Childhood depression is a different animal. We are more apt to see proneness to irritability, challenging behaviors and physical complaints. Children and the elderly may be decades apart in having much in common, but one thing is for sure: identifying depression in both can be tricky.
Working in a juvenile court, I see a lot of unruly kids. If I had to guess the percentage of our referrals toting an ODD diagnosis history, I’d say it approaches 50%. I joke that my job is to disprove all court-involved youth have ODD (and ADHD). Like ADHD being quickly applied to a fidgety kid, ODD is often a knee-jerk diagnosis for youngsters who are irritable/argumentative and unmotivated/only do what they want to do. If we cross-reference these “ODD” symptoms with depressive symptoms, however, there’s plenty in common and room for error.
Suggesting a child’s ODD could well be depression, I’ve often met with two arguments:
- “But he’s been this way for years!”
- Depression is usually thought of as something that is distinctly episodic. ODD tends to be seen as a personality issue of sorts given the tendency towards 1) long-standing patterns of 2) maladaptive interpersonal interactions and 3) reactive moodiness. These are three hallmarks of personality disorders, and it is easy to see some roots of the misconception. With this in mind, a key to sorting out depression from ODD is to consider that depression can be chronic (considered chronic in children if lasting at least one year [two in adults]).
- “What does she have to be depressed about, she’s a kid!?” Essentially, it must just be that she’s an ingrate with an attitude.
- Unfortunately, depression is not uncommon in youth. The Centers for Disease Control (CDC) note that upwards of 4% of children aged 3-12, and over 6% of kids aged 12-17 suffer from the disease. As we’ve seen in The New Therapist series on Major Depression beginning on 07/12/2020, depression can be endogenous. In other words, “it just happens;” nothing environmental needs to set it off. However, we also know that just because life looks rosy doesn’t mean it is.
Elora’s case illustrates both points nicely:
Elora, 13, is the only child of Rick and Amber. Rick, an attorney, often works late, rarely seeing her during the week. Amber is a nurse practitioner who, despite a 7-3:30 position, is often on call or socializing when with Elora in the home. They take expensive vacations and have every luxury. Since elementary school, Elora was a bit temperamental, but her parents figured she’d outgrow it. Now, in 7th grade, she had consistent “attitude,” especially with Amber. Everything was a power struggle. Elora’s grades dropped and her parents were on her back. Rick never reached out to her for fun, but blew up her phone with good grade pep talks. Their message was clear: Elora was expected to follow in their footsteps and be an academic all-star. She never knew anything different and was getting bored with it. Last year, Elora would sometimes sneak out and not bother doing her homework. “I want to feel alive,” she said of the excitement in getting one past her parents.
Besides, nothing was good enough. “A? Why not an A+?,” her parents would say. The older she got, the higher the pressure. This school year, Elora developed stomach discomfort and headaches. Amber told the school nurse it was just a school avoidance tactic and not come get her. Feeling invalidated, Elora would erupt at Amber when she got home. They’d argue until Elora left against Amber’s commands, or locked herself in her room and sobbed herself to sleep. Lately, the physical complaints increased and Elora began refusing to go to school. “We give you everything!” Amber would scold Elora, “All we ask is that you go to school and try your best, and we get nothing in return!” At a school meeting to discuss Elora’s concerns, it was sensed there was significant tension in the family and the school made a referral to Dr. H. In his office, Elora explained that she hated her parents and never felt good enough. She was groomed to be a “trophy child” to show off. Elora envied her friends who were allowed to just be kids. As she tired of being pushed to the limit academically, Elora loosened her grip on her studies. She also knew that doing the “bare minimum” to pass would irritate her parents; it was a way of shifting the power dynamic in her favor.
At first glance, Elora is a misbehaving brat. Looking closer, her behaviors were fueled by feelings of inadequacy, invalidation and losing out on childhood. Her boredom/unmotivated state is seen as defiance. Her somatic symptoms were conceptualized as opposition. Kids and teens aren’t the most articulate people yet, so she lashed out in anger to show her emotional state, and arguments ensued. Clearly, children with emotional problems are at risk of being seen as a problematic kid, and faulty treatment follows.
Tips for recognizing depression masquerading as ODD:
- Longstanding “attitude” isn’t necessarily a personality trait. Consider that depression can be chronic, even in children.
- Don’t assume anger and irritability are just sass. Children, especially teen boys, are prone to irritability, not sadness, when depressed.
- Find out what’s on the child’s mind. Are they dwelling on the past, or apprehensive about the future like we see in depression?
- Feelings of inadequacy, hopelessness, and little-to-no future orientation indicate depression.
- Schema questionnaires or thought inventories can be helpful with children, who may not be able verbally articulate what’s behind the feelings. ODD kids are not likely to harbor such a depressive theme to their thoughts.
- Children with depression are very prone to somatic symptoms (McCarthy, 2018), especially headaches and stomachaches.
- Lack of follow-through is often caused from the depressive features of boredom and lack of motivation. In ODD, lack of follow-through is akin to passive aggression.
- If appetite and sleep disturbances, and fatigue are present, depression is likely.
- Children with ODD don’t tend to socially isolate, depressed kids do.
- Depressed kids are not as likely to be vindictive nor make habit of intentionally irritating others like ODD kids.
If the course of the long-standing “ODD” symptoms have occurred in the company of social isolation, appetite disturbances, sleep problems, lack of motivation and poor self-esteem, chances are the “bad kid” should be treated as a depressed kid. Being a kid or teen is hard enough. Imagine those trials and tribulations coupled with feeling like hell and maybe not even knowing why, only to have people constantly telling you to shape up?
Kids like Elora need depression-focused treatment, not finger wagging. In turn, the behavioral dysregulation often takes care of itself. Chance are, there’s a good kid trying to reveal themselves. Let’s help them not miss out by not jumping to ODD conclusions.
Centers for Disease Control and Prevention. (2020, June 15). Data and statistics on children’s mental health. https://www.cdc.gov/childrensmentalhealth/data.html
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.
McCarthy, C. (2018, March). In children and teens, depression doesn’t always look like sadness. Harvard Health Blog. Retrieved from https://www.health.harvard.edu/blog/in-children-and-teens-depression-doesnt-always-look-like-sadness-2018031313472