In this section you will find:
Facts About Depression in Children and Adolescents
Depression is a common disorder among children (less than 18 years). Approximately 5% of children at any one time may suffer from serious depression. The prevalence of depression increases with age, especially after the onset of puberty. There is no gender related difference in the prevalence of depression among pre-adolescent children. However, onset of puberty is associated with a marked increase in the rate of depression among females, with a female to male ratio of 2:1. The prevalence of depression may be higher in children with other psychiatric disorders (ADHD, conduct disorder, eating disorders, anxiety disorders) and in those with general medical conditions (diabetes, asthma, cancers and other chronic illnesses). The prevalence may also be higher among children with developmental disorders and mental retardation.
It is often during adolescence that depression first manifests itself in girls, and for the first time girls outnumber boys 2:1 in prevalence of the illness. It is estimated that 4.7% of the teenage population suffers from depression. (Kashani and Sherman 1988) It was long believed that the tumultuous moods of the teenage years were "normal", but we now understand that excessive irritability, moodiness, sleep and appetite change may signal a vulnerability to depression. (Pine et al. 1999)
We also know that more minor symptoms which might not meet full criteria for Major Depressive Disorder (subsyndromal illness) may predispose girls to full blown episodes later in life. Numerous factors may predispose adolescent girls to depression. These include the increase in hormones associated with puberty, changes in body shape and emerging sexual identity, family stressors such as divorce and peer pressure. Separation associated with leaving for college is another stressor which may predispose to depression. Adolescents who develop depression often have recurrences in adulthood and a more severe course. Early detection is essential to minimize recurrences and morbidity from the illness.
What Does Depression Look Like in Children and Adolescents?
Depression in young people often looks different than it does in adults. In some cases, children or adolescents with depression may look sad or tearful more frequently than they had previously. In other cases, they may be constantly irritable, or they may be tired, listless, or uninterested in favorite activities. In general, depression is an episodic condition in which a child has symptoms for several weeks or months, which may then gradually resolve.
Treatment for depression usually speeds the process of reducing symptoms, reduces recurrence, and diminishes the time the child may be at risk for suicide or other consequences of the depressive episodes (such as school failure, loss of friends, or family conflict). Variations in the course and presentation of depressive episodes can make diagnosing depression a challenge. A trained clinician (such as a child psychiatrist, child psychologist, or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis.
At Home
At home, children with depression may have a combination of the symptoms listed below.
- Persistent sadness, downcast expression, or low mood, which may include tearfulness
- Increased irritability, such as more frequent tantrums and arguments or greater frustration over small disappointments
- Persistently decreased interest in activities they previously enjoyed (hobbies, sports, friends, family outings, foods, etc.)
- Sleep disturbances, including difficulty falling asleep, restlessness, early awakening, excessive sleeping, taking more naps, wanting to go to bed after school, or going to sleep earlier at night
- Appetite disturbance, either eating much more or much less than typically. A change in weight may occur.
- Increased fatigue or difficulty having enough energy to get through the day
- Increased physical complaints such as headaches and stomach aches
- Feelings of worthlessness or low self-esteem, often revealed by repetitive comments such as "I'm no good," "I can't do it," and by refusal to even try activities or to complete chores
- Suicide risk, self-harm behaviors, preoccupation with death, or thoughts about hurting oneself or others may accompany depressed moods. Children and adolescents may make comments about not caring whether they live or die, may give possessions away, or talk about how life would be different if they were no longer alive.
- Experimentation with alcohol or drugs as a way to reduce suffering. Drugs and alcohol can themselves produce or worsen depressive symptoms.
At School
At school, a child with depression may have a combination of the symptoms listed below.
- Difficulty concentrating and/or forgetfulness, which may affect many aspects of school activities, from following directions and completing assignments to paying attention in class
- Impaired ability to plan, organize, concentrate, and use abstract reasoning. This can affect behavior and academic performance.
- Social isolation or withdrawal from interactions with peers
- Problem behaviors at school, such as increased fights, arguments, or unusual behaviors
- Heightened sensitivity to perceived criticism
- Other conditions, such as Attention Deficit/Hyperactivity Disorder (ADHD), which may also be present, compounding any learning challenges. Having one mental health condition does not "inoculate" the child from having other conditions as well.
- Anxiety disorders which may lead to difficulty separating from parents, trouble transitioning from home to school, reluctance to attend school, or avoidance of play time with peers
At the Doctor's Office
Depression can be difficult to diagnose, and a clinician may need to see a child over time to determine the appropriate diagnosis. A trained clinician (such as a child psychiatrist, child psychologist, or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis of depression. Diagnosing and treating children with depression may involve some of the following challenges.
- Symptoms may vary over time, and the appearance of depression may change as a child grows
- Other conditions may look like depression (for example, bipolar disorder, learning disorders, developmental disorders, and certain medical conditions)
- Symptoms may be attributed to other factors such as conduct problems, oppositionality, disinterest in school, family stresses, or substance abuse
- Young people with symptoms of depression may not feel comfortable about their own feelings and may not volunteer information. Phrasing questions with particular sensitivity and compassion may allow a more complete picture of symptoms to emerge.
- Children may be unaware, or unwilling to admit, that their behavior may indicate symptoms of a disorder
- Families may need to be coached about what they can reasonably expect from their child. Children who suffer from depression will benefit if their family understands that therapy and medicines may reduce, but may not cure, symptoms.
