Depression is not confined to adulthood—it also can arise in childhood and adolescence. Depression in children can be triggered by a traumatic life experience, such as the death of a loved one, parents’ divorce, difficulty in school, or illness. A diagnosis of depression is made when the feelings of sadness are severe enough to disrupt the child’s daily life. Significant depression also can interfere with a child’s development and can potentially lead to alcohol or drug use, or suicide. Children who experience depression are more likely to be depressed as adults.
Research has indicated that rates of depression have risen in children and adolescents during the last few decades, although the reason for this rise is unclear. Just as in adults, depression in children can range in severity.
Major depressive disorder is the most severe form of depression. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revised (DSM-IV TR), defines a major depressive episode as five or more symptoms (which can include depressed mood or irritability most of the day, markedly diminished interest in activities, significant weight loss without dieting, insomnia or hypersomnia nearly every day, agitation, fatigue , feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicide) within a two-week period.
Dysthymic disorder is a milder but chronic form of depression that persists for at least one year in children (episodes last between two and three years). It is characterized by symptoms of depression or irritability, as well as appetite changes, difficulty sleeping, low self-esteem, fatigue, poor concentration, or feelings of hopelessness. Dysthymia can interfere with a child’s relationships, schoolwork, and self-esteem.
Approximately 1% to 2% of children and 5% of adolescents experience symptoms of depression, and 3% to 5% of young people have major depressive disorder. The incidence of depression is lower in young children and rises after puberty. In childhood, the rates of depression are about equal in boys and girls, but, in adolescence, girls are more than twice as likely to be depressed as boys, possibly due to hormonal changes that occur during puberty. Additionally, girls tend to have an internal locus of control, which is related to self-blame versus the external locus of control experienced by many adolescent males.
About two-thirds of children with depression have a concurrent mental disorder, and so are at higher risk for developing depression again after receiving treatment. Children with depression have a two- to fourfold increased risk of being depressed as adults. Nearly three-quarters of children and adolescents with depressive disorders do not receive appropriate treatment.
Although in some cases depression stems from a life event, in other situations it arises without apparent cause.
Doctors are unsure about the underlying causes of depression, but the problem may arise from neuro-transmitter abnormalities in the brain as well as hormone perturbations. Changes in the prefrontal cortex have been noted in childhood depression. Hormones seem to play a role in depression, too.
Depression has both genetic and social components. The condition runs in families, and there is evidence that a child is more likely to develop depression if his or her parent is depressed. Studies have indicated that identical twins, who share the same genes, are about three times more likely to both have major depressive disorder than are fraternal twins, who share fewer of the same genes. It also may be possible that growing up with a parent who is depressed may make a child more prone to duplicating the behavior. Negative parenting tactics (such as rejection and lack of nurturing) also can influence the development of depression.
Stressful experiences, such as the death of a loved one, moving to a new city, living in poverty, or suffering sexual or physical abuse , can trigger depression, especially in children who are already vulnerable due to inherited factors. Depression can be distinguished from normal sadness during these experiences because its duration is disproportionate to the event.
In some cases, a medical condition, such as cancer, infectious mononucleosis, anemia, thyroid disease, or vitamin deficiency, can trigger depression. Some medications, such as isotretinoin (Accutane), may also lead to depressive symptoms. Depression stemming from illness or medication is referred to as secondary depressive mood disorder.
A child who is experiencing depression may have uncontrollable feelings of sadness. He or she may lose interest in friends, school, and activities. Other symptoms of depression include:
- Feelings of worthlessness or hopelessness
- Crying for no apparent reason
- Change in appetite
- Weight loss or gain
- Disrupted or prolonged sleep
- Lack of energy
- Difficulty concentrating
- Irritable, aggressive, or hostile behaviors
- Aches and pains that have no known medical cause (this is particularly common in children under age seven, who are less able to articulate their emotions)
- Alcohol or drug use
- Suicidal thoughts or actions
Depression often occurs together with other mental disorders, including anxiety disorders , attention-deficit/hyperactivity disorder, substance abuse disorder, and oppositional defiant disorder.
Diagnosing depression may begin with the child’s primary care doctor, who can make a referral to a child psychiatrist or psychologist if necessary. The doctor will typically start a depression evaluation by interviewing the child and his or her parents. The assessment may include a physical history and examination to rule out any conditions that can cause depression, such as thyroid disorders.
To diagnose depression, doctors sometimes used questionnaires or scales. The Children’s Depression Inventory (CDI) is commonly used to diagnose children ages 7 to 17 years old. The results of this inventory are represented as a t-score. A t-score of greater than 20 on the long form or greater than 7 on the short form indicates a diagnosis of clinical depression.
Because patients with depression are at greater risk for attempting suicide (major depression increases the suicide risk 12-fold), doctors should assess the child’s suicide risk during the initial visit.
