Depression is a disorder that can strike anyone – including children and young people. The disorder generally develops gradually. The first signs may be that the child seems sad, tired or irritable, becomes socially withdrawn and loses interest in things he/ she normally enjoys. Young children may have difficulty saying that they are sad, and more often react with a stomach ache or headache. If the symptoms persist over an extended period or become very pronounced, it could be depression, and the child needs help to get well again.

The duration of depression varies greatly in children and young people. Sometimes the bout of depression is over within a few months. Depression usually lasts 9–12 months. In rare cases, untreated depression can last several years. Depression passes sooner with treatment.

As a rule, the improvement is evident, as the child/young person has longer and more frequent periods in a good mood. Often, parents will notice this before the child does. Tiredness and concentration problems may persist for several months after the child starts feeling better and has begun to take an interest in more activities. Accordingly, it is not unusual to need to restrict demands and activities a while longer to avoid overburdening the child.

There is no straightforward explanation of why some children and young people get depression. The cause is often a complicated interaction of different factors, such as heredity, susceptibility and various types of stress and pressure.

If there is depression in the immediate family, this increases the risk of children in the family becoming depressed. We do not know exactly why this is so, but it is probably a combination of genetic and environmental factors.

Some children are more susceptible to developing depression. This is sometimes the case in children with a severe physical ailment or other mental health problems. Children who have experienced traumatic life events – especially involving loss – are also at greater risk. Increased susceptibility may also be seen in children who tend to think negatively about themselves, others and the future.

Long-term stress and pressure increase the risk of depression in children. These pressures may be linked to experiences at school and with classmates (e.g. academic problems, or bullying) or negative experiences at home (e.g. a lot of arguments).

Depression affects the child’s level of functioning in many ways, for example the child’s emotional well-being, body, way of thinking, behaviour and motivation.

It is common to feel a little sad from time to time, to not want to do anything or lack self-confidence – even as a child. With actual depression, the symptoms have a certain degree of severity; a certain number of symptoms must be present; and the symptoms must have persisted most of the time for at least 14 days.

Depression in children and young people is diagnosed based on the same principles as depression in adults. Symptoms of depression are classified as core symptoms and accompanying symptoms.

• Feeling down. The child’s mood has changed. The child is sad, cries easily, has a feeling of emptiness, or cannot feel anything at all. Some children are irritable or sullen.
• Loss of desire or interest. The child loses the desire to do the things he/she normally enjoys doing. He/ she does not experience pleasure in the company of people or doing things that would normally be enjoyed. The child withdraws more into himself/herself and becomes more passive.
• Lack of energy and increased tiredness. The child feels tired, exhausted, and drained of energy. Everything is a big effort – even the things the child normally does

• Reduced self-confidence. The child feels that he/she is no good at anything or is insignificant to others.
• Self-reproach or feelings of guilt. The child engages in unreasonable selfreproach and exaggerated feelings of guilt and is unable to let go of these.
• Thoughts of death or suicide. The child speculates about death and may have thoughts that it would be better if he/she were not here at all. The child may also have more specific thoughts and plans about suicide. Some children may also self-harm or attempt suicide.
• Problems concentrating. The child has difficulty collecting his/her thoughts and has difficulty remembering things. He/she has difficulty making everyday decisions and choices.
• Agitation or inhibition. Agitation means the child is restless and unsettled. Inhibition is less common in children, but it is evident if the child moves or talks more slowly. The child’s language becomes more concise, with pauses. The child may also find that thoughts come more slowly.
• Sleep disorders. The child has difficulty getting to sleep at night and difficulty getting going in the morning. Perhaps he/she needs more sleep, but still feels tired and out of sorts throughout the day. Often the circadian rhythm becomes displaced, with the child awake late into the evening or at night and sleeping during the day.
• Changes in weight and appetite. The child loses his/her appetite and loses weight. Some children react in the opposite way and comfort-eat, so they put on weight.

Other symptoms A number of other symptoms are often observed in addition to the above. In some cases, these symptoms can be so intense that the depression is overlooked: Physical symptoms The child complains of a stomach ache, headache or other pains without having a physical ailment. This is seen particularly in younger children. Anxiety The child is anxious, has a lot of worries, or is anxious about being separated from the parents. Irritability The child becomes irritated more quickly and may become more aggressive or contrary. Behavioural problems Older children and young people with depression may react by violating norms, e.g. experimenting with drugs, playing truant, getting into fights or stealing

At least two core symptoms and two accompanying symptoms are present in mild depression.

Generally speaking, the child is able to continue a normal everyday routine of school and leisure activities, if he/she receives support. Mild bouts of depression often pass naturally.

At least two core symptoms and four accompanying symptoms are present in moderate depression.

the child has difficulty functioning normally at school, at home and in leisure time, and needs special conditions.

In severe depression, all three core symptoms are present, together with at least five accompanying symptoms.

The child is highly tormented, often has pressing suicidal thoughts and is unable to cope with a normal everyday routine. In rare cases there may be psychotic symptoms, such as delusions or hallucinations. An example of a delusion in depression could be that the person is convinced he/she is to blame for a serious accident. Hallucinations can include hearing voices saying negative things about the child or encouraging the child to commit suicide.

Depression is diagnosed on the basis of consultations with a therapist, your child and you. The therapist will ask about symptoms of depression and their degree of severity. The therapist may use questionnaires in the assessment and the potential risk of suicide must also be determined. The child’s life story is examined to gain an impression of personal resources and any mental problems or pressures. It is also important to know how the child is getting on at school with homework and classmates, and to explore family well-being – including whether your family is under any particular pressures.

