Depression in Children and Teens
What is depression in children and teens?
Depression is a serious mood disorder that can take the joy from a child’s life. It is normal for a child to be moody or sad from time to time. You can expect these feelings after the death of a pet or a move to a new city. But if these feelings last for weeks or months, they may be a sign of depression.
Experts used to think that only adults could get depression. Now we know that even a young child can have depression that needs treatment to improve. As many as 2 out of 100 young children and 8 out of 100 teens have serious depression.footnote 1
Still, many children don’t get the treatment they need. This is partly because it can be hard to tell the difference between depression and normal moodiness. Also, depression may not look the same in a child as in an adult.
If you are worried about your child, learn more about the symptoms in children. Talk to your child to see how he or she is feeling. If you think your child is depressed, talk to your doctor or a counselor. The sooner a child gets treatment, the sooner he or she will start to feel better.
What are the symptoms?
A child may be depressed if he or she:
- Is irritable, sad, withdrawn, or bored most of the time.
- Does not take pleasure in things he or she used to enjoy.
A child who is depressed may also:
- Lose or gain weight.
- Sleep too much or too little.
- Feel hopeless, worthless, or guilty.
- Have trouble concentrating, thinking, or making decisions.
- Think about death or suicide a lot.
The symptoms of depression are often overlooked at first. It can be hard to see that symptoms are all part of the same problem.
Also, the symptoms may be different depending on how old the child is.
- Both very young children and grade-school children may lack energy and become withdrawn. They may show little emotion, seem to feel hopeless, and have trouble sleeping. Often they will lose interest in friends and activities they liked before. They may complain of headaches or stomachaches. A child may be more anxious or clingy with caregivers.
- Teens may sleep a lot or move or speak more slowly than usual. Some teens and children with severe depression may see or hear things that aren’t there (hallucinate) or have false beliefs (delusions).
Depression can range from mild to severe. A child who feels a little “down” most of the time for a year or more may have a milder, ongoing form of depression called dysthymia (say “dis-THY-mee-uh”). In its most severe form, depression can cause a child to lose hope and want to die.
Whether depression is mild or severe, there are treatments that can help.
What causes depression?
Just what causes depression is not well understood. But it is linked to a problem with activity levels in certain parts of the brain as well as an imbalance of brain chemicals that affect mood. Things that may cause these problems include:
- Stressful events, such as changing schools, going through a divorce, or losing a close family member or friend.
- Some medicines, such as steroids or opioids for pain relief.
- Family history. In some children, depression seems to be inherited.
How is depression diagnosed?
To diagnose depression, a doctor may do a physical exam and ask questions about your child’s past health. You and your child may be asked to fill out a form about your child’s symptoms. The doctor may ask your child questions to learn more about how he or she thinks, acts, and feels.
It is common for children with depression to have other problems too, such as anxiety, attention deficit hyperactivity disorder (ADHD), or an eating disorder. The doctor may ask questions about these problems to help your child get the right diagnosis and treatment.
How is it treated?
Usually one of the first steps in treating depression is education for the child and his or her family. Teaching both the child and the family about depression can be a big help. It makes them less likely to blame themselves for the problem. Sometimes it can help other family members see that they are also depressed.
Counseling may help the child feel better. The type of counseling will depend on the age of the child. For young children, play therapy may be best. Older children and teens may benefit from cognitive-behavioral therapy. This type of counseling can help them change negative thoughts that make them feel bad.
Medicine may be an option if the child is very depressed. Combining antidepressant medicine with counseling often works best. A child with severe depression may need to be treated in the hospital.
There are some things you can do at home to help your child start to feel better.
- Encourage your child to get regular exercise, spend time with supportive friends, eat healthy foods, and get enough sleep.
- See that your child takes any medicine as prescribed and goes to all follow-up appointments.
- Make time to talk and listen to your child. Ask how he or she is feeling. Express your love and support.
- Remind your child that things will get better in time.
What should you know about antidepressant medicines?
Antidepressant medicines often work well for children who are depressed. But there are some important things you should know about these medicines.
- Children who take antidepressants should be watched closely. These medicines may increase the risk that a child will think about or try suicide, especially in the first few weeks of use. If your child takes an antidepressant, learn the warning signs of suicide, and get help right away if you see any of them. Common warning signs include:
- Talking, drawing, or writing about death.
