Depression in Children
Depression in young children is a difficult topic for most parents to conceive or to accept. Although children have always been vulnerable to a group of mental disorders, many children suffering from undiagnosed depression have been labeled as being shy, distant, lazy, stubborn, or disobedient. More recently, as awareness of emotional problems has increased, depressed children have often been diagnosed with a temporary response to stress (adjustment disorder), Attention Deficit Hyperactivity Disorder (ADHD), oppositional-defiant disorder, or some other setback. While a number of children do have these other disorders, they often coexist with or are misdiagnosed instead of depression.
Major depression is one of the mental, emotional, and behavior disorders that can begin during childhood and adolescence. This type of depression affects the child's thoughts, feelings, behavior, and body. Major depression in children and adolescents is serious; it is more than "the blues." Depression can lead to school failure, alcohol or other drug use, and even suicide.
Depression is a serious mental health issue that can disturb even very young children.
Depressed children are generally lacking in energy and enthusiasm. They often become withdrawn and are unable to concentrate or to enjoy life. If they are in school, they usually perform poorly. Sometimes they are irritable and unhappy or even aggressive. If they are old enough to talk, they may refer to themselves as stupid and ugly, disliked, unloved and incapable of being love, worthless, or even hopeless. They may be preoccupied with themes of death and dying, and, occasionally, they may think or even attempt suicide.
Even small children may do impulsive, dangerous things intended to hurt or to kill themselves, although their ideas of death are rather different from those of adults. The occurrence of depression is increasing in next generations and beginning at earlier ages. Although adolescent and adult females are diagnosed with a depressive disorder twice as often as males, boys up to age 12 are as likely to suffer from depression as girls.
Identifying the Signs
There are two primary types of depression: major depression which lasts at least two weeks; and the milder but chronic dysthymic disorder (a mood disorder characterized by mild depression), in which an enduring depressed mood seems to be connected to the child's temperament or personality. Though dysthymic disorder is uncommon in childhood, it may begin prior to adolescence. These children may go about their activities as though absorbed in an unhappy daze, with only brief periods of improved mood and outlook.
Major depressive disorder, the most severe and most disabling form of depression, occurs in incidents that affect approximately 1% of preschool children and 2% of pre-pubertal school-aged children at any given time. Moreover, approximately 2% of children suffer from dysthymia. More than two thirds of children with dysthymia develop major depression within 5 years.
Young children often do not talk about feeling depressed or down; therefore, puzzling, nonspecific physical complaints (headaches, stomachaches, other pains and aches) can be the first indications of severe depression in a school age child. Other young children with depression may also be irritable; experience anxiety at separation from their parents; poor concentration and hesitation or have exaggerated fears. Not all children who suffer with severe depression appear depressed, but instead may behave irritable or moody, switching from extreme sadness to sudden anger.
Usually, there are other clues or signs that a child is depressed. He/she may lose interest or enjoyment in most activities. The child may complain about being tired frequently or lack the energy to perform daily activities. He/she may sleep or eat too little or too much. Children with depression may have trouble concentrating or making decisions, feelings of worthlessness, anger, or guilt, may imply suicidal thoughts or pondering about death.
Signs of childhood depression:
• Regular sadness, weeping, crying; and/or hopelessness.
• Lack of interest in or failure to enjoy activities.
• Low energy; and poor concentration.
• Social separation, feeling of loneliness, and/or poor communication.
• Low self-esteem; guilt; extreme sensitivity to refusal or failure.
• Increased irritability, anger, or hostility; difficulty with relationships.
• Headaches and/or stomachaches.
• frequent school absences or poor performance
• A major change in eating and/or sleeping routine.
• Talk of or attempts of running away from home.
• Thoughts or expressions of suicide or self-inflicted behavior.
Causes of Depression in Children
Depression is a complicated condition. Likely rooted in a genetic and/or biochemical predisposition, depression also can be linked to unresolved grief, possibly in response to early real or imagined losses of nurturing figures. Depression may also reflect that the child has learned feelings of helplessness rather than feeling motivate and seek solutions for life's problems.
Some seriously depressed children have experienced early life or environmental stresses including childhood trauma, or the death of a parent or other significant people. They may live in families where they regularly witness or are victims of parental aggression, rejection, or target of strict punishment, or parents abusing one another. Such family pressures may contribute to the development of a depressive mood disturbance in a child.
Depression also runs in families. Often one parent of a depressed child has suffered with depression. Thus, both genetic risk and life experience can contribute to the child’s depression. Depression usually interferes with a child's social and academic performance. When a child is seriously depressed, school achievement declines and he/she loses interest in school and peer activities.
Sometimes the symptoms of restlessness, frustration, and decreased concentration may mislead parents or teachers into thinking that a child has attention deficit disorder while, in fact, the child is depressed. It is not uncommon for children who are evaluated for one condition to be diagnosed with the other disorder because the two different disorders can coexist.
Coexisting Disorders
More than half of depressed children also have at least one other psychological disorder, usually an anxiety disorder, attention deficit, conduct or oppositional-defiant disorder, or eating disorder. Almost one third of children diagnosed with Attention Deficit Hyperactivity Disorder and 20–30% of those who are initially diagnosed as depressed eventually turn out to have bipolar disorder, which is characterized by extreme mood swings from unrealistic elation to severe depression.
