Most discussions of depression assume that all depressed people resemble each other. In many ways they do, especially when the depression is of psychotic degree. But in many other ways they do not. Not every depressed person complains of being sad. A depression may show itself simply in a failure to live successfully and to accomplish age-appropriate tasks. In particular, depression presents differently in children and adolescents than it does in adults.
A child who is depressed may not complain of feeling bad, but rather of not getting along with friends or not wanting to go to school, He/she may regress to behavior seemingly outgrown previously, such as bed-wetting, or show a change in bowel habits, such as soiling or constipation. These symptoms may appear by themselves or together with more blatant disturbances of mood.
Similarly, if the task of adolescence is to separate emotionally from parents and become self-reliant, a depressed adolescent may show as a principal symptom the wish to stay home alone. He/she may lose interest in school and in friends. Or such an unhappy person may run away in an attempt to become independent all at once.
The inclination to injure oneself may appear at this age. Cutting, usually in areas of the body not readily discernible, is a disconcerting symptom which probably has less significance than it seems. It is not a sign of impending suicide. It occurs usually in the context of being frustrated. It is the kind of behavior, distressing though it is, that is likely to disappear with growing up. But, of course, it is an indication for treatment.
Antisocial behavior such as stealing, promiscuity, or the abuse of drugs and alcohol can be manifestations of a depression. Each of these behavior problems may require treatment apart from the underlying depression that causes them. Avoidance of school for instance, sometimes called a school phobia, will become chronic if not treated promptly, usually in part by bringing the child or adolescent to school despite his/her fears. If the habit of remaining at home become fixed, that individual’s entire subsequent experience with school will be adversely affected. School counselors can be particularly helpful in preventing the development of a school phobia. This condition, because it requires immediate intervention, should be regarded as an emergency.
Promiscuity, which may grow out of the contempt a depressed adolescent feels for himself or herself, may lessen considerably just by having the opportunity to talk with a sympathetic, non-judgmental person. To an extent, talking about a sexual impulse, or any other kind of impulse, can substitute for the impulsive act. Shoplifting, when it is impulsive, often goes away in the beginning of therapy. Either symptom unattended can set a pattern of behavior that continues into adult life long after the resolution of the depression that first provoked it.
The depression that appears in childhood and adolescence is more variable than that of adulthood, both in its symptoms and its course. The younger the person, the less likely it is that medication will work or be considered appropriate. Even so, probably medication is prescribed too frequently. An unhappy child is often the barometer of an unhappy family, and often the only treatment that really helps is family therapy.
The adolescent represents a special problem, both to his/her family and to anyone acting as therapist. Like anyone who is depressed, the adolescent is likely to be sullen, irritable, and withdrawn—and to seem lazy and rebellious rather than depressed-- unwilling to work rather than unable. Troubled adolescents may, in turn, see their parents as unsympathetic. A therapist has to spend considerable time interceding between parents and child. Often therapy is forced on the seemingly delinquent child. Under those circumstances the therapist may have trouble winning the patient’s confidence. It is natural to see the therapist as simply an agent of the parents or of some other authority, and consequently wrangle unceasingly in therapy.
The therapist must be careful not to respond by scolding, but should listen respectfully, and go out of the way not to patronize the patient by speaking in the vernacular of adolescence, or by putting on some other such pose. Such a mask is transparent. The therapist must be straightforward and genuine. Many experienced therapists avoid treating adolescents because they do not like to be reminded of their own turmoil growing up. To treat such a group of patients successfully, it is necessary to be able to tolerate dealing once again with these stresses.
It is readily apparent, looking through the range of symptoms described above, that many if not most children and adolescents have exhibited such behavior and made such complaints from time to time. They are not all depressed; and they do not all need to be in treatment. It is as if any emotional distress at all can become manifest only in certain ways—and these symptoms can be transient, and, considered from a certain point of view, may be only the ordinary difficulties of growing up. Still, they need to be dealt with so that a temporary problem does not become more serious. The emphasis should be on “transient.” If a child or adolescent seems troubled over a period of months or longer, it is reasonable to seek some kind of help. Therapy, even if it could have been avoided somehow, will not have an adverse effect by “labeling” the child as disturbed. Even when it is not absolutely essential, it can be useful. © Fredric Neuman (drawn in part from “Caring: Home Treatment for the Emotionally Disturbed.”) Follow Dr. Neuman's blog at fredricneumanmd.com/blog