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Child and Adolescent Depression: Diagnosis and Treatment

Depression in Children and Adolescents

Suicide in the School Setting

Depression and Suicide: Warning Signs

My Friend is Still a Kid: Kids Don't Die!

Making a Meaningful Memorial for a Friend

Mood Swings and Drugs

When a Parent is Depressed

Adult Depression

View Slides From Our Presentations on Depression and Mood Disorders

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Depression in Children and Adolescents
Carol E. Watkins, M.D.

Childhood and adolescent depression increased dramatically in the past forty to fifty years. The average age of onset has fallen. During childhood the number of boys and girls affected are almost equal. In adolescence, twice as many girls as boys are diagnosed. (Similar to adult rate) Repeated episodes of depression can take a great toll on a young mind. Well over half of depressed adolescents have a recurrence within seven years. Children with Major Depression have an increased incidence of Bipolar Disorder and recurrent Major Depression.

Characteristics of child and adolescent depression

In many ways, the symptoms are similar to those of adult depression. In the DSM-IV, the criteria for childhood and adult Major Depression are the same. Children may not have the vocabulary to talk about such feelings and so may express their feelings through behavior. Younger individuals with depression are more likely to show phobias, separation anxiety disorder, somatic complaints and behavior problems. With psychotic depression, children are more likely to report hallucinations. Older adolescents and adults with psychotic depression are more likely to have delusions. (Delusions require more advanced cognitive functioning than simple hallucinations)

One might observe the following external signs in a depressed child or adolescent.

  • Preschool or young elementary age: The child might look serious or vaguely sick. He might be less bouncy or spontaneous. While other children would become tearful or irritable when frustrated, this child may show these states spontaneously. He may say negative things about himself and may be self-destructive.
  • Older elementary school through adolescence: The adolescent may present with academic decline, disruptive behavior, and problems with friends. Sometimes one can also see aggressive behavior, irritability and suicidal talk. The parent may say that the adolescent hates himself and everything else.

Causes of Depression

How much is due to heredity and how much to environmental issues? Things associated with childhood depression include inconsistent parenting, stressful life experiences, and a negative way of viewing the world. Childhood depression is also associated with a family history of mood disorders and with the existence of other psychiatric conditions If the relative has had childhood or recurrent depression, the child is at even higher risk of developing depression. There are different theories on the causes of depression. Some feel that children inherit a predisposition to depression and anxiety but that environmental triggers are necessary to elicit the first episode of Major Depression.

When depressed adults are asked about their childhood experiences, they are more likely to report neglect, abuse rejection and parental conflict.

Consequences and Associated Conditions

Many children with depression have one or more other major psychiatric diagnoses. Anxiety Disorder, Substance Abuse, and ADHD are frequently associated with childhood depression. ADHD might be present before the first episode of depression and can complicate the treatment of both conditions. Substance abuse often starts after the first episode of depression, although this can vary in different individuals. The other conditions may persist even after the major depressive episode passes, and can render the individual more vulnerable to a recurrent depression. Children with depression accompanied by ADHD or Conduct Disorder are more likely to have adult criminal records and suicide attempts than individuals with depression alone.

Depression is associated with school and interpersonal problems. It is also correlated with increased incidence of suicidal behavior, violent thoughts, alcohol, early pregnancy, tobacco and drug abuse.

Depression can lead to an increased chance of suicide attempts and successful suicides. Since 1950, the adolescent suicide rate has risen four fold 12% of the total adolescent mortality in 1993 was due to suicide. Suicide is not always associated with MDD. Usually those who attempt suicide have more than one problem. One should be especially vigilant with those who have a relative who committed suicide or who are exposed to family violence.


Family Issues

Depressed children often have depressed or stressed parents. Can the stress of coping with a depressed child lead to parental rejection or is it the poor parenting that leads to the child's depression? The answer may be different in different cases. A depressed, hyperactive child may be hard to raise. Some parents have more coping skills than others. A child may learn to give up because parents have not modeled good ways of coping with stressful situations.. Some suggest that parental patterns of irritability, and withdrawal lead to low self-esteem in the child and that this predisposes the child to depression. Some suggest that a genetically vulnerable child is more likely to develop depression when exposed to family stress.


