Be a Depression Detective
Your child's wellbeing could depend on
your ability to recognize its symptoms.

by Suzanne Koup-Larsen

"It's like being beaten from the inside." That's how 9th grader Tom Nelson described his depression to his father, Dr. Gary Nelson, a United Methodist minister and counselor.

Although Dr. Nelson had years of clinical experience counseling depressed teens and their parents, it didn't quite prepare him to watch his own son suffer through depression. But his professional experience did allow him to recognize symptoms of childhood depression and get help for his son.

Depression has many symptoms, and each sufferer can express the ailment differently. Dr. Nelson uses the analogy of a buffet table. "Ten people go to a buffet table but come away with different plates of food." Similarly, no two depressed people will exhibit all their symptoms in exactly the same way.

Symptoms also vary by age, and depression is more difficult to diagnose in younger children, though it occurs. Young children with symptoms of anger and irritability are often misdiagnosed as having behavioral problems. Generally, depression is more common in adolescence, says Meredith Lutz Stehl, PhD, a psychologist at the A.I. duPont Hospital for Children in Wilmington, DE.

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According to Dr. Nelson, "Every teen goes through this kind of thing, but it's the intensity that's the tip." Also, says Dr. Stehl, in differentiating depressive symptoms and normal behavior, "interfering with function is the key focus."

The many symptoms of childhood depression include, but are not limited to:

Changes in sleep habits, both sleeping too much and insomnia

Fatigue, lack of energy

Loss of interest in things the child normally likes to do

Changes in eating habits, both weight loss or weight gain

Sensitivity to rejection, failure or criticism

Low self-esteem

Crying spells

Irritability

Hopelessness

Social isolation

Signs that may signal depression serious enough to warrant a trip to the doctor include:

Refusal to go to school

Running away from home

General withdrawal

Moods severely impacting the child's ability to get along with family and friends

Lack of interest; not wanting to do things the child usually likes to do

A very significant change in behavior, such as a child who loves school suddenly not wanting to go there.

With all of these warning signs, the key is a pattern of unusual behavior, not just a random incident. If you suspect a problem, your pediatrician is your first line of defense. The doctor will examine your child to rule out any medical causes, and then probably refer you to a psychologist or a psychiatrist.

Types and Treatment
There are three main types of depression affecting children:

Major depression is characterized by a persistent sad mood, lasting for two weeks or more.

Dysthymic disorder is a low-grade, long-standing depression, lasting for a year or more.

Bipolar disorder, also known as manic depression, usually follows a cycle of mood disturbance, varying from low or depressed moods to feelings of extreme irritability or explosive anger.

Depression is treatable and can be cured, but not in every case. "The recurrence rate is very high for childhood depression compared to adults," says Chandra Weerasinghe, MD, a psychiatrist specializing in adolescents at Bryn Mawr (PA) Hospital.

As a result, early diagnosis and treatment is very important. Dr. Weerasinghe characterizes both the causes and treatment of depression as "biopsychosocial." In treatment, "bio" refers to medication, "psycho" refers to therapy for what's going on in the child's mind, and "social" refers to the manipulation of social environmental factors that may be triggering the depressed feelings.

Medication Pros and Cons
The treatment of childhood depression with antidepressant medication has generated controversy. In 2005, the U.S. Food and Drug Administration ordered warn-ings for several anti- depressant labels because studies showed young adults taking the medications had increased thoughts of suicide.

According to Dr. Stehl, the number of patients reporting increased suicidal thoughts was very small, but if there are any occurrences, studies must report them. Unfortunately, suicidal thoughts are a symptom of depression, so it is difficult to interpret whether the medication was failing to treat that symptom, or causing it.

According to Dr. Weerasinghe, the warning was revised in May 2007 after studies in 2006 showed that the number of antidepressant prescriptions written was down, but the suicide rate was up. The revised FDA statement emphasizes that depression itself is an "important" cause of suicide.

Some child psychologists oppose the use of medication to treat childhood depression. "I feel as though the risks of medication far outweigh the positives in using them," says Phil Tenaglia, MA, a Hunting Valley, PA, psychologist.

The risks of using antidepressant medications include side effects such as decreased appetite, increased aggression, insomnia and irritability. Tenaglia uses the analogy of a painkiller. "It masks the pain, but doesn't treat the cause of it." Therapy is needed to get at the root problem of a child's depression, he says.

However, Dr. Nelson says his son had a very positive experience with antidepressants. "The Prozac took the anger away almost like magic," he says. But this was not the only piece of the puzzle; Tom needed therapy with a psychologist too. According to Dr. Stehl, a combination of medication and cognitive therapy produces the best result for most patients.

Through therapy, patients learn to resist environmental triggers and how to change the way they feel about certain events in their lives. Dr. Stehl believes therapy is effective because it "changes the way you're thinking about events, which changes the way you feel."

What Parents Can Do
Dr. Nelson used his personal and his professional experiences to write a book to help both parents and teens, A Relentless Hope: Surviving the Storm of Teen Depression (Cascade Books, $18).

He says the biggest challenge for parents is to shift the way they may be reacting to their child's behavior. "It's not their child rebelling, it's their child hurting," he says.

Dr. Weerasinghe emphasizes that parents need to recognize early depression symptoms for their children's sake. "The sooner they get treatment, the better the result," she says.

Suzanne Koup-Larsen is a local freelance writer.