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:
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:
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.
In slightly older children who can think and speak about their feelings and stressors, the main symptoms include:
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.
Adolescent children are the most capable of forming and expressing feelings of separation, hopelessness, and despair. As a group, they show symptoms such as
Adolescents also have the capability to plan and execute an attempt at suicide, which creates significantly more urgency about their diagnosis and treatment.
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:
These must be coupled with four or more of symptoms of the following to arrive at a diagnosis of depression in children:
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.