Risk Factors
For children of a depressed parent, the risk of depression is much higher than average. From studies with identical and fraternal twins as well as other siblings reared together and apart, it is estimated that 50% or more of the risk of childhood depression is inherited. Children under stress, those who have experienced a loss, those who abuse substances (including tobacco), those with chronic illnesses, and those who have attention, learning, or conduct disorders are at a higher risk for depression.
Although we do not know all of the factors that cause a genetically susceptible child to develop a depressive disorder, it is likely that major contributing factors include death or the divorce of parents; a child’s inability to adapt to impractical demands or encouraged to live according to strict moral beliefs by parents; failure to establish solid emotional bonds in infancy because of rejection or neglect; an excess of punishment and criticism with too little reward and praise; physical, emotional, or sexual abuse; bullying; and traumas such as terrorism or natural disasters.
Recent studies points to many of the major symptoms of depression in adolescents and adults anhedonia (a psychological condition characterized by an inability to experience pleasure from normally pleasurable activities), sadness and irritability, low energy level, recent changes in energy level, low self-esteem, crying, hyperactivity that begins after age 2, and playing or talking about themes involving death are also characteristic of depression in children. Difficulty experiencing joy when exposed to the pleasurable aspects of daily life is especially typical of most depressed children. There are, however, important age-related differences in the signs and symptoms of depression.
• From birth to age 3: Depression may be reflected in feeding problems, failure to thrive that has no identifiable physical cause, tantrums, lack of playfulness, detached, and less expression of positive feelings in general.
• Age 3–5: May be accident-prone, subject to phobias and exaggerated fears, likely to exhibit delays or regression in important developmental milestones such as toilet training, and prone to apologize excessively for minor mistakes and problems such as spilling food or forgetting to put away toys.
• Age 6–8: Expresses vague physical complaints, aggressive behavior, clinging to parents, and avoidance of new people and challenges.
• Age 9–12: Expresses morbid thoughts, extreme worry about school work, insomnia, and blaming themselves for disappointing their parents and teachers.
A child that exhibits some or even all of these traits does not automatically mean the child has a depressive disorder. When these signs and symptoms are present particularly if the symptoms are severe and/or persist regularly for a month or more, it is important to have the child evaluated by a mental health professional who specializes in children, especially if the child has other risk factors. Early diagnosis and treatment can shorten depressive episodes, help avoid future episodes, and prevent potentially dangerous or unsuccessful results such as school failure, self-injury, or suicide.
Evaluation and Treatment
For children with mild depression, cognitive-behavioral therapy is usually the first step. Cognitive-behavioral therapy is a type of psychotherapy that involves helping individuals develop coping skills that allow them to better handle upsetting situations and teaches them how to change destructive or negative thoughts. Family members may be asked to participate in therapy sessions. In cases concerning prolonged or severe depression, medication may be recommended to accompany the psychotherapy. Rarely is medication prescribed for depressed children who are under age 5 or 6. Psychotherapy, however, can be effective for preschool children. To help the youngest children, psychotherapy is directed at parents, the aim being to teach them how to help their child. Children and adolescents rarely require hospitalization for depression.
Individual Psychotherapy Therapy offers support and compassion while encouraging discovery of the depressed feelings and symptoms. Treatment may alternate between play and talk because a treatment goal is to help the child talk about her feelings. If a specific circumstance or event that has precipitated the depression divorce, for example therapy gives the child a chance to resolve some of his/her feelings and accept even a difficult reality.
For younger children or children who have trouble expressing through speech, play therapy can provide an opportunity to communicate feelings and awareness. Through play, the depressed child is able to communicate or act out in play his/her sense of loss, hopelessness, hostility or danger and ultimately deal with these painful emotions.
Cognitive Behavioral Therapy - Often effective in treating depression in older children, cognitive therapy focuses on the unreasonable ideas and unclear feelings which are part of depression, such as a negative view of the self, the world, and the future. Usually a depressed child feels guilt over failure, magnifies negative events, and minimizes positive events and achievements. Cognitive therapy focuses on identifying and correcting negative thought patterns or misinterpretations and on helping the child change her thinking.
Group Therapy - This approach in children aims to help them develop social skills that can lead to a greater sense of knowledge and self esteem. Children may find it easier to express feelings in a supportive group environment. Support groups for parents can help them manage specific problem behaviors, use positive reinforcement, communicate with children in an age appropriate manner, and become better listeners for their child.
Family Therapy - Family therapy deals with problems that may deteriorate depression in children such as a lack of parental boundaries (in which parents or caregivers treat their children as peers), severe marital conflict, strict or harsh rules, or neglectful or overly involved parent child relationships. In addition, family sessions may help identify other depressed family members and assist them in getting their own treatment.
Medication - Medications are sometimes used as part of a complete treatment approach with a depressed child. Research is ongoing to clarify the role of medication and the reaction in the developing child. Some recent studies have shown improvement with use of antidepressants. The more commonly prescribed antidepressants are fluoxetine (Prozac), imipramine (Tofranil), nortriptyline (Pamelor), paroxetine (Paxil), and sertraline (Zoloft). Other antidepressants include bupropion (Wellbutrin) and venlafaxine (Effexor). Before an older child begins taking a medication, specific target symptoms should be identified in a discussion between the child, the parent, and the physician. Possible side effects and other performances of the medication should also be fully discussed.
Hospitalization - A depressed child should always be evaluated for the risk of suicidal or self inflicting behavior. If a child is restless with death by suicide or has a well-thought out plan, hospitalization may be needed. Otherwise, as long as the child is able to function and his/her family is relatively supportive, intensive therapy can be done as outpatient sessions.
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