In our first episode in a series of episodes dedicated to the mental health of children, we talk to Children’s Behavioral Health experts about depression. When & why does it develop? And perhaps most importantly, we share resources on when & how to seek clinical help for your child.
1:48 – The basics of depression
3:41 – Depression is not just for adults
5:24 – Symptoms of depression
7:18 – Talking to your child or teenager about suicide and suicidal thoughts
9:35 – When to be concerned about your child’s mood
12:06 – Effects of a child’s environment on their mood
15:16 – Seeking professional help for your child
18:10 – Treatment for depression
21:04 – Monitoring your child’s medication
23:33 – How parents can help a child who is struggling with depression
Here at Children’s Hospital & Medical Center in Omaha, Nebraska, it’s all kids — all day, every day. Our pediatric experts are here to answer your questions and weigh in on hot topics, helping you keep your child healthy, safe, and strong. We’re here for you. Listen in.
Dr. McWilliams: Hi, I’m Dr. Jennifer McWilliams and I’m a child adolescent psychiatrist here at Children’s Nebraska. I’ve been working at Children’s for 5 years, I’ve been a psychiatrist for the last 12 years already. I’m here presenting with Dr. Akers.
Dr. Akers Hi, I’m Dr. Sean Akers. I’m a clinical psychologist here at Children’s Nebraska, and I’ve been here about 19 years actually, and I’ve been practicing for about 22 years, so I’ve been here a long time.
So today we’re going to talk about depression. We wanted to talk about some of the basics, and signs and symptoms, all the way into answering actually some questions about it for you. And so I think we’re going to start first with just describing it, and kind of what it is and what it is not. And Dr. McWilliams, why don’t you start off with just sort of describing it?
The basics of depression
Dr. McWilliams: A lot of parents really think of depression as being just really bad sadness. And there is a difference. Depression is actually a pretty well-defined clinical entity, and what defines it as being a disorder is that it actually causes people to have trouble functioning and doing their normal stuff. So a kid with depression is going to have trouble with school stuff, trouble with friends, trouble, you know, in their home environment. Whereas we all get sad from now and then, but it doesn’t keep us from being able to do our other activities.
The other challenge with depression is that it tends to be more long-lasting and overarching. So while people might have a few, you know, good moments here or there, they tend to feel more consistently down. That doesn’t necessarily mean sad. It can also mean irritable. A lot of kids, especially teenagers, can get really grumpy when they’re struggling with depression.
Sean, how do you describe depression?
Dr. Akers I think that’s a really good start and, you know, people do use the terms interchangeably sometimes like, “Oh, I’m depressed.” And there’s a difference between that sort of situational episodic sadness over a stressor versus something that does affect functioning and, you know…
And so we look at a cluster of symptoms. We have to remember that it’s not all or nothing, right? It’s not a, you know, somebody who’s perfectly content and always happy or they’re severely depressed. There’s a continuum there and we have variability in that. There can be mild depression, there can be moderate, there can be severe. That’s part of what makes it complex, is trying to tell them — not only the symptoms but the severity and the duration that comes along with all of these symptoms.
Depression is not just for adults
Dr. Akers And then, there’s also the misconception that only certain ages can have depression, you know, like only adults can be depressed. And what’s your experience about ages, Dr. McWilliams?
Dr. McWilliams: So, you know, early on in my training we were told that little kids couldn’t possibly have depression, that that was something that only adults faced. And now what we’re really recognizing is that kids, teenagers, definitely have a strong disposition towards depression, all the way down into the younger ages.
I’ve seen kids as young as early grade school struggling with depression. A lot of those littler kids have more atypical symptoms. They have more tummy aches or headaches, more trouble sleeping, not eating as well. And don’t show some of the more classic symptoms of negative thoughts that we see with some of the older kids, but it’s still just as real and just as problematic.
Dr. Akers That’s a good point. In terms of the differences between some kids and adults is that the kids do see a little bit more, what we call somatic — or body symptoms — that might be a little bit more present. And I do a lot of work in a hospital and so we look at some of those clusters of symptoms that somebody has — lots of headaches or tummy ache — sometimes that can be a symptom that they’re struggling with some emotions that we’re not quite aware of.
