Depression in Children

What is Depression in Children?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes several types of depression, which are major depressive disorder (MDD), disruptive mood dysregulation disorder (DMDD), persistent depressive disorder–also known as dysthymia, and another type that doesn’t fit specifically into other categories. This write-up discusses major depressive disorder (MDD) in children and teenagers.

MDD is the leading cause of disability in adolescents between the ages of 10 and 19 according to WHO’s 2014 report. Additionally, suicide is the third most common cause of death within this age group, with adolescent depression being a significant risk factor. Youths with depression generally encounter more stressful situations in the year leading up to diagnosis compared to other youths of the same age who are not dealing with depression.

What Causes Depression in Children?

Depression is caused by a combination of biological weaknesses and environmental factors that interact with each other, making it a complex condition to understand.

Genetics can play a significant role in the risk of developing depression. This has been shown in studies that reveal the risk for issues such as depression to be inherited is high – between 60% to 70% – especially in people between 13 and 35 years old. Furthermore, if parents have depression, their children are 2 to 4 times more likely to develop it too. It’s thought that certain gene’s interactions with the environment, can amplify this risk, particularly by making a person more vulnerable to stress. Some researchers also believe the presence of a specific variation of the serotonin transporter gene could increase the likelihood of depression, especially if a person has experienced hardship in life or abuse during early childhood.

Psychological stress triggered by life-altering events can also be significant contributors, and often set off depressive symptoms or episodes in youngsters, particularly girls. However, it’s crucial to mention that not everyone who experiences these stressful life situations will develop depression. These events can range from losses and abuses, to break-ups, bullying, and conflicts with parents.

From a cognitive perspective, adolescents with depression tend to have a more negative focus. Research shows that they remember more negative elements and less positive information than adolescents without depression. They also often underestimate their own abilities, which can contribute to and be perpetuated by their depressive condition. This could potentially lead to a cycle where depression and lack of self-confidence feed into each other. Rumination, which means constantly dwelling on one thing, is another factor that can contribute to the onset and perpetuation of depression.

In addition to the above, some other factors have also been linked to developing depression. Some of these include sleep problems like inefficient sleep or abnormal patterns of rapid eye movement sleep. Furthermore, certain medical conditions like epilepsy, multiple sclerosis, diabetes, and others, as well as mental health conditions such as anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder can be associated with depression. Some medications and substance use, particularly alcohol, might also increase the risk.

Risk Factors and Frequency for Depression in Children

Pediatric depression, or depression in children and teenagers, has different rates based on age and gender. At the age of 13, the yearly rate is between 1% and 2%. By age 15, the rate rises to somewhere between 3% and 7%. The occurrence of depression is equally common in boys and girls during childhood (a 1:1 ratio). However, during the teenage years, girls are twice as likely as boys to experience depression. In fact, after puberty, the risk of depression increases 2 to 4 times, specifically in girls.

Also, research has found that low- or middle-income countries tend to have higher depression rates in teenagers compared to wealthier countries. For boys, the rate sits between 10% and 13%, and for girls, it’s between 12% and 18%.

Pediatric depression’s annual rate is 1%-2% at age 13 and 3%-7% at age 15.
The condition equally affects boys and girls during childhood (1:1 ratio).
During adolescence, the ratio changes to 1:2, with girls being more susceptible.
After puberty, the depression risk increases 2 to 4 times, particularly in girls.
Studies show that rates of depression are higher in low to middle-income countries. For boys, the rates range between 10% and 13%, and for girls, they range between 12% and 18%.

Signs and Symptoms of Depression in Children

The criteria for diagnosing depression in children, according to the DSM-5, requires at least 5 of the following signs to be present within a two-week timespan. It’s crucial to note that this shift should represent a change in functioning. Also, at least one of these symptoms must be either a depressed mood or a reduction in interest or pleasure. Moreover, other medical conditions should not be able to explain these symptoms:

Experiencing a depressed or irritable mood most of the time on most days, demonstrated by feeling sad, empty, or hopeless as reported by the patient or observed by others
A significant decrease in interest or pleasure in activities
Not gaining weight as expected, noticeable weight loss when not dieting, or an unusual increase in weight or changes in appetite
Having sleep issues- either not sleeping enough or sleeping excessively
Feeling restless or moving noticeably slower than normal
Feeling a lack of energy almost every day
Experiencing feelings of worthlessness or irrational guilt
Having difficulty thinking, concentrating or being indecisive
Having repeated thoughts about death, recurrent suicidal thoughts without a specific plan, having prior suicide attempts, or having a definite plan for committing suicide

The condition results in significant distress or difficulty in social, work or other important life areas. This depressive episode can’t be explained by the effects of a substance, another medical condition, or other types of mental disorder. A history of manic or hypomanic episodes also disqualifies a diagnosis of depression.

