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Depression and suicide in children and adolescents: a spiritual perspective.

Depression in children and in adolescents refers to an enduring mood change with associated changes in important aspects of daily functioning, such as attention, appetite, and sleep. Suicidal behavior is a symptom, not a diagnosis, linked to depression. While depression is a condition with multiple etiologic factors, most can be encompassed in an interactive model--depression occurs when a vulnerable child interacts with a stressful environment. The point prevalence of depression ranges from 1 to 3% in prepubertal children and from 3 to 9% in adolescents, indicating that advancing age is a risk factor in depression. (1) Thus, any consideration of depression in children and adolescents must consider developmental factors. Children have a relative biologic vulnerability to depression, some more so than others, but this will not be reviewed here. This short report will focus on the relationship of emotional development to spiritual factors in the onset and maintenance of depression in children and adolescents.

Unarguably, the primary emotional developmental need of young children is to be safely and securely attached, or bonded, to parent or to caregiver. This protects against depression and, when absent, is strongly associated with depression. (2,3) Children who lack an attachment to a caregiver do not internalize a sense of self-efficacy and are prone to the development of the cognitive distortions so prominent in many instances of adult depression (eg, "I am not a person worthy of others' interest," or, in the vernacular of children, "No one loves me"). Interestingly, children who experience a constant availability of parents can be prone to depression as well. In such instances, children are not given the opportunity to learn from a specific challenge, as the overly available parent often removes the problem before the child has had a chance to address it himself.

Adolescence is the period of development during which a child negotiates the transition from the dependence of childhood to the independence of young adulthood. Perturbations in this process are also associated with depression and associated symptoms. Families who restrict their adolescent's developing need for autonomy often encounter strong resistance. In the temperamentally-assertive youth, this can clinically present as anger and, indeed, as rage. In the more timid adolescent, depression can result in a sense of helplessness and of feeling trapped. On the other hand, parents who do not provide appropriate limits, structure, and supervision for their children can engender depression, hopelessness, and a feeling of alienation from others. Adolescents can become suicidal when their hopelessness seems without end and their problems seem without solution.

Emotional development in children and adolescents must consider the influence of the family. Whether it is the child's need for trust and attachment or the adolescent's need for independence, the family regulates this process. (4) The family's spiritual perspective, or worldview, has only recently begun to receive significant attention in psychiatry, although it is certainly an important component which should be considered in any family assessment.

A healthy family environment with a high degree of marital commitment is instrumental in providing mental health benefits for children and adolescents. Research findings have supported a positive association between spirituality/religiosity and such supportive family environments. (5) Spirituality also models forgiveness for transgressions, a component in healing, increasingly recognized in secular settings. (6) In the right balance, families with a spiritual orientation are often available to their children because they believe God is available to them. Their spiritual resources and those of a spiritual community are an antidote to depression. In adolescence, spiritual families set clear limits on behavior, especially developing sexual impulses. These limits are freeing in that they protect adolescents from early sexual activity, increasingly seen as a major risk factor in adolescent depression. (7)

Yet these familial factors--availability in childhood and structure and limits in adolescence--can become contributors to psychopathology if taken to the extreme. Spiritual perspectives often can fuel overavailability or overprotectiveness. Religious families can see their children as "gifts from God" who require protection from a world which is sinful. By protecting them from the threatening external environment, families place children at risk for poor coping skills, a contributor to depression. In adolescence, rigid and unyielding limit-setting can also be supported by spiritual positions, which use religious precepts to support restrictiveness. (8) Moral failings in the family (eg, a parent's affair) can predispose to depression in children through the mechanism of increasing familial tensions. Such stressful events require a moral, or spiritual, intervention.

The busy clinician who encounters depressed children and adolescents should first consider family resources, both in the ability of the family to provide for medical treatments as well as in the ability of the family to understand psychological needs. Is the family unavailable--or too available--in responding to the child's needs? Does the family appropriately balance the adolescent's need for autonomy with clear limits and expectations? In addressing these questions, inquiry regarding the family's spiritual perspective can help determine whether spirituality is a resource needing enhancement or a harmful factor needing intervention. In either case, in complex situations, it may be necessary to refer to a mental health clinician knowledgeable in spiritual matters or a clergyperson knowledgeable in depression.

References

1. Waslick BD, Kandel R, Kakouros A. Depression in children and adolescents: An overview. In: Shaffer D, Waslick BD. The Many Faces of Depression in Children and Adolescents. Washington, DC, American Psychiatric Publishing, 2002.

2. Bowlby J. Attachment and Loss. London, Hogarth Press, 1969.

3. Sexson SB, Glanville DN, Kaslow NJ. Attachment and depression. Implications for family therapy. Child Adolesc Psychiatr Clin N Am 2001;10:465-486.

4. Josephson AM, Moncher F. Observation, interview, and mental status assessment (OIM): family unit. In: Noshpitz J, Harrison SI, Eth S, eds. Handbook of Child and Adolescent Psychiatry, vol. 5. New York, John Wiley and Sons, 1998, pp 393-414.

5. Mabe PA, Josephson AM. Child and adolescent psychopathology: spiritual and religious perspectives. Child Adolesc Psychiatr Clin N Am 2004;13:111-125.

6. McCullough ME, Pargament KI, Thoresen CE. Forgiveness: Theory, Research, and Practice. New York, Guilford Press, 2000.

7. Hallfors D, Waller M, Bauer D, et al. Which comes first in adolescence-sex and drugs or depression? Am J Prev Med 2005;29:163-170.

8. Josephson A. The interactional problems of Christian families and their relationship to developmental psychopathology: Implications for treatment. Journal of Psychology and Christianity 1993;2:312-328.
I am a firm believer in the people. If given the truth, they can be
dependent upon to meet any national crisis. The great point is to bring
them the real facts.
--Abraham Lincoln


Allan M. Josephson, MD

From the Bingham Child Guidance Center and the Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY.

Reprint requests to Allan M. Josephson, MD. Chief Executive Officer, Bingham Child Guidance Center, Professor and Chief, Division of Child and Adolescent Psychiatry, University of Louisville School of Medicine, Department of Psychiatry and Behavioral Sciences, 200 E. Chestnut Street, Louisville, KY 40202. Email: allan.josephson@louisville.edu
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Title Annotation:Special Section: Spirituality/Medicine Interface Project
Author:Josephson, Allan M.
Publication:Southern Medical Journal
Geographic Code:1USA
Date:Jul 1, 2007
Words:1162
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