One ten-year-old boy told us that he could count on his grandfather to help him feel better. After Jim got diagnosed with a serious eye-related disability, he said he was “embarrassed” to have to wear thick prescription glasses and to have to go to special classes with other disabled children. He started getting really sad—coming home and not talking to anyone—and his grandfather noticed. His grandfather didn’t ask what the matter was—he just told Jim to get his coat on. They went to the park and started tossing a baseball—a practice that continued every afternoon for a while. “He told me stories about his life, about coming over on a boat and working in a restaurant. He’s had a tough life. It made me feel a lot better,” says Jim. Jim may not be able to put it into words, but his grandfather’s stories probably helped so much because they expressed the clear message: we all have hardships that we have to bear, I too have felt sad and overwhelmed; I found a way of dealing with it and you’ll get through it too—we still care about you.
When boys have family and friends who offer this kind of sensitive support, they often can get over even difficult situations. The following steps should help when a boy needs some extra attention:
Create a safe space. Create a safe space in which your boy can express his feelings openly without fear of being shamed or reproached. Usually this means finding a time when there aren’t other distractions and explaining to the boy that he can say or express anything, that nobody will judge or punish him for what he shares.
Listen carefully. Listen very carefully to what a boy says. He may not open up immediately, and you might need to just listen patiently until he feels comfortable enough to explain exactly what he’s going through. Sometimes the boy may simply not yet be ready to talk. He may still need some private time. If you detect that this is the case, simply allow the boy to take that time and try to be completely available to him (i.e., don’t give him half your attention while also doing something else) when he emerges from his silence and seeks your help.
Be especially careful about shaming your son. When it’s your turn to talk, it’s best if you avoid saying anything that might humiliate or embarrass your son. Just about the most helpful thing you can say is that you understand the way he feels and that you are there to help him through in any way you can. Let him know how much you empathize with what he’s experiencing. Although sometimes it may seem easier to tease him a bit, to give advice, or to tell him that “everything will be fine,” these types of responses tend to cut off the boy’s ability to express his feelings genuinely. Instead, simply tell your boy that “it sounds like things are rough right now”—let him know that you care about the pain he’s feeling. In the end, all you need to do is be available, ask thoughtful questions that show that you care, really listen carefully, avoid judgments and lecturing, and express your love and concern genuinely.
WHEN THINGS GET WORSE
When a boy sees no sympathy at hand or if distressing circumstances beyond his control continue, his normal “action-oriented” coping strategies may become overwhelmed. He may no longer be able to forget his sadness by playing a hard game of hoops, punching pillows, or spending an evening alone listening to music. Attempting to repress his unhappiness and his shame over it may instead thrust him toward turbulent self-conflict, painful emotions jumbling his thoughts and churning his stomach. A young boy may become restless and impulsive, unable to focus and unable to behave appropriately. He may turn irritable or hostile, expressing his inner confusion by attempting to hurt others or taking dangerous risks like high-speed driving. He may express the physical aspect of his turmoil by getting sick, having chronic headaches or stomachaches. Or he may withdraw, becoming more and more sullen and estranged from those who care about him. All of these in moderation are normal coping mechanisms when a boy is in pain. But when boys act this way, it’s important to look beneath the surface, ask questions, express concern, and attempt to determine what the boy is experiencing; for when these behaviors become persistent or extreme, the boy may very well be on his way to depression.
Kenny Robinson, aged sixteen, was fortunate enough to have a mother who recognized that his angry and aggressive behavior was a nonverbal cry for help and did what she could to bring him back to health. Kenny started seeing a therapist weekly. In these conversations, Kenny was able to let down his mask of anger and express his underlying sadness about his father’s leaving home so abruptly.
“Nothing’s the same without my dad around,” he said. “Mom never has time anymore either. She’s too busy talking on the phone to her lawyer or her sister.”
“You feel like you’ve lost both your mom and your dad,” suggested the therapist.
Kenny’s eyes filled with tears. “Yeah. I don’t know what’s going on.”
His therapist brought Kenny’s mother into several sessions and helped her see how much Kenny needed her at this terrible time. Mrs. Robinson was clearly distraught and anxious about the family crisis, but was also concerned about Kenny.
The therapist suggested they institute “special time,” where Mrs. Robinson played whatever game Kenny suggested, as long as it didn’t hurt anyone (and with a spending cap if needed). They started with one hour a week of special time. Mrs. Robinson had trouble at first getting the energy to follow Kenny’s active play, but she saw how important it was to him.
Within a few weeks, the two developed a special game. Kenny was a detective who searched for missing persons and sent home good men who had been lost. Mrs. Robinson played her part with increasing enthusiasm. She realized Kenny needed to work through his father’s leaving in his own way.
She also realized how little she had been telling Kenny about why his father left. Now she made a conscious effort to sit down with him and give him any news she received. They imagined what it would be like to see his father again. She talked to Kenny and helped him sort through the confusing issues. She told him that she knew his father was trying to be a good man, but sometimes people do things that are wrong even when they’re trying their best.
