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Depression In Children

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Depression is more than just the typical mood swings characteristic of adolescents. Unfortunately there is a widespread belief that depression in adolescents is normal. This is not so, as most young people do not experience constant and overwhelmingly turbulent and emotional turmoil.

Young people can suffer depression. In fact, significant depression probably exists in about 5 percent of young people in the general population. Adolescents under stress, who experience loss, or who have attention, learning or conduct disorders are at a higher risk for depression. The behavior of depressed teenagers differs from the behavior of depressed adults. Mental Health professionals advise parents to be aware of signs in their youngsters such as:
  • Persistent sadness
  • An inability to enjoy formerly pleasurable activities
  • Increased activity or irritability
  • Frequent complaints of physical illnesses such as headaches and stomach aches
  • Frequent absences from school or poor performance in school
  • Persistent boredom, low energy, poor concentration
  • A major change in eating and/or sleeping patterns
A young person who used to play often with friends may now spend most of the time alone and without interests and things that were once fun, now bring little joy. Adolescents who are depressed may say they want to be dead or may talk about suicide. Depressed adolescents may abuse alcohol or other drugs as a way to feel better.

Adolescents who cause trouble at home or at school may actually be depressed but not know it. Because the young person may not always seem sad, parents and teachers may not realize that troublesome behavior is a sign of depression. When asked directly, these young people can sometimes state they are unhappy or sad. Early diagnosis and medical treatment are essential for the depressed adolescent. For help, parents should ask their family doctor to refer them to an adolescent psychiatrist, who can make a diagnosis and instigate treatment.

Treatment of depression is rarely brief since establishing new attitudes and behavior patterns takes time. However, treatment offers a good chance for considerable improvement in the present and hope for a more successful future.


Is Your Child Depressed?

If you suspect your child is depressed, you need to do more than tell him to "cheer up" or "snap out of it." If you don't get help right away, your child's life could fall apart, including his self-esteem, his school work, and his relationships with friends and family.

Here are some questions to ask yourself if you think your child might be depressed:
  • Does your child cry more often than in the past?
  • Does she complain of feeling blue or empty inside?
  • When things do not go your child's way, does he think his life is hopeless?
  • Does your child have a hard time falling asleep at bedtime, or does she awaken in the middle of the night and have trouble going back to sleep?
  • Has your child lost interest in his favorite activities?
  • Does he spend more time alone, away from friends and family?
  • Has your child gained or lost weight in recent weeks?
  • Does she seem more worn out and tired than in the past?
  • Does he sometimes talk about hurting himself?
If you answered "yes" to several of these questions, talk to your child's pediatrician. Before referring you to a child psychiatrist or psychologist, he or she will rule out medical conditions with symptoms that are like the symptoms of depression.

Once under the care of a psychiatrist or psychologist, your child may need several tests to find out whether he is actually clinically depressed. The therapist will have a long talk with both you and your child, reviewing her history and finding out about her moods and feelings. Once the therapist is sure that your child is depressed, treatment can begin.

Adapted from "Caring for Your School-age Child: Ages 5 to 12," © American Academy of Pediatrics


Adolescent Depression
Maurice Blackman, MB, FRCPC.
Clinical professor and director, division of child and adolescent psychiatry, University of Alberta Hospitals, Edmonton


Is Depression In Adolescents A Significant Problem?

The suicide rate for adolescents has increased more than 200% over the last decade. Adolescent suicide is now responsible for more deaths in youths aged 15 to 19 than cardiovascular disease or cancer.

Recent studies have shown that greater than 20% of adolescents in the general population have emotional problems and one-third of adolescents attending psychiatric clinics suffer from depression.

Despite this, depression in this age group is greatly under-diagnosed, leading to serious difficulties in school, work and personal adjustment which often continue into adulthood.


Why Is Depression In This Age Group Often Missed?

Adolescence is a time of emotional turmoil, mood swings, gloomy introspection, great drama and heightened sensitivity. It is a time of rebellion and behavioral experimentation.

Diagnosis, therefore, must rely not only on a formal clinical interview but on information provided by parents, teachers and community advisors. The patient's personality must be taken into account, as well as any obvious or subtle stress or trauma that may have preceded the clinical state. The therapeutic alliance is very important since the adolescent will not usually readily share his/her feelings with an adult stranger unless trust and rapport are established.

Confidentiality must be assured, but not to the point that the parents - who are often essential allies in treatment - are wholly excluded. Diagnosis may require more than one interview and is not a process that can be rushed. Inquire directly about possible suicidal ideation.


