Depression in Children – Causes, Signs and Symptoms

Depression in Children

Summary

Depression is a type of mental illness that sometimes affects children, causing them to feel sad, angry or frustrated for long periods of time. Major depression among children affects about 2 percent of children ages 6 to 12 years and 4 percent of adolescents, according to the National Alliance on Mental Illness (NAMI).

Some bouts of depression in children are severe but relatively short in duration. Others are mild, but may continue for years. Children may become depressed after a trauma, such as the death of a parent, family strife or illness. In other cases, the source of this change in mood is less obvious.

Experts classify depression in many different ways. The two general categories of depression are:

  • Major depression. Also known as clinical depression or unipolar depression, it is a severe type of depression that requires treatment. Most patients who experience a bout of major depression are likely to have recurrent bouts in the future. 

  • Bipolar disorder. Formerly known as manic depressive illness, it involves alternating periods of extreme highs (mania) and extreme lows (depression). Youth symptoms related to bipolar disorder differ somewhat from those experienced by adults. 

Experts may also use other categories to classify certain types of depression. They include:

  • Dysthymia. A chronic form of low-level depression that lasts for at least two years. Children with dysthymia have a perpetually gloomy mood.

  • Adjustment disorder with depressed mood. A bout of depression that occurs after a significant life change, such as the death of a loved one or a major disaster.

The causes of depression are not fully understood. Changes in brain chemistry appear to be responsible. In some children, depression may have a genetic link.

Depressed children may experience ongoing sadness, irritable mood and a sense of overall hopelessness. They may have little interest in new activities, and may no longer enjoy activities that previously provided them with pleasure. These children may have difficulties at school, somatic complaints, and aggressive or antisocial behavior patterns. Some may experience weight changes or disruption in their sleep patterns. Many depressed children complain of persistent boredom and may exhibit low levels of energy. They may even talk about wishing they were dead, or may make similar statements that indicate suicidal thoughts. 

Parents are urged to seek medical attention for any child who exhibits symptoms of significant depression that appear to be negatively impacting the child’s quality of life. If the physician suspects that a child is depressed, the patient may be referred to a child and adolescent psychiatrist or other mental health professional for further evaluation and treatment. 

Treatments for depression in children usually consist of psychotherapy, medications or a combination of the two. Psychotherapy may consist of individual therapy and family therapy, and antidepressants typically are the medication of choice in treating depression.

It is important to note that the U.S. Food and Drug Administration has advised that antidepressants may increase the risk of suicidal thinking in some patients, especially children and adolescents, and all people being treated with them should be monitored closely for unusual changes in behavior.

About depression in children

Depression is a mental illness that causes people to feel sad, angry, hopeless or frustrated for long periods of time, resulting in impaired psychosocial functioning. Major depression affects about 2 percent of children aged 6 to 12 years and 4 percent of adolescents. An estimated 20 percent of all youths will experience at least one episode of major depression by the time they are adults, according to the National Alliance on Mental Illness (NAMI).

Everybody has occasional periods in which they feel blue. Children are no exception to this rule. However, depression is a significant feeling of sadness and loss of interest in activities which interferes with a child’s ability to enjoy life. Scientists realize that depression among children is actually quite common. Also, juvenile mood disorders tend to be more chronic than adult-onset mood disorders.

Some bouts of depression in children are severe but relatively short in duration. Others are mild, but may continue for years. Children may become depressed after a trauma such as the death of a parent, family strife or illness (e.g., cancer, diabetes). Children who are abused or neglected are also at greater risk for depression In some cases, children may become depressed despite the lack of an obvious event that might have triggered the change in mood.

A child may experience just one episode of depression or may have several that are broken up by periods of normal mood. An episode of depression typically lasts for six to nine months. Children who have a bout of depression are at increased risk of suffering another similar episode within five years. They also are five times more likely to have depression as an adult than children who do not have depression, according to the National Mental Health Association (NMHA). In some cases, a child’s depression may go into remission before appearing again years later. In other cases, children may have more continuous depression that requires treatment into the adult years.

Children and adolescents with depression also frequently have or may develop other mental health disorders such as self-injury, eating disorders, anxiety disorders, learning disorders or substance abuse problems.

Children who suffer from depression may not always be able or willing to approach a parent or others about their condition. For this reason, parents must be vigilant in looking for signs that their child may be depressed. Parents are urged to ask about their child’s thoughts and feelings. In addition, parents can consult with a physician about whether or not the child’s emotions or behavior might indicate a problem.

