Causes for childhood depression: Although it is sometimes difficult to imagine that a child may be depressed, many children are experiencing childhood versions of depression. There are various possible causes for a child's depression. Some children have a genetic "tendency" for depression. This biological component refers to the degree to which a child has the inborn, presumably genetic potential to develop depressions. Except in extreme situations, the biological component should be understood as a risk or a contributing factor rather than a factor that predestines a child to depression. Some children experience external stressors that promote depression, such as divorce; this is the environmental component. Some children are more prone to depression because of the particular ways that they experience and organize their inner emotional life, such as through experiencing excessive guilt; this is the psychological component. Usually, childhood depression results from a combination of these components.  

Manifestations of childhood depression: Depression includes many uncomfortable feelings. Although each child will experience a different combination, the feelings include sadness, guilt, loneliness, anxiety and a unique quality of emotional pain that occurs in depression. Children use defense mechanisms to protect themselves from having to experience these very uncomfortable feelings. Some children use "internalizing" defenses. Others use "externalizing" defenses. Because a child uses these defenses, sometimes depression can be "silent," manifesting on the surface as a behavioral, social or even learning problem.

Children using internalizing defenses may think constantly about their problems, avoid tasks because they are sure of failure, and feel overly responsible and guilty. They may seem unhappy and complain that they are not good enough or not liked by peers - that they "mess up" and are stupid. For some internalizing depressed children, these negative thoughts may emerge only occasionally, such as when failure is anticipated or after a real or perceived failure. These children may complain that the task is too hard, their teacher is unfair or that they never get things right. Depressed children who are internalizers may also seem immature or regressed, because they cope with their depression and low self-esteem by seeking the comfort and guidance of others.

Children using externalizing defenses tend to deal with the uncomfortable feelings associated with their depression by becoming spaced out or distractible or through impulsivity, defiance or aggression. The externalizing child's defensive strategies include discharge of feelings through action, avoidance of feelings through spaciness, denial of interest in activities in which they expect to fail, and conflicts in relationships that transform their internal discomfort into an outward struggle with another person. Externalizing depressed children often fit the profile of children with Attention Deficit/Hyperactivity Disorders. It is important to differentiate depression from ADHD so that the correct treatment can be determined.
There are rare occasions when depressed children have symptoms similar to those that depressed adults have. These symptoms include lethargy, loss of appetite (or occasionally excessive appetite,) and sleep problems.

Next steps: We advise parents who are concerned about the possibility of depression to consult a mental health professional who specializes in the assessment and treatment of young children. Perhaps parents and  professional may conclude that the child's difficulties can be addressed with specific parenting or school approaches. Alternatively, parents may learn that their child's problems require a detailed assessment. Such an assessment should include an exploration of possible medical factors, genetic background, the child's developmental history and their family relationships. We would generally recommend several meetings between the child and the evaluating professional. Although mental health professionals vary in how they approach meetings with a child, Lucy Daniels Center clinicians believe that we learn the most about a child, and in the gentlest way, through play-based assessments. This is a way of observing and interacting with a child through play that the child chooses. Also, we recommend including formal psychological testing when a specific issue emerges that can be helpfully clarified with such testing, such as the possibility of a learning disability.

Treatment: Treatment will be clearly indicated if the mental health professional concludes at the end of the assessment that a child is indeed depressed. Treatment should be carefully tailored to each individual situation. Generally, Lucy Daniels Center clinicians believe that counseling for parents is an essential component of an adequate treatment approach for a child. Parents can be helped with developing special ways to parent their child and, if necessary, to make beneficial changes in the family including in their relationship with their child. Generally, children can benefit from a psychotherapy that is appropriately tailored to their needs. Children who have a significant emotional component in their depression benefit from a play therapy that is designed to help them overcome the emotional factors fueling their depression. Many depressed children also benefit from a psychotherapy that includes cognitive behavioral techniques, which help them find ways to overcome negative patterns of thinking and develop coping skills.

There are different opinions in the professional community about the use of anti-depressant medication in young children. Most studies have been unable to demonstrate significant positive effects of such medication for children in most circumstances. Yet many parents report that their children have benefited from anti-depressant medications. These reports are difficult to interpret, because approximately one out of three children who take a medication will have a reduction in the symptoms of depression, whether or not there was an active ingredient in the medication. This is called the placebo effect.

Because the research does not provide significant evidence supporting the use of anti-depressant medication in early childhood in most situations, and also because of our concern about the many unstudied and unresolved questions about the longer-term effects of the use of anti-depressant medication in young children, the Lucy Daniels Center recommends a conservative approach. Generally, we only recommend the use of medication as a component of the treatment when the depression is severe. However, parents should understand that some mental health professionals believe that anti-depressants have an important place in the treatment in children with moderate or even mild depressions. These professionals would refer to the minority of studies that lend support to the use of anti-depressant medications in childhood.

Depression is a treatable condition, and Lucy Daniels Center urges parents who are concerned about the possibility that their child is depressed to strongly consider consulting a qualified professional on their child's behalf.

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