Eman Basil EL Sabbagh Prof. Dr Hesham Safouh unit

Are they sad or Are they depressed?

Depression in children and teenagers is different from the feelings of sadness and other everyday emotions that most children experience.

If a child or teenager’s symptoms become persistent, disruptive, and interfere with social activities, interests, schoolwork and family life, he or she may be depressed. 

Depression is one of the most common complications of chronic illness.

It is estimated that up to one-third of individuals with a serious medical condition experience symptoms of depression.

Common chronic diseases associated with depression Cancer e.g. leukemia, lymphomas Respiratory e.g. Asthma, Cystic fibrosis Renal e.g. Chronic renal failure Hematological e.g. Hemophilia, Thalasemia Rheumatology: e.g. SLE, Rheumatoid artheritis, FMF Endocrine e.g. Diabetes Neurological e.g. Epilepsy, myopathy Cardiology e.g. Heart failure, Rheumatic heart

disease HIV, HBV, HCV Metabolic diseases e.g. wilson, gaucher, niemann

pick

It is very tricky to diagnose depression in a chronically ill child Some of the symptoms of depression may overlap the

symptoms of the chronic disease. For example, the chronic disease may make her tired and cause her to sleep more.

She may also lose interest in activities that she usually finds enjoyable because the chronic disease now makes them difficult to do.

the chronic disease or the medications she takes to treat the disease may cause her to eat more, or make it difficult for her to concentrate.

 if child feels sad or gloomy most of the time, has lost interest in his usual activities for 2 or more weeks, and shows some of the other symptoms listed, he may have depression.

Symptoms of depression in a child

1. Grumpy, irritable or sad mood

2. Loss of interest or enjoyment in activities that she typically finds fun

3. Inappropriate feelings of guilt, worthlessness, inadequacy, or incompetence

4. Poor or increased appetite; weight gain or loss

5. Insomnia, or sleeping more than usual

6. Low energy or exhaustion after doing simple tasks

7. Feelings of hopelessness

8. Decrease in productivity (e.g., being absent from school more than usual, cutting classes, or a drop in grades)

9. Trouble thinking or making decisions

10. Outbursts of shouting, complaining or crying

11. Excessive boredom

12. Loss of interest in friends and poor communication with people

13. Fear of death

14. Sensitivity to rejection or failure

15. Acting recklessly

How is a child's life affected by a chronic disease?

Discomfort or loss of energy Restriction of activities Disruption of his life due to medical

treatment Isolation from family and friends Feeling self-conscious, embarrassed, or

stigmatized if his disease makes him different from other people

WHY ARE CHILDREN WITH CHRONIC DISEASE AT RISK FOR DEPRESSION?

1) The symptoms of the chronic disease.

  The symptoms that are caused by the chronic disease may be stressors that lead to depression.

For example, if a child has pain or nausea because of the illness, these symptoms may limit his activities, which may be upsetting. Or, if the symptoms of the chronic disease are visible and obvious to other people, they may treat her differently, making her feel embarrassed and inadequate. 

2) Treatments for chronic disease How a child's chronic disease is treated medically may

lead to depression in two ways:

1. The medications for the chronic disease may cause depression. For example, depression is a side effect of high doses of prednisone, a drug used to treat severe asthma, arthritis, and inflammatory bowel disease. Depression can also be caused by phenobarbital, a medication used to treat children with epilepsy.

2. The treatment regimen may be difficult to follow. A child or adolescent may have to change his lifestyle or need help to follow his treatment regimen. The lifestyle changes may mean he can no longer do certain activities that were pleasurable, and this may make him feel unhappy. Similarly, relying on other people to help him with her treatment (for example, reminding him to take him medication) may make him feel like he cannot do things for himself and lower his self-esteem.

3) The sporadic nature of the chronic disease

Most chronic diseases have symptoms that come and go e.g. SLE. Sometimes the child may not be able to predict when she will have a flare-up of symptoms, and the uncertainty can be very upsetting. She may feel helpless and out of control, which may result in depression.

4) Loss of social contact with people  A child's chronic disease may cause him to lose

contact with people for many reasons:

1. He may have less energy or less time to do things he finds pleasurable.

2. Healthy friends may assume that he cannot act like them so they spend less time with him.

3. In immune deficient children, parents tend to isolate their children to protect them from any possible source of infection

Regardless of the reason, loss of social contact may be upsetting to the child and lead to depression.

5) The chronic disease may be stressful to the family A chronic disease affects not just the child but the

whole family. Family members may have to take on new roles they may be disappointed that they can no longer

participate in activities that they all used to enjoy together.

They might feel some how blamed for their child illness which can be reflected in form of overprotection or negligence

The resultant stress may give rise to conflict in the family, which in turn may lead to depression in the child. 

6) Chemicals in the brain Chemicals in the brain that cause some

of the symptoms of chronic disease also cause depression.

For example, pain from a child's chronic disease may be related to too little serotonin, a chemical in his brain. When he doesn't have enough serotonin, he may also be depressed. 

Why is depression a problem for children with a chronic disease?

Depression is harmful whether or not a child has a chronic disease

However, if a child has a chronic disease and is also depressed, the problems are compounded

Why is depression a problem for children with a chronic disease? ( Cont.)

1- Chronic disease symptoms may increase or get worse. For example, children with juvenile diabetes and depression have a greater risk of having eye problems than children with juvenile diabetes who are not depressed.

2-The risk of dying from the chronic disease is increased when the child is depressed. For example, depression has been found to increase the risk of death in people with asthma.

3-Child may be hospitalized more frequently and for longer durations.

4-The child may not be motivated to take good care of himself if he is depressed.

How to help children who have depression and a

chronic illness?

Role of parents Parents can help by being present for all procedures,

staying with their child (when possible) during hospitalizations and interacting with them as much as possible

 Parents can help by allowing children to help in the management of their illness (with supervision), as this increases compliance.

Parents should also reassure their children that the illness is not their fault

Parents should help facilitate their child’s participation in school or other activities to the extent allowed by the child’s doctors. Parents should avoid being over protective

Role of Physicians Develop new coping strategies for the chronic disease e.g.

1- positive reappraisal (reassessing the disease in a positive light)

2-putting in perspective (making a rational assessment of the impact of illness)

3- positive refocusing (shifting one’s thoughts to pleasant matters)

4-focusing on planning (using one’s energy to plan for the future, and make the best of the situation)

Change the medication used to treat the chronic disease if depression is a side-effect of the drug

Enroll the child or family in a support group

Have the child seen in individual psychotherapy or begin family therapy

Change the child's lifestyle to reduce stress levels e.g. healthy food and enough sleep

Take medication for the depression

Role of society

Awareness campaigns for children at schools

Funding psychotherapy centers that treat chronically ill children for free

Arranging events for the sick children to meet and have fun