December 2004
What distinguishes clinical depression from normal sadness in children and youth, and how can I seek help for a young person who is depressed?
Many children feel sad or down sometimes. However, a small number of youth experience a more severe form of sadness and low mood known as depression. What distinguishes clinical depression from “typical sadness” is the degree and duration of the episode, as well as notable changes that may occur in the child or adolescent.
The general features of childhood and adolescent depression include prolonged depressed or irritable mood and a lack of interest or pleasure (American Psychiatric Association, 1994). Changes in feelings, thinking, energy, and routine habits like sleeping and eating are common. Young people may lose interest in activities that they used to enjoy, such as spending time with friends. In addition, children and adolescents who are clinically depressed may become preoccupied with death, and some depressed youth even have thoughts about hurting or killing themselves.
The symptoms of depression can manifest themselves in different ways depending on the age of the young person. The younger a child is, the more difficult it is for him or her to understand and identify feelings. In very young children, the most common emotional signs of depression are sadness, anger and aggression, moodiness and irritability, a timid or fearful appearance, and shyness. Because young children with depression are unable to describe or understand their feelings, they may instead complain of physical symptoms that are unexplainable such as headaches, stomach aches, nausea, asthma, fatigue, trouble sleeping, and nightmares. They may also display aggressive, risky, or even self-endangering behaviors. Children with depression at this age may also have anxiety about separating from their parents and may be difficult to comfort.
Among older children, the most common emotional signs of depression are irritability, moodiness and cynicism, feelings of apathy, loneliness, anger, and hostility. An older child with depression may express low self-esteem or self-image, sometimes feeling as though he or she is not accepted by peers and is unloved by family members. The child may have trouble thinking or paying attention, even to TV programs or games, and may show little or no interest in activities that he or she once enjoyed. Depression can often cause poor school performance in young people and is associated with learning problems, acting out in school, and delinquency.
Clinical depression in teens is often more difficult to diagnose because normal adolescent behavior is marked by mood changes resulting from the normal maturation process, the stress associated with it, the influence of sex hormones, and independence conflicts with parents. In addition, when adults see resistant, belligerent, or hostile behavior from a teenage child, they often assume it is “normal” teenage rebellion. There should be reason for concern if an adolescent displays persistent depressed mood, low energy, or motivation; excessive sleeping; an increase or decrease in eating habits; faltering school performance; neglect of clothing and appearance; declining relations with family and friends; and/or drug or alcohol abuse. Among adolescents, depression is often associated with dropping out of school, substance use, sexual promiscuity, eating disorders, excessive risk-taking behavior, violence, and suicide.
The National Institute of Mental Health (NIMH) suggests that if one or more of these signs of depression persist, parents should seek help (NIMH, 2000):
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The following are specific examples of behaviors that a child with depression might exhibit (The Depressed Child, 1992):
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It is important to realize that depression is serious and, if left untreated, can become life-threatening. The most important first step in seeking help for a young person with depression is getting a thorough assessment from a professional, typically a child psychiatrist (a medical doctor who has received special training in diagnosing and treating psychiatric disorders in children). Once the professional has been determined the diagnosis, a treatment plan should be discussed with the patient and family.
A number of strategies have been developed for the treatment of depression; such approaches typically involve psychotherapy and/or antidepressant medication. Research suggests that, among adolescents, a combination of medication and psychotherapy is highly effective in treating depression (NIMH, 2004). Yet, because very little is known about the safe use of antidepressants with younger children, psychotherapy alone is often a more desirable treatment option. All young people taking antidepressant medication must be monitored very closely.
Other research suggests that psychological interventions are at least as effective as medication in the treatment of depression, even if severe (Antonuccio, Danton, & DeNelsky, 1995). Psychotherapy interventions can be implemented individually, in peer groups, or in a family therapy environment. Peer group approaches have been found to be effective for children, and family therapy may be helpful if family conflict is contributing to the depression. Play therapy is often appropriate for younger children. The two most common effective psychotherapy treatments are Cognitive-Behavioral Therapy (CBT) and Interpersonal Therapy (IPT).
