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Childhood Depression

Essentials

  • Childhood depression manifests itself in a multitude of ways at different ages, and the symptoms often cause irritation in adults.

Nature of childhood depression

  • A child experiences depression as a state of dissatisfaction or oppressive melancholy.
  • A depressed child loses the ability to experience interest, happiness and satisfaction with everyday activities and things, and e.g. time used for playing or hobbies is diminished or they are given up completely.
  • The child feels rejected, thinks that nobody cares about him/her and may become resistant to offers of help.
  • A depressive child often appears unhappy and miserable with reduced facial expression, or irritable and dissatisfied.

Prevalence

  • The prevalence of depression in children less than 13 years of age is about 3%, in girls aged 13 to 18 years about 6% and in boys of respective age 5% 2.
  • Symptoms of social withdrawal are found in about 3% of infants 3.

Signs and symptoms at different ages

Depression in the infancy

  • There are no official criteria for depression in the infant. Studies have been able to demonstrate that an infant may develop social withdrawal e.g. in response to unsatisfactory parent-child interaction 3, which is characterised by the following:
    • the parent does not seek eye contact or talk to the infant (no ”baby talk”)
    • the parent is very limited in expressing positive feelings towards the infant
    • handling of the infant by the parent is minimal, often mechanical, or the infant is not held close to the body
    • the parent complains how hard and difficult he/she finds caring for the infant
    • the parent is often worried and anxious about his/her ability to care for the infant
    • the parent may harbour ideas about suicide or killing the infant.
  • A socially withdrawn infant
    • avoids eye contact with the parent and in a more severe case also with other people
    • shows low interest in his/her environment and other people
    • shows reduced facial expressions; the look on the face may be sad or frozen
    • has diminished movements and vocalisation
    • has a subdued or whining cry
    • reacts to stimuli slower than normal
    • may suffer from sleeping and feeding problems
    • may slow down or even regress in both cognitive and motor development
    • may in extreme cases lose his/her zest for life.

Depression in children of preschool and school age

  • A depressed mood is often manifested by irritability and boredom.
  • Facial expressions may diminish, the child's movements may become awkward or the child may be hyperkinetic.
  • As the child becomes more disinterested and dissatisfied, his/her interest in hobbies and games diminishes or is lost altogether; friendships may also end.
  • Concentration difficulties lead to restlessness, and school performance often deteriorates.
  • The child may be tired and sleep a great deal or wake up in the small hours.
  • Different psychosomatic symptoms such as faecal soiling, headache and abdominal pain as well as other pains can also be signs of depression.
  • Changes in appetite may signify depression.
  • The child feels and describes himself/herself to be no good, and has feelings of failure and guilt.
  • The antics of the ”class clown” may hide feelings of inferiority behind the mask; by entertaining others the child tries to escape his/her feelings of hopelessness.
  • In some cases, depression is associated with violent temper tantrums or an inability to play with others.
  • Self-destructive behaviour associated with depression 1 may manifest itself in attempts to run away from home, as proneness to accidents and as suicidal talks and also attempts.
  • Prolonged depression leads to social withdrawal and isolation, and the child becomes susceptible to bullying at school, either as a victim or a perpetrator.
  • A child's depression can even lead to thoughts of self-destruction and, in extreme cases, acts of self-destruction.
  • Children's suicides are violent and often mistakenly interpreted as accidents.

Differential diagnosis

  • Somatic diseases, pain and hearing or vision impairment may also cause social withdrawal in infancy, and such conditions are first to be investigated and excluded.
  • Depression in children may coincide with an anxiety disorder, school phobia and behaviour disorder.
  • On the one hand, children and adolescents with depression often display various physical disorders, but on the other hand, a child with a physical illness may appear quiescent and depressed.
  • It is normal for a child sometimes to be sad, tired and exhausted, and a short-lived depressive reaction may be a developmental phenomenon, for example associated with an experience of loss or change.
  • Depression, even if of short duration, must be treated appropriately if it hinders mental development or has an adverse affect on the child's psychosocial coping, e.g. with friends or at school.

Evaluation

  • The diagnostics and treatment of depression usually require child-psychiatric evaluation or consultation.
  • When a child with depressive symptoms is seen by a doctor, child health clinic staff or school medical services, different types of questionnaires (such as Children's Depression Inventory, CDI) filled by the child and by the parents can be used to help in the assessment. In addition, the child and the parents, and possibly also other important adults, such as the child's teacher, are to be interviewed.
  • The aetiological factors for depression include genetic predisposition, negative factors associated with either the family or social relationships, experiences of loss (loss of family members or friends, frequent removals), and traumatic experiences, especially school bullying and domestic violence.
  • The parents should be asked about the family history regarding depressive and anxiety disorders as well as about stress factors and life events that have an effect on the family life.
  • When the child is interviewed, it is useful to ask directly about symptoms of depression (”Do you sleep well?”), the child's mood, life events and changes, particularly those connected with the family and friendships, as well as events at the day-care centre or at school.
  • If suicidal tendencies are suspected, direct questions should be asked (”Have you ever felt so bad that you have thought of hurting yourself or killing yourself?”).
  • If the child answers affirmatively, the parents should be asked whether they know how bad the child is feeling and that there is a risk of suicide.
  • In addition to the interview, attention should be paid to the child's demeanour and the interaction between the child and the parents, especially when evaluating small children.
  • When evaluating and treating depression in a child, the entire life situation of the family should be taken into account since depression may be linked with certain family events, and parents always play an important role in the treatment of the child.