Testing for Depression in Children

The US Preventive Services Task Force encourages regular mental health screenings for teenagers aged 12 to 18, with an emphasis on identifying symptoms of major depressive disorder. There are various mental health checklists used to spot the signs of depression, like the 9-item Patient Health Questionnaire which has a severity score ranging from 0 to 27, or the 20-item Zung Self-Rating Depression Scale, and also the 21-item Beck Depression Inventory-II.

It should be noted that there isn’t a specific blood test or scan that can determine if someone has depression. Nevertheless, doctors need to run some tests to make sure the symptoms are not caused by other health conditions. For example, they might check your blood count or your vitamin B-12 levels. They could also run tests on your electrolyte levels including magnesium, calcium, and phosphate. Tests may also be run on your thyroid hormones and liver and kidney function.

Additional tests might be needed if other health issues are suspected. These might include a urine drug test, a blood alcohol level test, an HIV test, a dexamethasone suppression test, and an ACTH stimulation test.

Treatment Options for Depression in Children

The goal of treating depression is to encourage recovery, help patients fully overcome symptoms, and enable them to return to their normal level of functioning. The methods for treating depression in children and adolescents are similar to adult treatment plans. However, with young patients, health professionals often begin treatment with psychosocial interventions.

Psychosocial interventions involve treating the child and their parents together, and are the first course of action for treating mild to moderate depression. This type of treatment involves educating the family about the illness and the importance of things like good nutrition and sleep. Exercise for at least half an hour a day is recommended. Therapy can also be useful, and may involve helping the individual understand and change the way they think and behave, improve problem-solving skills, and engage in lifestyle changes. Other forms of therapy can help reduce conflict within interpersonal relationships and improve communication. Family therapy can also be very beneficial for the individual and their relatives.

When it comes to medication, studies have shown that antidepressants work differently in adults compared to children. Placebos, or ‘dummy’ treatments, appear to have a stronger effect in children and adolescents, particularly those experiencing mild to moderate depression. It is crucial for healthcare providers to talk to the patient and their parents about the potential benefits and side effects of antidepressants. After the medication is first prescribed, weekly follow-ups are standard practice for the first month, allowing healthcare professionals to closely monitor side effects and provide support. The antidepressants most commonly used in children and adolescents are fluoxetine, sertraline, citalopram, and escitalopram, with the first and fourth being approved by the FDA for treating depression in adolescents. Venlafaxine, an SNRI (Serotonin-Norepinephrine Reuptake Inhibitor), is considered a secondary option due to its notable side effects.

Notably, one major side effect of antidepressants is an increase in suicidal thoughts, though not actual suicide attempts. Therefore, monitoring of suicidal risk is an integral part of treatment. Other potential side effects include stomach problems, agitation, nightmares, sleep disruptions, weight gain, and sexual dysfunction.

Lastly, healthcare providers should keep an eye on any other health conditions the patient might be dealing with simultaneously, such as sleep disorders, anxiety disorders, and other medical causes of depression.

When diagnosing bipolar disorder, doctors need evidence of at least one period of extremely high energy or elevated mood (manic or hypomanic episode). This can be tricky in children and teenagers, as bipolar disorders often begin with an episode of depression.

Adjustment disorder, another distinct mental health issue, starts after a major life event.

Substance use disorders can also look like depression. If a person is withdrawing from certain drugs, such as amphetamines or cocaine, or is intoxicated (especially on alcohol), they can show signs similar to those of depression. If the symptoms of depression appeared before the substance use or continue after the substance is no longer being used, then a separate diagnosis of depression may be made.

Certain medical conditions, such as multiple sclerosis, stroke, or underactive thyroid (hypothyroidism), can also cause symptoms that resemble depression.

Lastly, attention-deficit hyperactivity disorder (ADHD) can also mimic depression in children. For instance, symptoms of ADHD like a persistently irritable mood and trouble concentrating can be mistaken for depression in the pediatric population.

What to expect with Depression in Children

The length of time a person is depressed before they start treatment can significantly affect how severe their depression is and how much they can improve. Once treatment begins, it generally reduces the length of a depressive episode.

