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Dysthymia

  • It can be unbearable to imagine your child suffering the feelings of sadness, lethargy and discouragement caused by a depressive disorder like dysthymia—but it’s important to know that there’s hope. As awareness of adult mental health disorders has dramatically increased in recent years, so too has understanding of the many kinds of mood disorders that affect children. 

    While major depression is a well-known illness, dysthymia—also known as dysthymic disorder—is less familiar to most people. Like major depression, dysthymia is a mood disorder.

    The condition:

    • is less severe than major depression, but lasts for longer periods of time
    • may affect a child for as long as one to five years
    • affects about four out of 100 children and adolescents  in any year, but may affect upwards of 20% by the end of adolescence
    • is marked by a persistent feeling of mild depression, but may cause more extreme feelings from time to time
    • is often undiagnosed and if left untreated can lead to more serious mental health and behavioral problems
    • responds very well to psychotherapy and medication when treated by qualified mental health professionals

    How Boston Children's Hospital approaches dysthymia

    Children’s Hospital Boston has long been at the forefront of providing expert, compassionate care to children and adolescents with mental and behavioral health problems. Our Department of Psychiatry  team members are leaders in researching, diagnosing and treating dysthymia and other depressive disorders, as well as:

    Children’s approach to mental health care is evidence-based—which means that our treatments have been tested and proven effective through scientific studies, both here at our hospital and by other leading institutions worldwide. 

    Dysthymia: Reviewed by David R. DeMaso, MD
    © Children’s Hospital Boston; posted in 2011

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  • If your child has dysthymia, an important first step is familiarizing yourself with the basics about the condition and how it could affect her. 

    Children with dysthymia:

    • are in a depressed (and sometimes irritable) mood for most of the day, more days than not

    • feel an ongoing sense of worthlessness

    • lose interest in activities and hobbies they once enjoyed

    • are more likely to develop major depression in their teen or early adult years

    Unfortunately, many children with dysthymia don’t get the help they need: 60 to 80 percent of children with depressive disorders either are not diagnosed, or do not receive the treatment they need. If left untreated, dysthymia can lead to:

    • deteriorating schoolwork
    • frequent absences from school
    • dropping out of school
    • substance abuse and other destructive behaviors
    • strained relationships with family and friends
    • potential risk of suicide 

    What is dysthymia?

    Like major depression, dysthymia is a mood disorder. The condition:

    • is less severe than major depression, but lasts for longer periods of time

    • may affect a child for as long as one to five years

    • is not necessarily present every day, hour in hour out.

    • is marked by a chronic feeling of mild depression, but may cause more extreme feelings from time to time

    • has no single, identifiable cause; it may be linked to a family history of depression, factors in a child’s environment, or specific traumatic experiences

    Children with dysthymia:

    • are in a depressed (and sometimes irritable) mood for most of the day, more days than not
    • feel an ongoing sense of worthlessness, low self-esteem and hopelessness
    • lose interest in activities and hobbies they once enjoyed
    • are more likely to develop major depression in their teen or early adult years 

    Is dysthymia common? Who gets it?

    About four out of 100 children and adolescents have dysthymia. 

    Here at Children’s Hospital Boston, we understand that a timely, effective treatment plan makes all the difference for a child facing dysthymia. Our psychiatrists, psychologists and social workers are here to provide compassionate, knowledgeable care for your child and support for you and your family.

    Causes

    What causes dysthymia?
    The exact cause of dysthymia is not known, but experts point to several risk factors for childhood depression, including:

    • a family history of depression (children with a depressed parent have more than a 40 percent chance of also developing a depressive disorder) 
    • excessive stress 
    • a traumatic experience (physical and/or emotional) 
    • other mental health problems, such as anxiety
    • abuse or neglect 
    • death of a parent, relative, friend or other loved one 
    • a divorce or illness in the family 
    • loss of an important relationship (e.g., a romantic breakup) 
    • chronic social or academic difficulties 
    • dealing with a chronic medical illness
    • feeling “left behind” or “not good enough” when compared to peers 

    Signs and symptoms

    What are the symptoms of dysthymia?
    Symptoms of dysthymia may be very different from one child to another, so it is important to know your child’s usual moods, routines and habits in order to detect the possible onset of depression.

