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Warning Signs of Depression in Children and Adolescents

We know that depression affects everyone, even the old and the young. But, it can be very difficult to know how a young person is feeling, especially when they don’t even know how to describe what they’re experiencing. Young children don’t have the words to describe their emotions to adults. Sometimes teenagers feel like they are alone in their depression or don’t know how to ask for help. So, how can you, as a parent, tell if your child may be struggling?

First let’s learn a little about how a professional diagnoses depression. The diagnosis of depression is made by a doctor or therapist when a child or teen feels down or stops enjoying activities for a period of at least two weeks and the symptoms are bad enough to affect their ability to function. They also have at least 4 other symptoms such as sleeping more or less than usual, eating more or less than usual, loss of concentration and feeling overly guilty about things. They may have decreased energy and sometimes other people even notice that they move slower than usual. Unfortunately, many people with depression also have suicidal thoughts and may even make plans to take their own lives. Kids with depression can also have other scary symptoms like hallucinations or confusion about what is real.

There is also another type of depression that many people don’t know about. It is called dysthymia. When a child or teenager has dysthymia, they are depressed or irritable for more days than not for at least a 1 year period of time. They also have at least 2 other symptoms of depression such as changes in appetite, sleep or energy. Kids with this type of depression usually have milder symptoms in general, but it can be just as worrisome because they feel rather lousy for a long time. It can affect their grades, sports, relationships and keep them from doing things they might enjoy.

A great deal of research has been done to help us know who may be at risk for developing depression. Researchers have found that in childhood, boys and girls are about equally at risk for depression. Among teenagers, girls are around twice as likely to develop depression as boys. In total, about 2% of children and between 4% and 8% of teenagers are depressed. The statistics for dysthymia are very similar. We also know that people are more likely to have depression if there is a family history of depression or any history of traumatic events like physical or sexual abuse. Often the symptoms begin after a major stressor like the ending of a relationship or loss of a loved one.

So, occasionally kids ask for help when they are feeling depressed. But, in general we rely on parents to recognize when depression may be affecting their child. It’s important to know what to look for because sometimes depression can look different in children and adolescents than in adults. Like adults, kids will sometimes be more tearful or appear sad. They may talk about feeling hopeless or you may frequently hear statements such as “why bother?” and “who cares?” It is also very common to hear depressed kids complain that they’re bored because they are unable to find anything pleasurable.

But, depressed kids do not always look depressed. You should also be aware of your child being more irritable than usual. A depressed child is frequently more angry or hostile. They may also be more sensitive to criticism or rejection. You may even notice them spending more time alone when before they would play with friends. Of course, you should always be aware of dropping grades or frequent absences from school. Parents can also ask teachers if they have noticed any changes in behavior or performance.

If you feel that your child may be depressed, it is important to have them evaluated by a health professional. There are treatments available that are proven to help. Most primary care physicians are trained in the basic treatments for depression. They may refer your child to a child psychiatrist for additional help. Finding a therapist is also very helpful and your primary physician or psychiatrist can help with this too.

If you have any concern about your child’s safety, if they’re making statements about death or wanting to die or if they are making threats to harm someone else, please call 911 or take them immediately to the emergency room. These are serious symptoms of depression that should be treated urgently. It is always better to be overly cautious and have them evaluated than to risk anything bad happening to them or someone else.

Obsessive Compulsive Disorder in Children

We’ve all seen the television shows and movies depicting characters that have to touch things a certain number of times, wash their hands over and over, arranging things “just so”. Hollywood can make the rituals associated with obsessive-compulsive disorder seem entertaining, but for people suffering with the illness it is definitely not a laughing matter. And, while more commonly seen in adults, obsessive-compulsive disorder (OCD) can be just as disabling in children.

OCD is a type of anxiety disorder that typically involves obsessions (worries) and compulsions (rituals). The worries are usually very common thoughts, thoughts that everybody has at some point in their lives. For instance, an obsession might be “what if I accidentally stepped in front of a car?” or “I might get sick from touching that doorknob” or “I wonder if we left the stove on” or even worries about a loved one dying. For people with OCD, they cannot let the thought come and go the way other people do. Typically, the thought makes them feel anxious or guilty and they start to think about it more and more, wondering what it means that they had the thought to begin with. They wonder if maybe they really do want to step in front of a bus, or if they are going to get sick from touching that doorknob or maybe that their house will burn down because the stove may have been left on. It becomes a viscous cycle of thinking the thought and worrying about why they had the thought.

