A nine-year-old boy is brought to a child psychiatrist to be evaluated. The child’s recent history is troubled. He frequently refuses to attend school. When he does attend, his teacher’s report that he seems distracted and has difficulty concentrating. His mother relates that the boy seems sad and sometimes makes negative statements about his abilities and his worth. He also has dropped out of soccer, an activity he used to enjoy.

After ruling out any medical cause for the boy’s behavior, the child psychiatrist makes a diagnosis: depression.

DEPRESSION IN CHILDREN: A SPECTRUM
While it used to be thought that children do not experience clinical depression, medical research has proven otherwise. Serious emotional disturbances, which severely disrupt daily functioning in home or school, affect one in every 10 young people and can begin as young as kindergarten age.

After a child or adult has one episode of depression, the chance of that individual experiencing depression again is as high as 50 percent. For those who have a second episode, the chance of recurrence is 80-85 percent.

“Treatment for childhood depression is essential for a number of reasons,” says Mark Faber, M.D., Director of the Division of Pediatric Psychiatry at Saint Barnabas Medical Center. “First, there is the risk of suicidal thinking. Also as significant, the longer depression goes untreated, the more difficult it may be to treat and the greater the chance that it will return in the future.”

Normal childhood development involves the need to face challenges such as separating from the family, making friends, participating in group activities and pursuing academic achievements. Although there will certainly be “bumps in the road,” Dr. Faber says that extreme reactions to these obstacles may signal an underlying problem.

ADJUSTMENT REACTIONS
When life stresses affect a child’s behavior and function in the short term, but do not persist, the behavior is called an adjustment reaction. A change, such as a move from one state to another or a divorce, brings about tearful, irritable and anxious behavior in the child and gets in the way of his or her daily routine. The situation might last a few days to a few weeks, and generally resolves itself without medical treatment, says Dr. Faber.

Some common situations where adjustment reactions in children may occur:

Parents should work with the child to examine the underlying stresses and see if they can be alleviated. For stresses that cannot be changed, such as a parental separation, parents should try to address related issues. For example, if the separated partners are constantly fighting, they should try to eliminate conflict as much as possible for the benefit of the child.

MAJOR DEPRESSION
Depressed behavior with prominent symptoms that extend beyond a few weeks may indicate a more significant problem, such as clinical depression.

Signs to look for include the following:

While adjustment reactions can be effectively helped with support of family and friends and attempts to possibly change the stresses, major depression typically requires psychotherapy and/or medication.

Dr. Faber relates that genetics play a role in the emergence of depression, and those with a family history are more likely to suffer an episode. Biology also plays a role and a decrease in certain chemical messengers in the brain can result in major depression. Also, many children with depression may also suffer\ from other issues, such as attention deficit disorder, bipolar
disorder, social anxiety and obsessive/compulsive disorder.

Fortunately, with treatment, seven out of 10 children respond very well, says Dr. Faber. Cognitive behavioral strategies help patients identify negative thought patterns and establish other ways of thinking. Counseling helps patients to examine their stresses and see if they can be changed, or if the problem lies in their response to the situation.

Finally, medically-based conditions respond to antidepressants, such as those which increase serotonin in the brain.

“Most of these children grow up and function extremely well,” says Dr. Faber. “Treatment isn’t necessarily a lifetime thing. We have a starting point and an ending point and goals to be reached. Close follow-up assures the safe use of medication, if needed.”

For an appointment with the Division of Pediatric Psychiatry, please call The Saint Barnabas Pediatric Specialty Center at (973) 322-7600. The Division of Pediatric Psychiatry treats young patients in a range of areas, including depression, anxiety, ADHD and autism.

The Importance of Free Time

Many issues that can cause a child to have an adjustment reaction, or short-term depression, have always existed. They include pressure to fit in with peers and to achieve academic and social goals. The difference with today’s generation of children, says Dr. Faber, is that they have a deficit in free time that can affect their ability to cope.

“Now, with both parents working and the hyper-scheduling that takes place with activities, kids really feel stretched and stressed,” says Dr. Faber. “I think that is clearly a factor in their ability to cope. It is very therapeutic to have some time alone to create your own play.”

In addition to a lack of free time, Dr. Faber says that there is a greater expectation from parents that the child must get chosen for the best team, admitted to the most prestigious school and hired for “the right job.”

Rather than perpetuate this line of thinking, he tells parents to encourage children to work at a pace that is reasonable. Dr. Faber also endorses parent and child free time when the conversation and activity is more playful than goal-based.