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Depression—Behavioral Issues in Child Care and Schools

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ICD10

  • F32

  • F33

  • R45.2

  • Z55

How can children with depression be identified?

  • Depression in preschool-aged and young children can manifest in a number of ways. It is important to recognize that the mood symptoms young children with depression have do not mean that they can never be happy—just that they show these symptoms more easily and/or more intensely than other children the same age. Children with typical symptoms may be

    • Easily tearful

    • Hard to comfort

    • Sad and withdrawn

    • Irritable and angry

    • Showing less enjoyment with fun things

  • Children with depression can also have symptoms that affect their concentration, energy, sleep, and/or appetite (ie, too hungry or not hungry at all).

  • They may also blame themselves too much for things they did or even feel like they are responsible and guilty for things that they aren’t at all responsible for (eg, apologizing for a small mistake over and over for days, feeling guilty because a sibling broke a rule).

  • Most importantly, some young children with depression can talk about harming or even killing themselves.

How common is it?

  • About 2% of preschoolers and school-aged children and 5% of adolescents have clinically significant depression at any point in time.1,2

  • Depression is more common in children who

    • Have family members with depression or bipolar disorder

    • Have experienced any kind of stressful life events, including death or other losses in the family, parental arguing or divorce, exposure to violence, or conditions associated with poverty (and child care or education professionals may or may not know about it)

  • However, some children with depression have no obvious stressors at all.

What are the behaviors usually seen?

  • In children with depression, the mood symptoms of sadness or irritability can reveal themselves with

    • Difficulties when transitioning from activity to activity

    • Frustration when relatively small things do not go their way (eg, when an adult sets limits, in play with peers)

    • Playing alone or not playing

    • Worsened concentration in activities and classwork

  • The difficulties may include crying, yelling, talking back to adults, aggression, running out of the room, throwing toys, and refusing to participate in classroom activities or work.

When should a more concerning issue be suspected?

  • Any mood symptoms that are more intense than in other children the same age and/or that interfere with a child’s participation in classroom activities warrant further evaluation.

  • Anytime a child talks about killing himself or herself or harming other children, caregivers should be alerted. Young children may not have a full understanding of the connection between these words and the act of suicide, but nonetheless, talking about self-harm is a red flag that needs to be assessed, and these types of statements should not be ignored.

What are typical management strategies in the behavioral support plan?

  • In the classroom or early education setting, young children with depression

    • May need warnings ahead of transitions

    • Can sometimes benefit from playing in smaller groups or having a “buddy”

    • Have a harder time seeing the positive aspects of many situations, so it is important to praise them for things they do well or when they try hard

    • May need more time to do work or extra help that they didn’t need when they weren’t experiencing depression

    • May need help moving back into routine activities after breaking a rule and having a consequence

    • Often do not use words to identify feelings, so adults should help them label their feelings (“It looks like you are feeling angry that we have to finish playing outside.”)

    • Should not be exempt from the classroom behavioral management routines but (as with all children) do not benefit from overly strict, punitive environments

  • Child care and early education professionals should ask caregivers for specific recommendations for coping strategies that the child is learning in therapy that may also be used in the classroom.

  • In all classrooms, but especially in those with children with depression or self-injurious behaviors, sharp objects that could cause injury should not be accessible to children.

When should I ask for additional support?

  • A mental health consultant can help tailor expectations for children with depression and develop appropriate behavioral plans.

  • Young children suspected of having depression should undergo a full assessment by a pediatrician or developmental or mental health professional who has expertise in working with young children.

  • Young children with depression should undergo psychotherapy with a licensed mental health clinician. Especially for young children, therapy should include the caregiver(s). The best-studied treatment teaches caregivers to use the same skills therapists use to notice a child’s positive behaviors and efforts, which allows the child to develop coping skills and practice following directions. Other therapy approaches for school-aged children may include learning to practice coping strategies with homework (cognitive behavioral therapy), practicing emotional situations in role-play scenarios (interpersonal therapy), and talking about things on their mind (supportive therapy).

  • Medications are rarely used to treat depression in preschoolers; usually, medications are prescribed in this age group if children don’t improve with therapy. There is limited research about the safety of medications for depression in young children and whether they are helpful. In children older than 6 years, medications may be considered as part of the treatment plan for children who have moderate to severe depression, ideally in combination with therapy. The first-line group of medications are selective serotonin reuptake inhibitors, including fluoxetine, citalopram, and sertraline. Other classes of medications have undergone less research and/or have a higher risk of side effects in very young children with depression.

  • Depression runs in families, so it is important for other family members to get treatment if they have mood symptoms or signs of other symptoms, to be able improve the treatment outcome for the young child.

  • Direct communication between teacher and therapist can be incredibly valuable. The more information the therapist has, the more specific the child’s treatment plan can be. Child care and early education professionals are encouraged to share any observations they have about a child with depression and to complete any questionnaires requested by the therapist.

What training and/or policies may be needed?

Training child care and early education staff members about depression can help prevent having depressive symptoms interpreted as being oppositional or “bad” behaviors. Child care and early education professionals who have training in coping and relaxation strategies can help children with depression (and other children) practice organizing their feelings when they are distressed.

Where can I find additional resources?

  • American Academy of Pediatrics The Resilience Project: Depression fact sheet (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Depression-Fact-Sheet.aspx)

  • ParentsMedGuide.org (http://parentsmedguide.org)

References

  • Merikangas KR, He JP, Brody D, Fisher PW, Bourdon K, Koretz DS. Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics. 2010;125(1):75–81 PMID: 20008426 https://doi.org/10.1542/peds.2008-2598

  • Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychol Psychiatry. 2006;47(3- 4):313–337 PMID: 16492262 https://doi.org/10.1111/j.1469-7610.2006.01618.x

Adapted from Managing Behavioral Issues in Child Care and Schools: A Quick Reference Guide.

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The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

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