BApK

Bundesverband der Angehörigen psychisch erkrankter Menschen e.V.

Depression in childhood and adolescence

Mild depressive moods to severe depressive disorders are some of the most common mental illnesses affecting children and adolescents. The condition can start in childhood, it can become chronic and severely inhibit the child’s development. The risk of developing depression is under 2 percent in children of nursery and primary school age, but it increases significantly for adolescents. The condition can generally be treated easily.

Especially in children and adolescents the symptoms of the condition can be very different and complex and there are some aspects specific to age and stage of development. In general the younger the child the more difficult it is to recognise depression.

Depressive symptoms in children and adolescents are often not only a melancholy frame of mind with sadness, lack of interest, hopelessness, brooding or apathy, they may also be masked by physical symptoms or abnormal behaviour. In children, depression is often accompanied by symptoms of aggression, agitation, distractibility and inability to concentrate. Fear of separation and school phobia are other issues common in this age group. In adolescents on the other hand depression often occurs in conjunction with eating disorders, alcohol and drug problems.

In these cases the other more obvious problems are often recognised, whilst the symptoms of depression are overlooked. In addition it is often difficult to judge which phenomena are an expression of “normal” development - particularly in puberty, where mood swings and behavioural changes are also common.

Despite these difficulties it is particularly important to recognise depression early since many sufferers find their situation so hopeless that thoughts of suicide often seem the only way out. Any expression of such thoughts or even masked hints must always be taken seriously. In young people suicide is the second most common cause of death after road accidents.

Still, depression is no reason to give up hope. The earlier it is diagnosed and treatment initiated, the greater the chances of overcoming the condition and avoiding disadvantages for later life.

Signs of depression in childhood and adolescence

During puberty many young people often lose their equilibrium for a brief or extended period of time. This manifests itself in e.g. extreme changes of mood from cloud nine to the depths of despair, irritability, withdrawal, boredom or brooding, dissatisfaction with themselves and the world.

Many of these are also symptoms of depression. The boundaries between normal development and the symptoms of depression are not well defined – and therein lies the difficulty of establishing a definitive diagnosis. This leads to the fact that depression in childhood and adolescence is often not recognised at all or only very late. But: depression is an illness which must be taken seriously.

The symptoms of the illness can be very varied and complex, particularly in children. There are however a few clear signs of depressive conditions in childhood and in adolescence.

Please note that the following symptoms can only be taken as indications of depression and they may not occur all at once; diagnosis can only be made by a doctor. This also applies to the exclusion of physical causes for the depressive symptoms, e.g. thyroid dysfunction.

  • Constant sadness, sometimes also irritability
  • Constant lack of interest or cheerlessness
  • Sleeplessness or sleeping too much
  • Increased or diminished appetite
  • Constant tiredness
  • Feelings of guilt or worthlessness
  • Difficulties in concentrating and decision-making
  • Difficulties handling problems constructively and instead a retreat into alcohol or drug abuse
  • Thoughts of not wanting to live any more; expression of suicidal intent
  • Depression in the family

Risk factors / Protective factors

The reasons for developing depression are varied and not yet fully explained. Experts now assume that it is the interaction of certain biological (genetic), sociocultural and psychological factors which can contribution to developing depression. The significance of these factors is however viewed differently in the various models. All three areas provide starting points to explain, treat and overcome depression.

Some depressive episodes occur without any identifiable external reason, but in others there is a catalyst. Extreme external circumstances can affect the resilience of a child or young person and facilitate development of depression. But of course not everyone who faces dramatic events in their lives will become ill, because there are also many protective factors which help young people in particular to overcome such experiences.

Possible triggers (risk factors):

  • Excessive conflict, e.g. with parents, between parents or with friends
  • Lack of support and loving attention
  • Separation of parents; fracturing of the family
  • Heartache; unwanted pregnancy
  • No safe place to which the young person can withdraw
  • Severe illness or death of a person close to the child
  • Experience of violence or abuse
  • New home with a change of school
  • Failure at school or loss of work
  • Poverty

Protective factors (resilience factors):

  • Stable relationships within the family
  • Reliable friends
  • Personality factors such as:
    • self confidence
    • ability to deal with conflict
    • optimism

Consequences of depression in childhood and adolescence

How severe the effects of depression are in childhood and adolescence depends on the severity, the duration and the age of the person affected. Particularly in the case of adolescents there is a considerably increased risk that the depression could lead to thoughts of suicide or suicide attempts. Suicide is one of the most common causes of death in adolescence.

Physical effects

Depression is often also accompanied by physical symptoms. These include in particular psychosomatic conditions such as headaches and stomach pain with no organic cause, but also weight loss and disturbed sleep.

Psychological effects

Anxiety and hyperkinetic disorders (ADHS) often occur in conjunction with depression. Eating disorders and extremely inappropriate behaviour (hooliganism) are often associated with depression.

Disturbed development / Long-term effects

Depression can inhibit age-appropriate development in children and adolescents. Moreover, they have a significantly increased risk, even in adulthood, of again suffering from negative moods or depression.