The obsessions are most commonly associated with sex, religion, health and body issues. While adults usually recognize that the worries are extreme and often irrational, many kids with OCD lack the insight to recognize this. This sometimes makes it harder to discover that a child is struggling with OCD. Also, because children and adolescents are going through a lot of developmental changes, they may be more prone to having sexual obsessions or worries about their bodies. These can be very hard for kids to talk about, especially with their parents. Usually the rituals are performed to relieve the anxiety associated with the worries. Common compulsions are washing hands, repeating tasks over and over until they’ve done it “just right”, organizing and reorganizing until it feels right and checking to be sure everything is okay. With kids, parents are often are involved with the rituals, even if by accident. For example, a child may verbally check with a parent about whether something was cleaned. If the child is having guilty feelings about the obsessive thought, they may compulsively tell a parent about it to be sure that they are not a bad person for having the thought. Usually children with OCD have multiple obsessions and compulsions, which often change and evolve as the child matures.

OCD is typically an illness that affects an entire household, even if it’s not obvious that it’s happening. Sometimes parents try to make things easier for their child by cleaning more or making sure they don’t have to touch things that cause them distress. Children with OCD may have disagreements with siblings about how their room has to be arranged, and it might cause great distress if another family member disrupts the rituals. The amount of time spent on dealing with the obsessions and compulsions can impact the quality of life for the family if it disrupts the family schedule.

Pediatric OCD affects around 1-2% of kids. When it occurs in kids, it is slightly more common in boys. Boys also tend to develop the illness a little earlier than girls, but overall the average age that OCD develops in kids is around 9 to 10 years of age. The worries and rituals could slowly develop though and not be diagnosed as OCD for a couple of years because they can be very hard to talk about. OCD does seem to have a hereditary component, especially when it begins in childhood. Kids with OCD are more likely to have a close relative with OCD than kids without the illness.

Occasionally, things begin suddenly after a streptococcus infection, known as rheumatic fever. This is controversial but falls under the category of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS) which includes OCD, tics and a movement disorder known as Sydenham’s chorea. PANDAS is very rare and still heavily debated. But, while there is debate about the diagnosis and treatment of PANDAS, it is worthwhile to consider whether a child’s symptoms began after a strep infection. In some cases of PANDAS, the obsessions and compulsions get worse after future strep infections and may require more careful monitoring during these times.

Kids with OCD are also more likely to have other psychiatric disorders, particularly ADHD and Tourette’s syndrome. The earlier the onset of OCD, the higher the risk is for ADHD and Tourette’s syndrome. OCD is also commonly seen along with other anxiety disorders. Often these kids are anxious to begin with and have more worries in general. The distress associated with the obsessions and compulsions can often cause behavioral issues and may only be recognized because the child begins getting into arguments and fights. The increased stress could lead to depression and even suicidal ideation. Sometimes an autism spectrum disorder (ASD) can appear similar to OCD. Kids with an autism spectrum disorder can have a lot of rituals such as lining things up and difficulty with transitions and things occurring out of routine. The difference usually is that kids with an ASD are happy and gratified while they are doing the rituals, not completing the ritual because of anxiety. ASD children just prefer things to be a certain way. It’s a subtle but important difference.

Initial treatment for obsessive-compulsive disorder is typically a form of psychotherapy known as cognitive behavioral therapy (CBT). Studies have shown that CBT is as effective as medication in the treatment of mild to moderate OCD. CBT is a very specialized form of therapy that focuses on how our thinking affects our behaviors and vice versa. The key to treating OCD with therapy is changing the reaction to the thoughts and stopping the vicious cycles. CBT is the recommended therapy because it teaches the child long term skills for managing the obsessions and compulsions. If the OCD is very distressing or disruptive to the child’s life, medications can be started at the same time as therapy. The FDA has approved clomipramine, fluoxetine (Prozac), sertraline (Zoloft) and fluvoxamine (Luvox) for the treatment of OCD in kids. Similar medications such as citalopram (Celexa) and paroxetine (Paxil) are sometimes used as well. Occasionally the anxiety is so profound that additional medications in the benzodiazepine or atypical antipsychotics are added.

With appropriate treatment, OCD may go away completely. Sometimes symptoms improve with treatment but worsen or return during times of high stress, big life changes or illnesses. Recognizing the symptoms early can help a lot with treating OCD. The most important thing to remember for the child with OCD is that the thoughts that they’re having are normal thoughts. Removing the guilt and shame associated with the obsessions and normalizing the thoughts can go a long way with reducing the power that the thoughts have over the child. Finding a psychotherapist that specializes in CBT is a powerful gift for a child suffering with OCD. Just remember CBT, CBT and more CBT.


