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Depression in children
Julian Charles, Mandana Fazeli

D
Background iagnosing major depressive disorder (MDD) in children
Major depressive disorder (MDD) in children (5–12 years of (5–12 years of age) can be confronting. Important debates
age) is a confronting and serious psychiatric illness. MDD has continue regarding the validity of psychiatric diagnoses,
significant ramifications for the psychosocial development of especially in children and adolescents.1 Longitudinal research,
the child, yet it remains under-recognised and undertreated. however, has continually demonstrated that most adult disorders
General practice is where these children and their parents will have their origins in childhood, and most childhood disorders
first present. have consequences that persist to adulthood.2–4 There is evolving
evidence to suggest MDD, as we currently understand it, can
Objective even exist in preschoolers.5,6 Additionally, MDD that emerges
in children aged 5–12 years can be severe and lead to poorer
The aim of this article is to provide general practitioners
outcomes, compared with later onset MDD.7–10
(GPs) with a framework for considering MDD in a child and
Childhood MDD typically presents to primary care and
recommendations for treatment.
is undertreated. Parents will often approach their general
Discussion practitioner (GP) with concerns about their child’s behaviour
and/or with their child’s complaints of somatic symptoms. It can
Children with MDD have the same core features as adolescents be a challenging clinical scenario for GPs to recognise MDD in
and adults, taking into account the child’s capacities for a child, and formulate the presenting problem in the broader
cognition and language, and developmental stage. Earlier system within which the child exists. GPs therefore need to
onset of illness is associated with poorer outcomes and greater have an understanding of how childhood MDD presents and
psychiatric morbidity persisting into adulthood. MDD is more how to assess and treat it, and have a network of professionals
common than anticipated, and should be considered for any
to whom children can be referred when necessary and
child presenting with depressive symptoms and/or impaired
appropriate.
psychosocial functioning. Despite limited evidence, numerous
interventions exist that will, ideally, significantly affect the Childhood MDD: Risk factors and outcomes
child’s developmental trajectory. GPs are in an important position
Historically, society disregarded the notion that a child’s mental
to initiate these interventions.
health could be disturbed.11 Prior to the 1970s, depression was
typically viewed as an adult disorder because children were
seen as too developmentally immature to have this disorder.12
The American Psychiatric Association’s Diagnostic and statistical
manual of mental disorders (DSM) did not represent children until
its third edition in 1980.13 Since then, an established evidence
base has demonstrated that children can meet DSM adult
diagnostic criteria for MDD and that earlier onset of illness is
associated with:8,9,14
• increased number and severity of depressive episodes
• increased medical and psychiatric comorbidity
• increased suicidality
• increased emergency department visits
• greater social, educational and quality-of-life impairment.

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All of these associations have serious implications for prognosis How does a depressive episode present
and childhood development. in a child?
Childhood MDD is more common than generally realised, Depressive disorders in childhood, adolescence and adulthood
with studies suggesting its point prevalence is 1–2%.15,16 are typically defined by the same underlying features: changes
These rates underestimate the number of children who do not in mood, thinking and activity that are sufficient to cause
meet DSM-5 diagnostic criteria for MDD, but who present to impairment in personal and social functioning. In children,
primary care with clinically significant depressive symptoms and however, there are important differences, depending on their
functional impairment.17 There is no marked gender difference developmental stage, in determining how an episode of MDD
when compared with adolescent-onset MDD. The prevalence will present. Children will also vary in their ability to describe
increases to 4–5% with the onset of puberty,6,7 largely their internal world because of their speech and language
accounted for by the increase in prevalence for girls, with the capacity, cognitive function, level of distress/disorder, and
subsequent 2:1 female-to-male ratio.12 modelling opportunities (Table 2).
MDD is likely to be a final common pathway for complex, Children with depression typically find it hard to say positive
multifactorial aetiologies, including genetic, endocrine, things about themselves, and blame themselves for difficulties in
biochemical, psychological, social and socioeconomic their lives.22 Children are less likely to talk about subjective feelings
factors.18,19 The diathesis-stress model20 is a pragmatic way of and more likely to present with somatic symptoms (eg headache,
integrating the various aetiology theories. This model implies abdominal and musculoskeletal pain, fatigue).21,23 Children
that children have a pre-existing vulnerability through genetic, present more with mood lability, irritability and temper tantrums
endocrine, biochemical or environmental factors, which then rather than depressed mood.24 They may also express more
interacts with current psychological and social stressors. ‘externalising’ behaviours and be misdiagnosed with ‘oppositional
The vast majority of children presenting with MDD will have defiant disorder’ and ‘conduct disorder’.22,24 Children may deny
experienced longstanding psychosocial stressors, such as feeling sad, but acknowledge feeling ‘down’ or ‘grumpy’.22
family or marital disharmony, divorce and separation, domestic Younger children tend not to look depressed. Insomnia,
violence, physical and sexual abuse, school difficulties (eg weight loss, and increased or new onset of anxiety symptoms
bullying, academic failure) or social isolation.21,22 Chronic illness appear more common in younger children, whereas the
and disability are also important considerations (Table 1). Single neurovegetative symptoms of depression (more often seen in
risk factors associated with the onset of MDD are rare.22 adolescents) such as hyperphagia, hypersomnia, weight gain
These children will also have had longstanding symptoms, and psychomotor retardation seem to increase with age.21
comorbidity, and high levels of functional impairment before Anhedonia and social withdrawal remain significant symptoms
presentation and diagnosis,21 which are important implications and it is suggested that the presence of anhedonia in a younger
for a poorer prognosis. child is a sign of severe illness.25

