Sad, Mad, and Bad: What depression looks like in children

There are a limited number of mental health problems that are thought to affect kids. ADHD and Autism Spectrum Disorders are commonly diagnosed in childhood, while mood disorders are most common in teenagers and adults. However, this doesn't mean that children don't get depressed. Children experience depression differently from adults, and thus their symptoms can look very different. This can result in depression being underdiagnosed in kids, or not diagnosed until they are much older, despite early symptoms.

The most commonly known symptom of depression is depressed mood. In children, this can look more like irritability. They may have more outbursts, break down crying more often, or not get along as well with friends and family as they used to. The next most common symptom is anhedonia, which means less interest in pleasure. Kids may be less interested in seeing their friends or participating in favorite hobbies and activities. They might even come up with excuses or feign sickness so that they can stay home from a friend's birthday party or miss an outing. Adults often experience significant weight loss or gain, though this can be difficult to track in kids; instead, we need to look at where they are compared to their expected growth and weight gain. Kids are also more likely to have bodily symptoms, such as headaches and stomach aches, and may go to the nurse's office a lot with such concerns.

Of course, this is not to say that kids never experience adult depressive symptoms. Sleep problems are common with depression in adults and kids, as are feelings of guilt and trouble concentrating. However, kids are more likely to have trouble expressing these symptoms. They might not understand depression at all, or have the words to say what's going on for them. Even if they do, they might be afraid to express it. Depressed kids often withdraw from their families. If your kid avoids telling you about their day at school, they may be avoiding telling you about their difficult feelings, too.

Suicidality in depressed kids can be a tricky subject. Just because they're kids doesn't mean they don't get suicidal ideation, but not all talk of death indicates suicidality. This is especially true in elementary age kids, who may be just processing the idea of death or suicide, and who may be repeating things they've seen in the media or heard from friends. When kids talk about death, it's important to ask about the meaning of what they say and get a clear picture of what's going on for them before jumping to conclusions. The national suicide hotline (1-800-273-8255) has a youth division, and their website has many resources specific to many common causes of suicide in kids and teens, like bullying, gender/sexuality, abusive relationships, and more.

Many kids don't feel comfortable talking to the adults in their life. In some cases, it can be as simple as making sure they know you are a safe person to talk to. Talking about your feelings can help them feel more okay being open about theirs (even something as simple as "I'm frustrated that the waiter hasn't taken our order yet" or "I'm so tired from work"). Being more explicit about the okayness of difficult feelings might be necessary for some kids to safe talking about their difficult feelings. Just make sure you don't pressure your kids into talking to you. It's like one of those finger traps: pulling hard doesn't get them to open up as well as gentle nudges do.

If your kid won't talk to you, or you aren't sure you can help them on your own, therapy can be hugely beneficial. Not only can a therapist teach your kid about their emotions and how to deal with them, but they can also help you and your child open up to each other more. Cognitive Behavioral Therapy can teach a kid how their thoughts aren't always reliable (i.e. jumping to conclusions, minimizing strengths and maximizing problems, etc). Narrative Therapy can help kids explore who they are in relation to the world around them -- which can be important for kids nearing puberty. Gestalt Therapy can help kids process any bottled up feelings. Therapy can also help kids gain the communication skills necessary to talk through problems and difficult feelings with others. Many kids don't feel comfortable talking to the adults in their life, but are willing to talk to a therapist; often times the therapist is the only person in the kid's life who doesn't have expectations for them, and this makes them safe to talk to. A therapist isn't going to have a kid wash dishes or take a math test, and most kids understand that therapists are there to listen and help.

While childhood depression sometimes goes away, it can be hard to distinguish from lifelong depression in the moment. Untreated depression can make it hard for kids to learn, make friends, and thrive in their daily lives, and can thus affect their long term development. Symptoms of depression also often overlap with symptoms of other illnesses, mental and otherwise, so it is important to bring up any symptoms your child shows with their doctor. If handled effectively, childhood depression can often recede and leave no traces in adulthood.