Dr. McWilliams: It is important to remember that it can affect anybody at any age and so it’s kind of a universal disorder in that regard.
Symptoms of depression
Dr. McWilliams: Speaking of the symptoms, what are some of the classic hallmark symptoms that you look for when you’re assessing a child or a teenager?
Dr. Akers We’re certainly going to first look at mood. And you brought up the irritability. We certainly see that with teenagers a little bit more, but certainly sadness, feeling down. I’m going to pay attention, sometimes especially to the kids who have a little bit more anxiety that…when an anxiety is not treated, sometimes that can lead to depressive symptoms that we need to address as well.
One of the things that becomes more common that I see in the hospital is kids who — you know, you brought up the term functioning — when they’re, when we start hearing descriptions like, “Oh, they were very social but now they’re not, they’re starting to isolate a lot more. They’ve changed grades a lot, their grades are decreasing.” Or, “They’re not doing as many activities as they used to do.”
So I’m always looking for more dramatic changes in what they used to do versus what they are now. And then, you know, are they isolating or sleeping a lot? Are we seeing changes in sleeping and eating? You know, are they making more statements? Maybe sometimes they’re vague statements like, “Oh, I’m not very good,” or, “I’m not — I’m not a very good person.” Are they starting to be negative about themselves?
They may not come right out and say, “I’m feeling worthless.” But are they making some of those statements that are concerning that they may not use to? And, you know, there’s others.
What about you Dr. McWilliams?
Dr. McWilliams: Absolutely. I think you really hit on some of the big highlights. You know, especially changes in interest, changes in friends, sleeping more, not sleeping as much.
Talking to your child or teenager about suicide and suicidal thoughts
Dr. McWilliams: Of course, the most significant symptom of depression that we need to talk about are thoughts about suicide. Thankfully, that’s relatively rare in my clinical population. Obviously, working in the hospital, you see that at a much higher rate.
But that’s something that we always need to be willing to ask our kids and our teenagers about. You know, “I can tell that you’re really down. Have you been feeling so down that you’ve been thinking about, you know, hurting yourself or thinking that life’s not worth living?” and not being afraid to ask those questions.
A lot of people worry that they’ll plant the seed about suicide or self-harm by asking, and the facts are very much the opposite — that by asking, we actually have a better chance of connecting with our kids and letting them know that we understand what they’re going through.
Dr. Akers And I’m really glad you brought that up, and I see that a lot in the hospital and so that’s something that I have to screen for often. And we do have to make sure that it’s, that we understand that suicidal ideation or thoughts of suicide, can be a symptom of depression — but not everybody who has thoughts of suicide is depressed and not everybody who’s depressed has thoughts of suicide.
But we always want to screen and that’s really important — I want to reiterate that point that talking about it is not a cause of the symptoms. That we want to be open and honest and clear and just really straightforward about that. And the only other thing that we do want to talk about — not only about suicide — but feelings of hopelessness. You know, they’re starting to make comments about the “future doesn’t matter” or what does anything matter and they’re feeling just that nothing’s going to change and it’s all going to be bad. And again, those are statements that we want to pay attention to.
Dr. McWilliams: In my training, we call some of those a passive deathwish. And the way that I explain it when I’m talking to kids is, you know, maybe you don’t want to jump in front of the bus — but you wouldn’t be sad if the bus hit you.
And then, you know, remembering that all those feelings exist on a big spectrum, just like depression itself. So, talking to kids and finding out where they are, is really super important.
When to be concerned about your child’s mood
Dr. McWilliams: As a provider and a parent, what would you advise? When do you think people should be worried, when should parents be concerned about their kid’s mood?
Dr. Akers That’s a really good question and we hear that a lot. I have a couple of points about that. Number one is, we’re the experts in mental health but you’re the experts in your kid. And we really want to emphasize that you are the ones that are with your child all the time, and you know what’s typical for them and what’s not typical for them. And so paying attention to that. It’s really important.
