A group of female classmates has been harassing 13-year-old Marie for a month, making fun of her clothing and her weight. She has stopped socializing, other than to check Facebook to ensure no other hurtful things are being said about her. She sleeps fitfully, has stopped eating regularly and her grades have dropped.
Robert, Marie’s classmate, didn’t make the basketball team, which represented his singular dream. His recently divorced parents and his teachers have noticed he has grown much more irritable, to the point that other students avoid him.
His older brother, Randy, was previously a high school honor student. Now his grades have plummeted.
Kaitlyn, the girl who sits behind Randy in chemistry, smokes marijuana. She is often high in school and nearly always high when she is with her new group of friends. Her younger brother in fourth grade calls his foster mother and goes home sick from school one or two times per week.
Another student, Juan, always seems very sad. For two years, teachers have told his counselor about his mood. In Juan’s file, the counselor finds similar reports dating back to middle school.
Under the current criteria, any one of these students might potentially be diagnosed with major depressive disorder, which generally involves a client experiencing six or more of nine common symptoms for a duration of two weeks, or dysthymic disorder, which presents as having a chronic depressed mood with two established symptoms for two years or more.
But based on proposed revisions, when the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is published approximately two years from now, new criteria will likely suggest that each of these students is depressed — by degrees.
“[The DSM-5] will introduce the idea of looking at disorders such as depression on a spectrum, with certain severity levels used as cut points to identify maladaptive symptoms and functioning, much like we associate blood pressure of 140 over 90 as higher risk,” says Gary Gintner, associate professor of counselor education and program leader at Louisiana State University. “Depression, too, will have a dimensional rating that notes severity.”
But no matter the process for diagnosis, experts would say that all of these students have serious symptoms of depression and need attention from counselors to help them feel better and address the problem early when it is easier to make inroads.
Gintner says at any one time, about 2 percent of children younger than age 12 have depressive disorders. That number rises to between 4 and 8 percent for those ages 12 to 18. Once adolescent girls hit puberty, their risk of depression is double that of their male classmates (see sidebar, page 34). The rate of depression among young people has increased every decade since the 1940s, according to Gintner, who trains counselors in the use of the DSM and is an expert in planned revisions for the DSM-5.
Each of the professionals interviewed for this article noted that an early diagnosis of depression can make it easier to treat the issue successfully, often with talk therapy.
That means it is important for counselors — especially those in schools — to be the first line in identifying students struggling with depression.
According to Dr. Graham Emslie, a psychiatrist at Southwestern Medical Center in Dallas and a specialist in child depression, only about 40 percent of adolescents and children needing treatment get adequate care, often because the problem is not spotted. “It is a quiet problem,” he says. “We tend to relieve the symptoms or simply not identify it.”
One key indicator of depression among students is a precipitous drop in grades, he says, especially if accompanied by other symptoms of depression: low self-esteem, sleep problems, fatigue, apathy and feelings of worthlessness, changes in appetite, loss of pleasure in life and problems concentrating.
Gintner, a past president of the American Mental Health Counselors Association, a division of the American Counseling Association, notes that uncharacteristic or excessive irritability is a symptom associated with depressed adolescents and children. He adds that children may have temper tantrums, stomachaches or headaches associated with depression, while adolescents may be moody, act out or even injure themselves by cutting or burning their skin.
“Many times, the behavior is interpreted as oppositional, but the young person is actually depressed,” Gintner says. “The key thing to look for is if they have one of these other depressive symptoms (see sidebar, page 35). And it is critical to identify these problems early when there is a greater chance of treating them successfully.”
Often, experts say, life stressors cause depression. For children and adolescents, those stressors don’t necessarily stem from a serious personal failure or a major event such as the death of a loved one but rather from common daily hassles or interpersonal problems, such as changes in relationships with peers.
James Matta, an associate professor of counseling at Geneva College in Pennsylvania and senior research principal at the Western Psychiatric Institute and Clinic in Pittsburgh, says counselors should pay particular attention to feelings of hopelessness among young people. “It hinders an individual’s ability to form and maintain close relationships with family, friends and early romantic partners,” he warns.