- Giving away belongings.
- Withdrawing from family and friends.
- Having a plan, such as a gun or pills.
- Your child may start to feel better after 1 to 3 weeks of taking antidepressant medicine. But it can take as many as 6 to 8 weeks to see more improvement. Make sure your child takes antidepressants as prescribed and keeps taking them so they have time to work.
- A child may need to try several different antidepressants to find one that works. If you notice any warning signs or have concerns about the medicine, or if you do not notice any improvement by 3 weeks, talk to your child’s doctor.
- Do not let a child suddenly stop taking antidepressants. This could be dangerous. Your doctor can help you taper off the dose slowly to prevent problems.
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Depression is thought to be caused by an imbalance of chemicals called neurotransmitters that send messages between nerve cells in your brain. Some of these chemicals, such as serotonin, help regulate mood. If these mood-influencing chemicals get out of balance, depression or other mood disorders can result. Experts have not yet identified why neurotransmitters become imbalanced. They believe a change can occur as a response to stress or illness. But a change may also occur with no obvious trigger.
There are several things known to increase the chances that a young person may become depressed.
- Depression runs in families. Children and teens who have a parent with depression are more likely to develop depression than children with parents who are not depressed. Experts believe that both inherited traits (genetics) as well as living with a parent who is depressed can cause depression.
- Depression in children and teens may be linked to stress, social problems, and unresolved family conflict. It can also be linked to traumatic events, such as violence, abuse, or neglect.
- Certain thinking patterns and coping styles may make some children and teens more likely to develop depression.
- Children or teens who have long-term or serious medical conditions, learning problems, or behavior problems are more likely to develop depression.
- Some medicines can trigger depression, such as steroids or opioids for pain relief. As soon as the medicine is stopped, symptoms usually disappear.
- Alcohol and drug use may trigger depression in children and teens.
The symptoms of depression are often subtle at first. They may occur suddenly or happen slowly over time. It can be hard to recognize that symptoms may be connected and that your child might have depression.
- Unexplained aches and pains, such as headaches or stomach pain
- Trouble sleeping, or sleeping too much
- Changes in eating habits that lead to weight gain or loss or not making expected weight gains
- Constant tiredness, lack of energy
- Body movements that seem slow, restless, or agitated
Mental or emotional symptoms
- Irritability or temper tantrums
- Difficulty thinking and making decisions
- Having low self-esteem, being self-critical, and/or feeling that others are unfairly critical
- Feelings of guilt and hopelessness
- Social withdrawal, such as lack of interest in friends
- Anxiety, such as worrying too much or fearing separation from a parent
- Thinking about death or feeling suicidal
It’s important to watch for warning signs of suicide in your child or teen. These signs may change with age. Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.
Depression can have symptoms that are similar to those caused by other conditions.
Less common symptoms
Severely depressed children may also have other symptoms, such as:
- Hearing voices that aren’t there (hallucinations).
- Having false but firmly held beliefs (delusions).
Normal moodiness vs. depression
Telling the difference between normal moodiness and symptoms of depression can be hard. Occasional feelings of sadness or irritability are normal. They allow the child to process grief or cope with the challenges of life.
For example, grieving (bereavement) is a normal response to loss, such as the death of a family member or even the death a pet, loss of a friendship, or parents’ divorce. After a severe loss, a child may remain sad for a longer period of time.
But when these emotions do not go away or begin to interfere with the young person’s life, he or she may need treatment.
Some children who are first diagnosed with depression are later diagnosed with bipolar disorder. Children or teens with bipolar disorder have extreme mood swings between depression and bouts of mania (very high energy, agitation, or irritability).
It can be hard to tell the difference between bipolar disorder and depression. It is common for children with bipolar disorder to first be diagnosed with only depression and later to be diagnosed with bipolar disorder after a first manic episode. Although depression is part of the condition, bipolar disorder requires different treatment than depression alone.
Like depression, bipolar disorder runs in families. So be sure to tell your doctor if your child has a family history of bipolar disorder. For more information on bipolar disorder, see the topic Bipolar Disorder in Children and Teens.
