School & District Management

Lifelong Battle

By Marianne D. Hurst — February 11, 2004 12 min read
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An extensive body of research exists on how depression affects adults. Now more researchers are examining teenagers and children afflicted with the disease.

He’d always been a cautious and somewhat anxious child. And because he suffered from mild cerebral palsy, the doctors already had concerns about his social- emotional welfare even when he was a toddler. But no one suspected the depth of the problem that would manifest itself in 1st grade.

Initially, the Connecticut boy had danced off to kindergarten, eager and excited. But as time passed, he developed phobias, started muttering to himself frequently, pulled out his hair until he developed a bald spot, and sometimes became too anxious to leave the house.

By 1st grade, he was having a hard time going to school. He withdrew from other children, refused to go to friends’ parties, and became so fearful that he actually locked his mother out of the car one day when she tried to drop him off at school.

Illustration courtesy of KidsPeace.

—Illustration courtesy of KidsPeace

Despite reassurances both in the classroom and at home, his anxiety increased daily as did his tendency to worry and act out. Then, on what his mother recalls as an “awful afternoon,” he simply refused to get on the school bus. He stood by the curb, crying hysterically.

The boy was suffering from childhood depression. But making that diagnosis for many youngsters can be tricky, because little research has been done on depression in preschool- and elementary-age children.

The topic is starting to gather more interest in the education community, however, in response to concerns that children suffering from depression tend to do poorly in school. And a growing body of research documents the prevalence of depression in adolescents.

“There are kindergartners and 1st graders who experience depression,” says Kathie Halbach Moffitt, the project director for the depression-education project at the University of Connecticut health center in Farmington. “This can start very early.”

Overall, it is estimated that nearly 19 million adults in the United States suffer from depression. While research on the number of school-age children with depression varies, most experts agree that between 5 percent and 11 percent of 6- to 17-year-olds are living with the problem every day. Of those, experts say about two of three receive no treatment for the disease.

Selected Research

“Adolescent Suicidal Ideation and Attempts: Prevalence, Risk Factors, and Clinical Implications” (abstract only). Peter M. Lewinsohn, Paul Rohde, and John R. Seeley. Clinical Psychology Science and Practice. 1996.

“Advances in School-Based Mental Health Interventions: Best Practices and Program Models.” K. Robinson. Civic Research Institute. 2004.

“Childhood and Adolescent Depression: A Review of the Past 10 Years” (abstract only). B. Birmaher, N.D. Ryan, D.E. Williamson, D.A. Brent, J. Kaufman, R.E. Dahl, J. Perel, B. Nelson. Journal of the American Academy of Child & Adolescent Psychiatry. November 1996.

“Major Depressive Disorder in Older Adolescents: Prevalence, Risk Factors, and Clinical Implications” (abstract only). Peter M. Lewinsohn, Paul Rohde, and John R. Seeley. Clinical Psychology Review. 1998.

“Patterns of Comorbidity and Dysfunction in Clinically Referred Preschool and School-Age Children with Bipolar Disorder.” Timothy E. Wilens. Journal of Child and Adolescent Psychopharmacology. 2003.

“Mental Health: A Report of the Surgeon General.” 1999.

“Trends in the Prescribing of Psychotropic Medications to Preschoolers” (abstract only). Julie Magno Zito, Daniel J. Safer, Susan dosReis, James F. Gardner, Myde Boles, and Frances Lynch. Journal of the American Medical Association. February 2000.

“Youngsters’ Mental Health and Psychosocial Problems: What Are the Data?” December 2003. UCLA School Mental Health Project (requires Adobe’s Acrobat Reader).

“It’s a big problem,” says Jerald Newberry, the executive director of the health-information network for the 2.7 million-member National Education Association and a former psychologist for the 160,000-student Fairfax County schools in Virginia. “When we meet with our members to ask about the problems they face, [mental-health issues are] always number one or two.”

Depression is characterized by a number of symptoms, including persistent sadness, irritability, loss of appetite, feelings of hopelessness or worthlessness, lack of concentration, and poor sleeping patterns. There can be other symptoms too, which are harder to pinpoint and often manifest themselves differently depending on age and environment.

Experts say many students suffering from depression also suffer in the classroom because they lack the motivation to learn, are hypersensitive to criticism, and may not have the self-esteem to appreciate even small achievements.