Matta, an ACA member who presented on depression in young people at the 2011 ACA Annual Conference in New Orleans, adds that comorbidity is not adequately studied or identified, even though substance use disorders and depression are often linked. Depressed young people are twice as likely to have a substance abuse problem than other adolescents, he says, and “comorbidity is more often seen than not in adolescents with substance use disorders.”
Emslie says it is often difficult to determine whether certain characteristics and circumstances cause depression or whether they are symptoms of it. For instance, being bullied can cause children to become depressed, but depressed children might also be more likely to be targets of bullying because they are less likely to defend themselves and perhaps present themselves in a way that encourages bullies.
When school counselors are concerned about a student, Matta says, it is critical that they develop a baseline for the student’s mood, demeanor and performance in school, using communications with former teachers and counselors as a guide. Early treatment is key, he says.
“We are determining — and it’s very affirming to counselors — that psychotherapy or talk therapy is most useful for those with mild to moderate levels of depression,” he says. “Cognitive behavior therapy (CBT) and interpersonal therapy seem to be very effective.”
Laura Choate, an associate professor at Louisiana State University and the author of books and papers on depression, particularly as it relates to young women (see sidebar, this page), says considerable research has reached that conclusion about treatment. She says the most effective components of CBT to date are psychoeducation about the nature of depression, the development of problem-solving skills, self-monitoring, building relationship skills, communication training (assertiveness, social interactions, family communication, active listening), cognitive restructuring and behavioral activation — for instance, increasing pleasant activities or setting small, achievable goals.
Choate, a member of ACA, notes that a popular “Coping With Depression-Adolescent” program from Kaiser Permanente’s Center for Health Research is “among the most studied CBT programs for adolescents and has the most empirical support.” The training manual and student workbook in individual and group formats are available for free atkpchr.org/acwd/acwd.html.
Meanwhile, through interpersonal therapy, young people improve relationships by building support and developing their interpersonal competence, Choate says. “Most counselors are not familiar with interpersonal therapy, but there is a strong line of research supporting its effectiveness with adolescents, particularly with girls of color from impoverished backgrounds,” she says, noting that Laura Mufson, a researcher and professor at the Columbia University Medical Center, has developed research and training material surrounding the treatment.
Gintner says counseling should include positive interactions, active listening, restoring hope and doing problem solving for real problems. Emslie adds that family therapy is also useful.
Matta notes the American Psychiatric Association released guidelines for treatment of depression in October that suggested talk therapy is most effective initially for clients with less severe cases of depression. “Four to six weeks into treatment, if they are not showing improvement — or in more severe cases — then you consider an antidepressant,” Matta says.
Emslie agrees: “Data would suggest that the persistence of the problem in spite of attempts to improve the situation is the best indicator for medication. Unfortunately, only 40 percent of young people who suffer from depression are treated, and only 20 percent of those treated use medication.”
A study that Matta helped conduct found that young people with comorbidity who received both talk therapy and the antidepressant fluoxetine (more commonly known by the brand name Prozac) did not have significantly better results than those receiving only talk therapy, though both groups showed significant within-group improvement.
“It was not the specific intent of this study,” Matta says, “but its results support the recent recommendation that psychotherapy intervention should be considered the first-line treatment in comorbid populations, with pharmacotherapy being offered to those who do not respond to psychotherapy intervention alone.”
But Gintner cautions that the “old class” of antidepressants such as Elavil isn’t helpful with children and youth, while selective serotonin reuptake inhibitors (SSRIs) only seem to work with adolescents. He also notes these drugs are not without risks.
“In 2000,” he says, “studies began to find risk of suicide ideation or suicidal behavior increased from 2 percent with a placebo to 4 percent on SSRIs. It’s a risk, but not a huge risk, so we have to weigh the risk versus the benefit and, sometimes, the benefit is significant.” Research has shown that Paxil seems to have a higher incidence of suicidal ideation and acts, he says, while adding that Prozac is the only SSRI approved for use with youth by the U.S. Food and Drug Administration. The FDA recommends that youth taking SSRIs be seen by a psychiatrist every week for a month and be monitored closely, he points out.
Still, experts say better treatment techniques and the refined use of medication are helping increasing numbers of young people. And Matta notes the weighty issue is not without positive data. “Adolescent recovery rate is 90 percent over one to two years from the onset of depressive disorder with treatment,” he says. “So we do know how to treat it.”
