Depression in Children

• Clinically significant depression is severe enough to interfere with one's ability to function.
• It is quite common at every age, affecting more than 16% of children in the United States at some time in their lives, and is thought to be increasing in children and adolescents, both in this country and elsewhere.
• Other statistics about depression include its tendency to occur at a rate of about 2% before the teenage years and at approximately 5%-8% when both adolescents and children younger than adolescence are considered.
• It is a leading cause of health impairment (morbidity) and death (mortality).
• About 3,000 adolescents and young adults die by suicide each year in the United States, making it the third leading cause of death in people 10-24 years of age.

• Children may suffer from episodes of moderate to severe depression associated with major depressive disorder, or more chronic, mild to the moderate low mood of dysthymia.
• Depression may also be part of other mood disorders like bipolar disorder, as a result of psychosis (for example, having symptoms of delusions or hallucinations), as part of a medical condition like hypothyroidism, or the result of exposure to certain medications such as cold medications or drug abuse, like cocaine withdrawal.

• Depressive disorders in children do not have one specific cause. Rather, people with these conditions tend to have a number of biological, psychological, and environmental contributors to their development.
• Biologically, depression is associated with a deficient level of the neurotransmitter serotonin in the brain, a smaller size of some areas of the brain, and increased activity in other parts of the brain.
• Girls are more likely to be given the diagnosis of depression than boys, but that is thought to be due to, among other things, biological differences based on gender, and differences in how girls are encouraged to interpret their experiences and respond to them as opposed to boys.
• There is thought to be at least a partial genetic component to the pattern of children, and teens with a depressed parent are as much as four times more likely to also develop the disorder.
• Children who have depression or anxiety are more prone to have other biological problems, like low birth weight, suffering from a physical condition, trouble sleeping, and having a mother younger than 18 years old at the time of their birth.
• Psychological contributors to depression include
  • low self-esteem,
  • negative social skills,
  • negative body image,
  • being excessively self-critical, and
  • often feeling helpless when dealing with negative events.
• Children who suffer from conduct disorder, attention deficit hyperactivity disorder (ADHD), clinical anxiety, or who have cognitive or learning problems, as well as trouble engaging in social activities, also have more risk of developing depression.
• Depression may be a reaction to life stresses, like trauma, including
  • verbal, physical, or sexual abuse,
  • the death of a loved one,
  • school problems,
  • bullying, or
  • suffering from peer pressure.
• Youth who are struggling to adapt to the United States culture has found to be at higher risk for developing depression.
• Research differs as to whether obese children have an increased risk of developing depression.
• Other contributors to this condition include
  • poverty and financial difficulties in general,
  • exposure to violence,
  • social isolation,
  • parental conflict,
  • divorce, and
  • other causes of disruptions to family life.
• Children who have limited physical activity, poor school performance, or lose a relationship are at higher risk for developing depression, as well.

Clinical depression, also called major depression, is more than sadness that lasts for a day or two. In true depressive illnesses, the symptoms last weeks, months, or sometimes years if not treated. Depression often results in the sufferer being unable to perform daily activities, such as getting out of bed or getting dressed, performing well at school, or playing with peers.

General symptoms of a major depressive episode, regardless of age, including having a depressed mood or irritability or difficulty experiencing pleasure for at least two weeks and having at least five of the following signs and symptoms:

• Feeling sad or blue and/or irritable or seeming that way as observed by others (for example, tearfulness or otherwise looking persistently sad, or angry)
• Significant appetite changes, with or without significant weight loss, failing to gain weight appropriately, or gaining excessive weight
• Change in sleep pattern: trouble sleeping or sleeping too much
• Physical agitation or retardation (for example, restlessness or feeling slowed down)
• Fatigue or low energy/loss of energy
• Difficulty concentrating
• Feeling worthless, excessively guilty, or tending to self-blame
• Thoughts of death or suicide

Children with depression may also experience the classic symptoms but may exhibit other symptoms as well, including

• impaired performance of schoolwork,
• persistent boredom,
• quickness to anger,
• frequent physical complaints, like headaches and stomachaches,
• more risk-taking behaviors and/or showing less concern for their own safety.