Tic Disorders in Children

Tics are quick, repetitive movements of any part of the body including the mouth and vocal cords. They are often described by people as “relatively involuntary” because these movements can often be suppressed but not indefinitely. Often people will feel the tic coming and be able to suppress it temporarily. Most of the time there is a physical or mental urge to complete the tic before it occurs. Tics usually first appear in the face, but not always. They often migrate and spread to other parts of the body and may come and go over time depending on physical and emotional stress.

There are 2 types of tics which can be classified into 4 main disorders. The two types of tics are simple and complex. Simple tics involve one or a few muscle groups and are very brief. Examples of simple tics include eye blinking, shoulder shrugging, grunting, throat clearing, etc. Complex tics, on the other hand, are much more integrated actions. These involve multiple muscle groups and can be very elaborate and in many cases extremely disruptive.

Tics that occur regularly for more than four weeks and up to one year fall into the type of disorder classified as transient tic disorder. Once tics have occurred persistently for one year we further classify the disorder as chronic motor tic disorder, chronic vocal tic disorder or Tourette’s disorder (also known as Tourette Syndrome). As the names suggest, chronic motor tic disorder involves only motor tics (ex: twitching, eye blinking, head bobbing, shoulder shrugging), and chronic vocal tic disorder includes purely vocal tics (ex: grunting, coughing, throat clearing). Vocal tics can also include more complex sounds such as yelling bad words (coprolalia), repeating words (echolalia), or randomly saying nonsense words (palilalia). However, these are much less common. Tourette’s disorder (which I will now call TD) by definition requires at minimum one year of both vocal and motor tics, although the vocal and motor tics do not need to be present at the same exact time.

Tic disorders usually begin between the ages of 2 and 15 years old. The average age when they begin is around 6 years of age. Often symptoms will worsen until around age 10 and then gradually improve. Usually symptoms improve a lot during adolescence. Sometimes, however, symptoms continue into adulthood and are much more chronic. We are not completely sure why, but boys are 3 times more likely to have a tic disorder than girls. Overall, TD affects about 1% of the population at any point in their lives. Studies have definitely shown that tic disorders can run in families and have a genetic component. But, other factors such as anxiety, premature birth, infections, and head injuries can also play a role in the development of tic disorders.

People who develop tic disorders are also at higher risk for other psychiatric conditions. Attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are commonly diagnosed in people who have tic disorders. People with tic disorders are also more likely to have other anxiety disorders, aggressive behaviors, temper outbursts and social struggles. They may also be more prone to developing mood disorders such as depression if they experience bullying or shunning by peers. Occasionally, tic disorders occur suddenly after a bacterial infection. This is rare and controversial, but when it occurs there is typically a quick onset of tics, obsessions and compulsions following a streptococcal infection and is known as Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). Symptoms usually go away with antibiotic treatment for the underlying bacterial infection.

Management of tic disorders can depend a lot on how severe and disruptive the tics are for a person and the family. The goal of treatment for tic disorders is just to reduce the frequency or disruption of tics. Typically the only thing that really takes tics completely away is time. One treatment option is psychotherapy or talk therapy. Talk therapy is usually helpful for many reasons. Sometimes talking about the tics helps suppress the urge to tic. Keeping a log of things that make tics worse or better and discussing this with a therapist can be helpful in managing those things that worsen the tics and encouraging behaviors or activities that make them better. For people who experience urges to complete a tic, a form of therapy called cognitive behavioral therapy can help a person with a tic disorder manage how they respond to the urge to tic and think of alternative behaviors to reduce embarrassing or disruptive tics.

If the tics are disruptive to a person’s life and/or cause social issues, medications may be helpful. Two main classes of medications have been shown to be effective in making tics less frequent and less disruptive. Both types of medications have side effects and as always should be carefully considered with a physician before starting. The first type of medications is known as the antipsychotic medications, although we use them for more than just treating psychosis. These medications act on a chemical in the brain called dopamine. One particular drug in that class of medications, called pimozide, has been studied with positive results in tic disorders and has been given FDA approval for use in patients with TD. Examples of other antipsychotic drugs include risperidone and haloperidol. Another class of medications that we use is called the alpha-2 adrenergic agonists, which includes a drug called clonidine. These medications also affect dopamine in the brain but through a slightly different pathway. It’s important to talk with your physician about the risks and benefits of all treatments before starting a new medication.

The Tourette Syndrome Association has national and local chapters available and is a good resource for patients and families struggling with TD. For more information visit http://www.tsa-usa.org/index.html.