But depression, they caution, can’t always be seen through failing grades. Some depressed students can be extremely gifted and show no academic signs of failure. In fact, they try to cope with their troubled feelings by becoming perfectionists or overachievers—tactics that can lead to major emotional meltdowns when youngsters do not achieve perfection. In 2000, the U.S. surgeon general issued a groundbreaking report that concluded that one out of every five children in this country has a mental-health problem, and that between 10 percent and 15 percent of children and adolescents have some symptoms of depression.

Yet even with ongoing research and a strong advertising campaign by pharmaceutical companies to raise public awareness of the availability of medications to treat depression, the disease still goes relatively undiagnosed in children, authorities on the problem say. For instance, a report released last month by the Annenberg Foundation Trust, based in Sunnylands, Calif., found that only 46 percent of physicians who treat adolescents felt confident diagnosing depression in adolescents, and only half regularly screened teenagers for mental-health problems.

Even with ongoing research and a strong campaign to raise public awareness of the availability of medications to treat depression, the disease still goes relatively undiagnosed in children.

However, some experts warn that numbers on depression can be deceiving, especially those that estimate the percentage of children who have the disease. Many research studies, they say, are conducted on small groups and have severe limitations. A 2002 report by the Arlington, Va.-based American Psychiatric Institute for Research and Education, for instance, found that two surveys—the National Institute of Mental Health Epidemiologic Catchment Area Program and the National Comorbidity Survey—which are often cited to substantiate the growing need for mental-health treatments for adults, overstate the scope and severity of the problem.

“There’s a tendency for people to think that these numbers mean that all [depressed] kids have severe depression, the kind that leads to suicide,” says Rusty Selix, the executive director of the Mental Health Association of California. “But that’s not true. The numbers have validity, but you need to look at what the numbers are really telling you, and remember that not all depressive disorders have the same level of severity.”

While the Connecticut mother was clearly concerned about her son’s anxiety, it surprised her when he was diagnosed with depression in 1st grade. Depression, a problem all too commonly associated with adolescence, seemed impossible in a child his age, she recalls. The boy is now 13. (Education Week agreed not to identify the mother or her child.)

But the National Institute for Mental Health reports that large-scale studies suggest that 2.5 percent of children under 12 run the risk of experiencing a depressive episode. Researchers say a depressive episode generally lasts seven to nine months.

Moreover, once children experience depressive episodes, experts say, more than 70 percent relapse within five years. Children with depressed parents are also three times more likely to experience depression than youngsters whose parents do not suffer from it.

Many students could benefit from school-based mental-health programs that screen for depression, advocates of such services say. But significant barriers block the way.

To begin with, authorities say, school psychologists and counselors simply don’t have enough time to tackle the issue, because they spend so much time testing students with disabilities for learning problems, rather than working with students in general.

In addition, financial limits have led districts to cut counselors and school psychologists out of their budgets, forcing many schools to make do with part-time counselors only.

The National Institute for Mental Health reports that large-scale studies suggest that 2.5 percent of children under 12 run the risk of experiencing a depressive episode. Some experts, though, warn that numbers on depression can be deceiving.

Even in districts that do maintain full-time positions, many counselors serve only as academic advisers—finding their roles constrained by time, caseloads, or administrators’ fears about the possible legal and financial ramifications of dealing with mental-health issues.

Critics of such programs question not only their cost, but also what they see as their encroachment on parents’ turf. In 1999, Karen Holgate, the president of the Parent National Network, a California-based organization for parental rights, launched a campaign against Assembly Bill 1363, a school health-care bill that would have expanded school-based health clinics throughout California. Then-Gov. Gray Davis vetoed the bill.

Among other complaints, Holgate contended that the bill would limit parental consent by offering easy-access care, health screenings, and referrals based on students’ own requests. And to maintain student privacy and confidentiality, she says, the bill could have kept documentation collected in such clinics out of the hands of parents.

In papers she posted on the Internet, Holgate sharply criticized the growing belief that school-based health centers could be used effectively to treat depression and prevent school violence. The effort was a misguided attempt at the “medicalization of schools,” she argued.

