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Major Depression

  • Everyone, including children, goes through periods of feeling unhappy or listless. But if the feelings are very strong or persist for a long time, they might be caused by a medical problem. Major depression, or simply “depression,” is a serious condition that can take over your child’s mood and thoughts. The good news is that awareness and intervention from parents or other adults can help children with depression live normal and happy lives.

    A child with depression typically feels a constant sense of discouragement, a loss of self-worth and little interest in activities he used to enjoy. It’s important to understand that your child, or anyone with depression, cannot just "snap out of it" or make himself feel better. Without treatment, symptoms can last for months or even years.

    • Depression in children has dramatically increased in recent years – between 7 and 14 percent of children will experience an episode of major depression before they turn 15.
    • Before puberty, boys and girls are equally at risk for depression. By age 15, girls are twice as likely as boys to have experienced a major depressive episode.
    • Around 80 percent of people with major depression who seek treatment improve, usually within weeks.

    PLEASE NOTE:  If you feel your child is at immediate risk of self-harm or causing harm to others, you should call 911 right away.

    How Children’s Hospital Boston approaches major depression

    Children’s Department of Psychiatry has long been at the forefront of providing expert, compassionate care to children and adolescents with mental health issues. Our 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.

    We use “talk therapy” as our primary method of treatment for depression, focusing on teaching children helpful thinking and coping skills to overcome symptoms and adopt new, healthier thought patterns and behaviors.

    In certain instances, we might recommend the addition of anti-depression medication—always in conjunction with talk therapy. Children’s has a dedicated Psychopharmacology Clinic to help determine whether medication might be a helpful addition to the treatment plan.

    Our team is always aware that your child is, first and foremost, a child—and not merely a recipient of care. You and your family are essential members of the treatment team, and our compassionate mental health professionals will include you in the process at every step of the way.


    Major depression: Reviewed by David DeMaso, MD
    © Children’s Hospital Boston, 2011


    Boston Children's Hospital
    300 Longwood Avenue
    Boston MA 02115

     617-355-6680


  • What is childhood depression?

    Childhood depression is a mental health disorder characterized by a sad mood that is both prolonged and severe. Typically, if your child has major depression, he:

    • is in a depressed or irritable mood for most of the day nearly every day
    • shows a noticeable decrease in interest or pleasure in nearly all activities
    • may have severe problems with eating, sleeping, energy and concentration, feelings of worthlessness or extreme guilt and even little desire to live

    In order for your child’s problems to be considered major depression, three conditions must be met:

    1. Symptoms must persist for at least two weeks.
    2. The problems must cause distress and/or impair his function at home, at school or with friends.
    3. The mood must represent a distinct change from how he was before.

    Major depression can be treated with medication, therapy and hospitalization, if necessary.

    What’s the difference between depression and grief?
    Grief is a normal and natural response to loss. While grief and depression share certain symptoms (e.g. sadness, too much or too little sleep, changes in eating patterns), grief is not as constant. In other words, a person who is grieving may feel very sad when thinking about or remembering the loss, but feel somewhat better around friends and family. But someone with depression rarely finds relief from his or her sadness. Learn more about grieving and bereavement

    What are the risks of depression?
    If you think your child might be depressed, it’s important that he is evaluated sooner rather than later. If left untreated, depression could lead to:

    • failure in school
    • involvement in risky behaviors
    • difficulties with jobs and relationships in adulthood
    • attempted or successful suicide


    Causes

    Why do children become depressed?
    While the exact cause of depression and other mood disorders is not known, they've been linked to genetics and environmental factors. The most common factors associated with major depression include:

    • family history of depression
    • parents’ divorce
    • excessive stress
    • abuse or neglect
    • trauma (physical and/or emotional)
    • loss of a parent, caregiver or other loved one
    • loss of a relationship, such as moving away or loss of boyfriend/girlfriend
    • failure to accomplish tasks such as learning to read, or keeping up with peers in other activities
    • chronic illnesses, such as diabetes
    • other psychiatric disorders
    • other developmental, learning or conduct disorders

    There are biological, psychological and social factors that can contribute to depression separately or in combination.

    Biological

    • Depression is thought to be caused by a difference in the structure and function of your child’s brain that controls the intensity of sad or irritable moods.
    • There may be a genetic component. If other members of your family have had depression, your child is more likely to develop it, too.

    Psychological

    • Children have different temperaments. Two siblings can be raised in the same environment, and one may have depression, and the other may not.
    • Some children are simply quieter than others, and less likely to talk about the things that are bothering them.

