Major Depressive Disorder is defined by sad or irritable mood or loss of pleasure in things one used to find interesting, accompanied by a number of the following symptoms: inability to focus, thoughts of worthlessness, withdrawal, thoughts of death, poor sleep (too little or too much) and poor diet (over or under eating). These symptoms must be observable and cause clinically significant distress that impacts functioning.
The current Diagnostic and Statistical Manual (DSM-5) classifies Major Depressive Disorder under the category of Depressive Disorders, and Bipolar Mood Disorders are classified in a separate section.
In children, depression may often be marked by irritability. Children may be less able to define their own symptoms. They may have trouble talking about their feelings or may deny them entirely. In children, depression can be defined by irritable mood, loss of interest in activities and by considering parent and teacher reports of these and other depressive symptoms. Glaring symptoms include frequent thoughts of death and suicidal ideation. Large meltdowns that seem way more intense than you would expect may be related to depression.
Sad. Feelings of sadness. OR
Irritable Mood. May seem angry, frustrated, have a short temper, and cry easily.
Loss of Pleasure. Less interest or participation in activities the child used to enjoy.
Inability to focus. Seeming unable to focus on anything. May seem lethargic or spacey.
Thoughts of worthlessness. Your child may make a lot of negative self-statements. “I’m not good enough.” “Everyone else can do that but I can’t.” “I never do anything right.”
Withdrawal. Your child may stop spending time with friends or family and may spend all his or her time quietly in a bedroom. Playdates and interest in others may decrease.
Thoughts of death/ suicidal. May report wishing he or she had not been born, may discuss life without him or her, and may try to give away treasured possessions. May express a desire to hurt him or herself and may share a plan. Be open to listening to your child, and hear his or her feelings instead of saying not to feel that way. Seek support immediately, and make sure no weapons or other dangerous opportunities are available. Keep close supervision of your child.
Poor eating. May not be interested in eating or may eat excessively with a focus on carbohydrates.
Poor sleep. May not be able to sleep or may sleep all the time, generally a disruption in typical sleep patterns.
Cognitive Behavioral Therapy (CBT). Cognitive Behavioral Therapy is a modality with considerable research to support its effectiveness. With depression, often strategies can be taught and practiced in a setting that may be time limited. Eight to 10 sessions may be sufficient in building some of these skills. This therapy is often individual but may also be delivered in a group setting. Some goals of CBT include the following:
Increase Emotional Awareness. Activities to help your child recognize emotions may include drawing emotion faces, role playing and acting out different emotions, and recognizing them in the therapist. If CBT is offered in a group setting, practice recognizing emotions occurs through engagement with group members. Practice recognizing emotions at home, starting with positive ones and moving to sadness, worry, and other negative emotions. Journaling and completing homework assignments related to the emotional awareness goals can help some children remember and practice their skills at home
Improve Coping Skills. CBT often teaches and helps kids identify and practice coping skills, such as deep breathing, relaxation, reading, listening to music, taking a walk, jumping on the trampoline, or talking to a friend. Children learn to stop and identify their feelings and to take a break instead of yelling or hitting. They work with a therapist to recognize the antecedents, behaviors, and consequences associated with their thoughts and feelings.
Work to improve self-confidence. CBT focuses on identifying thoughts that lead to certain behaviors and determining whether those thoughts are valid or whether they are cognitive distortions. Children learn to combat negative thoughts and to see actions and experiences not as global and uncontrollable but as singular instances and under a child’s control.
Mindfulness. Mindfulness involves recognizing and accepting feelings and allowing them to just be. This practice involves scanning the body to notice any tension and working to let that tension go. Awareness of the present time and accepting thoughts and feelings are important in Mindfulness.
Relaxation and Meditation. Breathing and relaxation are encouraged in mindfulness and can make a big difference in reducing anxiety and the presence of negative, distorted thoughts.
Accepting Thoughts. Mindfulness focuses on acceptance and not on the immediate push to change and criticize ourselves.
Play Therapy. For young children, play therapy utilizes toys and art to allow a child a safe setting to act out their feelings and experiences. Guided play therapy can introduce coping skills and emotional awareness into the play themes.
Many tests and measures may be part of a psychological evaluation to determine whether depression is a relevant diagnosis. This evaluation can be challenging with children who are sometimes less able to report on their symptoms directly.
Projectives. Questions, open-ended sentences, and drawing tasks can allow a child to express their emotions and experiences indirectly. Themes can emerge related to sadness or rejection, and some insight may be derived from the collection of these measures.
