Pediatrician and adolescent specialist, Dr Anisha Abraham, gives us the following quick guide to depression among children and teens, what you need to look out for, and where to go for help in the Netherlands.
Could Anna be depressed?
Anna (not her real name) is a 12-year-old girl who has been more withdrawn and irritable than usual. She complains of frequent headaches. She refuses to go to her extracurricular activities and spends most of her time in her room alone. Her appetite has dropped. She doesn’t want to see her family or friends. She has recently made a comment on a social media site about not wanting to be around anymore. Her parents are very concerned and want to know what to do. Could Anna be depressed?
The answer is yes. Although Dutch children have been labelled among the happiest in the world, depression is still an issue facing young people here. In fact, the Dutch government recently started a campaign called “Hey, it’s okay”’ to talk about depression, especially aimed at youth. According to the World Health Organization, depression is the third leading cause of illness among adolescents globally, and suicide is the third leading cause of death in older teens. The good news is there is a lot that parents and caregivers can do to help prevent depression and give aid to struggling young people.
Anna has been more irritable and refuses to spend time with her family. Of course, young people can have mood swings as part of their normal development and want time alone. Mood swings can increase during the teen years when kids experience hormonal fluctuations and pubertal changes. However, Anna seems to have also withdrawn from her usual activities and friends. This and her comment on a social media site that she did not want to live should be taken seriously as a cry for help. What’s important to know is that depression can manifest itself differently among kids compared to adults.
What is depression?
According to The Center for Young Women's Health at Boston Children's Hospital, depression is a constant low mood that affects behaviors, thoughts, and well-being. Depression may also lead to physical problems, such as difficulties sleeping, eating, or concentrating. As is the case with Anna and her frequent headaches, depression may also show as non-specific aches and pains. In severe cases, a child may feel that life is not worth living and be at risk for suicide. While it’s normal for kids to feel sad or down occasionally, it is concerning if your child shows some or all of the following warning signs consistently for two or more weeks. He or she could be depressed.
Warning signs include:
- Sadness or hopelessness
- Irritability, anger, or hostility
- Withdrawal from friends and family
- Tearfulness or frequent crying
- Poor school performance
- Loss of interest in activities
- Changes in eating and sleeping habit
- Fatigue or lack of energy
- Unexplained aches and pains
- Difficulty concentrating
- Thoughts of death or suicide
What causes depression?
Depression is likely related to a number of factors. I often ask my young patients about a family history of depression, conflict among family members, or significant family transition or change (which happen often among expat families). I also ask if there is any history of being picked on, bullied, or abused; a recent change in friendships; or any difficulties with academics. Finally, having a medical or mental health condition such as ADHD, anxiety, obesity, or diabetes can put some kids at higher risk.
What happens if depression goes untreated?
Without adequate support and early treatment, depression can lead to more serious issues. Youngsters turn to a variety of negative behaviors to escape feelings of sadness or frustration, including excessive video game playing and internet use, and unhealthy use of social media. Excessive screen time may also exacerbate feelings of isolation and depression. Binge drinking and drug use may be used to self-medicate mood-related issues.
Can depression be associated with other mental health concerns?
Depression can be associated with poor body image, eating disorders, and self-injury. I routinely ask my patients about cutting and suicidal behavior, as the number of young people engaging in these practices is on the rise. Parents should know they are not increasing the likelihood of their children self-injuring simply by asking about it. To the contrary, it may be an important opportunity to get help early.
What are some treatments for depression?
No doubt, mental health issues, such as depression, can have a tremendous impact on kids and family. However, there are many things, you as a parent or adult can do to help.
The first step is to ask your child or teen if they are feeling down or depressed, or have thought of hurting themselves. Choose a safe place to talk, such as at the dining table, and let your child know what you have seen and why you are concerned. Ask your child to share what he or she is feeling, and get ready to listen without interrupting (see further strategies below).
If your child shows some or all of the following warning signs consistently for two or more weeks, he or she could be depressed.
If they are feeling sad or depressed, the next step is to consider getting counseling. Counseling may be provided through school counselors, social workers, psychologists, or psychiatrists. Counseling can help kids to understand their feelings and develop strategies for coping.
