Depression in Teenagers with Autism Spectrum Disorder [Level 1]

"How have some of you dealt with a depressed teenager? My autistic son is 16 (high functioning) and a loner. His self-esteem is shot, and we're worried. Any advice is greatly appreciated!!!"

Adolescents suffer from depression more often than any number of grown-ups who live their entire lives with it. Moms and dads are generally dismissive of their child’s low moods, because they think that ALL teenagers are simply moody, hormonal, or tired and cranky. 
This dismissive attitude generally results in teenagers being even more depressed, because they think their mother or father doesn’t care. Take that in combination with adolescents with High-Functioning Autism (HFA) or Asperger’s (AS) who have very little impulse control as it is, and you have a horrible combination.

Depression is a serious medical problem that causes a persistent feeling of sadness and loss of interest in activities. It affects how your teenage son or daughter thinks, feels and behaves, and it can cause emotional, functional and physical problems. Although mood disorders like depression can occur at any time in life, symptoms are significantly more pronounced in adolescents than grown-ups. To make matters worse, the HFA/AS teen’s depressive symptoms are usually more pronounced than that of a “typical” teen.

Issues such as peer pressure, peer rejection, bullying, academic expectations and changing bodies can bring a lot of ups and downs for HFA and AS adolescents. But for some of these young people, the lows are more than just temporary feelings — they're a symptom of depression. Adolescent depression isn't a weakness or something that can be overcome with willpower — it can have serious consequences and requires long-term treatment. For most HFA and AS adolescents, depression symptoms ease with treatment (e.g., medication and psychological counseling).

Adolescent depression signs and symptoms include changes in your HFA/AS adolescent's emotions and behavior, such as the examples below. Be alert for emotional and behavioral changes, such as:
  • Agitation or restlessness (e.g., pacing, hand-wringing or an inability to sit still)
  • Changes in appetite (e.g., decreased appetite and weight loss, or increased cravings for food and weight gain)
  • Disruptive or risky behavior
  • Extreme sensitivity to rejection or failure, and the need for excessive reassurance
  • Feelings of sadness, which can include crying spells for no apparent reason
  • Feelings of worthlessness, guilt, fixation on past failures or exaggerated self-blame or self-criticism
  • Frequent complaints of unexplained body aches and headaches, which may include frequent visits to the school nurse
  • Frequent thoughts of death, dying or suicide
  • Insomnia or sleeping too much
  • Irritability, frustration or feelings of anger, even over small matters
  • Loss of interest in, or conflict with, family and friends
  • Loss of interest or pleasure in normal activities
  • Neglected appearance (e.g., mismatched clothes and unkempt hair)
  • Ongoing sense that life and the future are grim and bleak
  • Poor school performance or frequent absences from school
  • Self-harm (e.g., cutting, burning, or excessive piercing or tattooing)
  • Slowed thinking, speaking or body movements
  • Tiredness and loss of energy
  • Trouble thinking, concentrating, making decisions and remembering things
  • Use of alcohol or drugs

It can be difficult to tell the difference between (a) ups and downs that are just part of being a young person and (b) full-blown depression. Talk with your teenage son or daughter. Try to determine whether your youngster seems capable of managing challenging feelings, or if life seems overwhelming. If depression symptoms continue or begin to interfere in your HFA/AS adolescent's life, talk to a physician or a mental health professional trained to work with these teens. Your adolescent's family physician is a good place to start. Your adolescent's school may recommend someone as well.

If you suspect your “special needs” son or daughter is depressed, make a physician's appointment as soon as you can. Depression symptoms likely won't get better on their own — and they may get worse or lead to other problems if untreated. Depressed adolescents may be at risk of suicide, even if signs and symptoms don't appear to be severe.  If you're an adolescent and you think you may be depressed — or you have a friend who may be depressed — don't wait to get help. Talk to a health care professional such as your physician or school nurse. Share your concerns with a mother or father, a close friend, your pastor, a teacher or someone else you trust.

==> Discipline for Defiant Aspergers and HFA Teens

If your teenage son or daughter is having suicidal thoughts, get help right away. Take all talk of suicide seriously. Here are some steps you can take:
  • Seek help from your physician, a mental health provider or other health care professional.
  • Reach out to family members, friends or spiritual leaders for support as you seek treatment for your HFA/AS adolescent.
  • Call a suicide hotline number — in the United States, call the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255) to reach a trained counselor or encourage your HFA/AS adolescent to do so.

