In this, second part of my discussion of parenting plans for the special needs children I would like to focus on DEPRESSIVE DISORDERS IN CHILDREN AND ADOLESCENTS
Depressive Disorders in children and teenagers include the following diagnoses: major depressive disorder, persistent depressive disorder (formerly known as dysthymia), and disruptive mood dysregulation disorder. The common feature of all these disorders is the presence of sad, empty, or irritable moods, accompanied by bodily and cognitive changes that can signiﬁcantly affect an individual’s capacity to function. Children and teenagers who suffer from depression often have depressed mood and a diminished interest in activities, reduced energy for schoolwork, insomnia, fatigue, and poor concentration.
Depressed teenagers in particular frequently have suicidal thinking and/or engage in self-harming behaviors that range from cutting, burning, or other forms of self-mutilation, to actual suicide attempts. Needless to say, these children or teenagers require a very high level of parental supervision.
Teen suicide is the third leading cause of adolescent death in our country). Non-suicidal self-injury behavior (NSIB), a frequent behavior in suicidal teenagers, involves intentionally injuring oneself in a manner that typically results in damage to body tissue, but without any conscious suicidal intent.
The course of depression is highly variable, ranging from a brief depressive episode related to speciﬁc circumstances (i.e., breakup with boyfriend or girlfriend, a relocation and loss of friends, divorce), to more low-grade but ongoing despondency, now referred to as persistent depressive disorder. By deﬁnition, this is more chronic in nature. The course of depression is also related to the effectiveness of treatment interventions and the extent and effectiveness of support in the home environment(s).
Divorce and Childhood Depression
While there are both temperamental and genetic factors that increase the risk of depression, adverse childhood experiences also constitute a potent risk factor for the development of depression. An adverse childhood experience would most notably include a child undergoing the disappointment, loss and stress of a divorce. However, divorce itself may not always be to blame for causing depression in children, as the cause may sometimes be the environment in the household that led to the separation or divorce. In some instances then, a high conﬂict or unhappy home environment may precipitate depression in a child or teen prior to separation, but the separation event itself and its aftermath, may also precipitate depression. Separation and divorce increases the risk for psychological problems in children and teens, including depression, when compared to children in continuously married families, especially during the ﬁrst 2 to 3 years after divorce. Also, children with parents in high conﬂict marriages are more at risk for experiencing depressive symptoms, peer difﬁculties, and poorer academic achievement, than children in low-conﬂict marriages.
Loss of important relationships is also a major risk factor for depression. It is well documented that children view the loss of the nonresident parent after separation as the most negative aspect of a divorce. According to an important study of children from preschool to college age conducted by Braver, Ellman, and Fabricus (2003), sadness, pain, distress, depression, and longing for the father are persistent issues for children following a separation or divorce.
Parent–child attunement: Parent attunement to a teenager’s mood is critical with adolescents who are prone to depression. They must also have the type of relationship with their son or daughter whereby a teenager will reveal the extent of their depression, or disclose whether they may be struggling with suicidal ideation or self-harm behaviors. Detecting depression in teenagers is especially challenging, as the overt symptom may not be depressed mood per se. Rather, depression may be expressed or masked by, a high level of irritability or increased aggression. Nonspeciﬁc physical complaints such as headaches, stomachaches, or fatigue may emerge, as well as extreme sensitivity to rejection or failure. An increase in reckless behavior or substance use/abuse might also mask underlying suicidal thoughts. In my mediation practice it is critical for me to determine the extent to which each parent understands the extent and complexity of the teenager’s problem and is willing to actively support the youth’s participation in treatment. This includes understanding that there may be symptoms, such as suicidal thoughts, that require immediate intervention, including possible hospitalization.
Teenager’s safety: Mood disorders can sometimes precipitate truly dangerous behaviors, including suicidal actions or non-suicidal self-injurious behavior. Risk is increased when teenagers abuse drugs and/or alcohol, as well as when they have access to potentially lethal means of harming themselves. This would include access to prescription and non-prescribed medications, guns, knives, or razor blades. Thus, the question becomes whether both parents can provide necessary supervision and environmental safety commensurate with actual risk. Seriously depressed or suicidal adolescents are at far more risk in the home of a parent who balks at locking up potentially dangerous items, or who fails to recognize the disinhibiting inﬂuence of alcohol and drugs.
Structure and limit setting: Depressed teens need support to maintain their regular routines and structure, and should not be allowed to use their problems as an excuse for poor school attendance, not completing homework, and not maintaining household chores and participating in family activities. Limit setting is especially important for the suicidal teenager, who may need to be carefully watched by parents and have their socialization activities restricted for a period of time to ensure both their safety and ability to manage the social world. Parent availability is a crucial concern, not only with respect to monitoring a child’s mood and safety, but also regarding their ability to take the child or teen to psychotherapy or psychiatric appointments, or participate in family meetings. Consideration should be given to placing a depressed child or teen in the primary custody of the parent that is most willing to become educated about the problem, fully comprehends the risk involved, and is motivated to support and participate in treatment. Sound parent communication skills and a comfortable and comforting parent–child relationship are additional protective factors. Joint physical custody may be appropriate if both parents possess such skills, but if not, shared custody may be inappropriate. Essentially with depressed teenagers, preservation of life and participation in mental health treatment should take priority over a child-sharing plan.
Treatment support and advocacy: As with other special need disorders, there is a high demand on parents of depressed youths to support mental health interventions. This goes beyond sheer availability, as there are invariably parent and family components to treatment plans for these adolescents. Medication may also be indicated, but parents sometimes disagree with this medical intervention. If a treatment plan has been determined and one parent is unable or unwilling to support it, the parent who will cooperate with and facilitate treatment may need to have temporary sole legal custody for decision making in this domain. Additionally, some seriously depressed children or teenagers may be unable to function in a regular school environment for a period of time. They may need to be placed on a “home and hospital” program, whereby they complete school lessons and assignments at home, under the supervision of a teacher designated by the school. Such home-based interventions often either requires an IEP being completed by the school, or a psychiatrist’s or psychologist’s written diagnosis and recommendation to the school often compels the school to arrange a home and hospital program. This demands not only parent availability, but assertive advocacy. In such situations, typical joint physical custody plans for this age group are rarely appropriate.
Parent communication and co-parenting relationship: Sound co-parenting relationships and reasonably healthy communication between parents is a general protective factor in divorce. The opposite—poor collaboration and communication—are especially salient risk factors in families with seriously depressed teens. Particularly given adolescents’ normative tendency to hold private their thoughts and feelings from their parents, coupled with the fact that teenage depression is not always recognizable to adults, the stakes are high when one parents misses critical signs of danger. When one parent’s resentments toward the other trump their willingness to work together, the depressed youth is extremely vulnerable. We want to emphasize however, that while it may be advisable to place a seriously depressed youth in one parent’s home, there are further risks when the other parent drops out of the picture. Thus, the custodial parent should also be the parent who understands the teenager’s need to keep contact with the non-custodial parent and will facilitate that contact, despite a changed timeshare schedule. Seeking the input of teenagers is especially important in determining the best custodial arrangement for assisting the depressed child or teenager to improve his or her symptoms and reduce the possibility of suicidal or non-suicidal self-injurious behavior.