Depression in children and adolescents

Helping Children at Home and School II: Handouts for Families and Educators

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DEPRESSION IN CHILDREN AND ADOLESCENTS:

A PRIMER FOR PARENTS AND EDUCATORS

By Ralph E. Cash, PhD, NCSP

Nova Southeastern University

Depression is a serious health problem that can affect people of all ages, including children and

adolescents. It is generally defined as a persistent experience of a sad or irritable mood as well as

anhedonia,

a loss of the ability to experience pleasure in nearly all activities. It also includes a range of

other symptoms such as change in appetite, disrupted sleep patterns, increased or diminished activity

level, impaired attention and concentration, and markedly decreased feelings of self-worth.

Major depressive disorder,

often called clinical depression, is more than just feeling down or having a

bad day. It is different from the normal feelings of grief that usually follow an important loss, such as a

death in the family. It is a form of mental illness that affects the entire person. It changes the way the

person feels, thinks, and acts and is not a personal weakness or a character flaw. Children and youth

with depression cannot just snap out of it on their own. If left untreated, depression can lead to school

failure, conduct disorder and delinquency, anorexia and bulimia, school phobia, panic attacks, substance

abuse, or even suicide.

Prevalence and Risk Factors

Research indicates that the onset of depression is occurring earlier in life today than in past

decades and often coexists with other mental health problems such as chronic anxiety and disruptive

behavior disorders. Researchers at the University of Oregon estimate that 28% of all adolescents (ages

13–19) will experience at least one episode of major depression, with the rate estimated as 3–7% from

ages 13–15 and about 1–2% for children under age 13 (see Seely, Rohde, Lewinsohn, & Clarke, 2002, in

“Resources” at the end of this handout). In 2001, suicide was the third leading cause of death among

those 15–24 years old (see the National Institute of Mental Health Fact Sheet in “Resources”). Up to 7%

of adolescents who develop major depressive disorder may eventually commit suicide.

Children and teens who are under stress, who have experienced a significant loss, or who have

attention, learning, or conduct disorders are at greater risk for developing clinical depression. There is

no difference between the sexes in childhood in vulnerability to depression. But during adolescence girls

develop depressive disorders twice as often as boys. 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.

Other risk factors for child and adolescent depression include previous depressive episodes, anxiety

disorders, family conflict, uncertainty regarding sexual orientation, poor academic performance,

substance abuse disorders, loss of a parent or loved one, break up of a romantic relationship, chronic

illnesses such as diabetes, abuse or neglect, and other traumas, including natural disasters.

Signs and Symptoms

Characteristics of depression that usually occur in children, adolescents, and adults include:

• Persistent sad and irritable mood

• Loss of interest or pleasure in activities once enjoyed

• Significant change in appetite and body weight

• Difficulty sleeping or oversleeping

• Physical signs of agitation or excessive lethargy and loss of energy

• Feelings of worthlessness or inappropriate guilt

• Difficulty concentrating

• Recurrent thoughts of death or suicide

Characteristics of childhood depression.

The way

symptoms are expressed varies with the developmental

level of the youngster. Symptoms associated with

depression more commonly in children and adolescents

than in adults include:

• Frequent vague, non-specific physical complaints

(headaches, stomachaches)

• Frequent absences from school or unusually poor

school performance

• School refusal or excessive separation anxiety

• Outbursts of shouting, complaining, unexplained

irritability, or crying

• Chronic boredom or apathy

• Lack of interest in playing with friends

• Alcohol or drug abuse

• Withdrawal, social isolation, and poor communication

• Excessive fear of or preoccupation with death

• Extreme sensitivity to rejection or failure

• Unusual temper tantrums, defiance, or oppositional

behavior

• Reckless behavior

• Difficulty maintaining relationships

• Regression (acting babyish, resumption of wetting

or soiling after toilet training)

• Increased risk-taking behavior

The presence of one or even all of these signs and

symptoms does not necessarily mean that a particular

person is clinically depressed. If several of the above

characteristics are present, however, it could be a cause

for concern and may suggest the need for professional

evaluation.

Evaluation and Treatment

Diagnostic evaluation.

The good news is that

depression is treatable. Virtually everyone who receives

proper, timely intervention can be helped. Early

diagnosis and appropriate treatment are essential for

depressed children and adolescents. Children who

exhibit signs of clinical depression should be referred to

and evaluated by a mental health professional who

specializes in treating children and teens. A thorough

diagnostic evaluation may include a physical

examination, laboratory tests, interviews with the child

and parents, behavioral observations, psychological

testing, and consultation with other professionals.

Treating depression.

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 participates in

treatment decisions. It is important to recognize that

illnesses in general and mental disorders in particular

have different overt characteristics and respond

differently to treatment in various cultural groups.

Therefore, diagnostic and treatment approaches must

be culturally sensitive to be effective.

What Adults Can Do to Help

It is important that all adults who have frequent

contact with children and adolescents know the warning

signs of depression. If you suspect a child may be

depressed, make sure parents or guardians are

informed. Do not hesitate to ask a child if he or she has

thought about, intends, or has plans to commit suicide.

You will not give the child any new ideas, and you may

save a life by asking. If a child admits to feeling suicidal,

stay with the child and get professional help

immediately. School personnel can also provide

important support by linking families with information

and referral to community agencies. In addition,

parents, school personnel, and other adults may play

key roles in monitoring the effectiveness of and helping

to ensure compliance with treatment plans.

