By Alan Harper, MA, LLP
Many adults are surprised when told that children and adolescents can and do become clinically depressed. We often think only adults have the type and severity of life stressors that can result in depression. After all, we adults have to deal with careers, financial concerns, marital issues, parenting challenges, tax season, home repairs, health problems, and more. Children and adolescents have little to worry about in their relatively stress-free lives. Children simply have to do their best in their fun classes at school, play with their friends, enjoy all the toys they've accumulated, and put up with Mom and Dad when told it's time to go to bed so they can rest up for another fun-filled, stress-free day.
Adolescent boys and girls have lives filled with Friday night football games, sleepovers at friends' houses, weekends at the mall, movie dates with their exciting new boyfriend or girlfriend. They enjoy group outings at local fast food restaurants where talk is friendly and no one is teased or ostracized. Life is good as a child and adolescent. School is fun, home is stable, friends are true, and bodies are healthy. Depression can wait until the real stressors of adulthood. Right? Well…not exactly.
As much as we may want the above scenarios to be true, the fact is the time of our lives from childhood through adolescence can be an emotionally tumultuous time. It can be filled with uncertainty, insecurity and confusion caused by difficult peer-relational issues, heart-breaking dating experiences, academic stressors, health problems and conflictual home environments. This is a time of transition from the relative protection of young childhood to the significant challenges of adulthood. The demands placed on children and adolescents by society, parents, peers, and the girls and boys themselves can be staggering.
Depression can and does occur in children and adolescents and is more prevalent in our culture than previously thought. The U.S. Center for Mental Health Services (CMHS) reports as many as one in every 33 children and one in every eight adolescents may be experiencing depression at some level. Two-thirds of children with mental health problems do not get the help they need. CMHS also reports that once a young person has experienced a major depression, he or she is at risk for developing another depression within the next five years. Plus, children or adolescents who have a family history of depression are more likely to struggle with it. Depression can significantly impact the life of a child or adolescent (and their families) through the disruption of peer relationships, academic performance and development, self-image and selfesteem. Thoughts of suicide or other self-destructive behaviors can occur with depression, which places further stress on the child or adolescent and increases the risk of physical harm or even death.
There is help for the depressed child or adolescent. Before help can be provided, however, the signs and symptoms of depression within the child and adolescent age range must be understood so parents and other caregivers can better determine when outside intervention is needed.
SIGNS AND SYMPTOMS
There are a number of signs and symptoms of childhood and adolescent depression, some of which are readily observable by others. Some others require questioning of the child or adolescent and/or deliberate monitoring of his or her moods and behaviors. Parents cannot count on their child or adolescent to openly state they are feeling depressed or are struggling in various areas of their lives. It is important that parents pay close attention to changes in their child or adolescent's general level of functioning in areas such as academics, peer relations, physical appearance and grooming, and involvement in usual areas of recreation. Significant and lasting declines in one or more of these areas may be an indication of depression, and should prompt further investigation. Parents must also listen for words indicating feelings of low self-worth and watch for observable moods that suggest chronic sadness, irritability or discouragement.
Common signs and symptoms of depression among children and adolescents include:
• Frequent sadness, tearfulness, or crying
• Relationship problems
• Feelings of hopelessness or helplessness
• Threats or attempts to run away from home
• Frequent complaints of various physical ailments
• Frequent school absences and/or poor school performance
• Low energy or restlessness
• Alcohol and/or drug use
• Persistent boredom
• Decline in activity level or interest in previously enjoyed activities
• Communication difficulties
• Social isolation
• Excessive guilt or low self-esteem
• Significant changes in eating and/ or sleeping patterns
• Increased levels of anger, irritability, or hostility
• Increased sensitivity to rejection or failure
• Concentration problems
• Thoughts or threats of suicide or other self-destructive behaviors
Not all children or adolescents will share the same signs and symptoms of depression. Some may appear sad, while others may act angry or irritable. One child may sleep excessively while another may have difficulty falling or staying asleep. It is important to look for changes in the typical moods, behaviors or physical functioning to determine whether depression may be present.
Also, it is important to remember that each individual sign or symptom above is not necessarily an indication of depression (although suicidal thoughts, threats or attempts do require immediate intervention). It is the combination of the various signs and symptoms that determines whether a depression diagnosis is made.
