Depression in Children and Young People: Understanding What Lies Beneath.

When we think about depression in children and young people, we often associate it with sadness, but depression does not always feel or look this way. A young person might instead describe feeling empty, numb or exhausted, or find that things which previously mattered to them have gradually lost their importance. They may withdraw from friends, struggle with school or university, become irritable, or find themselves caught up in guilt and criticism of themselves. Sometimes the difficulty is not an excess of painful feeling but the apparent disappearance of feeling altogether.

For parents, friends and teachers, one of the most confusing aspects of depression can be the absence of an obvious explanation. A young person who has changed considerably may be repeatedly asked what is wrong and find that they genuinely do not know. This can be frustrating for everyone involved. The people around them want to understand so that they can help, while the young person may increasingly feel that they ought to be able to provide an answer.

Not knowing why you feel the way you do can become part of the difficulty. If nothing terrible seems to have happened, a young person may begin to question whether they have any right to feel as they do. They may conclude instead that they are lazy, ungrateful or somehow failing at life. The absence of an explanation can then become further evidence that the problem lies within them.

Psychoanalytic psychotherapy begins from a different position. It recognises that we do not always fully understand our own thoughts and feelings, and that experiences can affect us before their meaning is consciously available to us. This is part of what psychoanalysis means by the unconscious. Something may first appear through a feeling, a relationship, a behaviour or an inability to do something before a person can begin to put it into words.

“I don't know what's wrong” is therefore not necessarily the end of the conversation. It can be where the conversation begins.

Sadness, Grief and Depression

Sadness is part of being human, and children and young people inevitably encounter disappointment, rejection, heartbreak and loss. Painful feelings in response to painful experiences do not automatically constitute mental illness. Grief, for example, can profoundly disrupt someone's life. A bereaved person may withdraw from ordinary activities, struggle to concentrate and find that much of what previously mattered temporarily loses its importance.

In his 1917 paper Mourning and Melancholia, Sigmund Freud was interested in why mourning and what was then called melancholia could appear remarkably similar while following different psychological paths. Melancholia is an older term and does not correspond precisely to a modern diagnosis, although what Freud describes would now be recognisable as a severe form of depressive experience.

In mourning, something has been lost and the person gradually has to encounter the reality of that loss. This does not mean that grief follows a predictable timetable, or that there comes a point when somebody simply “gets over” the person they have lost. Freud's idea is subtler. Memories, feelings and aspects of the relationship are gradually revisited and reorganised so that the person who has been lost can, in a sense, be carried internally. The relationship changes rather than simply disappearing.

This process can be extraordinarily painful, but something is moving. The loss gradually becomes part of the person's continuing life.

Freud thought that something different could happen in melancholia. There may be a recognisable loss, but the person becomes stuck in relation to it. At other times they may know that something has changed without being able to identify clearly what has been lost. The difficulty then concerns not only the lost person, relationship or possibility, but increasingly the person's relationship with themselves.

This distinction gives us a useful way of thinking about depression without suggesting that every depression is concealed grief. It also helps explain why asking a depressed young person what they are sad about does not always get us very far. There may not be a straightforward answer available.

Growing Up Also Involves Loss

Loss does not only mean bereavement. Development itself involves leaving things behind, although we rarely describe these experiences as mourning. A child's place within a family changes as the family changes. The arrival of a sibling, parental separation, moving home or changing school can alter relationships that previously seemed secure. Even positive developments involve giving something up. Becoming more independent means losing aspects of dependence, just as becoming older means discovering that childhood cannot be indefinitely preserved.

This becomes particularly important during adolescence. The body changes and relationships with parents are renegotiated, while friendships, sexuality and the opinions of other people acquire different meanings. The adolescent is beginning to discover who they might become while simultaneously losing aspects of who they have been.

The transition into young adulthood can intensify these questions because structures that previously organised life begin to fall away at precisely the point when the person is increasingly expected to organise life for themselves. Decisions about education, employment, relationships, sexuality, independence and where to live can begin to feel as though they say something definitive about who the person is.

