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Depression and Mood Dysregulation Disorder in Children and Adolescents

By Josephine Elia, MD, Professor of Psychiatry and Human Behavior, Professor of Pediatrics;Attending Physician, Sidney Kimmel Medical College of Thomas Jefferson University;Nemours/A.I. duPont Hospital for Children

(See also Depression in adults.)

Depression includes a feeling of sadness (or, in children and adolescents, irritability), and/or loss of interest in activities. In major depression, these symptoms last 2 weeks or more and interfere with functioning or cause considerable distress. Symptoms may follow a recent loss or other sad event but is out of proportion to that event and persists beyond an appropriate length of time. Mood dysregulation disorder involves persistent irritability and frequent episodes of behavior that is very out of control.

  • Physical disorders, life experiences, and heredity can contribute to depression.

  • Children and adolescents with depression may be sad, disinterested, and sluggish or overactive, aggressive, and irritable.

  • Children with disruptive mood dysregulation disorder have frequent, severe temper outbursts and, between outbursts, are irritable and angry.

  • Doctors base the diagnosis on symptoms as reported by the child, parents, and teachers and do tests to check for other disorders that can be causing the symptoms.

  • For adolescents with depression, a combination of psychotherapy and antidepressants is usually most effective, but for younger children, psychotherapy alone is usually tried first.

Sadness and unhappiness are common human emotions, particularly in response to troubling situations. For children and adolescents, such situations may include the death of a parent, divorce, a friend moving away, difficulty adjusting to school, and difficulty making friends. However, feelings of sadness are sometimes out of proportion to the event or persist far longer than expected. In such cases, particularly if the feelings cause difficulties in day-to-day functioning, children may have depression. Like adults, some children become depressed even when no unhappy life events occur. Such children are more likely to have family members with mood disorders (a family history).

Depression occurs in as many as 2% of children and 5% of adolescents.

Depression includes several disorders:

  • Major depressive disorder

  • Disruptive mood dysregulation disorder

  • Persistent depressive disorder (dysthymia)

Did You Know...

  • Some children with depression are overactive and irritable rather than sad.

Causes

Doctors do not know exactly what causes depression, but chemical abnormalities in the brain are probably involved. Some tendency to develop depression is inherited. A combination of factors, including life experiences (such as a loss early in life) and a genetic tendency (vulnerability), seems to contribute.

Sometimes another disorder, such as an underactive thyroid gland or drug abuse, is part of the cause. Recently, a few adolescents with persistent depression were found to have low levels of folate (a vitamin) in the fluid that surrounds the brain and spinal cord (cerebrospinal fluid).

Symptoms

As in adults, the severity of depression in children varies greatly.

Major depressive disorder

Children with major depressive disorder have an episode of depression that lasts 2 weeks or more.

Children typically have feelings of overwhelming sadness or irritability, worthlessness, and guilt. They lose interest in activities that normally give them pleasure, such as playing sports, watching television, playing video games, or playing with friends. They may profess intense boredom. Many of these children also complain of physical problems, such as stomachache or headache.

Appetite may increase or decrease, often leading to substantial changes in weight. Growing children may not gain weight as expected.

Sleep is usually disturbed. Children may have insomnia, sleep too much, or be troubled by frequent nightmares.

Depressed children are often not energetic or physically active. However, some, particularly younger children, have seemingly contradictory symptoms, such as overactivity and aggressive behavior. These children may seem more irritable than sad.

Symptoms typically interfere with the ability to think and concentrate, and schoolwork usually suffers. They may lose friends. Children may have suicidal thoughts and fantasies and may even attempt suicide.

Even without treatment, children with major depressive disorder may get better in 6 to 12 months. However, the disorder often recurs, particularly if the first episode was severe or occurred when children were young.

Disruptive mood dysregulation disorder

Children with disruptive mood dysregulation disorder are irritable most of the time for a long time, and their behavior is frequently out of control. They have frequent, severe temper outbursts that are much more intense and last much longer than the situation merits. During these outbursts, they may destroy property, or physically hurt others. Between outbursts, children are irritable or angry most of the day nearly every day. This disorder usually begins when children are 6 to 10 years old.

