Understanding And Dealing With Depression (ages 6 to 12 yrs. old)

By: Michael G. Conner, Psy.D,

Depression is one of the most common psychological/psychiatric disorders. It affects a person's overall energy, mood, expressions of emotion and behavior. Depression is commonly referred to as a Mood Disorder.  Emotion is what you are feeling at a given moment. How you feel over a long period of time is your mood.

An estimated 1 out of 10 children have difficulty escaping the symptoms of depression for long periods of time. The rate of depression is markedly lower (1%) in children ages 1 to 6 years old.  The rate is higher in older children ages 9 to 12 years (12%).

Symptoms and Behaviors Associated with Depression in Children

  • Crying, feeling sad, helpless or hopeless
  • Feeling discouraged or worthless
  • Loss of interest or pleasure in others or most activities
  • Fatigue and loss of energy nearly every day
  • Bad temper, irritable, easily annoyed
  • Fearful, tense, anxious
  • Repeated rejection by other children
  • Drop in school performance
  • Inability to sit still, fidgeting or pacing
  • Repeated emotional outbursts, shouting or complaining
  • Doesn't talk to other children
  • Repeated physical complaints without medical cause (headaches, stomach aches, aching arm or legs)
  • Significant increase or decrease in appetite (not due to appropriate dieting)
  • Change in sleep habits

Serious And Critical Symptoms

  • Suicidal thoughts, feelings or self-harming behavior
  • Abuse or prolonged use of alcohol or other drugs
  • Symptoms of depression combined with strange or unusual behavior

The Cause of Depression

Studies have shown that close relatives of persons with major depression are more likely to have the disorder than unrelated persons. A number of biochemical agents, called neurotransmitters, have been identified that may underlie depression. Medical and health related problems have also been related to symptoms of depression.

Biopsychosocial models of depression suggest that a number of factors may interact or operate singularly as a cause depression.

  • Genetic vulnerability (e.g. faulty production, transmission or reception of neurotransmitters and biochemical agents)
  • Developmental events (e.g. early childhood stressors, learned helplessness, object loss)
  • Psychosocial stressors (e.g. adults stressors, grieving)
  • Physiological stressors (e.g. medical conditions, disease, viral infections)
  • Personality traits (e.g. characteristics that influence reactivity to stress)

Psychosocial models of depression suggest that depression are a results of problems interacting with the environment. Some of the most common are

  • Loss or reduction of reinforcement
  • Social skills deficit
  • Lack of family cohesion, expressiveness, organization
  • Family conflict
  • Deficient ability to provide for self-monitoring, self-evaluation and self-reinforcement.
  • Negative views of self, the world and one's future.
  • Learned helplessness
  • Deficient problem solving skills.

Social models of depression suggest their are certain events tend to cause depression

  • Separation, divorce of parents or even close relatives.
  • Death of a loved one; a person or a pet.
  • A move from one town, or even one neighborhood, to another.
  • Academic, sports or athletic failure.
  • An injury or physical illness resulting in hospitalization or restricted activity.
  • Loss of customary surroundings, family, or close friends.
  • Embarrassment, shame, guilt or loss of "face".
  • Failure to live up to personal expectations.
  • Repeated physical, emotional or verbal abuse.

The correct diagnosis of depression is complicated. There are many alternative diagnostic systems and criteria for depressive syndromes. Using the Diagnostic and Statistical Manual of Mental Disorders there are four diagnostic categories involving depression.

  • Major Depression. A severe form of depression that may involve disturbed sleep, appetite, suicidal thinking or self-harming behavior, loss of interest, problems thinking or concentrating, fatigue or loss of energy, restlessness or lethargy, and lowered self-esteem.
  • Dysthymia. A less severe form of major depression in which symptoms are less evident and may appear chronic and last more than 2 years.
  • Separation anxiety disorder. Depressive symptoms that are clearly associated with a child's separation from those to whom he or she is attached.
  • Adjustment disorder with depressed mood. Depressive symptoms that emerge as a reaction to an identifiable psychosocial stressor. The reaction is viewed as maladaptive and the symptoms are considered in excess of what is usually expected.

Common Treatment Approaches

A large number of treatment strategies have been developed for the treatment of depression. Many of these approaches can be implemented individually, in groups or family therapy environment. There is considerable evidence to suggest that interventions which emphasize treatment of the family, and not the "identified patient", are critical to positive treatment outcome. Peer group approaches have been found to be effective for children. Play therapy is sometimes appropriate with younger children.

