essay on childhood disorders

Childhood Disorders: Causes, Prevention and Treatment Essay

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Introduction

Etiology of childhood disorders, classification and subtypes and symptomatology, social interventions.

Childhood disorders may go undetected and the suffering child is perceived as naughty or antisocial depending on how the illness manifests itself. This has lead to many children suffering without receiving treatment. Lack of treatment of these psychological problems can have catastrophic ends such as death or permanent social problems.

This essay discusses some of the common childhood disorders that affect children and pays particular attention to Separation anxiety disorder. It also discusses the symptoms associated with these disorders and the methods of treatment including social interventions.

Childhood disorders are the psychiatric abnormalities that affect school going or younger children. These disorders impair the child’s behavioral emotional, mental and social development. Symptoms of disorders usually start in early childhood though some begin during adolescence. Sometimes these disorders continue all through adulthood.

Childhood disorders can be caused by two key factors:

• Genetic abnormalities.
• Physical stress.

Genetic abnormalities can be divided into two groups: functional and structural.

The functional genetic abnormalities involve abnormalities in the brain chemicals called neurotransmitters which are involved in communication in the brain. Neurotransmitters include noradrenaline, dopamine, adrenaline, and GABA. These chemicals are responsible for the way a person feels and behaves. Abnormal working of the neurotransmitters or abnormalities in the brain leads to abnormal mental functioning and development. Neurochemicals serve as the brain’s messengers in communication between the brain and the neuron system. A change in the amount of neurotransmitters secreted can result in psychiatric disorders as can their absence and their chemical variants.

Neurochemical problems are associated with autism, schizophrenia, Attention Deficit Hyperactivity Disorder (ADHD), dyslexia, and so on.

Structural abnormalities of the brain can also cause mental disorders. For example, enlargement of the cerebral ventricles has been found to be a common finding in people suffering from schizophrenia. The common assumption is that enlarged ventricles occur from wasting of brain tissues around the ventricles. Other structural abnormalities include a decrease in the amount of gray matter in the brain. The gray matter is where most of the brain activity takes place. Lack of enough gray matter means lack of optimized brain activity. This could explain the difficulties associated with mental disorder in children. Brain structure abnormalities are associated with schizophrenia and autism.

Factors such as psychological trauma, illness or injury can lead to stress which can cause childhood disorders associated with behavioral problems and also problems in interaction with other people. Examples of these disorders include selective autism, reactive attachment disorder, conduct disorders and so on.

Attention – Deficit/Hyperactivity Disorder (ADHD)

This is the highest occurring childhood disorder involving neurological disorders. It can persist through adolescence and adulthood. The Diagnostic and Statistical Manual-IV, Text Revision book says that the percentage of children with ADHD is around 3-7. This disorder is characterized by lack of attention and hyperactivity. A child of school going age is generally very active especially in playing. However, the symptoms in this disorder are usually more exaggerated than normal and usually interfere with the child’s normal life. The condition is among the most misunderstood conditions with many parents and guardians thinking the abnormally hyperactive child is just being naughty.

The disorder begins to manifest itself at age 8-9 though 50% cases of the disorder usually arise before 4 years. The condition is more common in males than females with three out of four patient being boys (Barkley, R.A., 2005).

The condition sometimes occurs together with other mental disorders and this makes it hard to properly diagnose it.

There are three types of ADHD. This classification is based on the magnitude of strength of the symptoms present.

• Predominantly Inattentive Type – it is characterized by lack of concentration. The child is unable to complete given tasks or follows instructions or conversation. The child is prone to distractions.
• Predominantly Hyperactive–Impulsive Type – it is characterized by hyperactivity. The child cannot sit still and talks incessantly.
• Combined Type – in this type the sufferer usually has lack of concentration and is hyperactive. It is a combination of the two previously mentioned disorders.

The DSM-IV-TR outlines the criteria for spot on diagnosing this disorder. The first criteria outlines symptoms of inattentiveness that must be present for about 6 months to a point that causes disruption and hinders development for a diagnosis on ADHD to be made. These symptoms include:-

• Not paying attention to detail
• Inattentiveness when performing a task or playing
• Appears not to notice direct communication directed towards them
• Has problems in following instructions
• Is easily distracted

The second criteria helps to diagnose ADHD in a situation where six or more symptoms of hyperactivity are present for approximately six months and are disruptive and inhibit development. These symptoms of hyperactivity and impulsiveness include:

• The child finds it hard to stay still
• Restlessness which is characterized by standing when the child is supposed to be seated or playing at inappropriate times.
• Incessant talking
• Talking before statements or questions are completed
• Problems in waiting their turn especially when playing with others
• Constant interruptions and intrusions into other people’s affairs

ADHD is treated using drugs or behavioral therapies. A combination of the two is sometimes used (Barkley, R.A., 2005).

This disorder begins to manifests itself at infancy and is characterized by impairment in social interaction and inability to communicate (American Psychiatric Association, 2000). Those who are able to communicate verbally normally start doing so much later than their normal age-mates. The child also behaves in an unusual manner and possesses unusual interests. The disease is usually heartache to the parents of an autistic child as the child does not acknowledge the parents.

Autistic children do not like to be touched or even cuddled. They also tend to gaze inappropriately at something. Children with autism can possess unique intelligence in certain field such as music or painting. Some however tend to be severely mentally challenged. This disorder is detectable in a child of above 18 months. Disease such as congenital rubella syndrome in pregnancy and the use of thalidomide increase the risk of autism disorders.

• Poor social skills. The child may show lack of interest in social activities such as games around them. The sufferers may also not be interested at all in the people around them even their close family members. They also do not understand other people’s feelings and sometimes their own.
• Varied degree of poor communication skills with some autistic children not being able to talk at all. Those who are able to speak may have unusual words for things.
• May have repeated behaviors and routines
• Avoid eye contact prefer to be alone
• May experience problems adapting to change in their routine
• Repeat words said to them without comprehending them
• Learned skills are usually forgotten after a while. This often happens with learned words

Conduct disorders

According to the DSM- iv TR book the criteria for diagnosing this disorder states that patterns of ‘a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated’ should be present. Children with this disorder often lack feelings of remorse and tend to have a low self esteem despite them projecting an image of ‘toughness’ through their callous behavior. This condition can be classified as mild, moderate, or severe depending on the intensity of the symptoms.

The condition is associated with risky behavior such as substance use. The sufferer also experiences problems in school and at work. The condition is associated with suicidal thoughts and attempts.

Conduct disorders are of two types:

• The childhood onset type which begins before the age of 10 and which happens to be the most severe type. It persists into childhood. the disorder at times coexists with the Attention-Deficit/ Hyperactive Disorder. It is characterized by violent and victim oriented offenses.
• The adolescent onset type which begins after 10 years and is less severe as compared to the childhood onset type. This type is characterized by playing truant, stealing, and destruction of property.

Conduct disorders can be grouped into four: Aggressive conduct, Non aggressive conduct, Deceitfulness or theft, and Violation of rules conduct disorders.

The criteria for diagnosis of conduct disorders is that three or more symptoms of the disorders are present for approximately 12 months with one occurring in the past 6 months.

• physical cruelty to people and animals
• Use of weapon to cause harm or threaten others
• Deliberately destroying property especially through arson
• Use of lie to gain favors
• Skips school often
• Steals items of no value without force for example in a case of shoplifting

Dyslexia is a learning disability that impairs someone’s ability to read orally with the child substituting words with others and leaving out some (American Psychiatric Association, 2000). The person usually has difficulty in manipulating sounds and/or responding visual-verbally. They also have problems in understanding what they are reading. It usually affects males more than females due to the male’s disruptive attitude towards learning.

This reading disorder is associated with the Mathematical Disorder and the disorder of Written Expressions.

The condition is diagnosed if the child’s reading abilities fall below the expected score for their age, intelligence, and age-appropriate knowledge.

• clumsiness and uncoordinated movements
• difficulty in rhyming for example, ‘cat’ and ‘hat’
• trouble with dressing or tying laces
• trouble learning the alphabet
• inability to read

Opposition defiant disorders

This disorder is characterized by disobedience hostility and a defiant attitude toward authority persons. It usually starts at the age of 8 and is one common in boys than girls.

It is associated with a constant disruption in the care givers such as babysitters, harsh parenting, and in cases where the child has been neglected

• shows anger and resentment towards others
• argues with adults
• has a bad temperament
• is spiteful and seeks revenge

Separation anxiety disorder

This is the excessive inappropriate fear in children of being set apart from close family members especially parents. At some stage of their development, children will usually develop unwillingness toward separation from people they are fond of. This is usually accompanied by anxiety which is characterized by arguing and distress. However, in separation anxiety disorder, this anxiety is exaggerated. This excessive fear often greatly disrupts the child’s normal activities (American Psychiatric Association, 2000).

Children with this disorder are often scared of things that pose a danger to the closeness of the family such as kidnappers, muggers, car and plane travel, and so on. They also think about death quite often and they wish they were dead when they feel unloved. They also tend to lash out at the person responsible for the separation and can at times result in violence. These children will at times report seeing things that are just fragments of their imagination: things like seeing monsters when left alone especially in a dark room.

This disorder usually has a toll on the child’s life as it disrupts their social and academic life. A child with this disorder is usually reluctant to make friends with other people except family. Therefore the child usually leads a lonely life in school and this makes them hesitant to go to school. This fear of separation also makes a child skip school in order to avoid separating with the parent. This leads to long observe from school and this affects the child’s performance.

If left unattended this fear would have a negative effect on the child’s later relationship involving love and trust. Untreated separation anxiety disorder also predisposes one to panic attacks and phobias such as agoraphobia (American Psychiatric Association, 2000).

An imbalance in the neurotransmitters in the brain in thought to cause this disorder. Other factors that increase the risk of a child developing this disorder include the parent having agoraphobia the child coming from a very close family and the child having a personality that doesn’t embrace change.

Separation anxiety disorder can be triggered by a traumatic event in a child’s life such as child abduction, divorce, stress in the family say due to death, significant changes such as moving to a new neighborhood.

• Pains especially headaches or stomach that appear just before the separation
• Following the family member around
• Excessive nightmares that involve separation
• Resistance to attend school or move away from home
• Excessive persistent distress that is shown by crying, misery or tantrums in anticipation to separation. It may continue long after the separation

Separation anxiety is diagnosed as a disorder if the symptoms of anxiety continue to be experienced for over four weeks in children above 5 years of age (American Psychiatric Association, 2000). This disorder is treated using family play and cognitive behavior therapy. Treatment should include giving the sufferer and their family information about the condition so as to improve their understanding on the disorder.

This is particularly important as it will help the figure of attachment to understand why the child is behaving as they do. It will also help; the person to avoid the triggers of anxiety in the child. The children can be taught how to relax by say, deep breaths and self-soothing language.

Social interventions have been known to have a considerable positive effect in helping both the patient and the patient to cope. The technique is especially of help where the patient refuses to take the prescribed drugs to manage their condition. Interventions that are easy to understand and spot on combined with cognitive therapy bring out positive changes in the child’s health and also in the way the family and the child perceive and manage the condition. This method also prevents progression of some diseases into psychosis. It also improves the child’s social life and raises their self esteem, both of which are greatly negatively affected in most mental disorders.

This style of management is particularly client friendly as it allows the sufferer’s condition to be managed at home and hence reduces the chances of the patient being admitted to hospital due to a relapse. This is an advantage as it helps to avoid the big financial and mental strains that are incurred when one is admitted to hospital.

The social work intervention should be in line with the type of disorder. The interventions applied should cater for that particular child for it to be successful. It should be focused on the child as well as the parents. Working together with families to reduce high expression of emotion and to improve ways of coping is recognized as a way of reducing the rate of relapses in children with behavioral disorders such as schizophrenia. Social work interventions focusing on the child should be geared towards promoting the mental and social health of the sufferer (Vdebeck, S.L., 2007).

For children with behavioral problems the social worker should employ tactics that will rectify this behavior to a manage level whereas for children with emotional disorders such as separation anxiety disorder, the social worker should focus on increasing the self esteem of the child. Social interventions are particularly useful in helping children with social problems such as those with autistic disorders and separation anxiety disorders.

Of course tackling different disorders will require different techniques. Therefore the social worker should focus on bringing out the emotional strength of the child. They should also help the child to cope with these disorders and avoid triggers that make their emotions erupt (Ronen T., 1994).

Despite its effectiveness, social intervention remains a method that is least used in the management of childhood disorders. This is because this intervention still remains inaccessible to many sufferers who need it. This method of management is also faced by a problem in lack of trainees due to the restrictions on the NHS funding. Lack of trainees means that the number of therapists available is inadequate to cater for the large number of children in need of this intervention.

American Psychiatric Association. (2000). Diagnostic and statistical manual of Mental Disorders-fourth edition, text revision . American psychiatric publishers Inc.

Barkley, R.A. (2005). Attention-Deficit Hyperactivity Disorder, Third Edition: A handbook for diagnosis and treatment . New York. Guilford Publications Inc.

Centers for Disease Control and Prevention. Autism/ Attention – Deficit/Hyperactivity Disorder (ADHD). Web.

Ronen T. (1994). Cognitive – behavioral social work with children . British journal of social work. Volume 24, pp 273-285.

Separation Anxiety Disorder: Causes, Prevention and Treatment. Web.

Vdebeck, S.L. (2007). Psychiatric-mental health nursing . Lippincott Williams and Wilkins Publishers. Pp 71.

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IvyPanda. (2021, October 17). Childhood Disorders: Causes, Prevention and Treatment. https://ivypanda.com/essays/childhood-disorders-causes-prevention-and-treatment/

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Bibliography

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• Adversity in childhood...

Adversity in childhood is linked to mental and physical health throughout life

Read our collection on toxic stress and ptsd in children.

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• Peer review
• Charles A Nelson , Richard David Scott chair in pediatric developmental medicine 1 ,
• Zulfiqar A Bhutta , co-director, director of research 2 3 ,
• Nadine Burke Harris , surgeon general 4 ,
• Andrea Danese , professor of child and adolescent psychiatry 5 ,
• Muthanna Samara , professor of psychology 6
• 1 Department of Pediatrics, Boston Children’s Hospital and Harvard Medical School, Harvard Graduate School of Education, Boston, MA, USA
• 2 Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
• 3 Institute for Global Health and Development, Aga Khan University, South Central Asia, East Africa and UK
• 4 State of California, CA, USA
• 5 Institute of Psychiatry, Psychology and Neuroscience, King’s College London and the National and Specialist CAMHS Clinic for Trauma, Anxiety, and Depression, South London and Maudsley NHS Foundation Trust, London, UK
• 6 Department of Psychology, Kingston University London, London, UK
• Correspondence to: C Nelson charles_nelson{at}harvard.edu

The prevalence of “toxic stress” and huge downstream consequences in disease, suffering, and financial costs make prevention and early intervention crucial, say Charles A Nelson and colleagues

Today’s children face enormous challenges, some unforeseen in previous generations, and the biological and psychological toll is yet to be fully quantified. Climate change, terrorism, and war are associated with displacement and trauma. Economic disparities cleave a chasm between the haves and have nots, and, in the US at least, gun violence has reached epidemic proportions. Children may grow up with a parent with untreated mental illness. Not least, a family member could contract covid-19 or experience financial or psychological hardship associated with the pandemic.

The short and long term consequences of exposure to adversity in childhood are of great public health importance. Children are at heightened risk for stress related health disorders, which in turn may affect adult physical and psychological health and ultimately exert a great financial toll on our healthcare systems.

Growing evidence indicates that in the first three years of life, a host of biological (eg, malnutrition, infectious disease) and psychosocial (eg, maltreatment, witnessing violence, extreme poverty) hazards can affect a child’s developmental trajectory and lead to increased risk of adverse physical and psychological health conditions. Such impacts can be observed across multiple systems, affecting cardiovascular, immune, metabolic, and brain health, and may extend far beyond childhood, affecting life course health. 1 2 3 These effects may be mediated in various direct and indirect ways, presenting opportunities for mitigation and intervention strategies.

Defining toxic stress

It is important to distinguish between adverse events that happen to a child, “stressors,” and the child’s response to these events, the “toxic stress response.” 4 A consensus report published by the US National Academy of Sciences, Engineering, and Medicine (2019) defined the toxic stress response as:

Prolonged activation of the stress response systems that can disrupt the development of brain architecture and other organ systems and increase the risk for stress related disease and cognitive impairment, well into the adult years. The toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. Toxic stress is the maladaptive and chronically dysregulated stress response that occurs in relation to prolonged or severe early life adversity. For children, the result is disruption of the development of brain architecture and other organ systems and an increase in lifelong risk for physical and mental disorders.

What is childhood adversity?

A large number of adverse experiences (ie, toxic stressors) in childhood can trigger a toxic stress response. 4 5 6 These range from the commonplace (eg, parental divorce) to the horrific (eg, the 6 year old “soldier” ordered to shoot and kill his mother 7 ).

