Pediatric Depression

What is Depression?

Depression is a mood disorder, meaning that it negatively affects a person’s mood. It impacts how a person thinks, feels, and performs their daily activities. People with depression may go through prolonged episodes of hopelessness, sadness or excessive fatigue. Depression can affect any person of any race, gender, sex, age, income, and background.

Depression can present itself in many different ways. The most common form is major depression disorder, which can come in episodes and happen often. For a proper diagnosis of major depression disorder, the symptoms must be present for at least two weeks. However, if there is a safety concern for your child, please seek help immediately.

At what age can it develop?

Depression usually develops after age 10, but can occur sooner. 

How common is it?

Depression is seen in about 3%-8% of children in the United States. Younger children tend to not develop depression unless a traumatic or stressful experience occurs, but that isn’t always the case. Adolescents are more likely to develop major depressive disorder than younger children, so it’s important to know the signs that it might start to develop.

How is it diagnosed?

Depression is diagnosed if symptoms (listed below) last for two weeks or more. If you are noticing many of these symptoms in your child, schedule a visit, and we can do a screening for depression right here in the clinic. At our practice, we utilize screening tools such as the PHQ-9

Signs and Symptoms

Signs and Symptoms in children: (Keep in mind symptoms vary for each child and you don’t need to have all these symptoms to have depression)

  • Persistent feelings of sadness
  • Hopelessness
  • Irritability, anger
  • Fatigue and low energy
  • Increased emotional sensitivity
  • Changes in sleep patterns (more or less sleep)
  • Changes in eating patterns ( too much or too little)
  • Chronic physical issues such as pain, stomach aches, unusual rashes, even acute acne
  • Acting out 
  • Hiding in their room for long periods of time
  • Refusing to go to school or getting in trouble at school
  • Inability to have fun, mainly doing activities they once thought were fun
  • Difficulty focusing and remembering information
  • Thoughts of death or suicide.

What are the causes?

Sometimes there is no obvious “trigger” or “cause” for depression, however in most cases there are factors that contribute to developing depression. In children, these include: 

  • Family problems
  • School problems 
  • Bullying 
  • Feeling isolated, being excluded or having trouble fitting in (This is particularly harmful if you are excluded by others because of your race, religion, gender identity, or sexual orientation)
  • Loss of a loved one (through any cause, including death, incarceration, divorce, break up, etc) 
  • A traumatic experience (this can be an emotionally traumatic experience, or a physical or sexual assault)
  • Alcohol or drug use
  • Medications (some medications have depression as a side effect)
  • Other mental illnesses (like anxiety) are associated with depression
  • Family history of depression

How is it treated?

Talk therapy is recommended for anyone experiencing depression. They can help identify things in your life that are making the depression worse. In addition they can help you develop coping skills. 

For patients with moderate to severe depression we usually recommend medications (antidepressants). These can help balance the chemicals in the person’s brain to help them come out of their depressive episode.

Activities known to release chemicals such as dopamine, endorphins, and serotonin, all chemicals that tell the brain and body to be happy and can help with depression. These include:

  • going outside and exercising
  • meeting up with friends and family.

What if I don’t want to give medications to my child? 

We will always respect the parent’s decision about treatment. The decision to start medication is made by the parent. We will support you in making the decision that is right for you. Please know, however, that medications can work very well, especially when combined with talk therapy and stress reduction. 

What are the most common types of antidepressants?

 Fluoxetine (Prozac) and Sertraline (Zoloft) are the most common antidepressants that we have used. We use these because these medications have been around for a very long time and are quite safe. 

This is not to say there aren’t other kinds of antidepressants on the market. There are many out there that your medical provider might prescribe. It’s important to remember that not all people have the same reactions or results to the medication(s), which is why everyone has a different prescription. 

Every child is different, and as such, not every type of medication is going to be the best fit for them. Because of this, it might take a few months to sort out the correct medication type and dose properly. Your provider will ask that you come back every couple of weeks to check in about the dosing and how your child handles the medication, and to see if there needs to be any adjustments. 

