How should we treat depressed children?

Although childhood depression is common, it is generally considered difficult to treat. For one thing children don't seem to respond to antidepressants as well as adults. Why is this?

There are a number of aspects to treating childhood depression that differ from treating depression in adults. For one thing, children are not as good at telling a therapist or a parent what they are feeling and why. Their responses are less differentiated than those of most adults. The same behavioural or emotional response may occur in response to very different problems. One often has to figure out what is going on from collateral information provided by parents, caregivers, or teachers more than from information provided solely by the child. The child may not know or may not be able to communicate what the problem is.

Often children and adolescents are also very shy or uncommunicative with professionals and may not be sure what is permissible to discuss.

For all these reasons, treatment may often be misdirected. An antidepressant would not be as likely to be effective if the child's problem was school failure, bullying, sexual abuse or fear of family dissolution. In each of these cases other measures would be necessary to have any realistic chance of alleviating the depressed feelings.

On the other hand, I have seen children who have oppositional and aggressive behaviour toward parents, are withdrawn from peers and have few friends who respond miraculously to an antidepressant. It may not be obvious initially that the child is primarily depressed and the reasons for it may not be obvious. Are they depressed because they don't have any friends or do they not have any friends because they are depressed? Are they fighting with their parents and siblings because they are depressed or are they depressed because of poor family relationships?

I saw one such child recently who after two weeks on an antidepressant was transformed. Whereas she withdrew from friends before, she now sought them out and enjoyed being with them. Whereas she fought with everyone at home before, she was now cooperative and pleasant to everyone. Nothing had changed other than the fact that she felt differently. There had been no family therapy, no cognitive-behavioural therapy, and no interventions at the school. The only thing that changed was the addition of an antidepressant. The problem is that it can be devilishly difficult to be sure what is required in each individual case.

It is almost always possible to come up with a plausible story about why someone may be depressed. This story might lead one to engage in all sorts of other therapy to try and resolve suspected antecedent problems. This is especially true because in most cases they will have already been having problems for 1-2 years before being seen by a mental health professional.

One has to keep an open mind in approaching these problems and be prepared to change direction if the response to therapy is not as expected. It is important not to be too dogmatic about what will and won't work until you get involved and try to sort things out. We are sometimes surprised by the results.


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