Collateral Damage

Originally Appeared on OnHealth.Com (now WebMD)

The difficulty with figuring out the state of your child’s mental health is that he or she is, after all, a child. Behavior that in an adult would indicate a mental-health problem can be quite normal in a child. If a 33-year-old succumbs to the temptation to throw himself on the floor and have a temper tantrum then clearly something’s wrong, if it is a 3-year-old, though, then it’s just another day at the proverbial office. Or, if a 42-year-old suddenly becomes sullen and withdrawn then it’s “Houston, we have a problem,” but if it’s a 14-year-old, then it may just be “Houston, we have a hormone.”

Perhaps nowhere is that difficulty more pronounced than when it comes to diagnosing depression. Depression can strike any child, from toddler to teen and it can present itself in ways that are very different from how we see it in adults, says Dr. Christopher Bellonci, a certified child and adolescent psychiatrist and Medical Director at The Walker Home and School in Boston, MA. While it may manifest similarly to how we expect it to show itself in an adult — lethargy, lack of interest in things, an extremely pessimistic view of themselves and the world — it may also show through hyperactivity, aggressiveness, delinquency, opposition and failure in school.

Frequently depression presents itself differently in boys and girls. “There is a gender discordance between males and females about how they actually display depressive symptomytology,” says Bellonci. “Girls will [generally] show more of the negative symptoms of depression and look more withdrawn, look more sad, where the boys may present more agitated and aggressive.” Because society tends to expect girls to be quiet and boys to be boisterous, a parent may not be as quick to pick it up if these behaviors are exaggerated.

While depression in children can be caused by traumatic events — the death of a friend, loved one or pet, divorce or moving to a new neighborhood or city — parents are frequently most confused when depression seems to strike a child out of nowhere. It can help if, like any other medical condition, parents and children are aware of any family history of mental illness. “The first generation relatives of the kids of parents who have mood disorders themselves are at a much greater risk than a general population of developing a mood disorder,” says Bellonci. “It’s less strong [if it's the grandparents] but certainly siblings are quite significant in terms of the increased risk.”

So how exactly do you tell if your child has a problem or is just being childish? To start with it depends on the child. No sweeping rules can be applied to all kids says Bellonci. A parent or caregiver, he says, “[has to have]a good idea as to what your particular child’s baseline is like — because what you’re looking for is a deviation from that baseline.” In other words, if your child has always been a quiet or shy kid then continuing to exhibit that behavior probably isn’t a cause for concern. But if he or she were to suddenly be more aggressive or hyperactive, then you would want to investigate further.

Some other general, age-based guidelines:

Toddler to age 5: Both suicide and depression can occur in very young children. Because of their age, mental illness can be difficult to detect: These obviously are not kids who can say, “Mom or dad, I feel depressed today.” Parents need to be aware of changes in the child’s behavior. Particularly if there’s either aggressive behavior — which can mean biting or attacking other children — or social withdrawal in a child who was usually outgoing. Also be alert for drastic changes in the level of interest in play and what the content of that play is. Says Bellonci: “I often have kids who will be very dramatic in their play around themes of death, for instance, and these will be kids who sometimes have experienced a loss, but not always.”

Five to Preteen: In addition to drastic changes in behavior, depression in school age children may also show itself through vague physical complaints, like headaches, stomach aches or other general aches and pains. Often it will be associated with, “I don’t want to go to school or I don’t want to get out of bed.” Look for the physical complaint along with a loss of energy and/or the lack of interest in previously enjoyed toys and games. Remember this is about repeated deviation from normal behavior patterns: A periodic desire to get out of school, either just for the heck of it or because there’s a big test, is to be expected. The other thing to be aware of, says Bellonci, is that psychiatric illnesses in the pre-pubescents are more likely to be combined with other mental-health problems than is the case with adults or teen-agers. “They may have an anxiety disorder or a separation anxiety or an overanxious disorder or they may have attention deficit hyperactivity disorder in combination with a mood disorder such as depression,” he says. “So if someone already has a diagnosed psychiatric disorder in childhood they’re at greater risk for having another one.” Substance abuse, be it food, alcohol or drugs, can also start appearing now.

Adolescents: Change is what adolescence is all about: Bodies are changing, peer groups are changing, the school setting is changing and kids are expected to be much more autonomous. Figuring out deviations in the behavior of someone in the throws of puberty can be a tough thing to do. However, diagnostically it actually gets a little bit easier because depressive symptoms start looking more like those you see in adulthood. And, of course, the adolescent is much better at describing their internal world. As the parent of any adolescent will tell you, that doesn?t mean he or she will be willing to, but at the very least he or she has the ability.

In adolescence, the neuro-vegetative symptoms of depression — like changes in sleeping and eating patterns — appear more readily than during childhood. While some sleeping changes occur in adolescence naturally, dramatic changes like significant sleep loss or over sleeping can mean a problem, as can under or over eating. Also be aware of social withdrawal. Bellonci: “Adolescents by nature are a pretty social organization or social group and they’re going to really be looking to form peer groups as part of the developmental task, so if they start falling off in that capacity that’s a marker of trouble.”

What Are Your Options?

If you are concerned that your child may have a mental illness first get a thorough assessment by someone trained to work with children and adolescents, a child psychiatrist, pediatrician or social worker. After talking with you and your child, that person will come up with a theory of what they think is going on: Is the depression an organic problem or a reaction to some sort of environmental stress? Based on that diagnosis they will recommend a course of treatment. The standard treatments for depression are (in no particular order): Medication, psychotherapy and/or hospitalization. They are frequently used in conjunction with each other.

Hospitalization: Because it is usually used for people who pose a threat to themselves or others, it is very rarely prescribed for young children who suffer from depression.

Medication: While anti-depressants — like Prozac or Zoloft — are frequently prescribed for adolescents, in younger children they pose a number of problems. Because young kids’ livers and kidneys operate so efficiently, they can filter out all but (comparatively) large amounts of medication. Also clinical trials have shown very high success rates when children use either anti-depressants or placebos, which has raised some questions about the necessity of using these medications. Finally, there are questions about the long-term use of anti-depressants in children’s developing minds and bodies.

Psychotherapy: While young children can be the most difficult to treat because of their limited verbal skills, there are several cognitive behavioral therapies that are very effective for dealing with depression in both children and adolescents. As for classic psychotherapy, Dr. Bellonci says that while in gross numerical terms it has very poor outcomes, it is still frequently used because on an individual basis kids and parents report very good outcomes. Also, when dealing with depression, doctors psychiatrists and social workers usually suggest family therapy.