It usually takes more time to diagnose Major Depression in a child than it does to diagnose an adult. The diagnostic process should include interviews of parents and the child. I try to include both parents, even if the child is only living with one parent. Parents are more likely to report outward signs of depression. The child may be more aware of inward signs. Sometimes a parent's report is skewed by the parent's own agenda, so school and other outside reports are useful. (with written permission) Generally, there should be a recent physical. Although this is usually done by the primary care physician, the psychiatrist may do a screening neurological and relevant parts of a physical exam. The psychiatrist will ask about the developmental history and about the existence of other psychiatric conditions.


There is no cookbook technique. Treatment must be tailored to the needs and schedule of the child and his family. Generally, with mild to moderate depression, one first tries psychotherapy and then adds an antidepressant if the therapy has not produced enough improvement. If it is a severe depression, or there is serious acting out, one may start medication at the beginning of the treatment.


A variety of psychotherapeutic techniques have been shown to be effective. There is some suggestion that cognitive-behavioral therapy may work faster. Cognitive therapy helps the individual examine and correct negative thought patterns and erroneous negative assumptions about himself. Behaviorally, it encourages the individual to use positive coping behaviors instead of giving up or avoiding situations. After therapy is over, children may benefit from scheduled or "as-needed" booster sessions.

Many feel that family therapy can speed recovery and help prevent relapse. There are different styles of family therapy.


Most studies suggest that the older, tricyclic antidepressant medications (Amitryptiline, Imipramine Desipramine) are no better than placebo in the treatment of depression. Still, many of us have seen individual children and adolescents who have responded well. Tricyclic antidepressants can be an effective treatment for ADHD. Since there is a small risk of heart rhythm changes, in children on these medications, we usually follow EKGs. The usefulness of blood tricyclic levels is being debated.

SSRIs (Selective Serotonin Reuptake Inhibitors--Prozac, Zoloft etc.) have brightened the outlook for the medication treatment of child and adolescent depression. The side effects are not as annoying as those of the older medications. These medications are somewhat less toxic in overdosage. Fluoxetine (Prozac) has been approved by the FDA for the treatment of depression in children 8 and up. There is special concern about using paroxetine (Paxil) or venlafzxine (Effexor) with depressed children and adolescents.  As compared to adults, adolescents are a bit more likely to become agitated or to develop a mania while they are taking an SSRI. These medications can decrease libido in both adolescents and adult. I warn parents about the symptoms of mania, especially if there is a family history of Bipolar Disorder. If the child has had a manic episode in the past, one might want to consider a mood stabilizer such as Lithium, or Depakote.

Follow Up and Other Considerations

Some individuals have only one episode of depression, but often depression becomes a recurrent condition. Thus, one should educate the child and family about the early warning symptoms of depression so that they can get right back in to the doctor. It is also useful to discuss the child's particular "early warning signs" with the primary care doctor. Sometimes I schedule booster sessions in advance and other times, leave the door open for the child or family to schedule one or two sessions.

The decision about when to stop antidepressant medication can be complex. If the depressive episodes are recurrent or severe, one may consider longer term maintenance pharmacotherapy. If the depression was milder, the family wishes the child to be off medications, or there are side effects, one may consider stopping the medication several months or a year after the symptoms are gone. If there have been several recurrences, one might then talk to the patient and family about longer term maintenance. Exercise, a balanced diet (at least three meals per day) and a regular sleep schedule are desirable. If there is a seasonal component, a light box or light visor may be helpful.

If there are residual social skills problems, a social skills group through the school or other agency can help. Scouts and church youth groups can be enormously helpful. If parents and child consent, I will sometimes involve a scout leader or clergy.

