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.
• 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; (301) 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.