Types and differences of depression in children

There are several different types of depression that a child may experience. They include:

  • Major depression. Includes at least one episode of this disorder (also known as clinical depression or unipolar depression) marked by persistent sadness and symptoms such as weight changes, loss of interest in enjoyable activities, changes in sleeping patterns, social withdrawal and suicidal thoughts. Children who experience major depression are likely to experience future bouts of depression.

  • Bipolar disorder. Formerly known as manic depressive illness, it involves alternating periods of extreme mood swings (highs [mania] and extreme lows [depression]). Periods of depression are similar to those experienced during major depression. Manic periods include symptoms such as reduced need for sleep, rapid speech, racing thoughts and impulsive behavior. Youth symptoms related to bipolar disorder differ somewhat from those experienced by adults. For example, children who are in a manic phase are more likely than adults to be irritable and to engage in destructive behavior. They are also less likely than adults to be elated or euphoric. Bipolar disorder can be difficult to diagnose in children, as the signs and symptoms may be mistaken for those of other conditions, such as attention-deficit hyperactivity disorder (ADHD) and conduct disorders, as well as normal childhood development.

  • Dysthymia. A chronic form of low-level depression that lasts for at least one year in children. Children who have dysthymia have a perpetually gloomy mood and are more likely to be irritable than depressed. Dysthymia in children may be associated with ADHD and other medical or psychological conditions. Patients with dysthymia often go on to develop major depression, and vice-versa.

  • Adjustment disorder with depressed mood. A bout of depression that occurs after a significant life change, such as the death of a loved one or a major disaster. Children with this disorder go through a period of adjustment that is longer than normally would be expected or that interferes with their daily activities.

Potential causes of depression in children

The causes of depression are not fully understood. Changes in brain chemistry appear to be responsible for depressive emotions. Chemicals called neurotransmitters help send messages between nerve cells in the brain. Some of these neurotransmitters are responsible for regulating mood. Too many or too few neurotransmitters, particularly norepinephrine, serotonin and dopamine, are believed to cause alterations in mood.

In some children, depression appears to have a genetic link. The disease runs in families, and some children may be born with inadequate levels of mood-regulating neurotransmitters. This often results in depression.

In other cases, stressful events – such as the death of a loved one – can alter the levels of these neurotransmitters in a child, causing the child to become depressed. Children at high risk for depression include those who have conditions such as attention deficit hyperactivity disorder(ADHD), learning disorders, conduct disorder and anxiety disorders. A history of abuse, neglect, trauma or chronic illness (e.g., cancer, diabetes) also places children at greater risk for depression. In many cases, depression is the result of a combination of genetic and environmental factors. In other instances, the source of depression is not as obvious.

Signs and symptoms of depression in children

Depressed children may experience irritable mood or sadness that is frequently expressed by crying (especially in preschool-aged children) and a sense of overall hopelessness. They may have little interest in new activities, and may no longer enjoy activities that were previously pleasurable. These children often have difficulties at school, somatic complaints, and aggressive or antisocial behavior patterns. Some may experience changes in weight or disruption in sleep patterns.

Many depressed children complain of persistent boredom and may exhibit low levels of energy. They may have few friends, or begin to abandon friends they made earlier. They may even talk about wishing they were dead or make similar statements that indicate suicidal thoughts. Symptoms of depression may vary according to the age of the child.

Symptoms associated with preschool- or elementary school-aged children include:

  • Academic difficulties
  • Boredom
  • Crying more often than usual
  • Decreased interest in playing
  • Easily discouraged
  • Emotionally distant with family and friends
  • Increased irritability
  • Listlessness and moodiness
  • Sad appearance
  • Talk of death

Symptoms of depression among teenagers include:

  • Arguments with parents and teachers
  • Constant tiredness
  • Harmful behavior, such as self-injury
  • Refusal to do chores or homework
  • Withdrawal from favored activities
  • Suicidal thoughts or statements

Other general symptoms associated with depression in children include:

  • Poor self-esteem
  • High levels of guilt
  • Fear of rejection or failure
  • Persistent anger or hostility
  • Regular headache, stomachache or other physical ailments
  • Inability to concentrate
  • Changes in eating and sleeping patterns
  • Self-destructive behavior
  • Threats to run away from home

A child who has five or more symptoms associated wth depression for a period of at least two weeks is likely to be depressed. Depressed children are at significantly increased risk for attempting suicide. Suicide rates among young people have nearly tripled since 1960. According to the National Mental Health Association (NMHA), almost 5,000 individuals between the ages of 15 and 24 years kill themselves each year. It is believed that most of these suicide victims suffered from untreated depression.

Children whose depression continues into adolescence are at increased risk for abusing drugs and alcohol or engaging in unsafe sex or other risky behaviors.