Adversity can affect development in myriad ways, at different points in time, although early exposures that persist over time likely lead to more lasting impacts. Moreover, adversity can become biologically embedded, increasing the likelihood of long term change. Contextual factors are important.

Type of adversity— Not all adversities exert the same impact or trigger the same response; for example, being physically or sexually abused may have more serious consequences for child development than does parental divorce. 8 9

Duration of adversity— How long the adversity lasts can have an impact on development. However, it is often difficult to disentangle duration of adversity from the type of adversity (eg, children are often born into poverty, whereas maltreatment might begin later in a child’s life).

Developmental status and critical period timing— The child’s developmental status at the time he or she is exposed to adversity will influence the child’s response, as will the timing of when these adversities occur. 10

Number of adversities and the interaction among them—— The Adverse Childhood Experiences (ACE) study 11 12 and subsequent body of ACE research provide compelling evidence that the risk of adverse health consequences increases as a function of the number of categories of adversities adults were exposed to in childhood. Although this seems intuitive, it belies the fact that, when it comes to severe adversity (eg, maltreatment), few children are exposed to only a single form of adversity at a single point in time. In addition, the effects of exposure to multiple adversities is likely more than additive. Thus, multiple forms of adversity may act in complex and synergistic ways over time to affect development.

Exacerbating factors— Children with recurrent morbidities, concurrent malnutrition, key micronutrient deficiencies, or exposure to environmental toxicants may be more sensitive to the adverse effects of other forms of toxic exposures. 13

Supportive family environments— Children develop in an environment of relationships, 14 15 16 and supportive relationships can buffer the response to toxic stress. Safe, stable, and nurturing relationships and environments are associated with reduced neuroendocrine, immunologic, metabolic, and genetic regulatory markers of toxic stress, as well as improved clinical outcomes of physical and mental health. 17 18

Pre-existing characteristics —Many of the adversities being considered are not distributed at random in the population. They may occur more commonly in children and families with pre-existing vulnerabilities linked to genetic or fetal influences that lead to cognitive deficits. 19 20 21 Infants who are more vulnerable to adverse life events (eg, stigma) include those born very early (eg, at 25 weeks’ gestation) or very small (eg, <1500 g), those born with substantial perinatal complications (eg, hypoxic-ischaemic injury), infants exposed prenatally to high levels of alcohol, or those born with greater genetic liability to develop an intellectual or developmental disability (eg, fragile X syndrome) or impairments in social communication (eg, autism).

Individual variation— Finally, children may have different physiological reactions to the same stressor. For example, Boyce, 22 has proposed that by virtue of temperament, some children (such as those who are particularly shy and behaviourally inhibited) are highly sensitive to their environments and unless the environment accommodates such children, the risk of developing serious lifelong psychopathology is greatly increased; conversely, some children thrive under almost any conditions.

Figures 1 and 2 illustrate how duration and type of adversity interact with family environments and pre-existing characteristics to affect development ( fig 1 ), and how early adversity may become biologically embedded ( fig 2 ).

The interplay of adversities, context, and human development

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Some of the pathways that mediate exposure to early adversity and adult outcomes. Exposure to adversity early in life interacts with a child’s genetic endowment (eg variations in genetic polymorphisms), which in turn leads to a host of biological changes across multiple levels. These changes, in turn, influence adult outcomes (adapted from Berens et al 23 ). HPA axis (SHRP)=hypothalamic pituitary adrenal axis (stress hyporesponsive period)

Consequences of exposure to adversity

Behavioral consequences —Childhood exposure to adversity may result in a variety of behavioral and emotional problems 7 —for example, increased risk taking, aggressive behaviour, involvement in violence (home, school, and neighbourhood), and difficulties in relationships with others. 24 25 Of great concern is the development of post-traumatic stress disorder (PTSD). 9 26

Children experiencing trauma (eg, witnessing the murder of a family member; sexual assault) are also at elevated risk of several other psychiatric disorders, including depression, PTSD, conduct problems, substance abuse, self-harm, and suicidal thoughts and attempts. 8 25 Some forms of physical and psychological abuse in early childhood can be associated with eating disorders and mental health issues affecting typical development and education.

Neurobiological consequences —Many studies have identified structural and functional differences in brain development associated with environmental stressors, such as low socioeconomic status, 27 28 29 30 31 physical abuse, 32 and care giving neglect. 33 34 For example, exposure to maternal stress in infancy has been associated with reduced brain activity, as inferred from electroencephalogram testing 35 , and profound psychosocial deprivation has been associated with differences in overall brain volume along with reductions in white and grey matter volume in several brain areas 36 37 and reduced brain electrical activity. 38 39 Differences in brain development have also been associated with decreases in several cognitive functions, 40 and particularly executive functions, 41 and distally, in educational achievement. 42

Physical consequences —Early exposure to adversities, especially poverty, is associated with linear growth failure and wasting, and has recently been shown to be associated with reduced brain volume 43 and altered functional connectivity. 44 Children exposed to higher psychological stress have been shown to have higher cortisol levels and greater risk of common diseases of childhood, including otitis media, viral infections, asthma, dermatitis, urticaria, intestinal infectious diseases, and urinary tract infections. 45

Childhood adversities have also been associated with greater risk of adult chronic conditions, including cardiovascular disease, stroke, cancer (excluding skin cancer), asthma, chronic obstructive pulmonary disease, kidney disease, diabetes, overweight or obesity, and depression, as well as increased health risk behaviours. 46 47

Tables 1 and 2 show many of the physical and psychological harms observed among children and adults exposed to adversity early in life.

Health conditions in children associated with adverse childhood experiences (ACE)

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ACE-associated health conditions in adults associated with adverse childhood experiences (ACE)

What mediates the effects of adversity?

The link between exposure to adversity early in life and physical and psychological development are thought to be mediated through several direct and indirect pathways. We first talk about the effects on physical development, then turn our attention to psychological development.

Effects mediated directly may include altering the regulation of stress-signalling pathways and immune system function 48 ; changing brain structure and function 49 ; and changing the expression of DNA and by accelerating cellular ageing. 50 51 For example, abuse or neglect might directly lead to physical injury or undernutrition or malnutrition. Similarly, stress can directly lead to dysregulation of the hypothalamic-pituitary-adrenal axis and associated neuro-endocrine-immune 19 as well as epigenetic effects. 52

Effects mediated indirectly might include changing the quality of the care giving environment (eg, less responsive care 3 ) or the surrounding distal environment (eg, neighbourhood violence, which in turn will affect child development across several levels 53 ); or building dysfunctional cognitions about the self and the world. 25 54 55 The effects of food insecurity (leading to undernutrition or malnutrition) and unsafe or substandard housing (resulting in exposure to asthmagens or environmental toxicants such as lead) can lead to social disparities in health. 4 Distal effects of adversity include the early adoption of health damaging behaviors (eg, smoking, poor food choices) that later in life lead to diabetes, heart disease, and metabolic syndrome. 47

On the psychological side, early adversity can lead to the development of psychopathology early in life (eg, disruptive behavior) that later in life manifests in more severe forms (eg, antisocial personality). Furthermore, it can lead to the development of dysfunctional cognition about self and others. 54 The interplay of these different mediation mechanisms remains largely unclear.

Modelling the effects of adversity must take into consideration the type of adversity, the duration and timing of the adversity, the synergistic effects of multiple forms of adversity with the child’s genetic endowment ( fig 2 ), and the social supports and interventions on which the child can depend (such as caregivers to whom the child is attached).

What can we do now?

If we wish for today’s youth to inherit a world that is safe and conducive to healthy development, we must do all we can to create such a world, by preventing disorders from developing and intervening once they are apparent.

Even for children living in adverse circumstances, much can be done now to make a difference by preventing such disorders from developing and intervening once they have surfaced. For example, we can screen children experiencing adverse life events, and once screened refer such children to early intervention services, as California is doing (see elsewhere in this collection).

Intervention strategies have been developed to help children manage their toxic stress response 7 56 and to help families cope with adversity. Many children are resilient, and physician-community partnerships can help foster resilience. 26

Recommendations for research

Much of the evidence has depended on the use of self- or parent-report measures, which are relatively easy to score, can be scaled at population level, and can be used (with modification) across cultures. However, such measures are inherently subjective and prone to biases (eg, recall bias). Other measures, such as official court or child protection records, provide a more objective assessment but often underestimate the prevalence of adversity.

Objective and subjective measures of childhood adversity identify largely non-overlapping groups of individuals 57 and, thus, may be associated with health outcomes through different pathways. Subjective experience is particularly important for psychopathology, over and above objective experience. 54

A challenge in examining the effects of adversity on development is how to compare children growing up in different cultures. For example, one study 58 reported that a questionnaire on bullying used in different cultures and countries did not generalize well (eg, how one culture interpreted bullying differed from another). Adversity and trauma should be considered in context, and investigators in different cultures may need to develop different assessments.

To move away from subjective evaluations of toxic stress (eg, self- or other-report), and to gain insight into the neural and biological mechanisms that mediate the toxic stress response, several investigators have started to develop more objective biomarker panels for screening for toxic stress that use markers of neurological, immunological, metabolic, and genetic regulatory derangements. 59 60 61 As this work continues, issues to consider include how much better (eg, as predictors) such measures are than behavior, how early in life they can be used, and whether they are scalable.

The study of toxic stress and the toxic stress response needs to move away from correlational and cross-sectional studies and deploy designs that are amenable to drawing causal inference. This would include longitudinal studies and ideally studies that involve interventions. An advantage of the latter includes the ability to shed light on mechanism.

More attention also needs to be paid to individual differences. Different people respond differently to the same stressors. For example, only a minority of children who experience trauma or maltreatment go on to develop enduring psychiatric disorders; and some children develop physical health disorders such as asthma whereas others will not. 62 In addition, individual differences exist in biological sensitivity to stressors: for example, children identified as shy or inhibited early in life may be more vulnerable to stressors than children with more robust temperaments and who are less fearful of novelty 63 64 65 and are more predisposed to anxiety as adults. 66

Recommendations for policy

Policy is only as good as the underpinning evidence, and these recommendations have sufficient evidence to support them.

Careful consideration should be given to implementing evidence-informed policies for optimizing health, nutrition, and early child development, 67 which in turn can be expanded to include older children and adolescents. Although the first three years of life are generally emphasized, older children exhibit remarkable plasticity in molding their personalities and behaviors. 27 68 Effective interventions exist to treat and possibly prevent psychopathology emerging after childhood trauma, but implementation needs to be scaled up. 7

Linking and optimizing preventive child health and education initiatives early in life are key to successful intervention 69 and need to be done at the appropriate level in the health and education systems. The development of the nurturing care framework 70 has been a welcome step in this direction, engaging platforms such as community health workers and pre-schools . 71

Community, school, and after-school based interventions can reduce the effects of traumatic events among children and adolescents living in adverse circumstances. 25 72

Public health strategies for primary, secondary, and tertiary prevention of childhood maltreatment and adversity include both universal and targeted interventions, ranging from home visiting programs to parent training programs, routine screening for adversity, and cognitive behavioral therapy. 73 74

Key recommendations

Researchers should consider both objective and subjective measures of childhood adversity

Researchers should broaden assessment of interventions beyond mental health measures to more regularly include health outcomes such as asthma, infection, inflammation, and insulin resistance

Adversity and trauma should be considered in context, and investigators in different cultures may need to develop different assessments

Researchers should consider how much better (eg, as predictors) objective biomarker panels are than behavior, how early in life they can be used, and whether they are scalable

Researchers should move towards longitudinal studies and ideally studies that involve interventions

Researchers should pay more attention to individual differences

Governments should implement evidence-informed policies for optimizing health, nutrition, and early child development

Health and education systems should link and optimize preventive child health and education initiatives early in life at the appropriate level

Use community, school, and after-school based interventions

Consider public health strategies for primary, secondary, and tertiary prevention of childhood maltreatment and adversity

Acknowledgments

We thank Lee Anglin and Lily Breen for proofing the manuscript.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Commissioned; externally peer reviewed.

This article is part of a series commissioned by The BMJ for the World Innovation Summit for Health (WISH) 2020. The BMJ peer reviewed, edited, and made the decisions to publish. The series, including open access fees, is funded by WISH.

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Diagnosis and general considerations of treatment and prevention

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childhood disease and disorder

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childhood disease and disorder , any illness , impairment, or abnormal condition that affects primarily infants and children—i.e., those in the age span that begins with the fetus and extends through adolescence.

Childhood is a period typified by change, both in the child and in the immediate environment . Changes in the child related to growth and development are so striking that it is almost as if the child were a series of distinct yet related individuals passing through infancy , childhood , and adolescence. Changes in the environment occur as the surroundings and contacts of a totally dependent infant become those of a progressively more independent child and adolescent. Health and disease during the period from conception to adolescence must be understood against this backdrop of changes.

Although, for the most part, the diseases of childhood are similar to those of the adult, there are several important differences. For example, certain specific disorders, such as precocious puberty , are unique to children; others, such as acute nephritis—inflammation of the kidney—are common in children and infrequent in adults. At the same time, some diseases that are common in adults are infrequent in children. These include essential hypertension (high blood pressure of unknown cause) and gout. Finally, a major segment of pediatric care concerns the treatment and prevention of congenital anomalies , both functional and structural.

Apart from variations in disease due to differences between children and adults, certain other features of diseases in children need to be emphasized. Infectious disorders are prevalent and remain a leading cause of death, although individual illnesses are often mild and of minor consequence. Most instances of the common communicable diseases, such as measles , chicken pox , and mumps , are encountered in childhood. Disorders of nutrition, still of great concern, especially but not exclusively in developing countries, are of extreme importance to the growing and developing child. The unique nutritional requirements of children make them unusually susceptible to deficiency states: vitamin-D deficiency causes rickets , a common disorder of children in developing countries, and only rarely causes any disease in adults. The major environmental hazards that endanger the health of young children are either unavoidable, as in air pollution , or accidental, as in poisoning and in traffic injuries. Older children, especially adolescents, are exposed, as are adults, to environmental hazards that they deliberately seek, such as cigarette smoking and the use of alcohol and other drugs.

This article reviews the scope of diseases that affect children, with particular emphasis on the ways in which the unique attributes of the growing child and special aspects of his environment serve to modify the course, effects, and treatment of particular diseases.

Diagnosis of the diseases of childhood involves special considerations and techniques; for example, in evaluating genetic disorders, not only the patient but his entire family may need to be examined. Inapparent environmental causes of diseases, such as poisonings, must be considered and investigated thoroughly, by methods that at times resemble those of a detective. Diseases of the fetus may derive directly from disorders of the mother or may be caused by drugs administered to her. Diagnostic techniques have been developed that permit sophisticated examination of the fetus despite its apparent inaccessibility. The withdrawal of a small amount of the amniotic fluid that surrounds the fetus permits examination of fetal cells as well as the fluid itself. Chromosomal and biochemical studies at various stages of development may help to anticipate problems in the postnatal period; they may indicate the need for immediate treatment of the fetus by such techniques as blood transfusion; or they may lead to the decision to terminate pregnancy because serious, untreatable disease has been recognized. Other specialized techniques permit examination of the fetus by X-ray and ultrasound, and by electrocardiography and electroencephalography (methods for observing and recording the electrical activity of the heart and the brain, respectively). Fetal blood can be obtained for analysis, and certain techniques permit direct viewing of the fetus.

In examination of the infant, inaccessibility is no special problem, but his small size and limited ability to communicate require special techniques and skills. Of even more importance, however, is the fact that adult norms cannot be applied to younger age groups. Pediatric diagnosis requires knowledge of each stage of development, with regard not only to body size but also to body proportions, sexual development, the development and function of organs, biochemical composition of the body fluids, and the activity of enzymes. The development of psychological and intellectual function is equally complex and requires special understanding. Since the various periods of growth and development differ so markedly from one another, they are divided for convenience into the following stages: intrauterine (the period before birth), neonatal (first four weeks), infant (first year), preschool (one to five years), early school (six to 10 years for girls, six to 12 for boys), prepubescent (10 to 12 for girls, 12 to 14 for boys), and adolescent (12 to 18 for girls, 14 to 20 for boys). Only if appropriate norms are established for each stage of development can the child’s condition be adequately evaluated and the results of diagnostic tests properly interpreted. Thus, it is of no concern if a 12-month-old infant is unable to walk alone, although some infants are able to do so at nine months of age. The crucial question is at what age one becomes concerned if a developmental milestone has not been reached. Five-year-old boys average 44 pounds (20 kilograms) in weight but may vary from 33 to 53 pounds (15 to 24 kilograms). The hemoglobin level that is of no concern in the three-month-old infant may reflect a serious state of anemia in the older child. The blood levels of certain enzymes and minerals differ markedly in the rapidly growing child from those in the late adolescent , whose growth is almost complete. Failure of a 15-year-old girl to have achieved menarche (the beginning of menstruation) may be indicative of no abnormality in sexual development but requires careful evaluation.