Separation Anxiety Disorder in Children

Children look to their parents for security, guidance, comfort. Braving the world and experiencing things for themselves can be a very scary thing. Separation anxiety is defined as excessive worry or fear experienced by a child when they are separated from a primary caregiver. This is a completely normal situation for infants and toddlers as they begin to explore new boundaries and test their independence. Separation anxiety is considered a normal developmental event between the ages of 6 months and 30 months. It is often at its worst between 13 and 18 months. You may see a toddler playing freely and suddenly running back to a caregiver for reassurance. They are testing their level of comfort with the world.


Usually separation anxiety declines significantly between 3-5 years as children are able to rationalize the reason why they are separated from a caregiver and begin to trust that mom or dad is will really come back to them eventually. Occasionally though, this normal decline in anxiety doesn’t occur. Occasionally separations cause more and more distress and are accompanied by worry that the separation will be forever. There may also be headaches, stomachaches, school refusal and even nightmares about separation. When it causes this much distress beyond about 3 years of age, we would classify that as separation anxiety disorder (SAD).

SAD affects about 3-5% of children and adolescents. It may be slightly more common in girls than boys. In reality, many kids suffer from symptoms of separation anxiety disorder but are never diagnosed because the symptoms aren’t disruptive enough to seek treatment. It typically peaks between the ages of 7 and 9 and is often associated with a stressful life event. One of the key features of SAD as opposed to other anxiety disorders is that children with SAD typically are very content when they are with their primary caregiver. The anxiety is usually only present when they are away from their parent. This is different from generalized anxiety disorder, which is a type of anxiety that lasts all the time regardless of who is nearby. Kids, though, who are diagnosed with SAD are also more likely to have generalized anxiety, specific phobias/fears, ADHD, fear of social situations and even oppositional defiant disorder which can make diagnosis of SAD a little trickier.

There are a lot of theories about how SAD develops. Children with SAD are often more shy and introverted than children without SAD which could lead them to be more uncomfortable with new situations and environments to begin with. Sometimes they tend to cling more to their parents in uncomfortable situations. There may be a history of something bad actually happening to a parent or the child such as a car accident, medical problem, burglary, etc. That can trigger a fear that something will happen again when they are separated. There is also a theory that early in the child’s life the bond between the parent and child is stressed. For instance, if the child spends a lot of time away from his primary caregiver because of an illness, work, foster care, etc. then the usual period of testing the boundaries may be disrupted and lead to insecurity.

There is a hereditary component to SAD. Parents of children with separation anxiety are more likely to have depression, panic attacks and other symptoms of anxiety. So, while anxiety can be hereditary, it can also be something that kids pick up just by being around anxious parents. Different parenting styles may also predispose kids to SAD. For instance, if a parent is hesitant to let their child explore the world it may lead the child to think that the world is unsafe. It’s important for parent s and kids to develop a balance between testing the world and keeping each other protected and safe.

Treatment of SAD depends on the severity of the anxiety. If it is caught early and is not too disruptive to daily life, beginning with therapy can be very effective. One type of therapy called cognitive behavioral therapy (CBT) is heavily researched and most recommended. CBT is a type of talk therapy that is based on the theory that our thoughts affect our emotions and behaviors. For instance, if you’re thinking about a lot of negative things you are more likely to feel down or angry. Or, if you are thinking about all the things that can go wrong you will probably feel more nervous, anxious and scared. CBT is effect in SAD by helping the child break the cycle between worrying about what will happened when they are separated from their caregiver, feeling anxious about the separation and staying near their caregiver.

In true CBT, the key is completing the homework assignments that the therapist gives the family. Assignments usually involve exposing the child to planned separations and giving them techniques to reduce the anxiety during the separations. It’s important for the child to face the very situation that they are worried about and to re-learn that their parent will come back to them. This can be very hard for parents to do as well because of fear that they are causing more anxiety for their child. We would typically start with very short separations and increase the amount of time slowly until they no longer feel anxiety during separation. This particular type of CBT is called exposure therapy. With time, the child experiences less and less anxiety because the cycle is broken when mom and dad keep coming back to them. They slowly stop worrying about what will happen when mom or dad are gone because they do come back.

If kids are really anxious or cannot tolerate the exposure therapy even for short periods of time, adding medication is recommended. The class of medications known as the SSRIs, such as Prozac, Celexa, and Zoloft, are usually the first-line medications. These can be helpful in reducing the overall level of anxiety and improving mood. This particular class of medication does not work overnight and have to be taken daily. Usually some benefits are seen within 2-3 weeks but the full effects are not seen for 4-6 weeks typically. The choice to add medications is very individual and is important to discuss with your physician.