Diagnosis methods for depression in children

Parents are urged to seek medical attention for any child who exhibits symptoms of depression that appear to be negatively impacting the child’s quality of life. In diagnosing depression, a physician compiles a thorough medical history and performs a complete physical examination. If the child shows signs of depression, the physician may order blood tests and other procedures to help rule out medical conditions that may cause similar symptoms.

If the physician suspects that the child is depressed, the child may be referred to a child and adolescent psychiatrist or other mental health professional who can help make a more definitive diagnosis of depression. This evaluation includes a complete history of symptoms, including information about their onset, duration and severity. It is also noted whether the child has had these symptoms before and, if so, whether and how they were treated. Questionnaires (e.g., the Mood Disorder Questionnaire) and other evaluation tools may also be used to confirm diagnosis.

The physician or non-physician mental health professional will also ask about whether the child has thought about death or suicide and whether other family members have had a mood disorder or history of alcohol and drug use. The child will also be examined for other mental health disorders that often accompany depression. For example, children who have bipolar disorder may be found to also have attention deficit hyperactivity disorder (ADHD) or a conduct disorder.

Treatment options for depression in children

Treatments for depression in children usually consist of psychotherapy, medication or a combination of the two.

Psychotherapy is often valuable in helping children to address symptoms related to depression. This may include both individual therapy and family therapy sessions. Cognitive behavioral therapy(CBT) appears to be particularly effective in treating a child’s depression. As part of this therapy, children learn to develop a healthier, more positive view of themselves. Children may also benefit from interpersonal therapy(IPT), which focuses on a child’s relationship with others and attempts to improve the child’s interpersonal skills. Family therapy is a form of interpersonal therapy that involves the entire family. It may be particularly helpful when there are specific family-related stresses.

Medications such as antidepressants often provide significant relief from symptoms associated with depression. They are used most often in cases when psychotherapy alone fails to relieve symptoms and in situations where children have chronic or recurrent depression. These drugs help restore the proper balance of neurotransmitters in the brain and are typically used for a period of at least six months to one year. Some children may require long-term treatment that lasts for years. Although there has been little study regarding the efficacy of older drugs such as tricyclic antidepressants(TCAs) in treating depression in children and adolescents, newer selective serotonin reuptake inhibitors (SSRIs) do appear to be effective.

To date, only fluoxetine has been specifically approved by the U.S. Food and Drug Administration (FDA) to treat depression in children. However, many physicians prescribe other antidepressants on an “off-label” basis. This means physicians use their own judgment in deciding whether or not the drug may be helpful for the child, based on the child’s individual symptoms. This is considered to be a common and ethical practice, and in many cases these drugs are helpful for children with depression. However, recommendations vary between physicians, and parents are urged to discuss what is known about the drug with the physician, as well as weigh the potential benefits and risks of using such medications.

Parents should be aware that the FDA has advised that antidepressants – including fluoxetine – may increase the risk of suicidal thinking in some patients, especially children and adolescents, and all people being treated with them should be monitored closely for unusual changes in behavior. 

However, recent research indicates that the benefits of such medication in the treatment of depression far outweigh the risks.

Children and adolescents with bipolar disorder are usually treated with mood stabilizers (e.g., valproate) and antipsychotics. Supportive psychotherapy has been found beneficial as an additional treatment for bipolar disorder.

The FDA recommends special guidelines for children whose depression is being treated with medications. For the first month of treatment, children should visit the physician on a weekly basis. This should shift to every other week during weeks five through eight of treatment. If no problems emerge, the child should then visit the physician on week 12, and thereafter according to the physician’s recommendations.

Questions for your doctor

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Parents may wish to ask their child’s doctor the following questions related to depression in children:

  1. What symptoms might indicate that my child has depression?
  2. Which signs and symptoms might indicate that my child’s depression requires medical attention?
  3. How will you diagnose my child’s condition?
  4. What type of depression does my child likely have?
  5. Should I alert school or day care officials about my child’s depression?
  6. What are my child’s treatment options?
  7. Are there any potential risks or side effects of these treatments?
  8. Should my child take antidepressants despite FDA warnings about the drugs? What are the potential benefits and risks of taking these medications?
  9. When will I know that it’s appropriate for my child to discontinue antidepressant use?
  10. What steps can I take to increase the odds that my child’s treatment will be effective?
  11. Should my child undergo psychotherapy? Would family therapy be helpful?
  12. How long will it take for my child’s condition to improve?
  13. What signs might indicate that my child’s depression is improving?
  14. How likely is it that my child will suffer another bout of depression in the future?
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