What Are The Common Symptoms Of Adolescent Depression?

Depression presents in adolescents with essentially the same symptoms as in adults; however, some clinical shrewdness may be required to translate the teenagers' symptoms into adult terms.

Pervasive sadness may be exemplified by wearing black clothes, writing poetry with morbid themes or a preoccupation with music that has nihilistic themes.

Sleep disturbance may manifest as all-night television watching, difficulty in getting up for school, or sleeping during the day.

Lack of motivation and lowered energy level is reflected by missed classes.

A drop in grade averages can be equated with loss of concentration and slowed thinking.

Boredom may be a synonym for feeling depressed.

Loss of appetite may become anorexia or bulimia. Adolescent depression may also present primarily as a behavior or conduct disorder, substance or alcohol abuse, or as family turmoil and rebellion with no obvious symptoms reminiscent of depression.


How Can Suicide Risk Be Determined?

It is common for young people to be preoccupied with issues of mortality and to contemplate the effect their death would have on close family and friends. Thankfully, these ideas are usually not acted upon. Suicidal acts are generally associated with a significant acute crisis in the teenager's life and may also involve concomitant depression.

It is important to stress that the crisis may be insignificant to the adults around, but very significant to the teenager. The loss of a boyfriend or girlfriend, a drop in school marks or a negative admonition by a significant adult, especially a parent or teacher, may be precipitant to a suicidal act. Suicidal ideation and acts are more common among children who have already experienced significant stress in their lives.

Significant stressors include divorce, parent or family discord, physical or sexual abuse and alcohol or substance abuse. A suicide in a relative or close friend may also be an important identifier of those at the greatest risk. The teenager who exhibits obvious personality change, including social withdrawal, or who gives away treasured possessions may also be seriously contemplating ending his/her life.

Many more teenagers attempt suicide than actually succeed, and the methods used may be naive. There is a tendency to treat perceived minor attempts as attention seeking, histrionic and of no importance.

This is a mistake, as a teenager who has attempted suicide and has not received any relief from his or her impossible situation may well be a successful repeater. All suicidal behaviors reflect a cry for help and must be taken seriously.


How Can The Physician Best Manage The Depressed Patient?

The management of the depressed teenager begins at the first interview with the creation of a therapeutic alliance. It is important that the interview be conducted in a relaxed manner, preferably in a room other than a formal examination room. The teenager may have to be brought back the next day or on a number of successive days to adequately address problems. The physician must inspire confidence and trust, and be aware of his or her own biases. Teenagers can be oppositional and negative when depressed. They may have very fragile self-esteem and project their feelings onto the physician. It is important to understand this behavior as part of the depression and treat it accordingly.

Interviews should be conducted with and without the parent(s) present. The rules of confidentiality must be discussed with a clear understanding of which issues will be withheld (e.g., suicide intention). The teenager is an active participant in the treatment process and the physician must identify the problem to the patient and parent, offer hope and reassurance, outline treatment options and arrive at a mutually agreed-upon treatment plan. A family assessment should be undertaken to evaluate what support may be available from family members and what resources are available in crisis.


How Should Depression In Adolescents Be Treated?

There are two main avenues to treatment: psychotherapy and medication. Often, both may be required. The majority of mild depressions in teenagers respond to supportive psychotherapy with active listening, advice and encouragement.

Issues of alcohol and substance abuse may have to be addressed. Formal family therapy may be required to deal with specific problems or issues.

Co-existing conditions are not unusual in teenagers including anxiety, obsessive-compulsive disorder, learning disability or attention deficit hyperactive disorder. If present, they need to be addressed and treated,


When Should Medication Be Used?

Selective serotonin reuptake inhibitors (SSRIís) are well tolerated by teenagers because of their fairly rapid action and low tendency to cause side effects. Low side effects also make them particularly helpful in an impulsive patient population. It is important that an adequate time period be given to allow the medication to work (four to six weeks) and that adequate doses are used.

There are sufficient choices of SSRIs, so that a suitable medication can be found for most symptom clusters. Most teenagers can tolerate adult dosages, and lack of response may reflect a problem with dosage rather than the choice of medication. Anxiety reducing and sleep medication may also be helpful.


When Should The Patient Be Referred To A Psychiatrist Specializing In Adolescents?

