Major depression is currently the most prevalent mental health problem worldwide, to the extent that it is beginning to be considered to be reaching epidemic proportions.
When we think about this disorder we usually imagine an adult person, with a series of symptoms known to all: sadness, loss of the ability to enjoy, recurrent crying, etc. But does depression only occur at this stage of life? can it also occur at earlier times? can children develop mood disorders?
In the present article we will deal with the issue of childhood depression , with special emphasis on the symptoms that allow it to be differentiated from that of adults.
What is childhood depression?
Childhood depression differs in many ways from adult depression, although it tends to decrease as the years go by and adolescence approaches. It is therefore a health problem whose expression depends on the developmental period. Furthermore, it is important to take into account that many children lack the precise words through which to reveal their inner world , which can make diagnosis difficult and even condition the data on its prevalence.
For example, sadness is an emotion that is present in children who suffer from depression. Despite this, the difficulties in managing it generate different symptoms from those expected for the adult, as we will point out in the corresponding section. This requires coping strategies that the child has yet to acquire as his or her psychic and neurological development progresses.
Studies on this issue show a prevalence for childhood depression of between 0.3% and 7.8% (depending on the assessment method); and a duration for the same of 7-9 months (similar to that of the adult).
In the following we will deal with the particularities of childhood depression. All of them have to put us on alert about the possible existence of a mood disorder, which requires a specific therapeutic approach.
1. difficulty saying positive things about themselves
Children with depression often express themselves negatively, and even make surprisingly harsh assertions about their personal worth , suggesting a damaged self-esteem base.
They may point out that they don’t want to play with their peers because they don’t know how to “do things right”, or for fear of being rejected or treated badly. In this way, they often prefer to stay away from symbolic peer play activities, which are necessary for healthy social development.
When they describe themselves they often allude to undesirable aspects, in which a pattern of pessimism about the future and eventual guilt is reproduced for facts to which they did not contribute. These biases in the attribution of responsibility, or even in the expectations with respect to the future, are usually related to the stressful events associated with their emotional state: conflicts between parents, school rejection and even violence in the domestic environment (all of them important risk factors).
Loss of confidence is often widespread in more and more areas of a child’s daily life , as time goes by and effective therapeutic solutions are not adopted for them. In the end, it negatively conditions their performance in the areas in which they participate, such as academia. Negative results would “confirm” the child’s beliefs about himself, entering a cycle that would be harmful to his mental health and self-image.
2. Predominance of organic aspects
Children suffering from a depressive disorder often show obvious complaints of physical problems , which may lead to numerous visits to the paediatrician and make it difficult for them to attend school normally. The most common are headache (located in the front, temples and back of the neck), abdominal discomfort (including diarrhea or constipation), persistent fatigue and nausea. The face would tend to adopt a sad expression, and ostensibly decrease eye contact.
One of the best known characteristics of childhood depression is that it tends to be accompanied by irritability, which is much more easily identified by parents than the emotions that may underlie it. In these cases, it is very important to consider that the parents are good informants of their children’s behaviour, but they tend to be a little more vague at the time when their internal nuances are investigated. This is why sometimes the reason for the initial consultation and the problem to be addressed are somewhat different.
This, along with the fact that the child does not describe himself using the term “sad” (as he resorts to qualifiers such as “grumpy” or “angry”), can delay identification and intervention. In some cases, a diagnosis is even made that does not adhere to the reality of the situation ( defiant negativistic disorder, to cite one example). It is therefore necessary for the specialist to have precise knowledge of the clinical particularities of depression in children.
4. Vegetative and cognitive symptoms
Depression can be accompanied (in both children and adults) by a range of symptoms that involve functions such as cognition, sleep, appetite, and motor skills. Particular expressions have been observed according to the child’s stage of development, although it is considered that as time passes they are more similar to those of the adult (so that in adolescence they are comparable in many ways, not all).
In the first years of life insomnia , weight loss (or cessation of age-related gain) and motor agitation are common, while as the years go by hypersomnia, increased appetite and general psychomotor slowing are more common. In school, significant difficulty in maintaining focus (vigilance) and concentrating on tasks becomes evident.
5. Anhedonia and social isolation
The presence of anhedonia suggests a severe depressive state in children. This is a major difficulty in experiencing pleasure from what was previously reinforcing, including play and social activities.
Thus, they may feel apathetic/uninterested in exploring the environment, becoming progressively more distant and giving way to harmful inactivity. It is at this point that it becomes evident that the child is suffering from a different situation than the “behavioural problems” , as this is a common symptom in adults with depression (and therefore much more recognisable for the family).
Along with anhedonia, there is a tendency towards social isolation and the refusal to participate in shared activities (playing with the reference group, loss of interest in academic matters, rejection of school, etc.). This withdrawal is a phenomenon widely described in childhood depression, and one of the reasons why parents decide to consult a mental health professional.