Time vs Task: Bounds of attention

I once worked in a special needs class that consisted mostly of kids with Downs Syndrome and Autism Spectrum disorder. There were many patterns I noticed that ran through both groups, but at the end of the free period when we had to draw the students' attention back to classwork, one difference became clear: their attention spans.

Kids on the Autism Spectrum would drop what they were doing as soon as they were told that it was time for lecture. To these kids, making sure everything scheduled happened on time was important; if something came up and they had to skip math, they would be distressed -- even if they didn't really like math. In contrast, kids with Downs Syndrome wanted to finish what they were doing. If they were in the middle of a puzzle, they had to finish it. If they were watching a Youtube video, they couldn't hit pause until it was over. We'd have to keep track of their activities and anticipate when a good time to pull them away. If a kid was listening to music, we'd approach them five minutes before the end of the period and allow them one more song.

This is not meant to draw boundaries between diagnoses (not every person with one of these conditions will act like the kids in my class did), but it does illustrate two very different approaches to attention: time-bound and task-bound. Someone who prefers to stick to a schedule is more likely to have time-bound attention, finishing a task when it is time for the next task, even if the previous task isn't completely finished. Others may be more task-bound, preferring to finish one task before moving on to the next.

To apply this to yourself, imagine being a child reading your favorite book before bed. You are told that it is time to go to sleep, but you are in the middle of a chapter. How reluctant are you to put the book down? Regardless of how good the book is, are you willing to go to bed before the chapter is done?

Variable answers are expected here. A gripping mystery novel is going to treat your attention differently from a comic book, in the same way that activities you enjoy feel different from those you don't. A person's willingness to move on to the next task may depend on many things, including time spent or remaining in the task, time until you can return to the task, enjoyment, and rarity of the task. You may be more reluctant to leave a party if you are talking to a friend you haven't seen in months, or if you just started playing a particular game with them, even if your attention is typically more time-bound.

Stress can come up interpersonally when one person is time-bound and the other is task-bound. If two people are putting together a puzzle and it's time for dinner, one might want to pause to eat, while the other might want to finish the puzzle first. Similarly, if a person who is time-bound is waiting on someone task-bound, they may end up waiting longer than they expected, depending on what the task-bound person is doing. It is important not to act like one of these ways of viewing attention is "correct"; they both have strengths and flaws and places where they are more or less appropriate. Just as it may hurt to stop an important conversation before wrapping up because it's "time for lunch", it would be inappropriate to drag an appointment over time if one or both parties has another appointment right after.

Next time you find yourself in a battle between the task at hand and the next task, notice where your attention is drawn and why. Notice how fluid this is -- your willingness to be time-bound when you want to be task-bound, or vice versa. Your answers may differ each time you try this, or they may show consistent patterns in your behavior. And once you've noticed these patterns, you can better examine how that changes the shape of your life.

Friendzoned: How gender affects emotional support

Some of the first questions many therapists ask a client are those meant to assess their friendships and other close relationships. This is because having a supportive community is one of the biggest strengths in those facing mental health problems. Whether it's Generalized Anxiety Disorder or grief over a breakup, having people you can lean on for emotional support can help a lot.

Women are more likely to have such social supports than men. Part of this is due to traditional gender roles and expectations. Emotional vulnerability is considered feminine, and thus more acceptable for women than men. Of course, anger is an exception here, given that it is linked with violence, which is linked with masculinity. So men are more likely to come in with anger issues, while women are more likely to come in with anxiety and depression.

The second part of this phenomenon is the difference between male and female friendships. Because emotional vulnerability is acceptable in women, it becomes an important part of the way women connect with each other. You can see this in media directed at teen girls: they support each other at best and tear each other down at worst, but it's all based in their ability to be vulnerable with each other. The trope of the girl giving her friend a makeover isn't just about looks; it's about self-esteem. The image of a group of friends watching a sappy romance movie and eating ice cream after one of them was dumped isn't just about being there for the friend; it's about empathizing and validating her emotions.

