Depression is, by most accounts, on the rise among America’s children. A recent study published in the journal Translational Psychiatry provided the most disturbing news yet. It looked at data on adolescents ages 12 to 17, from the 2009 to 2014 editions of the National Survey of Drug Use and Health, an annual cross-sectional survey conducted in a representative sample of the U.S. population. Researchers concluded that a whopping 36.1 percent of girls had experienced a first bout of depression. Boys were recorded at 13.6 percent — much lower, but still alarmingly high.

Those children also exhibited more behavioral and academic problems than children with no history of depression, prompting the study’s authors to write: “High levels of impairment, suicide attempts, conduct problems and poor academic functioning argue against a ‘wait and see’ approach to clinical treatment of recent first-onset depression.” In other words, getting depressed kids into proper treatment is paramount.

But how do you treat a child with depression? Children, as most health practitioners are quick to say, are not “small adults.” They have their own biochemistry, their own cognitive capabilities and their own tolerances for medications, psychotherapy and other common treatments for depression. They also have more erratic and potentially dangerous reactions to those treatments, particularly medications. That’s why parents should employ the skills of a trained child and adolescent psychiatrist or psychologist for any child with mental illness.

[Read: Does My Child Have a Mood Disorder?]

Psychotherapy

“Most psychiatric symptoms were first described for adults, then later extrapolated to kids,” says Dr. Steven C. Schlozman, assistant professor of psychiatry at Harvard Medical School and associate director of the Clay Center for Young Healthy Minds. “That makes it a bit like fitting a square peg into a round hole.” That fit is made smoother by adding knowledge about childhood development into the geometry, he says. For instance, depression in children may manifest as irritability, rather than sadness or melancholy. “It is important for the physician to recognize this, because you might not think of someone who is irritable as being depressed,” he says.

Likewise, treatments must be adjusted to meet the developmental stage of the child. The treatments are, in broad strokes, the same as those used for adults. The American Academy of Child and Adolescent Psychiatry, or AACAP, says that treatment for childhood depression should include both psychotherapy and medication. “In milder forms of depression, it is reasonable to start with a psychotherapy, but treatment with a medication and psychotherapy should be considered for moderate to severe forms of major depression,” it recommends.

[See: 10 Concerns Parents Have About Their Kids’ Health.]

The AACAP says the following therapy styles can be used to help depressed children:

— Individual therapy. Well-studies therapies include cognitive behavior therapy, or CBT, and interpersonal therapy, or IPT. CBT teaches how to recognize and change unhealthy patterns of thinking that cause feelings and moods that can affect behavior. IPT helps depressed children identify interpersonal events and how these events affect their relationships, their moods and their lives.

— Family therapy. Here, a therapist helps the entire family — the child or adolescent, parents, siblings and even grandparents — improve communication and support skills to work together in more positive and constructive ways.

— Group therapy. Multiple patients are led by one or more therapists who teach the group how to better understand and recover from depression.

These therapies are tailored to kids, Schlozman says. “You are not looking for the same nuance or insight in a 13-year-old as you would in a 30-year-old. If you talk about ‘conflicted feelings’ to an 8-year-old, you will at best get a blank stare; at worst walking out.” Tailoring therapy to the age, through play and with toys and games, can help the child see where their problems lie. “You don’t explicitly interpret that they don’t like Buzz Lightyear because it reminds the child of Billy the bully. They know it,” he says.

Therapy for children may include “homework,” he continues. “I may say to the kid, ‘this weekend I want you to call two people and see if they want to do something. Take notes and tell me next week.’ Or, ‘if you are going to a party and feel anxious, do these relaxation exercises.’ You help them remember things are not as dark as they seem to be.”

Medication Is More Problematic

Antidepressants are well-studied in adults, but “their efficacy is not as well-established in children,” says David J. Miklowitz, director of the Child and Adolescent Mood Disorders Program at UCLA’s Semel Institute. “Typically in adults, the first-line medication is an SSRI, but the record of those in children is not that convincing, and only a little better in adolescents.”

The issue of medication was further muddied by a study published in 2016 in The Lancet. It found that most antidepressants are ineffective, and some may be unsafe, for children and teenagers with major depression. When researchers balanced the risks and benefits, they concluded that most antidepressants failed to offer any obvious advantage in children and teenagers.

[See: How to Find the Best Mental Health Professional for You.]

In addition, in 2004 the Food and Drug Administration issued a “black box” warning, its highest alert, that antidepressant medications may increase suicidal thoughts and behavior in a small number of children and adolescents. The FDA has approved just two drugs — fluoxetine (Prozac) and escitalopram (Lexapro) — to treat depression in children; Prozac for kids ages 8 and older and Lexapro for kids 12 and older.

Despite the warning, the FDA has not prohibited or removed these medications, and no suicides were reported in the studies that led to the warning. The warning is based on a very small number of cases, Schlozman says. The effects are both rare and quite apparent.

“Most people think [the medications] flip someone from depression to a more manic state, indicating they probably don’t have depression but do have bipolar disorder,” he says. Those kids tend to become agitated, anxious, restless and prone to self-harm. “We tell parents this might happen and to watch for it. Parents call and say, ‘he is acting really different.’ It is generally obvious. If parents go in with their eyes wide open, many of these problems are solvable with dosage adjustments or different medication,” he says. “That is why a good relationship with a psychiatrist is worth its weight in gold.”

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Depression in Kids: How Should It Be Treated? originally appeared on usnews.com