The most common form of depression, major depressive disorder (MDD), is characterized by chronic feelings of sadness or worthlessness, irritability, physical lethargy, insomnia and sometimes thoughts of suicide. This guide outlines how major depressive disorder is identified, diagnosed and treated in children.
MDD: What Is It?
Depression is a psychiatric disorder that afflicts young people with chronic feelings of sadness or worthlessness—the defining characteristic of the disorder is that it robs a person of the capacity for pleasure. Unhappiness triggered by events is not uncommon in children, but it normally goes away when circumstances change. Children with depression don’t recover when events change; their dark mood and lack of interest in things they used to enjoy will persist.
Depression can interfere with all aspects of a child’s life, resulting in absences from school, trouble socializing with peers, and, in severe cases, thoughts of suicide. Depression is diagnosed when negative feelings, lack of interest in previous activities, and physical symptoms like fatigue and insomnia persist for at least 2 weeks. Onset is usually in adolescence, and it is diagnosed about twice as often in girls than in boys.
The DSM-5 guidelines for major depressive disorder have been changed to eliminate what was called the “bereavement exclusion,” which ruled out diagnoses of depression for 2 months after the death of a loved one. This was changed to reflect current thinking that bereavement is a process that commonly continues for 1 to 2 years, and that the death of a loved one can also trigger a major depressive episode, especially in people who have already experienced an episode of depression. Instead of ruling out these cases, the manual offers detailed guidelines to help clinicians distinguish between the pattern of emotions experienced during grieving and the symptoms of a major depressive episode.
MDD: What to Look For
The key sign of depression is a change in mood: unusual sadness and a reduced interest in activities—sports, friends, school—a child had enjoyed. Anticipation of things she normally looks forward to is no longer pleasurable. Some depressed adolescents lose anticipatory pleasure but are able to enjoy what clinicians call “consumatory pleasure” — that is, the idea of pizza no longer interests them, they won’t seek an opportunity to get pizza, but served pizza, they can enjoy eating it. This presentation, known as atypical depression, can fool parents, who may dismiss their daughter’s dogged lack of interest as being oppositional.
Other signs of depression are unexpected, involuntary changes in weight; major shifts in sleep patterns; and sluggishness. A depressed child may express inappropriate guilt or be unusually harsh on herself — I’m ugly, I’m no good, nobody likes me. In the most extreme cases, depressed kids may have thoughts of or make attempts at suicide.
MDD: Risk Factors
Children who have negative temperaments are more likely to develop major depressive disorder. Those who have first-degree family members who have depression are also more at risk, as are kids who have had adverse childhood experiences. Having another major disorder or a chronic or disabling medical condition also makes children more likely to develop depression.
In diagnosing depression, a professional will depend upon observations of a child by family members and other adults involved in her care, as well as her own descriptions of her life.
For a diagnosis of major depressive disorder, a young person will be in a depressed or irritable mood most of the time, or lose interest or pleasure in daily activities most of the time, or both, for at least 2 weeks. These symptoms must be a distinct shift from previous functioning. In addition, she will show a variety of the following signs: marked weight loss or gain; sleeping too much or too little; restlessness or lethargy; fatigue; feelings of worthlessness or excessive or inappropriate guilt; cloudy or indecisive thinking; and a preoccupation with death, plans of suicide, or an actual suicide attempt. A clinician will also need to rule out other causes for these symptoms, including substance abuse, medical conditions like diabetes and hypothyroidism, and other psychiatric disorders. The condition must significantly interfere with her day-to-day activities.
Mild cases of depression are treatable with specialized psychotherapies alone, but experts agree that in most cases a combination of psychological and pharmacological therapies is the best approach.
Psychotherapeutic: Childhood and adolescent depression is often treated with interpersonal therapy, or IPT. In IPT, a therapist focuses on a young person’s relationships with peers and family, and how they can positively (and negatively) impact the child’s the inner life. IPT for young people with depression also encourages kids to seek out and participate in the activities they’ve lost interest in with the goal of jumpstarting recovery, a process called behavioral activation.
Cognitive behavioral therapy (CBT), which seeks to treat psychiatric disorders by teaching children how their thoughts affect feelings and behaviors, is used to treat depression.
Pharmacological: Many medications have proven effective in combating depression. A course of therapy usually begins with one of the reuptake inhibitors, medications that increase the supply of certain neurotransmitters—chemicals parts of the brain use to communicate with each other—a shortage of which has been associated with depression. These drugs include selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and norepinephrine and dopamine reuptake inhibitors (NDRIs). These medications, while still having some significant side effects, are safe if properly managed.
The FDA has decided, based on research, that all antidepressants run the risk of encouraging suicidal thoughts, and they all carry warning labels. But the phenomenon is rare and has been tied only to suicidal ideation, not actual suicide attempts.
MDD: Risk For Other Disorders
Depression is very often diagnosed alongside anxiety disorders like generalized anxiety disorder and panic disorder. Depressed youngsters are also more at risk than the general population to develop alcohol and substance dependencies.
MDD: Other Concerns
Suicide risk: Children and adolescents with major depressive disorder are at increased risk of committing suicide—the third leading cause of death among adolescents and young adults aged 15 to 24. Never ignore signs of suicidal behavior or ideation, which include: drastic changes in eating habits, sleep patterns, or personality; marked neglect of personal appearance; giving away personal belongings; sudden happiness after a period of depressed mood; and, of course, talk of suicide or of “going away” or “not being a problem anymore.” If you think your child or adolescent is suicidal, you can call the National Suicide Prevention Lifeline at 1-800-273-8255 or 911 if there is an emergency. Don’t hesitate—the risk of suicide in children and adolescents is all too real.