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Depression: The Warning Signs

May is mental health awareness month. It seemed only appropriate to address depression. As a parent, it can be hard to acknowledge that your kid may have depression. After all, they are a kid; they don’t have anything to be stressed about, right? The thing is, all depression isn’t situational (parental divorce, death of a siblings, etc.). Many kids who apparently ‘have it all’ are still depressed. Increasing your awareness could potentially save your child’s life one day.

What is depression?

The Mayo clinic has one of the most concise definitions of depression that I’ve seen. Their definition states:

“Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems.”

In mental health, there is one book that essentially outlines all mental conditions in medicine and it is considered the gold standard. It is the Diagnostic and Statistical Manual of Mental Disorders (DSM), the most current volume is volume 5 (published in 2013). To make a diagnosis of depression, a person is supposed to have 5 of 9 listed conditions for more than 2 weeks. It also notes that to have a diagnosis of depression, symptoms must cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” And “depression” should not be diagnosed if the symptoms are the result of effects from a substance or other medical condition.

Symptoms of depression

To meet a clinical diagnosis of depression, one doesn’t have to all of the symptoms. It’s also important to remember that kids can present in a variety of ways. While your mind may have pictured a depressed person as sad, mopey, crying all the time, and can’t get out of bed, that may not be how a kid actually presents. A kid may be irritable, tired, complaining of headaches, and having trouble sleeping (which can be a difficult presentation to decipher between other medical problems). Here’s the general list of symptoms:

  • Sadness
  • Irritability
  • Loss of interest in activities (that were previously considered pleasurable, e.g. sports or hanging out with friends)
  • Feeling hopeless or helpless
  • Feeling tired/fatigued
  • Sleep changes (either too much or too little)
  • Change in appetite (either overeating or not eating) which may result in changes in weight
  • Feeling guilty
  • Thoughts of suicide (or entertaining the idea of how life would be without you)
  • Vague physical complaints (e.g., headache, stomachache, overall feeling poorly)
  • Trouble concentrating (including failing grades)
  • Inability to make a decision (seemingly indifferent to options/choices)

Risk factors for depression

While risk factors don’t predict depression, they are just that: risk factors:

  • Parents that are depressed (there seems to be a genetic component to depression)
  • Having anxiety (depression and anxiety often co-exist)
  • Personal temperament (some people are inherently more happy or sad)
  • Negative thoughts
  • Chronic or intense stress
  • Family conflict
  • Poor health

Protective factors

Every parent wants to know how to help raise more emotionally resilient children. Sometimes, no amount of “perfect parenting” can prevent childhood depression. However, there are certainly factors that seem to be protective. They include (taken from

  • Positive physical development
  • Academic achievement/intellectual development
  • Good coping skills and problem solving skills
  • Involvement in 2 or more of the following: school, athletics, employment, religion, or culture
  • Family that provides: structure, limits, rules, monitoring, values, and supportive relationships
  • Presence of mentors and support systems

How is depression diagnosed?

Depression is usually diagnosed by a physician. Diagnosis includes a thorough history (including the history of symptoms, questions about suicide/death, and a family history of mental health illnesses). Physicians will often use standardized depression tools/questionnaires (the PHQ 9, Beck Depression Inventory, Hamilton Rating Scale for Depression, etc.). Do not be surprised if the physician asks to speak to your child privately. Those conversations (tailored to age appropriateness) will often inquire into sex, drugs, relationship problems (with parents or significant others), home environment, etc.

Depression treatment

There are a couple of different approaches to treatment of depression. The first includes psychotherapy, essentially talking with your “therapist” or psychologist. For some people, this approach is enough. However, many people who suffer from depression need the aid of a depression medication (sometimes in combination with therapy). Usually a class of medications called Selective Serotonin Reuptake Inhibitors (SSRIs) are used first line (this includes medications like Fluoxetine, a.k.a. Prozac and Sertraline, a.k.a., Zoloft). These medications are designed to increase a chemical in the brain called serotonin. Treatment duration is classically 6+ months. Your pediatrician will help you determine if your child will need to stay on the medication long term.

How big of a problem is this really?

The American Academy of Pediatrics states that in the United States, up to 3% of children and 8% of adolescents suffer from depression. Lifetime prevalence is around 18-20%. That’s an astounding number to me when I think that nearly 1 in 12 kids in the local junior high and 1 of 5 adults walking around have or will suffer from depression at some point.

Eight of the top 10 highest suicide rates in teens across the nation are in the states in the west. In Utah, where I live, suicide is the #1 killer of kids aged 10-18 years old. In most states, suicide ranks in the top 5 causes of death in adolescents. That’s a huge problem.

Hopefully by talking more and more about it, we can raise general awareness of depression and help our kids who are suffering needlessly.

Kids Who Refuse To Go To School

Every parent has heard their kid say, in response to being told it’s time to get up and go to school, “my stomach hurts.” “I don’t feel good.” “I don’t want to go to school today.” “Can I just stay home today?”