The chance of getting better from depression can also depend on how severe the depression is to start with. For example, people with severe depression only have a 20 to 30% chance of getting better, compared to those with mild-to-moderate depression who have up to a 90% chance of improving. In fact, 60% to 90% of mild-to-moderate depressive episodes in teenagers get better within a year. However, depression does typically come back within five years for around half to 70% of people.

Patients with severe depression receiving treatment from a mental health specialist are more likely to see their depression recur, with rates ranging from 50% to 64%. If a person’s depression only partially gets better, they have a high chance (67.6%) of falling back into depression compared to those who completely recovered initially (15.18%).

Children and teenagers who have repeated or long-term depression that continues into adulthood will likely face significant problems and limitations in their life.

Frequently asked questions

Depression in children refers to major depressive disorder (MDD), which is one of the types of depression included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is the leading cause of disability in adolescents between the ages of 10 and 19 and is associated with a higher risk of suicide.

Pediatric depression's annual rate is 1%-2% at age 13 and 3%-7% at age 15.

The signs and symptoms of depression in children, according to the DSM-5 criteria, include: - Depressed or irritable mood most of the time on most days, characterized by feelings of sadness, emptiness, or hopelessness. - Significant decrease in interest or pleasure in activities. - Not gaining weight as expected, noticeable weight loss when not dieting, or an unusual increase in weight or changes in appetite. - Sleep issues, such as not sleeping enough or sleeping excessively. - Restlessness or noticeably slower movement than normal. - Lack of energy almost every day. - Feelings of worthlessness or irrational guilt. - Difficulty thinking, concentrating, or being indecisive. - Repeated thoughts about death, recurrent suicidal thoughts without a specific plan, prior suicide attempts, or a definite plan for committing suicide. It's important to note that these symptoms should be present for at least two weeks and represent a change in functioning. Additionally, the symptoms should not be explained by other medical conditions, the effects of a substance, or other types of mental disorders. A history of manic or hypomanic episodes also disqualifies a diagnosis of depression.

Depression in children can be caused by a combination of biological weaknesses and environmental factors, including genetics, psychological stress triggered by life-altering events, cognitive factors such as negative focus and lack of self-confidence, sleep problems, certain medical conditions, mental health conditions, certain medications, substance use, and low- or middle-income countries.

The conditions that a doctor needs to rule out when diagnosing Depression in Children are: 1. Dysthymia 2. Other types of depression that do not fit into specific categories 3. Adjustment disorder 4. Substance use disorders 5. Medical conditions such as multiple sclerosis, stroke, or hypothyroidism 6. Attention-deficit hyperactivity disorder (ADHD)

To properly diagnose depression in children, doctors may order the following tests: - Blood count test - Vitamin B-12 level test - Electrolyte level tests (magnesium, calcium, and phosphate) - Thyroid hormone test - Liver and kidney function tests - Urine drug test - Blood alcohol level test - HIV test - Dexamethasone suppression test - ACTH stimulation test These tests are necessary to rule out other health conditions that may be causing the symptoms of depression. Additionally, doctors may also consider psychosocial interventions as a first course of action for treating mild to moderate depression in children.

Depression in children is typically treated through a combination of psychosocial interventions and, in some cases, medication. Psychosocial interventions involve treating the child and their parents together and can include educating the family about the illness, promoting good nutrition and sleep, and recommending regular exercise. Therapy may also be used to help the child understand and change their thoughts and behaviors, improve problem-solving skills, and make lifestyle changes. Additionally, family therapy can be beneficial. In terms of medication, healthcare providers may prescribe antidepressants, but it is important to closely monitor for potential side effects, including an increase in suicidal thoughts. Other health conditions that may be present, such as sleep disorders or anxiety disorders, should also be considered and addressed.

The side effects when treating depression in children can include: - Increase in suicidal thoughts (not actual suicide attempts) - Stomach problems - Agitation - Nightmares - Sleep disruptions - Weight gain - Sexual dysfunction

The prognosis for depression in children can vary depending on the severity of the depression and the timing of treatment. Here are some key points: - The length of time a person is depressed before starting treatment can significantly affect the severity of their depression and how much they can improve. - People with severe depression have a lower chance of getting better (20-30%) compared to those with mild-to-moderate depression (up to 90% chance of improving). - 60% to 90% of mild-to-moderate depressive episodes in teenagers get better within a year, but depression often comes back within five years for around half to 70% of people. - Patients with severe depression receiving treatment from a mental health specialist are more likely to see their depression recur (50-64% recurrence rate).

A mental health specialist.