Examples of risk-taking behaviors in children include unsafe play, like climbing excessively high or running in the street.

Parents of infants and children with depression often report noticing the following behavior changes in the child:

• Crying more often or more easily
• Increased sensitivity to criticism or other negative experiences
• More irritable mood than usual or compared to others their age and gender, leading to vocal or physical outbursts, defiant, destructive, angry, or other acting out behaviors
• Eating patterns, sleeping patterns, or significant increase or decrease in weight change, or the child fails to achieve appropriate gain weight for their age
• Unexplained physical complaints (for example, headaches or abdominal pain)
• Social withdrawal, in that the youth spends more time alone, away from friends and family
• Developing more "clinginess" and more dependent on certain relationships (This is not as common as social withdrawal.)
• Overly pessimistic, hopeless, helpless, excessively guilty, or feeling worthless
• Expressing thoughts about hurting him or herself or engaging in self-injury (like cutting or burning him or herself), reckless or other potentially harmful behavior
• Young children may act younger than their age or than they had before (regress).

• Family members and friends should seek mental health assessment and treatment for the depressed child.
• Adult family members may confer with the child's primary care doctor or seek mental health services by contacting one of the resources indicated below.
• Once the child with depression is receiving treatment, family members can promote good mental health by gently encouraging him or her to have a healthy lifestyle, including encouraging the child to maintain a healthy diet, including adequate water intake, get enough sleep, exercise regularly, remain socially active, and to engage in healthy stress-management activities.
• Research that analyzed the results of several studies (meta-analysis) has found that the positive impact of exercise on mood is even more than assumed due to its being part of a healthy lifestyle.
• Parents and other loved ones can also be helpful to the depressed child by discouraging him or her from engaging in risky behaviors.

• Many healthcare providers can help determine if the diagnosis of clinical depression is appropriate in children, including licensed mental health counselors, pediatricians, other primary care providers, specialists seen for a medical problem, emergency room doctors, psychiatrists, psychologists, psychiatric nurses, nurse practitioners, physician assistants, and social workers.
• Due to the societal stigma that can be associated with receiving mental health treatment, pediatricians and other primary care doctors are often the first professionals approached for diagnosis and treatment of depression.
• The practitioner consulted to assess a child for depression will likely perform or refer for a thorough medical interview and physical examination as part of assigning the correct diagnosis.
• Depression is associated with a number of other mental health conditions, like attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, bipolar disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and anxiety disorders, so the evaluator will likely screen for signs and symptoms of manic depression (bipolar disorder), a history of trauma, and other mental health symptoms.
• Childhood depression also may be associated with a number of medical problems, or it can be a side effect of various medications, exposure to drugs of abuse, or other toxins. Therefore, healthcare professionals often perform routine laboratory tests during the initial assessment to rule out other causes of symptoms.
• Sometimes, it may be necessary to perform an X-ray, scan, or another imaging study. As part of the evaluation, the sufferer may be asked a series of questions from a standardized questionnaire or self-test to help determine the risk of depression and suicide.

If it is determined that your child is suffering from clinical depression, the healthcare professional likely will recommend treatment. Treatment may include supportive therapy, like lifestyle and behavioral changes, psychotherapy, complementary treatments, and possibly medication for moderate to severe depression.

Psychotherapy

Psychotherapy ("talk therapy") is a kind of mental health counseling that entails working with a trained therapist to figure out ways to solve problems and cope with depression. It can be a powerfully effective intervention, even resulting in positive biochemical changes in the brain. For babies, music therapy and infant massage are useful interventions.

Two major kinds of psychotherapy commonly treat childhood depression: interpersonal psychotherapy and cognitive behavioral therapy. In general, these forms of treatment take weeks to months to complete and has the goal of alleviating depressive symptoms.

