Depression in Children and Adolescents

Most children and teens have days when they feel sad, lonely, or depressed. But, if your child seems persistently sad or hopeless for significant periods of time and it is affecting their school work, relationships or over all participation in life, he or she may suffer from childhood depression.

Although once thought to be rare or nonexistent, major clinical depression does occur in children and adolescents. It is not the same as feeling “down” or “blue” about disappointing or sad life events. It is a serious illness that your child is not choosing to experience and cannot just “snap out of” by thinking positive thoughts or “cheering up.” If he or she could do that, they most certainly would because as difficult as clinical depression is for loved ones it is even more painful for the child.Depressed adolescent

Childhood depression is a persistent sadness. During periods of a major depression the child feels alone, hopeless, helpless, and worthless. When this type of sadness is unending, it disrupts every part of the child’s life. It interferes with the child’s daily activities, schoolwork, and peer relationships. It can also affect the life of each family member.

What causes childhood depression?

The causes of childhood depression are unknown. It could be caused by any combination of factors that relate to physical health, life events, family history, environment, genetic vulnerability, and biochemical disturbance. Children who suffer from major depression are likely to have a family history of the disorder, often a parent who also experienced depression at an early age. Depressed adolescents are also likely to have relatives who have experienced depression, although the correlation is not as high as it is for younger children.

How common is depression in children and adolescents?

Studies have shown that on any single day about two percent of school-aged children and about eight percent of adolescents meet the criteria for major depression. Looking in the long term, the numbers are thought to be higher—for instance, one in five teens have experienced depression at some point. In primary care settings the rates of depression are higher still—as many as 28 percent for adolescents. Preschool depression has also begun to attract interest among professionals but it is thought that much more needs to be learned about how mood disorders may affect this age group.

Which youth get depression? 

During childhood, the number of boys and girls affected are almost equal. In adolescence, twice as many girls as boys are diagnosed. Well over half of depressed adolescents have a recurrence within seven years. Several factors increase the risk of depression, including a family history of mood disorders and stressful life events.

Repeated episodes of depression can take a great toll on a young mind. It is prudent to get an evaluation followed by tailored treatment to prevent the social isolation, poor self-esteem and the risks to safety that can occur from persistent depression.

Do youth with depression need treatment? Will they just “grow out of it”?

Episodes of depression in children appear to last six to nine months on average, but in some children they may last for years at a time. When children are experiencing an episode they do less well at school, have impaired relationships with their friends and family, internalize their feelings and have an increased risk for suicide. To ignore these warning signs and hope for the best while the child tries to cope is a risky decision. Fortunately there are effective treatments for youth depression.

How can you tell if your child is depressed?

Signs that frequently help parents or others know that a child or teen should be evaluated for depression include:

  • feeling persistently sad or blue
  • talking about suicide or being better off dead
  • becoming suddenly much more irritable
  • having a marked deterioration in school or home functioning
  • reporting persistent physical complaints and/or making many visits to school nurses
  • failing to engage in previously pleasurable activities or interactions with friends
  • abusing substances.

Because the child or teen experiencing depression may not always show significant behavioral disturbance—that is, the depression may be taking an internal toll without disrupting the family—parents sometimes “hope for the best” or fail to get a child evaluated.

What are the treatments for children and adolescents with depression?

There are two main types of treatments for children with depression that have well- demonstrated evidence of effectiveness:

  1. Psychotherapy (talk therapy)
  2. Pharmacotherapy (medications)

Rigorous studies have shown both talk therapy and medications to be useful. Both treatments were more effective than when a placebo alone was given. A landmark NIMH-funded study, Treatment for Adolescents with Depression Study (TADS), also demonstrated that the combination of the two interventions is likely to create even better results than either one alone. Family psycho-education has also been shown to be beneficial for children with depression ages 8–12.

Studies have shown the two different kinds of talk therapy I do to be effective for children and/or adolescents—cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). CBT concentrates on changing the negative attributional bias (seeing every cup as half-empty) associated with major depression. CBT attempts to challenge the automatic negative thinking that may contribute to depression. IPT focuses on a patient’s self-concept and relationships with peers and family. More unstructured supportive therapy, which I also do in conjunction with the above methods, may also be helpful but it is more difficult to study. Be sure to ask any potential therapists about the kind of psychotherapy they practice and why they feel it might help your child.

