All My Children

A persistent sad or negative mood

Most parents may at some point, if not frequently, complain that their teenager has a “lousy attitude.” It isn’t at all unusual for adolescents to experience emotions and mood swings that seem out of proportion to the circumstances. But the depressed child or teenager seems to be in a perpetual slump.

Unfortunately, you won’t hear a young person say, “In case you haven’t noticed, I’ve been depressed for the past several weeks.” Instead, you may see any of a number of the following signals that would appear disconnected:

• Continued overt sadness or moping, which may be accompanied by frequent episodes of crying.
• A loss of enthusiasm or interest in things that were once favorite activities.

• Increasing withdrawal and isolation from family and friends.

• Poor school performance: plummeting grades, loss of interest in schoolwork, and frequent absences.
• Outbursts of anger, arguing, disrespectful comments, or blatant hostility toward everyone at home.

• Repeated complaints about being bored or tired.

• Overt acting out: drug or alcohol use, running away, sexual activity, fighting, vandalism, or other antisocial activity.

This does not mean, of course, that all negative attitudes and actions are manifestations of depression. But a component of appropriate parental corrective action should be a willingness to entertain this possibility when a child or adolescent displays an unexpected and persistent disturbance in behavior.

Painful thoughts

If we compare depression to a very long, sad song, the mood disturbance just described is the mournful or agitated music. But accompanying the unhappy melody are painful lyrics—words that express, over and over again, a view of life that is anything but upbeat.

People who have experienced both depression and bodily injuries (for example, a major fracture) usually will confirm that physical pain is easier to manage than emotional pain. Usually one can expect physical pain to resolve or at least become tolerable. But no such hopeful expectation accompanies painful thoughts, which can roll into the mind like waves from an ocean that extends to a limitless, bleak horizon.

Painful thoughts, like a disturbed mood, can have several manifestations:

• Relentless introspection. Adolescents tend to be highly self-conscious during the normal (and necessary) process of establishing their identity during their transition into adulthood. But depression magnifies and warps this natural introspection into a mental inquisition. The inward gaze not only becomes a relentless stare, but it focuses exclusively on shortcomings. It can also move into some dangerous territory: “Wouldn’t I and everyone else be better off if I weren’t here? Why does it matter at this point whether I live or die?”

• Negative self-concept. Physical appearance, intelligence, competence, acceptance, and general worth are all subject to relentless and exaggerated criticism. This is not a healthy examination of areas that need improvement, nor repentance for wrongdoing that might lead to improvements in attitude and behavior. Instead, unrealistic self-reproach for whatever isn’t going well in life—or, at the opposite extreme, spreading blame to everyone else—is likely to dominate a depressed child’s or adolescent’s thoughts and interfere with positive changes.

A depressed teenager slumps into a lunchroom chair and moans, “I’m fat. I’m never gonna get a date. I’m stupid. I’ll never pass algebra. I feel miserable. I’m never going to feel good again.” Her friends, if they bother to hang around and listen to this litany of woe, may argue with her. “You’re not stupid. Stop talking that way.” If she persists in her lament, they may become fed up and agree with her, if only to end her complaints: “Okay, so you’re fat and stupid. C’mon, we’re gonna be late for class.” Her parents might unwittingly make a similar mistake in trying to bolster her spirits: “What are you talking about? You look fine to us, and you’re smart. That’s enough of this negative talk!” Such responses only build feelings of rejection and a conviction that “no one understands me.”

This state of affairs will be drastically worsened for those who have been subjected to emotional, physical, or sexual abuse during childhood or adolescence. Whether these assaults attack the heart (”You’re so stupid!” “Why can’t you be like ?”) or the body, they create a sense of worthlessness that supplies powerful fuel for an ongoing depression.

• Anxiety. Persistent worry, whether focused on a specific issue or a free floating apprehension that encompasses most daily activities, frequently accompanies depression. While a modest level of concern is not only normal but in fact necessary to motivate appropriate precautions for everyday activities, the anxiety associated with depression is disabling and actually interferes with effective responses to life’s challenges.

• Hopelessness. This is particularly troublesome for children and adolescents, not only because they may feel emotions so strongly, but also because they haven’t lived long enough to understand the ebb and flow of life’s problems and pleasures. Most adults facing a crisis will think back to the last twenty-seven crises they have already lived through and will have gained enough perspective to know that this current trial will probably pass as well. But when young people collide with a crisis (or at least what appears to be one from their perspective), they usually have far fewer experiences with which to compare it and a limited fund of responses. If they can’t see a satisfactory route past the current problem, it is no wonder they might begin to think that their “life is over” or “not worth living.” This dark view of life isn’t helped by some powerful voices in adolescent

popular culture (especially in music) that focus on rage, alienation, despair, and death.

Physical symptoms

No emotional event occurs without the body participating, and it should come as little surprise that physical symptoms accompany depression. Common problems include:

• Insomnia and other sleep disturbances. Difficulty falling asleep at night, awakening too early in the morning, and fitful sleep in between are very common in depressed individuals. This may be accompanied by a desire to sleep during the day. Some have hypersomnia (sleeping for excessively long periods of time), in which sleep seems to serve as an escape from the misery of waking hours. An important sign that depression is improving is the normalization of sleeping patterns.

• Appetite changes. Loss of appetite and weight or nonstop hunger and weight gain are not uncommon during depression. Such changes can complicate an adolescent’s normal concerns about appearance.

• Physiological problems. Depressed individuals often have a variety of physical complaints. Fatigue is almost universally present. Headaches, dizziness, nausea, abdominal cramps, episodes of shortness of breath, and heart palpitations are not at all unusual. Sometimes poor concentration, unusual pain patterns, or altered sensations in various parts of the body will raise concerns about a serious medical disorder. Very often an evaluation for an assortment of symptoms will uncover no evidence of an underlying disease but will lead an attentive physician to suspect depression. The absence of a serious diagnosis may bring a sigh of relief to a young patient (and most certainly to his parents) but can also cause dismay. “Are you saying all of this is in my (my child’s) head?” is a typical response. In fact, the symptoms are very real and a predictable component of depression. When depression improves with treatment, so do the physical symptoms.

Delusional thinking

Very rarely, a severe case of depression will also involve delusional thinking, in which the individual’s beliefs and sensory experiences do not match with reality. He may hear voices or have hallucinations. He might believe that others are trying to harm him or entertain grandiose ideas about his identity or purpose in life. This is not merely a depression but a psychosis, a serious disorder of neurochemical function in the brain that must be treated with appropriate medication. (Hospitalization is often required at the outset.) Many psychotic individuals require lifelong medication to prevent a relapse.

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