And the second point I’ll make is that this is partly where parenting gets hard. Because we want to have — there’s a balance there. We want to allow for experiences and sadness and feelings, and part of our job as parents is to allow kids to express feelings and sadness, and validate those feelings, and helping them negotiate those times, especially as they’re going through some of those early teenage years.
But then it gets to — the question is, what is that normal, you know, peer issues or sadness or issues to the point of where do we get concerned? And I’m always going to go back to what you said earlier, is when you start seeing more patterns and difficulties in functioning. You know, if they typically struggle in math, just struggling in math is different than all of their grades coming down. And having concerns that maybe they’re not showing the level of motivation or the level of energy. They’re coming across more fatigued all the time, wanting to sleep all the time. Where everything starts becoming a battle. They’re just grumpy and, you know, when you used to say, “Hey, I need for you to do dishes,” and they blow up. And we start seeing patterns of that versus just sort of these more smaller negotiations of life.
Dr. McWilliams: And I think you hit the nail on the head there that a lot of it is, you know, really knowing your kid and knowing what’s normal for them and what’s not. If your child has always loved baseball and has been a huge baseball player and suddenly decides that they want to quit the team — that’s a red flag. If your child has good friends and suddenly doesn’t want to go out with them — that’s a red flag. I think those things of — knowing your kid is the most helpful thing that we can do.
Effects of a child’s environment on their mood
Another issue that a lot of times comes up is a lot of parents say, “You know, there’s so much stress, there’s so much chaos going on in the world right now, who wouldn’t be depressed?” Or on the other hand, “My kid’s life is perfect. There’s nothing big going on.”
What’s your experience with effects of the environment on how kids’ moods are changing?
Dr. Akers Good question. I’m actually — I’ll back up one second there. We have to not only look at experiences and stressors, but we also want to take a look at biology. And you and I have talked a little bit about that — that some kids have more a propensity for stress, and from that, we all interpret things differently. We know we want to take into account different, different temperaments, different personalities.
And at the same time, what stresses people out is going to be different. And there’s a lot of stuff going on in the world right now, whether it’s a quarantine situation or you watch the news…and there’s a lot of issues going on in our society today that can be really stressful for kids. And so, it’s actually not that uncommon when I hear parents say, “They want for nothing, and I don’t know why they would be depressed.”
We want to take a step back sometimes. Some kids interpret things differently and sometimes we don’t know about things and I often see kids who are really hard on themselves or they’re perfectionistic, and they don’t tolerate getting a “B” in a class. When I was going through high school, a “B” was pretty darn good in some classes and so, just because I perceive some things in a certain way doesn’t mean your child is perceiving in the same way,
Dr. McWilliams: It’s also important to remember that good changes can be stressful. I’ve had kids who’ve gone off to college and been very excited about their dorm experience and then start to struggle with depression. And that almost is worse because it just becomes kind of a vicious cycle where they feel depressed, and then can’t understand why in the world everybody else in the dorm is having fun, and they’re feeling so down. So, you know, any big life change can be a precipitator for depression. Or, like you said, there is a very strong biological component to depression and for some folks, it’s just kind of part of their neurochemistry. And that’s important to recognize too, that it’s not anybody’s fault. No one chooses to be depressed.
Dr. Akers And I’ll add to that, like the transition to college, I think sometimes that can be really hard for kids to deal with those positive things because they start telling themselves, “I shouldn’t feel stressed about this, I should be excited.” And they put more pressure on themselves that, “I see everybody else making new friends and doing new activities and everybody else is happy, so I should be happy. Why am I not happy?” And it becomes confusing in that respect because it’s supposed to be a happy time when it may not be actually a happy time.
Seeking professional help for your child
Dr. McWilliams: Shifting gears a little bit — my husband always jokes that I have a tattoo on my forehead that says, “I’m a psychiatrist, please tell me your problems.” Grocery store clerks and everybody else always seems to be willing to bring up issues. That’s not actually the case and for a lot of folks, it’s hard to decide when it’s time to talk to somebody who’s a professional and not just the random person in your grocery store line.