I’ve had a recent surge in kids who refuse to go to school in my practice. Naturally, it causes a lot of stress for parents. Does my child really have “a stomachache or headache?” Or are they just feigning illness to avoid going to school? What is a parent to do about the child who simply won’t get out of the bed? Unfortunately, it is not generally one of those problems that get better with time. The more a parent allows a child to “not go to school,” the worse the problem tends to get. So the question remains: What does one do about a kid who refuses to go to school?

Step 1: Determine the Reason

The key to getting a kid to go to school is figuring out why the kid doesn’t want to go in the first place. There are a hundred different reasons kids don’t want to go to school, but they all essentially fall into 3 categories.

  1. Psychiatric causes: When a kid has an underlying psychiatric illness, doing seemingly simple things like attending school can be an insurmountable task.
    1. Examples include: anxiety and depression.
  2. Behavioral component: This area has a much broader scope. Examples include:
    1. Trying to escape an uncomfortable situation, like bullying by another student, a “mean teacher,” a stressful math test, etc.
    2. Seeking more attention or time with an important person, like a parent or peer.
    3. Desire for more entertaining activities, like playing video games at home or going to a local hangout.
  3. Special circumstances: These are much less common, but happen nevertheless
    1. Helping at home. If the parent is incapacitated or unable to do things necessary at home, the kid may stay home to care for the parent or younger siblings.
    2. Abuse. Kids may fear having bruises or injuries witnessed/reported by others.
    3. Truly sick kids. I categorize this as a special circumstance because parents usually know when their kids are sick and don’t make them go to school. I wouldn’t say a vomiting kid is a “refusal to go to school.” I’d just call that a sick kid. Occasionally, a child will really be sick and the parent won’t recognize it as such. This is rare (usually, the kid is trying to pull a fast one on the parents and feigning illness.)

Step 2: Make a plan

Once you’ve determined the reason for the school refusal, create a plan of attack.

  1. Psychiatric causes need medical help.
    1. Consider a therapist (psychologist)
    2. Determine if medication is warranted (with the guidance of your child’s doctor).
  2. Create a Behavior Plan
    1. Address any issues that can be feasibly dealt with (e.g., the bully, get a tutor for difficult subjects, etc.)
    2. Motivate successfully going to school. Create rewards or incentives for going to school (e.g., keeping a cell phone, earning media minutes, time with friends, etc.). School accommodations may need to be made for students in some circumstances (e.g., when a child is overwhelmed at school, the child may be allowed to go to the counselor’s office, etc.).
    3. Make the alternative (staying home) a horrible choice. Make staying home absolutely miserable for the child (e.g., no media, no cell phones, a Cinderella style list of chores, etc.).

Step 3: Follow through

  1. Once the plan has been established, get everyone on board. Discuss the plan with the school and the kid. Make sure everyone knows the plan and the consequences.
  2. If the kid refuses, hold him/her accountable.


I acknowledge how difficult this scenario is for parents, it’s much easier said than done. And every situation is so unique, what works for one kid, doesn’t necessarily work for another. In the last few months, I’ve helped many families come up with “a plan.” Here are examples of actual plans I’ve created with patients and parents that may help you to model your own plan.

I always start the conversation with the simple statement, “School is not optional.”

  1. Example A: Child has underlying depression, lacks motivation, and can’t seem to get up and to school. Consequently, child is failing and getting further and further behind.
    1. Plan: Parents and child to meet with the school counselor and teacher. The child agrees to: 1) Attend 100% (only excusing doctor approved medical illnesses), 2) Make an effort while in class, 3) Turn in at the end of class any work done in class (whether complete or not). The child does not then have to do any make up work or homework, simply show up and make an effort from here on out. The teacher agrees to: 1) Give the child a passing grade. I’ve yet to meet a teacher who isn’t willing to give a kid at least a “D” for simply showing up and making an effort while there. The life lesson is that you have to at least show up.
    2. It’s worth noting in this example that the kid also had to agree to take prescribed medication (and school was aware of underlying medical condition).
  2. Example B: Child refuses to go to school (stays at home playing video games while mom is at work).
    1. Plan: Neighbor takes child to school (since mom is at work). Video games removed and only given as a reward for going to school and getting homework done.
  3. Example C: Child complaining of daily stomachaches, “can’t go to school.” History revealed child was being bullied at school.
    1. Plan: Mom to meet with school counselor and parents of the other involved child and create strategy for helping bullying to stop. My patient was empowered with knowledge of “safe grown-ups” to talk to if it happens any more.

Caution: A word of caution about using “a home or an online” school program as a solution. I have had many parents, in desperation, resort to “home school” or “online” school when a child refuses to go to school. Every single case I can think of ended up going poorly when school refusal was the reason for initiating “home school” or “online” school. Ultimately, every parent says they wished they hadn’t, because it ends up compounding the problem. The child doesn’t magically start wanting to engage in academics at home as the underlying problem is not usually solved by home schooling. Usually, it just gives the child a stronger foothold for resisting school (because they no longer have to go to school and the struggle/conflict intensifies between the parent and the child). So be cautious if deciding to go down that road.