Treatment of childhood disease requires similar considerations with regard to various stages of growth and development. Variation in drug dosage, for example, is based not only on body size but also on the distribution of the drug within the body, its rate of metabolism, and its rate of excretion, all of which change during various stages of development. The inability of infants and small children to swallow pills and capsules necessitates the use of other forms and alternate routes of administration. Drug toxicity of importance at one stage of development may be of no concern at another; for example, the commonly used antibiotic tetracycline is best avoided in treatment of the child younger than age 10 because it is deposited in teeth, in which enamel is also being deposited, and stains them. When permanent teeth are fully formed, the deposition of tetracycline no longer occurs. The delayed consequences of certain forms of treatment, especially with radioactive isotopes—substances that give off radiation in the process of breaking down into other substances—might be of no consequence in the case of an elderly person with a life expectancy of 10 or 20 years but might deter a physician from the use of such treatments for the infant with his whole life in front of him. Finally, the nutritional requirements of the growing child must be considered when treatment of disease requires modification of the diet or administration of drugs that may affect the absorption or metabolism of essential nutrients.

The outlook for recovery from diseases in children is often better than it is for adults, since the child’s additional capacity of growth may counteract the adverse influences of disease. The bone fracture that results in permanent deformity in the adult, for example, may heal with complete structural normality in the child, as continued growth results in remodeling and reshaping of the bone. Ultimately, the infant who has one kidney removed because of infection or tumour most likely will have entirely normal renal (kidney) function because the remaining kidney will increase its size and functional capacity with growth. In contrast, removal of one kidney in the adult usually results in a residual functional capacity equal to 70 to 75 percent of that of two normal kidneys.

Thus, being in a period of rapid growth and development may favourably affect the child’s recovery in the course of a disease. The converse may also be true, however. The rapidly growing and maturing central nervous system , for example, is particularly susceptible to injury during the first two or three years of life; also, adolescents may react unfavourably to psychological stresses that are tolerated readily by more mature individuals.

In the general consideration of childhood diseases, a final aspect that merits emphasis is the role of prevention. The major factors responsible for the decline in infant and childhood mortality rates over the past decades have been the development and application of preventive measures. By the late 20th century, in most countries the death rate for infants under one year of age had decreased until it was scarcely more than a 10th of the rate in the 1930s. Socioeconomic factors—such as better maternal nutrition and obstetrical care and improved housing, water supplies, and sewage disposal—have been of prime importance in this decline, together with better hygiene at home, safer infant feeding techniques, and widespread immunization against common infectious diseases. In comparison to the favourable effect of these and other preventive measures, an increased capacity to treat diseases, even with such powerful tools as the antibiotic drugs, has had relatively little impact. In the developed countries, where the most common causes of childhood morbidity and mortality are accidents, prevention depends upon a willingness to design and modify communities and homes to make them safer for children. Just as important as the development of public health measures is their practical application; underutilization of established procedures and techniques for prevention of disease is a major health problem.

REVIEW article

Child and adolescent depression: a review of theories, evaluation instruments, prevention programs, and treatments.

• 1 Developmental and Educational Department, University of the Basque Country, Donostia/San Sebastián, Spain
• 2 Developmental and Educational Psychology Department, University of the Basque Country, Lejona, Spain
• 3 Personality, Evaluation and Psychological Treatments Department, University of the Basque Country, Donostia/San Sebastián, Spain

Depression is the principal cause of illness and disability in the world. Studies charting the prevalence of depression among children and adolescents report high percentages of youngsters in both groups with depressive symptoms. This review analyzes the construct and explanatory theories of depression and offers a succinct overview of the main evaluation instruments used to measure this disorder in children and adolescents, as well as the prevention programs developed for the school environment and the different types of clinical treatment provided. The analysis reveals that in mental classifications, the child depression construct is no different from the adult one, and that multiple explanatory theories must be taken into account in order to arrive at a full understanding of depression. Consequently, both treatment and prevention should also be multifactorial in nature. Although universal programs may be more appropriate due to their broad scope of application, the results are inconclusive and fail to demonstrate any solid long-term efficacy. In conclusion, we can state that: (1) There are biological factors (such as tryptophan—a building block for serotonin-depletion, for example) which strongly influence the appearance of depressive disorders; (2) Currently, negative interpersonal relations and relations with one's environment, coupled with social-cultural changes, may explain the increase observed in the prevalence of depression; (3) Many instruments can be used to evaluate depression, but it is necessary to continue to adapt tests for diagnosing the condition at an early age; (4) Prevention programs should be developed for and implemented at an early age; and (5) The majority of treatments are becoming increasingly rigorous and effective. Given that initial manifestations of depression may occur from a very early age, further and more in-depth research is required into the biological, psychological and social factors that, in an interrelated manner, may explain the appearance, development, and treatment of depression.

Introduction

Depression is the principal cause of illness and disability in the world. The World Health Organization (WHO) has been issuing warnings about this pathology for years, given that it affects over 300 million people all over the world and is characterized by a high risk of suicide (the second most common cause of death in those aged between 15 and 29) [ World Health Organization (WHO), 2017 ]. Studies on the child population which use self-reports to evaluate severe symptoms of depression, specifically the Children's Depression Inventory (CDI, Kovacs, 1992 ) and the Children's Depression Scale (CDS, Lang and Tisher, 1978 ), have observed prevalence rates of, for example, 4% in Spain ( Demir et al., 2011 ; Bernaras et al., 2013 ), 6% in Finland ( Puura et al., 1997 ), 8% in Greece ( Kleftaras and Didaskalou, 2006 ), 10% in Australia ( McCabe et al., 2011 ), and 25% in Colombia ( Vinaccia et al., 2006 ). The main classifications of mental disorders are the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 ( American Psychiatric Association, 2014 ), published by the American Psychiatric Association, which has become a key reference in clinical practice, and version 10 of the International Classification of Diseases (ICD-10, 1992), published by the WHO, which classifies and codifies all diseases, although initially its aim was to chart mortality rates. The new ICD-11 classification will be presented for approval to Member States at the World Health Assembly in May 2019, and is expected to come into effect on January 1, 2022 [ World Health Organization (WHO), 2018 ]. The two classifications offer different categorizations of depressive disorders, although certain similarities do exist, and it should be borne in mind also that both have been criticized for hardly distinguishing at all between child and adult depression.

Throughout history, there have been many different explanatory theories of depression. Biological and psychological theories are the ones which have mainly tried to explain the origin of this mental disorder. Biological theories have, from a variety of different perspectives, postulated that depression may occur due to noradrenalin deficits (e.g., Schildkraut, 1965 ; Narbona, 2014 ), endocrine disorders (e.g. Birmaher et al., 1996 ), sleep-related disorders (e.g., Sivertsen et al., 2014 ; Pariante, 2017 ), alterations in brain structure ( Whittle et al., 2014 ), or the influence of genetics ( Scourfield et al., 2003 ). Psychological theories have attempted to explain depression on the basis of psychoanalysis and, more specifically, in terms of attachment theories (e.g., Bowlby, 1976 ; Ainsworth et al., 1978 ; Blatt, 2004 ; Bigelow et al., 2018 ), behavioral models (e.g., Skinner, 1953 ; Ferster, 1966 ; Lewinsohn, 1975 ), cognitive models (e.g., Seligman, 1975 ; Abramson et al., 1978 ; Beck, 1987 ), the self-control model (e.g., Rehm, 1977 ; Rehm et al., 1979 ), interpersonal theory (e.g., Markowitz and Weissman, 1995 ; Milrod et al., 2014 ), stressful life events (e.g., Reinherz et al., 1993 ; Frank et al., 1994 ), and sociocultural models (e.g., Lorenzo-Blanco et al., 2012 ; Chang et al., 2013 ; Reeves et al., 2014 ).

Evaluating depression accurately has been another concern upon which psychology has focused, with attention being centered specifically around diagnosing this pathology in childhood and adolescence. Although many diagnostic instruments have been developed and validated, mainly for the adolescent and adult stages of life, it is still difficult to find diagnostic tests for evaluating depression in children. Preventing depression is another aspect to which much importance is attached by the World Health Organization (WHO) (2017) , which argues that school programs, interventions aimed at parents and specific exercises for the elderly population help reduce the prevalence of this pathology. Depression prevention programs do exist, but they are mainly targeted at adolescents and very few focus on children under the age of 10.

The treatment of depression is another aspect that should not be overlooked. In 2016, the WHO and the World Bank announced that investing in the treatment of depression and anxiety leads to four-fold returns, since these pathologies cost the global economy one trillion US dollars each year. Furthermore, they claimed that humanitarian emergencies and conflicts highlight a pressing need to broaden current therapeutic options. In this sense, the multiple different explanatory theories of depression have given rise to a plethora of different treatments (psychotherapeutic, behavioral, cognitive-behavioral, interpersonal, etc.) which are currently being analyzed with a high degree of precision and scientific rigor.

In light of the different aspects related to depression outlined above, the present study has the following aims: (1) To analyze the construct of depression offered by the two main mental disorder classifications (DSM-5 and ICD-10); (2) To provide an overview of the main explanatory theories of depression; (3) To outline the child and adolescent depression evaluation instruments most commonly used in scientific literature; (4) To provide a brief overview of child and adolescent depression prevention programs in the school environment; and (5) To describe the most scientifically rigorous and effective clinical treatments for this mental disorder.

The databases used for carrying out the searches were PubMed, PsycINFO, Web of Science, Scopus, Science Direct and Google Scholar, along with a range of different manuscripts. With the constant key word being depression, the search for information cross-referenced a series of other key words also, namely: childhood, adolescence, explanatory theories, etiology, evaluation instruments, prevention programs, and treatment. Searches were conducted for information published between 1970 and 2017.

Thus, first we describe the construct of depression and summarize the main explanatory theories. Next, we present the main evaluation instruments used to measure child and adolescent depression and report the results of a bibliographical review of prevention programs in school settings. Finally, we outline the main clinical treatments used nowadays to treat child and adolescent depression.

The Construct of Depression: DSM-5 and ICD-10

Depression features in both of the two most important global classifications: the DSM-5 and the ICD-10. As stated earlier in the introduction, the new ICD-11 classification will be presented for approval to Member States at the World Health Assembly in May 2019, and is expected to come into effect on January 1, 2022. The presentation of the new classification in 2019 will enable countries to plan for its implementation, prepare the necessary translations and train professionals accordingly [ World Health Organization (WHO), 2018 ]. In texts published by WHO collaborators ( Luciano, 2017 ), it has been suggested that the ICD-11 will include mood disorders within the mental and behavioral disorder category. However, until the final version is published, this information cannot be fully verified.

The two classifications (DSM-5 e IDC-10) offer different categorizations of depressive disorders, as shown in Table 1 . The WHO includes depressive disorders in the mood disorders category, although this review only focuses on Sections F32, F33, F34, and F38, which include the most frequent depressive disorders and which, in turn, contain subsections that will be further specified later on.

Table 1 . Depressive disorders according to the DSM-5 and the ICD-10.

According to the DSM-5, depressive disorders all have one common feature, namely the presence of sad, empty or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual's capacity to function (DSM-5). They may become a serious health problem if allowed to persist for long periods of time and occur with a moderate-to-severe degree of intensity. One important consequence of depression is the risk of suicide, which is, according the World Health Organization (WHO) (2017) , the second most common cause of death among young people aged between 15 and 29.

The main novelty offered by the DSM-5 in its section on depressive disorders is the introduction to Disruptive mood dysregulation disorder (which should not be diagnosed before the age of 6 or after the age of 18). This disorder is characterized by severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property). These outbursts often occur as the result of frustration and in order to be considered a diagnostic criterion must be inconsistent with the individual's developmental level, occur three or more times per week for at least a year in a number of different settings (at home, at school, etc.) and be severe in at least one of these. This disorder was added to the DSM-5 due to doubts arising in relation to how to classify and treat children presenting with chronic persistent irritability as opposed to other related disorders, specifically pediatric bipolar disorder. The prevalence of this disorder has been estimated at between 2 and 5%, with male children and teenage boys being more likely to suffer from it than their female counterparts.

Major Depressive Disorder

Major depressive disorder is characterized by a depressed mood most of the day, nearly every day, although in children and adolescents this mood may be irritable rather than depressed. The disorder causes a markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day, significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness, or excessive or inappropriate guilt, diminished ability to think or concentrate, recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In the United States, the 12-month prevalence is ~7%, although it is three times higher among those aged between 18 and 29 than among those aged 60 or over. Moreover, the prevalence rates for women are ~1.5–3 times higher than for men.

Persistent Depressive Disorder (Dysthymia)

Persistent depressive disorder (dysthymia) is a consolidation of DSM-5-defined chronic major depressive disorder and dysthymic disorder, and is characterized by a depressed mood for most of the day, for more days than not, for at least 2 years. In children and adolescents, mood can be irritable and duration must be at least 1 year. The DSM-5 specifies that patients presenting symptoms that comply with the diagnostic criteria for major depressive disorder for 2 years should also be diagnosed with persistent depressive disorder. When the individual in question is experiencing a depressive mood episode, they must also present at least two of the following symptoms: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration, or difficulty making decisions and feelings of hopelessness. The prevalence of this disorder in the United States is 0.5%.

Premenstrual Dysphoric Disorder

The diagnostic criterion for premenstrual dysphoric disorder states that, in the majority of menstrual cycles, at least five symptoms must be present during the last week before the start of menstruation, and individuals should start to feel better a few days later, with all symptoms disappearing completely or almost completely during the week after menstruation. The most important characteristics of this disorder are affective lability, intense irritability or anger, or increased interpersonal conflicts, markedly depressed mood and/or over-excitation, and symptoms of anxiety which may be accompanied by behavioral and somatic symptoms. Symptoms must be present during most menstrual cycles during the past year and must negatively affect occupational and social functioning. The most rigorous estimations of the prevalence of this disorder claim that 1.8% of women comply with the criterion but have no functional impairment, while 1.3% comply with the criterion and suffer functional impairment and other concomitant symptoms of another mental disorder.

Substance/Medication-Induced Depressive Disorder

Substance/medication-induced depressive disorder is characterized by the presence of the symptoms of a depressive disorder, such as major depressive disorder, induced by the consumption, inhalation or injection of a substance, with said symptoms persisting after the physiological effects or the effects of intoxication or withdrawal have disappeared. Some medication may generate depressive symptoms, which is why it is important to determine whether the symptoms were actually induced by the taking of the drug or whether the depressive disorder simply appeared during the period in which the medication was being taken. The prevalence of this disorder in the United States is 0.26%.

Depressive Disorder Due to Another Medical Condition

Depressive disorder due to another medical condition is characterized by the appearance of a depressed mood and a markedly diminished interest or pleasure in all activities within the context of another medical condition. The DSM-5 offers no information about the prevalence of this disorder.

The category Other specified depressive disorder is used when the symptoms characteristic of a depressive disorder appear and cause significant distress or impairment in social, occupational or other areas of functioning but do not comply with all the criteria of any depressive disorder, and the clinician opts to communicate the specific reason for this. In the Other unspecified depressive disorder category , on the other hand, the difference is that the clinician prefers not to specify the reason why the presentation fails to comply with all the criteria of a specific disorder and includes presentations about which there is insufficient information for giving a more specific diagnosis.

In the ICD-10, depressive disorders are included within the mood disorders category. The following disorders are analyzed below: single depressive episode, recurrent depressive disorder, and persistent mood (affective) disorders.

Single Depressive Episode

The classification Single depressive episode distinguishes between depressive episodes of varying severity: mild, moderate, and severe without psychotic symptoms. Characteristics common to all of them include lowering of mood, reduction of energy, and decrease in daily activity. There is a loss of interest in formerly pleasurable pursuits, a decrease in the capacity for concentration, and an increase in tiredness, even during activities requiring minimum effort. Changes occur in appetite, sleep is disturbed, self-esteem and self-confidence drop, ideas of guilt or worthlessness are present and the symptoms vary little from day to day. In its mildest form, two or three of the symptoms described above may be present, and the patient is able to continue with most of their daily activities. When the episode is moderate, four or more of the symptoms are usually present and the patient is likely to have difficulty continuing with ordinary activities. In its most severe form, several of the symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of somatic symptoms are usually present. If the depressive episode is with psychotic symptoms, it is characterized by the presence of hallucinations, delusions, psychomotor retardation, or stupor so severe that ordinary social activities are impossible; there may be danger to life from suicide, dehydration, or starvation.