When do you advise parents that it’s time to seek professional help?
Dr. Akers I think — my first thought to that is that — like when my kids were young — all my kids are adults now — and we had such a wonderful relationship with our pediatrician. We still have a — my youngest still is able to see her. And I think, always having that relationship and lifelong, you know, in many respects, relationship with their medical team, and having any of those first comments about, you know, this is what we’re starting to see.
And the other thing I’ll note is that like at our Children’s Physicians Clinics, they started doing depression screening. And I really support that not only with us. I’m just so happy that we do that. But that’s also seen around the country in many pediatrician offices, or they do what we do here, which is a PHQ-9. Then when they do a depression screening — and my kids all did it whenever they were in there — and I often say the pediatrician is sort of the captain in many respects of your child’s healthcare. And so I think that’s a good place to at least start when we start having any of those even little concerns that “this is what I’m seeing.”
Dr. McWilliams: I agree. I mean, the one thing that I want to really emphasize is that your primary care doctor, even if you’ve only been working with them for a brief period of time — they have the advantage of seeing hundreds, if not thousands of kids, and have a pretty good sense of where things fit in the normal range. Within the Children’s system, we are really lucky that we’ve got great pediatricians working with us, and we have a really close working relationship with them, so that if they have questions they can reach out to us and vice versa.
So, I agree with you completely that starting with your primary care provider is a fantastic place. A lot of parents, especially if they’ve had experience with other children that we’ve had depression, will go ahead and contact our behavioral health department directly. There’s no limitation on that. You’re more than welcome to. But also really emphasizing the pediatrician knows you guys best and can be a great team member, and as you said, the captain of your health care team.
Treatment for depression
Dr. Akers So then moving on to, as we wrap up, what would treatment look like? So somebody called their pediatrician and then they called our office and we set up an intake, what would that look like from our end?
Dr. McWilliams: So treatment plans really exist kind of on a spectrum, just like the disorder of depression itself. There’s been a tremendous amount of research that’s been done looking at treatments for depression for children and adolescents. For most mild to moderate depression, the most appropriate — the gold standard treatment — is therapy. Talk therapy, counseling, working with a psychologist or another independent licensed mental health professional. And so that’s really where we recommend starting for a lot of folks.
As kids slide down that continuum of severity into more moderate or severe depression, then a lot of times we see more of that biological component, and a lot of times that’s where medication really is necessary. And there has been a lot of research that’s been put into studying those medications. The primary family of medicines are called the SSRIs — selective serotonin reuptake inhibitors — and those can be very safe and very useful.
At the end of the day, for kids with that moderate to severe depression, though, the best, the most tried and true treatment plan, is that combination of medications plus therapy. One can help and the other can help, but together, they synergistically have the biggest impact on helping not only get over the depression symptoms — but prevent them from coming back in the future.
Dr. Akers Well Dr. McWilliams, when we have those conversations, I’ll say a couple things. Number one, when somebody comes into my office — it’s an intake. Very first time and we talk about, you know, “This is what an intake is going to be.” It’s usually going to be 15 minutes to an hour, and I’m just going to ask a lot of questions, and it’s really about getting to know each other, it’s going to ask questions about your functioning. School, home and relationships, friendships, and are doing things fun or does anything or things not sound fun anymore to you?
And so I really want to get to know you. And that’s the goal of the first time. It’s not necessarily even, “Let’s get to work immediately on depression.” We have to see what’s going on, because things can mask other things and we want to be really careful and clear that work for our treatment plan is focused on the right thing, such as difficulties in concentration. Can be anxiety, it can be with depression, it can be with attention issues. And so we want to be really clear what we’re focusing on. And that’s what the intake is really all about.
Monitoring your child’s medication
From your end, from a psychiatrist’s end — when we do start having those conversations about medicine, one question that some parents will ask is about the monitoring part. You know, “Are you just going to place my child on medications?” What would you explain to parents about that monitoring part?
