What is Depression?
Depression is a medical disorder that causes a person to feel persistently sad, low, or disinterested in daily activities. While everyone may have occasional moments of feeling sad or "blue," or a temporary period of sadness in response to a major loss, a depressive disorder causes those feelings to continue for an extended period. The tendency to develop depression involves complex genetic and environmental factors.
Depression in a child or adolescent is usually in the form of a major depressive disorder, in which multiple, significant symptoms of depression persist nearly every day for at least two weeks. Major depressive disorder affects about two percent of children and about five percent of adolescents. It can develop in response to a stressful situation or it may develop on its own.
Many children have symptoms of a milder depression, known as dysthymic disorder, that last for at least one year and impair their functioning at home and at school. Another type of depressive disorder is seasonal affective disorder or seasonal depression, which is diagnosed when the depression is triggered each year by the change of seasons (most often, during fall or winter). Symptoms or episodes of depression can also be seen in children or adolescents with bipolar disorder. top
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. A child or adolescent may have recurring depression or a single episode.
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. top
► 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
- 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 irritability, such as more frequent tantrums and arguments or greater frustration over small disappointments
- 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.
- Irrational worries or fears of being watched or listened to by others, or unusual worries of having thoughts or internal voices controlled by others
- Experimentation with alcohol or drugs as a way to reduce suffering. Drugs and alcohol can themselves produce or worsen depressive symptoms. top
► 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
- Learning disorders, particularly if undiagnosed or untreated, because the stress of coping with a learning disorder can trigger depression. A child's difficulties or frustrations in school should not be presumed to be due entirely to the depression. If the child still has academic difficulty after depression is treated, an educational evaluation for a learning disorder should be considered. A child's repeated reluctance to attend school may be an indicator of an undiagnosed learning disability. top
► 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 top
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. top
► 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 top
► 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
(click on "Drug Information") and in the book Straight Talk About
Psychiatric Medications for Kids (Revised Edition) by Timothy
E. Wilens, MD. top
► Interventions at Home
At home, as well as at school, interventions may be helpful to aid a child or adolescent.
- Adjust expectations until symptoms improve. Helping
a child make more attainable goals during a depressive episode
is important, so that the child can have the positive experience
of success. Once symptoms improve and depression lifts, expectations
- Simplify home life. While the child is depressed, a
busy after-school schedule or long list of household chores will
likely add to feelings of being burdened. The number of commitments
should be adjusted to the child's ability to be successful.
- Listen to the child's feelings. Isolation often perpetuates
depression. The simple experience of being listened to sympathetically,
without receiving advice, may have a powerful and helpful effect.
Parents should not let their own worries prevent them from talking
with their child at a time when their support is most needed.
- Small steps can make a difference. Keep a positive attitude
about whatever successes occur during this time. At the same time,
it is important to validate the child's feelings of frustration
when his or her efforts fail ("OK, you didn't score 100 on this
test, but you did get all of the items done this time- let's see
where you started missing items").
- Address comments about suicide. If a child makes a remark
about wanting to die, talk to the child about it without delay.
Talking about suicide does not encourage self-harm acts. It may
help clarify what the child meant by the remark, or help the child
determine what might be changed in order to make that feeling
- Talk as a family about what to say to people outside of
the family. Determine what feels comfortable for the child
(for example, "I was sick and got some help, and now I'm better").
Even if the decision is made not to discuss this medical condition
with others, having an agreed-on plan will make it easier to handle
unexpected questions and minimize family conflicts about this.
- Help prevent relapse. Assuring that a child takes medicine
daily for as long as prescribed, watching for symptoms of another
episode, and reducing stressors may all help prevent or postpone
another episode of depression. If symptoms do return, it is important
to know it is not anyone's fault but, rather, the nature of the
► Interventions at School
There are many ways that schools can help a child with depression succeed in the classroom. Parents and school staff, including teachers, guidance counselors, and nurses, should collaborate to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom.
Examples of some accommodations, modifications, and school strategies include the following:
- Schedule check-ins on arrival to see if the child can succeed in certain classes that day. Check-ins also provide an opportunity to share an encouraging word or to identify worries the child has for the day. Note that some children may want less attention, so finding the right balance of attention will be helpful.
- Provide more time to complete certain types of assignments
- Adjust homework load to prevent the child from becoming overwhelmed. Academic stressors, along with other stresses, are difficult for children to manage during a depressive episode
- Anticipate issues such as school avoidance if there are unresolved social and/or academic problems
- Be aware that some situations may be particularly difficult for the child. When a child with depression refuses to follow directions, for example, the reason may be anxiety, rather than intentional oppositionality.
- Encourage the child to help develop interventions. Enlisting the child in the task will lead to more successful strategies and will foster the child's ability to problem-solve.
- Please click on School-Based Interventions for a more complete list of school accommodations for children with depression
Flexibility and a supportive environment are essential for a student with depression to achieve success in school. School faculty and parents together may be able to identify difficult areas and develop remedies to reduce a child's challenges at these times. top
Many online resources and books are available to help parents,
clinicians, and educators learn more about children and adolescents
with depression. Click here for a wide
selection of resources. top
Information provided above on depression draws from sources including:
American Psychiatric Association, Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition. Washington, DC: American
Psychiatric Association, 1994
Dulcan, MK and Martini, DR. Concise Guide to Child and Adolescent Psychiatry, 2nd Edition. Washington, DC: American Psychiatric Association, 1999
Koplewicz, Harold. More Than Moody: Recognizing and Treating Adolescent Depression. New York: G.P. Putnam's Sons, 2002
Lewis, Melvin, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd Edition. Philadelphia: Lippincott Williams and Wilkins, 2002 top