If you think your teenage son or daughter is in immediate danger of self-harm or attempting suicide, make sure someone stays with her or him. Call 911 or your local emergency number immediately. Or if you think you can do so safely, take your HFA/AS adolescent to the nearest hospital emergency department.

It's not known exactly what causes depression. A variety of factors may be involved. These include:
  • Learned patterns of negative thinking. Adolescent depression may be linked to learning to feel helpless — rather than learning to feel capable of finding solutions for life's challenges.
  • Inherited traits. Depression is more common in individuals whose biological (blood) relatives also have the condition.
  • Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression.
  • Early childhood trauma. Traumatic events during childhood (e.g., physical or emotional abuse, loss of a mother or father, etc.) may cause changes in the brain that make a teenager more susceptible to depression.
  • Biological chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. When these chemicals are out of balance, it may lead to depression symptoms.

Many factors increase the risk of developing or triggering adolescent depression, including:
  • Abusing alcohol, nicotine or other drugs
  • Being a female (depression occurs more often in females than in males)
  • Being bullied or rejected by peers
  • Being gay, lesbian, bisexual or transgender (becoming socially isolated or experiencing bullying may increase the risk of depression)
  • Having a chronic medical illness (e.g., cancer, diabetes or asthma)
  • Having been the victim or witness of violence (e.g., physical or sexual abuse)
  • Having certain personality traits (e.g., low self-esteem or being overly dependent, self-critical or pessimistic)
  • Having few friends or other personal relationships
  • Having issues that negatively impact self-esteem (e.g., obesity, peer problems, long-term bullying or academic problems)
  • Having other conditions (e.g., anxiety disorder, anorexia or bulimia, attention-deficit/hyperactivity disorder or learning disabilities)

Family history and issues with family or others may also increase your HFA/AS adolescent's risk of depression:
  • Having a dysfunctional family and conflict
  • Having a family member who committed suicide
  • Having a mother or father, grandparent or other biological (blood) relative with autism, depression, bipolar disorder or alcoholism
  • Having experienced recent stressful life events (e.g., parental divorce, parental military service or the death of a loved one)

Untreated depression can result in emotional, behavioral and health problems that affect every area of your HFA/AS adolescent's life. Complications related to adolescent depression can include:
  • Academic problems
  • Alcohol and drug abuse
  • Family conflicts and relationship difficulties
  • Involvement with the juvenile justice system
  • Low self-esteem
  • Social isolation
  • Suicide

You may choose to start by contacting your HFA/AS adolescent's family physician. In some cases, you may be referred directly to a mental health professional, such as a psychiatrist or psychologist.

To the extent possible, involve your teenage son or daughter in preparing for the appointment. Then make a list of:
  • Questions that you and your HFA/AS adolescent want to ask the physician
  • Key personal information, including any major stresses or recent life changes your HFA/AS adolescent has experienced
  • Any symptoms your adolescent has had, including any that may seem unrelated to the reason you scheduled the appointment
  • All medications, vitamins, herbal remedies or supplements that your HFA/AS adolescent is taking

Basic questions to ask the physician include:
  • Are there any possible side effects with the medications you're recommending?
  • Are there any printed materials that we can take home?
  • Are there any restrictions that my adolescent needs to follow?
  • How will we monitor progress and effectiveness of the treatment?
  • Is depression the most likely cause of my youngster's symptoms?
  • Is there a generic alternative to the medicine you're prescribing?
  • My adolescent has these other health conditions. Could they be linked to depression?
  • Should my adolescent see a psychiatrist or other mental health provider?
  • What are other possible causes for my youngster's symptoms or condition?
  • What are the alternatives to the primary approach that you're suggesting?
  • What kinds of tests will my youngster need?
  • What treatment is likely to work best?
  • What websites do you recommend?
  • Will making changes in diet, exercise or other areas help ease depression?