The apparently liberating question “What do you want?” can therefore become an enormous demand when someone genuinely does not know.

Questions of identity, sexuality and gender may become particularly important during this period. The imagined future of childhood also begins to meet the more complicated reality of adult life. Some possibilities have to be chosen while others are relinquished, and the young person has to tolerate not yet knowing what kind of adult they will become.

None of this means that adolescence or young adulthood is inherently depressing. It means that development requires considerable psychological work. There are things to be gained through growing up, but there are also things that have to be lost, and these losses are not always immediately recognised as such.

When the Shadow Falls Across the Self

One of Freud's most striking observations in Mourning and Melancholia concerns what happens when the difficulty surrounding a loss becomes directed towards the self. He describes this with the famous phrase “the shadow of the object fell upon the ego.” Freud's use of the word ego here can sound more technical than it needs to. In this context, it is helpful to think of it broadly as the person's experience of “I”: their sense of themselves and of who they are. The image of a shadow falling across the ego therefore describes something much deeper than feeling unhappy. Something about the lost or troubled relationship has become entangled with the person's experience of themselves.

We can recognise something of this in forms of depression where disappointment repeatedly becomes self-accusation. A friendship ending is experienced not simply as a painful loss but as proof that nobody could really like me. An exam going badly becomes evidence that I am stupid. If somebody I love is unhappy, I must have failed them. Concern from parents can even be transformed into the belief that everyone would be better off without me.

The psychoanalyst Darian Leader develops these questions in The New Black: Mourning, Melancholia and Depression. One of his concerns is what becomes obscured when very different experiences of mourning, melancholia and unhappiness are gathered beneath the single word depression. A diagnosis can describe something important about a person's difficulties while still leaving open the question of what kind of depression this is and what it means for them.

This helps explain why reassurance sometimes has surprisingly little effect. Telling somebody who experiences themselves as fundamentally worthless that they have plenty to be proud of can fail to reach what they are describing. It can even feel strangely similar to being told the opposite, because the reassurance seems to belong to a version of them that they cannot recognise.

The question is therefore not whether their negative beliefs are factually correct. We also need to understand how the person has come to occupy such a punishing position in relation to themselves.

When Depression Feels Like Nothing

Not all depression has this self-persecutory quality. For some young people the experience is characterised less by an excess of painful feeling than by the apparent absence of feeling.

They may say that they do not feel anything, or that they no longer care. Things which once reached them seem unable to do so. Music that mattered becomes background noise, friendships require an effort that no longer seems worthwhile, and school, university or work becomes something to endure rather than participate in. For older teenagers and young adults, interest in intimacy and sexual relationships may also diminish.

This can easily be understood from outside as a problem of motivation, particularly when adults can see opportunities that the young person appears to be wasting. Yet motivation depends upon being able to experience something as worth moving towards. If interest, pleasure and desire have become inaccessible, repeated encouragement to make an effort may simply reinforce the sense that everyone else can see something the young person cannot.

There is an important difference, then, between a depression in which someone feels tormented by guilt and self-attack and one in which the world seems to have become emotionally flat. Both may receive the same diagnostic name, but the lived experience can be very different. This is one reason understanding the individual remains important alongside broad diagnosis.

Trauma, Childhood Experience and Depression

Not all depression can be understood primarily through a recent loss. Sometimes its roots extend much further back into the person's experience. Trauma does not only refer to a single catastrophic event. Abuse and neglect can be traumatic, but so can growing up within relationships that are frightening, unpredictable or unable to provide sufficient emotional care. Research into adverse childhood experiences, often referred to as ACEs, has found associations between childhood adversity and later mental health difficulties, including depression.

These findings describe increased risk rather than destiny. Counting adverse experiences cannot tell us what those experiences meant to a particular child, and people who have lived through apparently similar circumstances can be affected in very different ways. Understanding developmental trauma therefore involves more than establishing what happened. It also involves considering how the child experienced what happened and what adaptations they had to make in order to manage it.

