Childhood Depression: Matter of Life or Death

Because some depressed children appear happy, depression in children can be difficult to diagnose. But many depressed children become suicidal, making diagnosis crucial.

8 min read

Childhood is not a universally happy time, and for 3% to 8% of kids, depression will be part of the growing-up experience. Fortunately, children who experience depression usually respond to treatment, and that treatment can mean the difference between life and death, say experts.

While it is easy to blame childhood depression on 21st century life -- too much stress, too little "quality time" for families, too much exposure to violence, too little extended family, and too many children of divorce -- the reality is that depression has probably been stalking children for generations. For example, the 19th century American poet Henry Wadsworth Longfellow in the often-quoted poem The Children's Hour writes of "Grave Alice," who is accompanied by "laughing Allegra and Edith with golden hair." Readers of any era are led to believe that "Grave Alice" is not a happy-go-lucky child.

Experts tell WebMD that childhood depression is nothing new, but what is "new" is the realization that depressed children have a significant risk of suicide and that depressed children, even children with bipolar depression -- characterized by mood swings from "mania" to depression, do meet a set of defined criteria.

Joan Luby, MD, associate professor of psychiatry at Washington University at St. Louis School of Medicine, tells WebMD that even in preschool children "depression is pretty definable" and does follow criteria found in the DSM-IV, the psychiatry manual that describes the symptoms of mental illness. But those criteria, says Luby, "have to be translated" in a way that can be applied to children.

For example, very young children will know that something is wrong but may not be able to express the problem. In those cases, Luby says that a valid diagnosis can be "obtained by interviewing parents, by observing the child, and by the use of puppet interviews." The child, she says, can be encouraged to talk about feelings with the use of the puppet. Meanwhile, the parent interviews and observations can provide what Luby says is the most specific symptom of early childhood depression: anhedonia, which is the inability to experience joy or pleasure. She says that when she studied 174 children, "anhedonia never occurred in children who were not depressed."

The problem, however, is that while clinically depressed adults rarely appear happy, depressed children often appear happy, says child psychiatrist David Fassler, MD. He tells WebMD, "Children present in a lot of different ways. Sometimes kids are just like classically depressed adults -- they are withdrawn, sad, tearful, and have trouble sleeping. Other times they are irritable, can't sit still, and have trouble concentrating. And sometimes they 'look' happy." Fassler is a spokesman for the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.

Luby agrees and notes that children are "inherently joyful and often don't appear obviously sad." Also, their sadness is not constant, she adds. Sadness is often interrupted by normal mood periods, so it can be missed. Thus, rather than attempting to measure sadness, she measures the lack of pleasure by having parents interact in games and scenarios that "are specifically designed to elicit joy." Luby says, too, that the most reliable gauge of childhood depression is "parent reports."

Michael Naylor, MD, director of the division of child and adolescent psychiatry at the University of Illinois at Chicago, says, too, that depressed children are less likely to lose their appetites and sleep disturbances are more likely to have difficulty falling asleep, rather than waking in the middle of the night.

As difficult as it is to diagnose depression, treatment can be even more challenging, says Naylor.

He tells WebMD that most psychiatrists follow the "Texas Children's Medication Algorithm," which outlines a step-by-step approach to treatment. He says the plan recommends Prozac as the first-line drug treatment, because there is so little research into the efficacy and safety of antidepressant drugs in children that "the research is really only unequivocal in one drug, and that drug is Prozac, which has demonstrated that it is more effective than placebo."

He says another study suggested that Zoloft is also more effective than placebo, but the difference was not as great as in the Prozac studies.

But recently, antidepressants have been in the news because of concerns that they may be linked to increased suicidal thoughts or actual suicide in children and teens. The concerns prompted the FDA to require makers of 10 antidepressants to include warning labels on their products. The new labels, which will appear on Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro, Wellbutrin, Effexor, Serzone, and Remeron, warn of possible suicide, worsening depression, anxiety, and panic attacks in adults and children. The FDA said in a news release that it was not yet clear whether antidepressants contribute to the emergence of suicidal thinking and behavior, but they recommended close monitoring of all patients taking antidepressants.

