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 are out of proportion to that event and persist 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.
(See also Depression in adults.)
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 approximately 4% of children and adolescents under age 18 in their lifetime; it tends to increases with age. Female children and adolescents are twice as likely to be affected as males.
Depression includes several disorders:
Major depressive disorder
Disruptive mood dysregulation disorder
Persistent depressive disorder (dysthymia)
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Causes of Depression and Mood Dysregulation Disorder
Doctors do not know exactly what causes depression, but chemical abnormalities and irregularities in activation in the brain are probably involved in the development and worsening of depression and mood regulation disorders.
Some tendency to develop depression is inherited. A combination of factors, including life experiences (such as a loss early in life, abuse, injury, domestic violence, or having lived through a natural disaster), and a genetic tendency (vulnerability), all seem to contribute.
Social media and social networking sites have raised concerns because their use leads to decreased face-to-face interpersonal interactions, addiction-like behaviors, online bullying, and social pressure from increased social comparisons.
Sometimes another disorder, such as an underactive thyroid gland or substance use disorder, is part of the cause. Some 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).
During the COVID-19 pandemic, symptoms of depression doubled in young people, especially in older adolescents. This increase was due in part by the pandemic stressors, with further increases in those adolescents who had an actual COVID-19 infection. Mental health visits for depression also increased.
Symptoms of Depression and Mood Dysregulation Disorder
As in adults, the severity of depression in children varies greatly. While younger children may be unable to explain inner feelings or moods, older children and adolescents may be able to describe their symptoms more accurately.
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 (3 or more times per week). 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 and must usually occur in 2 or 3 different settings before doctors make the diagnosis.
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 of Depression and Mood Dysregulation Disorder
A doctor’s or behavioral health specialist's evaluation, based on standard psychiatric diagnostic criteria
Sometimes questionnaires about symptoms
To diagnose depression, doctors rely on several sources of information, including an interview with the child or adolescent and information from parents/caregivers 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 depression, 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 by taking a detailed history, which should include the following potential factors:
Domestic violence
Sexual abuse and exploitation
Side effects of illicit drugs and medications
Use of social media and social networking sites (length of time used and whether use occurred during the day or at night)
Doctors also ask specifically about suicidal behavior, including thoughts and talk about suicide.
Doctors do tests to determine whether an abnormal thyroid gland or a substance use disorder 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.
After depression is diagnosed, the family and social setting must be evaluated to identify stresses that may have caused or contributed to the depression.
Treatment of Depression and Mood Dysregulation Disorder
For most adolescents, psychotherapy and antidepressants
For younger children, psychotherapy followed, if needed, by antidepressants
Guidance for family members and school staff
Transcranial magnetic stimulation (TMS) used with other treatments
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 professionals. If risk of suicide is high enough, children require brief hospitalization to keep them safe.
For most adolescents, a combination of psychotherapy and medications is more effective than either alone. But for younger children, treatment is less clear. Psychotherapy alone may be tried first, and medications 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 medications help correct chemical imbalances in the brain. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, escitalopram, sertraline, and paroxetine, are the commonly prescribed antidepressants for depressed children and adolescents. Some other antidepressants, including serotonin–norepinephrine reuptake inhibitors (SNRIs) (such as duloxetine and desvenlafaxine) and 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.(SSRIs), such as fluoxetine, escitalopram, sertraline, and paroxetine, are the commonly prescribed antidepressants for depressed children and adolescents. Some other antidepressants, including serotonin–norepinephrine reuptake inhibitors (SNRIs) (such as duloxetine and desvenlafaxine) and 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, doctors may consider adding specific forms of folate to the treatment plan that can cross into the brain tissue.
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 2 or more episodes of major depression, they may be treated indefinitely.
Antidepressants and suicide
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 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 medication treatment as long as doctors and family members are alert for worsening symptoms or suicidal thoughts.
Whether or not medications are used, the possibility of suicide is always a concern in any child or adolescent with depression. The following can help reduce the risk:
Parents and mental health care professionals 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.
Antipsychotics
In very severe depression, psychotic symptoms may emerge (for example, delusions, hallucinations, and disorganized thinking and speech). These require treatment with a class of medications called antipsychotics.
Transcranial magnetic stimulation (TMS)
Transcranial magnetic stimulation (TMS) is a method of treatment where brief magnetic pulses are applied to the brain through an electromagnetic coil placed near the patient's scalp to reduce depression. TMS is thought to work by increasing the activity of a couple of neurotransmitters that are normally reduced during depression.
A TMS device has been used successfully in adolescents with depression aged 15 and older under several circumstances: on its own, when paired with other treatments such as antidepressants and talk therapy, or when more standard treatments have been ineffective. Adolescents and young adults with depression and anxiety have also shown improvement in both disorders with TMS. Use of this device is not yet approved in younger children. Side effects reported with TMS include pain at the treatment site, headaches, transient blurry vision (it resolves after 5 days).
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