To make the most of the time allotted, make sure your HFA/AS son or daughter is ready to answer questions from the physician, for example:
  • Are you using any mood-altering substances, such as alcohol, marijuana or street drugs?
  • Do you ever have suicidal thoughts when you're feeling down?
  • Do you generally always feel down, or does your mood change?
  • Do you have a history of significant weight gain or loss?
  • Do you have any biological (blood) relatives — such as a mother or father or grandparent — with depression or another mood disorder?
  • Does your mood ever swing from feeling down to feeling extremely happy and full of energy?
  • How long have you felt depressed?
  • How much do you sleep at night? Does the amount change over time?
  • How severe are your symptoms? Do they interfere with school, relationships or other day-to-day activities?
  • What is your diet like?
  • What other mental or physical health conditions do you have?
  • What, if anything, appears to worsen your symptoms?
  • What, if anything, seems to improve your symptoms?
  • When did family members or friends first notice your symptoms of depression?

When adolescent depression is suspected, the physician will generally do these exams and tests:
  • Lab tests. For example, your HFA/AS adolescent's physician may do a blood test called a complete blood count, or test your teen’s thyroid to make sure it's functioning properly.
  • Physical exam. The physician may do a physical exam and ask in-depth questions about your HFA/AS adolescent's health to determine what may be causing depression. In some cases, depression may be linked to an underlying physical health problem.
  • Psychological evaluation. This evaluation will include a discussion with your son or daughter about thoughts, feelings and behavior, and may include a questionnaire. These will help pinpoint a diagnosis and check for related complications.

To be diagnosed with depression, your teenage son or daughter must meet the symptom criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Symptoms can be based on your HFA/AS adolescent's feelings or on the observations of someone else. For a diagnosis of major depression, the following symptoms must occur most of the day, nearly every day, during at least a two-week period, and be a change or worsening in the adolescent's usual attitude and behavior.

Your adolescent must have at least one of the following:
  • Diminished interest or feeling no pleasure in any or most activities
  • Depressed mood, such as feeling sad, empty or tearful (in adolescence, depressed mood can appear as constant irritability)

Your adolescent must also have four or more of the following:
  • Fatigue or loss of energy
  • Feelings of worthlessness, or excessive or inappropriate guilt
  • Insomnia or increased desire to sleep
  • Recurrent thoughts of death or suicide, making a suicide plan or a suicide attempt
  • Restlessness or slowed behavior that can be observed by others
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in adolescence, failure to gain weight as expected can be a sign of depression)
  • Trouble making decisions, thinking or concentrating

To be considered major depression:
  • Symptoms are not caused by grieving (e.g., temporary sadness after the loss of a loved one)
  • Symptoms are not due to the direct effects of something else (e.g., drug abuse, taking a medication or having a medical condition such as hypothyroidism)
  • Symptoms aren't due to a mixed episode, which is mania along with depression that sometimes occurs as a symptom of bipolar disorder
  • Symptoms must be severe enough to cause noticeable problems in day-to-day activities (e.g., school, social activities or relationships with others)

Other types of major depression include:
  • Psychotic depression. This is severe depression accompanied by psychotic symptoms, such as delusions or hallucinations.
  • Dysthymia. Dysthymia is a less severe, but more long-term form of depression. While it's usually not disabling, dysthymia can prevent your teenage son or daughter from functioning normally in a daily routine and from living life to the fullest.
  • Atypical depression. In this type of depression, key signs and symptoms include increased hunger, weight gain, sleeping a lot, feeling that your arms and legs are heavy, and difficulty maintaining relationships.

 ==> Discipline for Defiant Aspergers and HFA Teens

There are several other conditions with symptoms that can include depression. It's important to get an accurate diagnosis so that your HFA/AS adolescent gets appropriate treatment. Your physician or mental health provider's evaluation will help determine if the symptoms of depression are caused by one of the following conditions:
  • Adjustment disorder. An adjustment disorder is a severe emotional reaction to a difficult event in your life. It's a type of stress-related mental illness that may affect feelings, thoughts and behavior.
  • Bipolar disorder. Bipolar disorder is characterized by mood swings that range from the highs of mania to the lows of depression. It's sometimes difficult to distinguish between bipolar disorder and depression, but it's important to get an accurate diagnosis because treatment for bipolar disorder is different from that for other types of depression.
  • Cyclothymia. Cyclothymia, or cyclothymic disorder, is a milder form of bipolar disorder.
  • Schizoaffective disorder. Schizoaffective disorder is a condition in which a person meets the criteria for both schizophrenia and a mood disorder such as depression.
  • Seasonal affective disorder. This type of depression is related to changes in seasons and diminished exposure to sunlight.