    Common warning signs are: 

    • persistent sadness or “moping”
    • sleeping too much or too little
    • feeling hopeless or helpless
    • low self-esteem
    • feeling inadequate compared to friends and peers
    • excessive guilt
    • feeling or expressing a desire to die, “disappear” or “just sleep forever”
    • loss of interest in usual activities and favorite hobbies
    • difficulty with relationships
    • withdrawing from friends and family
    • changes in appetite or weight
    • decreased energy
    • difficulty concentrating
    • difficulty making decisions
    • suicidal thoughts or attempts
    • frequent physical complaints such as headache, stomachache or fatigue
    • running away or threats to run away  
    • hypersensitivity to failure or rejection
    • irritability, hostility or aggression

    If any or all of these symptoms are ongoing—meaning they last for at least two weeks—and noticeably disrupt your child’s home, school and social life, your child is likely to have a depressive disorder requiring prompt medical treatment.

    If your child expresses a desire or plan to die, “disappear,” or “just sleep forever,” you should always take his feelings seriously and seek immediate help.  Learn more about recognizing the warning signs of suicide.

  • The first step in treating your child’s dysthymia is forming an accurate and complete diagnosis.

    How is dysthymia diagnosed at Children’s Hospital Boston?
    A child psychiatrist, psychologist or social worker makes the diagnosis after conducting a comprehensive psychiatric assessment with you and your child. During the assessment—which is an interview—you will be asked about your child’s symptoms, as well as his social, medical, school and family histories.

    Working with the Children’s mental health clinician, you will arrive at a formulation or explanation of your child’s problem, and can then begin a mutually agreed upon treatment plan. 

    Because depression has shown to often co-exist with other mental health problems, such as substance abuse and anxiety disorders, seeking a diagnosis and beginning treatment as soon as possible are very important.

    FAQ

    Q: Are depressive disorders like dysthymia common in kids?
    A: Yes. Depressive disorders, including dysthymia, are among the most common mental, emotional and behavioral problems affecting children. According to the U.S. Center for Mental Health Services, as many as one in every 33 children and one in every eight teens may be depressed.

    Q: How can I tell if my child has dysthymia, or is just “going through a phase” or “down in the dumps”?
    A: Nearly all children—and especially adolescents—go through pronounced phases of “moodiness,” wanting to be alone and fretting about their lives and relationships. 

    The difference between these normal ups and downs of teenage life and the presence of a depressive disorder is that a truly depressed child will experience extended and intense feelings of sadness, hopelessness and helplessness.

    You should seek prompt treatment for your child if any of the following symptoms persist for two weeks or more:

    • feeling sad, worried or hopeless
    • expressing low self-esteem or making negative comparisons to peers (“I’m so stupid compared to everyone else in the class,” “I’m so much uglier than all my friends”)
    • sleeping too often or not often enough
    • withdrawal from family and friends (constantly staying in her room with the door closed, not taking calls or visitors)
    • sudden change in weight or appetite
    • unprovoked irritability, hostility or aggression
    • diminished performance in school
    • complaining of headaches, stomachaches or other physical symptoms with no identifiable medical cause

    If your child:

    • begins giving away treasured possessions
    • refers to “not being around” in the future
    • expresses a wish to “disappear” or “sleep forever”
    • expresses a desire to die
    • mentions a plan to die

     … you should always take these warning signs of suicide very seriously and seek immediate help.

    Q: Why is psychotherapy, or “talk therapy,” helpful in treating dysthymia?
    A: Psychotherapy (“talk therapy”) has proven to be an extremely effective method of overcoming the seemingly “unshakeable” sad, hopeless feeling that is the calling card of dysthymia.

    An experienced mental health professional will use psychotherapy to help your child adapt new, healthy and constructive responses to stress and sadness. Therapy will teach your child:

    • how to vocalize feelings of hurt, anxiety, anger and low self-esteem

    • techniques (such as deep breathing, meditation, exercise and mentally picturing a relaxing place or scenario) for reducing the physical feelings associated with depression

    • new thought patterns to replace the destructive ones—for example, responding to an initial sense of hopelessness by remembering, “This is just my brain making me feel like this will go on forever. But really, it’s just a temporary feeling and I will work through it.”

    • how to improve their problem solving abilities

    • how to enhance their social skills

    Q: Why do some children need antidepressant medication for dysthymia?
    A: Some children may need medication to ease their feelings of sadness, tiredness and hopelessness to a manageable degree, so that they can begin to benefit from psychotherapy.