Trauma can also pass between generations in less obvious ways. Philip Larkin's famously bleak line, “Man hands on misery to man”, captures something recognisable, although what is transmitted between generations is rarely handed on deliberately. Parents inevitably bring something of their own childhoods, losses, fears and experiences of being parented into their relationships with their children.

Someone who grew up with emotional absence may find emotional closeness difficult, while somebody whose own childhood was frightening may become intensely anxious about keeping their child safe. A parent who was never permitted to be angry may find their child's anger particularly difficult to tolerate. None of this requires conscious intention.

Recognising intergenerational patterns is not about blaming parents. Parents themselves have histories, and what has never been understood or spoken about in one generation can sometimes make itself felt in the next. One of the possibilities offered by psychotherapy is that something which has been repeated without being understood can gradually become thinkable.

For a young person who becomes depressed, their history can therefore matter. Feelings of worthlessness, fear of rejection, difficulty trusting relationships or a tendency to turn anger against themselves may have a history that began long before the moment at which they became visibly depressed.

This relationship between early experience and later emotional development is explored further in Developmental Trauma in Children and Young People: Understanding the Impact of Early Experience.

Self-Harm, Anger and Destructiveness

Depression and self-harm can intersect in different ways, which is another reason not to assume that the behaviour has the same meaning for everyone. Someone who feels emotionally numb may use physical pain as a way of feeling something when very little else gets through. Where depression is dominated by guilt, shame or self-hatred, hurting the body may instead acquire a punitive meaning.

Self-harm can also be connected with anger that has been difficult to recognise or express. Anger towards parents, friends, circumstances or people who have hurt or disappointed us is not always easy to acknowledge. For some young people, an attack that cannot easily be directed outwards becomes turned against themselves.

Destructiveness towards the self does not only take the form of physical injury. A young person may repeatedly damage friendships, abandon opportunities, provoke rejection or undermine something they say they want. Describing this as “self-sabotage” can make the behaviour sound deliberately irrational, when it may have an important psychological function.

For somebody who already experiences themselves as worthless, failure may be painful but familiar. Allowing something to succeed can sometimes be more unsettling because it challenges an established understanding of who they are. What appears to be the destruction of an opportunity may therefore confirm something the person has come to believe about themselves.

The question is not simply how to stop the behaviour, important though that may be, but what function it has come to serve. I explore this further in Self Harm in Teenagers: A Guide for Parents.

Depression, Anxiety, School Refusal and Demand Avoidance

Depression rarely exists within a neat psychological boundary. Anxiety may become entangled with it, and both can become visible through difficulties that initially appear to be about behaviour.

A young person who becomes overwhelmed by school may begin staying at home. As attendance falls, they fall behind academically and friendships change in their absence. Anxiety and shame about returning increase, so the solution of staying away begins to contribute to the difficulty it originally helped them manage. What appears from outside simply as refusal can therefore be the visible end of a much more complicated process.

Avoidance and refusal can have many meanings. Depression will not explain every child who struggles with demands, but for some it can form part of the picture. When ordinary activities have become overwhelming or meaningless, withdrawing from what is being asked can become more understandable.

This is also relevant when thinking about PDA and demand avoidance. Describing a behaviour as demand avoidance tells us something about what is happening but does not necessarily explain why it is happening for this particular child. The meaning of the demand, the relationships surrounding it, anxiety, depression, neurodivergence and previous experience may all be relevant.

Similar processes can continue into university and employment. A young adult who appears to have “given up” may be struggling to imagine themselves moving forward at all. The external demand to get on with life can become particularly painful when the internal sense of having a future has become uncertain.

These questions are considered further in School Refusal: Looking Beyond the Behaviour and PDA and Demand Avoidance in Children and Young People: Looking Beyond the Behaviour.

Depression, Identity and Neurodivergence

Questions about identity run throughout development but can become particularly intense during adolescence and the transition into adulthood. A young person is negotiating how they experience themselves, how they imagine other people see them and where they feel they belong. Sexuality, the body, gender, friendships and intimate relationships can all become part of this developing sense of self.

