Simon was a 6-year-old boy diagnosed with high functioning autism who was very withdrawn and disengaged at home and school. Simon had been participating in individual psychotherapy for about a year at the time of the session described later. Therapy sessions tended to be filled with play that was highly repetitive and ritualistic. As our work unfolded, an ongoing theme that emerged was how sad, lonely, and isolated Simon felt and an acute awareness of his diagnosis of autism. Although he preferred playing alone and resisted all forms of social contact, Simon demonstrated by his behavioral retreat that he was extremely flooded by the presence of others. Over the course of the first year of treatment, Simon showed a growing desire for closeness with others but was at an impasse about how to open his world to others without shutting down. I had to follow his lead, letting him set the play theme which was almost always about aliens going off to outer space to escape earth. The sessions described later depict how he expressed his deep sense of loneliness and sadness to me and my response in helping him to make sense of his depression.

Gina was a 15-year-old who was diagnosed with high functioning autism and depression. We had been working together for 4 years using a variety of modalities to access her internal world. Often she could depict her emotional life best through drama or storytelling. Her depression worsened at age 15 when her beloved dog, Snowy, died from liver failure. Gina was extremely attached to Snowy and used her as her confidant and source of comfort. Below is a description of one of our sessions when we used storytelling to understand Gina’s depression.

Ziza was a 9-year-old girl with a complicated history. In addition to her learning and developmental problems of dyslexia and sensory integration disorder, she came from a family with multiple difficulties. Her father was severely depressed and suffered from alcoholism which ultimately led to the parents’ divorce when she was 5 years old. Several years later, her mother moved in with her female partner, taking all 4 children with her. The father moved away to another city and ceased all contact with the children. In addition, her mother reported that she had terrible postpartum depression after Ziza was born, her depression lasting for several years. In the family there was an 18-year-old sister, a 16-year-old brother, and a 6-year-old sister.

The first sign that something was awry when Sonia started doing things like going out to the city park with her girlfriends, dressed as a homeless person, and drinking cider out of a paper bag. It was around this time that Sonia’s best friend tried to commit suicide and was hospitalized. Shortly after this Sonia called a meeting with her parents and told them that she needed help—either a therapist or medication.

The first and most important intervention for any child suffering from depression is validation. The child needs to feel that they are listened to and understood. Often the first step in therapy is to hear the child’s story, to bring their conflict to consciousness, and to better understand the depths of their distress and the conflicts that they experience. An important part of validation is to help the child understand how they think and feel and what drives the depressive thoughts and feelings. This requires an investigative mind and capacity to pull apart the conflict underlying the depression. Often in depression, the conflict relates to activity versus passivity. The child may be fearful of being judged by others, then he resorts to doing nothing and isolating himself from others to avoid situations that may cause him to be ridiculed. Or the child has become inert, feeling hopeless, and that life is futile. He may sleep for long periods of the day, unable to motivate himself to do anything, watching TV without even knowing what he has watched. In these examples, it is helpful to highlight when the child is active and passive, the benefits of each of these states for the child’s goals, and how the child’s mood drives these behaviors (see Skill Sheets #9: Validation and #12: Thinking with a clear mind).

When a child is depressed, they become immobile and unable to experience pleasure. It is very important to begin with small behavioral changes and help the child to start seeking active in positive, pleasurable activities rather than withdrawing. By engaging in pleasurable activities, the child can activate the reward-centers of the brain and increase endorphins which elevate mood. Finding activities that are interesting or novel will help the child to distract themselves from whatever is bothering them. These activities also serve to build self-esteem and a sense of competence (see Skill Sheets #11: Creating positive life experiences and #16: Keeping track of positive behaviors).

Many children who are depressed and withdrawn become inert, don’t move, and as a result, do not stimulate their vestibular system which processes movement, increases arousal states, and is important for maintenance of muscle tone and posture. By moving and exercising, mood becomes elevated. If the child is depleted of energy, they may begin introducing movement by simply sitting on a rocking chair or a swing. Engaging in physical activity, such as a sport, yoga, dancing, or bike riding is ultimately more effective because the body is physically active. By stimulating the movement receptors in the body and brain, mood improves as a result of elevating arousal levels (see Skill Sheet #3: Moving for mood regulation and sleep).