In the Netherlands, it is common for a child to be seen by their huisarts (primary care doctor) for a referral for counseling and to rule out any physical causes for change in mood. The huisarts may, in turn, refer a child or teen to the Parent and Child Team (OKT), Community Health Services (GGD), Arkin Institute for Mental Health, or other specialized organisations for further evaluation. As wait times can vary, it is important to have regular follow-up with your huisarts, particularly if the level of depression increases.
It is also vital that your child or teen feel comfortable with their mental health provider. Having an open discussion with your huisarts about your child’s needs, language of choice, specific diagnosis, etc, can be helpful in finding the right provider. Some parents may choose to use the private system, and find a provider directly, without a referral. Although the wait time may be reduced, and this may allow for more autonomy, parents will need to pay out-of-pocket for such services, which can be quite expensive over time.
Counseling, such as cognitive behavioral therapy, is often a good initial treatment for mild to moderate cases of depression. In some cases, if depression doesn’t resolve with ongoing counseling, a trial of medication, alongside therapy, may be warranted. In severe cases, day treatment or inpatient care may be necessary. Of note, if your child or teen is actively considering suicide, they need immediate intervention by a mental health provider (or to be taken to the nearest emergency room).
Additional strategies to consider:
Trust your gut: Be aware of your child’s body language, comments, and other subtle clues to changes in mood and behavior. Kids may not always disclose issues to parents. Concerns voiced by peers or comments posted by your child on social media may also be important signs of a problem. If you suspect there might something wrong, then trust your instinct, and talk to your child openly.
Validate emotions and acknowledge strengths: Simply acknowledging your child’s sadness is key to making him or her feel understood and validated. To booster resilience, take time to talk about the activities they are doing well in, such as the arts or sports.
Increase personal and family time: Studies have shown that when families spend more time together, such as during meals, kids do better emotionally. Communicate daily with your kids. Listen. Talk to them about their school life and activities and how they are handling problems and making decisions. Setting aside time every day to talk and connect meaningfully with your child may go a long way to addressing (and preventing) depression.
Get kids connected: As with the case of Anna, kids who are depressed may pull back from friends and activities that they used to enjoy. Encourage them to reconnect. Help facilitate positive activities that will allow them to be with people they enjoy.
Eat well: Research has shown that there is a very strong link between mental and physical health. Unfortunately, young people are often prone to eating lots of convenience food. As a parent, you can help by encouraging healthy behaviors at home. Make sure your child is getting the nutrition they need for optimum brain health - eating lots of healthy fats, fruits and veggies, and protein. Avoid highly processed or sugary foods, which may cause rapid changes in energy level and mood.
Ensure adequate sleep: Studies show that kids today are simply not getting enough sleep. Many of my teen patients confide they are up very late, usually on the internet. Interestingly, kids who turn to electronic diversions such as TV and the internet to help them de-stress may end up being over-stimulated and have difficulty with sleep or even, over time, with weight management. Help your youngster by making sure they get enough rest.
Get active: Exercise produces chemicals that provide a feeling of well-being and help counteract stress. Parents should try to limit “screen time,” i.e., use of television, videos, and computer games, and increase the amount of outdoor and physical activities. Take walks, hike, or bike together as a family.
Volunteer in the community: Another meaningful and creative way to be active is to find volunteer or community service activities. In fact, helping others in need can serve as a very strong antidepressant, and can boost a child’s (and adult’s) mood.
Explore alternative methods of handling mood: Breathing and stretching techniques in yoga help relax muscles and release tension. There has been increasing awareness regarding the benefits of meditation and mindfulness to help kids develop resilience and prevent depression. For older kids who are more literate, encourage them to write, or journal, to express their mood.
Young people face innumerable pressures these days. It is not unusual for kids to experience occasional sadness or mood swings, particularly as they enter puberty. However, persistent irritability, sadness, complaints of pain, lack of interest in usual activities, and/or increase in alcohol or drug use may indicate depression, which can impact every aspect of a child’s (and their family’s) life. The good news is that there are clear strategies and resources available for parents in the Netherlands to help prevent and address depression and to ensure that their child gets back on track.
Dr Anisha Abraham, MD, MPH, FAAP is a pediatrician with a specialty in adolescent medicine. Anisha is currently on faculty in the Department of Pediatrics at the University of Amsterdam and at Georgetown University Hospital in Washington, D.C. She also serves as a consultant in schools, helping coach teens to promote healthy behaviors and develop resilience. Anisha lives in Amsterdam and is married with two boys.