Suicidal tendencies

Depression is often accompanied by suicidal tendencies. Whilst suicide in childhood tends to be rare, suicide rates increase steadily from the age of 15. There is an increased risk in the case of adolescents who have already attempted suicide and also if there have been cases of suicide or attempted suicide among family or friends (models of behaviour). Suicide threats should always be taken seriously.

Treatment

The treatment plan should always be adapted to the individual living conditions and development stage of the child, i.e. age, school and family circumstances. The parents of affected children must always be involved. Almost all children and adolescents with depression are treated on an outpatient basis. In rare cases treatment in a psychiatric clinic for children and adolescents is necessary, for instance if the child no longer wants to live, announces an intention to kill themselves, deliberately and repeatedly injures themselves or if the safety of the child within the family can no longer be guaranteed around the clock.

Treatment for depression can include the following components:

First point of contact

The first point of contact for parents is generally the paediatrician or GP, who has known the child and the family for some time and can judge any changes. He also knows specialists who can offer further help. These include, e.g. paediatric psychiatrists or psychotherapists specialised in treating children and adolescents. In addition some educational and family advice centres or school psychologists are particularly well qualified in the treatment of children and young people suffering mental illness.

Psychotherapy

The main treatment approach for depressive conditions in childhood and adolescence is psychotherapeutic measures. These may include various forms of therapy depending on symptoms, usually incorporated into family counselling or some form of family therapy.

The efficacy of ‘cognitive behavioural therapy’ is proven. Cognitive behavioural therapy can consist of: removing stress factors and developing positive activities; supporting and underlining existing abilities and strengths (resources); training social competences; learning problem-solving strategies; recognising and dispersing negative thoughts; building up self-confidence and self-esteem.

Medical treatment

In addition, drug treatment for depression may be sensible and necessary, particularly in the case of difficult progressions. Before treatment is initiated, both the child and parents should be fully informed.

Supplementary therapies

Relaxation, body awareness, play therapy; physical activity, fresh air, sunlight

Self-help

There is very little awareness of self-help offers; they can never replace professional treatment. Self-help offers for relatives provide the opportunity to exchange experiences with other parents or relatives.

Tips for parents and other relatives

  • If you suspect your child might be suffering from depression do not ignore it. The condition makes many parents feel helpless. A child who is depressed is not lazy, aggressive or unbearable because they want to be; it is because they are ill and need help. Find out about the condition (leaflets, advice centre) and assure yourself that depression is usually easily treatable, but rarely goes away on its own.
  • Having a child who is depressed is no reason to doubt your abilities as a parent, but it is a reason to seek professional help. As a basic rule: the earlier treatment is initiated the better.
  • Depression does not affect only the sufferer, the illness impacts the whole family. Apportioning blame to the other partner or child is not helpful. Try instead to find ways out of the situation and help the child. If at all possible do not take action over the head of the child.
  • Sit down with your child, who is desperate and may also be self-harming, and have a calm and soothing conversation just between the two of you. Tell your child that you have noticed changes in them and that you are worried about their well-being. If you are feeling uncertain, admit it. It is important that the child realises that you care without putting them under any pressure.
  • Be patient and don’t expect too much from the initial conversation. Try not to look for solutions immediately, try to just listen and find out more.
  • Support your child, but make sure you don’t take over completely. Leave your child a certain amount of responsibility for themselves. Encourage the child to see a doctor or an advice centre.
  • If you are concerned that your child is harbouring thoughts of self-harm or if a suicide attempt has already been made, do not delay seeking medical help or having the child admitted to a children’s psychiatric or psychosomatic clinic, if necessary even against their will. But do remember than referral to a clinic can only be made by a doctor.
  • In crisis situations you can contact the “social psychiatric service” (Sozialpsychiatrischen Dienst) which every town or district has, or the ambulance service or police. It may be useful to keep these numbers handy for emergencies.
  • Accept that you cannot treat your child’s illness. Leave therapy to the professionals (doctor, psychotherapist). Ask about the nature and goals of treatment. If you support the treatment that can be a great help.
  • Despite your concern, try not to let your child’s illness dominate the whole family. Treat yourself to breaks to recharge your batteries and don’t forget that your partner and other children have their own needs too. Give them your attention and time.

Further information

www.buendnis-depression.de/depression/kinder-und-jugendliche.php: German Alliance Against Depression; Information page on depression in childhood and adolescence

www.fideo.de: Fighting-Depression-Online by the German Foundation for Help with Depression; Information and moderated forum for young people from the age of 14; also information for relatives

www.nummergegenkummer.de: Working Group Association Child and Youth Line; telephone advice and advice by e-mail for children and young people from professional advisors or young people for other young people; telephone advice for parents

www.bke.de: Various advisory offers by the Federal Conference for Parental Advice for parents and young people, addresses of advice centres, moderated forum, chats

www.youth-life-line.de: Youth-Life-Line within the association AKL (Working Group Life); Online peer advice for young people in crisis situations and in case of suicide risk; the young advisors are supported by specialists

www.u25-deutschland.de: AKL Freiburg and German Caritas Association; Information and online peer advice for young people under 25 in crisis situations and in case of suicide risk

www.nethelp4u.de: Email advice from adolescents for adolescents; Evangelische Jugend Stuttgart (Stuttgart Christian youth association)

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