More intensive psychotherapy may be needed for a longer period when treating very severe depression or for depression that is accompanied by other psychiatric symptoms.

• Interpersonal therapy (IPT): This form of psychotherapy seeks to alleviate depressive symptoms by helping children with depression develop more effective skills for coping with their emotions and relationships. IPT uses two strategies to achieve those goals:
  • Educating the child, his or her parents, and other family members about the nature of depression: The therapist will reassure the child and his or her loved ones that depression is a common illness and that most people tend to improve with treatment.
  • Defining problems (such as abnormal grief or interpersonal conflicts): The therapist can help the child set realistic goals for solving problems and work with him or her and the child's family using different treatment techniques to reach these goals.
• Cognitive-behavioral therapy (CBT): This approach to psychotherapy helps to decrease depression and the likelihood it will come back by helping the child change his or her way of thinking about certain issues. In CBT, the therapist uses three techniques to achieve these goals.
  • Didactic component: This phase helps to establish positive expectations for treatment and promote the child's participation in treatment.
  • Cognitive component: This promotes identifying the thoughts and assumptions that play a role in the child's behaviors, especially those that may predispose the sufferer to be depressed.
  • Behavioral component: This uses behavior-modification methods to teach the child more effective ways of dealing with problems.

Medications

The most commonly used group of antidepressant medications prescribed for children is the selective serotonin reuptake inhibitors (SSRIs). SSRI medications influence the levels of serotonin in the brain. For many prescribing professionals, these medications are the first choice because of the significant degree of effectiveness and safety of this group of medicines. Examples of these medications are listed here:

• Fluoxetine
• Sertraline 
• Paroxetine 
• Fluvoxamine
• Citalopram 
• Escitalopram 
• Vortioxetine 
• Vilazodone

Only fluoxetine and escitalopram are approved by the Food and Drug Administration (FDA) to treat childhood depression and only in those 8 years of age and older for fluoxetine, and 12 years old and older for escitalopram. Any other medications used to treat this condition in children or using an antidepressant in younger children is therefore considered to be being used "off label." The use of paroxetine has fallen out of favor due to its lack of consistent efficacy in the context of the risk of possible side effects.

Although FDA-approved for use in teenagers with schizophrenia rather than for depression, atypical neuroleptic medications like aripiprazole and risperidone are sometimes prescribed in addition to an antidepressant in children who either suffer from severe depression, fail to improve after receiving a trial of an antidepressant in addition to, or instead of, an antidepressant in children who have bipolar disorder.

Doctors sometimes prescribe non-neuroleptic mood-stabilizer medications with an antidepressant to treat children with severe unipolar depression who do not improve after receiving trials of different antidepressants. Physicians might consider these medications in addition to or instead of an antidepressant in children who suffer from bipolar disorder.

Examples of such non-neuroleptic mood stabilizers include divalproex sodium, carbamazepine, and lamotrigine. Of the non-neuroleptic mood stabilizers, lamotrigine seems to be unique in its ability to treat unipolar depression effectively by itself as well as in addition to an antidepressant. However, only people 16 years of age or older use the drug due to potentially serious side effects.

Other antidepressant medications work differently than the commonly used SSRIs. Physicians may prescribe the following medications when SSRIs have not worked:

• bupropion,
• venlafaxine,
• duloxetine,
• desvenlafaxine, or
• levomilnacipran.

About 60% of children who take antidepressant medication improve. It may take anywhere from one to six weeks of taking medication at its effective dose to start feeling better. The prescribing professional will likely assess the depressed child who is receiving the medication again soon after it is started to determine if the medication is being well tolerated and if symptoms have begun to improve. If not, the doctor or other prescriber might adjust the dose of the medication or prescribe a different one.

After symptoms start to improve, the prescribing healthcare professional will likely encourage the parents of the depressed child to continue giving the medication for six months to a year because stopping the medication too soon may result in symptoms returning or worsening. Some people need to take the medication for longer to prevent the depression from returning. Stopping treatment abruptly may cause the depression to return or for withdrawal effects (discontinuation syndrome) to occur, depending on which medication the doctor prescribes.