Working nonverbally with a child can be a very powerful modality to get in touch with somatic responses associated with depression. Use of music, art, and dance are especially powerful in installing a sense of emotional well-being. Music with strong rhythms and a deep bass or interesting melody can change a child’s emotional state. Art projects with lots of color and texture, such as working with clay, fiber arts, beading, painting, or woodworking evoke emotional expression and release. When working nonverbally, it is often helpful to enjoy the quietness of the activity. Once this has been experienced, the therapist can bridge the nonverbal with verbal mediation, helping the child to understand the somatic responses that accompany the nonverbal activities. Noticing the effect these activities have on the body and mind is very powerful—how the muscles relax, the breathing is deeper, and the heart rate is slower. A sense of peace and calm should accompany these activities that go with a feeling of well-being. The therapist should help the client to observe these states of being much like a mother might observe and notice her young baby as he explores an object in his hands, taking pleasure in her baby’s own sense of discovery. Developing a sense of observing ego is very powerful in the healing process. The use of nonverbal medium often helps the child turn off the excessive verbal chatter or distracting thoughts in the head, allowing space for positive self-reflection and pleasure.

Children who are depressed sometimes feel better when in a stimulating, busy environment, especially when surrounded by happy, energetic people. The reality is that some children feel that they can’t mobilize their energy to leave the house for these types of activities. Being content alone may be a good first place to focus. The child may be easily overwhelmed by stimulating environments, especially if they have been secluding themselves at home. It is not uncommon for a child who is depressed to induce a state of sensory deprivation by their own isolation. A solitary activity that gives them pleasure and provides sensory stimulation may be a good place to start. Craft projects, reading, playing a musical instrument, or cooking may help the child to lift their mood.

Many times children who are depressed become isolated from others which compound their sense of loneliness and rejection. Finding structured activities that ensure interactions with others on a regular basis is important. Participating in a social skills group, a scout troop, sports or dance team, or art class provide structured activities that are organizing. Simply going to the playground or walking the dog in places where people gather may be a good first step if the child feels they can’t initiate conversations with others. If the child resists leaving the house, it may be wise to arrange for someone he loves to visit regularly. The focus needs to be on going to positive places that give the child pleasure and being around people who make them feel happy. The child should seek out people who are positive and provide them with an uplifting attitude about their life. It is important to minimize contact with people who are down or negative as much as possible.

Making changes in the child’s daily schedule is important so that there are varied, pleasurable activities throughout the day coordinated with organizing rituals (e.g., mealtimes, bathing, recreation, exercise, baking, school work, etc.). It is useful to identify activities or environmental factors that might have a negative impact on the child’s mood. Here are a few guidelines:

Often the child who is depressed is a pro at negative thinking, turning their mind quickly to the worst possible scenario. It is often helpful to talk with them about the worst thing that can happen to “lance the boil” so to speak. Could they stand it if that really happened? The child may fear a terrible illness will befall them, that someone might die, or that their close friend or relative will leave them. The reality might be that one of these things might actually happen and the child needs to take realistic steps to cope with the possibility of these things happening. Preparing for the worst that can happen allows the child to avoid being blindsided and taken unaware. It is also important for the therapist to give the message that they can endure the distress of the child’s life with them, that they can bear it, and move to a better place (see Skill Sheet #12: Thinking with a clear mind).

Some depressed children are in a chronic state of shutdown and withdrawal and suffer from sensory deprivation. They may develop a lifestyle that has very little stimulation, or in the case of children with bipolar illness, they may overstimulate themselves constantly. It is important to identify what is comforting and what is irritating to their nervous systems. Visual and auditory stimulation may be intensely overwhelming for them. It is very useful to figure out what is self-calming to the child and the optimal number and type of activities for the child in a given day. Planning out a daily and weekly schedule of pleasurable activities will help the child to begin to anticipate and tolerate stimulation.

