The teenage years are full of ups and downs. Every day presents a new challenge. Teens are learning who they are, finding their place within the social structure of their friends and classmates, adjusting to physical changes, figuring out their sexuality, all while trying to be good at something, do well in school and be liked by others.
It’s not surprising that teens can get moody or angry for seemingly little or no reason. That’s normal teenage turbulence.
But the challenges of being a teen can also trigger clinical depression. Add to all this the possibility that a teen may not yet have the self understanding to label their negative feelings or identify what triggers those feelings. They may not be used to talking about how they feel. So they may not ask for help when they need it.
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That’s why my fellow pediatricians and I have started to screen all our teen patients for depression with a short questionnaire. We get positive screens pretty frequently. Often parents are not surprised, but sometimes they are. Sometimes we even have push back from parents who don’t want their teen screened or assume that they are fine and want us to assume that they are fine too. When the screen is positive, we dig deeper to figure out if the teen is depressed or just experiencing ups and downs.
How do we know what is normal teenage turbulence with its ups and downs, and what is depression? The biggest clue is if your teen is spending more time down than up. Depressed teens have a feeling of either depressed or irritable mood more days than not. It’s concerning when they are having impairment in their day to day activities- i.e. they are not functioning as their usual selves.
In addition to depressed or irritable mood, we also look for teens to have at least 4 of the other 8 symptoms of depression which are discussed below. We use the mnemonic SIGECAPS to remember the other symptoms of depression – Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psycho-motor disturbance, Suicidal ideation. These are explained below.
Depressed or Irritable Mood
Adults are more reliably able to verbalize feeling down, depressed, sad, or hopeless, but many teens may just seem irritable, easily annoyed, on edge, touchy, or angry. Family members and friends have to “walk on egg shells” all the time around them. They may lash out with little provocation. This can also be normal behavior for teens: what teen isn’t ornery sometimes? Who doesn’t have some down days? The key here is that the irritable or depressed mood is there most of the time, more days than not, over at least two consecutive weeks.
This can be either sleeping too much or sleeping too little- or have erratic sleep patterns. They may complain of having a hard time sleeping at night even if they are not laying awake thinking about their problems. They may sleep excessively during the day. A normal teen needs 9 hours of sleep per night, and with all the homework, practices, work shifts, rehearsals etc that kids have these days, teens are unfortunately often sleep deprived and tired, and have to catch-up on sleep on the weekends. Depressed kids, however, never seem to be able to catch up, or the normal amount of rest just doesn’t cut it for them.
Diminished interest or pleasure
Depressed teens may lose enjoyment they used to get from their preferred activities. They just don’t want to draw anymore, they don’t get any enjoyment from playing football like they used to, or don’t enjoy playing an instrument like they did. Everything seems hopeless and purposeless. Relationships with friends or loved ones just aren’t important anymore and they may withdraw from social interaction. Another way this can manifest is lack of motivation- they may feel unmotivated to do their homework, go to school or do anything.
Feelings of worthlessness or guilt
Depressed teens often tell me they feel stupid, or like a failure, or say other self-deprecating things. They may excessively internalize things going on around them and blame themselves unnecessarily. They may appear extremely sensitive and interpret events or things people say or do as evidence of their inferiority or incompetence. They may be excessively self critical or struggle to identify positive self attributes, or be preoccupied with letting others down.
Fatigue or loss of energy
Depressed adolescents often complain of not having any energy or feeling tired all the time. Sometimes they say they feel physically weighed down, like their arms and legs are heavy.
Poor concentration or impaired decision-making
Depressed teens often have a harder time focusing compared to their baseline. They may say they have a harder time getting their homework done or it may take them longer. They may have a harder time thinking through a decision and become more indecisive. This can lead to decline in their school, extracurricular or job performance.
Appetite or weight changes
Depressed teens often tell me they just don’t feel like eating. Or sometimes they find themselves eating way more than usual. Many times adults have weight loss, teens may just not be gaining enough weight. Depression can be co-morbid with an eating disorder like anorexia (refusing to maintain a normal body weight by restricting intake).
Psychomotor agitation (restlessness or hyperactivity) or retardation (sluggishness)
This is less common for teens in my experience, but they may admit to feeling sluggish in their movements or speech. Sometimes the teen doesn’t realize it, but parents notice they take longer to answer questions or form thoughts or sentences, or aren’t as active as usual. Sometimes kids become more restless and fidgety.
Suicidal ideation refers to thoughts about suicide. These thoughts can range through the spectrum of suicidal thought: first, a teen may just feel like they don’t want to live anymore, or think that their family or friends would be better off without them; next they may be thinking about what they could do to end their life; then develop the intention to follow through with those thoughts; and finally, actually make a plan to carry those thoughts out. It’s critical to know where a teen is on that spectrum. Don’t be afraid to ask. You will not plant the idea of suicide in a teen by talking about it. For coaching videos on how to talk about suicide, click here.
Any sign of suicidal ideation must be taken seriously and evaluated promptly. A teen’s decision to take their own life can be impulsive and occur without much warning. If your child tells you they are even thinking about suicide, make contact with their doctor or another professional immediately, or call the National Suicide Prevention Lifeline at 1-800-273-8255, accessing resources at uofuhealth.org/safeut, or take your child to the Emergency Room to talk with a crisis worker. If they have thought of a specific means they would use to commit suicide, they may need to be temporarily admitted to a hospital to keep them safe.
Treatment of Depression
Sometimes there is a stigma placed by society on treating mental health problems. It shouldn’t be that way. There is no shame in taking your child to a Pulmonologist to treat their asthma or a Neurologist to treat their seizures. Likewise, there should be no shame in seeking help for your child’s mental health.
A mainstay of treatment of depression in teens is counseling, which can help with many typical teenage problems as well. Through counseling, teens learn coping strategies, self-management skills, and self-awareness. Therapy can be hard work, but it leads to true healing when there is a good therapeutic relationship.
When teens are having a lot of impairment from their symptoms, medication is a safe and effective treatment used to help get teens better faster along with counseling. Though we can’t rely on medication to solve all problems, it can be very important for some kids to start turning around. I think of antidepressant medication like a cast for a fracture. It helps to stabilize the damage, decrease pain, and allow the healing to begin, which happens through the work of therapy, leading to changes in patterns of thinking, lifestyle changes, interpersonal connection, and addressing past trauma.
If you have concerns about your teens’ mental health, please don’t hesitate to make an appointment with your child’s doctor. As pediatricians, we are just as much teen doctors as we are baby doctors. We seek to care for the whole child- that means mental and emotional as well as physical health. We also encourage parents to care for their own mental health, as it is closely connected with the mental health of their children.
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