Pediatric Depression Clinical Presentation

Updated: Apr 19, 2023
  • Author: Spencer E Black, MD; Chief Editor: Caroly Pataki, MD  more...
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The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) uses the same basic criteria to diagnose depression in adults and children. [1]  

The DSM-5-TR defines a major depressive episode as a syndrome in which at least 5 of the following symptoms have been present during the same 2-week period: 

  • Depressed mood - For children and adolescents, this also can be an irritable mood 

  • Diminished interest or loss of pleasure in almost all activities 

  • Weight change or appetite disturbance - For children, this can be failure to achieve expected weight gain 

  • Sleep disturbance 

  • Psychomotor agitation or retardation 

  • Fatigue or loss of energy 

  • Feelings of worthlessness or inappropriate guilt 

  • Decreased concentration or indecisiveness 

  • Suicidal ideation or thoughts of death 

At least 1 of the 5 symptoms must be diminished interest/pleasure or depressed mood. Symptoms must cause significant distress or impairment of functioning in social, occupational, or other important areas. Depression should not have been precipitated by the direct action of a substance or the result of a medical condition and should not be better explained by bereavement or schizoaffective disorder. Depressive episodes may occur independent from and be superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or a psychotic disorder not otherwise specified. 

Depressive disorders can be rated as mild, moderate, or severe. The disorder can also occur with or without psychotic symptoms, which can be mood congruent or incongruent. Depressive disorders can be determined to be in full or partial remission. When an episode lasts more than 2 consecutive years, the depression should be diagnosed as chronic. Depression may also have melancholic features. Either a loss of pleasure in almost all activities or a lack of reactivity to usually pleasurable stimuli is present. Additionally, at least 3 of the following are required: 

  • A depressed mood that is distinctly different from the kind felt when a loved one is deceased 

  • Depression that is worse in the morning 

  • Waking up 2 hours earlier than usual 

  • Observable psychomotor retardation or agitation 

  • Significant weight loss or anorexia 

  • Excessive or inappropriate guilt 

Seasonal mood disorder 

The seasonality of a depressive disorder can also be specified. To diagnose a seasonal mood disorder, a regular temporal relationship should exist between the depression and a particular time of year. An individual should have demonstrated at least 2 episodes of depressive disturbance in the prior 2 years, and seasonal episodes should substantially outnumber nonseasonal episodes. 

Diagnosing seasonal affective disorder (SAD) in children is difficult because they experience the recurrent universal stressor of beginning school every autumn. In addition, a young child might present with an apparent seasonal depressive disorder but not yet have had prior episodes. 

Atypical features in depression 

A depression may also be identified as having atypical features. Characteristics of this subtype are mood reactivity and exclusion of melancholic and catatonic subtypes in addition to 2 or more of the following for a period of at least 2 weeks: 

  • Increase in appetite or significant weight gain 

  • Increased sleep 

  • Feelings of heaviness in arms or legs 

  • A pattern of long-standing interpersonal rejection sensitivity that extends far beyond the mood disturbance episodes and results in significant impairment in social or occupational functioning 

Family history

Familial, social, and environmental factors appear to play significant roles in the course of depressive illness in children and youths. Good evidence indicates that depression can be recurrently noted in families from generation to generation. [40] Thus, a thorough family history is also quite important. 


Physical Examination

A complete mental health evaluation should always include a medical evaluation. Organic etiologies that may imitate a depressive disorder must be ruled out. Conditions believed to mimic depressive disorders fall into major general categories, including the following: 

  • Infections 

  • Medications 

  • Endocrine disorders 

  • Tumors 

  • Neurologic disorders 

  • Rheumatologic disorders 



Depression is highly comorbid with anxiety and attention disorders and may lead to behavioral problems, substance use, and impaired functioning in adulthood. [2]