    Here at Children’s, medication is never a standalone treatment—we only prescribe it in conjunction with talk therapy. Learn more about how Children’s prescribes psychiatric medication.

    Q: What is the “black label warning” I keep hearing about when it comes to certain psychiatric medications?
    A: Since 2004, the U.S. Food and Drug Administration has placed a black warning label on antidepressant medications. The warning label states, in part:

    Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.”

    If your child is prescribed any medication for dysthymia, your clinician will carefully go over the specifics of the drug, as well as any potential side effects you should watch for. We will closely monitor your child for any sign of a negative response to the medication, and are always here to address any concerns you may have.  However, evidence-based studies have shown that a combination of psychotherapy and medication are the most effective interventions for moderate or severe depressions. 

    Q: Can I prevent my child from becoming depressed?
    A: There is some evidence that depressive episodes in children may be prevented. Through a series of long-term studies with families, William R. Beardslee, MD, Children’s academic chair of Psychiatry, has developed a step-by-step approach that helps families cope with depression while nurturing resiliency in children.

    This approach is now being used across the country and around the world. 

    Q: What is the long-term outlook for my child?
    A: The outlook for a child with dysthymia depends greatly on being diagnosed and properly treated as early as possible. If left untreated, dysthymia can lead to major depression, which carries a substantial risk of:

    • failure, chronic absenteeism or dropping out of school
    • involvement in destructive behaviors, including substance abuse
    • difficulties with relationships, jobs and responsibilities in adulthood
    • suicidal thoughts or attempts

    The good news is that children with depressive disorders, including dysthymia, respond very well to psychotherapy and medication when treated by qualified mental health professionals.

    Q: What if my child has been diagnosed with another mental health issue, in addition to dysthymia?
    A:
    A child with dysthymia often has another mental health condition, including:

    If your child has another mental or behavioral health problem, the conditions must be treated at the same time.  Your clinician will develop a dual treatment plan that meets your child’s specific needs.

    Q: What is the most important thing I need to know about childhood depression?
    A: If you suspect your child may be depressed, it’s essential that you speak with a qualified mental health professional as soon as possible. Children with depressive disorders respond well to treatment that is administered by trained clinicians. By closely working with the treatment team, you can help your child go on to enjoy an active and fulfilling life.

    It’s also important to note that a depressed child can’t just “snap out of it,” or will herself out of her feelings—and telling her to do any of these things is likely to only make the depression worse. Like a child with a chronic medical illness, children who are depressed require qualified and consistent clinical care and family support.

    Helpful links for younger children

  • It's entirely natural that you may be scared, worried and confused about your child's mental health right now. But you can be rest assured that at Boston Children's Hospital, your child and family are in good hands.

    If your child has dysthymia, it's important to understand that he cannot just “snap out of it” or will himself to feel better. A depressed child feels a constant sense of discouragement, a loss of self-worth and loss of interest in activities he used to enjoy. Without treatment, these symptoms can last for months or even years and can lead to major depression.

    The good news is that, like all mood disorders, dysthymia is treatable. Treatments for dysthymia will vary from child to child, and your Children's clinician will work with you and your child to determine the right approach over the long term.

    Psychotherapy

    The best treatment for dysthymia is usually psychotherapy, or “talk therapy,” to help your child learn how to cope with his feelings. Coping strategies learned in therapy include:

    • identifying and talking about feelings, worries and relationships
    • stopping automatic negative thoughts (“Nothing I do will ever turn out right”)
    • relaxing the mind and body
    • finding activities that are engaging and comforting
    • discovering and appreciating positive things about themselves
    • building hope for the future

    Using these strategies, your child will be able to:

    • focus on changing his distorted views of himself and the environment around him
    • work through difficult experiences and relationships
    • identify stressors in his life and ways to avoid them

    Family therapy can also be useful in providing a support system for your child and addressing the concerns and issues faced by other family members. If environmental circumstances in your child's life—for example, being bullied at school or coping with a parent's alcoholism—are triggering his feelings of depression, it is also critical to change these circumstances as much and as quickly as possible.

    Antidepressant medications

    If your child's dysthymia does not adequately respond to psychotherapy, your clinician may add an antidepressant medication to the treatment plan. These medications can help your child feel more relaxed, motivated and comfortable while working on coping skills in therapy.