Recognizing Anxiety In Children

Recognizing and diagnosing anxiety disorders in children can be really tricky. There is often a lot of overlap between anxiety, depression, ADHD, and other disruptive behavioral disorders. Anxiety disorders is a broad term that encompasses generalized anxiety disorders, obsessive compulsive disorders, separation anxiety, and phobias (including social anxiety). As you’ll see, so many of the symptoms can fit into lots of different diagnoses.

Anxiety Symptoms

Must be:

Excessively worried and anxious about a number of situations (largely over exaggerated or unrealistic).

May have:

  • Guilt
  • Fear
  • Irritability
  • Poor sleep
  • Weight loss
  • Sleep disturbances
  • School problems (including not wanting to go)
  • Poor concentration
  • Restlessness
  • Experience brief panic attacks (with pounding heart, shaking, fear, sweating)

Should you treat anxiety?

If the answer is yes to most or all of these, you should strongly consider treatment for your child.

  1. Does the anxiety inhibit your child from normal life functioning (e.g., social interactions, school)?
  2. Is the anxiety present more often than not? (Specifically, has it lasted more than 6 months, more than 3-5 times a week, lasts for hours–not just a few seconds or minutes).
  3. The anxiety does not have another explanation that needs to be addressed (e.g., substance use/abuse, depression from a major life event like death or divorce).
  4. Is there a strong family history of anxiety?

How do I treat anxiety?

The most effective treatments utilize a combination of techniques: behavioral therapies, medications, and counseling,

  1. Behavioral therapies: these approaches work on teaching the child to changes his/her thoughts into a more positive context when faced with anxiety provoking situations. The child may learn relaxation strategies, distraction techniques, etc.
  2. Medications: Most anxiety disorders are treated with a class of medications called selective serotonin reuptake inhibitors (SSRIs). Interestingly, it is one of the same classes of drugs used to treat depression. Because of the complexity of the brain and the high rate of what are called comorbid conditions (meaning increased likelihood of having more than one mental involvement at a time), your pediatrician may look into treating other things first. For example, I have had patients with both ADHD and anxiety, and we’ve opted to treat the ADHD first. Personally, I don’t like throwing too many things at a kid all at once (it makes monitoring what’s working and side effects very difficult). Sometimes, fixing the biggest problem first, makes the second problem seem nearly insignificant and easy to manage without need for more medications.
  3. Counseling: I have seen some parents who have remarkable skills at being able to walk their child through panic attacks and anxiety provoking situations. While some of those parents have innate skills, many learned them through hours of counseling with their child.

What about the “not so bad, but still anxious” kid?

So if you’re reading this and thinking, ‘Yeah, but Dr. Wonnacott, what about my kid that has a tendency to be anxious, but I don’t necessarily want to medicate?’ First look at the grown-ups in your child’s world. Are any of them “high strung” or “anxious?” Is there anything you can do to help relax the grown-up who is influencing the child? Second, look into a number of the behavioral therapies that are used in kids with full-blown anxiety disorders. Even if your child doesn’t meet a complete diagnosis, many of the skills learned there can be utilized as you child encounters stresses as an adult (e.g., deep breathing, mindfulness, relaxation, counting, object focusing, body awareness).

You know your child best, and are best equipped to help him or her. If your child is really struggling, and you’re really worried, talk to your pediatrician. We’re here to help.

Postpartum Depression vs. Baby Blues: What’s the Difference?

The birth of a baby is a wonderful experience. However, many women feel sad, anxious, afraid, or angry after childbirth. The postpartum period is a time of extreme stress with the responsibility that surrounds such an enormous life change. This stress combined with the hormonal changes of childbirth can take a toll on a new mom. It is important for new moms, their family members/support system, and healthcare providers to recognize this stress.

Baby Blues

Somewhere between 70-85% of postpartum women experience some symptoms of “baby blues.” Baby blues causes a rapidly changing mood (the reason a new mom is happy one minute and crying the next). Other symptoms include irritability, trouble sleeping, and anxiety. Symptoms peak around the 4th or 5th day post delivery and usually stop by 2 weeks. These symptoms do not usually interfere with a mom’s ability to care for her newborn.

Postpartum Depression

Postpartum depression is different from the baby blues, symptoms are persistent and often more debilitating. Postpartum depression happens in about 10-15% of women. Symptoms of postpartum depression include:

  • Sluggishness, fatigue
  • Feeling sadness, hopeless, helpless, or worthless
  • Difficulty sleeping/sleeping too much
  • Changes in appetite
  • Difficulty concentrating/confusion
  • Crying for “no reason”
  • Lack of interest in the baby
  • Fear of harming the baby or oneself
  • Moms with postpartum depression can have some or all of the above symptoms. These symptoms often lead new moms to feel guilty, ashamed, and isolated. The important thing for moms to realize is that they are not alone. Many women experience postpartum depression. Their feelings are real. There is help.

If postpartum depression is suspected, please contact a healthcare provider. Some websites that I feel have good information include the following: (search “postpartum depression”)