Recurrent Depressive Disorder

Recurrent depressive disorder is characterized by repeated episodes of depression similar to those described above for single depressive episodes without mania. There may be brief episodes of mild mood elevation and over activity (hypomania) immediately after a depressive episode, sometimes precipitated by antidepressant treatment. The more severe forms of this disorder are very similar to manic-depressive depression, melancholia, vital depression, and endogenous depression. The first episode may occur at any age, from childhood to old age. The onset may be either acute or insidious and can last from a few weeks to many months. Recurrent depressive disorder can be mild or moderate, but in neither of these is there any history of mania. This section also includes recurrent depressive disorder currently in remission, in which the patient may have had two or more depressive episodes in the past, but has been free from depressive symptoms for several months.

Persistent Mood [Affective] Disorders

Persistent mood [affective] disorders are persistent and usually fluctuating disorders in which the majority of episodes are not sufficiently severe to warrant being diagnosed as hypomanic or mild depressive episodes. Since they last for many years and affect the patient's normal life, they involve considerable distress and disability. This section also includes cyclothymia and dysthymia. Cyclothymia is a persistent instability of mood involving numerous periods of depression and mild elation, none of which are sufficiently prolonged to justify a diagnosis of bipolar affective disorder or recurrent depressive disorder. This disorder is frequently found among the relatives of patients with bipolar affective disorder and some patients with cyclothymia eventually develop bipolar affective disorder. For its part, dysthymia is a chronic depression of mood, lasting at least several years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of mild, moderate, or severe recurrent depressive disorder.

Other Mood (Affective) Disorders

Finally, other mood (affective) disorders include any mood disorders that do not fall into the categories described above because they are not of sufficient severity or duration. They may be single, recurrent (brief), or specified episodes.

The manifestations and symptoms of depression vary in accordance with age and level of development. However, it is clear that the DSM-5 and the ICD-10 do not distinguish between adult and child depression, although by including disruptive mood dysregulation disorder, the DSM-5 does take into account the fact that children and young people aged between 7 and 18 may express their distress in other ways, through chronic, severe, and recurrent irritability manifested verbally and/or behaviorally. Similarly, major depressive disorder specifies that in children the mood may be irritable rather than depressed. However, no distinctions of this kind are found in the ICD-10, an absence which may lead to the faulty inference that the characteristics of child and adolescent depression are similar to those of adult depression.

Explanatory Theories of Depression

Depressive disorders cannot be explained by any single theory, since many different variables are involved in their onset and persistence. The principal biological and psychological theories were therefore taken as the main references for this section. Subsequently, the contributions made by each of these theories regarding depression were studied by conducting searches in PubMed, Web of Science, Science direct, and Google Scholar. With the constant key words being depression, child depression and adolescent depression, the search for information cross-referenced a series of other key words also in accordance with the specific theory in question. Due to the importance of some seminal works in relation to the development of psychological theories of depression, certain authors have remained key references for decades. A total of 64 bibliographical references were used. The following is a summary of the various explanations for the onset of depression, according to the different theoretical frameworks.

Biological Theories

If a mood disorder cannot be explained by family history or stressful life events, then it may be that the child or adolescent in question is suffering from a neurological disease. In such a case, depressive symptoms may manifest early in children and adolescents as epileptic syndromes, sleep disorders, chronic recurrent cephalalgias, several neurometabolic diseases, and intracranial tumors ( Narbona, 2014 ).

Noradrenalin Deficit

Serotonin is a monoamine linked to adrenaline, norepinephrine, and dopamine which plays a key role, particularly in the brain, since it is involved in important life regulation functions (appetite, sleep, memory, learning, temperature regulation, and social behaviors, etc.), as well as many psychiatric pathologies ( Nique et al., 2014 ). Serotonin modulates neuroplasticity, particularly during the early years of life, and dysfunctions in both systems contribute to the physiopathology of depression ( Kraus et al., 2017 ). MRI tests in animals have revealed that a reduction in neuron density and size, as well as a reduction in hippocampal volume among depressive patients may be due to serotonergic neuroplasticity changes. Branchi (2011) , however, argues that improving serotonin levels may increase the likelihood of both developing and recovering from the psychopathology, and underscores the role played by the social environment in this process. In this sense, Curley et al. (2011) point out that the quality of the social environment may influence the development and activity of neural systems, which in turn have an impact on behavioral, physiological, and emotional responses.

Endocrine Alterations

Age-related changes and the presence of biological risk factors, including endocrine, inflammatory or immune, cardiovascular and neuroanatomical factors, make people more vulnerable to depression ( Clarke and Currie, 2009 ). Indeed, some studies suggest that depression may be linked to endocrine alterations: nocturnal cortisol secretions ( Birmaher et al., 1996 ), nocturnal growth hormone secretion ( Ryan et al., 1994 ), thyroid stimulating hormone secretion ( Puig-Antich, 1987 ), melatonin and prolactin secretions ( Waterman et al., 1994 ), high cortisol levels ( Herane-Vives et al., 2018 ), or decreased growth hormone production ( Dahl et al., 2000 ). Puberty and the accompanying hormonal and physical changes require special attention because it has been proposed that they could be associated with an increased incidence of depression ( Reinecke and Simons, 2005 ).

Sleep Disorders

Sleep problems are often associated with situations of social deprivation, unemployment, or stressful life events (divorce, bad life habits, or poor working conditions) ( Garbarino et al., 2016 ). It also seems, however, that sleep disorders are linked to the development of depression. This relationship occurs as a result of how insufficient sleep affects the hippocampus, heightening neural sensitivity to excitotoxic insult and vulnerability to neurotoxic challenges, resulting in a net decrease in gray matter in the hippocampus in the left orbitofrontal cortex ( Novati et al., 2012 ).

For their part, Franzen and Buysse (2008) state that bidirectional associations between sleep disturbances (particularly insomnia) and depression make it more difficult to distinguish cause-effect relations between them. It is therefore unclear whether depression causes sleep disturbances or whether chronic sleep disturbances lead to the appearance of depression. What does seem clear, however, is that treating sleep disturbances (both insomnia and hypersomnia) may help reduce the severity of depression and accelerate recovery ( Franzen and Buysse, 2008 ).

Longitudinal studies have identified insomnia as a risk factor for the onset or recurrence of depression in young people and adults ( Sivertsen et al., 2014 ). In comparison with the non-clinical population, depressed children and adolescents report both trouble sleeping and longer sleep duration ( Accardo et al., 2012 ).

For their part, Foley and Weinraub (2017) observed that, among preadolescent girls, early and later sleep problems directly or indirectly predicted a wide variety of social and emotional adjustment disorders (depressive symptoms, low school competence, poor emotion regulation, and risk-taking behaviors).

Altered Neurotransmission

Studies conducted over the past 20 years have shown that increased inflammation and hyperactivity of the hypothalamic–pituitary–adrenal (HPA) axis may explain major depression ( Pariante, 2017 ). Some of the pathophysiological mechanisms of depression include altered neurotransmission, HPA axis abnormalities involved in chronic stress, inflammation, reduced neuroplasticity, and network dysfunction ( Dean and Keshavan, 2017 ). Other studies report alterations in the brain structure: smaller hippocampus, amygdala, and frontal lobe ( Whittle et al., 2014 ). Nevertheless, the underlying molecular and clinical mechanisms have yet to be discovered ( Pariante, 2017 ). Major depressive disorder in children and adolescents has been associated with increased intracortical facilitation, a direct neurophysiological result of excessive glutamatergic neurotransmission. However, contrary to the findings in adults with depression, no deficits in cortical inhibition were found in children and adolescents with major depressive disorder ( Croarkin et al., 2013 ).

Genetic Factors

Other studies have highlighted the importance of genetics in the onset of depression (40%) ( Scourfield et al., 2003 ). It is important to recognize that a genetic predisposition to an excessive amygdala response to stress, or a hyperactive HPA axis (moderate hyperphenylalaninemia) due to stress during early childhood may trigger an excessive effect or alter an otherwise healthy psychological system ( Dean and Keshavan, 2017 ). Kaufman et al. (2018) support a potential role for genes related to the homeobox 2 gene of Orthodenticle (OTX2) and to the OTX2-related gene in the physiopathology of stress-related depressive disorders in children. Furthermore, genetic anomalies in serotonergic transmission have been linked to depression. The serotonin-linked polymorphic region (5-HTTLPR) is a degenerate repeat in the gene which codes for the serotonin transporter (SLC6A4). The s/s genotype of this region is associated with a reduction serotonin expression, in turn linked to greater vulnerability to depression ( Caspi et al., 2010 ).

For their part, Oken et al. (2015) claim that psychological disturbances may trigger changes in physiological parameters, such as DNA transcription, or may result in epigenetic modifications which alter the sensitivity of the neurotransmitter receptor.

Psychological Theories

This section outlines the different psychological theories which have attempted to explain the phenomenon of depression. Depression is a highly complex disorder influenced by multiple factors, and it is clear that no single theory can fully explain its etiology and persistence. It is likely that a more eclectic outlook must be adopted if we are to make any progress in determining the origin, development, and maintenance of this pathology.

Attachment-Informed Theories

Attachment theory was the term used by Bowlby (1976) to refer to a specific conceptualization of human beings' propensity to establish strong and long-lasting affective ties with other people. Bowlby (1969 , 1973) proposes that consistency, nurturance, protectiveness, and responsiveness in early interactions with caregivers contribute to the development of schemas or mental representations about the relationships of oneself with others, and that these schemas serve as models for later relationships. Bowlby's ethological model of attachment postulates that vulnerability to depression stems from early experiences which failed to satisfy the child's need for security, care and comfort, as well as from the current state of their intimate relations ( Bowlby, 1969 , 1973 , 1988 ). Adverse early experiences can contribute to disturbances in early attachments, which may be associated with vulnerability for depression ( Cummings and Cicchetti, 1990 ; Joiner and Coyne, 1999 ). Associations between insecure attachment among children and negative self-concept, sensitivity to loss, and an increased risk of depression in childhood and adolescence have been reported ( Armsden et al., 1990 ; Koback et al., 1991 ; Kenny et al., 1993 ; Roelofs et al., 2006 ; Allen et al., 2007 ; Chorot et al., 2017 ). Relationships between secure attachment and depression seem also to be mediated by the development of maladaptive beliefs or schemas ( Roberts et al., 1996 ; Reinecke and Rogers, 2001 ).

Thus, attachment theory has become a useful construct for conceptualizing many different disorders and provides valuable information for the treatment of depression ( Reinecke and Simons, 2005 ).

Ainsworth described three attachment styles, in accordance with the child's response to the presence, absence, and return of the mother (or main caregiver): secure, anxious-avoidant, and anxious-resistant ( Ainsworth et al., 1978 ). The least secure attachment styles may give rise to traumatic experiences during childhood, which in turn may result in the appearance of depressive symptoms.

Similarly, Hesse and Main (2000) argued that the central mechanism regulating infant emotional survival was proximity to attachment figures, i.e., those figures who help the child cope with frightening situations. Using Ainsworth's strange situation procedure, Main (1996) found that abused children engaged in more disorganized, disruptive, aggressive, and dissociative behaviors during both childhood and adolescence. Main (1996) also found that many people with clinical disorders have insecure attachment and that psychological-disoriented and disorganized children are more vulnerable.

For his part, Blatt (2004) explored the nature of depression and the life experiences which contribute to its appearance in more depth, identifying two types of depression which, despite a common set of symptoms, nevertheless have very different roots: (1) anaclitic depression, which arises from feelings of loneliness and abandonment; and (2) introjective depression, which stems from feelings of failure and worthlessness. This distinction is consistent with psychoanalytical formulations, since it considers defenselessness/dependency and desperation/negative feelings about oneself to be two key issues in depression.

Brazelton et al. (1975) found that at age 3 weeks, babies demonstrate a series of interactive behaviors during face-to-face mother-infant interactions. These behaviors were not found to be present in more disturbed interactions, which may trigger infant anxiety.

In a longitudinal study focusing on the relationship between risk of maternal depression and infant attachment behavior, Bigelow et al. (2018) analyzed babies at age 6 weeks, 4 and 12 months, finding that mothers at risk of depression soon after the birth of their child may have difficulty responding appropriately to their infant's attachment needs, giving rise to disorganized attachment, with all the psychological consequences that this may involve. Similarly, Beeghly et al. (2017) found that among infants aged between 2 and 18 months, greater maternal social support was linked to decreasing levels of maternal depressive symptoms over time, and that boys were more vulnerable than girls to early caregiving risks such as maternal depression, with negative consequences for mother-child attachment security during toddlerhood.

Authors such as Shedler and Westen (2004) have attempted to find solutions to the problems arising in relation to the DSM diagnostic categories, developing the Shedler Westen Assessment Procedure (SWAP-200) to capture the wealth and complexity of clinical personality descriptions and to identify possible diagnostic criteria which may better define personality disorders.

For their part, Ju and Lee (2018) argue that peer attachment reduces depression levels in at-risk children, and also highlight the curative aspect of attachment between adolescent peers.

Behavioral Models

The first explanations proposed by this model argued that depression occurs due to the lack of reinforcement of previously reinforced behaviors ( Skinner, 1953 ; Ferster, 1966 ; Lewinsohn, 1975 ), an excess of avoidance behaviors and the lack of positive reinforcement ( Ferster, 1966 ) or the loss of efficiency of positive reinforcements ( Costello, 1972 ). A child with depression initially receives a lot of attention from his social environment (family, friends…), and behaviors such as crying, complaints or expressions of guilt are reinforced. When these depressive behaviors increase, the relationship with the child becomes aversive, and the people who used to accompany the child avoid being with him, which contributes to aggravating his depression ( Lewinsohn, 1974 ). Low reinforcement rates can be explained by maternal rejection and lower parental support ( Simons and Miller, 1987 ), by a lower rate of reinforcement offered to their children by mothers of depressed children ( Cole and Rehm, 1986 ), or by low social competence ( Shah and Morgan, 1996 ).

Depression is mainly a learned phenomenon, related to negative interactions between the individual and his or her environment (e.g., low rate of reinforcement or unsatisfactory social relations). These interactions are influenced by cognitions, behaviors and emotions ( Antonuccio et al., 1989 ).

Cognitive Models

The attributional reformulation of the learned helplessness model ( Abramson et al., 1978 ) and Beck's cognitive theory ( Beck et al., 1979 ) are the two most widely-accepted cognitive theories among contemporary cognitive models of depression ( Vázquez et al., 2000 ).

Learned helplessness is related to cognitive attributions, which can be specific/global, internal/external, and stable/unstable ( Hiroto and Seligman, 1975 ; Abramson et al., 1978 ). Global attribution implies the conviction that the negative event is contextually consistent rather than specific to a particular circumstance. Internal attribution is related to the belief that the aversive situation occurs due to individual conditions rather than to external circumstances. Stable attribution is the belief that the aversive situation is unchanging over time ( Miller and Seligman, 1975 ). People prone to depression attribute negative events to internal, stable and global factors and make external, unstable, and specific attributions for success ( Abramson et al., 1978 ; Peterson et al., 1993 ), a cognitive style also present in children and adolescents with depression ( Gladstone and Kaslow, 1995 ).

The Information Processing model ( Beck, 1967 ; Beck et al., 1979 ) postulates that depression is caused by particular stresses that evoke the activation of a schema that screens and codes the depressed individual's experience in a negative fashion ( Ingram, 1984 , p. 443). Beck suggests that this distortion of reality is expressed in three areas, which he calls the “cognitive triad”: negative views about oneself, the world and the future as a result of their learning history ( Beck et al., 1983 ). These beliefs are triggered by life events which hold special meaning for the subject ( Beck and Alford, 2009 ).

Self-Control Model

This theory assumes that depression is due to deficits in the self-control process, which consists of three phases: self-monitoring, self-evaluation, and self-administration of consequences ( Rehm, 1977 ; Rehm et al., 1979 ). In the self-monitoring phase, individuals attend only to negative events and tend to recognize only immediate, short-term consequences. In the self-evaluation phase, depressed individuals establish unrealistic evaluation criteria and inaccurately attribute their successes and failures. If self-evaluation is negative, in the self-administration of consequences phase the individual tends to engage very little in self-reinforcement and very frequently in self-punishment.

Both Rehm's self-control model ( Rehm, 1977 ) and Bandura's conception of child depression ( Bandura, 1977 ) assume that children internalize external control guidelines. These guidelines are related to family interaction patterns and both may contribute to the etiology or persistence of depression in children.

In a study conducted with children aged between 8 and 12 years, Kaslow et al. (1988) found that depressed children had a more depressive attributional style and more self-control problems.

Interpersonal Theory

This model, which is closely linked to attachment theories, aims to identify and find solutions for an individual's problems with depression in their interpersonal functioning. It suggests that the difficulties experienced are linked to unresolved grief, interpersonal disputes, transition roles and interpersonal deficits ( Markowitz and Weissman, 1995 ).

Milrod et al. (2014) argue that pathological attachment during early childhood has serious consequences for adults' ability to experience and internalize positive relationships.

Similarly, various different studies have highlighted the fact that one of the variables that best predicts depression in children is peer relations ( Bernaras et al., 2013 ; Garaigordobil et al., 2017 ).