There is not a single cause for childhood depression, but a myriad of risk factors (biological, psychological and/or social) whose convergence contributes to its final appearance. Below we proceed to detail the most relevant ones, according to the literature.
1. Parent’s cognitive style
Some children tend to interpret the daily facts of their lives in catastrophic and clearly disproportionate terms. Although many hypotheses have been put forward to try to explain the phenomenon, there is a fairly broad consensus that it could be the result of vicarious learning : the child would acquire the specific style that one of his parents uses in order to interpret adversities, adopting it as his own from now on (because attachment figures act as role models).
The phenomenon has also been described in other disorders, such as those included in the category of clinical anxiety. In any case, studies on the subject indicate that there is a four-fold increased risk of a child developing depression when either parent is suffering from it, in contrast to those with no family history of any kind. However, a precise understanding of how genetics and learning might contribute, as independent realities, to all this has not yet been achieved.
2. Conflicts between care figures
The existence of relational difficulties between parents stimulates in the child a feeling of helplessness . The foundations on which their sense of security is built would be threatened, which is aligned with the usual fears in the age period. Shouting and threats can also precipitate other emotions, such as fear, which would become decisively installed in their internal experience.
Studies on this issue show that the warmth of attachment figures, and consensual agreements on parenting, act as protective variables to reduce the risk of the child developing clinically relevant emotional problems. All this regardless of whether the parents remain together as a couple.
3. Family violence
Experiences of sexual abuse and mistreatment (physical or psychological) are very important risk factors for the development of childhood depression. Children who suffer from overly authoritarian upbringing styles , in which force is unilaterally imposed as a mechanism to manage conflict, may show a state of constant hyperactivity (and defenselessness) that translates into anxiety and depression. Physical aggressiveness is related to impulsivity in adolescence and adulthood, mediated by the functional relationship between limbic (amygdala) and cortical (prefrontal cortex) structures.
4. Stressful events
Stressful events, such as parental divorce, moving or changing schools, can be at the root of childhood depression. In this case the mechanism is very similar to that seen in adults, with grief being the natural result of a process of adaptation to the loss. However, this legitimate emotion can progress to depression when it involves the summative effect of small additional losses (reduction of rewarding activities), or a poor availability of emotional support and affection.
5. Social rejection
There is evidence that children with few friends are at greater risk of developing depression, as well as those living in socially impoverished environments. Conflict with other children in their peer group has also been shown to be related to the disorder . Likewise, suffering bullying (persistent experiences of humiliation, punishment or rejection in the academic environment) has been closely associated with childhood and adolescent depression, and even with the increase in suicidal ideation (which fortunately is infrequent among depressed children).
6. Personality traits and other mental or neurodevelopmental disorders
High negative affectivity, a stable trait for which a significant genetic component has been mapped (although its expression can be shaped through individual experience), has been described as increasing the risk of the infant suffering from depression. This translates into an overly intense emotional reactivity in the face of adverse stimuli , which would strengthen its effects on the emotional life (separation from parents, moving, etc.).
Finally, it has been described that children with neurodevelopmental disorders, such as attention deficit disorder with or without hyperactivity (ADHD and ADD), are also more likely to suffer from depression. The effect extends to learning problems (such as dyslexia, dyscalculia or dysgraphia), tonic and/or clonic dysphemia (stuttering) and behavioural disorders.
Cognitive-behavioral therapy has been shown to be effective z in child population. The aim is the identification, discussion and modification of negative basic thoughts; as well as the progressive and personalized introduction of pleasant activities. Furthermore, in the case of children, the intervention is oriented towards tangible aspects located in the present (immediacy), thus reducing the degree of abstraction required. The contribution of the parents is essential in the whole process.
Interpersonal therapy has also proved effective in most studies in which it has been tested. The purpose of this form of intervention is to investigate the most relevant social problems in the child’s environment (both those in which he or she is involved and those in which he or she is not directly involved), seeking alternatives aimed at favouring the adaptive resources of the family understood as a system.
Finally, antidepressants may be used in cases where the child does not respond adequately to psychotherapy. This part of the intervention must be carefully assessed by a psychiatrist, who will determine the risk-benefit profile associated with the use of these medications in childhood. There are some warnings that they may increase suicidal ideation in people under 25 years of age, but it is generally considered that their therapeutic effects far outweigh their drawbacks.
- Charles, J. (2017). Depression in Children. Focus, 46(12), 901-907.
- Figuereido, S.M., de Abreu, L.C., Rolim, M.L. and Celestino, F.T. (2013). Childhood depression: a systematic review. Neuropsychiatric Disease and Treatment, 9, 1417-1425.