History and exam

Key diagnostic factors

Positive family history of depression, other parental psychopathology, history of stressful life events or trauma, female sex, postnatal status, comorbid psychiatric disorders or chronic medical illnesses, and neighbourhood and social instability are important risk factors for depression.

A child needs to have either sad/irritable mood or anhedonia as one of the symptoms to meet the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 diagnostic criteria for major depressive disorder (MDD).

Irritable mood could be as common as sad mood.

To meet DSM-5 MDD episode criteria, the mood must be present most of the day, almost every day, for at least 2 weeks, and co-exist with 4 other depressive symptoms.

To diagnose persistent depressive disorder (dysthymia) in children or young people, a sad or irritable mood needs to be present for at least 1 year.

A child needs to have either sad/irritable mood or anhedonia as one of the symptoms to meet the DSM-5 diagnostic criteria for MDD.

Depressive symptoms need to cause significant impairment in one or more areas of functioning (e.g., school, home, social settings) to meet DSM-5 criteria for major depressive disorder or persistent depressive disorder (dysthymia).

There should not be a history of manic or hypomanic episode.

There are overlapping symptoms between major depressive disorder and bereavement.

Other diagnostic factors

One of the DSM-5-listed depressive symptoms for major depressive disorder and persistent depressive disorder (dysthymia).

Frequently related to decreased school performance. The poor school performance should not relate to lack of ability to do the work.

During summer months, when school is out, may manifest as taking longer to read or remember what was read, not being able to follow a TV programme, or having to ask parents to make choices.

If a child has a history of poor concentration (e.g., with ADHD), there must be a worsening with the onset of mood disturbance for this to be counted as a depressive symptom. It must be a change from baseline.

One of the DSM-5-listed depressive symptoms for major depressive disorder and persistent depressive disorder (dysthymia).

Insomnia may be initial, middle, or terminal. Initial and middle insomnia are more common forms of insomnia in child depression.

Hypersomnia usually presents more commonly among adolescents than among young children.

One of the DSM-5-listed depressive symptoms for major depressive disorder and persistent depressive disorder (dysthymia).

Appetite could decrease or increase, with or without weight change.

One of the DSM-5-listed depressive symptoms for major depressive disorder and persistent depressive disorder (dysthymia).

One of the DSM-5-listed depressive symptoms for major depressive disorder. A child may have negative self-perception or excessive guilt.

Decreased self-esteem is among the most common depressive symptoms in children.

One of the DSM-5-listed depressive symptoms for persistent depressive disorder (dysthymia).

One of the DSM-5-listed depressive symptoms for major depressive disorder.

Although it is not a DSM-5 diagnostic criterion for major depressive disorder, excessive somatic complaints may be common in younger depressed children.

A common sign of a depressed child.

One of the DSM-5-listed depressive symptoms for major depressive disorder. Various degrees of suicidality may present, ranging from morbid thoughts of death to suicidal thoughts with plans and intent.

The milder forms of suicidality are more common.

Depression frequently co-occurs with substance abuse during adolescence.

In addition, some substances are known to cause depressive symptoms.[51][52] According to the DSM-5 diagnostic criteria, a diagnosis of major depressive disorder or persistent depressive disorder (dysthymia) should not be made if the symptoms are thought to be related to the direct effect of a substance or a medication.

Risk factors

Family loading of depression is the single most significant predictor for the development of a depressive disorder.[29]

Based on twin and adoption studies, genetic factors are estimated to account for up to 40% of variance in depression. Evidence also indicates that the hereditability of depression is higher in girls than in boys in adolescence.[30]

Children with depressed parents are 2-4 times more likely to have depression.[31]

Both maternal and paternal depression have been linked to depression and other psychiatric disorders in children.[32][33][34] This impacts children through both genetic and environmental effects, and is associated with more marital conflict, poor parenting, and decreased support.[35][36]

In addition to parental depression, high rates of other parental psychopathology (e.g., alcohol abuse, substance disorders, suicidal behaviours, anxiety disorders) have been found in children and adolescents with depression.[37][38]

Childhood depressive disorder is highly comorbid with other psychiatric disorders.

Comorbid anxiety disorders occur in 30% to 80% of children with depression, and comorbid disruptive disorders occur in 10% to 80%. These conditions are most frequently comorbid with depressive disorders and frequently precede depression.[39]

Stress and trauma trigger a depressive episode in children and adults. Genetic evidence has illustrated the interplay between stress, trauma, and genetic vulnerability.[40]

Increases susceptibility to depression, particularly during adolescence.

By adolescence, the prevalence rate of depression in females is almost twice that of depression in males.[4]

Most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are quite resilient and emerge from adolescence as healthy adults. However, the effects of homophobia and heterosexism can contribute to health disparities in mental health between LGBTQ and other youth, with higher rates of depression and suicidal ideation.[41] LGBTQ youth also have higher rates of abuse that account for some of this disparity.[42][43]

Depression rates are higher among chronically ill children.

Up to 26% of children with diabetes mellitus have depression, and up to 30% of children with asthma have a depressive disorder.[44][45]

About 10% to 20% of women giving birth develop postnatal depression.[46][47] Up to 48% of adolescent mothers in the US have been found to have depressive symptoms (surveyed at a mean of 17 months postnatal).[48][49]

Neighbourhood instability, violence, and poor resources provided by the school and neighbourhood have been associated with the development of childhood depression and other psychopathologies.[37][50]

Both corticosteroids and interferon have documented depression as adverse effects.

Depression frequently co-occurs with substance abuse during adolescence. There is evidence that substance abuse may increase the risk of developing depressive disorders, and some substances are known to cause depressive symptoms.[51][52]

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