Stressful Life Events

Studies focusing on the adult population have reported that between 60 and 70% of depressed adults experienced one or more stressful events during the year prior to the onset of major depression ( Frank et al., 1994 ). In children and adolescents, modest associations have been found between stressful life events and depression ( Williamson et al., 1995 ). For their part, Shapero et al. (2013) found that people who had suffered severe emotional abuse during childhood experienced higher levels of depressive symptoms when faced with current stressors. Sokratous et al. (2013) argue that the onset of depression is not only triggered by major stressful events, but rather, minor life events (dropping out of school, your father losing his job, financial difficulties in the family, losing friends, or the illness of a family member) may also influence the appearance of depressive symptoms.

Events such as the loss of loved ones, divorce of parents, mourning or exposure to suicide (either individually or collectively) have all been associated with the onset of depression in childhood ( Reinherz et al., 1993 ). Factors such as a history of additional interpersonal losses, added stress factors, a history of psychiatric problems in the family and prior psychopathology (including depression) increase the risk of depression in adolescents ( Brent et al., 1993 ). Birmaher et al. (1996) found that prior research into stressful life events in relation to early-onset depression had been based on data obtained from self-reports, making it difficult to determine the causal relationship, since events may be both the cause and consequence of depression.

However, not everyone exposed to this kind of traumatic experience becomes depressed. Personality and the moment at which events occur are both involved in the relationship between depression and stressful life events, although biological factors such as serotonergic functioning ( Caspi et al., 2010 ) also exert an influence.

Sociocultural Models

These models postulate that cultural variables are responsible for the appearance of depressive symptoms. These variables are mainly acculturation and enculturation. In acculturation, structural changes are observed (economic, political, and demographic), along with changes in people's psychological behavior ( Casullo, 2001 ). Some studies link increased suicide rates with economic recession ( Chang et al., 2013 ; Reeves et al., 2014 ). Enculturation occurs when the older generation invites, induces or forces the younger generation to adopt traditional mindsets and behaviors.

In an attempt to better understand the influence of culture and family on depressive symptoms, Lorenzo-Blanco et al. (2012) tested an acculturation, cultural values and family functioning model with Hispanic students born in the United States. The results revealed that both family conflict and family cohesion were related to depressive symptoms.

Another study carried out with girls aged 7–10 years ( Evans et al., 2013 ) observed that internalizing an unrealistically thin ideal body predicted disordered eating attitudes through body dissatisfaction, dietary restraint and depression.

Finally, the importance of family interactions in the onset of depressive symptoms cannot be overlooked. Parenting style has been identified as a key factor in children's and adolescents' psychosocial adjustment ( Lengua and Kovacs, 2005 ). Parental behavior has been studied from two different perspectives: warmth and control. Warmth is linked to aspects such as engagement and expression of affection, respect, and positive concern by parents and/or principal caregivers ( Rohner and Khaleque, 2003 ). In this sense, prior studies have identified a significant association between parental warmth and positive adjustment among adolescents ( Barber et al., 2005 ; Heider et al., 2006 ). Rohner and Khaleque (2003) argue that children's psychological adjustment is closely linked to their perception of being accepted or rejected by their principal caregivers, and other studies have found that weaker support from parents is associated with higher levels of depression and anxiety among adolescents ( Yap et al., 2014 ).

Similarly, Jaureguizar et al. (2018) found that a low level of perceived parental warmth was linked to high levels of clinical and school maladjustment, and that the weaker the parental control, the greater the clinical maladjustment. These authors also found that young people with negligent mothers and authoritarian fathers had higher levels of clinical maladjustment.

In short, according to the different theories, depression may be due to (1) biological reasons; (2) insecure attachment; (3) lack of reinforcement of previously-reinforced behaviors; (4) negative interpersonal relations and relations with one's environment and the resulting negative consequences; (5) attributions made by individuals about themselves, the world and their future; and (6) sociocultural changes. It is likely that no single theory can fully explain the genesis and persistence of depression, although currently, negative interpersonal relations and relations with one's environment and sociocultural changes (economic, political, and demographic) may explain the observed increase in the prevalence of depression.

Evaluation Instruments

Many different evaluation instruments can be used to measure child and adolescent depression. Tables 2 , 3 outline the ones most commonly used in scientific literature. Table 2 summarizes the main self-administered tests that specifically measure child and adolescent depression, while Table 3 presents tests that measure child and adolescent depression among other aspects (i.e., broader or more general tests). Finally, Table 4 summarizes the main hetero-administered psychometric tests for assessing this pathology.

Table 2 . Self-administered psychometric tests designed specifically for evaluating child and adolescent depression.

Table 3 . Self-administered general psychometric tests which, among other variables, also assess child and adolescent depression.

Table 4 . Hetero-administered psychometric tests for assessing child and adolescent depression.

As shown in the tables above, there are several self-administered instruments that can be used with children from age 6 to 7 onwards, although their duration should be taken into consideration in order to avoid overtiring subjects. While it is clear that an effort has been made to design shorter measures (compare, for example, the 66 items of the CDS with the 16 items of the longest version of the KADS), the duration of the test should not be the only aspect taken into account when selecting an evaluation instrument.

One of the most widely used instruments to measure child depression in the scientific literature is the Children's Depression Inventory-CDI ( Kovacs, 1985 ), which is based on the Beck Depression Inventory-BDI ( Beck and Beamesderfer, 1974 ). Thus, it is based on Beck's cognitive theory of depression. Following this same theoretical line, the Children's Depression Scale-CDS ( Lang and Tisher, 1978 ) was designed, but in this case, this instrument was not created based on another instrument previously designed for adult population (as in the case of the CDI), but instead from its beginnings, it was conceived exclusively to assess child depression. Chorpita et al. (2005) explain that the CDI measures a broader construct of negative affectivity rather than depression as a separate construct, and that it may be useful for screening for trait dimensions or personality features, whereas other instruments, such as the Revised Child Anxiety and Depression Scale-RCADS ( Chorpita et al., 2000 ), measure a specific clinical syndrome.

Table 2 describes many other instruments that are very useful as screening tests for depression and depressive disorder, such as the Center for Epidemiological Studies Depression Scale for Children-CES-DC ( Weissman et al., 1980 ) (based on the Center for Epidemiological Studies Depression Scale for Adults, CES-D; Radloff, 1977 ), the Mood and Feelings Questionnaire-MFQ ( Angold et al., 1995 ), or the Depression Self-Rating Scale for Children-DSRS ( Birleson, 1981 ). This last one, for example, is useful to measure moderate to severe depression in childhood and is based on the operational definition of depressive disorder, that is, a specific affective-behavior pattern that implies an impairment of a child's or adolescent's ability to function effectively in his/her environment ( Birleson, 1981 ).

The cognitive and affective component of depression is the one that is most present in the instruments described in Table 2 . In fact, for example, the Short Mood and Feelings Questionnaire (SMFQ) includes the cognitive and affective items from the original MFQ item pool, in addition to some items related to tiredness, restlessness, and poor concentration ( Angold et al., 1995 ). In the SMFQ, more than half of the items from the MFQ were removed, and even so, high correlations between the MFQ and the SMFQ were found ( Angold and Costello, 1995 ), which may be indicating that the really important items were the cognitive and affective items that were maintained. Reynolds et al. (1985) defended that children could accurately report their cognitive and affective characteristics, so “ if one wishes to know how a child feels, ask the child” ( Reynolds et al., 1985 , p. 524).

Depending on the specific aim of the evaluation or research study, a broader diagnostic measure, such as those outlined in Table 3 , may also provide valuable information. Finally, it is worth noting that only two hetero-administered instruments were found for teachers, with all others being clearly oriented toward the clinical field. In this sense, special emphasis should be placed on the need to develop valid and reliable instruments for teachers, since they may be key agents for detecting symptoms among their students. While it is important to train teachers in this sense, it is also important to provide them with instruments to help them assess their students. The instruments that are currently available have produced very different results as regards their correlation with students' self-reported symptoms, although in general, teachers tend to underestimate their students' depressive symptoms ( Jaureguizar et al., 2017 ).

Child and Adolescent Depression Prevention Programs in the School Environment

Extant scientific literature was reviewed in order to summarize the main depression prevention programs for children and adolescents in school settings. The databases used for conducting the searches were PubMed, PsycINFO, Web of Science, Scopus, Science Direct, and Google Scholar, along with a range of different manuscripts. With the constant key word being depression, the search for information cross-referenced a series of other key words also, namely: “child* OR adolescent*,” “prevent*program,” and “school OR school-based.” Searches were conducted for information published between January 1, 1970 and December 31, 2017.

First, articles were screened (i.e., their titles and abstracts were read and a decision was made regarding their possible interest for the review study). The inclusion criteria were that the study analyzed all the research subjects of the review study (depression, childhood, or adolescence and prevention programs in school settings), that study participants were aged between 6 and 18, that the study was published in a peer-reviewed journal and that it was written in either English or Spanish. Review studies and their references were also analyzed. Studies focusing mainly on psychiatric disorders other than depression were excluded.

Finally, 39 studies were selected for the review, which explored 8 prevention programs that are outlined in Table 5 . In general terms, child depression prevention programs are divided into two main categories: universal programs for the general population, and targeted programs aimed at either the at-risk population or those with a clear diagnosis. Although scientific literature reports that targeted programs obtain better outcomes than universal ones, the latter type nevertheless offer certain advantages, since they reach a larger number of people without the social stigma attached to having been specially selected ( Roberts et al., 2003 ; Huggins et al., 2008 ). Thus, the ideal context for instigating universal child depression prevention programs is the school environment.

Table 5 . School-based child and adolescent depression prevention programs.

Table 5 outlines the most important child depression prevention programs carried out in the school context. They are all cognitive-behavioral programs implemented either by psychologists or teachers with specialist training, consisting of between 8 and 15 sessions. Only a few universal programs designed to prevent the symptoms of depression focus on younger children, since most are targeted mainly at the adolescent population ( Gillham et al., 1995 ; Barrett and Turner, 2001 ; Farrell and Barrett, 2007 ; Essau et al., 2012 ; Gallegos et al., 2013 ; Rooney et al., 2013 ). Indeed, in the present review, only four universal child depression prevention programs were found that were aimed at a younger age group (between 8 and 12): the Penn Resiliency Program, FRIENDS, the Aussie Optimism Program, and FORTIUS (see Table 5 ).

As shown in the table, the results of the various programs outlined are not particularly positive, since on many occasions the effects (if there are any) are not sustained over time or are limited in scope (being dependent on who applies the program or on the sex of the participant, etc.). Nor is the distinction between universal and targeted programs particularly clear as regards their effects, since although targeted programs may initially appear to be more effective, their impact is not found to be sustained in the long term.

Greenberg et al. (2001) argue that researchers should explain whether their prevention programs focus on one or various microsystems (basically family and school), mesosystems or exosystems, etc. (following the model described by Bronfenbrenner, 1979 ), or are centered exclusively on the individual and his or her environment, since this will influence the results reported. These same authors conclude that programs focused exclusively on children and adolescents themselves are less effective than those which aim to “educate” subjects and bring about positive changes in their family and school environments.

As Calear and Christensen (2010) point out in their review, some authors suggest that the fact that some targeted programs are aimed at people with high levels of depressive symptoms entails a broader range of possibilities for change; however, this does not help us understand why these changes are not sustained over time. Thus, further research is required in this field in order to identify what specific components of those programs observed to be effective actually have a positive impact on the level of depressive symptoms, how these programs are developed, who implements them and whether or not their effects are sustained in the short, medium, and long term.

Clinical Treatments for Depression

In order to draft this section, a search was conducted for the most commonly-used therapies with proven efficacy for treating depression. The databases used were PubMed, Web of Science, Science direct, and Google Scholar. The key words used in the search were treatment, depression, child depression, and adolescent depression. A total of 30 bibliographic references were used in the drafting of this summary, including the major contribution made by The American Psychological Association's Society of Clinical Psychology ( American Psychological Association, Society of Clinical Psychology (APA), 2017 ) regarding the most effective psychological methods for treating depression.

Although the World Health Organization (WHO) (2017) claims that prevention programs reduce the risk of suffering from depression, it has yet to be ascertained what type of programs and what contents are the most effective. The WHO also states that there are effective treatments for moderate and severe depression, such as psychological treatments (behavioral activation, cognitive behavioral therapy, and interpersonal psychotherapy) and antidepressant drugs (although it also warns of adverse effects), as well as psychosocial treatments for cases of mild depression. Moreover, a study conducted with adolescents by Foster and Mohler-Kuo (2018) found that the combination of cognitive-behavioral therapy and fluoxetine (antidepressant drug) was more effective than drug therapy alone.

The efficacy of treatment with antidepressants has been called into question for some years now. Iruela et al. (2009) claim that tricyclic antidepressants (imipramine, clomipramine, amitriptyline) are not recommended in childhood and adolescence since no benefits other than the placebo effect have been proven and furthermore, they generate major side effects due to their cardiotoxicity. They are therefore particularly dangerous in cases of attempted suicide. These same authors also advise against the use of monoamine oxidase inhibitors (MAOIs) due to dietary restrictions, interactions with other medication and the lack of clinical trials with sufficiently large groups which guarantee their efficacy. SSRIs or serotonergic antidepressants are the ones that have been most extensively studied in this population. The most effective is fluoxetine, the use of which is recommended in association with cognitive psychotherapy for cases of moderate and severe child depression.

On another hand, Wagner and Ambrosini (2001) analyzed the efficacy of pharmacological treatment in children and adolescents and stated that, at best, antidepressant therapy for depressed youth was moderately effective. Peiró et al. (2005) indicate that there is a great debate about the safety of selective serotonin reuptake inhibitors (SSRIs) in childhood. SSRIs, except for fluoxetine in the United States, have never been authorized by any agency for use in children or adolescents, mainly because of the risk of suicide to which they are associated. In 1991, the Food and Drugs Administration (FDA) claimed that there was insufficient evidence to confirm a causal association between SSRIs and suicide. Vitiello and Ordoñez (2016) conducted a systematic review of the topic and found more than 30 controlled clinical trials in adolescents and a few studies with children. Most studies found no differences between studies that administered drugs and those that used placebo, but they did find fluoxetine to be effective. They noted that antidepressants increased the risk of suicide (suicidal ideation and behaviors) compared to studies that had used placebos. The authors recommend using antidepressants with caution in young people and limiting them to patients with moderate to severe depression, especially when psychosocial interventions are not effective or are not feasible.

As regards the effectiveness of psychodynamic treatments, Luyten and Blatt (2012) advocate the inclusion of psychoanalytic therapy in the treatment of child, adolescent and adult depression. After conducting a review of both the theoretical assumptions of psychodynamic treatments of depression and the evidence supporting the efficacy of these interventions, these authors concluded that brief psychoanalytic therapy (BPT) is as effective in treating depression as other active psychotherapeutic treatments or pharmacotherapy, and its effects tend to be maintained in the longer term. They also observed that the combination of BPT and medication obtained better results than medication alone. Longer-term psychoanalytic treatment (LTPT) was found to be effective for patients suffering from chronic depression and co-morbid personality problems. Together, the authors argue, these findings justify the inclusion of psychoanalytic therapy as a first-line treatment in adult, child, and adolescent depression.

In a qualitative study carried out by Brown (2018) on parents' expectations regarding the recovery of their depressed children, a direct relationship was observed between said expectations and type of attachment. Parents who remained more passive and expected expert helpers to fix their child experienced reduced hope months after finishing the program. However, when parents changed their interactions with their child and adopted more positive expectations regarding their cure, they felt a more sustained sense of hope. Moreover, when parents themselves participated in therapy sessions, as part of their child's treatment, they felt greater hope and effectiveness in contributing to their child's recovery.

The American Psychological Association's Society of Clinical Psychology [ American Psychological Association, Society of Clinical Psychology (APA), 2017 ] has published a list of psychological treatments that have been tested with the most scientific rigor and which, moreover, have been found to be most effective in treating depression. These treatments are as follows:

– Self-Management/Self-Control Therapy ( Kanfer, 1970 ). Depression is due to selective attention to negative events and immediate consequences of events, inaccurate attributions of responsibility for events, insufficient self-reinforcement, and excessive self-punishment. During therapy, the patient is provided with information about depression and taught skills they can use in their everyday life. This 10-session program can be delivered either in group or individual formats, at any age.

– Cognitive Therapy ( Beck, 1987 ). Individuals suffering from depression are taught cognitive and behavioral skills to help them develop more positive beliefs about themselves, others, and the world. Méndez (1998) argues that therapists working with depressed children should pursue three changes: (1) Learn to value their own feelings; (2) Replace behaviors which generate negative feelings with more appropriate behaviors; and (3) Modify distorted thoughts and inaccurate reasoning. The number of sessions varies between 8 and 16 in patients with mild symptoms. Those with more severe symptoms show improvement after 16 sessions.

