According to the DSM-IV, the criteria for diagnosing childhood and adolescent depression are identical to those for adults, apart from the fact that irritability can appear instead of sadness. In addition, the depressed child tends to exhibit anxiety symptoms (for example, abandonment anxiety), somatic complaints and behavioural modifications to a greater extent than adults. This clinical profile, even though it is not specific, must cause the clinician to suspect depression.
The age of the depressed child and his/her mental level play a central role in the clinical profile of the disorder. Most children do not demonstrate affective verbal expressions before the age of 7. They express depression by means of nonverbal communication, such as facial expressions or bodily stance, whose exact interpretation by the clinician demands considerable experience and sensitivity. At school age, not only does the child's ability to verbally describe his/her mood improve, but teachers' parameters are added as well as the child's functional level in school as a means of evaluating his/her condition. In adolescence, depression becomes gradually more similar to adult depression.
In treating the child who is suffering from ADHD, it is important to remember that psychostimulants are liable to arouse a clinical depression which was previously covert. Depressive symptoms also play a prominent role in the clinic for children with CD/ODD. On the other hand, a behaviour disorder may lead the child to recurrent social failures that in turn lead to damage of self-worth and subsequently to depression. Accordingly, depression is one of the main phenomena that must be examined and discounted in children exhibiting any kind of behaviour disorder. This demand is especially vital in light of the empathic failure that these children create, due to which internalizing disorders are not examined or diagnosed sufficiently .
PTSD is also characterized by a high prevalence of depressive symptoms. Many children who exhibit clinical depression conceal a history of acute or chronic trauma. In addition, these children are liable to be ''many-layered'': i.e. depression may be the most prominent clinical feature, and only a more in-depth evaluation will make it possible to locate the old trauma and other characteristics of PTSD, which are hiding beneath the behavioural turmoil. This combination of PTSD and depression is one of the most challenging and difficult to decipher conditions among those included under the heading of ''the difficult child''.
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