Referral should be considered under a number of circumstances. If the physician cannot engage in conversation with the teenager because of the patient's resistance or the physician's own insecurity about dealing with this age group, then referral is suggested. This is particularly important if the depression is judged to be severe or if there have been some suicidal concerns.

Referral should also be considered if the patientís condition does not improve in the expected time or if there is any deterioration or worsening of the depression despite adequate treatment.

It should be stressed that the majority of teenage depressions can be managed successfully by the primary care physician with the support of the family.


Letís Talk About Depression
www.psychologyinfo.com/depression/teens.htm

Approximately 4 out of 100 teenagers get seriously depressed each year. Sure, everybody feels sad or blue now and then. But if you're sad most of the time and it's giving you problems with:
  • your grades
  • your relationships with your family and friends
  • alcohol, drugs, or sex
  • controlling your behavior in other ways
Then the problem may be Ė DEPRESSION. The good news is you can get treatment and FEEL BETTER SOON.


What Is Depression?

Clinical Depression is a serious illness that can affect anybody, including teenagers. It can affect your thoughts, feelings, behavior, and overall health.

Most people with depression can be helped with treatment. But, most depressed people never get the help they need. When depression isn't treated, it can get worse, last longer, and prevent you from getting the most out of your life. Remember, you're only a teenager once.


How Do I Know When I'm Depressed? How Can I Tell If A Friend Might Be Depressed?

First, there are two kinds of depression: The sad kind, called major or reactive depression, and manic-depression or bipolar illness, when feeling down and depressed alternates with being speeded-up and sometimes acting reckless.

If you have had several of these symptoms, and they've lasted several weeks, or cause a big change in your routine, you should talk to someone who can help, like a psychologist, or your school counselor!

When You're Depressed
  • You feel sad or cry a lot and it doesn't go away.
  • You feel guilty for no real reason; you feel like you're no good; you've lost your confidence.
  • Life seems meaningless or like nothing good is ever going to happen again.
  • You have a negative attitude a lot of the time, or it seems like you have no feelings.
  • You don't feel like doing a lot of the things you used to like-- like music, sports, being with friends, going out-- and you want to be left alone most of the time.
  • It's hard to make up your mind. You forget lots of things, and it's hard to concentrate.
  • You get irritated often. Little things make you lose your temper; you over-react.
  • Your sleep pattern changes; you start sleeping a lot more or you have trouble falling asleep at night. Or you wake up early most mornings and can't get back to sleep.
  • Your eating habits change; you've lost your appetite or you eat a lot more.
  • You feel restless and tired most of the time.
  • You think about death, or feel like you're dying, or have thoughts about committing suicide.
When You're Manic
  • You feel high as a kite, like you're "on top of the world".
  • You get unreal ideas about the great things you can do---things that you really can't do.
  • Thoughts go racing through your head; you jump from one subject to another, and you talk a lot.
  • You're a non-stop party, constantly running around.
  • You do too many wild or risky things: with driving, with spending money, with sex, etc.
  • You're so "up" that you don't need much sleep.
  • You're rebellious or irritable and can't get along at home or school, or with your friends.

Talk To Someone About Depression

If you think you're depressed...TALK TO SOMEONE! If you are concerned about depression in yourself or a friend, TALK TO SOMEONE WHO CAN HELP. There are many people who you can talk to:
  • a psychologist
  • your school counselor
  • your parents, or a trusted family member
  • your family doctor
  • your clergy
  • a professional at a mental health center
Remember - Depression can affect people of any age, race, ethnic, or economic group.


Treatment for Depression
  • Having depression doesn't mean that a person is weak, or a failure, or isn't really trying. It means they need Treatment.
  • Most people with depression can be helped with counseling, provided by a professional psychologist, and some are helped with counseling and medicine.
  • Counseling, or psychotherapy, means talking about feelings with a trained psychologist who can help you change the relationships, thoughts, or behaviors that are causing the depression. Think about it, you feel depressed because you think your life is bad. What if you're wrong? What if you're missing all the good things around you? What if your future holds a lot more promise than you think? When you're depressed, you're in a rut, and you can't see anything good. You need to talk to someone who can help you get out of that rut! Don't wait, ask your parents, or your school counselor for help today.
  • Medicine is used to treat depression that is severe or disabling. Antidepressant medications are not "uppers" and are not addictive. When depression is so bad that you can't focus on anything else and when it interferes with your life in an overwhelming way, medication might be necessary.
  • With treatment, most depressed people start to feel better in just a few weeks.

You Are Not Alone!