Table 1. Risk Factors for developing MDD in childhood

Social Individual

Family Friends High-risk group

Persistent family disagreement Absence of intimate relationship Refugees and asylum seekers Family history of psychiatric illness
and/or parental discord Low number and infrequent Aboriginal and Torres Strait – genetic risk
Single parent contact with friends Islander peoples Past history of major depressive
Abuse/neglect; exposure to Being bullied and/or bullying Children in out-of-home care disorder
domestic violence Recent, severe personal People with sexual minority status Attention deficit hyperactivity
Lack of authorative parenting and disappointment with a close friend Homeless disorder, disruptive disorders of
parental monitoring childhood
‘Offenders’, particularly those
Psychiatric illness in parent(s) in secure institutions Neurodevelopmental disorder/
(especially depression, maternal autism spectrum disorder/learning
Victims of community disaster
postnatal depression, substance disorder
use) Complex physical illness/disability
Sudden events in family (death, Cognitive style (self-devaluation
serious illness, separation) and ruminative style)
Lower intelligence quotient (IQ)
and educational aspiration

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Table 2. MDD symptom presentation in children aged 5–12 years

MDD symptoms How symptoms may present in a child

Depressed mood Irritable, temper outburst, cranky, unhappy, miserable

Anhedonia/lack of interest Loss of interest in pleasurable activities (eg does not want to see friends, do usual activities)

Somatic symptoms Stomach ache, headache, musculoskeletal pain, fatigue

Sleep disturbance Change in sleep

Appetite disturbance Failure to meet expected weight gain, not getting hungry, eating too much

Concentration Concentration difficulty

Motor Moving and walking slowly, restlessness

Cognitions Guilt, fear of bad things going to happen, being bad person, hating themselves, thinking no one loves them, negative
comments about themselves

Suicidal ideation Thoughts of death/talk about death/wanting to kill themselves

Behaviour Anger, aggression, poor impulse control, separation anxiety

Function Social withdrawal, impairment in relationships with family/friends, reduced activities, decline in academic performance

