It’s 3.30 pm and ten-year old Aaron’s mum is waiting for him at the school gate. She sees him coming out – dragging his feet and looking miserable. One of his friends, Jason, asks if he wants to come and play – Aaron mumbles, "No". He gets into the car and snaps at his mum when she asks how his day was. They drive home in silence as he stares out of the window. When she asks him to put away his bag and his lunchbox, he gives her a withering look and leaves the task undone. He goes to his room and doesn’t even stop to forage in the cupboard for something to eat.  His mum thinks that this pattern of low mood, general disinterest in the activities he used to enjoy, withdrawal from his friends, decreased appetite, irritability (particularly in the afternoons) and disobedience has been evident for some months. She wonders whether she should call her doctor.
In the last fifteen to twenty years, there has been an acceptance of the research findings that suggest that children as young as five or six may become clinically depressed. Clinical depression is not the same thing as the feeling of being temporarily unhappy after a loss of some kind, like moving away from an old neighbourhood, or having an argument with a friend.  Major losses such as a death in the family or parental separation may produce profound unhappiness for a while, but not necessarily result in clinical depression. Clinical depression manifests as a significant change in the child’s functioning over an extended period of time – both at home and in other environments. Teachers may notice a drop in academic and sporting performance, restlessness and complaints of headache or tummy ache, a deterioration in social functioning, and being absent from school more than usual. Parents may notice the changes described in the story of Aaron at the beginning of this article.
What is important to note is that, although children with depression present the same kinds of symptoms as depressed adults, the predominant symptoms may differ. For example, depressed children may commonly display physical complaints (like sore tummy or headache) and irritability, while adults may more commonly display eating and sleeping disturbances, and feelings of guilt and worthlessness. Children who are at risk for the development of depression include those with a biological parent who suffers from depression, those who suffer from longstanding anxiety, learning problems or ADHD, and those with chronic medical problems. Preadolescent boys and girls have similar rates of depression – this is in contrast to adolescent and adult rates where females outnumber males. Some research reports that up to five percent of preadolescent children in the general population meet criteria for a depressive disorder.
The research on the treatment of mild to moderate depression suggests that individually based cognitive behavior therapy is effective for the treatment of children and adolescents with depression. However, the problems associated with depression such as social and problem-solving difficulties also need to be addressed in order for the gains to be maintained. Children who are severely depressed may need medication to help them recover enough to engage in the psychotherapy described here.
Cognitive behavior therapy helps people understand the associations between their thoughts, feelings and behavior. Depressed children often believe that they are defective in some way, or that others don’t like them, and that things cannot improve. They may also have difficulty managing their negative emotions and their behavior. They may be frequently tearful or irritable and find it difficult to change the way they feel. Family and friends may bear the brunt of negative attitudes and aggressive outbursts.
These difficulties are addressed in therapy. Children may be taught how to identify their own, and other people’s, emotional experiences, and to keep a record of the thoughts they have in situations when they feel good or bad. Parents can help by keeping their own record of the child’s mood and behavior in relations to events during the day, and reminding the child to complete record-keeping.Children are taught to challenge their negative thoughts with “mini-experiments” in which they check out whether things are as bad as they seem. For example, a child who believes that she has no friends may be taught some social skills and then she asks someone to play with her. When the friend plays with her, her belief that she has no friends is challenged. Children are taught strategies for coping with bad feelings by doing things that make them feel better like listening to music, talking to a friend or parent, or playing with a favouite pet. Irritability or anger may be expressed in less destructive ways by using a punching bag or enagaging in exercise.
Importantly, children learn to access reward when they are coping well. So, a child may ask a parent to provide some treat like special time together or a small material reward when behavior is positive. Parents can help by being firm, fair and consistent in the management of inappropriate behavior and by rewarding all instances of self-management. It may be difficult not to become very upset by a child’s distress, but the child needs to see that the parent is still in charge and can provide a safe, warm environment for the sad, scared child.
In Aaron’s case, his mother can help by ensuring that she concentrates on developing problem-solving strategies with him, rather than concentrating on his distress itself. Creating situations that are pleasurable for Aaron (such as having a friend over to play and getting them involved in a fun activity or going on a fun outing) will help to lift his mood as depressed children tend to be more reactive to positive experiences than do depressed adults. It is helpful to consider what the triggers have been for the low mood in order to be able to talk to Aaron about this time in his life and counteract negative influences on his emotional development. Important aspects to consider are whether he is having problems at school (speak to his teacher) or with friends (speak with their parents if necessary); whether there have been any significant changes in his home life (for example, parental separation, death of a family member, or serious illness); how his mother’s coping resources have been recently (her stress will communicate itself to him, and she may not have her usual levels of energy available for managing him); in fact, any events or influences that might leave him feeling helpless, worried or distressed over a period of time can contribute to an episode of depression. It would also be helpful if Aaron could have access to someone to share his concerns with – a close family member, teacher or other mentoring figure.
While clinical depression is fairly rare, the cognitive behavioral strategies outlined here can be used to counter instances of negative thinking, emotions and behavior in everyday situations. Building up a repertoire of self-management skills will stand anyone in good stead should they be called upon to cope with difficult circumstances in the future.