There is no reason these questions should have easy or immediate answers. For some young people, uncertainty itself becomes frightening, particularly when the surrounding world seems to expect certainty. The pressure to define oneself can arrive at precisely the moment when identity feels least settled.

Neurodivergent young people can experience depression just as anyone else can, and autism or ADHD should not automatically become explanations for it. At the same time, the person's experience of being neurodivergent matters. Years of feeling different without understanding why, experiences of exclusion or bullying, sensory overwhelm, repeated misunderstandings or the effort involved in navigating environments organised around neurotypical expectations can all affect how somebody comes to experience themselves.

Receiving an autism diagnosis can itself have different meanings. For some young people it brings relief and provides a way of understanding experiences that had previously been confusing. For others it can initially feel upsetting, stigmatising or like an unwanted definition of who they are. These responses can also change over time.

The important thing is not to allow one label to swallow the person. Saying somebody is autistic does not explain why this particular autistic person has become depressed, any more than diagnosing depression tells us what their depression means. I discuss this in more depth in Autism, Neurodivergence and Psychoanalytic Psychotherapy: Understanding the Individual.

Diagnosis, Medication and Understanding the Individual

A diagnosis of depression can be important. It can recognise the seriousness of a young person's difficulties, provide language for an experience that has been difficult to understand and help them access appropriate support. Diagnosis, however, is a beginning rather than a complete explanation.

The different experiences described throughout this article inevitably complicate the question of treatment. Someone tormented by guilt and attacks upon themselves is not necessarily experiencing the same psychological difficulty as someone whose emotional world has become numb. Depression following a recognisable loss may have a different history from depression that seems to have emerged without an identifiable reason. Careful assessment therefore involves getting to know something of the person as well as identifying symptoms.

Psychoanalytic psychotherapy is one of the established psychological treatments used for depression in children and young people. The National Institute for Health and Care Excellence (NICE) produces evidence-based guidance for health and care services in England, including recommendations about the assessment and treatment of depression in children and young people. Current NICE guidance on depression in children and young people places psychological therapies at the centre of treatment and includes what it terms psychodynamic psychotherapy among its treatment options for moderate-to-severe depression. Psychoanalytic and psychodynamic psychotherapy belong to closely related traditions, and the Short-Term Psychoanalytic Psychotherapy model discussed below sits within this area of treatment.

Short-Term Psychoanalytic Psychotherapy for Adolescents (STPP) was developed specifically for adolescent depression and was one of the treatments studied in the large NHS IMPACT trial. I subsequently worked with this model for a number of years in NHS child and adolescent mental health services, including with young people whose depression was complex or had not responded to previous treatment.

Psychotherapy can therefore provide treatment while also allowing a more detailed understanding of what is happening to emerge. For some young people, psychotherapy itself brings substantial change. For others, the process of getting to know the person and their depression may contribute to thinking about whether additional medical or psychiatric assessment would be helpful.

Medication can also be helpful for some young people. Reducing the intensity of depressive symptoms may make everyday life more manageable and allow someone to engage more fully with relationships, education or psychotherapy. Medication will not be appropriate for everybody, however, and people do not all respond to it in the same way. The fact that the diagnosis of depression encompasses such different experiences is one reason treatment cannot simply be reduced to matching a diagnostic label with a single intervention.

Current NICE guidance reflects the need for careful assessment. Antidepressants are not recommended as the initial treatment for mild depression in children and young people. For moderate-to-severe depression, decisions about medication form part of specialist assessment and treatment, with antidepressants normally used alongside psychological therapy.

Medication and psychotherapy do not therefore need to be placed in opposition. For some young people medication may reduce the intensity of symptoms enough for other things to become possible. Psychotherapy addresses a different set of questions about how the person experiences themselves and their life, what has happened to them, what they have lost, what they want and how they might live.

These are not questions medication is intended to answer.

Psychotherapy, the Unconscious and Not Knowing

Psychotherapy does not require a young person to arrive with a coherent explanation of what is wrong. The work can begin with confusion, silence, anger, numbness or simply not knowing.