Dr. McWilliams: Absolutely. So I’d be concerned if somebody started someone on medication and just said, you know, “See you later.” Typically these medications — we recommend seeing somebody back within 4 to 6 weeks of starting the medicine. Medicines don’t work overnight and they take 4 to 6 weeks, so we don’t want to tinker and play with them at first. So we give it a month with the understanding that our team is always here and any other psychiatrists or primary care provider is always available, so if you start to see side effects or problems with the medication, you give us a call right away.
Once somebody has been established on the medication and is starting to do better, then still — even then we want to see them back every month or two, to monitor how that medication is working.
Dr. Akers I think that explanation really helps people feel like we’re going to make sure that things are helpful and that we’re going to keep an eye on things because we know — we’re not going to just do something and not monitor it.
Dr. McWilliams: The other question that I get a lot from parents is, “How long are kids going to be on medicines if we do have to go that route? And, you know, there’s the perception that you’re going to have to be on medicine always and forever. And the research has actually been pretty clear that if someone continues to take medication for 9 to 12 months after they start feeling better, and then we kind of appropriately taper and stop the medicine, then the chances of those symptoms coming back are very low.
Whereas if they stopped the medication abruptly as soon as they start feeling better, the chances of those symptoms coming back are relatively high. Another factor in there, again, is working with therapists or psychologists to work on different strategies to manage your depression symptoms so that we’re not just relying on pills alone.
Dr. Akers Right, and ideally, what we often want to see, is that medication is helping. And then, oftentimes, that actually makes treatment — the therapy part — more effective because we’re really able to then talk about stuff. You know, the issues that are going on, without it being a crisis or without it being so severe that we’re really talking about functioning. Then we can really get to the meat of what’s going on. And that’s why we often see that combination be really helpful.
How parents can help a child who is struggling with depression
Dr. McWilliams: So, to kind of wrap up, because I know that we want to respect everybody’s time — besides talking to someone like you or me, what advice would you give to parents on what they can do to help their kids if they’re struggling with depression?
Dr. Akers Beyond what we already talked about, you know, being aware and knowing your child and talking to your pediatrician. What I really would like parents’ role to be is that we understand that therapy works, therapy helps, and medications and all of these things are — depression is treatable. And so your role, in many respects, is to help guide that process. And one of the things that we see sometimes is, is really making sure that when parents destigmatize therapy, and are supportive of that and are talking through openly about that process. And be willing and open. And showing that talking about your feelings, and being open and honest about those things, can really help. That’s, I think, really critical for making the therapy process helpful, As well as, you know, just coming in and working with myself, or all of our wonderful therapists or psychiatrists here.
Dr. McWilliams: Absolutely. I always kind of halfway joke that the struggle with depression and other mental health concerns is that they attack your brain. They hijack your thought process. And so for the patient, the kid, or the teenager, things may seem completely hopeless, even as they’re starting to get better.
And so as a parent, really support them and help them recognize that while things seem maybe bleak now, that they’re going to get better. That they are moving the right way and that they have a team of people that are there for them.
Dr. Akers Yeah and that team aspect, I think — it’s really important. Again, we’re the mental health professionals, and I’m an expert in therapy, and you’re [Dr. McWilliams] an expert with medications and all of the things that you do here. And parents are the expert on their kids and their family, and we all know in many respects that captain of the team that we work with, as well. And that team aspect of working together can be just really powerful.
Dr. McWilliams: Absolutely. And I think just to kind of wrap things up from my standpoint, I think my message for parents and family is to remember that we’re here and can be part of your team. But we trust that you are the expert in your child. So, we appreciate you taking the time to learn about depression. We encourage you to call us with any questions that you might have.
Dr. Akers And I’ll just add that depression is treatable. The earlier we treat it the better. If we wait for a year or two and the symptoms have been going on for a long time, it does become a little bit harder at times. So the more you’re aware, and the more you know and ask for help, and sooner you do it, the more we can get started and really help that treatment process. I really appreciate you listening and I hope you guys have a really good day.