Treatment of depression in children and young people varies, depending on what symptoms the child has and the severity of the symptoms. Individual consideration must always be given in arranging treatment.

Psychoeducation and relief from stress are key elements when treating depression in children. For children in mild depression, these two treatment elements are generally sufficient for them to get better. Children with moderate depression will often also need psychotherapeutic treatment and possibly also medication. Children with severe depression will often need psychotherapeutic treatment and medication in addition to psychoeducation and relief from stress.

Psychoeducation is learning about the disorder. You and your child, and possibly other family members, will be given indepth information about what depression is, the typical progression of depression, what relieves depression, how those around the child can provide support, etc. Gaining a greater understanding of what depression is can help your child, and you as parents, to deal with the symptoms until the disorder abates. Knowledge of the disorder also makes it possible for you to recognise signs of depression so your child can get help sooner if things get bad again.

The intention in providing relief from stress is to limit circumstances or situations in which the child feels the most stress or pressure. In concrete terms, this could be done by shortening the school day, restricting homework or demands at home, or limiting the child’s participation in large-scale social events. The purpose of providing relief from stress is to enable the child to avoid facing defeat and to save his/her energy. If there are specific, stressful issues in the child’s life or your everyday family life, you must of course try to resolve or ease them.

Relief from stress does not mean leaving your child to his/her own devices instead of participating in family life. Concurrent with relief from stress, it is important that your child receives support to continue to do things that are enjoyable, or at least satisfying, such as spending time with close friends and family or participating in specific, manageable tasks.

Cognitive behavioural therapy is the most common type of therapeutic treatment for children and young people with depression, but other types of counselling may also be used.

In cognitive therapy, the therapist and the child focus on investigating and trying out alternative ways of thinking and acting in given situations so the child gradually learns more positive and less black-and-white ways of thinking.

During therapy, you and your child will also be given support in the matter of constantly adapting demands and activities to the child’s energy levels. As parents, you will always be involved in the therapy to some extent, as you play a major part in helping and supporting your child. Cognitive behavioural therapy also focuses on the family, and on how your mutual interaction in the family affects and is affected by your child’s depression.

If psychoeducation, relief from stress or psychotherapy have not had an effect on the symptoms of depression, and your child is thus still burdened by the symptoms, the therapist will consider medication as a supplementary treatment. Medication is not a replacement for other measures, but a supplement.

Medication for children and young people in depression will be arranged by doctors specialising in child and youth psychiatry. By agreement with a specialist, this treatment may also be administered by a GP.

Treatment of depression in children and young people is usually handled on an outpatient basis, i.e. without hospitalisation. In some cases, e.g. where the child has psychotic symptoms; is at risk of committing suicide over an extended period; or has depressive symptoms that do not abate, the patient may be admitted to hospital for treatment. Here, too, the focus is on reducing demands and stimuli, re-establishing a normal circadian rhythm and eating pattern and identifying stress that may have triggered the depression or may be sustaining it.

You both play a key role in assisting your child when he/she is in depression. Your child needs you to be able to listen, to be present, and to help make everyday life easier. Knowing your child as you do, there is a great deal you can contribute to gaining an understanding of the things that put him/her under pressure, and thus also what may relieve those pressures and provide positive experiences.

Your child needs to be aware – and reassured – that, despite his/her own low self-esteem and self-reproach, he/ she is loved and valued. You can keep your child’s hopes up, and, for instance remind him/her that depression is a disorder that will pass, or remind him/her of the progress that has been made.

In talking with your child, it is important that you do not try to contradict or correct his/her perceptions or experiences, but that you listen with empathy and, when relevant, present your alternative and more positive views.

It is also important to ask about and listen to your child’s thoughts of suicide, if any. Here, you should express empathy for his/her pain and at the same time assure him/her of your help and protection. As parents of a child in depression, you also have an important task in helping your child – as far as at all possible – to maintain a normal circadian rhythm and normal eating patterns, and to motivate him/her to participate in activities and to get exercise and fresh air.

Generally speaking, as a family, you need to try to limit the amount of criticism, angry outbursts and conflict, as children and young people in depression are particularly negatively affected by this. When giving your child an instruction and when correcting him/her, make sure you speak in a neutral or cheerful tone of voice.

As parents of a child or young person in depression, it is easy to become over-involved to the point that you have difficulty allowing the child to be himself/ herself. It is important to strike a balance between respecting your child’s boundaries and offering help and support.

Children and young people in depression often have difficulty maintaining contact with their friends and networks. Here you can be a great help. For example, you could help your child by organising short visits or, with your child’s agreement, keeping his/ her network informed and encouraging the network to continue sending messages to your child – even if, for a while, he/she is not able to reply personally or receive visits.

• Remember that depression is a disorder and not anyone’s fault.
• Remember that most episodes of depression respond well to treatment.
• Learn about depression, and support your child during treatment.
• Listen and show empathy, but do not try to argue or convince your child.
• Accept that your child is sad.
• Avoid criticism and reproach. Lower your expectations of your child.
• Help your child to maintain a normal circadian rhythm and eating patterns.
• Support contact between your child and your child’s network.
• Be open – agree with your child how to tell other people about your child’s depression.
• Seek support, and give yourself breaks.
• Accept that you cannot solve all the problems yourself, and focus on the areas where you can make a difference.
• Be patient – with yourself, too.