Depression in Children and Adolescents

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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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


  • 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


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.


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


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


Sudden changes in behavior

Aggressive, angry or agitated


Increased risk-taking

Changes in appetite or sleep


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



Recommended reading:

When Nothing Matters Anymore: A Survival

Guide for Depressed Teens


Bev Cobain

The Power to Prevent Suicide: A Guide for

Teens Helping Teens


Richard Nelson and Judith Galas

Carol E. Watkins, M.D


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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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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 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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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


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,


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