– Interpersonal Therapy ( Klerman et al., 1984 ). García and Palazón (2010) identified four typical focal points for tension in depression, related to loss (complicated mourning), conflicts (interpersonal disputes), change (life transitions), and deficits in relations with others (interpersonal deficits), which generate and maintain a depressive state. It uses certain behavioral strategies such as problem solving and social skills training and lasts between 12 and 16 sessions in the most severe cases, and between 3 and 8 sessions in milder cases.

– Cognitive Behavioral Analysis System of Psychotherapy ( McCullough, 2000 ). This therapy combines components of cognitive, behavioral, interpersonal, and psychodynamic therapies. According to McCullough (2003) , it is the only therapy developed specifically to treat chronic depression. Patients undergoing this therapy generate more empathic behaviors and identify, change and heal interpersonal patterns related to depression. Patients are recommended to combine the therapy with a regime of antidepressant medication.

– Behavior Therapy/Behavioral Activation (BA) ( Martell et al., 2013 ). Depression prompts sufferers to disengage from their routines and become increasingly isolated. Over time, this isolation exacerbates their depressive symptoms. Depressed individuals lose opportunities to be positively reinforced through pleasant experiences or social activities. The therapy aims to increase patients' chances of being positively reinforced by increasing their activity levels and improving their social relations. The therapy usually lasts between 20 and 24 sessions, with the brief version consisting of between 8 and 15 sessions.

– Problem-Solving Therapy ( Nezu et al., 2013 ). The aim is to enhance patients' personal adjustment to their problems and stress using affective, cognitive, and behavioral strategies. The therapy usually comprises around 12 sessions, although substantial changes are generally observed from the fourth session onwards. This therapy is widely used in primary care. It is an adaptation that is easy to apply in general medicine by personnel working in those contexts, and can be completed in around 6 weeks ( Areán, 2000 ).

The treatments that, according to the American Psychological Association, Society of Clinical Psychology (APA) (2017) , have modest research support and could be used with children are as follows:

– Rational Emotive Behavioral Therapy ( Ellis, 1994 ). This short-term, present-focused therapy works on changing the thinking which contributes to emotional and behavioral problems using an active-directive, philosophical and empirical intervention model. Using the A-B-C model (A: events observed by the individual; B: Individual's interpretation of the observed event; C: Emotional consequences of the interpretations made), the aim is to bring about the cognitive restructuring of erroneous thoughts, so as to replace them with more rational ones. The most commonly used techniques are cognitive, behavioral, and emotional.

– Self-System Therapy ( Higgins, 1997 ). Depression occurs as the result of the individual's chronic failure to achieve their established goals. During therapy, patients review their situation, analyze their beliefs and, on the basis of the results, alter their regulation style and move toward a new vision of themselves. Therapy generally consists of between 20 and 25 sessions.

– Short-Term Psychodynamic Therapy ( Hilsenroth et al., 2003 ). The aim of this therapy is to help patients understand that past experiences influence current functioning, and to analyze affect and the expression of emotion. The therapy focuses on the therapeutic relationship, the facilitation of insight, the avoidance of uncomfortable topics and the identification of core conflictual relationship themes. It is usually combined with pharmacological treatment to alleviate depressive episodes.

– Emotion-Focused Therapy (emotion regulation therapy or Greenberg's experiential therapy) ( Greenberg, 2004 ). According to Greenberg et al. (2015) , this therapy combines elements of client-based practices ( Rogers, 1961 ), Gestalt therapy ( Perls et al., 1951 ), the theory of emotions and a dialectic-constructivist meta-theory. The aim is to create a safe environment in which the individual's anxiety is reduced, thereby enabling them to confront difficult emotions, raising their awareness of said emotions, exploring their emotional experiences in more depth and identifying maladaptive emotional responses. The therapy is delivered in 8–20 sessions.

– Acceptance and Commitment Therapy ( Hayes, 2005 ). This theory has become increasingly popular over recent years and is the contextual or third-generation therapy that is supported by the largest body of empirical evidence. It is based on a realization of the importance of human language in experience and behavior and aims to change the relationship individuals have with depression and their own thoughts, feelings, memories, and physical sensations that are feared or avoided. Strategies are used to teach patients to decrease avoidance and negative cognitions, and to increase focus on the present. The aim is not to modify the content of the patient's thoughts, but rather to teach them how to change the way they analyze them, since any attempt to correct thoughts may, paradoxically, only serve to intensify them ( Hayes, 2005 ).

Ferdon and Kaslow (2008) , for their part, in a theoretical review of the treatment of depression in children and adolescents, concluded that the cognitive-behavioral-therapy-based specific programs of the Penn Prevention program meet the criteria to conduct effective interventions in children with depression. In adolescent depression, the cognitive-behavioral therapy and the Interpersonal Therapy–Adolescent seem to have a well-established efficacy. Weersing et al. (2017) , in this same line, state that, although the efficacy of treatments in children is rather weak, cognitive-behavioral therapy is probably the most effective therapy. They also confirm that, in depressed adolescents, cognitive behavioral therapy, and interpersonal psychotherapy are appropriate interventions.

There are other studies also which focus on treatments for depression in childhood. For example, Crowe and McKay (2017) carried out a meta-analysis of the effects of Cognitive Behavioral Therapy (CBT) on children suffering from anxiety and depression, concluding that CBT can be considered an effective treatment for child depression. According to these authors, the majority of protocols for children have been adapted from protocols for adults, and the most common techniques are psychoeducation, self-monitoring, identification of emotions, problem solving, coping skills, and reward plans. Similarly, cognitive strategies include the identification of cognitive errors, also known as cognitive restructuring. In another meta-analysis conducted to analyze the efficacy and acceptability of CBT in cases of child depression, Yang et al. (2017) observed that, in comparison with the control groups that did not receive treatment, the experimental groups showed significant improvement, although they also pointed out that the relevance of this finding was limited due to the small size of the trial groups.

Another study carried out in Saudi Arabia concluded that student counseling in schools may help combat and directly reduce anxiety and depression levels among Saudi children and adolescents ( Alotaibi, 2015 ).

Family-based treatment may also be effective in treating the interpersonal problems and symptoms observed among depressed children. The data indicate that the characteristics of the family environment predict recovery from persistent depression among depressed children ( Tompson et al., 2016 ). In this sense, Tompson et al. (2017) compared the effects of a family-focused treatment for child depression (TCF-DI) with those of individual supportive psychotherapy among children aged 7–14 with depressive disorders. The results revealed that incorporating the family into the therapy resulted in a significant improvement in depressive symptoms, global response, functioning, and social adjustment.

To conclude this section, it can be stated that treatment for depression should be multifactorial and should bear in mind the personal characteristics of the patient, their coping strategy for problems, the type of relationship they have with themselves and the type of relationship they establish with their environment (friends, school, family, etc.). Thus, in order for the individual to attain the highest possible level of psychological wellbeing, attention should focus on both these and other related aspects.

Conclusions

The present review aims to shed some light on the complex and broad-ranging field of child and adolescent depression, starting with a review of the construct itself and its explanatory theories, before continuing on to analyze existing evaluation instruments, the main prevention programs currently being implemented and the various treatments currently being applied. All these aspects are intrinsically linked: how the concept is defined depends on the explanatory variables upon which said definition is based, and this in turn influences how we measure it and the variables we define as being key elements for its prevention and treatment.

It is interesting to note the low level of specificity of both the construct itself and the explanatory theories offered by child and adolescent psychology, which suggest that child depression can be understood on the basis of the adult version of the pathology. This may well be a basic error in our approach to depression among younger age groups. The fact that universal prevention programs specifically designed for children are obtaining only modest results may indicate that we have perhaps failed to correctly identify the key variables involved in the genesis and maintenance of child and adolescent depression.

The review of current child and adolescent depression prevention programs revealed that the vast majority coincide in adopting a cognitive-behavioral approach, with contents including social skills and problem solving training, emotional education, cognitive restructuring, and strategies for coping with anxiety. These contents are probably included because they are important elements in the treatment of depression, as shown in this review. But if their inclusion is important and effective in the treatment of depression, why do they not seem to be so effective in preventing this pathology? There are probably many factors linked to prevention programs which, in one way or another, influence their efficacy: who implements the program and what prior training they receive; the characteristics of the target group; group dynamics; how sessions are run; how the program is evaluated; and if the proposed goals are really attained (e.g., training in social skills may be key, but perhaps we are not training students correctly). Moreover, in universal prevention programs carried out in schools, the intervention focuses on students themselves rather than adopting a more holistic approach, as recommended by certain authors such as Greenberg et al. (2001) . But, if we accept that depression is multifactorial and that risk and protection factors may be found not only in the school environment but also in the family and social contexts, should prevention not also be multifactorial?

There is therefore still much work to be done in order to fully understand child and adolescent depression and its causes, and so design more effective evaluation instruments and prevention and treatment programs. Given the important social and health implications of this disorder, we need to make a concerted effort to further our research in this field.

Author Contributions

MG designed the study and wrote the protocol. EB and JJ conducted literature review and provided summaries of previous research studies, and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

The Research Project was sponsored by the Alicia Koplowitz Foundation, with grant number FP15/62.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: depression, adolescent, child, instruments, prevention, treatment

Citation: Bernaras E, Jaureguizar J and Garaigordobil M (2019) Child and Adolescent Depression: A Review of Theories, Evaluation Instruments, Prevention Programs, and Treatments. Front. Psychol. 10:543. doi: 10.3389/fpsyg.2019.00543

Received: 13 March 2018; Accepted: 25 February 2019; Published: 20 March 2019.

Reviewed by:

Copyright © 2019 Bernaras, Jaureguizar and Garaigordobil. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Joana Jaureguizar, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Children’s mental health is in crisis

As pandemic stressors continue, kids’ mental health needs to be addressed in schools

Vol. 53 No. 1 Print version: page 69

• Mental Health
• Schools and Classrooms

As the United States approaches 2 full years of the COVID-19 pandemic, mental illness and the demand for psychological services are at all-time highs—especially among children. While some children benefited from changes like remote learning , others are facing a mental health crisis. Prior to COVID-19, Centers for Disease Control and Prevention ( CDC ) data found 1 in 5 children had a mental disorder, but only about 20% of those children received care from a mental health provider. Whether kids are facing trauma because of child abuse or loss of a family member or everyday anxiety about the virus and unpredictable routines, they need even more support now—all amid a more significant shortage of children’s mental health resources.

In a 2020 survey of 1,000 parents around the country facilitated by the Ann & Robert H. Lurie Children’s Hospital of Chicago , 71% of parents said the pandemic had taken a toll on their child’s mental health, and 69% said the pandemic was the worst thing to happen to their child. A national survey of 3,300 high schoolers conducted in spring 2020 found close to a third of students felt unhappy and depressed much more than usual.

Mental health crises are also on the rise. From March 2020 to October 2020, mental health–related emergency department visits increased 24% for children ages 5 to 11 and 31% for those ages 12 to 17 compared with 2019 emergency department visits, according to CDC data (Leeb, R. T., et al., Morbidity and Mortality Weekly Report , Vol. 69, No. 45, 2020).

Emergency visits could be mitigated with more widespread outpatient care, but even before the pandemic, kids often had to wait months for appointments (Cama, S., et al., International Journal of Health Services , Vol. 47, No. 4, 2017). Only 4,000 out of more than 100,000 U.S. clinical psychologists are child and adolescent clinicians, according to APA data. School psychologists are also in short supply, leaving kids without enough support at school. The National Association of School Psychologists (NASP) recommends a ratio of 1 school psychologist per 500 students; current NASP data estimate a ratio of 1 per 1,211 students.

The pandemic has also exacerbated existing disparities in mental health services. A 2020 technical report from the University of Massachusetts Boston and the University of Massachusetts Amherst found that students who needed access to school-based services the most, particularly those with lower socioeconomic backgrounds, had lower rates of counselors and school psychologists in their districts.

While federal funding has provided schools with money to support students’ well-being, psychologists have been seeking additional long-term solutions to address the mental health problems revealed and exacerbated by the pandemic, from building mental health into school curricula to training teachers in prevention strategies to support students based on psychological science.

Here are some of the most notable ways psychologists have worked to address students’ mental health and what’s ahead.

Bringing mental health into the classroom

The American Rescue Plan Act, passed in March 2021, included $170 billion for school funding, and many schools used the funding to hire mental health workers, including psychologists. Other federal and state funding is being allocated toward training more psychologists. For example, in Nevada, which has historically ranked last in U.S. mental health, the University of Nevada, Las Vegas, received a grant to train school clinicians in urban diversity and social justice, and Nevada State College received funding to create a new program to train school mental health clinicians, including psychologists.

While the field of psychology recognizes a shortage of mental health services for kids, addressing those needs may not be a realistic solution until the workforce grows. Relying on temporary funding to hire permanent staff isn’t financially sustainable for lower-income districts, said Kenneth Polishchuk, APA’s senior director for congressional and federal relations. As a result, Polishchuk said, many schools are hiring mental health providers on a short-term basis, as well as taking a preventative approach focused on training teachers in psychological principles .

Psychologists in some districts are training teachers in basic social and emotional skills to help students cope with stress and anxiety in real time, said Kathryn H. Howell , PhD, an associate professor of child and family psychology at the University of Memphis and chair-elect of APA’s Committee on Children, Youth and Families. Howell said equipping kids with coping skills in the classroom can prevent strain on school psychologists while also improving students’ ability to learn.

“As psychologists, we don’t just want to bring in interventions that only we as experts can deliver,” Howell said. “We need to make it sustainable by teaching those on the front lines how to equip kids with the skills they need to thrive.”

Some teachers are incorporating formal mental health lessons into their curriculum with help from psychologists. New York state requires basic mental health education in health classes, and Peter Faustino, PsyD, a school psychologist in Scarsdale, New York, said he’s been receiving requests from teachers for help incorporating pandemic-relevant topics like anxiety, trauma, and warning signs of suicide into their classes. Other schools, he said, are investing in social and emotional health training programs for staff, such as Yale University’s RULER program , which teaches school leaders and teachers how to equip students with emotional intelligence skills.

Training teachers to address trauma

Along with more minor mental and behavioral health concerns, teachers are facing an unprecedented number of students with trauma, said Laurie McGarry Klose, PhD, president of NASP and director of the School Psychology Program at Trinity University in San Antonio, Texas. And many teachers don’t feel equipped to handle their students’ struggles: A 2020 survey by the New York Life Foundation and American Federation of Teachers found that only 15% of educators said they felt comfortable addressing grief or trauma tied to the pandemic.

As a result, psychologists are finding new ways to share their expertise with school personnel. For example, Samuel Song , PhD, a professor of school psychology at the University of Nevada, Las Vegas, and president of APA’s Div. 16 (School Psychology), is working on a grant with colleagues to deliver a four-part web-based curriculum on trauma-informed practices. Such programs can help teachers identify signs of trauma in students and also cope with their own trauma, which Klose says are equally important. Teachers are more likely to dismiss trauma-driven behaviors as belligerence when they’re under strain, so with proper resources and training, they can better identify kids who are struggling and route them to appropriate support services within the school system.

Mental Health Primers , developed by the Coalition for Psychology in Schools and Education, also provide information for teachers to identify behaviors in the classroom that are symptomatic of mental health and other psychological issues, with the goal of directing teachers to appropriate resources for their students.

“We know one-on-one therapy won’t be possible for every kid who’s struggling, so we need a multipronged approach to help build the capacity of teachers and staff to support kids in the classroom setting,” said Melissa Pearrow , PhD, a professor of counseling and school psychology at the University of Massachusetts Boston.

Resilience is built outside the classroom, too. Howell said psychologists and graduate students from her department at the University of Memphis are also working with local community centers to train leaders in emotional health principles. “We want to help provide mentors that can be present in kids’ lives beyond their parents, who are already dealing with a lot,” she said. “We have the expertise and scientific background, and they have expertise in working directly with families and systems, so how can we pair our expertise and learn from each other?”

Ensuring long-term resilience

While short-term crisis funding has helped many communities and schools hire mental health professionals and develop related programs, psychologists and policymakers continue to advocate for more permanent solutions. In a September 2021 address to the House Energy and Commerce Subcommittee on Oversight and Investigations , APA CEO Arthur C. Evans Jr., PhD, encouraged Congress to consider long-term investments in states’ and school systems’ mental health workforces and infrastructures. In October 2021, the Biden administration and U.S. Department of Education released new guidance for schools to better help students’ mental health needs.

Several bills could help protect kids’ mental health in the long term. President Biden proposed an additional billion dollars to procure health care professionals—including mental health professionals—in schools. As of November 2021, the bill has passed in the House and will soon go before the Senate.

