Until the 1980s, it was generally thought that children could not become depressed. Now researchers recognize that children, like everyone else, are not immune from this insidious and dangerous disease. Because children often do not have the capacity to step back, look at themselves, and recognize that the way they're feeling isn't normal for them, diagnosis and treatment of depression is more difficult than for adults. It used to be thought that depression was caused by the loss of a loved one and the action of a punitive superego on the self — a harsh way of evaluating oneself against standards that are impossible to meet. But now it seems to be accepted that depression is much more complex than that, perhaps with a genetic component, certainly a psychophysiological disease that affects thought, emotions, behavior, and the body.

Depression can present a confusing picture in children and adolescents. Sometimes children will let it be known that they feel hopeless, empty, or permanently sad — the signs we look for in adults. But more often children cannot express their feelings so directly and we must interpret their behavior. Children, especially boys, may simply appear unusually angry or sullen. If this mood is unrelieved for more than a week, and especially if it does not seem to come in response to some real disappointment or loss, most likely the parent should seek help.

Other signs of depression in children include changes in appetite or energy level; sleeping a great deal more or less than usual; a drop in school performance; and excessive worrying. Especially worrisome is a loss of interest in things that used to give pleasure, as when a child seems not to care any longer for favorite toys or activities. Injuries that may seem accidental may have been the result of carelessness. The child may talk about death or thoughts of punishment.

Though it's clear now that preadolescent children do suffer from depression, the actual incidence is not known. Diagnosis is difficult. Estimates range from a few tenths of a percent to the 15 to 20 percent that is found in adults. One estimate which fits our experience is that 10 percent of all children will suffer a depressive episode before age 12.

It's well recognized now that suicide, usually a result of depression whether diagnosed or not, is on the increase among teens. But thoughts or wishes of death, and self-destructive behavior (often misinterpreted by adults as risky or dangerous play) are increasingly reported by young children. The idea that a child might think of taking his or her own life is horrifying and repugnant. And while we may be able to entertain the idea in theory, in real life when we run across such a child, perhaps in our own family, our denial kicks in.

Every child therapist can tell stories about seemingly caring parents who were unable or unwilling to take the simplest concrete steps — locking up medicines, getting rid of guns — to protect a suicidal child or adolescent. Therapists, teachers, physicians and others who know the child can get fooled as well, so that though a child or teen may sound seriously depressed to a neutral third party, we're so close to the picture that we don't get the complete message. I have talked with a surprising number of adults who remember suicide attempts as a child or teen. They were upset and hurt, felt that no one cared and that life wasn't worth living. They took a bottle of pills and went to sleep, expecting never to wake up. Fortunately, they weren't knowledgeable about the lethal dosage. Because they were convinced that no one cared, they told no one. But things got a little better, and they didn't repeat.

That's the best news about depression. It usually doesn't last too long. Patients usually respond well to treatment, both medication and psychotherapy. Parents can often make some adjustments in the way the family interacts to help a child or teen feel better.

The bad news is that so few get help when they need it. Among depressed adults, only one in three is treated. In one study of 27 severely disturbed teen suicide victims, only two were being treated when they died, and only one-third had ever been seen by a mental health professional.