    Medication is not a “standalone” treatment; Children's always considers it part of a two-prong approach, with psychotherapy as a necessary component. Our Psychopharmacology Clinic  is devoted to helping children, families and clinicians decide whether medication might be a useful part of treatment.
     

    Commonly prescribed antidepressant medications include: 

    SSRIs (selective serotonin reuptake inhibitors, which adjust the levels of serotonin—a chemical that regulates mood—in the brain)

    • Celexa
    • Lexapro
    • Luvox
    • Prozac
    • Zoloft

    Atypical antidepressants (drugs that impact both serotonin and other chemical messengers in the brain)

    • Cymbalta
    • Desyrel
    • Effexor
    • Remeron
    • Serzone
    • Wellbutrin

    No single medication is effective in all children. Families should expect a trial-and-error process that can last weeks, or even months, as doctors find the drug regimen that works best.

    Since 2004, the U.S. Food and Drug Administration has placed a black warning label on antidepressant medications. The warning label states, in part:

    Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.”

    If your child is prescribed any medication for dysthymia, your clinician will carefully go over the specifics of the drug, as well as any potential side effects you should watch for. Our team has years of experience in managing the use of psychiatric medications in children of all ages and with a wide variety of conditions. We will closely monitor your child for any sign of a negative response to the medication, and are always here to address any concerns you may have.

    Learn more about psychiatric medications.

    Coping and support

    The ups and downs experienced by a child—and family—living with a depressive disorder can feel overwhelming. In addition to the information about dysthymia provided here, you may find comfort and support from the following resources: 

    Patient and family resources at Children's

    Children's Center for Families is dedicated to helping families locate the information and resources they need to better understand their child's particular condition and take part in their care. All patients, families and health professionals are welcome to use the Center's services at no extra cost. The center is open Monday through Friday from 8 a.m. to 7 p.m., and on Saturdays from 9 a.m. to 1 p.m. Please call 617-355-6279 for more information. 

    The Advocating Success for Kids (ASK) Program at Children's provides multidisciplinary evaluation, referral and advocacy services for children under age 14 who are experiencing behavioral, emotional, learning or developmental problems, either at home or at school. ASK works with children who receive their primary care either at Boston's Bowdoin Street Community Health Center, Martha Eliot Health Center or Joseph M. Smith Community Health Center or at Children's Primary Care Center. For more information about ASK, please call 617-355-4690.

    The Depression Experience Journal is an online collection that features thoughts, reflections and advice from kids and caregivers facing depression.

    Children's Integrative Therapies Team provides a number of services for hospitalized children, their families and their caregivers, including:

    • massage therapy
    • acupuncture
    • yoga
    • therapeutic touch

    Visit our “For Patients and Families” page  for what you need to know about:

    • getting to Children's
    • finding accommodations
    • navigating the hospital experience 

    Please note that neither Boston Children's Hospital nor the Department of Psychiatry at Children's unreservedly endorses all of the information found at the sites listed below. These links are provided as a resource.

     Helpful links for parents

    Helpful links for teens

    Helpful links for younger children

  • At Children’s Hospital Boston, we’re dedicated to proving the effectiveness of our treatment approaches through rigorous scientific testing. Our research program is one of the largest and most active of any pediatric hospital in the world.

    Each day, we are working toward important discoveries to propel new advances in preventing, diagnosing and treating mental and behavioral disorders. This research reinforces our ongoing commitment to enhancing mental health for all children and adolescents. 

    Children’s research projects with promise for preventing and treating childhood depression include:

    • William Beardslee, MD, academic chair of Psychiatry at Children’s, is the principal investigator of long-term study that he and several colleagues first began in 1979. Researchers closely examined the lives of 275 children from 143 families in which the parents had depression or several risk factors for depression. Using data from this study, Beardslee has identified risk factors for depression in children and implemented a prevention program for families in crisis.
       
    • Eugene D’Angelo, PhD, chief of Children’s Division of Psychology, is working with Beardslee on a large, multi-site study of families in which parents have depression and youngsters are manifesting its symptoms. The study uses a group approach in working with families to avoid depression.

    In addition, Children’s has developed landmark programs to raise awareness of childhood depression and advocate for community involvement in preventing depression and suicide, including:

    • A community prevention program for preventing and treating depression in high school students, building wellness into the school curriculum and training educators and parents to recognize and address mental health issues
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