So what happens when you remove the emotional vulnerability from a close friendship? You get something close to what male friendships look like: a connection based in mutual interests, activities, and practicality. While it's not uncommon for two women with very little in common to become friends, this is far more rare with men. A guy's best friend may be someone they go to the gym with, someone they sit next to at work, or someone who reads the same books they do. A girl's best friend is likely to be someone who knows her more deeply than anyone else.

Of course, this is not to say women don't have shallow friendships and men don't have deep ones. Even media sometimes portrays men with emotionally deep relationships. Usually, however, this is referred to as a "bromance" and is played for laughs. It's not often these kinds of relationships are shown between multiple men, much less being shown as the norm. When it does show up, it's far more likely to happen between brothers, work partners (ie co-detectives), or best friends. Further, this model is based on Western gender norms, and thus might not apply to everyone in the same way. Some cultures reinforce emotional support more or less, and in different ways. Western gender norms don't account for other gender identities either. Those who are nonbinary or from other cultures might find that this applies differently, or not at all. Still, this is a useful frame to apply to others, especially in noticing different expectations for a close friendship or romantic relationship.

Speaking of romantic relationships, this often ends up being where men get most of their emotional support from. This is especially true in a heterosexual relationship, where the woman sees emotional support as part of any close relationship, not necessarily something specific to romantic situations. In a sense, a man is more likely to put all his eggs in one basket. His girlfriend can get her emotional needs met elsewhere if need be, but to him, she is likely the only person he can talk to about his troubles. This is why, statistically, the end of a long-term relationship affects men more harshly than women. If your emotional support comes only from within a romantic relationship, being single means you don't get any support. Worse still, men who struggle in their dating life have little to no support around this struggle, which in turn makes it harder to date. It becomes a downward spiral.

What about friendships between men and women? Well, this is where things get complicated. The old adage "Men and women can't be friends" probably comes from these different perspectives in what a friendship consists of. This is also why a woman whose friendship with a man is high in shared interests and low in emotional intimacy might be seen as "one of the guys". Since men usually only get emotional intimacy from romantic relationships, they think of this kind of closeness as a hint that the woman is interested in them romantically. This link is so ingrained that some men may associate emotionally close male bonds with gay relationships -- note the root "romance" in the phrase "bromance", and how often media makes fun of close male friends by calling them gay).

This is where the idea of the Friend Zone comes into play; this phrase has come to exemplify the difference between male and female relationships. A guy who feels he has been put in the friend zone by a girl probably saw the potential for a romantic relationship due to their emotional connection -- something that is rarer for him than for her. However, the girl may feel like she was seeking a perfectly normal friendship with a guy, only to be surprised that he was seeking a romantic relationship with her! In both cases, expectations didn't match up, and this can lead to the end of the relationship. The guy doesn't understand why the girl would provide and ask for emotional support while wanting to just be friends, and the girl doesn't understand why the guy would assume she was romantically interested when all she was doing was being a good friend.

It is important to note that while traditional gender roles can sometimes feel like they doom us to a certain kind of life, the world is shifting rapidly. On any middle or high school campus you can often find a few guys who prefer to make friends with girls, and vice versa -- often because of the ways they prefer to have friendships. More and more, people are picking and choosing what parts of their expected role they want to hold on to, if any. A particularly introverted woman may not want to have friendships that are about anything but shared interests, and this is okay as long as she finds other ways to regulate and process her feelings. Someone else may have a best friend they rely on for emotional support, and many other friendships based on a shared hobby. Finding something that works for you matters more than doing what other people decide is the right way to be healthy.

I want to encourage you to examine how traditional gender roles affect the way you build your friendships. Even if you don't identify as a man or a woman, the existence of these roles and friends who do or don't ascribe to them can have an impact. Someone raised a woman may feel they are expected to do emotional work for all their friends because this is what it means to be a good friend. Their friend may have been raised to see male roles as being preferable, and thus not want to be emotionally close with or show weakness to any of her friends. There are many ways people can respond to expectations, and even the "emotional closeness vs interest focused" dichotomy is overly simplistic and contains many other dynamics within it. But having emotionally close relationships (even just one or two!) is a protective factor for those with lots of life stress. If you find yourself bottling up strong emotions, needing to talk to someone but not feeling like you can reach out, consider opening up to someone a little. It doesn't need to go deep fast -- you can start with how much you hate being stuck in traffic or that you're upset you have to work on a Friday night. And if they respond in a way that feels good? Then, this might be the start of a beautiful friendship.