Jim Paterson is a writer and editor and the head of counseling at Argyle Middle School in Silver Spring, Md. Contact him firstname.lastname@example.org
Letters to the editor: email@example.com
The gender-depression connection
Before adolescence, an equal number of boys and girls experience depression, but after puberty, girls are twice as likely as boys to develop depression, particularly around age 13, according to the American Academy of Child and Adolescent Psychiatry. The question is why.
Laura Choate, an associate professor at Louisiana State University and author of the book Girls’ and Women’s Wellness: Contemporary Counseling Issues and Interventions, published by ACA, says a definitive answer to that question has yet to emerge, although several different possibilities would appear to make sense.
“Researchers have developed no comprehensive model to explain these sex differences because it is likely there are multiple processes contributing to them,” Choate says. “Overall, girls have more cognitive, biological and interpersonal vulnerability factors prior to adolescence and face more stressful events during the transition to adolescence. It is the combination of these factors that lead to the higher rates [of depression].”
Stress: “Compared with boys, girls experience more stressors during early adolescence,” Choate says. “In addition, girls are more affected than boys are by these stressful life events and are more likely to become depressed in response to life stressors, particularly when these are interpersonal in nature.” She notes that studies show interpersonal stress is associated with higher depression and lower self-esteem for girls but not for boys.
Transition to puberty: Girls who reach puberty early are more likely to experience a host of negative psychological outcomes such as lower self-esteem, a history of suicide attempts and a lifetime of eating and disruptive behavior disorders, Choate says. A change in schools, such as the transition to high school, can add to these problems.
Choate explains that girls who mature physically at a younger age are more vulnerable to being “pressured to participate in activities they are not cognitively or emotionally mature enough to handle.” They are also more likely to be sexually harassed and pressured into sexual activity before they are developmentally ready, which can increase the likelihood of depression.
Confusing feelings: Girls tend to be excessively empathetic, Choate says, which can make them feel guilty and overly responsible for another person’s problems. In addition, girls often exhibit high levels of compliance and overregulation of emotions, which can contribute to developing a depressive disorder.
Rumination: Choate says girls generally tend to engage in a “ruminative” style of thinking about problems, which is linked to depression. In other words, they think about and talk about their depressed mood rather than developing possible solutions and actively solving the problem. They also tend to blame themselves.
The idea of “co-rumination” — excessive talk about problems within friendships or romantic relationships — adds to the problem, Choate says. “Interestingly, even though the use of social media has not been directly measured as a source of girls’ problems, this co-ruminative tendency among friends has been recently termed ‘Facebook depression.'”
Connections: Girls are socialized with a greater need for affiliation than boys, according to Choate. This means girls are more likely to measure their self-worth and form their self-esteem on the basis of the success of their relationships and on others’ approval of their appearance and behavior. This makes girls more likely to become depressed if their peers reject them in any way.
Appearance: According to research, Choate says, the most important factor in self-worth for girls is confidence in their appearance, while for boys, it is confidence in their abilities. “Because adolescent girls are so concerned with gaining the approval of others, and because a thin, beautiful and sexy appearance is so highly valued in today’s culture, girls may become overly concerned with their appearance, weight and shape in determining a sense of self. Girls who internalize the thin-beautiful-sexy ideal are more likely to have body dissatisfaction, which is strongly linked to depression in girls.”
— Jim Paterson
Symptoms of depression
According to the American Academy of Child and Adolescent Psychiatry,
the symptoms of depression in children and teens are as follows:
- Frequent sadness, tearfulness, crying
- Decreased interest in activities or inability to enjoy previously favored activities
- Persistent boredom; low energy
- Social isolation and poor communication
- Feelings of guilt and low
- Extreme sensitivity to rejection or failure
- Increased irritability, anger or hostility
- Difficulty with relationships
- Frequent complaints of physical illnesses such as headaches and stomachaches
- Frequent absences from school or poor performance in school
- Poor concentration
- Major change in eating and/or sleeping patterns
- Talk of or efforts to run away from home
- Thoughts or expressions of suicide or self-destructive behavior