Child: care, health and development 1975, h 225-232
Physical signs in association with depressive illness in childhood A. MACAUSLAN Clinical Assistant in charge of the Reading Difficulties Clinic, St Thomas's Hospital^ London SEi yEH Accepted for publication 16 Jxme 1975
SUMMARY Although behavioural disturbances associated with depression in childhood are often discussed, descriptions of somatic phenomena are less commonly reported. This paper compares the frequency of neurological signs observed in a group of depressed children with a control group. The possibility that minimal brain dysfunction might play a part in the production of signs is considered. It was found that there was a statistically significant difference between the incidence of physical signs found in the control group and in the depressed children. Depression in children has been described by a number of authors. The symptoms considered to be typical of the condition are persistently lowered moodj sleep disturbances, social withdrawal, fears about death, non-attendance at school, aggression, somatic disturbances and general anxiety (Toolan 1962, Murray 1970, Cytryn et al. 1972, Kielholz 1972, Rideau 1972). It has been recognized that the form of the illness varies not only with the personality of the patient but also with his or her stage of developmental progress (Frommer 1972). A psychiatrist's view of a depressed child is necessarily focused on the mood and behavioural problems arising from the disease, and although comment about somatic symptoms may be made (Frommer 1968, Annell 1972), it is unusual for somatic signs to be recorded unless enuresis and encopresis be included amongst these. However, the strong and important association between organic brain dysfunction and child psychiatric disorder has been demonstrated in the Isle of Wight Study, though obvious depressive disorders were found to be rare (Rutter et al. 1970a, b). Moreover, there is evidence to suggest that affective disorders have a biochemical basis (Robins & Hartman 1972). In order therefore to explore the possibility that depressive illness in children might be associated with somatic dysfunction, a group of depressed children and a group of controls were subjected to a series of neurological tests. 225
The control group consisted of 17 children aged between 6 and 11 years, who attended a primary school in Central London and who were chosen as neither their fanuUes, their teacher nor their family doctors were concerned about their behaviour, their scholastic achievement or their health. Their reading and spelling abilities were known to be within the average expected for their chronological ages. The majority were re-examined after approximately i year. The depressed group consisted of 25 children aged between 7 and 13 years, the diagnosis of depression having been made in the Child Psychiatric Department of St Thomas's Hospital, and their IQs having been estimated and found to be within the normal range by the psychologist. The majority were also re-examined after approximately i year.
THE TEST SERIES
The battery consisted of five tests, four of which had been validated by other authors (Barges & Lezine 1965, Paine & Oppe 1966, Touwen & Prechtl 1970). The exact technique used is described in the Appendix, those for fingertip touching, diadochokinesis, graphaesthesia and right/left differentiation on others being unaltered. The test for overflow movements was an adaptation of that described by Fog & Fog (1963). Positive findings were recorded in all cases if the immature rather than the mature form was observed, irrespective ofthe age ofthe child performing the task, and, in the relevant tests, failure to achieve a negative result with either hand was recorded as positive.
Both groups were subjected to the same series of neurological tests (see below). Alteration in the performance of any one of these tests could be expected to change from an immature to a mature form during the development of a normal child. In four ofthe tests this change could be expected to occur about the age of 8.
SIGNIFICANCE OF MINIMAL CEREBRAL DYSFUNCTION
Because it was felt that the presence of minimal brain dysfunction (Bax &
Depressive illness in childhood
TABLE I. Controls without possible minimal brain dysfunction
Case nutnber I 2
3 4 5 6 7 8 9 ro
Age at Age at first Number of second Number of History examination physical examination physical (pre- and peri-natal) (years) signs (years) signs Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant
7-01 701 801
7-08 7-08 9'io 9-07 9-05 ro-o7 1008 10-10
2 2 0 0 0 0
TABLE 2. Controls vnth possible minimal brain dysfunction
Case number II 12
14 15 16
Age at Age at first Number of second Number of History examination physical examination physical (pre- and peri-natal) (years) signs (years) signs Maternal toxaemia of pregnancy Maternal toxaemia of pregnancy Active maternal tuberculosis, fetal distress Premature birth Immature bone age, ? cause Maternal tuberculosis and pyelitis Maternal anaemia
7 06 7-06
TABLE 3. Depressed children without possible minimal brain dysfunction
Case number 18 19 20 21 22
23 24 25 26 27 28
Age at second Number of Age at first Number of examination physical examination physical History (years) signs (years) signs (pre- and peri-natal) Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant Nil relevant • Nil relevant Nil relevant
7-07 708 807 808
9 06 9'07 1000 10
4 4 4 5 3 4
II 03 1207
8ro 10-01 9-08
MacKeith 1963) might influence the results, the control group has been subdivided into those without a history suggesting this condition (Table i) and those with such a history (Table 2), and the depressed group similarly, no history (Table 3), and possible history (Table 4). Pasamanick & Rnobloch (1966) have expressed the view that the complications of pregnancy and prematurity are of greater importance in the production of neuropsychiatric disorders of children ±an are the complications of labour, though more recent evidence suggests that difficult labour resulting in perinatal anoxia may be signiflcant (Towbin 1971, Goldberg & Schifiman 1972). Therefore those children who had a history ei±er of prenatal or perinatal trauma have been designated as being at risk of minimal brain dysftmction.