Story Telling. Tests like the Roberts or TAT involve presenting story cards to an individual and having him or her tell a story about the vague card. Again, themes and emotional content are noted as well as the support of self and support from others.
Rating Scales. Sometimes it is easier for children to express feelings by answering questions. Parents and teachers can also complete questionnaires to provide a sense of how each child appears and performs in different settings. This feedback adds to the data because an evaluation is conducted in one setting that is not natural to the individual.
Play observation. Watching a child play with toys can provide insight into their feelings of sadness by attending to themes introduced by the child.
Observation during testing. Looking for depressed mood, sad facial affect, slow processing, verbal fluency, body language and noting interactions with examiners can provide insight into depression.
Executive functioning and processing speed measures. Often, depressed individuals have diminished performance on tasks. A child tested during a depressive episode is likely to process slowly and to have difficulty with executive functioning skills, such as planning, problem-solving, and attention. A year later, after treatment, some of these areas may be vastly improved.
WHERE TO GO FOR HELP WITH DEPRESSION
A referral for a comprehensive neuropsychological evaluation may be warranted to confirm depression and to better understand your child’s strengths and weaknesses. This type of assessment includes evaluations of your child’s cognitive ability, adaptive skills, language skills, social skills, mood and anxiety. Other areas may be evaluated as concerns arise. Referrals may include Applied Behavior Analysis (ABA) therapy, Psychotherapy, group therapy, parent consultations, and an Individualized Educational Plan (IEP) or a Section 504 plan.
Psychotherapy. Psychotherapy occurs in an office with a psychologist or therapist and is often focused on improving emotional awareness, coping skills, and restructuring negative thoughts. The psychotherapy modality that has the most research for treating depression is cognitive behavioral therapy (CBT). Other modalities that may be helpful include play therapy (for young children) and mindfulness, which teaches awareness of emotions, acceptance, relaxation and meditation.
Parent Consult. Parent consultation can follow a CBT or a Family Systems model and can provide guidance to parents on strategies to use to hear and support their child and to help them feel understood. It also may focus on principles of reinforcement by noting that punishment is not effective for depressed children. Consultation can also focus on the parent’s experience and emotional well-being.
School Services. School-based supports, such as an IEP or a Section 504 plan, can help your child receive accommodations and modifications that they may require to access learning in the classroom setting. Taking a comprehensive neuropsychological report to any of these professionals will help them to get an understanding of your child. It will be important to think about how these therapies fit together and about how different skills are being built and addressed to best support your child. Emotional disabilities, such as depression, can impact school performance and social skills. Individual meetings with the school counselor or school psychologist may provide emotional support, assignment of a peer buddy or mentor at school can help as positive event scheduling, and a lunch bunch or social group may also help build peer support. In order to write a formal plan, your school team will need to find an educational impact of the depressive symptoms in some aspect of your child’s education. It may be easier to obtain support through a Section 504 plan if your child’s grades and test scores are not at all impacted. A 504 Plan requires a medical condition that impacts functioning, but academics and test scores need not be directly impacted. An IEP is a more detailed document that does require clear educational impact of symptoms. In addition to emotional supports, goals in an IEP would also address challenges in reading, writing, math or communication. Ask your school about both an IEP and a 504 to determine which plan would best serve your child.
Psychiatrist. Sometimes children with depression do take medication prescribed by a psychiatrist. Usually, this medication is to treat low mood and to increase serotonin in the brain. Medications can be quite effective for these symptoms. Keep your pediatrician in the loop about your child’s mental health, and request a referral to a child psychiatrist to learn more about the benefits and side effects of medication.
Depression is a common diagnosis and can be treated. Taken together, it is valuable to obtain a diagnosis and to engage in the appropriate therapies as early as is feasible. With these supports in place, it is possible to see improvement in depressive symptoms, better coping skills and emotional awareness, and the potential to live a happy life.
 Beck, Judith S. & Beck, Aaron T. (1995). Cognitive behavior therapy, 2nd edition: Basics and beyond.
 Knaus, William & Ellis, Albert (2012). The cognitive behavioral workbook for depression: A step-by-step program.
 Seligman, Martin E.P. (1995). The optimistic child: A revolutionary program that safeguards children against depression and builds lifelong resilience.
 Huebner, Dawn (2006). What to do when you grumble too much (A kid’s guide to overcoming negativity).
 Emberley, Ed & Miranda, Anne (1997). Glad monster, sad monster.
 Curtis, Jamie Lee (2007). Today I feel silly.
 Cain, Janan (2000). The way I feel.
 Lichtenheld, Tom (2007). What are you so grumpy about?
 Eastman, P.D. (2003). Big dog…little dog.