There's help out there and you can ask for help. And if you know someone whom you think is depressed, you can help. Listen and encourage your friend to ask a parent or a responsible adult about treatment. If your friend doesn't ask for help soon, talk to an adult you trust and respect---especially if your friend mentions suicide. Your friend's life is more important than keeping a secret!


What About Suicide?

Most people who are depressed do not commit suicide. But depression increases the risk for suicide or suicide attempts. It is NOT true that people who talk about suicide do not attempt it. Suicidal thoughts, remarks, or attempts are ALWAYS SERIOUS! If any of these happen to you or a friend, you must tell a responsible adult IMMEDIATELY. It's better to be safe than sorry.


Why Do People Get Depressed?

Sometimes people get seriously depressed after something like a divorce in the family, major financial problems, someone you love dying, a messed up home life, or breaking up with a boyfriend or girlfriend.

Other times, depression just happens. Often teenagers react to the pain of depression by getting into trouble with alcohol, drugs, sex; trouble with school or bad grades; problems with family or friends.

This is another reason why it's important to get treatment for depression before it leads to other trouble.


Alcohol, Drugs and Depression

A lot of depressed people, especially teenagers, also have problems with alcohol or other drugs (Alcohol is also a drug). Sometimes the depression comes first and people try drugs as a way to escape it. In the long run, drugs or alcohol just make things worse. Other times, the alcohol or other drug use comes first, and depression is caused by :
  • the drug itself
  • withdrawal from
  • the problems that substance abuse causes
And sometimes you can't tell which came first... the important point is that when you have both of these problems, the sooner you get treatment, the better. Either problem can make the other worse and lead to bigger trouble, like addiction or flunking school. You have to be honest about both problems---first with yourself and then with someone who can help you get into treatment. It is the only way to really get better and stay better.


Myths About Depression

Myths often prevent people from doing the right thing. Some common myths about depression:

Myth: It's normal for teenagers to be moody. Teens don't suffer from "real" depression.
Fact: Depression is more than just being moody. And it can affect people at any age, including teenagers.

Myth: Telling an adult that a friend might be depressed is betraying a trust. If someone wants help, he or she will get it.
Fact: Depression, which saps energy and self-esteem, interferes with a person's ability or wish to get help. It is an act of true friendship to share your concerns with an adult who can help. No matter what you "promised" to keep secret, your friend's life is more important than a promise.

Myth: Talking about depression only makes it worse.
Fact: Talking about your feelings to someone who can help, like a psychologist, is the first step towards beating depression. Talking to a close friend can also provide you with the support and encouragement you need to talk to your parents or school counselor about getting evaluated for depression.


Childhood Depression in Teens
depression.about.com/msubadol.htm
Resources concerning the diagnosis and treatment of teen depression; suicide prevention.

The following are on this web site:
  • Alice's Garden
  • Adolescent depression information for parents.
  • Bipolar Children and Teens
  • Resources on bipolar mood disorder written from the perspective of a mother of a bipolar child.
  • Center for Adolescent Health Factsheets
  • A fact sheet on adolescent depression.
  • Diagnosis and Treatment of Bipolar Disorder
  • An article about the special problems encountered when attempting to diagnose bipolar disorder in children and the methods used.
  • Diagnosis and Treatment of Bipolar Disorder
  • Includes two articles about bipolar disorder and the difficulties in diagnosing it. Second article discusses the difficulty in distinguishing between "bad" behavior and bipolar disorder as well as comorbidity with ADHD and CD (Conduct Disorder).
  • Forgotten Kids Official Web Page
  • The "Forgotten Kids" have no visible disability; but, because their behaviors may seem odd or unpredictable to themselves as much as society, they become overlooked. This site is dedicated to them.
  • Guidelines for Clinicians Working with Gifted Suicidal Adolescents
  • Treatment guidelines for therapists working with gifted suicidal adolescents.
  • Is Your Child Depressed?
  • Some questions from the American Academy of Pediatrics to ask yourself if you think your child may be depressed.
  • Mood Disorders in Children and Adolescents
  • Article about childhood and adolescent depression as one of the most under-diagnosed illnesses in psychiatry.
  • Suicide and Homicide among Youth
  • Investigating violence among our youth.
  • The Homosexuality Factor in Youth Suicide
  • An article about suicide in homosexual teens.
  • What to Do When a Friend is Depressed
  • What to do when a friend is depressed. A guide for teenagers.
  • You Asked About...Adolescent Depression
  • Answers to frequently asked questions about adolescent depression.

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