8 Strategies for Working with Grieving Children

Childhood depression is not easy to think about. For many years, children who showed signs of what would be called depression in adults suffered quietly while they were regarded as shy, lazy, or disobedient. The symptoms might be attributed to an adjustment disorder (a temporary response to recent stress), attention deficit disorder, or conflicts with their parents, teachers, classmates, and playmates.

The symptoms
Now we know that depression can occur even in young children. As in adults, one form the symptoms take is major depression, a recurring disorder that lasts at least two weeks (but usually several months). Another form is dysthymia, a less severe but longer-lasting disorder that often develops into major depression. Depressed children and adolescents are generally listless, withdrawn, and seemingly unable to concentrate or enjoy life. Sometimes they are sulky and irritable. They may insist, heartbreakingly, that they are stupid and ugly, could never accomplish anything worthwhile, and will never be loved. But the depression is not always so easy to recognize. A child who hits his baby sister, picks fights at school, or has frequent stomachaches and headaches may be as depressed as one who is obviously morose and withdrawn. And some typical symptoms of depression in adults, such as appetite loss and weight loss, are much less common in children and adolescents.

The picture changes with age. Up to age three, the signs may include feeding problems, tantrums, and lack of playfulness and emotional expressiveness. At ages 3-5, depressed children may be accident-prone and subject to phobias. Even before age 5, they may show signs of self-reproach by apologizing unnecessarily for minor mistakes and transgressions like spilling food or forgetting to put clothes away.

Children of early school age (6-8) sometimes show depression with vague physical complaints and aggressive behavior. They may cling to their parents and avoid new people and challenges. At ages 9-12, some common symptoms are morbid thoughts and lying awake worrying about schoolwork. By then, children have enough intellectual capacity and social understanding to think about reasons for their depression, and they may blame themselves for disappointing their parents.

Depressed adolescents sometimes seem to be angry rather than sad -- uncommunicative, hypersensitive to criticism, and generally annoying to their parents and others. They may show their depression through delinquent behavior -- running away from home, reckless driving, stealing, drug and alcohol abuse. But some suffer depression in its full adult intensity, with anxiety, dread, guilt, and a sense of hopelessness. They may even suffer more than adults, because limited experience of the world causes them to overreact to minor humiliations and setbacks.

Bipolar (manic-depressive) disorder (See Harvard Mental Health Letter, April and May 2001) can also occur in children, although it is not common. Unlike adults, children and adolescents are generally not elated during the manic phase of the cycle. They are more likely to be angry, irritable, and restless, with paranoid thoughts. Adolescents may have delusions, hallucinations, and other symptoms that create a potential for confusion with schizophrenia.

At least 50% of depressed children and adolescents also have at least one other psychiatric disorder -- usually an anxiety disorder, conduct disorder, eating disorder, or (in teenagers) alcohol or drug dependence. About 30% of children diagnosed with attention deficit disorder (distractible, hyperactive, and impulsive) eventually turn out to have bipolar disorder. Tobacco addiction, which almost always begins with adolescent smoking, is sometimes the result of depression -- nicotine may have an antidepressant effect, and depressed people find it especially difficult to quit smoking.

Genetics of childhood depression
According to the 1992 National Comorbidity Survey, at any given time, nearly 2% of children ages 7-12 in the United States have major depression. The rate of 6%-9% among late adolescents is similar to the adult rate. The lifetime rate of dysthymia is 4%-8% among children ages 7-18, and more than two-thirds of children with dysthymia develop major depression within five years. Until puberty, boys and girls are equally likely to become depressed, but afterward depression becomes more common in girls, reaching the 2:1 adult ratio in late adolescence. As in adults, major depression in children and adolescents is a recurrent illness with repeated relapses. About one-third relapse within two years, and 70% relapse at least once. In 20%-30% of depressed children, bipolar illness develops in the late teens or early 20s. Among adults with bipolar disorder, 25%-45% say their first episode of mania came before age 21.

