History and exam

Key diagnostic factors

common

sad and/or irritable mood

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

Irritable mood could be as common as sad mood, but typically does not present without the presence of sad mood concurrently.

To meet DSM-5-TR MDD episode criteria, the sad/irritable mood or anhedonia must be present most of the day, almost every day, for at least 2 weeks, and coexist 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, and is typically of lesser intensity than during a depressive episode.

decreased interest or lack of enjoyment

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

significant functional impairment

Depressive symptoms need to cause significant impairment in 1 or more areas of functioning (e.g., school, home, social settings) to meet DSM-5-TR criteria for major depressive disorder or persistent depressive disorder (dysthymia).

no evidence of a manic or hypomanic episode

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

no history of recent bereavement

There are overlapping symptoms between major depressive disorder and bereavement.

Other diagnostic factors

common

decreased concentration or indecision

One of the DSM-5-TR 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 program, 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.

insomnia or hypersomnia

One of the DSM-5-TR 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.

change of appetite or weight

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

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

excessive fatigue

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

feelings of worthlessness or excessive guilt

One of the DSM-5-TR 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.

feelings of hopelessness

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

psychomotor agitation or retardation

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

somatic complaints

Although it is not a DSM-5-TR diagnostic criterion for major depressive disorder, excessive somatic complaints may be common in younger depressed children, most commonly headaches or abdominal pain.

social withdrawal or change of friends

A common sign of a depressed child.

uncommon

recurrent thoughts of death or suicidal ideation and self-harm

One of the DSM-5-TR 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.

increased substance use

Depression frequently co-occurs with substance use problems and disorders during adolescence.

In addition, some substances are known to cause depressive symptoms.[57][58] According to the DSM-5-TR 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

strong

positive family history of depression

Family loading of depression is the single most significant predictor for the development of a depressive disorder.[36]

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.[37]

Children with depressed parents are 2 to 4 times more likely to have depression.[38]

Both maternal and paternal depression have been linked to depression and other psychiatric disorders in children.[39][40][41] This impacts children through both genetic and environmental effects, and is associated with more marital conflict, poor parenting, and decreased support.[42][43]

other parental psychopathology

In addition to parental depression, high rates of other parental psychopathology (e.g., alcohol use disorder, substance use disorders, suicidal behaviors, anxiety disorders) have been found in children and adolescents with depression.[44][45]

personal history of other psychiatric disorders (e.g., anxiety)

Depression in childhood is frequently associated with psychiatric and behavioral comorbidities. In the US, around 73.8% of children ages 3 to 17 with depression also have anxiety, and 47.2% have co-occurring behavioral problems.[3]

stress or trauma

Stress and trauma trigger a depressive episode in children and adults. Genetic evidence has illustrated the interplay between stress, trauma, and genetic vulnerability.[46]

female sex

Increases susceptibility to depression, particularly during adolescence.

By mid-adolescence, the prevalence rate of depression in females is almost twice that of depression in males.[5]

sexual minority status

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.[47] LGBTQ youth also have higher rates of abuse that account for some of this disparity.[48][49]

personal history of chronic medical illness

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.[50][51]

postpartum status

About 10% to 20% of women giving birth develop postpartum depression.[52][53] Up to 48% of adolescent mothers in the US have been found to have depressive symptoms (surveyed at a mean of 17 months postpartum).[54][55]

neighborhood and social instability

Neighborhood instability, violence, and poor resources provided by the school and neighborhood have been associated with the development of childhood depression and other psychopathologies.[44][56]

immunosuppressive medications (e.g., corticosteroids, interferon)

Both corticosteroids and interferon have documented depression as adverse effects.

substance use problems/disorders

Depression frequently co-occurs with substance use problems/disorders during adolescence. There is evidence that substance use problems may increase the risk of developing depressive disorders, and some substances are known to cause depressive symptoms.[57][58]

Use of this content is subject to our disclaimer