    Environmental

    • A stressful environment at home, school or in the community can contribute to depression.
    • Your child may experience depression if he feels unhappy with his environment and powerless to make any change to it.

    No matter what the underlying cause, we know how hard depression can be on your child and your family both, and we’re here to help.

    Could a physical illness be causing my child’s depression?
    Low thyroid levels may sometimes cause fatigue and other symptoms that may mimic symptoms of depression. Your child’s doctor can discuss this with you in more detail.


    Signs and symptoms

    What are the signs and symptoms of depression?

    While each child may experience symptoms differently, some of the most common include:

    • persistent feelings of sadness
    • feeling hopeless or helpless
    • having low self-esteem
    • feeling inadequate
    • excessive guilt
    • loss of interest in usual activities or activities once enjoyed
    • difficulty with relationships
    • sleeping too much or too little
    • changes in appetite or weight
    • decreased energy
    • difficulty concentrating
    • trouble making decisions
    • suicidal thoughts or attempts
    • frequent physical complaints such as headaches, stomach aches or fatigue
    • running away or threats of running away from home
    • hypersensitivity to failure or rejection
    • irritability, hostility, aggression

    In order for your child’s problems to be considered major depression, three conditions must be met:

    1. Symptoms must persist for at least two weeks.
    2. The problems must cause distress and/or impair his function at home, at school or with friends.
    3. The mood must represent a distinct change from how he was before.


    Long-term outlook

    What’s the long-term outlook for my child?

    Depression is considered to be a recurrent illness. It’s impossible to say for sure for any given child, but it is thought that:

    • one-third of children respond to a course of medication and therapy and then never need it again
    • one-third of children may experience another bout of depression and need to go back on medication and/or re-enter therapy
    • one-third of children may need to stay on medication and/or in long-term therapy


    FAQ

    Q: Will my child get better?
    A:
    The majority of children respond to treatment for depression, so it’s most likely that your child will, too.

    Q: When?
    A:
    This depends on many factors. A child who is good at communicating may benefit from talk therapy (our primary method of treatment) more quickly than a child who is more hesitant. If your child is taking medication, it may take a while to find the ones that work best.

    Q: What is the treatment for depression?
    A:
    Treatment for depression may be biological, psychological and environmental:

    • biological- your doctor may prescribe anti-depressants or other drugs that can help with your child’s depression.
    • psychological – your child may benefit from talk therapy, which is aimed at learning helpful thinking and coping skills to overcome symptoms and adopt new, healthier thought patterns and behaviors.
    • environmental– if your child’s situation at home or school is stressful, a change may help end his depression.

    Another psychological treatment may simply be time. Your child’s brain is continually growing and developing, usually until he is 22 to 24 years old. Depression often goes away on its own as a teenager enters his early 20s and becomes better able to manage his thoughts and feelings.

    Q: How can I pay for my child’s treatment?
    A:
    If you have health insurance, many plans cover mental health treatments. Our How-to Guide to Children’s Mental Health Services in Massachusetts can help you figure out other ways to get your child the help she needs.

    Q: What is dysthemic disorder?
    A:
    Dysthemic disorder, or “dysthemia,” is a milder form of depression. If your child has dysthemia, he will be in a depressed or irritable for most of the day, more days than not, for at least a year. He may not seem as depressed as a child with major depression, but still not function or feel well.

    To be diagnosed with dysthemia, your child must show impaired functioning at home, school and/or with friends. Children with dysthemia may also experience a bout of major depression; this is sometimes called “double depression.”

    It's estimated that around four out of 100 chldren and teens have dysthemia, and it' s equally common in boys and girls. Children with dysthemia are mroe likely to develop major depression as teenagers or young adults.

    Q: Are antidepressants safe for children to take?
    A:
    The safety and efficacy of antidepressants for children and teens have been studied extensively. Prozac and other medications known as selective serotonin reuptake inhibitors (SSRIs) have been shown to be safe in most studies and can be effective for teenagers, but should be carefully monitored by the prescribing physician. If your child’s treatment provider thinks that she may benefit from taking antidepressants, she will discuss this with you in detail.

    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, warning that antidepressants can increase the risk of suicidal thinking and behavior in children and adolescents with major depression and other psychiatric disorders.

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

    Q: What should I do if I think my child is depressed?
    A:
    If you think your child is depressed, it’s important that you take him to be evaluated as early as possible. Contact your child’s pediatrician, who may refer you to a mental health professional.