One must treat comorbid psychiatric disorders such as anxiety and ADHD. Since a young person who has had a depression is more vulnerable to drug abuse, one should start out early with preventative measures. The primary care doctor can be a partner in monitoring for relapse, substance abuse and social skills problems during and after the psychiatric treatment.

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It’s 1 AM, Do You Know Who’s Treating Your Kids’ Depression?

Did you know he’s depressed? His friends do...

Over 18 million Americans are depressed. As many as 2 million of these are adolescents. In some cases, the biological tendency toward depression runs in a family. In other cases, depression is brought on by life stress. In some cases, unfortunately, we never know.

American families today are busy. Parents, especially those heading a household alone, may need to work long hours to provide financial support. A parent may be starting to date again, or may simply be dealing with his or her own depression. A depressed teen may sense the parent’s stress or preoccupation and feel guilty about burdening the parent with his own problems. Some parents may try to make the adolescent feel better by minimizing the problem or they may actually rebuff his request.

Increasingly, adolescents have been seeking each other out when they are confused, depressed or in trouble. Sometimes, they may form an elaborate network of support for a depressed or suicidal peer. At its best, this can be a valuable early warning system for troubled teens. Other times, it may involve sharing antidepressant medications, hiding a runaway, or avoiding needed psychiatric help. There is also risk for the adolescent helpers. These helpers may be trying to cope with their own drug abuse or emotional problems. They often feel a great sense of responsibility toward the depressed individual. If their friend does commit suicide, the survivors are left with tremendous guilt.

Parents and adolescents should be aware of the warning signs of depression and suicidal thoughts. It is important to take the time to communicate with the depressed individual. Make sure that he or she gets help from responsible adults.

Possible warning signs of depression

Sudden changes in behavior

Aggressive, angry or agitated behavior

Increased risk-taking

Changes in appetite or sleep patterns

Lower self-esteem

Gives up valued possessions and settles unfinished business.

Withdraws from friends, activities, and family

Changes in dress or appearance

Significant losses or family stress


Recommended reading:

When Nothing Matters Anymore: A Survival Guide for Depressed Teens by Bev Cobain

The Power to Prevent Suicide: A Guide for Teens Helping Teens by Richard Nelson and Judith Galas

Carol E. Watkins, M.D


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My Friend is Still a Kid: Kids Don't Die!

Carol E. Watkins, M.D.

Your friend, is dead. The words sound so final, so cold. Maybe it was your classmate, boyfriend or confidant. Maybe he died from cancer, a car accident, or by his own hand. Somehow you can’t bring yourself to believe it. He wasn’t even 18. Aren’t your parents and grandparents supposed to die first?

If you lose a young friend, you may feel a mixture of emotions that will come as a surprise to you. Some feelings and thoughts are fleeting, and some may stay with you for a lifetime. Everyone experiences grief differently, but many pass through several stages of grief. These are denial, anger, bargaining, depression and acceptance. Some people cycle through some of these stages several times as different experiences or phases of life remind them of the loss.

Some who are experiencing denial or anger may want to rid themselves of possessions that remind them of the lost friend. If you can’t stand to look at certain objects, put them away for safe-keeping and wait a few weeks or months before deciding what to do with them. These mementos may be a source of comfort later. Talk to friends. Share funny and happy stories about your friend’s life. This helps make the loss more real and helps make sense of the death by celebrating the life. If you have questions about how the death occurred, ask the friend’s family or the school counselor.

You may feel plagued by feelings of responsibility or “What ifs?” Tell yourself that you are not responsible for your friend’s death. Cry and shout if you need to do so. Some find comfort in action. Join with others to create a memorial or to raise awareness about the illness that led to your friend’s death.

Take care of yourself. Some adolescents become depressed and even suicidal themselves after the death of a friend. Talk, write or compose music. Keep active. If you feel that you are losing control, seek adult guidance.

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Making a Meaningful Memorial for a Friend

Carol E. Watkins, M.D.

Often it is difficult to make sense of the death of a child or adolescent. One of the ways to deal with grief is to take action. By doing so, you can celebrate and memorialize the life of the friend you have lost. 


