Parents often mistake depression in children for moodiness.
By Daniel DeNoon
Reviewed By Brunilda Nazario
Sometimes, it isn't just a phase kids are going through. Sometimes it's depression.
Sometimes kids get sad. They may act depressed. Most kids get over the worst of these symptoms in a couple of days. Some don't.
Parents, if they know to look, can tell the difference, says Marilyn B. Benoit, MD, immediate past president of the American Academy of Child and Adolescent Psychiatry and clinical professor at Georgetown University, in Washington.
"Parents know in their heart of hearts something has changed in their child and it is not going away," Benoit tells WebMD. "A child who is unhappy about a friend who treated them badly, they normally will get over that in a couple of days. But parents know when something is sticking and not going away. Most kids bounce back from an adverse experience in just a few days. Depressed children are still sad after a couple of weeks."
Can school-aged children -- even toddlers -- be depressed?
"Absolutely: In preschool and in school years, children suffer from depression," Benoit says.
"There really is clinical depression in toddlers, preschoolers, and school-aged children," Jeffrey Dolgan, PhD, chief of psychology at The Children's Hospital, in Denver, tells WebMD. "It is something a few years ago we weren't recognizing."
How common is it? That depends on your definition. Benoit and Dolgan note that most children with depressive disorders also suffer from anxiety. Some experts, however, see the anxiety as the underlying problem for the vast majority of these kids. One of them is Harold S. Koplewicz, MD, founder and director of the New York University Child Study Center, and director of child and adolescent psychiatry at NYU/Belleview Hospital Center.
Koplewicz, Benoit, and Dolgan agree that childhood depression is -- like adult depression -- a brain disorder brought on by changes in the chemistry of the brain. These changes often have their roots in the hormonal changes of the teen and young adult years.
"Depression in preteen children is a rare phenomenon," Koplewicz tells WebMD. "They don't have the right chemical or anatomical changes that put you at risk."
Even so, genuine depression is by no means unknown in preteens.
"As rare as it is, there is a group of school-aged kids -- and even a few preschoolers -- who do experience full-blown depressive episodes," Koplewicz says. "It is one of those times where it is not a parent or an environment that has done this. It is a predisposition, the same way some kids have autism or learning disabilities or a full-blown gift for music at age 5 or 6. It is purely a DNA blip."
Childhood Depression, Childhood Anxiety
Whether a child suffers from true depression or a kind of anxiety, the condition is serious.
Prior to puberty the equivalent of depression in children is anxiety, Koplewicz says. "When kids are anxious they most probably have similar biochemical issues to teenagers. ... So these anxiety disorders are most likely, in prepuberty, the predisposition to depression."
In fact, kids who have anxiety as children are more likely to have teen depression. About half of depressed teens had a childhood anxiety disorder. And 85% of teens who have both anxiety disorders and depression had their anxiety disorder first.
"So anxiety in children is serious, and we tend to minimize it," Koplewicz says. "Anxiety is probably toxic to the brain. We tend to think it is all within the normal range of childhood behavior, and it is not."
Childhood anxiety disorders are persistent symptoms that center on a single theme. They cause children a great deal of distress and disrupt their daily lives. These disorders fall into three categories:
- Separation anxiety. The most common childhood anxiety disorder is when a child fears there is a threat to his family. There's a deep-seated fear that something bad is going to happen to one of the family members -- or to the child. Being apart from their family is scary to these kids. They may get very real headaches, stomachaches, or diarrhea on school days -- but the pain comes from their brains, not their bowels.
- Social phobia. These kids are extremely uncomfortable with the social aspects of school. They often become "socially mute." They'll talk with their father or mother or sister, but not with anyone outside the home. Often they refuse to go to school.
- Generalized anxiety disorder. These kids worry excessively about the future. "They worry about how they will do in college, even though they're in third grade," Koplewicz says. "You ask, 'How did you do in soccer?' 'Two goals,' they'll answer. 'That's good,' you say. 'Yeah, they say, but I'm worried about the spelling test tomorrow.'"
"Hoping it is a phase, hoping the child will grow out of it, is a very big mistake," Koplewicz says. "All these disorders cause distress and dysfunction. It makes people feel hopeless. And hopelessness is what makes people want to hurt themselves. It isn't depression, it is hopelessness."
Signs Your Child Is Depressed
According to the American Academy of Child & Adolescent Psychiatry, any of these symptoms may mean your child is depressed:
- Frequent sadness, tearfulness, and/or crying
- Decreased interest in activities or inability to enjoy previously favorite activities.
- Persistent boredom; low energy. "The hallmark of depression is this inability to have joy," Dolgan says. "There's this low energy, this shutting away, shutting down."
- Social isolation, poor communication. "A child given the opportunity to play with friends who prefers to be alone" may be depressed, Dolgan says.
- Low self-esteem and guilt. "The kids feel they're not good or not worth very much," Dolgan says. "I often ask, 'Are you important to somebody?' Depressed kids say no."
- Extreme sensitivity to rejection or failure
- Increased irritability, anger, or hostility
- Difficulty with relationships
- Frequent complaints of physical illnesses such as headaches and stomachaches. "A lot of these kids have physical illnesses for no real cause, especially stomachaches and headaches," Dolgan says.
- Frequent absences from school or poor performance in school.
- Poor concentration
- A major change in eating and/or sleeping patterns
- Talk of or efforts to run away from home
- Thoughts or expressions of suicide or self-destructive behavior
"You know your child. You know when things have changed. When you get that red flag, do something. Don't ignore it," Benoit says.