Many of these children also have other disorders, such as

When these children become adults, they may develop depression or an anxiety disorder.

Because these children sometimes appear out of control, doctors often used to diagnose them as having bipolar disorder. However, doctors now realize that this disorder is not bipolar disorder.

Persistent depressive disorder

This disorder resembles major depressive disorder, but symptoms are not usually as intense and last a year or longer.

Diagnosis

  • Interviews or structured questionnaires

  • Tests to check for other causes of symptoms

To diagnose depression, doctors rely on several sources of information, including an interview with the child or adolescent and information from parents and teachers. Sometimes doctors use structured questionnaires to help distinguish depression from a normal reaction to an unhappy situation.

Doctors diagnose a depressive disorder when children or adolescents have one or both of the following:

  • A feeling of sadness or irritability

  • Loss of interest or pleasure in almost all activities (often expressed as boredom)

Also, children must have had these symptoms most of the day nearly every day during the same 2-week period, and they must have other symptoms of depressions, such as loss of appetite and weight and problems sleeping.

Doctors try to find out whether family or social stresses may have precipitated the depression. Doctors also ask specifically about suicidal behavior, including thoughts and talk about suicide.

Doctors do tests to determine whether a physical disorder, such as an abnormal thyroid gland or drug abuse, is the cause of the symptoms.

If adolescents have depression that persists and does not respond to usual treatments, doctors may do a spinal tap to check for a deficiency of folate in cerebrospinal fluid.

Treatment

  • For most adolescents, psychotherapy and antidepressants

  • For younger children, psychotherapy followed, if needed, by antidepressants

  • Guidance for family members and school staff

Treatment of depressive disorders depends on the severity of symptoms. Any child who has suicidal thoughts should be closely supervised by experienced mental health care practitioners. If risk of suicide is high enough, children require brief hospitalization to keep them safe.

For most adolescents, a combination of psychotherapy and drugs is more effective than either alone. But for younger children, treatment is less clear. Psychotherapy alone may be tried first, and drugs are used only if needed. Individual psychotherapy, group therapy, and family therapy may be beneficial. Doctors also advise family members and the school on how they can help children continue to function and learn.

Antidepressant drugs help correct chemical imbalances in the brain. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, sertraline, and paroxetine, are the drugs most commonly prescribed for depressed children and adolescents. Some other antidepressants, including tricyclic antidepressants (such as imipramine), may be slightly more effective, but they tend to have more side effects, so they are rarely used in children.

If folate deficiency is identified in the cerebrospinal fluid, treatment with leucovorin (also called folinic acid) may be helpful.

In children, as in adults, depression often recurs. Children and adolescents should be treated for at least 1 year after symptoms have disappeared. If children have had two or more episodes of major depression, they may be treated indefinitely.

Antidepressant drugs and suicide

Recently, there has been concern that antidepressants may cause a slight increase in the risk of suicidal thinking and behavior in children and adolescents. This concern has led to an overall decrease in the use of antidepressants in children. However, this decrease in the use of antidepressants has been associated with an increase in the rate of death by suicide, perhaps because depression is then not adequately treated in some children.

Studies have been done to try to settle this issue. They found that suicidal thought and attempts may increase very slightly in children who take antidepressants. However, most doctors believe that the benefits outweigh the risks and that children with depression often benefit from drug treatment as long as doctors and family members are alert for worsening symptoms or suicidal thoughts.

Whether or not drugs are used, suicide is always a concern in a child or adolescent with depression. The following can help reduce the risk:

  • Parents and mental health care practitioners should talk about the issues in depth.

  • The child or adolescent should be supervised appropriately.

  • Regular psychotherapy sessions should be included in the treatment plan.

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • ZOLOFT
  • TOFRANIL
  • PAXIL
  • PROZAC, SARAFEM