Childhood Depression: Early Recognition Leads to Successful Treatment

David Fassler, MD

Until the early 1980's, few people thought children could suffer from clinical depression. Today we know that children can and do become depressed. Depression in children is not a passing phase or part of the normal ups and downs of growing up. It's a real, identifiable and potentially fatal illness that affects millions of American children under that age of 18, and very often leads to serious emotional consequences later in life. Fortunately, it's a disease that can be effectively treated, although like most illnesses, treatment is most effective when the disease is recognized early on.

Alert parents can play a vital role in helping children overcome depression by identifying its basic signs and symptoms. Parents should be concerned if their child seems hopeless, helpless or enveloped in a sadness much greater than children normally feel from time to time. It's also important for parents to note if the symptoms become intense, overwhelming or enduring to the point where they interfere with the child's ability to play with friends or take part in daily activities at home or in school. Lack of energy, dramatic weight loss, vague or frequent physical complaints, and sleep often disrupted by bad dreams are other signs the child may be suffering from depression. If these symptoms persist over several weeks or months, the child needs to be evaluated by a physician or other qualified mental health professional.

Suicidal thoughts, plans and actual attempts can also be a very real and dangerous component of depression in children and adolescents. Over 3,000 young people commit suicide each year. It is the third leading cause of death among young people 15 to 24 years of age, following unintentional injuries and homicide. For each completed suicide, there are several hundred attempts. In Vermont, surveys of high school students indicate that one child in six thinks about suicide each year, and by the end of high school, nine percent of all children have actually made at least one suicide attempt. Although girls are twice as likely to attempt suicide, boys actually account for 80% of all suicide related deaths.

In addition to depression, other risk factors associated with suicide include:
•    Family history of suicide attempts
•    Exposure to violence
•    Impulsivity
•    Aggressive or disruptive behavior
•    Access to firearms
•    Substance abuse

Young people who are thinking about suicide may also stop planning for or talking about the future. They may decide to settle old debts or obligations, or begin to give away important possessions. They may also make overtly suicidal statements or comments such as, "I won't be a problem for you much longer." Any child with suicidal thoughts, plans or warning signs should be evaluated immediately.

In addition to meetings with the child and parents, a psychiatric evaluation will typically include a review of the child's:
•    Early developmental history
•    Past medical history
•    Family history
•    School performance
•    Peer interactions

It may also include a review of records from the school and the child's pediatrician or primary care physician. Although psychological testing may also be useful, there is no single definitive test or measure for depression. Depression is also not an easy diagnosis to make. Many other psychiatric disorders and other medical conditions can present with similar signs and symptoms. Depression can also co-exist with other problems including anxiety disorders, conduct disorders, attention deficit hyperactivity disorder, learning disabilities or substance abuse. A careful and comprehensive assessment is needed to fully and accurately evaluate these different problems.

Signs and symptoms of depression in children and adolescents include:
crying
•    Feeling hopeless, helpless, withdrawn
•    Change in behavior, loss of interest in usual activities
•    Change in sleep, appetite or energy
•    Missed school or poor school performance
•    Frequent physical complaints
•    Irritability, fighting, trouble concentrating
•    Thoughts about death, suicide or running away

If treatment is called for, parents can help by continuing to play a vital, supportive role throughout the process. Treatment should be individualized, based on the comprehensive evaluation of the child and family. It will often include a combination of individual therapy for the child, family therapy and consultation with the child's school. Some children will also benefit from treatment with antidepressant medication. Medication can be extremely helpful, and even life saving for some children, but medication alone is rarely the appropriate treatment for complex child psychiatric disorders such as depression. Children generally respond best to a treatment plan that combines a number of approaches under close professional supervision.

Parents can also assist by taking what is often a very difficult step, not blaming themselves for their child's medical condition. Depression is no more the result "bad parenting" than are diabetes or cancer. All are real illnesses which require careful evaluation and appropriate treatment. And the good news is that we can help most children and adolescents who suffer with depression. Treatment is available, affordable and effective. But the real battle against depression starts with education. We must erase the myths and stigma that still surround the disease, encourage early recognition, and make sure that children have access to the comprehensive treatment services they need and deserve.

David Fassler, M.D. is a child and adolescent psychiatrist practicing in Burlington, Vermont. He is also a Clinical Professor in the Department of Psychiatry at the University of Vermont. Dr. Fassler serves as a Trustee at Large of the American Psychiatric Association (www.psych.org), and a Board Member of the Federation of Families for Children's Mental Health (www.ffcmh.org). He is also a member of the Work Group on Consumer Issues of the American Academy of Child and Adolescent Psychiatry (www.aacap.org).