Your 3-year-old isn’t her usual spry self. She no longer brightens at the sight of you first thing in the morning. She refuses to eat & she hasn’t been this cranky since she first started teething.

Instead of tagging along with her older siblings or contentedly scribbling in her favorite Blues Clues coloring book, she gazes blankly out the window, listless & dejected. Could she be depressed?

Depression in Preschoolers
Like most people, you probably assume preschoolers are too young to get the blues. But new research shows clinical depression knows no age. Depression - & even thoughts of suicide -- are as likely to affect toddlers & adolescents as they are adults. 

In an ongoing National Institute of Mental Health study, researchers at Washington University School of Medicine revealed that children experience the same symptoms of depression often found in adults & with the same severity.

Children are more depressed than ever before, prompting a major Surgeon General report on children’s mental health & sending our nation’s behavioral health caseload soaring to record highs.

According to the National Mental Health Association, 1 in 3 American children suffers from depression. Magellan Behavior Health, the leading mental health provider in the US, reports that more than 3,500 of its nearly 149,000 members with depressive disorders are under age 10.

In spite of the staggering statistics, depression remains the most under-diagnosed & under-treated illness among children & adolescents.

Unlike the reddish, raised bumps of chickenpox or the leaky nose of the common cold, the symptoms of depression aren't so concrete & consequently, often go unnoticed by unsuspecting parents.

Detecting Depression
What are the signs of childhood depression? What behaviors should parents look out for?

Toddlers & children who are depressed are persistently irritable, withdrawn & lethargic, says Dr. Elizabeth Rody, child & adolescent psychiatrist & medical director for Magellan Behavioral Health’s New Jersey Regional Service Center.

“Depressed children lose interest in activities that once captivated them,” says Rody. “Like adults who are depressed, an overwhelming sense of hopelessness & doom prevails.”

Other symptoms of pediatric depression parents should be aware of include:

• excessive crying & persistent sadness
• lack of enthusiasm or motivation
• increased agitation & irritability
• chronic fatigue & lack of energy
• withdrawal from family, friends & activities once enjoyed
• changes in eating & sleeping habits (significant weight loss or gain, excessive sleep, insomnia)
• frequent complaints of physical problems, such as stomachaches & headaches
• lack of concentration & memory loss
• feelings of worthlessness or excessive guilt
• extreme sensitivity to rejection or failure
• major developmental delays (in toddlers - not walking, talking or expressing self)
• play that involves harm toward self or others, or that revolves around sad or morbid themes
• recurrent thoughts of death or suicide

Is It Just a Passing Phase?
It’s not unusual for children to feel down in the dumps from time to time. Knowing this, how can parents tell normal fluctuations in mood apart from serious depression? The answer is in the duration of the depressive behavior.

According to Mental Health: A Report of the Surgeon General, children who are depressed experience depressive episodes that last on average from seven to 9 months, although some child development experts say depressive behaviors lasting beyond 2 weeks warrant further investigation. Either way, it’s best to let mental health professionals decide.

Rule Out Physical Illness First
Depression isn’t always to blame for despondent behavior in children. Physiological problems, such as malnutrition, mononucleosis, allergies & other illnesses can all spur irritable moods, fatigue & withdrawal. This is why Rody stresses that parents take their children to the family pediatrician first, before booking an appointment with a mental health professional.

Once common health problems are ruled out at the primary care level, the next step is to get a referral to a child & adolescent psychiatrist for evaluation. In addition to lengthy psychological tests & blood work, parents should be prepared to review their child’s entire medical history.

Who is at Risk?
Although the precise causes of childhood depression aren't yet known, studies on adults with depression point to genetic predisposition & environmental influence.

“It’s some nature & some nurture,” says Rody. “Let’s compare depression to heart disease. You could have a family history of heart disease & at the same time live the couch potato lifestyle. Both could bring on a heart attack. Depression is the same way. It’s not one or the other. It’s a complex combination of factors.”

Children whose parents &/or siblings suffer from depression are more likely to develop symptoms of the disease. Learning disabilities, says Rody, such as Attention Deficit Hyperactivity Disorder (ADHD) & dyslexia can also contribute to the onset of childhood depression.

Environmental factors that place children at risk for depressive disorders include physical, sexual & verbal abuse, neglect and a history of substance abuse in the family. Divorce and the loss of a loved one can also cause emotional upheaval in a child, but are not always precursors to depression.

Taking Your Child’s Emotions Seriously, Asking the Right Questions
Even if your child is only a toddler, his emotions are very real. Experts believe the more parents pay attention to their children’s feelings, the better equipped they are to pick up on and seek treatment for depression.    

“If your child says, ‘I’m so sad I’m gonna jump out of this window,’ you’d better take it seriously,” cautions Rody. “Instead of getting trapped into thinking, ‘He’s four. That couldn’t possibly mean anything,’ you should be following up right away.”

Here are some follow-up questions Rody has used with child and adolescent patients in the past to get to the root of their depressive behavior:

• What happened today to make you seem so sad?
• What makes you happy?
• What are you looking forward to?
• What do you wish would happen to you?
• If you could change something about yourself, what would it be?

Treatment Options
Treatment for child and adolescent depression often includes a combination of individual psychotherapy and family counseling. Optimally, stresses Rody, therapy should involve parents, siblings and other important figures involved in the child’s life, like day care teachers and grandparents.

More comprehensive treatment plans may include play therapy, ongoing evaluation & in some cases, medication.

Antidepressant medications are often prescribed to treat milder cases of depression. However, it’s important to note that the Food & Drug Administration hasn't yet approved antidepressants for children under 8 years old.

For more information about depression in children, consult the following resources:

The American Academy of Child & Adolescent Psychiatry, 1-(800) 333-7636, www.aacap.org

The National Mental Health Association, 1-(800) 969-NMHA, www.nmha.org

Mental Health: A Report of the Surgeon General, Chapter 3: Children & Mental Health : click here

Last reviewed:   On 13 Feb 2006   By John M. Grohol, Psy.D.