Kids with separation anxiety disorder generally do very well with appropriate treatment. The earlier treatment is sought, the more easily the cycle of worrying can be broken. Most children recovery quickly and do not require long term treatment for the separation anxiety.

What is ADHD?

ADHD is a term thrown around pretty loosely by many people, especially parents, teachers and doctors. The disorder has received a lot of hype in the media, and it may seem like every other child is being diagnosed with it these days. With all the information in magazines and on television, it can be very difficult for parents to know when to seek treatment for their child. So, what is ADHD and what behaviors should you be looking for?

First of all, ADHD stands for Attention Deficit Hyperactivity Disorder. In 1994, the diagnostic guidelines changed slightly, so that only the term ADHD is used, although we now have three subtypes of the disorder depending on specific symptoms. Prior to 1994, the terms ADD and ADHD were used depending on whether the child was hyperactive or not. This change still causes some confusion, so we’ll go into the subtypes a little bit more.

The first subtype is the inattentive subtype. These kids tend to be the quiet kids who are easily distracted. They may be the ones staring out the window during class instead of listening to the teacher. They often daydream or seem to not really be listening when you are speaking directly to them. Often they do not finish their assignments and start many projects that never get finished. These kids also have problems staying organized and frequently lose things like books, pencils, and lunchboxes because they are so easily distracted. Unfortunately, it is this group of kids who are the hardest to diagnose because they are not running around the room causing trouble. Girls tend to fall into this category more often than boys, although that is definitely not written in stone. The second subtype is the hyperactive-impulsive subtype. Usually these kids are easy to spot because they seem to have so much energy. They may fidget or squirm around a lot and seem to really have trouble sitting still. Teachers may complain to parents that they are always getting out of their seat during class and speaking out of turn. They seem to talk endlessly and run around like an Energizer bunny. It can be very difficult to get these kids to participate in quiet time activities like drawing or reading, because they seem to always need to be moving. Kids with hyperactive symptoms are much easier to recognize because they can be quite disruptive. As the saying goes, the squeaky wheel gets the grease!

The third subtype of ADHD is called the combined type. Just as it sounds, this subtype is a combination of the inattentive and hyperactive-impulsive subtypes. So, these children show many characteristics of both types of ADHD. This is the most commonly diagnosed version of the disorder because many kids with the hyperactive traits also have problems with organization and concentration. Boys tend to fall more frequently into the hyperactive-inattentive and combined subtypes than girls, but again this is definitely not always the case.

So, what happens next if a child has any of these symptoms? How do you know for sure if your child has ADHD? If you or your child’s teachers, daycare providers, etc, have any concerns about ADHD the first thing to do is schedule an appointment with either your family doctor or pediatrician. If your child already sees a child psychiatrist or psychologist for another reason, it would also be okay to mention your concerns to them. But, usually the primary care doctor does the initial workup. They will typically have both you and your child’s teachers fill out forms with questions about your child’s behaviors. It is important for the doctor to have both perspectives because sometimes children only have problems at home or only at school and can be a sign that issues other than ADHD may be going on.

Usually your doctor will ask you to bring the completed forms in with you to an appointment. Often the initial visit for possible ADHD is a little bit longer than a normal appointment so that the doctor has time to review the forms and discuss things with you and your child. Just like with any other medical condition, the doctor will want to know many things, like how long the symptoms have been going on, when you notice the symptoms, how often you notice them, etc. There are many rules for diagnosing ADHD that your doctor will be very careful about following, just as with any other disorders like strep throat or ear infections. The doctor may even order some labs to look for things like thyroid disorders and high lead levels since these issues can often cause symptoms similar to ADHD.

If your child’s physician feels that your child does have ADHD, there are many different treatment options that he or she will discuss with you. Usually it does involve a stimulant medication, but there are other options. You can refer to our article on ADHD treatment for more information about these therapies. ADHD can coexist with other disorders such as depression, anxiety, oppositional defiant disorder, among others. So, if you are concerned that there may be more going on than just ADHD it is important to bring this up with your doctor. Often times the family doctor or pediatrician will refer patients to a child and adolescent psychiatrist if your child doesn’t respond well to treatment or if they feel there may be more things going on than just ADHD. So, don’t worry if this happens. It just means that your doctor thinks a specialist could offer a different perspective. Every child with ADHD is different, but it is a treatable condition. It may take a little time to find the right treatment, so be patient and openly discuss your concerns and expectations with the doctor. Having ADHD does not mean that your child will never do well in school. It is important to remember that many children with ADHD grow up to be very intelligent and highly functioning adults.