The Differential Diagnosis of Adolescent Depression

Adolescence is both a time of tremendous gains and some inherent losses. You can help your teenage patients through this turbulent time by asking a few specific questions, checking their psychosocial functioning, and distinguishing the somewhat common depressive symptoms from a true depressive disorder. Approximately 10% of patients will need further evaluation sometime during their adolescence, and a few will require urgent referral to protect their safety if you uncover any suicidal ideation or planning.

As children enter adolescence, they make major gains – in intellectual capacity, autonomy from their parents, and physical stature – all things that bring them closer to adulthood. Increasingly, they readily go to school independently, even driving during the later high school years, and participate in activities with less or no adult supervision.

We often look at adolescence as the second major time in life, the first during the beginning 2 or 3 years of life, with rapid, multifaceted growth. But what people often don’t appreciate as much is that, as a child becomes a teenager, they lose a bit of their childhood. Part of the expected moodiness of adolescence stems from puberty and hormonal changes, but some also comes from an unspoken, even unconscious, undercurrent of loss.

The home is no longer seen as the center of their universe. Developmentally, adolescents become closer to adults who are not their parents. They might suddenly become develop an intense relationship to a teacher, coach, and friends. This is often appropriate as they transition to adulthood and test out different relationships. Teenagers often have several of these close ties and integrate aspects of these relationships into their emerging identity. Teens learn to transition from counting on their parents, to relying on friends and, in early adulthood, looking primarily to themselves for decision making.

In our society, this transition often takes about a decade, starting when a child is 12 or 13 years old. Educational requirements have extended this transition, so it doesn’t end for many people until they are out of college.

You can see a variation or cycling concerning levels of maturity within this 10-year period. Sometimes, teenagers will get very, very close (commonly called a "crush") to a teacher, coach, or friend and almost forget their parents. Then some kind of problem will arise – they don’t make the team, feel rejected by a friend, or they get a "D" on a test – and they go back toward their parents, for a while. With each cycle, adolescents become less dependent on their parents and more comfortable with trying to make it in the world. By the time they are in college, they may cycle for weeks with very little refueling from the parent "gas station."

The undercurrent of loss of their childhood during this time is normal and nothing you have to change. It’s just an expected, normal part of everyone’s development.

The loss experienced by parents often is more obvious. They might talk about their teenager and say: "He’s never home. He’s always somewhere else with his friends, and we miss him." We also expect parents to become sad when the adolescent or young adult leaves home, and "empty nest syndrome" is a common topic.

Parents often will ask you if their child’s withdrawal, moodiness, or introspection is a sign of depression or part of teenage life. This can be a challenging question for pediatricians in primary care. You are asked to figure out if the adolescent in front of you is experiencing a real depression or just cycling through the common mood variations of adolescent development.

Adolescent depression can be more subtle to diagnose. It’s not like attention-deficit/hyperactivity disorder, which you can see in your waiting room when a child is all over the place or when you talk with the child in an exam room and he cannot stay on topic. In contrast, most adolescents and adults can put on a front, yet feel depressed. Until symptoms and functional impairment become quite severe, no overt sign might be apparent that they are depressed.

The differential diagnosis also is difficult, because a high percentage of seventh-, eighth-, and ninth-graders will report depressive symptoms if you give them a questionnaire. Look for more intense, multiple depressive symptoms. This can distinguish a real depression that warrants additional intervention from the normal day-to-day challenges of junior high school. Approximately 30%-40% will report not feeling good about themselves, feeling down, or withdrawing from family and friends at the some time. Although most teen patients experience these depressive symptoms as part of development, expect 5%-10% of your patients to report serious depression.