Treatment Psychological Interventions for the Prevention of Depression in Children and Adolescents, Prevention of Relapse and Recurrence of a Depressive Disorder in Children and Adolescents

General principles

  • A depressed child needs support from an adult who is able to cope with the child's feelings and who can also show affection towards, and take care of, the child.
  • Parents, or those taking the responsibility of parenthood, will benefit from factual information regarding childhood depression (psychoeducation).
  • The younger the child the more the treatment should target the parents who will eventually implement the treatment.
  • Short-term depression, when it clearly is a response to a change,
    • can be treated at a child health clinic or by the school medical services in cooperation with the family.
    • requires a follow-up of an adequate length to determine whether the depression has improved or whether prolonged depression requires continued treatment at a specialist level.
  • Indications for medical specialist care or other specialist care (child psychiatric clinic or family guidance centre):
    • prolonged depression (duration more than 2 months), even with mild symptoms
    • severe depression affecting the functional capacity of the child
    • depression associated with multiple or severe signs of a behaviour disorder.

Choosing the mode of treatment Psychological Therapies Versus Antidepressant Medication for Depression in Children and Adolescents

  • Therapy that targets the entire family is indicated especially for younger children if the parent(s) show depressive signs or if the child has signs of neglect.
  • When treating infants and young children, it is important to ensure that there is an adequate amount of good quality interaction with an adult. This can be provided either by treating parental depression and encouraging the parents to engage in interaction with the child or, should this prove unsuccessful, by providing the infant/toddler with a carer from outside the family unit. In more serious cases, interaction therapy may be considered.
  • University hospitals have the facilities to provide psychiatric treatment for young children.
  • Individual therapy is especially suitable for adolescents, but in some cases it may also be used for younger children Cognitive Behaviour Therapies in the Depression in Children and Adolescents.
  • Evidence exists of the efficacy of cognitive behavioural therapy (CBT) in the treatment of depression Cognitive Behaviour Therapies in the Depression in Children and Adolescents.
  • Also regular exercise may be beneficial in the treatment of children's and adolescents' depression.
  • Children who are at risk of suicide should urgently be referred to specialist health care. The primary aim of treatment is to ensure physical safety, which can be done on an outpatient basis or in a hospital ward.
  • Inpatient treatment is also indicated for children whose depression considerably affects their school performance and other psychosocial coping.
  • The selective serotonin reuptake inhibitor (SSRI) fluoxetine Newer Generation Antidepressants in Childhood and Adolescent Depression can be used, in conjunction with other treatment, to treat severe or prolonged depression in children. In the latest studies, the efficacy of SSRIs has been inferior to what was reported earlier, and increased suicidal thoughts have been connected with SSRIs in some studies.
  • Tricyclic antidepressants are not beneficial Tricyclic Antidepressant for Depression in Children and Adolescents in children of primary-school age, and there is no evidence for the effectiveness of SSRIs in children 11 years and younger.
  • The use of medical treatment in childhood depression should always be carefully considered by a child psychiatrist, and any treatment should be monitored with frequent follow-ups.

Prognosis

    References

    • Dopheide JA. Recognizing and treating depression in children and adolescents. Am J Health Syst Pharm 2006 Feb 1;63(3):233-43. [PubMed]
    • Jane Costello E, Erkanli A, Angold A. Is there an epidemic of child or adolescent depression? J Child Psychol Psychiatry 2006;47(12):1263-71. [PubMed]
    • Puura K, Mäntymaa M, Luoma I et al. Infants' social withdrawal symptoms assessed with a direct infant observation method in primary health care. Infant Behav Dev 2010;33(4):579-88. [PubMed]
    • Guedeney A, Fermanian J. A validity and reliability study of assessment and screening for sustained withdrawal reaction in infancy: the Alarm Distress Baby Scale. Infant Mental Health Journal 2001;22: 559-575.
    • Wegner M, Amatriain-Fernández S, Kaulitzky A et al. Systematic Review of Meta-Analyses: Exercise Effects on Depression in Children and Adolescents. Front Psychiatry 2020;11():81. [PubMed]