Kenny and his mother and the therapist also spent two sessions talking about how Kenny could stop fighting with other kids. He said quietly, “I fight because the other kids say rotten things about my dad.” At this point, Mrs. Robinson started crying and reached over to hug Kenny, who also began to cry. Kenny agreed to try to find ways to talk to kids about his dad, instead of hitting them.
Over the months of therapy, Kenny’s school problems have abated. The family has many rocky times ahead, but at least now mother and son are going through them together.
Kenny was lucky that his mother dealt with his angry behavior by sending him to therapy instead of sending him to his room. All too often, a boy’s action-oriented coping style confuses the most well-meaning parents and teachers. We take the actions at face value and react accordingly. We punish the angry or impulsive child and medicate the overactive one. We push the “malingering” boy to toughen up and get back into the swing of things. And, worst of all, we tend to isolate the withdrawn or angry boy. We see his tough, sullen exterior, and say, “He’s a teenager, what do you expect? It’s a phase. He’s just being a boy.” And so we let him drift away.
Some of us may not recognize these signs of sadness in boys, in part because we’re eager not to. It’s painful to have to admit that someone we love is suffering. It’s hard to realize that a boy, whom we prefer to see as tough and strong, can be weighed down by extreme unhappiness. Some parents just accept the outward action behaviors as if they were an inevitable fact of nature, that all young boys act up and that teenagers are rebellious. But behind many of these external displays of boyhood energy and activity are often boys in trouble, boys in pain.
THE DIFFICULTY OF DIAGNOSING DEPRESSION IN BOYS
Diagnosing depression in boys is difficult for several reasons. First, as we’ve already seen, it’s often hard to draw the line between the normal strategies a boy uses to deal with day-to-day hurts and disappointments from the symptoms of actual de
pression (these symptoms will be described later in this chapter).
Second, depression is hard to diagnose in boys because boys so often mask the very behaviors we traditionally associate with depression—sulking, crying, withdrawing.
The third and, I believe, most important reason recognizing boys’ depression is so difficult is that we tend to look for it using benchmarks more appropriate to girls and women. Some of the classic symptoms of depression in women include becoming weepy, openly expressing hopelessness, helplessness, and despair, showing dependence on others or seeking out—and then rejecting—help from others. Yet these symptoms are less common in boys, and in fact many depressed boys may exhibit none of them.
If we are to recognize depression when it strikes boys, I believe we need to understand the unique constellation of symptoms that occur in boyhood depression. When we comprehend the specific ways in which boys show—or mask—their unhappiness and other symptoms of depression, it becomes easier to catch depression in its early phases before it becomes severe and difficult to reverse.
Consider, for example, fifteen-year old Ed, a quiet boy who actively denied that he had any emotional problems or that he was experiencing any emotional pain. When I first met Ed, he sat across a desk from me in a small hospital office, rubbing his head in his hands and saying over and over again. “I don’t know how I got here.”
“You tried to kill yourself,” I replied softly. “You took a lot of pills and booze, then tried to use your father’s pistol to finish the job.” Luckily, the gun had discharged accidentally, the neighbors had called the police, and here was Ed—alive and showing no scars.
He smiled wanly at me. “It’s a mistake, just a big mistake.”
But I knew better. In the emergency room, he had upset the doctors by cursing them when he realized he was still alive. This was no mere “attempt” and certainly no “mistake” but a determined end run toward death.
But unlike some of the girls on this locked ward, Ed showed no outer signs that he had narrowly survived a suicide attempt. He had no slashed wrists, no teary, red-rimmed eyes, no sad, needy look about him. Indeed, Ed denied being depressed.
Ed reluctantly answered my questions about his family. He hadn’t seen his dad in three years, since dad remarried and had another child. His older brother and sister were “getting by” on their own. His brother was an electrician; his sister, a nurse. He, the baby of the family, was living at home with mother. He was barely passing any of his classes and had been threatened with suspension for truancy.
After we worked together for a while, Ed was able to talk about his anger at his family. Brother Greg was drinking heavily and abusing his wife. Dad, also an alcoholic, was flatly refusing to pay child support and refusing to see Ed and his siblings. “I guess the Grady men don’t give a shit about the future,” said Ed with his typical half-grin.
“I think a lot of young men aren’t sure what their future could be,” I offered.
“Yeah. What’s there to look forward to? Life sucks and then you die.”
As we worked together, it was clear that Ed felt deeply hurt by his father’s abandonment. But instead of grieving, Ed learned to put on a false front, to grin and crack jokes. That was easier than pretending he still cared about his father. He had quite a vocabulary around angry words: “Pissed off,” “fed up,” “Po’d.” But he vehemently denied he was depressed. And he vehemently denied he needed help. “All I want is a pack of Winston’s and a chance to get out of here. I’ll be fine.”