The Dark Side: Emotional regulation and kids

When young kids are struggling to deal with strong emotions, it can be difficult to explain what's going on in a way that doesn't shame them for having feelings. Further, it can be hard to find ways for kids to deal with those strong feelings. Meditation, yoga, and journaling all seem like the kinds of things that would bore kids, and explaining to them why habits like these can be important is difficult -- especially for kids who struggle to think abstractly!

Most kids respond well to examples they can relate to, either in their daily lives or in fiction. This is why many children's TV shows will demonstrate a dilemma and show the main character's search for a solution. Shows aimed at younger kids may include jingles or catch phrases to remind kids of the skills the show is trying to teach (such as manners, problem solving, and conflict resolution). Connecting material kids learn to the media they enjoy engages them and helps with understanding. It is no wonder that so many teachers write math problems and spelling test sentences about popular TV, movies, and games. The same idea can be easily applied to the social and emotional skills we teach our kids.

Perhaps my favorite example of this is a metaphor connecting Star Wars and emotional regulation. In the series, Jedis (basically magical space knights) use something called The Force to harness supernatural abilities. These abilities can help them in combat, interpersonal situations, and in daily life. The Force is described as having a dark side and a light side, which can hurt or help people accordingly. Put the supernatural abilities aside, and a lot of this sounds like things you could tell a kid about their emotions.

Many kids who know Star Wars know Kylo Ren, the newest villain to be introduced in the movies. Kylo Ren is often shown to be angry and destructive. It is heavily implied that his anger outbursts are part of what drew him to the dark side in the first place. By contrast, Jedis like Obi Wan are often shown to be calm and collected. They even meditate! This can serve as an example as to how emotions (like The Force) can be destructive if you let them control you. Jedis undergo years of training to learn how to use The Force safely, just as many of us may go to therapy to learn to regulate our feelings.

Jedi meditation is described as being necessary to harness The Force, and while meditation may not work for all kids, the description of it (examining each thought or feeling and letting it go) may help with finding emotional regulation techniques that do work for them. While diaries are less common than they used to be, many kids still use different types of journals, online and off -- this is, in fact, why some kids post so much on social media. Arts and crafts can be helpful for kids who aren't as good with words, as can sports and movement (like running or playing soccer if not yoga or dance). Many activities that are built for kids can help here, but don't underestimate a kid's ability to meditate (guided or otherwise!) or write just because of their age.

Even if the Star Wars metaphor itself doesn't work, a lot of the media kids consume have deeper messages and themes. So next time you want to explain a difficult social or emotional concept to a kid, look at their favorite books, movies, and TV shows. You might find an example already woven into the story.

When To Go To Bed Angry

Popular advice for struggling couples is to never go to bed angry. The thought is, to work on problems when they're fresh, rather than letting them simmer until they explode. While this is great advice for some couples (enough so that some make it a policy or rule within their relationship!) it can add to the tension for others. Why? It may lead to staying up trying to talk through issues when both people would rather be asleep. While it is important to talk about things that come up rather than putting them on the back burner, trying to talk things through when one or both people don't have the energy to do so can make the problem worse, not better.

This isn't just about arguments before bed, either. On the way to dinner with the in laws, while driving up a particularly difficult road, and before work are all times when an argument might feel particularly inopportune. Being able to save something like this for later is an important skill, both for an individual and especially for a couple.

If the thought of doing this makes you anxious or upset, notice that! There may be valid concerns underlying there, and maybe just waiting for a more opportune moment to talk things over isn't the best way of handling this. Does having to wait to bring something up make you feel like you're going to explode? Do you worry that the problem is going to be forgotten about and never discussed? Are you likely to forget all the emotions around the problem in the morning, and undersell yourself? These thoughts and feelings are important to take note of, so don't just push them aside. This is all information that you can use.