  • Cognitive.  Cognitive approaches utilize specific strategies that are designed to alter negatively based cognitions. Depressed patients are trained to recognize the connections between their thoughts, feelings, and behavior; to monitor their negative thoughts; to challenge their negative thoughts with evidence; to substitute more reality-based interpretations for their usual interpretations; and to focus on new behaviors outside treatment.
  • Behavioral.  Behavioral approaches designed to increase pleasant activities include several components such as self-monitoring of activities and mood, identifying positively reinforcing activities that are associated with positive feelings, increasing positive activities, and decreasing negative activities.
  • Social Skills. Social skills training consists of teaching children how to engage in several concrete behaviors with others. Initiating conversations, responding to others, refusing requests, making requests, etc. Children are provided with instructions, modeling by an individual or peer group, opportunities for role playing and feedback. The object of this approach is to provide the child with an ability to obtain reinforcement from others.
  • Self-Control.  Self-control approaches are designed to provide the self-control strategies including self-monitoring, self-evaluation, and self- reinforcement. Depressive symptoms are considered to be the result of deficits from one or more areas and are reflected in attending to negative events, setting unreasonable self- evaluation criteria for performance, setting unrealistic expectations, providing insufficient reinforcement, and too much self-punishment.
  • Interpersonal.  Interpersonal approaches focus on relationships, social adjustment and mastery of social roles. Treatment usually includes non-judgmental exploration of feelings, elicitation and active questioning on the part of the therapist, reflective listening, development of insight, exploration and discussion of emotionally laden issues, and direct advice.
  • Medications.  Several class of medications are used with adult populations. Major types include monoamine oxidase inhibitors (e.g. phenelzine), tricyclics (e.g. imipramine and amitriptyline) and SSRIs (e.g. Prozac, Paxil, Zoloft, Serazone, Luvox), but other classes have emerged as well. These drugs are not without side effects. These drugs have been shown to be 50-70% more effective with adults than placebos and no other treatment. Although the number of people who simply get better because of a medication alone is rather low.  Other factors seem to make a bigger difference for most people. There is also research that suggests that these medications are no more effective than a placebo and less effective that placebos that have a mild side-effect. Very little is known about the safe use of antidepressants with children. The risks and side effects of medications and the findings that competent therapy and counseling interventions can be more effective restrict the use of medications with children.

Psychotherapy requires significant commitment where as treatment of depressive disorders with medication requires less effort. Since normal depression can improve over time and without therapy, a brief period of medication may not be of benefit. Psychotherapy can be helpful in cases of normal depression and can help insure the condition does not become chronic. Antidepressant medications require a substantial period of time before they take effect and several trials of different medications may be necessary to find a medication that actually works. Medications alone appear to be helpful in approximately 15% of the cases. However, the use of medications require a substantial commitment for period of time up to 9 months. The dosage may need to be increased over time. In some cases, a patient can terminate their medications after 6 to 9 moths without a risk of relapse. Unfortunately there is no way to know if a person will relapse of not. Side effects are the primary reason why people stop taking their medications. The side effects of antidepressant medications can vary greatly and can have a significant or even traumatic impact on self-esteem and quality of life.

Psychotherapy is almost always the first treatment of choice except in cases where depressive symptoms are so severe or critical that immediate relief is necessary to restore functioning and to prevent immediate and severe consequences. Medication is usually the second choice after a comprehensive and competent trial of psychotherapy. Combined use of medications and psychotherapy at the onset of treatment can confound evaluation of treatment effectiveness and the observed source of change. It is harder in a combined medication and therapy approach to tell which approach is or is not helping and how much it is helping. However, research has found that combined psychotherapy and medication is often necessary and beneficial. Psychotherapy can be a very effective alternative to the use of medications.

Psychotherapy, or the psychotherapist, can generally be considered ineffective if a trial of 3 months has not produced a measurable and noticeable improvement. A decision to change therapists or to start a medication may be necessary at this point. Several trials of psychotherapy or medications may be necessary to successfully treat depressive disorders.

The prognosis for treatment of depression in children is good. Positive treatment outcomes are primarily dependent on a correct diagnosis, and understanding of the etiology, and implementing an appropriate intervention.

Advice To Parents

  • Seek immediate advice and consultation from a crisis intervention specialist or qualified health care professional if there are any of the critical symptoms listed above.
  • Seek advice and consultation as soon as possible from a qualified mental health professional if the symptoms of depression are severe, prolonged, debilitating, unexplained or unusual.
  • Seek medical advice if you suspect health problems or symptoms are not explained and there has not had a medical evaluation for the child's symptoms.
  • Seek consultation regarding alcohol use. Alcohol use by children is never appropriate.
  • Evaluate drug use.  Drugs that are not medically appropriate or approved by your physician can contribute to depression.
  • Learn more about any medications the child is taking. Ask your physician and pharmacist about potential interactions and side-effects. There are many.
  • A normal depression is usually temporary, can come and go, but should diminish over time.  Allow the child space and time.
  • Maintain a regular and nutritional diet. Avoid meal skipping. A proper diet is a critical source of energy and the child's ability to cope and recover.
  • Maintain a regular sleep cycle. Avoid sleeping or napping during the day if it is difficult to sleep during regular times. Irregular sleep patterns prolong or worsen symptoms of depression.
  • Stay involved and minimize extended isolation from positive activities and influences.
  • Maintain regular or routine physical activity that is appropriate for any existing medical condition. Physical activity can help relieve or manage depression.
  • Spend time with the child, be caring, listen well and show understanding.
  • Take time on a regular basis to help the child enjoy pleasurable activities and recreational interests.

copyright 2001 to 2005,  Michael G. Conner