Despite his pain, despite his clear suicidal intent, Ed might not have been diagnosed with depression by a mental health worker who was focused too strictly on current methods of diagnosis, which rely heavily on the criteria in the Diagnostic and Statistical Manual of Mental Disorders, or the DSM. In this reference book for clinicians, we find that diagnosing depression is done according to a checklist: a patient must show a certain minimum number of symptoms. First and foremost, he must be suffering a depressed mood or have lost the ability to take any interest or pleasure in the world. In addition, he must suffer at least four other symptoms from a list that includes: weight loss, sleep disturbances, agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, trouble concentrating, trouble making decisions, and thoughts of suicide.
Such criteria are not designed specifically for children and are based on a narrow model of depression, one heavily influenced by the way depressed women tend to behave. According to these criteria we would have trouble diagnosing Ed as depressed, yet we know that he was so despairing that he was ready to end his life. It’s not that the traditional DSM criteria are never helpful in diagnosing depression in boys, for they are. It’s just that they’re incomplete and do not recognize the broad range of symptoms in boys that we’ve been discussing.
Nonetheless, most mental health professionals currently use these adult criteria to diagnose depression for children as young as nine years of age. For children younger than nine, especially preschool-age children who are not yet necessarily able to articulate their feelings in a clear way, depression is usually inferred primarily from a sense of the child’s outward demeanor (how sad his face looks) or mood—that is, through the child’s conduct (especially acting out or problems with disobedience) or through complaints about physical problems (such as headaches or stomachaches). In children of school age up to and including the prepubescent years, features such as mood disturbance, irritable behavior, and more adultlike sadness are also considered. In addition, both preschool and prepubescent children may express feelings of worthlessness, low self-esteem, and a type of apathy or lack of pleasure called anhedonia. Finally, mental health professionals look for certain anxieties, phobias, and even the mention of suicide in children within this age range.
In addition to the fact that this approach uses too narrow a set of symptoms to identify depression in boys, there’s another problem. Making a diagnosis based on such criteria often depends on a patient’s telling a clinician about his problems and the clinician’s understanding and acting upon what the patient reports. Yet we know that boys and men minimize their problems, underreport their symptoms, and forget about troubles as soon as possible. We also know that medical professionals may actually “collude” with men’s reluctance to see or discuss their feelings of sadness. In 1991, Potts, Burnam, and Wells, from the Rand Corporation, compared the way doctors diagnosed male patients suffering from depression-like symptoms to how these patients responded to a more objective—and anonymous—questionnaire, something called the Diagnostic Interview Schedule. The surprising result was that about 65 percent of the men diagnosed as healthy by the doctors were actually suffering from depression, according to their answers on the questionnaire. In other words, the physicians failed to catch over three out of five male depressions. Many depressed men don’t tell their doctors about their troubles, and many doctors aren’t asking the right questions or aren’t “hearing” the answers men are giving them. Potts, Burnam, and Wells concluded that physicians are unlikely to press men about symptoms or to inquire in any depth once their male patients assure them that things are fine. Physicians, believing that they are helping men to avoid feelings of shame, go along with the code of silence.
With boys, especially young boys, the dialogue between the child and his parent, physician, or other caregiver, may be even more limited. The boy may not be able to find words to express his feelings or the adult listening to the boy may not be closely enough attuned to the boy’s subtle cries for help to realize how much the child is hurting. Given this important communication gap—and, additionally, if the adult is looking for symptoms that are more typical in women such as sudden teary outbreaks—it’s little surprise that depression in boys so often goes undetected and thus untreated.
HOW DO YOU TELL IF A BOY IS DEPRESSED?
What type of criteria should we use to better diagnose boys who are depressed? I would propose creating a new diagnostic tool specifically desig
ned to identify depression in boys. This would recognize that boys (and men) tend to act out depression through myriad behaviors, some of which look the same as those traditionally associated with depression in women but many of which look different. Bearing in mind too that every depressed boy is likely to have symptoms that look different from those of the next boy and that these symptoms will also vary depending on the specific age of the boy, I would recommend that we diagnose depression by watching carefully for the following symptoms:
1. Increased withdrawal from relationships and problems in friendships. Though a boy may deny that he’s doing so, he may tend to spend less time than usual with friends and family. He may become further disconnected from them emotionally, acting more and more like something of a loner. He may stop talking and respond to questions reluctantly. At home he may spend long periods of time in his own room, shrinking from interactions with other family members. At school he may retreat from students and teachers and avoid participating in classroom discussions and activities. He may try to sit in the back of the room, sequester himself during recess or study-breaks, and sit alone during lunch. He may try to avoid going to gym class, skip other courses, or become completely truant. When asked who his friends are, he may report that he has very few or none. He may seem unable to keep a “best” friend. This group of symptoms may appear in boys of all ages.
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