Thoughts about suicide and death increase with age, but still investigations in children with MDD. It would be prudent to
occur in a significant proportion of children under 12 years of consider physical examination and investigations for anaemia,
age.21,24 Their conceptualisation of death and the language used thyroid dysfunction, vitamin deficiencies, viral (and post-viral)
around death and suicide will vary depending on the child’s age. illnesses and diabetes (Box 1).
Self-injury also occurs in children under 12 years of age, with
no marked gender difference in rate. The method of ‘hitting self’ Screening tools
is more frequent in younger children. This remains the most Screening scales and structured interviews based on the DSM-5
common method in older boys, whereas ‘cutting’ becomes more framework are the methods commonly used to screen and
common with older girls.26 assess depression in children.28 Using these questionnaires
The severity of MDD – mild, moderate, severe – is based can be helpful in detecting symptoms that are important but
on the number of symptoms present (ie minimum to meet not part of the initial complaint. They are usually designed in
diagnosis versus majority symptoms present), distress short and long versions, and include separate forms for parents
generated by the intensity of the symptoms and subsequent and/or teachers. The number of valid instruments for children
psychosocial impairment.27 under 12 years of age is limited.28 Commonly, recommended
questionnaires to use in primary care for assessing childhood
The GP’s assessment MDD include:
Assessing a child who presents with symptoms of MDD takes • Preschool Feelings Checklist, including 16 ‘Yes’ or ‘No’
time – the anathema of a busy GP. However, the majority questions, www2.tulane.edu/som/tecc/upload/Preschool-
of children with MDD are assessed and treated within the feelings-checklist.pdf
primary sector; only a small percentage are managed within • Mood Feeling Questionnaire (MFQ) for children aged
a child psychiatric service. Therefore, in the majority of cases, eight years and older, http://devepi.duhs.duke.edu/mfq.html
it is the GP who needs to ensure they have a comprehensive • Children’s Depression Inventory 2 (CDI 2) for children aged
understanding of the clinical scenario. Generating a formulation seven years and older, www.pearsonclinical.com.au/products/
on the basis of your assessment is paramount, despite it view/448
inevitably being incomplete; a diagnosis and formulation is what
informs management (Table 3). Treatment from a GP’s perspective
Differential diagnoses of physical illnesses are important GPs are ideally placed to engage with the child and their parents,
to consider. Limited evidence exists to guide pathology and commence treatment – an enormous amount can be

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Box 1. Important considerations as part of a routine biopsychosocial assessment

The beginnings of a formulation

• The child and a particular range of symptoms is usually presented by another. This unique scenario holds important information about the child’s care
system and how they are impacted.
• Who is this child and family, and why are they presenting now? Reasons can rarely be attributed solely to the child. What is happening in the home,
school and broader system for this child/family?
• Ask parents their theory as to why their child is presenting like this.
• Treatment will remain inadequate unless precipitating and perpetuating factors are addressed.
• Ascertain knowledge of the child and their care system’s strengths and protective factors. A helpful assumption is this child and their parent(s) are
trying their best to manage.
• Consider all risk factors.

Working with the family system

• Establish trust, as sensitive issues need to be explored with the child and parent(s).
• Explore relationship difficulties within the family and screen for abuse or neglect – more common than anticipated.
• Is the child symptomatic of dysfunction in the family system?
• Is there parental mental illness? Evidence demonstrates children of parents with mental illness have increased risk for a broad range of mental health
disorders35 and children of mothers with depression are at an increased risk of developing MDD36 – likely a combination of genetic and environmental
risk factors.

Exploring symptoms
• Account for developmental issues in understanding the child’s symptoms.
• Ask about thoughts of death and suicide even in younger children. The language of the questions will need to be adjusted when exploring this. For
example, ‘How do you feel about living?’ ‘Is it worthwhile living?’ ‘Do you have a future?’
• Ask open-ended questions about self-injury; explore various self-injury methods.
• Determine the functional impairment for this child.

Comorbidity and differential diagnoses

• Consider the lens you are looking through given extensive symptom overlap exists with other psychiatric disorders (a significant impediment
of categorical diagnoses).
• Comorbidity is the rule – concurrent symptoms of anxiety and behavioural disturbance are present in almost all cases.22 Consider ADHD, anxiety
disorders (including separation anxiety) and learning disorders.8
• Consider cognitive, speech and language functioning – impairments in these areas are under-recognised and have tremendous impact on a child’s
educational and psychosocial trajectory.37
• Try to differentiate between an unhappy or sad and pervasively depressed child.
• Differential diagnoses may include sadness, persistent depressive disorder (dysthmia), anxiety disorders, and adjustment disorder with depressed
mood. Although rare in this age group, bipolar depression needs to be considered, particularly in those with a family history of bipolar disorder or
psychotic illness.
• Rule out medical conditions causing/contributing to MDD, using pathology investigations only as clinically indicated.
• Early consideration and proactive diagnosis of the psychogenic origins of physical symptoms.

achieved within general practice, and simple remedies are often Psychological aspects
all that is required.29 The assessment process in itself is often the • Provide psycho-education for the child, family or school
beginning of treatment. It is crucial that the philosophy guiding regarding your formulation of the problem and diagnosis.
management views the whole child and their system, not just a • Offer self-help approaches, such as educational leaflets, online
particular pattern of signs and symptoms.22 resources, help lines, self-diagnosis tools, peer, social and
family support groups, complementary therapies or religious
Suggested GP interventions and spiritual groups.22
• Treat whatever ensures engagement if there is comorbidity.
Biological aspects
• Follow up – in addition to monitoring the trajectory/response
• Address sleep problems. to treatment, do not underestimate the ‘containment’ of
• Initiate behavioural activation and scheduling of pleasurable anxiety for the child and family by offering follow-up. This
activities. communicates you are ‘holding them in mind’ and will be part
• Encourage exercise and healthy diet. of their journey through this challenging time.