Also as of November 2021, bipartisan lawmakers are working to pass the Student Mental Health Helpline Act , which would create a grant program to support existing and promote new statewide student mental health and safety helplines. The Comprehensive Mental Health in Schools Pilot Program Act, a bill referred to the House Committee on Education and Labor in May 2021, would provide resources for low-income schools to integrate social and emotional learning and evidence-based, trauma-informed practices into all aspects of the school environment. Also in May 2021, the House passed the bipartisan Mental Health Services for Students Act, which would build partnerships between schools and community-based organizations to provide school-based mental health care for students. It now awaits consideration by the Senate.

Until new laws go into effect, psychologists are committed to finding new ways to address children’s mental health, not only for their own well-being but for the common good. “It’s not only the right thing to do to make sure people can have as full a life as they possibly can,” said Alan Leshner, PhD, the former director of the National Institute on Drug Abuse and former deputy and acting director of the National Institute of Mental Health, who has recently turned his attention to student mental health as a member of the National Academies of Sciences, Engineering, and Medicine Committee on Mental Health, Substance Use, and Wellbeing in STEMM Undergraduate and Graduate Education. “Young people are critical to the future of society, so it’s in society’s interest to make sure we don’t lose the talent youth could contribute to a set of problems that can be alleviated.”

Additional resource

• Applauding the surgeon general’s December 7 advisory on ‘Protecting Youth Mental Health’  (APA Services, Inc.)

2022 trends report

• This article is part of our 14 emerging trends special report. Explore our full coverage on how the pandemic era is changing attitudes toward science and mental health .

Contact APA

• Read the complete 2022 trends report .

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Module 13: Disorders of Childhood and Adolescence

Perspectives on childhood disorders, learning objectives.

• Describe and compare viewpoints from the major psychological perspectives related to childhood disorders

The Biological Perspective

Figure 1 . Childhood disorders encompass a large category of disorders that can be explained by the interplay between biological, social/cultural, and psychological causes. Some childhood disorders, such as autism spectrum disorder, are known to have strong genetic and biological causes (autism is estimated to have a heritability rate of up to 90%, and ADHD up to 74%). Some disorders, such as learning disabilities cause by Down syndrome and fragile X syndrome can be entirely explained by biological factors. Other learning disorders and behavioral disorders have fewer biological ties and can be better explained by sociocultural and psychological factors.

As you know, the biological perspective focuses on the nature aspect regarding the etiology of childhood disorders. In other words, it looks at genetic or hereditary reasons for a disorder. Researchers and professionals who embrace this way of thinking believe that a genetic trait (something that someone is born with) is the underlying root of the mental health or development problem. Types of disorders that would fall in line with the biological perspective would be Down’s syndrome, fragile X syndrome (both caused by genetic abnormalities), and motor disorders (caused by a genetic mutation affecting the cerebrum). It is believed that various genes and gene mutations may be an underlying cause for autism. In other disorders, such as stuttering, ADHD, learning disorders, and conduct disorders, there isn’t enough evidence to suggest that nature alone is the reason for the development of these disorders, however, research suggests that there may be some familial heredity, indicating some genetic predisposition is at play. Twin studies and family mental health/development history can help researchers learn more about possible biological causes for disorders in children and adolescents.

The Sociocultural Perspective

The sociocultural perspective views a person’s behaviors and/or symptoms in light of their culture and background. A critical part of development and growth includes social activities such as education and learning. Children learn from adults who, generally, provide an explanation of what one “can” or “can’t” do, as well as providing children with a model of socially acceptable behavior; this can also be seen carried out through media and in other realms.

Psychologist Lev Vygotsky described and explained childhood disorders in light of the greater sociocultural context. For example, he viewed disorders as social abnormalities and argued that they’re not actually abnormal behaviors unless they go against what is considered normal in a social context. A disability will psychologically affect someone very differently based on various social environments. Vygotsky provided an example by mentioning that a child who was blind would have a much different experience were they a young girl in America versus a young boy in Ukraine, the child of a highly affluent German, etc. According to Vygotsky, from this social perspective, the main issue for a child with a disability, is not the development, mental or neurological problem in and of itself, but rather the social implications that it bears. [1]

It is important to always consider the cross-cultural impact of research and how treatment might look in different settings with families that have different religious beliefs, social upbringing, and cultural contexts. This may be part of the neurodiverse movement as well (mentioned previously on the page discussing autism spectrum disorder). What would it look like if those with mild ASD weren’t diagnosed but rather seen as functioning differently and socially accepted for who they were and how they interacted with the world?

The Psychodynamic Perspective

Psychodynamic theory suggests that there are three areas at work in determining a person’s personality and behavior: the id, superego, and ego. Disorders that could possibly be viewed as being “stuck” in the id could be conduct disorders since these involve more primitive drives and urges of “acting out” versus trying to live up to standards of “right” and “wrong” within socially acceptable norms.

The Humanistic Perspective

The humanistic perspective rejects the idea of biological determinism—that regardless of nature, nurture has more influence in determining the potential outcomes of one’s life. According to Rogers, parents can help their children achieve their ideal self by giving them unconditional positive regard, or unconditional love. In the development of self-concept, positive regard is key. Unconditional positive regard is an environment that is free of preconceived notions of value.

Figure 2. FAS is caused by environmental influences that cause biological damage to a developing fetus.

According to Maslow’s Hierarchy of Needs, at the very minimum, children must have their physiological, safety, and love/belonging needs met before they can achieve self-esteem and eventually, self-actualization. When the needs at the bottom of this hierarchy aren’t met (due to abuse, neglect, etc.) this can lead to mental health and emotional concerns. These challenges are what could contribute to the development of disorders. Fetal alcohol syndrome (FAS) or oppositional defiance disorder, for example, may fall in line with this viewpoint since these are seen as being caused by the environment versus having a strictly biological cause. FAS is caused by environmental exposures, such as prenatal exposure to alcohol, drugs, and toxins. Though there is some research to indicate that genes, hereditary traits, and neurobiological factors may cause ODD, there are studies that show environmental risk factors that increase the risk of development for ODD. These factors include negative parenting practices, insecure parent-child attachments, and family instability—all areas that would affect the basic physiological and safety needs of a child.

The Cognitive Perspective

Cognitive psychology focuses on studying our thoughts and their relationship to our experiences and our actions. Viewed as a cognitive disorder and treated with CBT or other types of psychotherapy, ADHD symptoms have been found to be reduced; coupled with proper medication management, functioning may greatly improve.

Conduct disorders may be another category that could be viewed from this perspective. Most theories hold that, although inhibition of antisocial conduct is primarily mediated by affective empathy (i.e., vicarious affective responsiveness), cognitive dimensions of empathy such as perspective-taking skills also play a substantial role. For instance, it has been suggested that the ability to differentiate among and identify others’ affective states and the ability to take their cognitive and affective perspective are prerequisites for empathizing and thereby inhibiting antisocial conduct. [2] With this prerequisites in mind, the types of treatments implicated could help children with conduct disorders possibly learn empathy and thus reduce symptoms of these disorders.

The Behavioral Perspective

Another way of looking at childhood disorders is through the lens of conditioning. If someone is  conditioned to act or react a certain way, this conditioning could lead to the diagnosis of certain disorders. For example, a child with a learning disorder who is shamed for doing poorly in school may become averse to going to school. Some use this explanation to argue against labeling children with disorders. On the other hand, conditioning could be used to evoke the reaction a parent wishes to see in their child, perhaps helping them sleep or concentrate better. This could be a helpful type of treatment for children with anxiety or easily distracted. [3]

This video conveys important information about the causes of neurodevelopmental disorders and how they are influenced by multiple factors.

You can view the transcript for “Neurodevelopmental disorders: Sufficient and necessary causes | NCLEX-RN | Khan Academy” here (opens in new window) .

• Gindis, Boris. (1995). The Social/Cultural Implication of Disability: Vygotsky's Paradigm for Special Education. Educational Psychologist . 30. 77–81. 10.1207/s15326985ep3002_4. ↵
• Anastassiou-Hadjicharalambous, X., & Warden, D. (2008). Cognitive and affective perspective-taking in conduct-disordered children high and low on callous-unemotional traits. Child and adolescent psychiatry and mental health , 2(1), 16. https://doi.org/10.1186/1753-2000-2-16 ↵
• Darling, N. (2018, June 18). Classical conditioning can help your child sleep and focus. Psychology Today . https://www.psychologytoday.com/us/blog/thinking-about-kids/201806/classical-conditioning-can-help-your-child-sleep-and-focus ↵
• Modification, adaptation, and original content. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY-SA: Attribution-ShareAlike
• The Humanistic Perspective. Provided by : Lumen Learning. Located at : https://courses.lumenlearning.com/wm-lifespandevelopment/chapter/the-humanistic-perspective/ . License : CC BY-SA: Attribution-ShareAlike
• ADHD. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Attention_deficit_hyperactivity_disorder#Management . License : CC BY-SA: Attribution-ShareAlike
• Cognitive and affective perspective-taking in conduct-disordered children high and low on callous-unemotional traits. Authored by : Xenia Anastassiou-Hadjicharalambous and David Warden. Provided by : Child and adolescent psychiatry and mental health. Located at : http://ncbi.nlm.nih.gov/pmc/articles/PMC2500005/ . Project : NCBI. License : CC BY: Attribution
• Fetal alcohol syndrome. Authored by : Grace Martin. Located at : https://commons.wikimedia.org/wiki/File:Fetal_Alcohol_Syndrome.svg . License : CC BY-SA: Attribution-ShareAlike
• Neurodevelopmental disorders: Sufficient and necessary causes. Provided by : Khan Academy. Located at : https://www.youtube.com/watch?time_continue=639&v=lc5XDJIgz1s&feature=emb_logo . License : Other . License Terms : Standard YouTube License

Childhood Disorders

Asperger’s, ADHD, Autism, Conduct Disorder, Oppositional Defiant, Separation Anxiety, Tourette’s

Children struggling with mental health and learning disorders are at risk for poor outcomes in school and in life.  Childhood differs from adulthood in that children experience many physical, mental, and emotional changes as they progress through their natural growth and development while learning how to cope with, adapt, and relate to others and the world around them.  Some disorders such as anxiety disorders, eating disorders, mood disorders and schizophrenia, can occur in adults as well as children while others only begin in childhood such as Aspergers, Autism, ADHD, and Tourettes.  It is not unusual for a child to have more than one disorder.

Asperger’s, conduct disorder, oppositional defiant, separation anxiety, tourette’s.

• Disorders & Issues
• Childhood Mental Disorders

Childhood Mental Disorders And Illnesses Research Articles And Resources

Ad Disclosure: Some of our MentalHelp.net recommendations, including BetterHelp, are also affiliates, and as such we may receive compensation from them if you choose to purchase products or services through the links provided

What Are Childhood Mental Disorders?

A childhood mental disorder is a significant change in behavior that causes serious problems with the way a child or adolescent functions on a daily basis. Persistent and serious disruptive behavior problems that interfere with home, play, or school activities may require intervention by a mental health professional. (1) Without proper treatment, these disorders may continue into adulthood. Like any childhood illness, the symptoms, behaviors, and problems associated with a childhood mental disorder may vary from child to child. Contributing factors such as home life, developmental strengths and weaknesses, coping mechanisms, and support systems can cause marked differences in the behaviors of different children with the same disorder. For example, in spectrum disorders such as autism , a wide range of emotional and mental disabilities and abilities may exist. On one end of the spectrum, a child with autism may be nonverbal and completely dependent, while on the other end, a child may have superior intellectual abilities while still being socially inhibited. (2)

What Causes Childhood Mental Disorders?

While some children's mental health issues are hereditary, it's more often a combination of genetics and childhood experiences that contribute to these conditions. Toxic stress , such as mental and physical abuse , bullying , or profound neglect, can cause brain damage in very young children. This damage increases the likelihood that significant mental health disorders will present themselves early on or in the future. Children exposed to family stress such as persistent poverty, domestic violence , or a parent with substance abuse issues are especially vulnerable to childhood anxiety and childhood depression . (4)

Some mental health disorders in children, such as attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder, haven't been found to have a specific cause. Theorists attribute these disorders to everything from red food dye to childhood vaccines, but there's no clinical evidence to support these claims. Research is ongoing, with one recent study finding that women who have a fever in their second trimester may have a stronger chance of having a child with autism. (5)

If these disorders and childhood illnesses are recognized and treated early, children are more likely to reach their full potential. Many adults with mental health problems say they wish they'd received treatment earlier. (6)

What Are the Symptoms of Childhood Mental Disorders?

While there isn't a single set of symptoms of childhood mental disorders, some disorders share many of the same symptoms. There's a list of warning signs parents and teachers can look out for; however, not all are indicative of mental illness. They can instead be a sign of some sort of extraordinary stress or trauma. The warning signs include: (7)

• Prolonged sadness lasting more than two weeks
• Missing or avoiding school
• Avoiding or withdrawing from social interaction
• Changes in performance in grades or extracurricular activities
• Self-abuse, such as cutting, or talking about wanting to hurt themselves
• Lack of concentration
• Speaking about suicide or death
• Frequent stomachaches or headaches
• Extreme irritability with frequent outbursts
• Trouble sleeping
• Harmful out-of-control behavior
• Unexpected weight loss or gain
• Drastic mood, personality, or behavior changes
• Sudden changes in eating habits

If your child exhibits one or more of these warning signs, consult your family physician for a complete examination to rule out physical causes. Avoid the temptation to brush it off as a stage or phase. Early diagnosis is the best way to receive much-needed support and help slow the progress of potentially dangerous mental disorders.

Does My Child Have a Mental Disorder? How Are Childhood Mental Disorders Diagnosed?

A children's mental health diagnosis is accomplished by assessing the signs and symptoms and how they affect everyday life. After a complete physical exam by your family doctor, the child may be referred to a mental health professional for further evaluation. The evaluation can include a parent's observations and concerns, academic history, the family's mental health history, and an interview with the child. A doctor will use the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a basis for a diagnosis and treatment plan. Diagnosing children is often a lengthy process because children may not comprehend or express their feelings well.

What Is the Best Treatment for Childhood Mental Disorders?

Psychotherapy , also called talk therapy, helps children learn to talk about their thoughts and feelings and how to handle them. It teaches children new behaviors and coping skills for behaviors such as anger or social anxiety. Occupational therapy and cognitive behavioral therapy can also be useful tools. Medications such as stimulants , mood stabilizers , antidepressants , antipsychotics , or antianxiety medicines, may be prescribed as part of the treatment plan. Your provider will explain each medication's side effects, benefits, and risks. It can be administered by school administrators if necessary. (7)

How to Cope With a Childhood Mental Disorder Diagnosis

Having a child with mental illness, especially a challenging disorder such as oppositional defiant disorder (ODD) , can be stressful for the entire family. Family counseling can help everyone cope. Enroll in parental training that's specific to dealing with a child with a mental disorder, and pursue stress management techniques to help unwind. Enlist the cooperation of your child's counselor and school for help with other aspects of your child's development and treatment and assistance monitoring behavior patterns when your child is outside your care.

How to Help Someone With a Childhood Mental Disorder

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Childhood anxiety disorders: lessons from the literature

Affiliation.

• 1 Anxiety Disorders Program, Hospital for Sick Children, Toronto, Ontario. [email protected]
• PMID: 11086555
• DOI: 10.1177/070674370004500805

Studies of childhood anxiety disorders have increased in recent years, but the clinical implications of the work are sometimes difficult to discern. This paper reviews salient findings (related to the assessment and management of anxious children) published in the last 5 years. The high comorbidity among disorders, the occurrence of different disorders in the same child over time, recent changes in diagnostic categories, the availability of new anxiety measures, and poor correspondence between parent and child reports of symptoms all underscore the need for thorough assessment. Increasing evidence supports cognitive-behavioural treatments for anxiety disorders, alone or in combination with pharmacotherapy. Other important aspects of management suggested by developmental studies of anxious children include psychoeducation about constitutional factors in the development of anxiety, interventions to address parental anxiety, parenting advice regarding behaviour management and reduction of family conflict, and treatment of child impairment to decrease the risk of depression. Questions requiring further research are identified.

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Impact of adverse childhood experiences in young adults and adults: a systematic literature review.

1. Introduction

2. materials and methods, reliability and validity, 3.1. antisocial and criminal behavior, 3.1.1. young adults, 3.1.2. adults, 3.2. sexual behavior and intimate partner violence, 3.2.1. young adults, 3.2.2. adults, 3.2.3. adults and young adults, 3.3. attachment, quality of life, and therapy alliance, 3.3.1. young adults, 3.3.2. adults, 4. discussion, 4.1. general impact, 4.2. personality traits and psychopathy, 4.3. aggression, 4.4. limitations, 5. conclusions, author contributions, institutional review board statement, informed consent statement, conflicts of interest.