At first, depression in a child or teen may appear as irritability, sadness, or sudden, unexplained crying. He or she may lose interest in activities enjoyed in the past or may feel unloved and hopeless. He or she may have problems in school and become withdrawn or defiant.
An episode of depression lasts an average of 8 months.footnote 1 Even with successful treatment, as many as 40 out of 100 children with depression will have another episode within a few years.footnote 2
Less than half of children and teens with depression receive treatment.footnote 3 This may be partly due to the old belief that young people don’t get depression.
Also, teens often do not seek help for depression. They may think feeling bad is normal, or they may blame something else (or themselves) for their symptoms. Or they may not know where to go for help. Tell your child to ask for help if he or she feels bad. And let your child know who to go to for help with depression or other problems.
Drugs and alcohol
Some teens will have alcohol or drug use problems along with depression. When this happens, depression is harder to treat, and it can take longer for treatment to work. Drug or alcohol use also increases the risk of suicide.
Early diagnosis and treatment of depression and good communication with your child can help prevent substance use. For more information about substance use in young people, see the topic Teen Alcohol and Drug Use.
Often a child who is depressed will have other disorders along with depression, such as an anxiety disorder, a behavior disorder like attention deficit hyperactivity disorder (ADHD), an eating disorder, or a learning disorder.
These problems may occur before a young person becomes depressed. Some children with depression develop serious behavior problems (conduct disorder), often after becoming depressed. If your child has one of these disorders, it may require treatment along with depression.
Children and teens with depression are also at a higher risk for problems such as:
- Poor school or job performance.
- Problems in relationships with peers and family members.
- Early pregnancy.
- Physical illness.
Treatment in the hospital
For severe depression, your child may need to be hospitalized, especially if he or she is out of touch with reality (psychotic) or is having thoughts of suicide.
During treatment for depression, make sure that your child takes medicines and attends counseling appointments as directed, even if he or she feels better. A common cause of relapse is stopping treatment too soon.
Suicide and depression
It’s very important to recognize the warning signs of suicide in your child or teen. Carefully watch for signs of suicidal behavior if your child has recently:
- Broken up with a girlfriend or boyfriend.
- Had disciplinary troubles in school or with the law.
- Had problems with poor grades or had trouble learning.
- Had family problems.
- Been the victim of repeated bullying.
- Had substance use problems.
- Started, stopped, or changed doses of an antidepressant medicine.
It is extremely important that you take all threats of suicide seriously and seek immediate treatment for your child or teenager. If you are a child or teen and have these feelings, talk with your parents, an adult friend, or your doctor right away to get some help. If your child is suicidal, call 911 or other emergency services immediately.
What Increases Your Risk
Several things increase a young person’s chance of developing depression. These include:
- Having a parent or immediate family member who is depressed. This is the most important risk factor for depression. Children or teens who have a parent with depression are up to 3 times more likely to develop depression.
- Having been depressed before, especially if depression first occurred at an early age.
- Having a long-term medical condition, such as diabetes or epilepsy.
- Having another mental disorder, such as conduct disorder or an anxiety disorder.
- Having a family member or close friend die.
- Being physically or sexually abused.
- Having problems with alcohol or drug use.
Other risk factors for depression include:
- Being a girl in early puberty. Until puberty, boys and girls have an equal risk for depression. After puberty and as adults, females are twice as likely as males to become depressed.
- Being exposed to repeated family conflict.
- Not having good social relationships with peers.
- Being a bully or a victim of bullying.footnote 4
When should you call your doctor?
Call 911, the national suicide hotline at 1-800-273-TALK (1-800-273-8255), or other emergency services right away if:
- Your child is thinking seriously of suicide or has recently tried suicide. Serious signs include these thoughts:
- Has decided how to kill himself or herself, such as with a weapon or pills.
- Has set a time, place, and means to do it.
- Thinks there is no other way to solve the problem or end the pain.
- Your child feels he cannot stop from hurting himself or someone else.
Call a doctor right away if:
- Your child hears voices.
- Your child has been thinking about death or suicide a lot but does not have a suicide plan.
- Your child is worried a lot that the feelings of depression or thoughts of suicide are not going away.
Seek care soon if:
- Your child has symptoms of depression, such as:
- Feeling sad or hopeless, or being irritable.