It is important that parents pay close attention to changes in their child or adolescent's general level of functioning... It is important to look for changes in typical moods, behaviors or physical functioning to determine whether depression may be present. It is also important to remember the above changes in moods, behaviors, physical symptoms and general functioning must be present on a fairly consistent basis for at least two weeks before a depression diagnosis should be considered. Children and adolescents will occasionally experience emotional turmoil that may mimic depression, but be resolved within a few days. This is not considered depression, but rather a temporary emotional upheaval that does not require the same type of intervention. This is not to say parents should wait two weeks to seek help if serious concerns exist. Rather, the depression diagnosis itself requires two consecutive weeks of impairment.
What About the Threat of Suicide?
Unfortunately, there is a risk of suicide with depressed children and adolescents, especially when the depression is severe, stressors are significant, and social support is perceived by the child as minimal or non-existent. Suicide has been identified as the third leading cause of death within the 15 - 19 year-old age range and the sixth leading cause of death with 5 - 15 year olds. Parents should always take threats of suicide seriously. Seek immediate intervention to determine the level of risk and develop a plan of action to prevent the child from harming him or herself.
If it appears a risk of suicide exists, measures need to be taken to make the home as safe as possible by denying easy access to firearms, razor blades, potentially dangerous medications, etc. Studies show girls are more likely than boys to attempt suicide, but boys are more likely to succeed given the fact they often choose more lethal methods such as guns. Again though, all threats need to be taken seriously. Parents should seek immediate help if it appears their child is in imminent danger of self-harm. Options for getting assistance include calling 911, contacting suicide prevention hotlines, and reporting concerns through the crisis lines at inpatient facilities.
TREATMENT OPTIONS
Medications
Treatment options for the depressed child or adolescent have improved dramatically over the past few decades. Much has been learned about the physiological and psychological nature of depression, which has prompted both medical and therapy advances. It is now known that clinical depression involves declines in neurotransmitter functioning within the brain, which can be alleviated through the use of a wide assortment of antidepressant medications. These medications can be prescribed through the child's physician or psychiatrist following a thorough review of the history and nature of the specific evidence of depression. Side effects can occur with antidepressant medications and should be discussed with the prescribing physician prior to beginning the medication treatment. Intolerable or overly-concerning side effects may require a change in medication, however many side effects tend to be temporary and relatively mild. Any concerns need to be promptly addressed with the prescribing physician.
Therapy
In most cases, therapy should be a part of the treatment plan when medication is prescribed, in order to determine whether underlying issues are contributing to the depression. If a child or adolescent relies entirely on an antidepressant medication to alleviate depression symptoms, the symptoms may return once medication treatment is completed. Working with a qualified therapist can help the child or adolescent identify and resolve the issues and problems that may have caused the depression. These issues may be social in nature, prompting a therapy focus on building and maintaining effective peer relationships.
Or perhaps they may be associated with specific family issues that can be addressed through family therapy with an emphasis on family dynamics, communication styles and individual roles. Specific trauma events can result in depression including emotional, physical and sexual abuse, loss of a loved one (pets included) through death or other means, or serious health concerns with the child or another family member. Significant transitions such as changing residences, schools or peer groups, changes in the family structure, or parental divorce can also contribute to the onset of depression.
Entering a new phase of life such as middle school or high school, enduring the challenges of puberty, or experiencing new responsibilities through employment or extracurricular school activities can create emotional turmoil as the child or adolescent struggles to establish and maintain a sense of confidence, competence, and control.
Whatever the underlying issue(s) may be, therapy can help alleviate contributing self-defeating thoughts, perspectives, and behaviors. Therapy can help the child or adolescent respond to his or her daily challenges and circumstances in ways that are both realistic and productive. Therapy that emphasizes proactive problem-solving, monitoring and modifying selfdefeating thoughts and behaviors, and building effective communication and relational skills can be very helpful in treating depression. This assumes therapy efforts take into account, and consistently honor, the individuality of the child or adolescent in treatment.
Hospital Treatment
Sometimes intervention beyond medication and therapy is needed, especially when the risk of suicide or other self-destructive behaviors exist. Admission to a child and adolescent inpatient facility may be considered as a means to provide immediate safety and initiate medication treatment and therapy intervention. Admissions are typically brief (a few days), can help stabilize the child, and significantly lower the risk of self-harm behaviors. Partial program admissions are also available at some facilities. These programs are typically held from morning until late afternoon and provide more intense interventions than traditional outpatient therapy, while allowing the child to return home to his or her family until the program resumes the following morning. Continuation of schoolwork is encouraged, so that additional stressors are not placed on the child upon discharge from the program.
