Depression in Children and Adolescents
in the School Setting
and Suicide: Warning Signs
Friend is Still a Kid: Kids Don’t Die!
a Meaningful Memorial for a Friend
Swings and Drugs
a Parent is Depressed
Slides From Our Presentations on Depression and Mood Disorders
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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.
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
- 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.
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
Consequences and Associated
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.
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
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
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.
AM, Do You Know Whos Treating Your Kids Depression?
Did you know hes 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
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 parents 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
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
Sudden changes in behavior
Aggressive, angry or agitated
Changes in appetite or sleep
Gives up valued possessions
and settles unfinished business.
Withdraws from friends,
activities, and family
Changes in dress or appearance
Significant losses or family
When Nothing Matters Anymore: A Survival
Guide for Depressed Teens
The Power to Prevent Suicide: A Guide for
Teens Helping Teens
Richard Nelson and Judith Galas
Carol E. Watkins, M.D
Friend is Still a Kid: Kids Don’t Die!
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
cant bring yourself to believe it. He wasnt even 18. Arent 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 cant 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 friends 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 friends 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 friends 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 friends 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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a Meaningful Memorial for a Friend
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 friends 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 friends 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.
commemorating a friends life may not mean that you agree with the way he
died. Seeking to understand someones reasons for drunk driving or suicide
is not the same as condoning a self-destructive act.
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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Swings and Drugs
Which came first, the chicken or
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
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 dont need this too. Talk to a trusted adult and get
Carol E. Watkins,