Many types of treatment are available. In some cases, a primary care physician can prescribe medications that relieve depression symptoms. However, many adolescents need to see a psychiatrist or psychologist or other mental health counselor. A combination of medications and psychotherapy is very effective for most HFA/AS adolescents with depression.

If your teenage son or daughter has severe depression or is in danger of self-harm, she or he may need a hospital stay or may need to participate in an outpatient treatment program until symptoms improve.

Antidepressants and increased suicide risk— Although antidepressants are generally safe when taken asdirected, the FDA requires that all antidepressants carry "black box" warnings, the strictest warnings for prescriptions. In some cases, kids, teens and young people under the age of 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. So, individuals in these age groups must be closely monitored by parents and health care providers.  If your son or daughter has suicidal thoughts while taking an antidepressant, immediately contact your physician or get emergency help.  For most HFA/AS adolescents, the benefits of taking an antidepressant generally outweigh any possible risks. In the long run, antidepressants are likely to reduce suicidal thinking or behavior.

Antidepressants and pregnancy— If your teenage daughter is pregnant or breast-feeding, some antidepressants may pose an increased health risk to her unborn or nursing youngster. If your daughter becomes pregnant, make certain she talks to her physician about antidepressant medications and managing depression during pregnancy.

Finding the right medication— Everyone's different, so finding the right medication or dose for your HFA/AS son or daughter may take some trial and error. This requires patience, as some medications need eight weeks or longer to take full effect and for side effects to ease as the body adjusts.  If your adolescent has bothersome side effects, she or he shouldn't stop taking an antidepressant without talking to the physician first. Some antidepressants can cause withdrawal symptoms unless the dose is slowly tapered off — quitting suddenly may cause a sudden worsening of depression. Encourage your adolescent not to give up. If antidepressant treatment doesn't seem to be working, your adolescent's physician may recommend a blood test called cytochrome P450 (CYP450) to check for specific genes that affect how the body processes antidepressants. This may help identify which antidepressant might be a good choice. However, these genetic tests have limitations and may not be widely available.

Hospitalization and other treatment programs— In some HFA and AS adolescents, depression is so severe that a hospital stay is needed, especially if your son or daughter is in danger of self-harm or hurting someone else. Getting psychiatric treatment at a hospital can help keep your adolescent calm and safe until symptoms are better managed. Day treatment programs also may help. These programs provide the support and counseling needed while your adolescent gets depression symptoms under control.

Managing medications— Carefully monitor your HFA/AS adolescent's use of medications. To work properly, antidepressants need to be taken consistently at the prescribed dose. Because overdose can be a risk for adolescents with depression, your adolescent's physician may prescribe only small supplies of pills at a time, or recommend that you dole out medication so that your son or daughter does not have a large amount of pills available at once.

Medications— Because studies on the effects of antidepressants in HFA and AS adolescents are limited, physicians rely mainly on adult research when prescribing medications. The Food and Drug Administration (FDA) has approved two medications for adolescent depression — fluoxetine (Prozac) and escitalopram (Lexapro). However, as with grown-ups, other medications may be prescribed at the physician's discretion (off label), depending on your HFA/AS adolescent's needs. Talk with your adolescent's physician and pharmacist about possible side effects, weighing the benefits and risks. In some cases, side effects may go away as the body adjusts to the medication.

Psychotherapy— Psychotherapy is a general term for treating depression by talking about depression and related issues with a mental health provider. Psychotherapy may be done one-on-one, with family members, or in a group.  Through these regular sessions, your teenage son or daughter can:
  • explore relationships and experiences
  • find better ways to cope and solve problems
  • learn how to identify and make changes in unhealthy behaviors or thoughts
  • learn about the causes of depression
  • set realistic goals

Psychotherapy can help your son or daughter regain a sense of happiness and control, and help ease depression symptoms like hopelessness and anger. It may also help your HFA/AS adolescent adjust to a crisis or other current difficulty.