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Share and Cite

Silva, C.; Moreira, P.; Moreira, D.S.; Rafael, F.; Rodrigues, A.; Leite, Â.; Lopes, S.; Moreira, D. Impact of Adverse Childhood Experiences in Young Adults and Adults: A Systematic Literature Review. Pediatr. Rep. 2024 , 16 , 461-481. https://doi.org/10.3390/pediatric16020040

Silva C, Moreira P, Moreira DS, Rafael F, Rodrigues A, Leite Â, Lopes S, Moreira D. Impact of Adverse Childhood Experiences in Young Adults and Adults: A Systematic Literature Review. Pediatric Reports . 2024; 16(2):461-481. https://doi.org/10.3390/pediatric16020040

Silva, Candy, Patrícia Moreira, Diana Sá Moreira, Filipa Rafael, Anabela Rodrigues, Ângela Leite, Sílvia Lopes, and Diana Moreira. 2024. "Impact of Adverse Childhood Experiences in Young Adults and Adults: A Systematic Literature Review" Pediatric Reports 16, no. 2: 461-481. https://doi.org/10.3390/pediatric16020040

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• DOI: 10.3390/children11060671
• Corpus ID: 270231950

Characteristics of Adolescents with and without a Family History of Substance Use Disorder from a Minority Cohort

• K. Cheslack-Postava , Y. Cycowicz , +10 authors Christina W. Hoven
• Published in Children 31 May 2024
• Sociology, Psychology

46 References

Delay discounting and family history of psychopathology in children ages 9–11, sex differences in stress responses among underrepresented minority adolescents at risk for substance use disorder., delay discounting and neurocognitive correlates among inner city adolescents with and without family history of substance use disorder, individualized approach to primary prevention of substance use disorder: age-related risks, substance use predicted by parental maltreatment, gender, and five-factor personality, evaluation of analysis approaches for latent class analysis with auxiliary linear growth model, shaping vulnerability to addiction – the contribution of behavior, neural circuits and molecular mechanisms, defining the phenotype of young adults with family histories of alcohol and other substance use disorders: studies from the family health patterns project., adverse childhood experience effects on opioid use initiation, injection drug use, and overdose among persons with opioid use disorder., the abcd study of neurodevelopment: identifying neurocircuit targets for prevention and treatment of adolescent substance abuse, related papers.

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Cerebral Palsy: A Narrative Review on Childhood Disorder

Sakshi basoya.

1 Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND

Sunil Kumar

Anil wanjari.

Cerebral palsy, one of the most common reasons for infirmity in children and young people in developed countries, refers to several neurological diseases that impact movement and coordination. Central nervous system damage received during the first stages of brain development can cause cerebral palsy, a non-progressive condition that manifests as impairments of movement and posture. Two cases per 1000 are reported, and the causes include those mentioned for high-risk infants. Mental retardation, sensory deficiencies, failure to thrive, seizures, and behavioral or emotional issues are some of the associated difficulties. To enable interdisciplinary intervention, early identification is crucial. The result varies depending on the topography, severity, and presence of concomitant abnormalities in cerebral palsy. Cerebral palsy is caused by a static injury to the cerebral motor cortex that happens before, during, or within five years after birth. Various circumstances can influence the disease, including cerebral anoxia, cerebral hemorrhage, infection, and hereditary disorders. Interventions for children are typically provided as part of multidisciplinary rehabilitation programs. Musculoskeletal complaints are common, and pain is a significant underreported symptom.

Introduction and background

Cerebral palsy, a leading factor in childhood impairment, is one of a variety of non-progressive postural and motor dysfunction syndromes [ 1 , 2 ]. Recent definitions allow physicians to understand more than simply the movement problem that arises from an irreversible injury to the developing brain [ 3 , 4 ]. Historically, cerebral palsy has been defined as a condition of movement and posture [ 5 ]. Complementary and alternative therapies are frequently used by families treating their progeny with cerebral palsy holistically; nevertheless, the prevalence of their usage and the price of these alternatives remain unknown [ 6 , 7 ]. Cerebral palsy is predominantly a mobility issue, but many children who have it also have additional disabilities that may lower their quality of life and shorten their lifespan [ 8 ]. Spasticity is one of the defining problems of cerebral palsy [ 5 ]. Reduced movement control, weakness, lassitude, atypical tone, atypical posture, bone deformity due to the development of muscle contracture, and pain of increased intensity that may occur during active or passive movement as well as a result of flexor or extensor spasms are some of the characteristics of upper motor neuron syndrome [ 5 ]. The four subtypes of cerebral palsy-related movement disorders include ataxia, mixed/other, dyskinesia, and spasticity. The most prevalent mobility difficulty in 80% of kids with cerebral palsy is spasticity [ 9 , 10 ]. The aim of the article is to spread knowledge about cerebral palsy and available treatment modalities in society.

Search methodology

We undertook a systematic search through PubMed, Google Scholar, National Library of Medicine, Proceedings of the National Academy of Sciences and Central in May 2023 using keywords such as “Cerebral palsy”, “musculoskeletal complaints”, “spastic tetraplegia”, “spasticity”, and “sensory deficits” (((Cerebral palsy (Title/Abstract)) OR (Cerebral palsy (MeSH Terms))), (musculoskeletal complaints (Title/Abstract)) OR ((musculoskeletal complaints (MeSH Terms)), (spastic tetraplegia (Title/Abstract)) OR (spastic tetraplegia (MeSH Terms)) and (spasticity (Title/Abstract)) and (spasticity (MeSH Terms)). The selection of the studies depended on the following inclusion criteria: (1) cerebral palsy (its occurrence in children); (2) pattern of presentation in children; (3) musculoskeletal complaints; and (4) English language. The following were the exclusion criteria: (1) case study; (2) animal studies; (3) bench research; (4) not an empirical study (e.g., theory or opinion articles); and (5) non-English language research. Figure ​ Figure1 1 shows preferred reporting items for systematic reviews and meta-analysis flow diagram for a literature search.

Adopted from the preferred reporting items for systematic reviews and meta-analysis (PRISMA)

Etiology of cerebral palsy

Brain damage or improper prenatal or neonatal brain development causes cerebral palsy. The non-progressive ("static") condition known as cerebral palsy can appear before, during, or after childbirth. The etiology of a patient is usually complex [ 11 ]. These causes can be separated into three categories: prenatal, perinatal, and postnatal causes. Some of the prenatal diseases known to play a part in the development of cerebral palsy include chromosomal abnormalities, intrauterine infections, intrauterine stroke, and congenital brain malformation [ 12 ]. The perinatal causes of cerebral palsy include hypoxic-ischemic insults, central nervous system (CNS) infections, strokes, and kernicterus [ 13 ]. In the category of postnatal causes, there are both accidental and unintentional CNS infections, strokes, and anoxic insults [ 11 ]. Cerebral palsy is far more likely to occur in premature babies. Additional risk factors for cerebral palsy in multiple pregnancies include intrauterine growth restriction, maternal drug abuse, hypertension, chorioamnionitis, aberrant placental pathology, meconium aspiration, newborn hypoglycemia, and genetic predisposition [ 14 , 15 ]. Figure ​ Figure2 2 shows the pathophysiology of cerebral palsy in a flow diagram manner.

Credit: Image created by the author

Classification of cerebral palsy

According to the kind of movement issue that is present (spastic, athetoid, ataxic, or mixed), the body parts affected (hemiplegia, diplegia, or quadriplegia), or the functions impacted (mild, moderate, severe, or profound), cerebral palsy is frequently categorized [ 4 ]. Spastic cerebral palsy comes in many types depending on the body parts affected [ 16 ]. In spastic hemiplegia or hemiparesis unilateral side of the body is affected by the arm, hand, and occasionally the leg. While intellect is often normal, children of this kind may experience delays in their ability to speak. Spastic diplegia or diparesis causes less damage to the arms and face in people of this kind, who often suffer muscular stiffness in the legs [ 17 ]. Language proficiency and intelligence are typically average. Spastic quadriplegia or quadriparesis is the most severe kind of cerebral palsy, characterized by a floppy, or weak, neck and extreme rigidity in the limbs and legs. Spastic quadriplegics are typically unable to walk and frequently have speech difficulties. Intellectual or developmental disability of this kind can range from mild to severe.

Dyskinetic cerebral palsy is a kind that entails erratic hand movements, feet, arms, or legs that are sluggish and out of control [ 16 ]. Some kids may drool or make faces due to hyperactive facial and tongue muscles. People with this kind frequently struggle to walk or sit upright. Intellectual difficulties are typically absent in people with dyskinetic cerebral palsy. Ataxic cerebral palsy has an impact on balance and depth perception. When walking or performing rapid or precise actions like writing, buttoning a shirt, or reaching for a book, people with ataxic cerebral palsy have difficulty [ 16 ]. In mixed types of cerebral palsy, the symptoms overlap with those of the other types which are spastic, dyskinesia, and ataxic.

Clinical presentation of cerebral palsy

Cerebral palsy presents with a variety of signs and symptoms, but the primary ones are motor problems, sensory deficiencies, and related comorbidities that result from static damage to the developing brain. Communication occurs between the cerebral cortex, thalamus, basal ganglia, brain stem, cerebellum, spinal cord, and communicating sensorimotor channels to normal coordination of motion [ 18 ]. This complex network is exposed to risk on many different fronts. As the kid gets older, these indications and symptoms evolve, and new traits are added to the list. These include functional gastrointestinal disorders causing bowel blockage, emesis, and difficulty in passing stool, as well as spasticity and contractures, poor feeding, salivation, communication challenges, osteopenia, osteoporosis, fractures, and pain [ 19 ]. Figure ​ Figure3 3 shows the symptoms of cerebral palsy in children. Clinically, it is determined by a subjective physical examination, and it is frequently rated using the Modified Tardieu Scale and Modified Ashworth Scale in order to determine severity. Unwanted, regularly recurring, involuntary movements known as dyskinesias are generally caused by sickness or harm to deep brain regions.

Credit: Image created by the author Sakshi Basoya

Clinical Presentation of Hemiplegic Cerebral Palsy

Clinical features of hemiplegic cerebral palsy include decreased movement on the affected side, early hand effect (damage to the hands is more severe than that to the legs), delayed walking, hemicircumductive gait, increased muscle tone, tiptoe walking (which is caused by increased tone in the gastrocnemius muscle), Babinski is positive, and deep tendon reflexes are present.

Clinical Presentation of Diplegic Cerebral Palsy

Commando crawl is characterized by increased tone in the lower limbs, difficulty changing diapers, leg spasticity, ankle clones, and excessive hip adduction. Additionally, the Babinski sign is positive on both sides, scissoring is visible on axillary suspension, equinovarus deformity is visible, and an unproportionate increase in the size of the upper torso is present along with normal intelligence.

Clinical Presentation of Spastic Quadriplegic Cerebral Palsy

This kind of cerebral palsy is the most prevalent and severe. The characteristics of spastic cerebral palsy include upper motor neuron hypertonia, mental retardation, seizures, difficulty swallowing, increased tone in all limbs, brisk reflexes, bilaterally positive Babinski sign, flexion contraction of the ankle and wrist, delay in meeting developmental milestones, microcephaly, and speech and hearing issues that cause a difference in the child's development compared to other children of the same age.

Diagnosis of cerebral palsy

A clinical diagnosis of cerebral palsy is usually made before the age of two, with the majority of cases being identified in the first year of life [ 20 ]. Though not every symptom or indication is present in every person, it is diagnosed based on both clinical symptoms and neurological indicators. It's crucial to avoid making the diagnosis too early in infancy, especially if the symptoms are mild, as early neuromotor abnormalities might resolve, especially in preterm newborns [ 21 ]. It's critical to exclude genetic and metabolic conditions that manifest with symptoms similar to cerebral palsy. To make an early diagnosis (including eliminating masqueraders) and to help choose a course of therapy, it is critical to identify particular etiologies. The first stage in the etiologic examination is the brain MRI, which is the acknowledged standard screening evaluation for all people with cerebral palsy. About 83-86% of people with cerebral palsy have macroscopic aftereffects of brain damage or abnormalities [ 22 ]. Labeling children as having cerebral palsy only based on aberrant examination findings without supporting evidence of activity limitation is not helpful; instead, the degree of activity limitation should be described. Brain imaging can be beneficial in locating the underlying problem in the brain and occasionally offers etiologically pertinent information. A clinical assessment for cerebral palsy is typically prompted by a child's failure to meet expected developmental milestones, particularly in babies who have risk factors for the condition [ 23 ]. The existence of aberrant brain imaging is not a criterion for diagnosis, nor is it a conclusive indicator of cerebral palsy in the absence of motor symptoms [ 20 ]. In order to properly organize and carry out an early intervention program for a child with cerebral palsy, a complete neurodevelopmental assessment of the child should also evaluate any accompanying deficiencies [ 24 ].

Management of cerebral palsy

A team approach is most helpful for treating children with cerebral palsy; the team should include an orthopedist and doctor. Good sitting posture, preventing hip dislocation (spastic hip disease), and maintaining appropriate custodial care are top priorities in the non-ambulatory patient [ 4 ]. Every child is different and has differing degrees of disability. Although classification is crucial for identifying each child's disability and organizing the administration of care, each child's requirements must be considered when designing a treatment plan. Spastic cerebral palsy most frequently takes place in this type. Because of their rigid muscles, people with spastic cerebral palsy frequently make jerky motions. In order for the child with cerebral palsy to receive the greatest care possible, his or her family and community must be considered [ 25 ]. Early identification has become essential in the medical care of cerebral palsy, and it is thought that this would provide patients early access to treatments that could naturally alter the trajectory of the disorder [ 26 ]. These experts may play a number of distinct roles in looking after a patient with the disorder, depending on the setting in which they operate. Given the wide range of functional deficits and the possibility of temporal fluctuation, a customized therapeutic approach is needed. Treatment options are often symptomatic in order to promote independence, function, and/or ease of care while reducing adverse effects [ 25 ]. Only the child's epilepsy may be treated at a different hospital [ 27 ]. Adults and children should be provided primary care by physicians with the assistance of specialists in neurology, orthopedics, and rehabilitation medicine [ 28 ]. Doctors should work with them as well as educators, nurses, social workers, and rehabilitation therapists. Due to mounting evidence of neuroplasticity, the focus of rehabilitation therapy has lately switched to neurological rehabilitation. This strategy takes advantage of the brain's innate ability to evolve and adapt throughout a patient's life in order to enhance growth and function [ 28 ]. People with cerebral palsy live longer than the average population; thus, therapies must be developed to meet their needs as they age. Therefore, effective therapy often requires multidisciplinary support from families, healthcare professionals, therapists, educators, and other community members while taking cognition, language, learning, and behavior into consideration [ 22 ]. The foundation of habilitative and rehabilitative care for persons with cerebral palsy has traditionally been physical therapy and other non-pharmacologic therapies. There are many different non-pharmacologic treatments available, and more are always being created.

By blocking the sensory portion of the deep tendon reflex, the widely used neurosurgical surgery known as selective dorsal rhizotomy (SDR) reduces spasticity mostly in the legs. Children with spastic diplegia (without dystonia), which is frequently caused by periventricular leukomalacia, who are capable of participating in SDR, have strong antigravity muscles, have selective motor control, and have not responded to less invasive interventions, are most likely to benefit from extensive rehabilitation [ 29 - 31 ]. Electrodes are implanted during deep brain stimulation (DBS) in deep gray areas like the globus pallidus. A generator positioned subcutaneously in the upper chest regulates stimulation. More broadly, the outcome data in individuals with dyskinetic cerebral palsy are scarce and inconsistent. With some notable exceptions, DYT1 dystonia often responds well to DBS, particularly in patients with shorter disease duration and no orthopedic deformity. However, subsequent worsening of dystonia may occur [ 32 - 35 ]. Table ​ Table1 1 gives the summary of the studies included in the narrative review.

DBS: Deep brain stimulation

Conclusions

Cerebral palsy, despite being classified as a developmental brain injury, cannot be consistently or clearly linked to certain brain lesions. It is a complicated, diverse condition. The existence of a developmental disruption leading to motor or postural deficits is the only feature of cerebral palsy. Few animal models of cerebral palsy have successfully replicated the motor symptoms of the condition, an important aspect of the diagnosis, despite the fact that many have concentrated on inducing a brain lesion. It is believed that with the development of biomarker discovery, our comprehension of the etiopathophysiology of cerebral palsy will also grow, opening up additional potential for creating innovative prognoses and therapies. It is linked to pregnancy and birth problems, including "birth asphyxia" and low birth weight.

The authors have declared that no competing interests exist.

Author Contributions

Concept and design:   Sakshi Basoya, Sunil Kumar, Anil Wanjari

Acquisition, analysis, or interpretation of data:   Sakshi Basoya, Sunil Kumar, Anil Wanjari

Drafting of the manuscript:   Sakshi Basoya, Sunil Kumar, Anil Wanjari

Critical review of the manuscript for important intellectual content:   Sakshi Basoya, Sunil Kumar, Anil Wanjari

Supervision:   Sunil Kumar, Anil Wanjari

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