chronic illness in children is already heartbreaking, adding to this depression and the equation is far more disastrous

1.  By Eman Basil EL Sabbagh
Prof. Dr Hesham Safouh unit

2. Are they sad or Are they depressed?
 Depression in children and teenagers is
different from the feelings of sadness and
other everyday emotions that most children
experience.
 If a child or teenager’s symptoms become
persistent, disruptive, and interfere with social
activities, interests, schoolwork and family life,
he or she may be depressed.

3.  Depression is one of the most common
complications of chronic illness.
 It is estimated that up to one-third of individuals
with a serious medical condition experience
symptoms of depression.

4. Common chronic diseases
associated with depression
 Cancer e.g. leukemia, lymphomas
 Respiratory e.g. Asthma, Cystic fibrosis
 Renal e.g. Chronic renal failure
 Hematological e.g. Hemophilia, Thalasemia
 Rheumatology: e.g. SLE, Rheumatoid artheritis, FMF
 Endocrine e.g. Diabetes
 Neurological e.g. Epilepsy, myopathy
 Cardiology e.g. Heart failure, Rheumatic heart
disease
 HIV, HBV, HCV
 Metabolic diseases e.g. wilson, gaucher, niemann
pick

5. It is very tricky to diagnose
depression in a chronically ill child
 Some of the symptoms of depression may overlap
the symptoms of the chronic disease. For example,
the chronic disease may make her tired and cause
her to sleep more.
 She may also lose interest in activities that she
usually finds enjoyable because the chronic disease
now makes them difficult to do.
 the chronic disease or the medications she takes to
treat the disease may cause her to eat more, or
make it difficult for her to concentrate.
 if child feels sad or gloomy most of the time, has lost
interest in his usual activities for 2 or more weeks,
and shows some of the other symptoms listed, he
may have depression.

6. Symptoms of depression in a child
1. Grumpy, irritable or sad mood
2. Loss of interest or enjoyment in activities that she typically finds fun
3. Inappropriate feelings of guilt, worthlessness, inadequacy, or
incompetence
4. Poor or increased appetite; weight gain or loss
5. Insomnia, or sleeping more than usual
6. Low energy or exhaustion after doing simple tasks
7. Feelings of hopelessness
8. Decrease in productivity (e.g., being absent from school more than
usual, cutting classes, or a drop in grades)
9. Trouble thinking or making decisions
10. Outbursts of shouting, complaining or crying
11. Excessive boredom
12. Loss of interest in friends and poor communication with people
13. Fear of death
14. Sensitivity to rejection or failure
15. Acting recklessly

7. How is a child's life affected
by a chronic disease?
 Discomfort or loss of energy
 Restriction of activities
 Disruption of his life due to medical
treatment
 Isolation from family and friends
 Feeling self-conscious, embarrassed, or
stigmatized if his disease makes him
different from other people

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

10. 2) Treatments for chronic
disease
 How a child's chronic disease is treated medically may
lead to depression in two ways:
1. The medications for the chronic disease may cause depression. For
example, depression is a side effect of high doses of prednisone, a
drug used to treat severe asthma, arthritis, and inflammatory bowel
disease. Depression can also be caused by phenobarbital, a
medication used to treat children with epilepsy.
2. The treatment regimen may be difficult to follow. A child or adolescent
may have to change his lifestyle or need help to follow his treatment
regimen. The lifestyle changes may mean he can no longer do certain
activities that were pleasurable, and this may make him feel unhappy.
Similarly, relying on other people to help him with her treatment (for
example, reminding him to take him medication) may make him feel
like he cannot do things for himself and lower his self-esteem.

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

12. 4) Loss of social contact with
people
 A child's chronic disease may cause him to
lose contact with people for many reasons:
1. He may have less energy or less time to do
things he finds pleasurable.
2. Healthy friends may assume that he cannot
act like them so they spend less time with him.
3. In immune deficient children, parents tend to
isolate their children to protect them from any
possible source of infection
 Regardless of the reason, loss of social
contact may be upsetting to the child and lead
to depression.

13. 5) The chronic disease may
be stressful to the family
 A chronic disease affects not just the child but the
whole family.
 Family members may have to take on new roles
 they may be disappointed that they can no longer
participate in activities that they all used to enjoy
together.
 They might feel some how blamed for their child
illness which can be reflected in form of
overprotection or negligence
 The resultant stress may give rise to conflict in the
family, which in turn may lead to depression in the
child.

14. 6) Chemicals in the brain
 Chemicals in the brain that cause some
of the symptoms of chronic disease also
cause depression.
 For example, pain from a child's chronic
disease may be related to too little
serotonin, a chemical in his brain. When
he doesn't have enough serotonin, he
may also be depressed.

15. Why is depression a problem
for children with a chronic
disease?
 Depression is harmful whether or not a
child has a chronic disease
 However, if a child has a chronic
disease and is also depressed, the
problems are compounded

16. Why is depression a problem for
children with a chronic disease? (
Cont.)
1- Chronic disease symptoms may increase or get worse. For
example, children with juvenile diabetes and depression
have a greater risk of having eye problems than children
with juvenile diabetes who are not depressed.
2-The risk of dying from the chronic disease is increased when
the child is depressed. For example, depression has been
found to increase the risk of death in people with asthma.
3-Child may be hospitalized more frequently and for longer
durations.
4-The child may not be motivated to take good care of himself
if he is depressed.

18. Role of parents
 Parents can help by being present for all procedures,
staying with their child (when possible) during
hospitalizations and interacting with them as much as
possible
 Parents can help by allowing children to help in the
management of their illness (with supervision), as this
increases compliance.
 Parents should also reassure their children that the
illness is not their fault
 Parents should help facilitate their child’s participation
in school or other activities to the extent allowed by
the child’s doctors. Parents should avoid being over
protective

19. Role of Physicians
 Develop new coping strategies for the chronic disease e.g.
1- positive reappraisal (reassessing the disease in a positive light)
2-putting in perspective (making a rational assessment of the impact of illness)
3- positive refocusing (shifting one’s thoughts to pleasant matters)
4-focusing on planning (using one’s energy to plan for the future, and make the
best of the situation)
 Change the medication used to treat the chronic disease if depression is a side-
effect of the drug
 Enroll the child or family in a support group
 Have the child seen in individual psychotherapy or begin family therapy
 Change the child's lifestyle to reduce stress levels e.g. healthy food and enough
sleep
 Take medication for the depression

20. Role of society
 Awareness campaigns for children at
schools
 Funding psychotherapy centers that
treat chronically ill children for free
 Arranging events for the sick children to
meet and have fun