- Not enjoying anything.
- Often complaining of stomachaches or headaches.
- Having trouble with sleep.
- Feeling guilty.
- Feeling anxious or worried.
- Your child has been treated for depression for more than 3 weeks but is not getting better.
Who to see
Treatment for depression may involve professional counseling, medicines, education about depression for your child and your family, or a combination of these. It is important that your child establish a long-term and comfortable relationship with the care providers for the treatment of depression.
Your child may be diagnosed and treated by more than one health professional, including a:
- Family medicine physician.
- Physician assistant.
- Nurse practitioner.
Professional counseling (or psychotherapy) for depression can be provided by a:
Other health professionals who also may be trained in counseling include a:
Exams and Tests
Your doctor or another health professional will evaluate and diagnose depression in your child by asking questions about your child’s medical history and conducting tests to find out if symptoms are caused by something other than depression. Your child may be given a physical exam or blood tests to rule out conditions such as hypothyroidism and anemia. Your child may be asked to complete a mental health assessment, which tests his or her ability to think, reason, and remember.
You may be asked to help complete a pediatric symptom checklist, a brief screening questionnaire that helps to diagnose depression or other psychological problems in children. Also, your child may be asked to take a short written or verbal test for depression.
Sometimes a more thorough evaluation may be needed to fully assess your child’s depression. Interviews may be conducted with the parents or with other people who know the young person well. Specific information may be obtained from the child’s teachers or from social service workers.
The sooner treatment begins for depression, the sooner your child is likely to recover. Waiting to seek treatment for depression may mean a longer and more difficult recovery.
Treatment typically includes professional counseling, medicines, and education about depression for your child and your family.
Home treatment is an important part of treating depression. It includes regular exercise, healthy eating, and getting enough sleep.
Medicines used to treat childhood depression include several types of drugs called antidepressants.
An important part of treatment is making sure that your child takes medicines as prescribed. Often people who feel better after taking an antidepressant for a period of time may feel like they are “cured” and no longer need treatment. But when medicine is stopped too early, symptoms usually return. So it is important that your child follows the treatment plan.
The U.S. Food and Drug Administration (FDA) has issued an advisory on antidepressant medicines and the risk of suicide. Talk to your doctor about these possible side effects and the warning signs of suicide
Before prescribing medicine, your doctor will check your child for possible suicidal thoughts by asking a few questions. See a list of questions your doctor may ask your child.
Education of your child and family members can be provided by a doctor either informally or in family therapy. Some of the most important things that your child and family members can learn include:
- Knowing how to make sure a child is following a treatment plan, such as taking medicine correctly and going to counseling appointments.
- Learning ways to reduce stress caused by living with someone who has depression.
- Knowing the signs of a relapse and what to do to prevent depression from recurring.
- Knowing the signs of suicidal behavior, how to evaluate their seriousness, and how to respond.
- Learning how to identify signs of a manic episode, which is a bout of extremely high mood and energy, or irritability that is a sign of bipolar disorder.
- Seeking treatment if you are a parent with depression. If a parent’s depression goes untreated, it may interfere with the recovery of the child.
Your child may need treatment for other disorders that may be causing ongoing symptoms, such as:
A brief hospital stay may be needed, especially if your child:
- Is showing any warning signs of suicide (such as talking about death or suicide and giving away belongings).
- Is so depressed that he or she becomes out of touch with reality (psychotic) or has hallucinations or delusions.
If your child is depressed, consider removing all guns and potentially fatal medicines from your home, especially if your child has shown any warning signs of suicide. Although overdosing on medicine is the most common way that teens attempt suicide, your child is at higher risk for dying by suicide if you have a gun in your home, particularly if it is easy to get to it or if you store it loaded.footnote 5
It is difficult to prevent a first episode of depression. But it may be possible to prevent or reduce the severity of future episodes of depression (relapses).
- There is some evidence that if a child receives cognitive-behavioral therapy (CBT) in a group setting, it can help prevent or delay the onset of depression in a child or teen whose parent has a history of depression (which puts the child at greater risk for becoming depressed).footnote 6
- Your child must take medicines as prescribed, keep counseling appointments, eat a balanced diet, and get regular exercise. For more information, see the topic Physical Activity for Children and Teens.