The genetic contribution to mood disorders is especially high when the symptoms first appear in childhood or adolescence. For children of a depressed parent, the risk of depression is much higher than average. According to one report, more than 50% of children with a parent who has a history of major depression have an episode of depression themselves by age 20. Identical twins are highly concordant (matched) for childhood depression, and even more concordant for childhood bipolar disorder. But fraternal twins are no more concordant than any other brothers or sisters. A family history of personality disorders, panic disorder, or alcoholism also raises the risk of early depression. The heritability (proportion of individual differences in susceptibility associated with genetic difference) of childhood depression is estimated at 50% or more.

Other causes
What causes a genetically vulnerable child to develop the symptoms is not known, although both common sense and psychological theory have suggested many possibilities: the death or divorce of parents; a child's inability to conform to an unattainable ideal or live according to rigid moral convictions instilled by parents; failure to establish emotional bonds in infancy because of rejection or neglect; too much punishment and criticism with too little reward and praise; anger turned inward because there is no safe way to express it. Sexual or physical abuse may lead to depression by causing lasting changes in the regulation of stress-related hormones and neurotransmitters. And depressed parents influence the child's environment as well as passing on their genes. They are often too preoccupied with personal misery to show much sensitivity to their children's needs. The children's resulting withdrawal and apathy reinforce the parents' feelings of inadequacy, further raising the risk that the children will become depressed.

Causes of adolescent depression are particularly easy to suggest. Teenagers may have trouble giving up childhood comforts and pleasures while trying to establish an adult identity. Hormonal changes subject them to sexual tensions and aggressive impulses they don't know how to cope with. They may feel the need to deny dependence on their parents while also living up to what they suppose to be their parents' expectations. All the while, they have the intellectual capacity for self-criticism without the experience needed to put minor failures into perspective. Homosexual adolescents may be at especially high risk because isolation, concealment, social stigma, and family misunderstanding often make sexual development more emotionally difficult.

But many of the family conditions suggested as causes could instead be the effects of a child's or a parent's depression, or even of genetic vulnerability. There is no reliable evidence for a single biological, psychological, or social explanation of childhood depression. Twin and adoption studies have not shown that a common family environment affects the chance that a child will become depressed. After adjusting for genetic predispositions, it does not seem to matter whether the father is present, how many children there are, or even whether there is serious family conflict. The rate of depression in adopted children is correlated with the rate in their biological rather than their adoptive parents.

We know more about the adult consequences and adult outcomes of childhood mood disorders, and what we know is not reassuring. The childhood problems usually persist in adult life. About 90% of people who have manic episodes in childhood will also have them in adulthood. Depressed children are also vulnerable to a variety of personality disorders. According to recent research, the odds of antisocial, histrionic, and borderline personality are increased four times in adolescents with depression or bipolar disorder, regardless of social class, family conflict, other psychiatric disorders, or a history of child abuse or neglect.

Diagnosing Depression
A correct diagnosis is especially important for children and adolescents, because 6-9 months, the length of an untreated episode of major depression, is a much longer time in their lives than it is in an adult's -- and chronic dysthymia can be even more incapacitating. It is important to interview both parents and children. Parents are better at describing the child's behavior and children more reliable in identifying their own moods. Formal diagnostic interview schedules and checklists of symptoms are available for both parents and children. But depressed children may have difficulty understanding the questions, and adolescents may be unwilling to answer because they mistrust adults or hate to admit weakness. It may help to have an older brother or sister present during the interview. The diagnosis of depression in adolescents who are addicted to alcohol or drugs is controversial, because drug-induced symptoms are too easily mistaken for depression.

Depression in a teenager should not be dismissed as "just a stage." Adolescents are sometimes expected to have serious emotional problems -- to be lonely, confused, angry, rebellious, and despairing. But however it may sometimes seem to their parents, normal teenagers do not go through a period of emotional turmoil that resembles a psychiatric disorder. Studies show that most of them do not feel misunderstood or miserable most of the time. When an adolescent does show signs of severe depression, it should always be treated as soon as possible, especially since there is some evidence that each untreated depressive episode makes the next one more likely.
- Depression in Children Part I; Harvard Mental Health Letter; Feb 2002, Vol. 18, Issue 8.

Personal Reflection Exercise #6
The preceding section contained information about depression in children. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 20
What are the signs of depression in a child up to age three? Record the letter of the correct answer the Answer Booklet.