What Schools Can Do

Schools can facilitate prevention, identification, and

treatment for depression in children and adolescents.

Students spend much of their time in schools where they

are constantly observed and evaluated, and come into

contact with many skilled and well-educated professionals.

Effective interventions must involve collaboration

between schools and communities to counter conditions

that produce the frustration, apathy, alienation, and

hopelessness experienced by many of our youth.

Involvement in research-based programs such as the

Surgeon General’s 1999 Call to Action to Prevent Suicide

or the Yellow Ribbon Suicide Prevention Program and

National Depression Screening Day (SOS High School

Suicide Prevention Program) can greatly enhance

schools’ efforts to organize prevention and intervention

programs to combat depression. (See “Resources” for

information about these programs.) Some of the most

important steps for schools to take include:

• Develop a caring, supportive school environment for

children, parents, and faculty.

• Ensure that every child and parent feels welcome in

the school.

• Prevent all forms of bullying as a vigorously

enforced school policy.

• Establish clear rules and publicizing and enforcing

them fairly and consistently.

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Depression in Children and Adolescents: A Primer for Parents and Educators

• Have suicide and violence prevention plans in place

and implementing them.

• Have specific plans for dealing with the media,

parents, faculty, and students in the aftermath of

suicide, school violence, or natural disaster.

• Break the conspiracy of silence (making it clear that

it is the duty of every student to report any threat of

violence or suicide to a responsible adult).

• Ensure that at least one responsible adult in the

school takes a special interest in each student.

• Emphasize and facilitate home-school collaboration.

• Train faculty and parents to recognize the risk

factors and warning signs of depression.

• Train faculty and parents in appropriate interventions

for students suspected of being depressed.

• Utilize the expertise of mental health professionals

in the school (school psychologists, school social

workers, and school counselors) in planning

prevention and intervention, as well as in training

others.

Resources

Merrell, K. W. (2001).

Helping children overcome

depression and anxiety: A practical guide.

New York:

Guilford. ISBN: 1-57230-617-3.

National Institute of Mental Health. (2001).

Depression

in children and adolescents (Fact Sheet for

Physicians).

Bethesda, MD: Author (NIH Publication

No. 00-4744). Available:

www.nimh.nih.gov/publicat/depchildresfact

National Institute of Mental Health. (2001).

Let’s talk

about depression

[for teens]. Bethesda, MD: Author

(NIH Publication No. 01-4162). Available:

www.nimh.nih.gov/publicat/letstalk.cfm

National Institute of Mental Health. (2001).

Suicide

facts.

Bethesda, MD: Author. Available :

www.nimh.nih.gov/research/suifact.cfm

Seeley, J., Rohde, P., Lewinsohn, P., & Clarke, G. (2002).

Depression in youth: Epidemiology, identification,

and intervention. In M. Shinn, H. Walker, &. G.

Stoner (Eds.),

Interventions for academic and

behavior problems II: Preventive and remedial

approaches

(pp. 885–912). Bethesda, MD: National

Association of School Psychologists. ISBN: 0-

932955-87-8.

U.S. Public Health Service. (1999).

Mental health: A

report of the Surgeon General.

Washington, DC:

Author. Available:

www.surgeongeneral.gov

U.S. Public Health Service. (1999).

The Surgeon

General’s call to action to prevent suicide.

Washington, DC: Author. Available:

www.surgeongeneral.gov

U.S. Public Health Service. (2000).

Report of the Surgeon

General’s Conference on Children’s Mental Health: A

national action agenda.

Washington, DC: Author.

Available:

www.surgeongeneral.gov

World Health Organization. (2000).

Preventing suicide: A

resource for teachers and other school staff.

Geneva:

Mental and Behavioral Disorders, Department of

Mental Health (WHO). Available:

http://www.who.int/entity/mental_health/media/en/

62.pdf

Websites/Organizations

American Academy of Family Physicians, P.O. Box 11210,

Shawnee Mission, KS 66207; (800) 274-2237;

www.aafp.org

American Psychological Association, 750 First Street,

NE, Washington, DC 20002; (202) 336-5500;

www.apa.org

American Psychiatric Association, 1400 K Street, NW,

Washington, DC 20005; (202) 682-6000;

www.psych.org

Depression and Bipolar Support Alliance, Suite 501, 730

N. Franklin Street, Chicago, IL 60610; (800) 826-

3632; (312) 642-0049;

www.dbsalliance.org

National Association of School Psychologists, Suite 402,

4340 East West Highway, Bethesda, MD 20814;

(301) 657-0270;

www.nasponline.org

National Institute of Mental Health, Office of

Communications and Public Liaison, Information

Resources and Inquiries Branch, Room 8184, 6001

Executive Boulevard, MSC 9663, Bethesda, MD

20892; (310) 443-4513;

www.nimh.nih.gov

National Mental Health Association, 1021 Prince Street,

Alexandria, VA 22314; (800) 969-NMHA;

www.nmha.org

SOS High School Suicide Prevention Program/National

Depression Screening Day—

www.mentalhealthscreening.org/sos_highschool

Yellow Ribbon Suicide Prevention Program: (303) 429-

3530;

www.yellowribbon.org

Ralph E. “Gene” Cash, PhD, NCSP, is on the faculty of the

School Psychology program at Nova Southeastern

University in Ft. Lauderdale, FL.

© 2004 National Association of School Psychologists, 4340 East West Highway,

Suite 402, Bethesda, MD 20814—(301) 657-0270.

Helping Children at Home and School II: Handouts for Families and Educators

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