Something that might help quell these fears of putting off a discussion is to record your feelings while they're fresh. Any time you put off a discussion for a time when emotions aren't as high, it can feel like you're likely to forget something or sell yourself short. Depending on how you best process information, you can try writing something down in a journal, typing something up in Word, or recording yourself talking into your phone. You can format this like a list of talking points, pretend it's a letter or voicemail to the other person, or just ramble until you have nothing left to say. Later, when it's time to discuss the problem, you can choose to show the other person your recording or writing directly, or read/listen to it yourself and tell them whatever you feel still sticks. It's entirely possible that you'll realize that you completely disagree with your past self, and that's perfectly okay! This is part of the reason why it can be good to put off discussions like this in the first place -- anger and fear can cloud discussing what's really going on.

Getting some distance from an argument can also help in making sure you don't play your normal role. If you're likely to get angry and your partner tends to withdraw in fear, keeping a calm head can help your partner stay engaged during what might otherwise be a rough conversation. Looking back over your thoughts, you may notice somethings that come up when emotions are high, such as blaming, hiding, or defensiveness. Notice what tactics you're prone to using. And next time you and your partner start to argue, see if you can change the normal course of it -- even if that just means talking about it later.

Distraction techniques: active, passive, and regulatory

When life gets difficult, it can often become tempting to distract yourself from your own thoughts and feelings. Loved ones may scold us for this, telling us that we should confront our feelings, because distracting ourselves doesn't accomplish anything. However, distraction is an important part of distress tolerance. Imagine Jill, a young woman who, in typical romantic comedy fashion, gets fired and dumped on the same day. Sure, distracting herself isn't going to help her find a new job, but binge-watching her favorite TV series would give Jill time to let her emotions around the problem cool down before she decides to start working on it.

Of course, different kinds of people may require different kinds of distraction. For Jill, a more passive distraction like watching TV is perfect; she may not have the energy to do much else. However, her now-ex Bob is worried about how awkward their break-up is going to make things with their mutual friend group. If he sat down to watch TV, he would still be worrying about it. Bob needs a distraction that he can throw himself into, something that takes so much effort and focus that he can't spend any time worrying. So instead, he decides to pick up his guitar and practice a new song he's been trying to learn. Bob opts for a more active distraction.

The examples above not only show the difference between passive and active distraction, but also how to match what kind of distraction you need to your mood. For a lot of people, depression makes it hard to do things, so a more passive distraction may be preferred. Jill would not have had the energy to practice an instrument while depressed. On the other side, anxiety often manifests as a sort of nervous energy, which can easily be redirected. Of course, this isn't the case for everyone. Some people find anxiety paralyzing, so they may prefer a passive distraction despite being anxious. The important thing here is that the activeness and passivity of your distraction match your energy level.

What some people find to work as a distraction, others might find works better as emotional regulation. Maybe the real reason Jill didn't want to play music is that it wouldn't distract her at all, and would instead remind her of Bob even more! A few days after the break-up, Jill may still be feeling sad and missing him, so she sits down at her piano and plays the saddest song she knows. Here she is not using music to distract her from her feelings. On the contrary, she is leaning into her emotions, and letting them out. The song she plays could be the same exact song that Bob was trying to learn on his guitar; the important thing here is the approach. Jill is choosing an activity that matches her mood. If she was angry about the breakup, she might play an angry song, or go to a kickboxing class. If she was sad, but didn't want to play music, she might write a long letter to Bob, then shred it.