- Make sure that your child has a good social support system, both at home and through teachers, other family members, and friends who can provide encouragement and understanding.
- Learn to recognize early symptoms of depression, and seek immediate diagnosis and treatment if they occur.
- Some schools provide educational materials and group therapy opportunities to those at high risk for depression, such as those who have family conflict or problems with peers.
Do everything possible to provide a supportive family environment. Love, understanding, and regular communication are some of the most important things you can provide to help your child cope with depression.
In addition to having a positive home life, staying in professional counseling, and taking medicines as prescribed, good lifestyle habits can help reduce your child’s symptoms of depression. Encourage your child to:
- Get regular exercise, such as swimming, walking, or playing vigorously every day. For more information, see the topic Physical Activity for Children and Teens.
- Avoid alcohol and illegal drugs, nonprescription medicines, herbal therapies, and medicines that have not been prescribed (because they may interfere with the medicines used to treat depression).
- Get enough sleep. If your child has problems sleeping, he or she might try:
- Going to bed at the same time every night.
- Keeping the bedroom dark and quiet.
- Not exercising after 5:00 p.m.
- Eat a balanced diet. If your child lacks an appetite, try to get him or her to eat small snacks rather than large meals.
- Spend time with supportive friends.
- Be hopeful about feeling better. Positive thinking is very important in recovering from depression. It is difficult to be hopeful when you feel depressed, but remind your child that improvement occurs gradually and takes time.
If you notice any warning signs of suicide (such as aggressive or hostile behavior, excessive thoughts about death, or detachment from reality), seek professional help immediately by calling either your child’s doctor, a professional counselor, or a local mental health or emergency service. Create a plan to help keep your child safe. Lock away knives and other sharp objects, firearms, poisons, and medications. Call 911 if you feel your child is in immediate danger.
Although experts believe that, for many children with depression, the benefits of medicine outweigh the risks, research on antidepressant medicine in children is limited. The long-term effects and safety of medicines used to treat depression in children and teens are still unknown.
You may have heard about concerns regarding a possible connection between antidepressant medicines and suicidal behavior. The U.S. Food and Drug Administration (FDA) has issued advisories about this issue.
Especially during the first few weeks of treatment with an antidepressant, there is a possible increase in suicidal feelings or behavior. A child beginning antidepressant treatment should be watched closely. But children with untreated depression are also at an increased risk for suicide. So it is important to carefully weigh all of the risks and benefits of antidepressant medicine.
Antidepressant medicines include:
- Bupropion (Wellbutrin, for example).
- Fluoxetine (Prozac, for example).
- Venlafaxine (Effexor, for example).
What to think about
Antidepressant medicines such as fluoxetine (Prozac, for example) can be effective in treating depression, but it may take 1 to 3 weeks before your child starts to feel better. It can take as many as 6 to 8 weeks to see more improvement. Make sure your child takes antidepressant medicines as prescribed and keeps taking them so they have time to work. If you have any questions or concerns about the medicine, or if you do not notice any improvement by 3 weeks, talk to your child’s doctor.
Some antidepressants may also be effective in treating other conditions such as anxiety.
Your child may have to try several medicines or different dosages before the most effective treatment is discovered. After the right medicine and dosage is found, your child may need to continue taking the medicine for several months or longer after the symptoms of depression have subsided, to prevent depression from occurring again.
Some children who are first diagnosed with depression are later diagnosed with bipolar disorder, which has symptoms that cycle from depression to mania (very high energy, often with euphoria, agitation, irritability, risk-taking behavior, or impulsiveness). If your child or teen has bipolar disorder, a first episode of mania can happen spontaneously. But it can also be triggered by certain medicines such as stimulants or antidepressants. That is why it is very important to tell your child’s doctor about any family history of bipolar disorder and to watch your child closely for signs of manic behavior. For more information about bipolar disorder in young people, see the topic Bipolar Disorder in Children and Teens.
The U.S. Food and Drug Administration (FDA) has issued an advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. These signs may include talking about death or suicide and giving away belongings. This is especially important at the beginning of treatment or when doses are changed.
Besides taking medicine, other treatment for depression includes professional counseling and electroconvulsive therapy.