    If you’re concerned that your child might harm herself or others, call your child’s mental health practitioner or primary care doctor immediately. If he or she is unavailable, take your child to the emergency room. It’s very important that you take any signs that your child may be suicidal seriously. Learn more about teen suicide

  • The first step in treating your child is forming an accurate and complete diagnosis. If you suspect that your child is depressed, your child’s mental health clinician (who may be a child/adolescent psychiatrist, child psychologist or social worker who specializes in child and adolescent mental health) will ask you and your child to come in for one or more interview(s). The clinician will ask about your child’s:

    • symptoms
    • social history
    • medical history
    • academic history
    • family history

    It can sometimes be hard to distinguish between sadness and grief and major depression. In order to correctly diagnose your child with major depression, doctors use a standardized set of two types of symptoms that must be present.

    Core symptoms

    • persistent sadness
    • persistent loss of interest in almost all activities

    Associated symptoms

    • loss of energy
    • loss of appetite (or increase)
    • changes in sleeping patterns
    • agitation or irritability
    • feelings of worthlessness or excessive guilt
    • indecisiveness
    • wanting to die

    Major depression is when one or both of the core symptoms persist for at least two weeks along with five of the associated symptoms. If the symptoms are due to substance abuse, a medical illness or grief over a recent loss, they are usually not signs of depression.

    If your child shows some symptoms but not enough to indicate major depression, she may have dysthemia.

  •  At Boston Children's Hospital, we view the diagnosis as a starting point. Your child's clinician will take into account his situation and your thoughts and preferences, but treatment is often therapy, with or without medication.

    Therapy
    Talking with a therapist can help your child learn to manage sad feelings by developing new strategies. These include learning how to:

    • identify and talk about feelings
    • stop thinking automatically negative thoughts
    • find activities that are soothing and comforting
    • discover and appreciate good things about himself
    • build hope for the future

    Therapy can also help your child:

    • work through difficult relationships and situations
    • identify stressors in and figure out how to avoid or handle them
    • improve his view of her environment

    As with any treatment, parents and teachers play a vital and supportive role.

    Medication
    If your child's depression does not improve with therapy, or his depression is so severe that he has lost most of his ability to function or begins to think about harming himself, we may prescribe antidepressants. These can not only help your child feel better, but also help him feel more motivated to work on coping skills in therapy.

    Unfortunately, no single medication is effective in all children, and a trial-and-error period may last for weeks or even months as doctors find the best treatment for your child. When considering medication as a treatment option for your child, his clinician will take into account:

    • how well the drug has been shown to treat the symptoms your child is showing
    • his family history
    • side effects of the drug, if any
    • how easy it will be to take the medication as prescribed

    It's important to remember – and for your child to remember – that in order to have a chance for it to work, medication must be taken regularly as prescribed. Learn more about psychiatric medications for children and adolescents

    Environment
    While not a treatment in the strictest sense of the word, paying attention to your child's environment can also help treat his depression. If a situation at home could be contributing to your child's depression, family therapy may be helpful. If other circumstances are triggering the sad feelings, and it is at all possible to change them, doing so will increase the chance of successful treatment.

    If your child is diagnosed with a mental health condition in addition to depression, such as anxiety, trment must address both conditions.

    If your child's depression is particularly severe, debilitating or self-endangering, hospitalization may be required. Here at Children's Psychiatry Inpatient Service, our experts provide family-oriented psychiatric assessment and treatment with the goal of returning your child to a more comfortable environment for ongoing care.


    Coping and support

    Depression can make your child feel like he's all alone, and it's often hard on the whole family, too. That's why we've developed several ways to help you connect with resources and support. Depression in children is not uncommon, and there's a lot of help available.

    In cooperation with the Boston Bar Association, we've developed a How-to Guide to Children's Mental Health Services in Massachusetts. This guide can help answer questions including:

    • Is my child's behavior just a phase?
    • Can my child's school help us?
    • Should my child see a professional?
    • What other services are out there?
    • How do I pay for them?

    The Advocating Success for Kids (ASK) Program at Children's provides multidisciplinary evaluation, referral and advocacy services for children under age 14 with behavioral, emotional, learning or developmental problems, either at home or at school. ASK works with children who receive their primary care at: 

    For more information about ASK, please call 617-355-4690.