Support Groups
In cases of identified trauma or various issue-specific problems contributing to depression, support groups within the community may be available. The child's therapist, physician, or psychiatrist may be able to assist in identifying some of these resources.
The issue of which intervention to seek can be a challenge. In cases when the child's depression is strictly biological (although that's difficult to determine), medication treatment may be sufficient. At other times, it may be best to forego medication treatment until a course of therapy has been tried. This is especially true in cases when the child or adolescent is struggling with grief/loss issues. In these types of cases, medication treatment may mask the issues causing the depression, resulting in the continuation of the contributing issues and the return of the child's symptoms when termination of medication treatment is attempted. Parents may seek advice regarding the various treatment options from any of the above professionals.
PRACTICAL TIPS
What Can Parents Do To Help?
There are many things parents can do to help their child or adolescent recover from depression. Conversely, there are also many things parents sometimes do that can actually create more difficulties for the child and perhaps even worsen the depression. Below is a list of some of the ways parents may support and assist their child or adolescent, as well as a number of reactions to avoid.
• Seek help from a qualified mental health professional as soon as it appears the child or adolescent may be depressed. Do not hesitate to take emergency measures (crisis line, 911, etc.) if it appears the child is at immediate risk of self-harm.
• Stay involved throughout the course of the child's treatment whether it involves medication, therapy, or both. Ask questions of the mental health professionals regarding treatment plans, medication issues, and ways you can assist with treatment through necessary changes in the home environment and/or ways you respond to the child.
• Proactively address any concerns or reasonable suspicions of drug or alcohol use. Drug and alcohol use can intensify the downward spiral of depression and can be a significant obstacle to effective treatment.
• Monitor the depressed child or adolescent's moods and behaviors without "suffocating" him/her with outward concern or questions.
• Maintain home rules and expectations concerning the child as consistently as possible, except in cases when specific changes have been discussed and identified as part of the treatment plan. Parents sometimes become overaccommodating to a depressed child or adolescent, which can actually encourage the continuation of the depression due to the perceived "benefits" of being depressed.
• Monitor and encourage healthy nutrition and sleep habits with the depressed child. Clinical depression has a biological dimension that can be affected by the consistency and quality of physical self-care.
• Encourage the depressed child to maintain reasonable physical, recreational, and social activity levels. These activities will provide opportunities for emotional respite from the depression and help maintain much-needed social contacts.
• Make it clear that you are available to the child to assist in any reasonable way possible, but don't be surprised if he or she rarely takes you up on your offer. Simply sensing you as an available quiet strength can sometimes be enough to help the child feel your support.
• Allow the depressed child some "space," but discourage prolonged isolation.
• Do not be overly critical of your depressed child, or suggest they "snap out of it." They probably would if they could and what they really need from you is nonjudgmental support, encouragement, and understanding. But remember, reasonable expectations should continue in most areas of the child's life, including academics, behavior, and household responsibilities.
SUMMARY
Children and adolescents can, indeed, become depressed. Contributing factors vary among individuals, as do specific signs and symptoms. But risk factors apply to all, including the potential for social problems, academic impairment, family disruption, selfesteem problems, self-abuse, and even death through the act of suicide. Children and adolescents cannot be counted on to openly point out they are struggling with depression. Often they are not even aware they are depressed or that help is possible. Parents and other caregivers must be aware of the signs and symptoms of child and adolescent depression in order to determine when professional intervention may be needed. They also should be knowledgeable of area resources available for the diagnosis and treatment of depression for their children, or for addressing immediate crises. Traditional treatment for depression includes therapy and/or medication, as well as support groups and other options when deemed necessary and beneficial. The period of childhood through adolescence can be a time of excitement, happiness and growth. It can also be a time of uncertainty and despair as significant challenges and transitions are negotiated. If and when depression occurs, help is available. Parents should seek help through qualified mental health professionals and become knowledgeable about depression and the issues specific to their child's struggles. They should remain involved in the treatment process and be willing to make reasonable changes in the home environment and in the ways they respond to their child. Finally, they should consistently provide support, encouragement and stability to the child.
Pine Rest
Alan Harper is a limited license psychologist working at the Pine Rest Campus Clinic. He has been employed with Pine Rest since 2000