RESULTS AKD CONCLUSIONS
I Figure i shows the mean number of physical signs plotted against the mean age for the subgroup at the first and second examination separately for each of the four subgroups. For each subgroup, except the control children with no history of minimal brain dysfunction (normals), there is a statistically significant drop in the number of physical signs observed on the second examination (Po-o$) between those with a history and those without, and no interaction between 'history' and 'depression* (P>005).
Depressive illness in childhood
COMMENT The finding of some signs in children of an early age may be regarded as normal for that age, but are regarded as indicating a delay in development of the child when found to be present in an older age group. The test series used in this study is constructed to ehcit signs of this type. The presence of a greater incidence of physical signs amongst the depressed children than amongst the normal controls, suggests that depressive disease in children can produce somatic signs of developmental significance. ACKNOWLEDGEMENTS I would like to express my thanks to the Research (Endowments) Committee of St Thomas's Hospital who made the work at the Hospital possible, and to the Department of Health and Social Security for providing support under the terms of ECN 764 for the work at the School. I am very grateful to Dr E. Frommer and Dr J. Scopes for their advice and encouragement, and to Dr A. J. Fox for his invaluable assistance with the statistics.
The test series
Fingertip touching The procedure described by Touwen & Prechtl (1970) was used, a child's inability to place either of his index fingers correctly on the examiner's finger being recorded as positive. Diadochokinesis The procedure by Touwen & Prechtl (1970) was used, a positive result being recorded if pronation and supination were awkward, the elbow moving over a distance of 5-15 cm. Overfiow movements Fog & Fog (1963) described a hand/hand test, the child exerting pressure with the thumb and first finger, a similar movement being observed in the other hand. An adaptation of this procedure was used, the child being asked to grip the examiner's forefinger firmly with one hand whilst opening and closing the other, A positive was recorded when the examiner felt synchronous pressure exerted on/his forefinger. Graphaesthesia The procedure described by Paine & Oppe (1966) was used, a positive being recorded if the child failed to recognize the numerals i, 8 and o traced on either palm. Right and left differentiation The procedure described by Berges & Lezine (1965) was usedj a positive being scored if the child failed to recognize right or left on the examiner. REFERENCES A.-L. (1972) Depressive states in childhood and adolescence. In Proceedings of the Fourth U.E.P. Congress, Stockholm, ed. Annell A.-L.j pp. 11-26. Almqvist & Wiksell, Stockholm
& MACKEITH R . (1963) Minimal Cerebral Dysfunction. Clinics in Developmental Medicine 00. 10. Spastics Society and Heinemann, London BERGES J. & LEZINE L (1965) The Imitation of Gestures. Clinics in Developmental Medicine no. 18. Spastics Society and Heinemann, London CYTRYN L . & MCKNEW D . H . (1972) Proposed classification of childhood depression. American Journal of Psychiatry 129, 149-155 FOG E . & FOG M . (1963) Cerebral inhibition examined by associated movements. In Clinics in Developmental Medicine no. 10, ed. Bax M. & MacKeith R. Spastics Society and Heinemann, London FROMMER E.A. (1968) Depressive illness in childhood. In Recent Developments in Affective Disorders, ed. Coppen A. & Walk A. British Journal of Psychiatry Special Publication, no. 2 R.M.P.A., London FROMMER E.A. (1972) Diagnosis and Treatment in Clinical Child Psychiatry. Heinemaim, London GOLDBERG H . K . & SCHIFFMANN G . B . (1972) Dyslexia. Grune & Stratton, New York KiELHOLZ P. (1972) Aetiologische Faktoren bei Depression. In Proceedings of the Fourth U.E.P. Congress^ Stockholm, ed. Annell A.-L., pp. 63-74. Almqvist & Wiksell, Stockholm MURRAY P . A . (1970) The clinical picture of depression in school children. ^owrKa/ of the Irish Medical Association 63, 53-56 PAINE S. & OPPE T.E. (1966) Neurological Examination of Children. Spastics Society and Heinemann, London PASAMANICK B . & KNOBLOCH H . (1966) Retrospective studies in the epidemiology of reproductive casualty. Merrill-Palmer Quarterly of Behaviour and Development 12, 7-26 RiDEAu A. (1972) Les etats depressifs du debile profund jeune. In Proceedings of the Fourth U.E.P. Congress, Stockholm, ed. Annell A.-L., pp. 126-132. Almqvist & Wiksell, Stockholm ROBINS E . & HARTMAN B . K . (1972) Biochemical Theories of Mental Disorders In Basic Neurochemistry, ed. Albers R.W., Siegel G.J., Katzman R. & AgranofF B.W. Little, Brown, Boston RUTTER M . , GRAHAM P. & YULE W . (19703) A Neuropsychiatric Study in Childhood. Spastics Society and Heinemann, London RUTTER M . , TIZARD J. & WHITMORE K. (1970b) Education, Health and Behaviour. Longman, London TOOLAN J.M. (1962) Depression in children and adolescents. American Journal of Orthopsychiatry 32, 404-415 TOUWEN B . C . L . & PRECHTL H.F.R. (1970) The Neurological Examination of the Child with Minor Nervous Dysfunction. Spastics Society and Heinemann, London TowBiN A. (1971) Organic causes of minimal brain dysfunction. Journal of the American Medical Association 217 (9), 1207-1214 BAX M .