The Connecticut mother, as her surprise faded, began to acknowledge similarities she and her son shared. She also suffers from depression, and, as a youngster, she too had been persistently fearful, sad, and preoccupied. Her condition went virtually unnoticed by those around her, in part because she did well in school and didn’t have any noticeable problems. “People with depression are different,” she says. “You know that you’re not normal on some level. You have to put up a good face to survive.

“Before I knew that there was a reason why I felt the way I did,” she continues, “I’d see regular people doing regular things—watch them get enjoyment out of simple things—and I’d wonder, how do they do it? Why do they do it when the world is so hard?”

It took her many years, she says, to understand why other people seemed so positive in what to her was a cruel and unforgiving world. Her son’s anxiety made more and more sense, and she desperately wanted to help him avoid the years of suffering she had endured.

The Connecticut boy spent his first year of therapy talking out his problems with a psychologist.

"[Depression] is such a serious, lifelong, life-altering illness,” his mother says. “It affects one physically, emotionally, and spiritually. Even when you know what depression is, it’s hard to conquer. And for kids, it’s even more baffling because they don’t have any point of reference.”

Yet despite the weekly therapy sessions, the boy’s worrying did not ebb. His mother utilized every avenue of cognitive therapy, but it soon became clear that talking wasn’t enough. He needed medication in addition to emotional support.

Of the 157 million prescriptions issued for antidepressants in 2002, about two percent were for children ages one to 11, and five percent were for adolescents ages 12 to 17, according to the U.S. Food and Drug Administration. Still, many critics voice concern that school-based mental-health programs might add to society’s increasing tendency to medicate children at the first sign of a problem, rather than trying other approaches.

Marla Filidei, the vice president of the Los Angeles-based Citizens’ Commission on Human Rights, a nonprofit group that investigates violations in the psychiatry field, argues that the placement of mental-health staffing and services in schools poses a grave risk to otherwise healthy children. Many students, she says, could be misdiagnosed by “subjective testing” that has little scientific backing.

The students would then be placed on drugs that they might not need, and that could be potentially harmful to them.

Paxil, a commonly prescribed antidepressant and one of a number of drugs currently under review by the FDA, was recently banned in the United Kingdom for use with children under 18.

For instance, Filidei points out that Paxil, a commonly prescribed antidepressant and one of a number of drugs currently under review by the FDA, was recently banned in the United Kingdom for use with children under 18. An FDA report released last week questioned the effectiveness of antidepressant use on children, and raised concerns about the potential risk of an increase in suicides for children using such drugs. Critics who argue that antidepressants are overused say the report supports their arguments.

“Clinical depression—what does that mean?” Filidei says. “They’re using a subjective list of criteria that can be very loosely interpreted to put 12- and 13-year-olds on drugs. It’s criminal, quite honestly.”

Another potential problem, she says, is the failure of some schools to inform parents about the screening process and the potential risk factors involved in medicating children.

So what is a school’s role in identifying and treating childhood depression? It’s a frustrating question for many school psychologists and counselors faced with an already daunting list of challenges.

“You can’t tell children to leave depression at the schoolhouse door,” Newberry of the NEA says. In the long run, he adds, ignoring the issue is likely to have far-reaching consequences because depressed children tend to become depressed adults.

Others echo his sentiments.

“If it were handled early, we could snap that cycle,” says Erika Karres, a retired teacher who taught grades 7-12 in Orange County, N.C., for 30 years, and is a strong advocate for school- based mental-health programs. “Teachers need to be aware that 20 percent of any student body will have depression,” she says. “Awareness doesn’t cost any money.”

Many administrators, though, are reluctant to initiate programs because of the potential social, financial, and legal ramifications. Inconsistent local funding is a problem, and there are no national standards for school-based mental-health care.

“The necessity just hasn’t been impressed upon school leaders,” says Karres, referring to attentiveness to students’ depression. “Especially now when everything deals with achievement. ... [But school administrators need] to understand that depression affects achievement.”

The Connecticut mother agrees.

“Depression just doesn’t grow out of nothing,” she says. “There’s a source, but the behaviors often come across as defiant. It’s not recognized as depression. [The children] are saying something to you when they act like that, ... but instead of seeing what the behavior is saying, we punish it.”

Coverage of research is underwritten in part by a grant from the Spencer Foundation.

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