There are many kinds of memorials. Every culture, from ancient to modern, has developed unique ways for the living to pay tribute to the dead. Some believe that these rituals give special benefits to the deceased, but others see the funeral and memorial arrangements as powerful source of comfort and support for the living. The most common in our culture is the grave marker, which provides a specific place for family and friends to visit. But there are many other types of memorials that you can create yourself. These may be based on your interests and talents or your relationship to your dead friend.


You and your friends may organize your own meaningful memorial service with different individuals providing anecdotes, and simply a place to weep and laugh together. Photographs, videotape, or sports items may serve as reminders of your friend’s life.


If you are artistically or musically talented, you might compose music or a painting to express your grief, anger or love. A particular painting or musical arrangement may evolve and change as you move through your grief. If you write, you may embark on a series of stories or poems.


Your school or place of worship may allow you to build a memorial garden. Working in the earth can be therapeutic, and planting can express hope in the future.  If you do build a garden, be sure that someone makes a commitment to maintain it. Weeds and neglect do not make a good memorial.


Anger is a form of energy. Can you transform this energy into something strong and positive? You might organize a group to promote awareness of the condition that caused the friend’s death. If he died as a result of drunk driving, you might promote SADD (Students Against Drunk Driving.) You might organize discrete rides home for classmates who become intoxicated at parties.


Celebrating and commemorating a friend’s life may not mean that you agree with the way he died. Seeking to understand someone’s reasons for drunk driving or suicide is not the same as condoning a self-destructive act. 


Finally, your own life can be a memorial.  You bear within you the rich, bittersweet lessons learned from your friend's short life and death. 

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Mood Swings and Drugs

Which came first, the chicken or the egg?

Which came first, the drugs or the mood swings? Too often, I have to figure this out. His parents or teachers sent him to see me because he have had mood swings, verbal explosions and sleep problems. The drug screen comes back positive for cocaine and marijuana, and the garbage can search reveals empty wine bottles.

He has a problem with drugs and alcohol. He has mood swings. Drugs can cause mood swings. On the other hand, someone with depression or mania may use drugs to take away the pain of uncontrollable mood changes. Figuring out the answer often requires some expert detective work. He need to open up and give me a detailed, honest history. His family members must also be frank about their own drug and psychiatric histories. No more secrets.

Adolescents may abuse drugs for a variety of reasons. These often include peer group pressure, parental drug and alcohol use, depression or just a desire for a new experience.

No adolescent should use alcohol or illegal drugs. However, there are certain individuals who are at increased risk. These individuals should be cautious even as adults. Some people can drink for quite a while before running into problems. Others have problems after that first drink. If close family members have had problems with drugs or alcohol, you are at increased risk. If you are depressed or already have trouble with mood swings, you are more likely to become addicted, and may have more trouble getting off drugs. There is evidence that drug use may cause an individual with a biological tendency toward bipolar disorder to develop the illness earlier in life. High school is difficult enough; you don’t need this too. Talk to a trusted adult and get help early.

Carol E. Watkins, M.D.

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 Northern County Psychiatric Associates 

Our practice has experience in the treatment of Attention Deficit disorder (ADD or ADHD), Depression, Separation Anxiety Disorder, Obsessive-Compulsive Disorder, and other psychiatric conditions. We are located in Northern Baltimore County and serve the Baltimore County, Carroll County and Harford County areas in Maryland. Since we are near the Pennsylvania border, we also serve the York County area.   Our services include psychotherapy, psychiatric evaluations, medication management, and family therapy. We treat children, adults, and the elderly.

We also maintain a list of informative web sites on mental health topics, such as Attention Deficit Disorder, Parenting and Support Groups.

Awards for  the NCPA site

Northern County Psychiatric Associates
Lutherville and Monkton
Baltimore County, Maryland
Phone: 410-329-2028
Web Site 


Carol E. Watkins, M.D.
Glenn Brynes, Ph.D., M.D.

Copyright 2006  Northern County Psychiatric Associates
Last modified: October 05, 2007

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