Treatment methods for children with depression include therapy and medication. Therapy may be conducted individually, in groups, or with the child’s family. Cognitive-behavioral therapy (CBT) is the most thoroughly studied treatment for childhood depression, and research indicates that it is effective for treating mild to moderate depression. CBT involves changing the negative or distorted thoughts that are leading to the depression, and improving the child’s coping skills. The therapist can help the child deal with grief and more appropriately handle his or her emotions, as well as educate the parents about developing healthier communication strategies and familial relationships. Interpersonal therapy (IPT), which is based on the belief that depression is triggered by interpersonal disputes, has also been shown to positively influence depressive symptoms in children and adolescents.
In moderate to severe cases of depression, doctors may prescribe antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) , such as fluoxetine (Sarafem) and paroxetine (Paxil). Presently, fluoxetine is the only SSRI approved by the U.S. Food and Drug Administration for treating depression in children 8 to 17 years of age. SSRIs work by restoring the correct balance of serotonin in the brain. However, because antidepressants have been linked to an increased risk of suicidal thoughts and behaviors in children and adolescents (the packaging of SSRIs carries a black-box warning regarding this risk), doctors should carefully monitor their young patients for any signs of suicidal tendencies during treatment. Due to their high risk of side effects and lack of effectiveness in a younger population, tricyclic antidepressants such as imipramine (Tofranil) are not recommended for children and adolescents.
The recommended treatment duration for children experiencing their first episode of depression is at least six months. Medication should be tapered off over a period of one to two months to prevent symptoms of withdrawal. Subsequent depressive episodes require at least one year of treatment, and children who have had more than three episodes should be treated indefinitely. More severe cases of depression may require a combination of medication and psychotherapy. Patients with treatment-resistant depression may require additional medication, such as lithium, as well as extended CBT.
Children or adolescents who are exhibiting suicidal behaviors may be hospitalized until it has been determined that they are no longer a danger to themselves.
Research indicates that starting treatment early can improve the outcomes for children and adolescents with depression. Children usually recover faster from major depressive episodes than adults. In most cases, children will recover from an initial depressive episode within one to two years, even if they have not been treated in some cases. However, children who have had at least one depressive episode face an increased risk of recurrence during adolescence and adulthood.
Cognitive behavioral therapy (CBT) —A treatment that helps patients control the negative thoughts that are leading to their depressive symptoms.
Dysthymic disorder (dysthymia) —A mood disorder characterized by feelings of sadness, as well as excessive fatigue, low energy, disturbed sleep, poor concentration, feelings of hopelessness and/or low self-esteem. Symptoms persist for more than two years but are not severe enough to qualify for a diagnosis of major depressive disorder.
Hypersomnia —Excessive sleepiness and the inability to stay awake during the day.
Interpersonal therapy (IPT) —A form of treatment for depression that focuses on improving the patient’s relationships with friends and family members.
Neurotransmitter —A chemical that carries messages between nerve cells in the brain.
Oppositional defiant disorder —A type of behavior disorder characterized by defiant or disobedient behavior toward authority figures.
Selective serotonin reuptake inhibitors (SSRIs) —A class of antidepressant medications that help improve mood by increasing the amount of the neurotransmitter serotonin in the brain.
Tricyclic antidepressants —A class of medications that is used to treat depression.
Although little research exists on the prevention of depression in children, there is some evidence that CBT can prevent the onset of major depression in children with depressive symptoms and/or anxiety disorders. Family dynamics also can have an impact on the development of depression. A stable, loving, and communicative family can decrease a child’s vulnerability to the condition. Parents can help prevent potential problems by identifying depression earlier, when the treatment success odds are greatest. Early identification of depression involves looking for the warning signs, which may be more subtle in children than they are in adults. For example, a depressed child may appear bored, overly tired, withdrawn, or irritable. Children with depression also may experience aches and pains that are not associated with any obvious medical condition.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington, D.C.: American Psychiatric Association, 2000.
Gillberg, Christopher, Richard Harrington, and Hans-Christoph Steinhausen, eds. A Clinician’s Handbook of Child and Adolescent Psychiatry. Cambridge: Cambridge University Press, 2006.
Jongsma, Arthur E., Jr., L. Mark Peterson, and William P. McInnis. The Child Psychotherapy Treatment Planner. 4th ed. Hoboken, NJ: John Wiley & Sons, 2006.
Wilmshurst, Linda. Essentials of Child Psychopathology. Hoboken, NJ: John Wiley & Sons, 2005.
Zalsman, Gil, and David Brent. Depression, An Issue of Child and Adolescent Psychiatry Clinics. Philadelphia: Saunders, 2006.
The American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Avenue N.W., Washington, D.C. 20016-3007. (202) 966-7300. <http://www.aacap.org>.
Families for Depression Awareness, 395 Totten Pond Road, Suite 404, Waltham, MA 02451. (781) 890-0220. <http://www.familyaware.org>.
National Alliance on Mental Illness, Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA 22201-3042. (800) 950-6264. <http://www.nami.org>.
U.S. Department of Health & Human Services Substance Abuse and Mental Health Services Administration (SAMHSA), 1 Choke Cherry Road, Rockville, MD 20857. (240) 276-1310. <http://www.samhsa.gov>.
Stephanie N. Watson