Common side effects of antidepressants

Side effects will vary depending on the type of medication you are prescribed. 

Trouble sleeping, skin rashes, headaches, joint and muscle pain, upset stomach, nausea, or diarrhea are all common side effects or the typical antidepressants. The reactions may be mild, temporary, or both. If side effects are severe, your doctor will work with you and your child to figure out the next steps. Usually this includes changing the medication dose, switching medications, or stopping medications completely. 

How long will my child be on antidepressants?

Every child and every adult has a different diagnosis and needs different prescriptions, and will have a different experience on medication. Some people are on for a shorter amount of time than others, and some people are on antidepressants for the rest of their lives.

If my child is feeling better, can they stop taking the medications?

Only discontinue use with a medical provider’s approval. Please do not abruptly stop taking medication or you could have serious side effects. In many cases it is best to slowly lower your dose before stopping completely.  Have an open conversation with your provider so that they can help you get the care you need. 

How will we know if the medication is working?

Your child should begin to feel better in 1-2 months. If you and your child don’t notice a difference, talk to your provider. If we are prescribing medication to your child we will be meeting with you and your child regularly to discuss effectiveness. 

What are some alternative treatments?

Many people look to alternative treatments instead of medication. We will always recommend talk therapy for your child and will help find a clinician or organization that meets your family’s needs. For other non-medication treatments, the best are to get more exercise, better sleep and stress reduction. 

What happens if depression is left untreated?

When left untreated, people tend to engage in risky behavior such as substance abuse and alcohol addiction. Untreated depression can ruin relationships and interfere with work performance, which can cause someone to do worse in school or at work. More dangerous behaviors can include self-harm and/or suicidal thoughts or actions. 

What are the symptoms that my child is having suicidal thoughts?

If suicidal thoughts or actions are presented, call emergency services immediately or take your child to the nearest emergency room or crisis center (3300 Henry Avenue, Falls Two Building, 3rd Floor , Philadelphia PA 19129) or call the crisis hotline at 215-685-6440 or 1-800-273-8255.

There are warning signs of suicide, and it’s essential that you recognize them:

  • Talking about wanting to die or to kill oneself;
  • Looking for a way to kill oneself;
  • Talking about feeling hopeless or having no purpose;
  • Talking about feeling trapped or in unbearable pain;
  • Talking about being a burden to others;
  • Increasing the use of alcohol or drugs;
  • Acting anxious, agitated, or reckless;
  • Sleeping too little or too much;
  • Withdrawing or feeling isolated;
  • Showing rage or talking about seeking revenge; and
  • Displaying extreme mood swings.

How do I talk to my child about depression?

You can start by reassuring your child that this is nothing to be embarrassed about or ashamed about; it happens to anyone at any time. You can talk about what the next steps are depending on where you are in the process. The most important part is that you are a support system for them because depression is scary, but it doesn’t have to be overwhelming. The first step is reaching out for help.

Isn’t it typical for kids/teenagers to feel down and upset? How do I know if my child is just “down” or if it is depression? 

Kids and teenagers are under a lot of stress from many areas of their lives: social networking (making and retaining friendships and relationships); emotional control (staying level-headed throughout work and school); expectations (school grades, work obligations, etc.) and more. So yes, they will feel down and upset occasionally when things don’t work out. However, if they’re feeling down and upset constantly and for an extended period of time, that could be an indicator for depression. Especially if they have experienced trauma, loss, or other significant life event. 

How do I talk to my child(ren) about suicide? (Adapted from the Society for the Prevention of Teen Suicide)

It’s a scary subject to bring up, much less to even think about. But that doesn’t mean it’s not an important one. In fact, we think it’s just as important to check in with your child frequently to see how they are feeling. We have a few tips and steps to help you talk to your child about suicide.