Earlier this month, the British Medical Journal published an analysis of six studies that included 940 children and adolescents taking Paxil, Effexor, Zoloft, Prozac, or placebo. In that analysis, the researchers reported that the benefit of antidepressants was overstated. They also voiced some concern that drug treatment, often considered easier and less labor intensive, was too often being substituted for proven techniques such as cognitive behavioral therapy.

All of the experts interviewed by WebMD agree that it takes more than a pill -- even a very good pill -- to treat depression in children.

Victor Fornari MD, associate chairman for education and training in the department of psychiatry at North Shore University Hospital on Long Island, says he doubts any psychiatrists would consider medication alone as a good treatment plan.

He tells WebMD that the depressed child needs a comprehensive approach that includes supportive care, family therapy, and medication. Moreover, children taking antidepressants require very close monitoring. "When I start antidepressants in a child, I tell them to come in the next day, then again in three days and then every week." He says weekly visits continue until he is confident that the drug is working and the dose is correct.

But Fornari says that antidepressants are an important part of the treatment in most children and "can mean the difference between a child who is in school and one who is not."

Michael Faenza, president and CEO of the Alexandria, Va.-based National Mental Health Association, tells WebMD that his group estimates that "one in eight adolescents is affected by depression. Think about it, that's kids in every classroom."

He agrees that antidepressants do appear to work in most children, although he notes that it is still unclear if the drugs are associated with an increased risk of suicide. "We have had a tripling of the suicide rate in young people since 1960," he says. "Much of that increase occurred in the absence of antidepressant treatment."

Faenza says his group is worried that recent headlines about suicide and antidepressants will keep parents from seeking treatment for their children, which could have disastrous effects since "only about one in three children who need mental health care are currently receiving it."

What is urgently needed, says Faenza, is more research into the effect of antidepressants and other treatments, such as talk therapies. And that research is needed now, he says.

One doctor who agrees with the urgency is Harvard-trained pediatrician Neal Bahr, MD, who is now executive producer of the television program Law and Order: SVU. Bahr tells WebMD that he decided to dramatize the problem of depressed kids in a show broadcast last year. In that show, a 14-year-old has a "manic reaction" to antidepressants.

While antidepressants are very appropriate when properly used, Bahr says he wanted to illustrate the potential dangers when the drugs are not used properly and the patient is not closely supervised. "I think we need more research into the ways in which these drugs affect developing brains, and until we have that research, we need to be cautious," he says.

Part of that caution means age appropriate treatment, says Luby. She notes that there are no studies that demonstrate the efficacy of talk therapies in very young children, but says that it is very possible that the youngest children may be especially receptive to therapy because their brains are still developing and changing.

In the youngest children, play therapies are usually the first treatment option. Play therapy uses dolls and toys as well as drawings to help children open up. Usually several sessions are needed and parents should realize that the number of sessions is likely to relate to the extent of the depression. It is not uncommon for children to have weekly sessions for three to six months.

Older children may benefit from more traditional talk therapies, such as cognitive behavioral therapy, which is also known as CBT. This approach combines "thinking" therapy with behavior therapy. The goal is to modify mood by changing thinking.

One approach is called Child and Family Focused Cognitive Behavioral Therapy, which is structured for 12 sessions with the child, siblings, and parents. This approach is specifically designed for use with children who have been diagnosed with bipolar disorder -- which involves episodes of both depression and mania. Mania symptoms include inflated self-esteem, decreased need for sleep, and excessive talking. Mani N. Pavuluri, MD, from the University of Illinois at Chicago developed the therapy and he says it can be used with both young children and teens. Moreover, sessions can be planned on a weekly basis or can be spaced at intervals of two to four weeks.

Pavuluri says this approach can be described as a RAINBOW: R for routine; A for affect regulation; I for I can do it; N for No negative thoughts or live in the Now; B for Be a good friend or Balanced life style for parents; O for "Oh how can we solve it?"; and W for ways to get support.

Bahr notes that in his TV show the depressed child was involved in a violent crime, an outcome that he says can happen when children fail to receive appropriate treatment. He says his real take home message to viewers is one that most experts would endorse: "I want every child who needs treatment to receive complete and through evaluation by a child psychiatrist."

Published April 14, 2004.