History

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

Complications

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

Differential Diagnoses

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Author

Spencer E Black, MD Associate Professor, Department of Pediatrics, Division of Pediatric Behavioral Medicine, Primary Children's Hospital, University of Utah School of Medicine

Spencer E Black, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Tami D Benton, MD Clinical Director, Child and Adolescent Psychiatry, Psychiatrist-in-Chief, Executive Director, Department of Child and Adolescent Psychiatry and Behavioral Science, Children's Hospital of Philadelphia

Tami D Benton, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Angelo P Giardino, MD, PhD, MPH, FAAP Wilma T Gibson Presidential Professor and Chair, Department of Pediatrics, University of Utah School of Medicine; Chief Medical Officer, Intermountain Primary Children's Hospital

Angelo P Giardino, MD, PhD, MPH, FAAP is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, International Society for the Prevention of Child Abuse and Neglect, Ray E Helfer Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgements

Jacqueline Lynch, MSW, Research Assistant, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.