Often the child who is depressed, irritable, and angry derails social interactions by communicating in ways that turn other people off. It is helpful in therapy to talk through how to approach others to promote listening and communication (see Skill Sheet #20: Communicating effectively with others). The child should figure out what they want to have happen and what they want others to hear or understand. In essence, the structure of the communication is like an ice-cream sandwich with two positive statements and a request or message sandwiched in between. The theory behind this is that the child is more likely to get positive engagement with others and receptivity if they can learn to be positive in how they deliver their messages. For example, Connor was accustomed to bossing family members around, telling them what to do and how, and if they didn’t cooperate with his plan, he screamed, slammed doors, or stormed out in a huff. No one in his family liked him or wanted to spend time with him. We made a list of things he wanted to communicate with his family and we thought through how to convey the messages using the ice-cream sandwich. Here’s an example:

Many children experiencing depression feel numb and unable to define the emotions that they feel. They often have a limited range of emotions, primarily feeling gloomy or sad most of the time and not knowing how to experience pleasure, joy, excitement, or assertiveness. Some individuals describe it as if their emotional life was flat and they do not know how they feel about things. Others feel so absorbed by their black cloud that no other emotions can be experienced. It is important in treatment to help the child read their internal emotional experiences and connect them with bodily sensations and thoughts. As the therapist helps the child observe what he might be feeling and why, it offers the child something to react to and to begin to attach words to feelings. This process helps the child develop a specificity to his internal emotional life that can be very useful as he moves through his day-to-day life outside of therapy. It is very important to tie feelings that the child experiences to what they are sensing in their body. For instance, how do “sad” and “angry” feel different for the child? The child may shutdown with both emotional states, but when feeling sad, they notice that they feel very tired whereas when they are angry, they wish to retreat but their heart is pounding.

Once the child has learned to recognize his feelings with more specificity, it is important to identify the negative cognitions he holds and consciously change negative thoughts to positive ones. These cognitions may be things like, “I am a failure,” “I cannot stand it,” “I do not deserve,” or “I am not good enough.” In therapy it is useful to “unpack” what goes into the negative cognition. For example, Rick installed the feeling that he was a failure since his childhood when his parents constantly offered attention to his older sibling who suffered from cerebral palsy and couldn’t feed himself. Rick felt undermined and never received attention for his accomplishments, his good grades and sports awards going unnoticed. He felt that his role in the family was to stay out of the way and be “the good boy.” Understanding the underpinnings of the negative cognition is very helpful. The therapist should assist the client in identifying what situations evoke the negative cognitions along with the accompanying physical sensations. For example, in Rick’s case, he felt incompetent at school and home, feeling that he never measured up to his parents’ expectations which reinforced his feeling that he was a failure. He experienced a sinking feeling in his stomach and often felt like he was invisible. He was able to identify specific situations that reinforced his negative cognition. His teachers often overlooked Rick when kids were raising their hands to answer questions or to participate in special projects. His mother often ignored him when he walked in the door after school. Each time these things happened, Rick felt reinforced that, yes indeed, he was the failure that he always thought he was.

Some children suffering from depression become quite inflexible and rigid in their thinking, having difficulty taking into account another person’s perspective. It is not uncommon for the child to project onto others the negative cognitions that they feel about themselves. As one helps the child to be open that others are likely to have a different point of view than they do, it is important to help them open their mind to other ways of thinking about a situation. People suffering from depression often blame themselves or others for their problems or they overpersonalize situations, ascribing innocuous things with personal meaning. It’s helpful to guide the child to speculate what others might be thinking and to avoid thinking in words like “always, never, every time, everyone, or no one.” Likewise, the child may jump to the conclusion that the worst possible outcome will happen or they believe that their negative feelings are true without questioning them.

Many children who are depressed submit to their depression and become inert. Children with bipolar illness or depression accompanied by irritability and anger may feel compelled to act on their impulses or emotions. The first step for better emotional regulation is for the child to be strategic with their emotions. This requires the child to identify their feelings, to tolerate their existence, and to separate their feelings from their behavior. It is useful for the child to think through what the end result is that they would like to accomplish, then to decide whether it is in their best interest to take opposite action to their instinct, or to wait, tolerate the emotional state, self-distract and self-calm, and do nothing to avoid more negative consequences. The latter is especially important for children with bipolar illness or anger management problems who tend to react or do manic activities that derail them.