Antidepressant therapy can be an effective treatment option for child and adolescent depression, but it also carries risks. Fluoxetine (Prozac) appears to be the only antidepressant specifically approved by the FDA for the treatment of depression in children ages 8 and older. Doctors can prescribe other antidepressant medications “off label” (not specifically approved by the FDA for that condition). If a doctor suggests another medication it is a good idea to ask more questions, i.e. why he or she is not recommending the medication approved by the FDA for this condition, and what research and experience are the basis for the recommendation. You may ask for a second opinion from another doctor if you are not sure this is the best course of action.

Three important considerations with the use of antidepressants in children and adolescents have been identified:

  1. Suicidal thoughts. In 2004, the FDA issued a strong “black box” warning about the risk of increased suicidal thoughts and actions in a small percentage of children and adolescents who take antidepressants. While none of the 2200 children and adolescents in antidepressant studies killed themselves, a review of the data determined that the rate of suicidal thoughts was about 4% for those taking the medication, double the rate expected. Therefore it is important to have regular care assessments, monitoring and follow-up, particularly in the first months of medication treatment.In addition, in 2006 the FDA expanded the warning about suicidal thoughts and antidepressants to include adults under the age of 25. Since all treatment options have risks and benefits, the best strategy is to educate yourself about the choices you can make, to share the decision with your child or teen and to evaluate what is best in the context of a comprehensive care plan.
  2. Bipolar disorder. Children and adolescents who first experience a major depressive episode may, over time, be predisposed to bipolar disorder. Reviewing any family history of bipolar disorder and being mindful of this possibility is a good idea when treating a child or adolescent experiencing a major depressive episode as antidepressants may increase the risk of mania in some youth.
  3. Research on depression in children and adolescents. Research is ongoing in this important area and more needs to be learned. Ask your caregiver about how the latest research studies have influenced the treatment plan. Look through the NIMH website for a summary of the latest research.

What is the right treatment for my depressed child?

Once the diagnosis is made, ask the clinician to collaboratively develop a treatment plan with your child and family. Target symptoms that you and your child are hoping will improve (e.g. sleep problems, self-harming statements, school attendance or performance) that will help track your child’s progress. Treatment needs to be specific to your child and his or her world. For example, if there is a co-occurring anxiety or alcohol problem, those must also be addressed. If there is a learning disability or bullying problems at school, those too need attention. Addressing family stresses or conflict may also be part of helping the youth.

A comprehensive treatment plan often involves educating the child or adolescent and the family about the illness, counseling or psychotherapy, ongoing evaluation and monitoring, and, in some cases, psychiatric medication. Optimally this plan is developed with the family, and, whenever possible, the child or adolescent should also participate in treatment decisions.

If you have concerns about your child’s safety, be sure to have a plan for responding to these concerns. This should include how to access resources after hours and on weekends.

In general, the youth, family and clinician should give that plan an adequate period of time to be  determined in concert with the clinical and medical doctor (e.g., eight to 12 weeks). The treatment should be reevaluated at the end of that time if it is not working.

How long should my child stay on treatment?

Treatment duration should be driven by the severity of the symptoms and the observed improvement. Assuming a simple and positive treatment response, medications are typically continued at least six months after response before tapering off. Many therapists will decrease the frequency of psychotherapy sessions but continue some maintenance therapy longer than the initial eight to 12 weeks of treatment. Treatment for a first episode of depression is likely to last at least six to 12 months with either treatment but may be longer.

For recurring depression, many clinicians will recommend a person stay on medication and in counseling for considerably longer periods, sometimes for years, to prevent a recurrence. In that case, one key is to help the youth recognize when their symptoms are recurring or worsening so that additional supports can be activated

Please Contact Me

If you have questions or believe your child needs an evaluation or treatment for depression, contact me by phone or email.

Sources:

American Academy of Family Physicians, Shawnee Mission, KS 66207; (800) 274-2237; www.aafp.org
American Psychological Association, Washington, DC 20002; (202) 336-5500; www.apa.org
American Psychiatric Association, (202) 682-6000; www.psych.org
Depression and Bipolar Support Alliance, (800) 826-3632; (312) 642-0049; www.dbsalliance.org
National Association of School Psychologists, (301) 657-0270 www.nasponline.org
National Institute of Mental Health, Office of Communications and Public Liaison, Information Resources and Inquiries 20892; (301) 443-4513;  www.nimh.nih.gov
National Mental Health Association, (800) 969-NMHA; www.nmha.org
National Institute of Mental Health summaries of research studies. www.nimh.nih.gov
American Association of Child and Adolescent Psychiatry