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Table 3. Common approach to formulation – Factors to consider in a child presenting with MDD

Predisposing Precipitating Perpetuating Protective

Biological Genetic (considering the Hormonal effect, Impact of past episodes Absence of comorbidity
gene-environment interaction) puberty Physical illness, medications
Physical illness Physical illness, medications

Psychological Temperament Acute life event and its Impact of past episodes Absence of comorbidity
Cognitive style meaning for child Sense of humour
Poor emotion regulation skills High to normal intelligence
Low perceived academic and Adaptive emotion regulation
social competence skills
Problem-focused coping style

Social Familial adversity Acute and chronic Impact of past episodes Positive friendship networks
Life events life events Continuing familial adversity Close relationship with one or
Parental mental illness Poor peer relationships more family members
Socially valued
Personal achievements

Social aspects psychodynamic psychotherapy.22 No clear evidence exists for one

• Coordinate care team or key stakeholders. therapy over another,22 although CBT or IPT may offer slightly
• Enhance child and their family’s strengths or protective factors. greater efficacy.30
• Liaise with school. Referral to a child psychiatrist or psychiatric service is
• GPs may experience subtle pressure from parents to diagnose suggested:
the problem ‘within the child’, prescribe medication or make • in mild illness if there is minimal improvement with an
a referral to a psychologist. Helping parents appreciate the adequate trial (two to three months) of non-pharmacological
multifactorial aetiologies for any child with MDD, and the interventions
importance of taking the time to develop this understanding in • in moderate-to-severe illness
order to advance a comprehensive treatment approach with a • if high-risk suicidal ideation is present
greater chance of effecting change, may alleviate some of this • if the GP or parents are considering medication.
pressure.
• Actively address modifiable risk factors – for example, bullying Medication
at school, abuse or neglect at home, parents with mental Antidepressant medications can be considered in severe illness if
illness or substance use. symptoms do not improve with an adequate trial of psychological
• Always consider the needs of the child at home when your therapy (about six sessions),22 or if symptoms are particularly
patient is a parent with a mental illness or substance use disabling. Careful review of formulation/diagnosis and treatment
disorder. Consider referral to services such as ‘Children of thus far is recommended first. A discussion with the child and
Parents with a Mental Illness’ (refer to ‘Resources’). their parents should occur regarding the paucity of evidence for
antidepressants in this age group;22,31 a risk–benefit analysis,
Formal psychological interventions and referral including the small risk of increased behavioural disturbance and
Ideally, a GP should feel supported at any point of uncertainty suicidal ideation, should be discussed.32 If an antidepressant is
via primary or secondary consultation with a child psychiatrist or started, the child should be reviewed weekly for the first month
psychiatric service. Options for treatment will depend on services to assess suicidal thoughts, behavioural changes and side
available – they remain limited in more remote areas. effects.22 It is recommended that medication only be prescribed
An initial period (<4 weeks) of ‘watchful waiting’ is by a child psychiatrist and alongside psychotherapy.22 There is
reasonable for those with mild illness and/or who do not want mixed evidence to suggest the combination of medication and
an intervention beyond what they can achieve with their GP.22 psychotherapy may have superior efficacy to either alone.33,34
Referral for psychological therapy should occur if there is no Evidence for the efficacy of antidepressants in children is
improvement after this time, or if moderate-to-severe illness is lacking, and the majority of trials suggest minimal or no benefit
present. The most common formal psychological treatments in over placebo, potentially doing more harm than benefit.31
children include cognitive behavioural therapy (CBT; individual or Fluoxetine is the only antidepressant with demonstrated efficacy
group), interpersonal therapy (IPT), family therapy and individual over placebo in children.31 No antidepressant, including fluoxetine,

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 FOCUS DEPRESSION IN CHILDREN

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