CBT is based on the theory that people with depression have distorted thoughts about themselves, the world, and the future. CBT focuses on changing these distortions by helping the person examine and correct these negative thought patterns and by teaching the individual to use positive coping behaviors instead of giving up or avoiding situations. During CBT, children and teens are trained to recognize the ways in which their feelings are connected to their thoughts and behavior . They are taught to challenge their negative thoughts and to substitute more reality-based interpretations. They may also learn communication, problem-solving, anger-management, relaxation, and social skills. CBT may be given in either a small group or individual format, and has been shown to be helpful in either form.
Interpersonal therapy (IPT) is also a commonly used treatment type. The primary goal of this therapy is to improve communication skills and increase self-esteem. IPT focuses on working through the relationships and social interactions that a person has with family members and friends. The treatment helps the person identify and develop more adaptive methods for dealing with interpersonal issues. When using IPT with adolescents, the therapist addresses developmental issues most common to this age group, such as separation from parents, exploration of authority in relation to parents, development of dyadic interpersonal relationships with members of the opposite sex, initial experience with the death of a relative or friend, and peer pressure (The International Society for Interpersonal Psychotherapy, 2004). Typically, IPT takes place in an individual format in which the therapist works one-on-one with the child or teen and his or her family.
Additional Resources:
Evidence Based Treatment for Children and Adolescents www.effectivechildtherapy.com
This site is an excellent resource for information about many childhood mental health disorders and the treatments that are most effective. The site offers links to other resources containing information on childhood and adolescent depression, advice on obtaining treatment, and opportunities to communicate with other families and individuals coping with depressive disorders.
Wing of Madness: A Depression Guide Site http://www.wingofmadness.com/index.htm
This site contains information, articles, guides, and other resources about clinical depression. It also provides a Communicate section, offering message boards and chat rooms for people to ask questions, talk to others, and find support for dealing with depression.
NAMI http://www.nami.org/Content/ContentGroups/Helpline1/Facts_About_Childhood_Depression.htm
The National Alliance for the Mentally Ill (NAMI) is a nonprofit, grassroots, self-help, support and advocacy organization of consumers, families, and friends of people with severe mental illnesses. This page on the NAMI site includes information about depression in young people and advice for parents and care givers.
About Teen Depression http://www.about-teen-depression.com
This site targets parents of adolescents with depression. It provides important facts about teen depression and difficulties in diagnosing teen depression, treatment options, symptoms, statistics, and hope for parents of depressed teenagers.
The American Academy of Child and Adolescent Psychiatry (AACP) http://www.aacap.org
This site provides information to aid in the understanding and treatment of the developmental, behavioral, and mental disorders affecting children and adolescents. The site offers information about child and adolescent psychiatry, fact sheets for parents and caregivers, current research, practice guidelines, managed care information, awards and fellowship descriptions, meeting information, and more.
References:
American Academy of Child & Adolescent Psychiatry. (1992). The depressed child. American Academy of Child & Adolescent Psychiatry, 4. Retrieved December, 2004 from http://www.aacap.org/publications/factsfam/depressd.htm .
Antonuccio, D. O., Danton, W. G., & DeNelsky, G. Y. (1995). Psychotherapy versus medication for depression: challenging the conventional wisdom with data, Professional Psychology: Research and Practice , 26(6), 574–585. Retrieved December, 2004 from http://www.apa.org/journals/anton.html.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.
The International Society for Interpersonal Psychotherapy (ISIPT). IPT for depressed adolescents. Retrieved December, 2004 from http://www.interpersonalpsychotherapy.org/index.html.
National Institute of Mental Health (NIMH) (2000). Depression in Children and Adolescents: A Fact Sheet for Physicians, Retrieved December, 2004 from http://www.nimh.nih.gov/publicat/NIMHdepchildresfact.pdf .
National Institute of Mental Health (NIMH) (2004). Combination Treatment Most Effective in Adolescents with Depression, Retrieved December, 2004 from http://www.nimh.nih.gov/press/prtads.cfm