Depression and grief
Diagnostic criteria for episodes of major depression from the DSM IV (APA, 1994) and lCD 10 (ICD, 1992) classification systems are presented in Figure 9 .1. Major depression is a recurrent condition involving low mood; selective attention to negative features of the environment; a pessimistic cognitive style; self-defeating behaviour patterns; a disturbance of sleep and appetite; and a disruption of interpersonal relationships (Harrington, 1993; Kovacs, 1997; Reynolds and Johnson, 1994). Loss is often the core theme linking these clinical features: loss of an important relationship, loss of some valued attribute such as athletic ability or health, or loss of status. With respect to perception, having suffered a loss, depressed children tend to perceive the world as if further losses were probable. Depressed children selectively attend to negative features of the environment and this in turn leads them to engage in depressive cognitions and unrewarding behaviour patterns which further entrench their depressed mood. In severe cases of adolescent depression, youngsters may report mood congruent auditory hallucinations. With respect to cognition, depressed children describe themselves, the world and the future in negative terms. They evaluate themselves as worthless and are critical of their academic, athletic, musical and social accomplishments. Often this negative self-evaluation is expressed as guilt for not living up to certain standards or letting others down. They see their world, including family, friends and school as unrewarding, critical and hostile or apathetic. They describe the future in bleak terms and report little if any hope that things will improve. Where they report extreme hopelessness and this is coupled with excessive guilt for which they believe they should be punished, suicidal ideas or intentions may be reported. Extremely negative thoughts about the self, the world and the future may be woven
Depression and grief 205 together in severe cases into depressive delusional systems. In addition to the content of the depressed youngster's thought being bleak, they also display logical errors in their thinking and concentration problems. Errors in reasoning are marked by a tendency to maximize the significance and implications of negative events and minimize the significance of positive events. Concentration and attention difficulties lead to difficulties managing school work or leisure activities demanding sustained attention. With respect to affect, low mood is a core feature of depression.