    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 Children's chaplaincy is a source of spiritual support for parents and family members. Our program includes nearly a dozen clergy members—representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian and United Church of Christ traditions—who will listen to you, pray with you and help you observe your own faith practices during your child's treatment.

    The Experience Journal was designed byChildren's psychiatrist-in-chief David DeMaso, MD and members of his team. This online collection features thoughts, reflections and advice from kids and caregivers dealing not only with physical illnesses like asthma and diabetes, but also with such mental health conditions as depression and ADHD.

    Visit our For Patients and Families page to learn about:

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

    Helpful links

    Please note that Boston Children's Hospital does not unreservedly endorse all of the information found at the sites listed below. These links are provided as a resource.

    For teens:

    For younger patients:


  • Children’s Hospital Boston is home to the world’s most extensive research enterprise at a pediatric hospital. We also have many partners with the top research, biotech and health care organizations, and we work together to find innovative ways to improve kids’ health.

    At Children’s Department of Psychiatry, we’re committed to helping your child live a full and healthy life. Our experienced team of researchers focus on finding answers to two simple questions: What puts a child at risk for mental illness? How can we help?

    What puts a child at risk for mental illness?

    1. Problem: Depression and anti-social behaviors are increasingly prevalent among children and teenagers, yet their causes and the best approaches to treatment are still not well understood.

    Innovative solutions:

    • William Beardslee, MD, Academic Chair, Department of Psychiatry led a long-term study that followed 275 children from 143 families in which the parents had depression or several risk factors for depression. From this, he identified risk factors for depression in children and went on to implement a prevention program for families in crisis. This research effort is now focused on helping other investigators use the approach and finding still more ways to prevent and treat childhood depression. Learn More
    • Researcher Michelle Bosquet, PhD, studies the impact of the mother’s anxiety, depression and posttraumatic stress disorder (PTSD) on infant emotional and physical development. She is investigating associations between mothers’ traumatic life experiences and the abilities of mothers and infants to regulate their emotions and physical responses to stress. She hopes this will help us design programs that prevent mental health problems in vulnerable children.
    • The research of Enrico Mezzacappa, MD, examines the role of a child’s social and familial environments in the development of aggressive behaviors. His goal is to understand how children develop the basic cognitive processes central to prosocial behavior, and how this can be encouraged. Learn More.   

    How can we help?

    1. Problem: For many patients and families, the challenges of coping with chronic illness are exacerbated by emotional and mental stressors.

    Innovative solutions:

    • Psychiatrist-in-Chief, David M. DeMaso, MD, focuses on how children and their families respond to the psychological stresses associated with chronic illness. DeMaso developed the Experience Journal,an innovative computer-based intervention that uses the reflections of children, parents, and healthcare givers on the experience of childhood depression, pediatric heart disease, organ transplants and inflammatory bowel disease.
    • Lisa Scharff, PhD, associate director, Pain Treatment Service, focuses on the psychological and behavioral factors involved in how children and adolescents experience of pain and disability. She also conducts trials of nonpharmacological pain management strategies, such as biofeedback and hypnosis.

    2. Problem: Research has shown that preterm infants are significantly more at risk for attention deficit disorder, lower IQ, difficulties in social-emotional functioning and increased need for specialized school services.

    Innovative solution:

    • Heidelise Als, PhD, director, Neurobehavioral Infant and Child Studies, has developed an individualized, behaviorally-based developmental care model which is changing Newborn Intensive Care Units (NICUs) around the world. Study results are consistent and demonstrate improved lung function, feeding behavior and growth; reduced length of hospitalization, improved neurodevelopmental function, and improved brain function for the infants who received this care, as compared to the control groups who received the respective NICU's current best practice. Learn More

    We also have researchers whose focus is pinpointed on behavioral or emotional aspects of specific diagnoses:

    • Joseph Gonzalez-Heydrich, MD, medical director, Outpatient Services, conducts research on psychiatric disorders in children with epilepsy and pediatric bipolar disorder. He approaches these disorders from two directions --probing the bases for these disorders as well as seeking better treatments for them. Learn More
    • Susan Waisbren, PhD, directs a research program on the behavioral and developmental aspects of phenylketonuria and other inborn errors of metabolism. Her research focuses on intergenerational considerations in PKU and the developmental implications of a statewide newborn screening program. Learn More.
    • The research of Kerim Munir, MD, MPH, DSc, is focused on defining the physiological underpinnings of autism and other developmental disorders. His recent work has explored the possibility of an autoimmune origin for autism. Learn More

    Find out more aboout our research.


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