"Go with your gut feelings. If you have a worry, let's get it checked out," Dolgan says. "Good parents are tuned in to their kids, but they don't always know what the signals mean."
Most parents begin by taking their child to a pediatrician, although some go directly to a child psychologist or child psychiatrist.
But beware of an immediate jump to treatment. Benoit, Dolgan, and Koplewicz each stress that the most important first step is to get a proper diagnosis.
The Key: Diagnosis
"In real estate they say the most important three things are location, location, and location. In the depressed child it is diagnosis, diagnosis, and diagnosis," Koplewicz says. "Before we treat a child who has a sad demeanor or a demoralized state, we want to make sure that child really has depression. The way to do that is to ask your pediatrician or psychiatrist or psychologist, 'What is my child's diagnosis? Explain it so I can understand, and tell me what are my treatment options.'"
Most parents first take their child to a pediatrician. Unfortunately, many pediatricians lack the specific training needed to correctly tell when a child is depressed or anxious.
"I think there is a public health problem," Koplewicz says. "You have 16,000 child psychiatrists and 8,000 child psychologists, and 8 million children and teens who need help. We have to decide whether to train pediatricians and nurses and counselors in the diagnosis of this disorder so we can get this properly diagnosed."
Koplewicz believes that the heart of the problem is that insurance companies are less willing to pay for mental health care than for physical health care.
"As a nation we don't treat psychiatric illness as we do physical illness," he says. "There are not enough experts. We have to demand from insurance companies to get parity, and pediatricians must get sufficient time to see kids to make this decision. It is a matter of whether we get training so the diagnosis can be made. Learning all your diagnostic skills from the pharmaceutical representative is a problem."
Children younger than 5 years old can get depressed. But their depression most often reflects the mental state of their primary caregiver -- usually their mother, Benoit says.
"Very often, in that preschool group, the child's affective state is highly connected to the mother's state," she says. "I could give you many cases of that, where the mother is the primary agent of what is happening with the child. If anyone does not take a look and do an evaluation of the primary caregiver, I think they would be missing a tremendous amount."
Treating Childhood Depression
What happens when a child is treated for depression?
"What a parent should expect is a discussion about the depression, a discussion about the various intervention methods one would consider from the least to the most aggressive, and a discussion about suicide or self-harm and what parents should be alert to," Benoit says.
Treatment requires the involvement of the parents.
"Parent must be given a lot of information about what the options are, and a sense that it is they, the parents, who choose how they would like treatment to start," Benoit says. "I tell people about medication, I talk about providing psychotherapeutic support, and what I might want to do first. I never do anything at that first session, unless the child is suicidal. I say, "I want you to think about it, then come back. As long as a child is not suicidal, we have some time to think and talk to the pediatrician."
But Dolgan stresses the importance of treating the symptoms of depression before tackling any long-term issues.
"The comprehensive treatment is individual and family work. Parents are in the mainstream of the treatment," he says. "The short-term goal ought to be symptom reduction. You have to work on symptoms. And if some situation is prompting or triggering the depression, you know that from meeting the parents."
Antidepressant medication can be an important part of treatment. But it can't be the only treatment.
"Watch out for providers who promise magic in a bottle," Dolgan says. "Maybe you don't have to invest in a full course of psychotherapy. But with little ones, there is nothing like it. They have to learn how to manage the illness, what to do, how to know if they are relapsing into a severe depression, and what are some coping and compensatory skills. There is a lot you can teach kids of what to do when getting depressed."
But when properly prescribed, antidepressant medication can be very helpful.
"People worried about the side effects of psychiatric medications should know that there is a side effect to not taking medications, too -- kids remain sick," Koplewicz says. "Medications for these disorders shouldn't be controversial -- if a teen or child or adult has been properly diagnosed with this disorder. Then it is effective and remarkably safe if properly monitored. But first, you have to have the disorder. You need someone to really clarify and say this is not a response to a bad life situation, this is acute clinical depression."
Unfortunately, many children have very good reasons to be sad and to feel depressed. Such children, Koplewicz stresses, do not have depressive disorders. They are demoralized.
"A lot of kids' life experiences are very depressing. They live in poverty. Their parents are abusive or neglectful or just divorced and still fighting. They are in inadequate educational systems. All those are depressing situations," Koplewicz says. "These situations don't necessarily create depression, but they may create behavioral symptoms. These kids may become rambunctious, unhappy, tearful. But we are not talking about the same thing as adult depression. You should feel badly when life is crummy."
And it's not only underprivileged kids whose lives can make them act depressed, says Alvin Rosenfeld, MD, a child and adolescent psychiatrist in private practice in Connecticut and New York.
"Much that looks like depression is the product of over-pressured, overscheduled youth and families," Rosenfeld tells WebMD. "When you cut back, the symptoms diminish."
Published April 14, 2004.
SOURCES: Harold S. Koplewicz, MD, founder and director, New York University Child Study Center; professor, clinical psychiatry and pediatrics, NYU School of Medicine; director,child and adolescent psychiatry, NYU/Belleview Hospital Center, New York. Jeffrey Dolgan, PhD, chief, psychology, The Children's Hospital, Denver. Marilyn B. Benoit, MD, immediate past president, American Academy of Child and Adolescent Psychiatry; clinical professor, Georgetown University, Washington. Alvin Rosenfeld, MD, child and adolescent psychiatrist, Greenwich, Conn. and New York City. "The Depressed Child," American Academy of Child & Adolescent Psychiatry web site, accessed April 13, 2004.
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