Complementary medicine is sometimes used for depression in adults. But there is no evidence that these therapies are safe for use by children or teens.footnote 2 They can interfere with other medicines, such as antidepressants. Always tell your doctor if you are using any complementary therapies.
Other treatment choices
- Types of counseling most often used to treat depression in children and teens are:
- Cognitive-behavioral therapy, which helps reduce negative patterns of thinking and encourages positive behaviors.
- Interpersonal therapy, which focuses on the child’s relationships with others.
- Problem-solving therapy, which helps the child deal with current problems.
- Family therapy, which provides a place for the whole family to express fears and concerns and learn new ways of getting along.
- Play therapy, which is used with young children or children with developmental delays to help them cope with fears and anxieties. But there is no proof that this type of treatment reduces symptoms of depression.
- Electroconvulsive therapy (ECT) may be an effective treatment for a teen or older child who is severely depressed or does not respond to other treatment, although this treatment is rarely used for children and teens. Even though it is an effective treatment for adults with major depression, there are currently no long-term studies on the safety of using ECT.footnote 2
What to think about
The U.S. Food and Drug Administration (FDA) has approved the vagus nerve stimulator (VNS) implant for treatment of depression in adults. This device may be used when other treatments for depression have not worked.
A generator the size of a pocket watch is placed in the chest. Wires go up the neck from the generator to the vagus nerve. The generator sends tiny electric shocks through the vagus nerve to that part of the brain that is believed to play a role in mood.
More study is needed to see how well this works in children who have depression.
- Post-Traumatic Stress Disorder
- Growth and Development, Ages 11 to 14 Years
- Growth and Development, Ages 6 to 10 Years
- Health Screening: Finding Health Problems Early
- Helping Your Child Build Inner Strength
- Bipolar Disorder in Children and Teens
- Growth and Development, Ages 15 to 18 Years
- Seasonal Affective Disorder (SAD)
- Wagner KD, Brent DA (2009). Depressive disorders and suicide. In BJ Sadock et al., eds., Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed., vol. 2, pp. 3652–3663. Philadelphia: Lippincott Williams and Wilkins.
- Hazell P (2011). Depression in children and adolescents, search date July 2011. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.
- Substance Abuse and Mental Health Services Administration (2009). Major depressive episode and treatment among adolescents. National Survey on Drug Use and Health (NSDUH) Report. Rockville, MD: Substance Abuse and Mental Health Services Administration. Available online: http://oas.samhsa.gov/2k9/youthDepression/MDEandTXTforADOL.htm.
- Vanderbilt D, Augustyn M (2011). Bullying and school violence. In RM Kliegman et al., eds., Nelson Textbook of Pediatrics, 19th ed., online chap. 36.1. Philadelphia: Saunders Elsevier. Available online: http://www.expertconsult.com.
- Dulcan MK, et al. (2012). Special clinical circumstances. In Concise Guide to Child and Adolescent Psychiatry, 4th ed., pp. 209–254. Washington, DC: American Psychiatric Publishing.
- Garber J, et al. (2009). Prevention of depression in at-risk adolescents: A randomized controlled trial. JAMA, 301(21): 2215–2224.
Other Works Consulted
- Brent DA, Wheersing VR (2007). Depressive disorders. In A Martin, FR Volkmar, eds., Lewis’s Child and Adolescent Psychiatry, 4th ed., pp. 503–513. Philadelphia: Lippincott Williams and Wilkins.
- March JS, et al. (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) Randomized Controlled Trial. JAMA, 292(7): 807–820.
- Mrazek DA, Mrazek PJ (2007). Prevention of depression and suicide in children and adolescents. In A Martin, FR Volkmar, eds., Lewis’s Child and Adolescent Psychiatry, 4th ed., pp. 171–177. Philadelphia: Lippincott Williams and Wilkins.
- Sass A, et al. (2014). Adolescence. In WW Hay Jr et al., eds., Current Diagnosis and Treatment: Pediatrics, 22nd ed., pp. 117–157. New York: McGraw-Hill.
- Wagner KD, Brent DA (2009). Depressive disorders and suicide. In BJ Sadock et al., eds., Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed., vol. 2, pp. 3652–3663. Philadelphia: Lippincott Williams and Wilkins.
Current as of: May 28, 2019