  • Find a good time when you have your child’s full attention. The less distractions, the better. 
  • Think about what you want to say before you meet with your child. Keep the language you use to their level (ex. An eight-year-old vocabulary probably doesn’t include medical terms or the full understanding of some of the words that an adult uses)
    • Having a reference point is a good way to bring up the topic. 
      • “I was reading an article the other day…”
  • If this isn’t a topic that makes you feel comfortable, let your child know. This establishes that you are both on the same level of comfort. 
    • “I think that this is an important conversation to have, but that doesn’t mean it’s an easy or even comfortable one for you or for me.”
  • Ask your child directly about suicide. Don’t beat around the bush, or leave room for misinterpretations or miscommunications.
    • “Have you ever had suicidal thoughts?”
    • “Have any of your friends talked about it?”
  • If your child tries to brush off the conversation, talk about why it’s an important conversation to have, and any experiences you or someone you know (without naming names) have had or are currently experiencing.
  • Listen to what your child has to say. Let your questions be answered and consider what they say, without interruption. 
  • If something they say worries you or alerts you, bring it up calmly.
    • “You’ve brought something up, and if it’s okay with you, I’d like to explore it with you more.”
  • Any previous thoughts of suicide should be revisited, even if it was a long time ago.
  • Ask about the problem that caused suicidal thoughts or behavior. 
  • Form a plan, and check in often. 

**Note, this might not work for every child, as everyone is different and reacts differently to these conversations. Use this template as a starting place and then tailor it to your child’s personality and life. 

Are there organizations to help me learn about depression?

Yes indeed! Online resources are listed below:

Physical Organizations and Support Groups

*Physical Illness

  • Sometimes depression could be the result of a chronic medical condition. It’s very unlikely to happen, but for certain medical situations, depression can occur. 

Other resources

We assess for depression using the PHQ-9 tool. Feel free to complete this assessment and bring it to the office during your child’s visit, if you are concerned your child might be depressed. We will talk to you and your child about how they have been feeling, and we can help figure out the best treatment for your child.

PHQ-9 PDF link

https://adaa.org/understanding-anxiety/depression  – ADAA has helpful information on depression, including symptoms, different types of depression, and where to find help.

http://www.mentalhealthamerica.net/conditions/depression-teens – Mental Health America has a helpful resource about depression in teens, how to recognize the symptoms of depression as well as suicide, and how a parent can help.   

Crisis Text Line https://www.crisistextline.org/ Text your concerns to 741-741. A trained crisis counselor will respond and have a text-based conversation with you.

Suicide Hotline– Call 1-800-273-8255 for resources for you or your loved one, if you are concerned about suicide.

Mobile Crisis – In Philadelphia, if you are worried your child is having behaviors you cannot control, you can call the Philadelphia Crisis Line, which provides telephonic support, or can send out a Mobile Crisis team. Call 215-685-6440, 24 hours/7 days per week.Crisis Center – If your child is experiencing emotions or behaviors that may cause a life-threatening injury to him/herself or others, you can take your child to Philadelphia’s Children’s Crisis Response Center, at 3300 Henry Avenue, Falls Two Building, 3rd Floor, Philadelphia PA, 19129; 215-878-2600, 24 hours/7 days per week.

Spotlight On

Karam Mounzer, MD

Dr. Mounzer identified two major gaps in the care of patients with HIV/hepatitis C (HCV) co-infection, and the complexity of multidrug-resistant HIV treatment. He is involved with many clinical trials focusing on drug development and better understanding of HIV immunopathogenesis with the Wistar Institute. He is involved in teaching and mentoring.

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Dr. Karam Mounzer

Dr. Mario Cruz

Dr. Mario CruzDr. Cruz is a board certified pediatrician who serves as the Medical Director for our Pediatrics and Adolescent Health Center. He has presented and/or published in the fields of community violence and domestic violence prevention, quality improvement, behavioral health, curriculum development and mentorship. In 2019 he received the Greater Philadelphia Social Innovation Award for Innovations in Healthcare.


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