Not only is distraction anecdotally helpful, but research has been done to track symptoms in those who do and don't use the technique. A Swedish study showed that patients admitted to the hospital after a car accident were less likely to develop PTSD if they played Tetris within a few hours of admission. Some of the core symptoms of PTSD involve recurring thoughts, intrusive memories, and flashbacks, and it is thought that distracting a person from ruminating over the event blocks this pattern from forming. Those who distracted in this study had fewer intrusive memories in the week following, and these intrusive memories diminished faster. An earlier Oxford study showed that in a case of simulated trauma, playing Tetris was the best of three options, with taking an online trivia quiz as worse than doing nothing. This indicates that choosing the wrong distraction technique (in this case, a passive one rather than an active one) can actually be hurtful. In this case, it makes sense that a failed distraction could actually train the brain to ruminate even while occupied. A distraction must be sufficiently distracting without being overwhelming.

This is not to say that distraction is always the best technique to use in a given situation. Distraction works best as distress tolerance, and is not a replacement for emotional regulation. As discussed above, the two work differently. Distracting yourself instead of using emotional regulation can lead to unprocessed or buried thoughts and feelings. In the moment, it can be hard to tell whether distracting yourself is helping or not. Different people have different tells (losing track of time, forgetting to do something important like eat lunch, etc) but generally, distraction should make you feel better, not worse. If you feel worse after a period of distraction, it may not be the right technique to be using. So next time you are feeling overwhelmed and need to veg out, go ahead! Just take the time to think about the kind of distraction you need first. 

The two types of Self

When you think of the Self, do you imagine it as something growing and changing, or consistent over a person's life? The definition of the Self is arguably one of the biggest differences between classical and postmodern psychology. Classical theories have their basis in the idea of a True Self, a fundamental unchanging part of a person that stays with them since birth. They may talk of upbringing, life circumstances, and social influence as things that change behavior, but they never change who you are underneath all of that. An artist may always be an artist, even in a world where they had no choice but to sell bread and raise children.

Postmodern theories of psychology look at the ways our behavior changes overtime, and instead see the Self as that which changes. Just as a person can change what they like, they can change who they are. A rambunctious teenager can change and become a stoic adult, and this isn't because they became any more or less in touch with a True Self, but because that Self changed, whether due to social pressure or just maturity.

These different perspectives change the ways clinicians approach their clients. A therapist who believes in the True Self may push a client to become more in touch with lost parts of themselves, while a more postmodern therapist might push a client to grow and change, exploring new hobbies and not remain attached to certain parts of their identity. I want to propose a third idea, which is that this theoretical rift is caused by two different definitions in the word Self.

In a sense, this debate is no different from nature versus nurture. While popular science shifts focus between the two, the truth is somewhere in the middle. Some of who we are is in our genes (brown eyes, wavy hair, a bit of a sweet tooth). The rest (taste in music, friends, hobbies) is influenced by how we are raised. So it can't be radical to suggest that between the True Self and the Changing Self, both as well as neither are true.

The two types of self I want to talk about are those I call the Momentary Self and the Lifetime Self. While there are parts of a person that never change (LS), it is impossible to ignore the ways in which parenting, culture, trauma, and major life events can change a person (MS). Difficulty comes with distinguishing which parts of a person are part of which Self.

Perhaps the most salient example of this in recent history is the debate on where sexuality comes from. While there is a major movement of people who believe that LGBT identities are inherent, there is a significant population that doesn't feel this to be the case. For example, people who have experienced traumas in early childhood may feel that those traumas made them gay or lesbian. The fact that they weren't "born this way" doesn't make their sexuality any less valid. Further, some feel their sexuality is fluid; not only has it changed, but it is likely to change again in the future. While the first population may have sexuality as part of their Lifetime Self, these people may see it as part of their Momentary Self. For a less controversial example, you can note the difference between someone who has been highly social since birth and someone who has taught themselves to be more social. Both may see extroversion as a trait they have, though they came about it in different ways.

It can require a lot of work and introspection to know which parts of yourself are Lifetime and which parts are Momentary. The assumption of identity being one or the other is dated; it may take more work, but sorting through the parts of Self can do a lot to settle things like self esteem and compassion. Trying to change something that's part of your Lifetime Self can be frustrating. Insisting that part of your Momentary Self is stuck like that forever can be stifling. Letting these parts speak for themselves can be freeing.