Excerpts from Your Child on Depressive Disorders
As parents, we want our children to be happy. Yet despite our best efforts to please and protect them, children encounter disappointment, frustration, and, at times, real heartbreak.
All children feel sad or needy sometimes. However, there are some children who seem constantly sorrowful, hopeless, and helpless. Seriously depressed youngsters experience disturbing symptoms that are beyond the range of normal sadness.
Identifying the Signs
There are two basic types of depression: major depression which lasts at least two weeks; and the milder but chronic dysthymic disorder, in which a long‑standing depressed mood seems to be connected to the child's temperament or personality. Young children often do not talk about feeling depressed or down; therefore, vague, nonspecific physical complaints (headaches, stomachaches, other pains and aches) can be the first indications of severe depression in a school‑age child. Other young children with depression may also be irritable; experience anxiety at separation from their parents; or have exaggerated fears. Not all children who suffer with severe depression appear depressed, but instead may seem irritable or moody, swinging from great sadness to sudden anger.
Usually, there are other clues or signals that a child is depressed. She may lose interest or pleasure in most activities. She may complain about being tired most of the time or lack the energy to engage in her normal activities. She may sleep or eat too little or too much. She may have trouble concentrating or making decisions, Feelings of worthlessness, anger, or guilt may find expression in suicidal thoughts or ruminations about death.
Children with dysthymic disorder have milder but still harrowing symptoms of depression ‑ a depressed, irritable, volatile mood; appetite and sleep changes; diminished energy; low self‑esteem; feelings of hopelessness; poor concentration and indecisiveness ‑ that last for a year or longer. Though dysthymic disorder is uncommon in childhood, it may begin prior to adolescence. The depressed moods color every experience, impression, and response. These children may go about their activities as though wrapped in a despondent gauze, with only brief periods of improved mood and outlook.
Causes and Consequences
Depression is a complex and multifaceted condition. Likely rooted in a genetic and/or biochemical predisposition, depression also can be linked to unresolved grief, possibly in response to early real or imagined losses of nurturing figures. Depression may also reflect that the child has learned feelings of helplessness rather than feeling empowered to seek solutions for life's problems. Depressed thinking tends to be negative, hopeless, and self‑defeating, reinforcing feelings of depression.
Some seriously depressed children have experienced early life or environmental stresses including childhood trauma, or the death of a parent or other significant people. They may live in families where they regularly witness or are victims of parental aggression, rejection, or scapegoating, strict punishment, or parents abusing one another. Such family pressures may contribute to the development of a depressive mood disturbance in a child.
Depression also runs in families. Often one parent of a depressed child has suffered with depression. A depressed parent is also likely to be less responsive to her child Thus, both genetic risk and life experience can contribute to her depression.
Depression usually interferes with a child's social and academic functioning. When a child is seriously depressed, school performance deteriorates and she loses interest in school and peer activities. She may complain of headaches or stomachaches or develop severe fears or phobias.
Sometimes the symptoms of restlessness, agitation, and decreased concentration may mislead parents or teachers into thinking that a child has attention deficit disorder while, in fact, the child is depressed. It is not uncommon for children who are evaluated for one condition to be diagnosed with the other disorder since the two different disorders can coexist.
How to Respond
In trying to decide if symptoms are serious enough to seek help, talk to you child. Let her know that you see her sadness. By showing interest and the desire to help her understand her feelings, you bring hope to the child.
Without pressuring her, point to activities she enjoys and handles successfully. Help build self‑esteem by recognizing small triumphs and admiring her competence. As you listen to her, she will naturally feel protected and cared for.
At the same time, try to determine whether the child seems capable of handling the feelings on her own or whether she seems overwhelmed. If the symptoms persist, particularly if they are dangerous or seriously interfere with the child's life, ask your child's physician for names of a child and adolescent psychiatrist or other mental health professional experienced in working with children.
Treatment should begin with a full evaluation which usually includes all members of the family. An assessment will be made to rule out an underlying physical disease or illness that could also produce depressive symptoms.
Parents will be asked to describe symptoms and such behavioral changes as irritability, moodiness, loss of interest, and sleep and appetite changes and to report the duration of symptoms as well as any possible precipitating event.
Mary parents who are also depressed may have trouble accurately describing the child’s symptoms. They may either view everything in negative terms, therefore exaggerating problems, or be so preoccupied with their own depressive symptoms that they fail to observe the child accurately. In such families, it is not uncommon for parents to be unaware of their child's sadness, suicidal thoughts, or sleep disturbances.
Individual Psychotherapy Therapy offers support and empathy while encouraging exploration of the depressed feelings and symptoms. Treatment may alternate between play and talk because a treatment goal is to help the child talk about her feelings. If a specific circumstance or event has precipitated the depression ‑ divorce, for example ‑ therapy gives the child a chance to resolve some of her feelings and accept even a difficult reality.
For younger children or children who have trouble expressing themselves in speech, play therapy can provide an opportunity to communicate feelings and perceptions. Through play, the depressed child is able to communicate or enact in play her sense of loss, powerlessness, aggression, or danger ‑ and eventually deal with these painful emotions.
Cognitive‑Behavioral Therapy Often effective in treating depression in older children, cognitive therapy focuses on the irrational beliefs and distorted thoughts which are part of depression, such as a negative view of the self, the world, and the future. Usually a depressed child personalizes failure, magnifies negative events, and minimizes positive events and attributes. Cognitive therapy focuses on identifying and correcting negative thought patterns or distortions and on helping the child change her thinking.
Group Therapy This approach in children aims to help them develop social skills that can lead to a greater sense of mastery and self‑esteem. Children may find it easier to express feelings in a supportive group environment. Support groups for parents can help them manage specific problem behaviors, use positive reinforcement, communicate with children in an age‑appropriate manner, and become better listeners for their child.
Family Therapy Family therapy addresses problems that may worsen depression in children such as a lack of generational boundaries (in which parents or caregivers treat their children as peers), severe marital conflict, rigid or chaotic rules, or neglectful or overly involved parent‑child relationships. In addition, family sessions may help identify other depressed family members and assist them in getting their own treatment.
Medication Medications are sometimes used as part of a comprehensive treatment approach with a depressed child. Research is underway to clarify the role of medication and the response in the developing child. Some recent studies have shown improvement with use of antidepressants. The more commonly prescribed antidepressants are fluoxetine (Prozac), imipramine (Tofranil), nortriptyline (Pamelor), paroxetine (Paxil), and sertraline (Zoloft). Other antidepressants include bupropion (Wellbutrin) and venlafaxine (Effexor). Before an older child begins taking a medication, specific target symptoms should be identified in a discussion between the child, the parent, and the physician. Possible side effects and other aspects of the medication should also be fully discussed.
Hospitalization A depressed child should always be assessed for the risk of suicidal or self‑endangering behavior. If a child is preoccupied with death by suicide or has a well-thought‑out plan, hospitalization may be needed. Otherwise, as long as the child is able to function and her family is relatively supportive, intensive therapy can be done on an outpatient basis.
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