You are your adolescent's best advocate to help her or him succeed. Here are some steps you and your “special needs” child can take that may help:
  • Encourage communication with your HFA/AS adolescent. Talk to your son or daughter about the changes you're observing and emphasize your unconditional support. Create an environment where your youngster can share concerns while you listen.
  • Help the HFA/AS adolescent avoid alcohol and other drugs. Your son or daughter may feel like alcohol or drugs lessen depression symptoms, but in the long run they worsen symptoms and make depression harder to treat.
  • Learn about depression. Education can empower your teenage son or daughter and motivate her or him to stick to a treatment plan. It can also benefit you and other loved ones to learn about your adolescent's depression and understand that it's a treatable condition.
  • Make sure your HFA/AS adolescent adopts healthy habits. Even light physical activity can help reduce depression symptoms. Sleeping well is important for all adolescents, especially those with depression. If your teenage son or daughter is having trouble sleeping, ask the physician for advice.
  • Pay attention to warning signs. Work with your HFA/AS adolescent's physician or therapist to learn what might trigger depression symptoms. Make a plan so that you and your child know what to do if symptoms get worse. Ask family members or friends to help watch for warning signs.
  • Stick to the treatment plan. Make sure your HFA/AS son or daughter attends appointments, even if he or she doesn't feel like going. Even if your adolescent is feeling well, make sure he or she continues to take medications as prescribed. If your child stops taking medications, depression symptoms may come back. Quitting suddenly may cause withdrawal-like symptoms.

Avoid replacing conventional medical treatment or psychotherapy with alternative medicine. When it comes to depression, alternative treatments aren't a substitute for professional care. But some mind-body therapies may help.

Complementary and alternative medicine practitioners believe the mind and body must be in harmony to stay healthy. Examples of mind-body techniques that may be helpful for depression include:
  • Acupuncture
  • Guided imagery
  • Massage therapy
  • Meditation
  • Music or art therapy
  • Relaxation techniques
  • Spirituality
  • Yoga or tai chi

Relying solely on these therapies is generally not enough to treat depression. But they may be helpful when used in addition to medication and psychotherapy.

Showing interest and the desire to understand your HFA/AS adolescent's feelings lets her or him know you care. You may not understand why your adolescent feels hopeless or why she or he has a sense of loss or failure. Listen to your “special needs” child without judging and try to put yourself in his or her position. Help build your child’s self-esteem by recognizing small successes and offering praise about his or her competence.

Encourage your HFA/AS adolescent to:
  • Ask for help. Adolescents may be reluctant to seek support when life seems overwhelming. Encourage your son or daughter to talk to a family member or other trusted adult whenever needed.
  • Connect with other adolescents who struggle with depression. Talking with other adolescents facing similar challenges can help your son or daughter cope. So can learning skills to manage life's challenges. Local support groups for depression are available in many communities. And support groups for depression are offered online (but check them out to make sure they're credible and trustworthy sites).
  • Encourage your HFA/AS adolescent to keep a private journal. Journaling may help improve mood by allowing your child to express and work through pain, anger, fear or other emotions.
  • Have realistic expectations. Many adolescents judge themselves when they aren't able to live up to unrealistic standards (e.g., academically, in athletics, in appearance, etc.). Let your teenage son or daughter know that it's OK not to be perfect.
  • Make and keep healthy friendships. Positive relationships can help boost your HFA/AS adolescent's confidence and stay connected with others. Encourage her or him to avoid relationships with peers whose attitudes or behaviors could make depression worse.
  • Simplify life. Encourage your son or daughter to carefully choose obligations and commitments, and set reasonable goals. Let your child know that it's OK to do less when she or he feels down.
  • Stay active. Participation in sports, school activities or a job can help keep your teenage son or daughter focused on positive things, rather than negative feelings or behaviors.
  • Stay healthy. Do your part to make sure your child eats regular, healthy meals, gets regular exercise and gets plenty of sleep.
  • Structure time. Help your child plan activities by making lists or using a planner to stay organized.

There's no sure way to prevent depression. However, these strategies may help. Encourage your HFA/AS adolescent to:
  • Boost low self-esteem by recognizing small steps toward getting better.
  • Get treatment at the earliest sign of a problem to help prevent depression from worsening.
  • Maintain ongoing treatment, if recommended, even after symptoms let up, or have regular therapy sessions to help prevent a relapse of depression symptoms.
  • Reach out for friendship and social support, especially in times of crisis.
  • Take steps to control stress, for example, not committing to too many obligations at once.

Resources for parents of children and teens on the autism spectrum:

==> Videos for Parents of Children and Teens with ASD

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