By: Cassandra M. Faraci, Psy.D.

As hard as it may be for adults to believe, depression is becoming a major issue among children and teenagers. According to the Centers for Disease Control and Prevention (CDC), approximately 3% of children between the ages of 3 and 17 have been diagnosed with a depressive disorder. This does not account for children with depression who have been misdiagnosed or who have not received services and, therefore, have not been diagnosed.  In addition, 75% of children with depression have another diagnosed mental disorder: about 75% of these children have an anxiety disorder as well, and about 50% of these children have behavior problems (cdc.gov).

Because the risk for depression increases with age, it is more important than ever to identify risk factors as early as possible and put efforts into prevention or, if necessary, early intervention so that the depression and its resulting impairing consequences don’t become severe. If untreated, children with depression are at a higher risk for more severe depressive episodes and suicide (ADAA.org). What makes it harder is that depression is considered an internalizing disorder which means, for some children, the symptoms may be hidden from adult awareness. Identification of at-risk children is very important, and we must put extra effort into being aware of signs and symptoms of depression; they’re not as obvious as a child exhibiting externalizing behavior issues such as aggression, hyperactivity, and impulsivity. Here are some behaviors (ADAA.org) that could indicate a child is struggling with depression:

  • Sadness and/or crying
  • Irritability and anger (often a more common presentation than sadness)
  • Mood swings
  • Loss of interest in activities that the child used to enjoy
  • Loss of energy/lethargy
  • Concentration difficulties
  • Withdrawal from social interactions
  • Talking about death and dying
  • Giving away prized possessions
  • Writing goodbye notes to loved ones
  • Increase or decrease in sleep
  • Increase or decrease in appetite and/or weight
  • Feelings of worthlessness and low self-esteem
  • Feelings of guilt
  • Talking about having little hope for the future
  • Sudden change in academic performance or getting in trouble at school

We all occasionally experience these symptoms. Maybe we just got bad news at work. Maybe we are in the middle of a fight with a loved one. How do we know if it’s just a normal reaction to a stressor or possibly something more serious? For a Major Depressive Disorder (MDD) in children, 5 or more of these symptoms need to occur most of the day, nearly every day for at least a period of 2 weeks and represent a change from their typical presentation. For Persistent Depressive Disorder (PDD, formerly called Dysthymia), often considered to be a milder and longer-lasting version of a MDD, milder symptoms need to occur for at least 1 year. In both situations, there needs to be evidence of significant distress and/or impairment in their daily lives such as interfering in social relationships or academic performance. In typical instances of sadness or feeling “bummed” which is common and normal among all of us, we wouldn’t see the intensity level, duration of time, or frequency of symptoms that we see in MDD or PDD.

It is inaccurate to assume that a child must have all symptoms above to be depressed. In fact, only a few of these are needed to have a depression diagnosis. So, if you see a child with some of these symptoms but think, “Well, they don’t appear sad, so it can’t be depression”, you could be wrong. Often, children don’t present with sadness as is common in adults. Instead, a child may be more angry and irritable in combination with some other depression symptoms. A good rule of thumb: When in doubt, check it out. Refer a child to a licensed mental health therapist for an evaluation. It’s a win-win: If the diagnosis is caught, you may have saved the life of a child. If the child does not meet criteria for this diagnosis, another one may be present and thus can be clinically addressed, or an at-risk child has been identified, and prevention efforts can be underway by parents, teachers, school administrators, and other adults in the child’s life.

With all of this said, what can adults do to prevent symptoms in at-risk children or provide early intervention strategies for those already diagnosed? Cognitive Behavioral Therapy (CBT) is often the first line of treatment recommended and has substantial scientific support for its effectiveness. Below are some CBT strategies that scientific studies support in working with depressed children:

  • Validate feelings. Whether a child is expressing worry, anger, or sadness, it’s a great idea to validate their feelings by telling them that their feelings make sense and are understandable. Even if you believe that the child shouldn’t feel a certain way because you understand the situation differently, it’s important to acknowledge that this child is experiencing his or her world in a certain way, and we all have different ways of processing everything. Our adult brains might have more wisdom and experience behind it, but a child’s brain hasn’t had enough life experience nor development to understand the world the way adults do. Send the message that they’ve been heard and that their emotional response makes sense to you. That in and of itself will be comforting to a sad child.
  • Be a good listener. Related to validating, repeat back to the child what he or she has verbalized to you. Don’t jump to solve problems for them or explain to them why their feelings make no sense or why they should feel differently. Let them feel heard. When you are expressing yourself to another adult, how good does it feel when you believe that your opinions and feelings have been received? Help the child feel better in the moment by truly listening and communicating that they’ve been heard.
  • Guide children in the ABCs of human behavior. Teach children the difference between antecedent (A) situations, beliefs (B) about situations, and consequences (C) that occur both emotionally and behaviorally (what they feel and what they do). Often, children (and adults) assume that a stressful situation causes them to feel a certain way, but it’s their interpretation of the situation that causes feelings. For example, let’s say that someone accidentally bumps into me in the hallway (situation), and I think (belief), “Wow. She did that on purpose!” My resulting feeling is going to be anger, and my behavior may involve getting into an argument. Let’s rewind and try this again. Put me in the same situation: Someone bumps into me in the hallway. Now, what happens if I believe, “Yikes. She must be in a rush.” Will my feeling change? Will my behavior change? Yes. I’m more likely to feel annoyed or even sorry for her. Instead of getting into an argument, I’m probably just going to go about my day and move on from the situation. By helping children separate the ABCs, you are arming children with the wisdom that there are multiple points of change and that there are some areas in their control in making changes.
  • Guide children to apply the ABCs to examples in their lives. When a child presents an upsetting situation to you, they’re likely connecting the A to the C and forgetting that there is a very important B component. This often leads children to believe that the world is an unjust and scary place that they can’t control and to erroneously assume that the world (situation) caused them to feel badly. Prompt them with, “What did you think in that situation?” or “What went through your mind when….?” The important thing here is to help children be aware of their beliefs about the situations which upset them, as this is where their control will lie.
  • Come up with external explanations. Dr. Martin Seligman is a pioneer in cognitive behavioral psychology, and his research showed that there is a distinct pessimistic thinking pattern among depressed individuals and those at risk for depression. One part of this thinking pattern involves explaining negative events as caused by something personal. When a child gets a bad grade on a test, he or she might explain this outcome by saying, “I’m so stupid” instead of “That test was really difficult.” A child’s automatic belief may be something negative about him- or herself, but adults can ask children, “What else may have played a role in [negative outcome]?” After practicing this over and over, a child may begin to come up with external explanations for negative events without adult intervention. This is an important skill for working with depression as it directly affects a child’s self-esteem.
  • Come up with temporary explanations. Similar to explaining negative events personally, depressed children often believe that a stressful situation will last indefinitely. Using the example of the bad grade on a test discussed above, a child may further believe, “I’m always going to get bad grades.” It’s important for children to understand that negative things happen to all of us and that they’re time-limited experiences. Helping the child re-interpret the bad grade as, “I got a bad grade on this test, but I could do better on the next one” is incredibly important in having a healthy emotional reaction. Having children see the downsides of their world as temporary helps them maintain hope and thus buffers against depression.
  • Come up with specific explanations. The final dimension Dr. Seligman discusses in preventing or addressing depression is explaining negative life events as specific to one area and not pervasive across multiple areas. Sticking with the bad grade example, a child may also believe, “I’m probably going to get a bad grade in science, too. I’ll also probably fail in the soccer game after school.” If adults can help children contain a negative situation to a specific area, a child can be hopeful that other areas of life might have more positive outcomes. It’s when a child explains negative events as due to their (personal) weaknesses and believes that these negative events will be long-lasting (permanent) and inevitable in all areas of life (pervasive) that we see depression develop. Our goal as adults is to help children see stressful events as caused by external events and/or time-limited stressors and/or specific situations.
  • Normalize disappointments. We want children to understand that life contains disappointments from time to time. It’s not realistic to expect adults to shelter children from stressors and disappointments so that they never feel negative emotions. Let children know that everyone gets disappointed – even you! Discuss that life’s road can be “bumpy” but that it’s important to find solutions around the “bumps” and to keep going because the road will become smooth again.
  • Be mindful of your words. When addressing children, be very, very mindful of how you explain a negative event involving the child. Are you blaming the child? Are you using personal, pervasive, and permanent explanations? Avoid using explanations that involve describing the child as a whole. For example, if a child gets a bad grade, we would not want to say, “You’re not the smartest kid in the class” or “You are just too lazy.” This further reinforces a depressed child’s beliefs that something negative about themselves (personal) caused the stressful situation. Instead, explain negative events in external, temporary, and/or specific terms such as, “That test [specific] was probably very hard [external]. Let’s talk about different study habits that we can try for next time [temporary].”

 This may sound simple in theory, but implementation is often challenging. As adults, we may not always explain our own negative situations in external, temporary, and specific ways, so it might be challenging to begin to understand the world in this way. However, it’s vital to a child developing healthy coping strategies and to provide resilience among life’s stressors. If you’re struggling with how to do this, we’re specialized in helping children (and adults) see their worlds in more realistic and optimistic ways. Developing resilience is important for mental health as healthy eating and exercising is for physical health. Contact us at (908) 914-2624 or email us at info@anxietyandbehaviornj.com to learn more about how we can help.