Psychoanalytic psychotherapy takes the unconscious seriously. This does not mean that the therapist possesses a hidden explanation that the young person does not know. Rather, it recognises that none of us has complete access to why we feel, think and behave as we do.

Something can affect us profoundly before we have words for it. An old loss can acquire a new significance during adolescence, anger can appear as an attack upon the self, or a pattern may repeatedly emerge within relationships without the person understanding why it keeps happening. What initially appears inexplicable can begin to acquire meaning through speaking and being listened to over time.

Psychotherapy is therefore not simply an attempt to persuade someone to think more positively. It provides a relationship in which experiences that have felt disconnected can begin to be thought about together. Feelings that seemed absent may become accessible, while harsh assumptions about the self can become something to question rather than automatically accept as truth. Losses that were never recognised as losses may gradually become possible to mourn.

For adolescents and young adults, this work also concerns the future. Growing up increasingly involves encountering questions for which nobody else can provide the answer: what matters to me, what kinds of relationships do I want, what do I want to do with my life, and who am I becoming?

Psychotherapy cannot answer these questions for someone, but it can provide somewhere in which they become possible to ask. This process is explored further in How Can Talking Therapy Help? Understanding Psychotherapy.

When Depression Becomes Dangerous

Understanding the individual meaning of depression does not mean overlooking its seriousness. Depression in children, teenagers and young adults can involve increasing hopelessness, profound withdrawal, self-harm or thoughts about suicide, and these require careful attention.

A young person talking about suicide or expressing the belief that others would be better off without them should be taken seriously. Where there are concerns about immediate safety, seeking urgent professional help takes priority over trying to understand everything first.

Psychotherapy can provide somewhere to explore the meaning of distress, but understanding and safety are not alternatives. At times immediate support is needed before, or alongside, deeper therapeutic work.

Beginning To Understand Depression

The word depression can give the impression that something has been explained when it may actually mark the beginning of a question.

Depression can involve profound sadness, but it can also involve guilt, anger, anxiety, emptiness, exhaustion, self-hatred or an absence of feeling. It may follow a recognisable loss, emerge in the context of earlier trauma, or appear without an explanation the young person can identify. These different experiences can look similar enough to share a diagnosis while having very different meanings within an individual life.

For children, teenagers and young adults, all of this takes place while they themselves are changing. Childhood gives way to adolescence and adolescence to adulthood. Relationships, bodies and expectations change, while dependence and independence have to be renegotiated. Questions about identity, sexuality, work, relationships and the future become increasingly difficult to avoid.

There are things to be gained through growing up, but there are also things that have to be lost. Most of these losses can gradually become incorporated into a developing life. At other times something becomes stuck. The world loses its meaning or, in Freud's remarkable image, the shadow of what has been lost falls upon the person's sense of themselves.

This brings us back to the young person who is asked what is wrong and answers, “I don't know.”

Rather than treating that answer as an obstacle, we can take it seriously. There may be something that cannot yet be explained, something that has not yet been understood or perhaps something for which words have not yet been found.

Not knowing does not have to end the conversation. It can be where the conversation begins.

Bibliography Links

Freud, S. (1917). Mourning and Melancholia. Freud's classic exploration of mourning, loss, identification and melancholia.

Leader, D. (2008). The New Black: Mourning, Melancholia and Depression. Penguin. A contemporary psychoanalytic exploration of mourning, melancholia and the different experiences gathered beneath the modern category of depression.

Goodyer, I. M. et al. (2017). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial. The Lancet Psychiatry, 4(2), 109–119.

National Institute for Health and Care Excellence (NICE). Depression in children and young people: identification and management (NG134). UK clinical guidance covering assessment and treatment of depression in children and young people.

Written by Ben French BSc, C-Psych, C-Obs, MA Psych.

Ben French is a Child and Adolescent Psychotherapist. He is registered with the British Psychoanalytic Council as a Child, Young Person and Family Psychotherapist. He has over 20 years’ experience working with children and young people, including work in NHS CAMHS and education, and works with children, teenagers and young adults aged 2–25 at Eastbourne Child Therapy.