- Symptoms may return during periods of high stress
How Is Depression Treated?
Determining the correct underlying diagnosis will allow the clinician to select the appropriate treatment recommendations. Depression is treatable through ongoing interventions provided by a child's medical practitioners, therapists, school staff, and family. These treatments include psychological interventions (counseling), biological interventions (medicines), and accommodations at home and school that reduce sources of stress for the child. Open, collaborative communication between a child's family, school, and clinicians optimizes the care and quality of life for the child with depression.
Psychological Interventions (Counseling)
Counseling can help children with depression, and everyone around them, to understand that symptoms of depression are caused by an illness with complex genetic and environmental origins--not by flawed attitude or personality. Counseling also can reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child's particular needs with their clinician to determine which psychological treatments could be most beneficial for their child.
- Individual psychotherapy is generally recommended as the first line of treatment for children and adolescents with mild to moderate depression. Psychotherapy is also helpful when ongoing stressors exacerbate the symptoms. Depressed children or adolescents may carry a sense of failure, as if the illness was their fault. Individual psychotherapy can help reduce symptoms, and can help young people to become aware of, and address, their feelings of failure and self-blame.
- Cognitive Behavior Therapy (CBT) can teach a child new skills to reduce some symptoms of depression, particularly the negative thoughts or feelings accompanying depression. In CBT, a child or adolescent is helped to become aware of, and to describe, his or her negative thoughts or feelings. A trained clinician guides the child to think of new, more positive alternatives. The young person is then given a chance to practice new ways of thinking and feeling outside the clinical visit, and to discuss his or her experiences with the clinician afterwards. These methods are based upon well-researched practices that have helped many children and adolescents.
- Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child with a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
- Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting
- School-based counseling can be effective in helping a child with depression navigate the social, behavioral, and academic demands of the school setting
Biological Interventions (Medicines)
While psychotherapy may be sufficient to treat some children with depression, other children's symptoms do not improve significantly with psychotherapy alone. These children may benefit from medications.
The U.S. Food and Drug Administration (FDA) has approved one antidepressant medication, Prozac (fluoxetine), for treating children and adolescents with depression. Medications approved by the FDA for other uses and age groups are also prescribed for young people with depression. The FDA allows doctors to use their best judgment to prescribe medication for conditions for which the medication has not specifically been approved.
The following medications are commonly prescribed for children and adolescents with depression:
- Antidepressants. The most commonly prescribed antidepressants, including Celexa, Lexapro, Luvox, Paxil, Prozac, and Zoloft belong to a group of medications called Selective Serotonin Reuptake Inhibitors, or SSRI's. Other commonly prescribed antidepressants include Effexor, Remeron, and Wellbutrin.
- Antipsychotic medications. These medications (also called neuroleptics) may be prescribed if persistent and unusual worries develop, such as the fear of being harmed by others, or if the sensation develops of hearing or seeing things that are not really present. Examples of these drugs are Abilify, Geodon, Risperdal, Seroquel, and Zyprexa.
In most cases these medicines begin to be effective in reducing symptoms after the child or adolescent has taken them for at least 2-4 weeks. Fully 12 weeks may be required in order to determine whether the medication is going to be effective for a particular individual. Medications should only be started, stopped, or adjusted under the direct supervision of a trained clinician.
There is no "best" medicine to treat depression, and it is important to remember that medicines usually reduce rather than eliminate symptoms. Different medicines or dosages may be needed at different times in a child's life or to address the emergence of particular symptoms. Successful treatment requires taking medicine daily as prescribed, allowing time for the medicine to work, and monitoring for both effectiveness and side effects. The family, clinician and school should maintain frequent communication to ensure that medications are working as intended and to monitor and manage side effects.
The following cautions should be observed when any child or adolescent is treated with antidepressants.
- Benefits and risks should be evaluated. Questions have arisen about whether antidepressants can cause some children or adolescents to have suicidal thoughts. The evidence to date shows that antidepressants, when carefully monitored, have safely helped many children and adolescents. The latest reports on this issue from the U.S. Food and Drug Administration can be found on its web site at www.fda.gov. Consideration of any medicine deserves a discussion with the prescribing clinician about its risks and benefits.
- Careful monitoring is recommended for any child receiving medication. Though most side effects occur soon after starting a medicine, adverse reactions can occur months after medicines are introduced. Agitation, restlessness, increased irritability, or comments about self-harm should be addressed immediately with the clinician if any of these symptoms emerge after the child starts an antidepressant. Frequent follow-up (weekly for the first month) is now advocated by the FDA for children starting an antidepressant.
- Some children who appear depressed have bipolar disorder, which may need to be treated differently than depression. In some individuals with bipolar disorder, antidepressants may initially improve depressive symptoms but can sometimes worsen manic symptoms. While antidepressants do not "cause" bipolar disorder, they can unmask or worsen manic symptoms. For individuals with bipolar disorder, doctors commonly prescribe a mood stabilizer together with an antidepressant in order to minimize the risk that manic symptoms will be worsened by the antidepressant.
Helpful information about specific medications can be found at www.medlineplus.gov (click on "Drug Information") and in the book Straight Talk About Psychiatric Medications for Kids (Revised Edition) by Timothy E. Wilens, MD.
Sources
The content for Depression in Children and Adolescents was provided by the following NNDC sites unless otherwise specified above: