Chronic Illness and Depression In Children
Written by Vanessa Malcarne, Ph.D
Associate Professor, Department of Psychology
San Diego, CA
2001

Depression in Children
Years ago, psychologist believed that children could not suffer from depression in the same way that adults could. This was partly due to the belief that children were not cognitively mature enough to experience loss and emotional pain in the same way adults could. For example, many psychologists believed that a negative view of the future was essential to the experience of depression, and it was thought that children didn’t really understand the concepts of past, present, and future very well. Today we know that children do experience depression, and in similar ways to adults. Children can experience all of the symptoms of depression: sadness, hopelessness, lack of energy, low self-esteem, appetite changes, and confusion. It is believed that children are especially likely to show social withdrawal and irritability when they are depressed. Depression is a very serious problem for children, one that needs careful attention and treatment. Chronic Illness and Depression
Children who suffer from chronic illness are particularly vulnerable to depression. Having a chronic illness presents a big challenge for a child. The symptoms of the illness, particularly if visible as in scleroderma, can lead to children being rejected by their peers, and to social withdrawal. They can also lead to low self-esteem and children feeling bad about themselves. Children may feel hopeless, and believe that their illness will never get better. Having an illness may affect children’s appetite, sleep patterns, or energy, and prevent them from doing the things they want to do. Is Your Child Depressed?
Here are some of the warning signs for depression. You’ll need to look for them, rather than wait for your child to come to you – one of the key features of depressed children is that their problems are often overlooked, because they don’t talk about their depression. Instead, they may appear very quiet and well – behaved, and as a result nobody really notices how unhappy they are. This is certainly not true for all depressed children – may “act out” their depression through misbehavior and are obviously angry and upset. But no matter how your child expresses depression, it’s unlikely that he or she will seek out to tell you, “I’m depressed” – so it will be up to you and others close to the child to keep an eye out for significant changes in mood and behavior. Ask Yourself These Questions:

• Does your child cry often, seemingly for no reason? Does your child often complain of stomach upset, headaches, pain, or other physical problems, but it seems that he or she isn’t really sick? Does your child sleep much more or much less than he or she used to? Does your child eat much more or much less than he or she used to ? Does your child have little energy and seem tired out much of the time? Does your child seem confused and distracted, and have trouble following orders or completing tasks? Is your child often moody, cranky, and irritable? Does your child talk about being “no good” or worthless” Does your child blame many things on him or herself, even when he/she is not at fault?
• Has your child ever talked about or tempted suicide?

If you answered yes to Question #10, and believe that your child may be suicidal, you should seek immediate help from a health professional. Children do commit suicide, although rarely, and any suggestions of suicidal thoughts or actions should always be treated very seriously.

Helping the Depressed Child
If your child is suffering from depression, that can make the entire experience of chronic illness much worse and more devastating than it needs to be. Having a chronic illness like scleroderma puts children at risk for emotional problems such as depression. If you think your child might be depressed, don’t despair – there are many things that can be done to help your child. Help is available, whether through family members, friends, physicians, mental health professionals, teachers, and other school personnel, support groups, or even medications. Depression does not have to be a part of your child’s life!

Many parents are surprised to learn that their child is experiencing emotional problems. This is particularly true when the child’s problems are we refer to as internalizing problems – meaning that they are problems largely felt by the child, and not necessarily expressed to the external world. In contrast, externalizing problems refer to problems such as acting out, disobedience, lying, stealing, and other conduct problems, which are much more visible, and also much more disturbing – to adults. Research shows that children with internalizing problems like depression and anxiety are often overlooked by parents and teachers, because these children are quiet and complaint, and don’t tend to get into much trouble. Don’t assume that everything is fine because your child is quiet and doesn’t complain about his or her illness. Actually, if your child never complains or acts out, that might be a sign that something is wrong. It’s normal for children to be frustrated when they have a chronic illness like scleroderma, and some acting out behavior is to be expected. This doesn’t mean that every child who never gets angry or upset is depressed – what it means is that you should not assume everything is fine just because your child never tells you anything is wrong. The bottom line is that you should talk with your child, and encourage him or her to share feelings and frustrations with you. Keep an open line of communication, and don’t wait for your child to come to you. Also watch your child’s behavior – changes such as withdrawal, lack of interest in previously enjoyed activities, irritability, lethargy, and changes in school performance are all signs that depression might be a problem. Enlist Social Support
Children who have chronic illness often feel alone. If you haven’t been very available to your child, now’s a good time to step up your efforts. Spend personal time with your child, and engage him/her in family activities. Enlist the support of your spouse and/or other children, plus extended family like grandparents. Help your child feel loved and appreciated. Another place to get support for your child is in the community. Talk with your child’s teachers; they’ll have ideas for how to help your child. Enroll your child in activities like club, the arts, and sports, where he or she will meet other children in a non-illness-related setting. Finally, in many communities there are organized support groups focusing on various issues. Look for support groups for children/families who face chronic illness. Research has clearly shown that support groups are helpful for many problems, and this is a way your child can meet with other children facing similar challenges. Some groups involve parents and children; this is also very helpful and provides you with support as well. Your health provider should be able to give you information about support groups in your community. Get Professional Help
Many people resist contacting mental health professionals, believing they only help the most severely disturbed children. This is a misconception – these professionals regularly help children and families cope with problems like divorce, illness, and school difficulties. There are many different types of mental health professionals, and it can be confusing to try to find someone who is right for you. Ask your pediatrician for a referral, or talk to other parents of children who are coping with illness for a recommendation. Psychiatrists, who have medical training, are a good choice if medication is to be considered for your child’s depression. Psychologist have extensive assessment and therapeutic training, especially in family interventions. Social workers and marriage/family therapists also good choices. I often recommend that people obtain services at a clinic where a psychiatrist and a psychologist or other therapist are on staff, so they benefit from the combined expertise of these professionals. Professional help for depression in children with chronic illness will optimally involve individual attention for your child as well as therapy for the entire family. This doesn’t mean that there is anything horribly wrong with your child or your family – what it means is that you are all struggling to cope with a very difficult challenge, and sometimes this can be overwhelming. At these times, the calm, objective direction of a professional can be extremely helpful in reestablishing equilibrium and a sense of some of a professional can be extremely helpful in professionals are usually familiar with community-based services like support groups and can help you find the services you need. How do you know you are getting the right kind of help? First, you should be comfortable with the persons providing the services. If you don’t feel comfortable with the professional help you are getting, it won’t be beneficial to you. Find services elsewhere. Second, some therapeutic approaches are more supported by research than others. Cognitive-behavioral therapy ( CBT ), a time-limited approach focusing on changing negative beliefs and dysfunctional behaviors, has been shown to be an effective treatment of depression in adolescents, and to be more effective than family-focused therapy or than therapy that mainly focuses on providing support. Ask what approach your therapist uses, and why. And look for signs of improvement you shouldn’t have to wait months or years to see some positive change.

What about medication?This is a difficult question, best answered by consulting your pediatrician or psychiatrist. There are many medications being used to treat depression in children, although many are not supported by research and it’s unclear if they are safe for use with young people. Most research supports the use for children of medications known as selective serotonin reuptake inhibitors (SSRIs). Research does not support the use of tricyclic antidepressants (TCAs) for children. Medications are usually used for youngsters with more serious problems, and should always be used in combination with therapy. If your child’s problem is more mild, you should consider trying therapy first, and only turning to medication if the problem persists or becomes more serious.

National Institute of Mental Health
Office of Communication and Public Liason
Information Resources and Inquiries Branch
6001 Executive Boulevard , Rm 8184, MSC 9663
Bethesda , MD 20892-9663
(301) 443-4513
Email: nimhinfo@nih.gov
Website: http://www.nimh.nih.gov National Mental Health Association
1021 Prince Street
Alexandria , VA 22314
(800) 969-NMHA
Email: infoctr@nmha.org
Website: http://www.nmha.org
Sponsor of Childhood Depression Awareness Day American Psychological Association
750 First Street, N.E.
Washington D.C. 20002
(202) 336-5500
Website: http://www.apa.org American Psychological Association
1400 K Street, N.W.
Washington , D.C. 20005
Website: http://www.psych.org

Please keep in mind, this webpage is for your information only.
Please check with your child's physician for any treatments.

For more information on Juvenile Scleroderma, contact:

Juvenile Scleroderma Network, Inc.
1204 W. 13th Street, San Pedro, CA 90731

Tel: (310)519-9511 (Pacific Time)
24 Hour Support Line: 1-866-338-5892 (toll-free)
Speak to another JSD parent for emotional and logistical support provided by home-based JSD volunteers. For medical advice, please contact your child's physician.

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