When kids can't shake the blues

Michelle had already decided: This counselor could not help her.

So she folded her body up into the chair. She hid her face behind her hair. She would not give that woman a single word.

"I was in my own shell," said Michelle, now 20, who agreed to be interviewed on the condition that her real name not be used.

At the time, she was in eighth grade. She had just started carving neat little slices into her skin. One day, a teacher noticed blood stains on the sleeve of her shirt. The school later assigned Michelle a counselor from Youth Eastside Services.

She was diagnosed with major depression, a disorder that affects about 5 percent of children and adolescents, according to the U.S. Surgeon General's Report on Mental Health. It's marked by a cluster of symptoms that last longer than two weeks, from changes in sleep and weight to irritability and indecision. Often children drop out of activities and withdraw from their friends.

The average length of a depressive episode runs from seven to nine months, according to the Surgeon General's report. But people who are diagnosed with depression as children are more likely to have another depressive episode in their lifetime, according to the report; as many as 40 percent will relapse within two years, and 70 percent will relapse by adulthood. Childhood depression can be hard to detect. Some parents dismiss depressive behavior as the mood swings that come with growing up. Some kids don't know how to describe what they're feeling, or fear they will be rejected as different if they do.

But there are serious risks that come with depression. Most children who suffer from it also have another mental disorder, whether it's related to substance abuse or anti-social behavior, according to the Surgeon General's report. Depression is also a significant risk factor for suicide, particularly among girls.

The state's most recent Healthy Youth Survey gives some insight into the scope of the problem. The survey asked a random sampling of about 185,000 students about their feelings and behavior.

Nearly 30 percent of the eighth-graders who answered the survey said they felt sad or hopeless almost every day in the past two weeks.

About 1 in 7 said they had seriously considered suicide in the past 12 months.

Gender differences

It's unclear exactly what causes depression in children and adolescents. But experts agree genetics has something to do with it; studies cited in the Surgeon General's report show that 20-50 percent of depressed children and adolescents have a family history of the disorder.

There are also differences by gender, said Theodore Beauchaine, associate professor of psychology at the University of Washington. Beauchaine is studying the roots of depression and conduct disorders in children with funding from the National Institute of Mental Health.

In early childhood, he said, the rates of depression for boys and girls are about the same. But by the age of about 16, girls are twice as likely to suffer from depression, while boys are twice as likely to suffer from a conduct disorder.

"We think it has something to do with puberty, but we haven't put a definitive finger on it," said Beauchaine.

One theory: Because girls enter puberty earlier, they may have more years of intense, emotional experiences before their brains develop the coping skills they need. Another theory: It has something to do with the different ways boys and girls express their emotions.

Beyond the science of the brain, Beauchaine said, there are outside "stressors" that can contribute to any child's depression. For some, it could be the death of a parent. For others, it could be a family move from one side of the country to another.

A study in the Seattle School District is looking at how the move into high school affects children who have tested "vulnerable" for depression. Nearly 400 students and their parents have participated in the study so far.

Some children are given seminars in survival skills as they make the transition. Others are given no help at all. The idea is that basic life lessons, from time management to communication skills, can reduce the risk for developing depression as children move into high school.

Every year during the screening process, lead researcher Elizabeth McCauley, a professor in the department of psychiatry and behavioral sciences at the UW, finds students who are already depressed. The good news, she said, is that the district has resources available for those children.

A few years ago, concerned by the rising national rates of youth suicide, the district began a partnership with Public Health — Seattle & King County. There are mental-health counselors in 14 schools now.

Last year alone, those counselors saw more than 1,400 students.

Treatment

Even as awareness of childhood depression grows, there is still some question about how best to treat it.

One of the most promising practices is something called cognitive behavioral therapy. Experts say it's helpful even when a child is on medication. The therapy challenges a child's negative assumptions about life, even as it encourages behavior that can bring the child slowly out of isolation.

"One thing that's useful is to put them on a regimen of doing more," said Beauchaine, of the UW. "That in itself has mood-elevating qualities."

The therapist may encourage the child to make a coffee date with her friends once a week, or take a jog around the neighborhood. Anything to get the child out of the house, and into the world.

Anti-depressants remain controversial in some circles. The federal government warned in 2004 that they may actually increase the risk for suicide. But studies since have refuted that theory. Researchers with Group Health studied the records of more than 65,000 patients and found the risk of suicide declined significantly once they started taking the newest generation of anti-depressants, including Prozac.

The study, released last month, included about 6,000 children, 5 to 17 years old. That group was more likely to attempt suicide before medication, but the study found the risk declined once they started taking the drugs.

Beyond the safety concerns, McCauley, of the UW, said there is the question of whether children will take the medication they have been prescribed. A Medicaid study she worked on found that many kids stopped taking their medication for a variety of reasons.

Children are often resistant to treatment, she said, convinced that nothing will help. They don't want to take medication; it doesn't work fast enough. They don't want to start activities again; how can something so simple help, when the problem is so profound?

They have a hard time finding hope in the future.

"Adolescents are all-or-nothing thinkers," said McCauley. "It's very hard for them to say: 'I'm not popular now, but I'm going to be popular in college.' "

That's why parents play such a critical role in any child's recovery, experts say. They can provide rewards, support and a long-term vision that can be convincing to some children. Even if they are not part of a child's therapy, they can play cheerleader from the sidelines.

Michelle's parents provided little support. They had emigrated from Eastern Europe during the Cold War, and could not understand her kind of behavior — all this sleeping and crying and refusing to eat. Didn't she have food on the table? A room of her own?

"They were frustrated and saying: 'She'll be fine, she just needs to do her homework,' " said Debbi Halela, director of general counseling at Youth Eastside Services.

Medication did not work for Michelle. So Halela treated her for years with twice weekly therapy, encouraging her to talk out her feelings and write them out in daily journal entries.

But even with the counseling, and the journal writing, and the support of her teachers, Michelle struggled with suicidal thoughts for years. She developed an eating disorder. She couldn't stop cutting her skin.

"It just felt good," said Michelle. "It felt like I was releasing anger out of myself."

There were times when Halela wondered whether the girl could pull herself out of it, whether she wanted to stay sick, for the comfort of all that support. But during her third hospitalization, Michelle made a decision. She heard the pounding on the walls. She heard the screaming in the halls. And right then and there, Michelle recalled, she decided: This is not going to be my life.

Her grades improved later that year. She got a job. She stopped the cutting. And late in her senior year, she met the man she would marry. She told him one day about the dark places she used to stay — and he accepted it all. She went to bed that night, crying with relief.

Two years later, Michelle has a career in the health-care industry. She has plans for a five-child family. When she sits down to talk these days, her long hair is pulled back. Her face is lit bright with a smile.

Cara Solomon: 206-464-2024 or csolomon@seattletimes.com