Depression as a Continuum

Psychological adjustment problems are common for youngsters affected by physical conditions; however, many of the psychological symptoms that are recognized by the pediatrician or assessed by the mental health clinician do not meet threshold criteria for a DSM-IV-TR diagnosis (Bennett 1994). Evidence strongly suggests that these subthreshold symptoms of depression may impact outcome and should be a focus of intervention (Oguz et al. 2002; Todaro et al. 2000). In a study of 159 children ages 4-16 undergoing tonsillectomy, 17% had transient symptoms of a depressive episode, which had resolved 3 months later, suggesting the need to identify at-risk populations prior to procedures and to provide follow-up for persistent cases (Papakostas et al. 2003).

Another significant contributory factor to the presentation of psychological distress in the pediat-ric patient is the presence or absence of social support. In studies examining depression in patients with chronic illness, absence of social support has been associated with the onset of depressive symptoms (von Weiss et al. 2002). Further complicating the assessment of depression are the predictable grief reactions that accompany the diagnosis of a new chronic physical illness. Although most patients will move beyond this mourning and learn to live with their chronic illness, those with more risk factors, such as prior histories of depression, high familial conflict, or early life trauma, are likely to develop a depressive disorder.

The factors described above contribute to the differing meanings of depression in the medical setting. Depression may range from a transient mood change requiring no treatment to a severe clinical disorder associated with thoughts of death requiring psychiatric hospitalization (Beasley and Beardslee 1998). Because of their focus on severe psychopa-thology, mental health classification systems may be of limited value to pediatricians considering a wider range of behavioral and emotional symptoms. To address this issue, the Diagnostic and Statistical Manual for Primary Care, Child and Adolescent Version, has been introduced to provide a system to identify and classify emotional disorders ranging on a continuum from developmental variation to problem to disorder (Wolraich et al. 1996).

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