Side effects of antidepressant medications vary significantly from drug to drug and from person to person.

• Common side effects can include dry mouth, upset stomach, nausea, tremor, insomnia, blurred vision, constipation, and dizziness.
• In rare cases, some people of all ages become acutely more depressed when on the medication, even having suicidal or homicidal thoughts, and/or attempting or completing suicide or homicide. Children and teenagers are particularly vulnerable to this rare possibility. However, when considering this risk, it is imperative to consider the risk of the possible serious outcomes that can result from untreated depression.

Alternative treatments

People use a number of nonprescription herbal supplements like St. John's wort and dietary supplements like vitamin C and B complex vitamins as remedies for depression. There is little known about the safety, effectiveness, or appropriate doses of these remedies, despite their being taken by thousands of people around the world.

• While some of the best-known alternative remedies continue to be studied to see how well they work, there remains little evidence that herbal supplements effectively treat moderate to severe clinical depression.
• Medical professionals are often hesitant to recommend herbs or dietary supplements to treat depression, particularly in children, because the FDA doesn't regulate them (as prescription drugs are) to ensure their purity, quality, and effectiveness.

• Depression can be chronic, in that 85% of people who have one episode of the disorder will have another one within 15 years of the first episode.
• Depressed individuals exposed to trauma are less likely to respond to treatment with antidepressant medication than those who have not experienced trauma.
• Young people with depression are more likely to develop a severe mental illness during adulthood compared to children who do not suffer from depression.
• Depression is the leading cause of disability in the United States for people over 5 years of age, particularly for females.
• Childhood depression is a risk factor for a number of potentially negative outcomes, like academic and interpersonal problems, as well as issues with drugs and attempting suicide, and engaging in other forms of self-harm.
• Since early treatment of childhood depression improves the prognosis, improving access to care (including encouraging parents and other family members to seek mental health treatment for their child) promotes a better prognosis.
• Children with depression are also more likely to have poor academic performance and to engage in alcohol and other drug abuse.
• As adults, people who had depression during childhood and adolescence are at risk for having trouble maintaining employment, as well as family and other social disruptions during adulthood.

• For children, from infancy through the teenage years, strong, healthy parent-child attachment can help protect the child from developing depression.
• Parental behaviors that tend to foster healthy attachment with their children involve consistent love and care, as well as attentive responsiveness to the child's needs, including age-appropriate steps toward the child's gradual independence.
• Preventing depression in childhood tends to involve addressing risk factors, both specific and nonspecific, strengthening other protective factors, and using an appropriate approach for the child's developmental level.
• Such programs often use cognitive-behavioral and/or interpersonal approaches, as well as family-based prevention strategies because research shows that these interventions are the most effective.
• Protective factors for adolescent depression include involving supportive adults, strong family and peer relationships, healthy coping skills, and emotional regulation.
• Children of depressed parents tend to be more resilient when the child is more able to focus on age-appropriate tasks in their lives and on their relationships, as well as being able to understand their parents' condition.
• For depressed parents, their children seem to be less likely to develop the disorder when the parent is able to demonstrate a commitment to parenting and to relationships.

American Association of Suicidology
http://www.suicidology.org
202-237-2280

American Foundation for Suicide Prevention
http://www.afsp.org

The Jason Foundation
http://www.jasonfoundation.com

National Alliance for the Mentally Ill
2101 Wilson Boulevard Suite 300
Arlington, VA 22203
HelpLine: 800-950-NAMI (6264)
Or Text "NAMI" to 741741
http://www.nami.org/

National Institute of Mental Health
866-615-6464
http://www.nimh.nih.gov

National Suicide Prevention Hotline
800-SUICIDE (784-2433)
http://www.suicide.org

National Suicide Prevention Lifeline
800-273-TALK (8255)

Substance Abuse and Mental Health Services Administration (SAMHSA)
877-726-4727
http://www.samhsa.gov