Depression was formerly thought to occur only in adults, because children were felt to lack the necessary cognitive and emotional make-up that could give rise to this disorder. However, the use of standardized criteria shows that not only do children suffer from depression, but the rates of both depression and suicide in this group is showing a rise with each new generation. Even in preschoolers, one of every hundred may be diagnosed as depressive, two of every hundred school-age children, and 5-8 per hundred adolescent children. The spectrum of disease ranges from sad reactions to normal stress and ultimately to clinical depression.
Depression affects both young boys and girls equally, but shifts to twice as high in adolescent females compared to males in the same age group.
Factors which increase the risk of depression in childhood include:
- History of depression in the family
- Previous history of depression
- Presence of strife in the family
- Poor performance at school
- Dysthymia (persistent mild depression)
- Anxiety and anxiety disorders
- Substance abuse
Depression in preschool children
In very young children who cannot express their feelings or thoughts in words, depression is diagnosed mainly on the basis of the child’s behavior. Clues to depressive mood may include:
- Withdrawal from those who care for the child
- Delay or regression in the normal milestones of development
- Failure to grow normally in the absence of any physical cause.
This information is derived from the history supplied by the child’s caregivers, coupled with observation of the parent-child relationship by trained observers, and play interviews by professionals familiar with dealing with this age group.
Depression in school age children
In slightly older children who can think and speak about their feelings and stressors, the main symptoms include:
- Physical complaints such as non-organic headaches and stomach pain
- Anxiety shown as extreme reluctance to attend school and to be separated from the parents
- A change in mood, for example frequent quarrelsomeness, irritability or tantrums. These actually reflect a poor self-image and feelings of guilt
- A tendency to overachieve and gain acceptance by compliance.
Stress in this age group arises from quarrels within the family, criticism of the child or a poor academic performance and consequent lack of acceptance. Information about these children may be derived not only from the parents and the children, but from the child’s teachers.
Depression in adolescents
Adolescent children are the most capable of forming and expressing feelings of separation, hopelessness, and despair. As a group, they show symptoms such as
- Loss of enjoyment of former interests
- Weight change
- Substance abuse to a far greater extent than young children.
Adolescents also have the capability to plan and execute an attempt at suicide, which creates significantly more urgency about their diagnosis and treatment.
Symptoms of childhood depression
In general, symptoms of childhood depression overlap with those of adults. Very anxious children often develop mood disorders in later life.
The symptoms of depression are present almost every day for two weeks or longer, for most of the hours of the day. The most important ones are:
- Irritability and anger
- Chronic feelings of sadness and/or hopelessness or
- Loss of enjoyment
These must be coupled with four or more of symptoms of the following to arrive at a diagnosis of depression in children:
- Guilt and self-blame or feelings of worthlessness
- Low self-esteem
- Insomnia or oversleeping
- Changes in appetite and weight
- Somatic symptoms such as stomach pain or headaches without organic cause
- Suicidal thoughts and attempts
Screening for childhood mood disorders
Screening of a general childhood population for depressive symptoms may involve the use of questionnaires such as the Pediatric Symptom Checklist by the parents and caregivers of children between 6 and 12 years of age. Its advantages include the little time needed to fill it out, its wide acceptability, and relatively good sensitivity and specificity.
Outside of such screening, parents may raise their concerns about their children’s psychological wellbeing, and these concerns should be taken seriously by evaluating the child at the first opportunity. Research shows that less than a third of parents ever discuss such issues with the children’s healthcare providers, and even in such circumstances, only about 40% of the pediatricians address these concerns.
A third source of referral may arise from the provider’s own observation and assessment of the child and/or the family.
The first step in diagnosis involves a thorough medical examination and evaluation of the mental and cognitive processes. If required, laboratory tests may be ordered to rule out certain medical disorders which can mimic psychological conditions. These could include liver or kidney disorders, anemia or seizure disorders.
The psychiatric history will explore the child’s symptoms as well as the developmental history. The family and social history, including any mental illness, and the school environment, all or any of which may produce chronic or overwhelming stress, should be elicited.
Direct interviews with the child may occur in a variety of formats, including open-ended questions in young children, observation of play and parent-child interactions in infants and very young children, to questions requiring more detailed answers in teenagers. In addition to the information on the child’s symptoms, the healthcare provider must rule out learning or neurologic disabilities which could affect the child’s normal development and learning abilities.