In-depth look at depression in children and adolescents. Signs your child could be depressed, types of depression in children, risk of suicide.

Untreated depression. It's the number one cause of suicide among teens and adults.

The statistics are startling. As many as 8 percent of adolescents attempt suicide today. And completed suicides have increased by 300 percent over the last 30 years. (Girls make more attempts at suicide, but boys complete suicide four to five times as often as girls.) It is also known that 60-80 percent of suicide victims have a depressive disorder. A 1998 study showed, however, that only 7 percent of suicide victims are receiving mental health care at the time of their death.

Characteristics of Depression

Up until about 30 years ago, many in the field of psychology believed that children were incapable of experiencing depression. Others believed children could be depressed, but would most likely express their dysphoria indirectly through behavior problems, thereby "masking" their depression.

Three decades of research have dispelled these myths. Today, we know that children experience and manifest depression in ways similar to adults, albeit with some symptoms unique to their developmental age.

Children can experience depression at any age, even shortly after birth. In very young children, depression can manifest in a number of ways including failure to thrive, disrupted attachments to others, developmental delays, social withdrawal, separation anxiety, sleeping and eating problems, and dangerous behaviors. For the purposes of this article, however, we will focus on school-aged children and adolescents.

Children and the Risk of Suicide

In general, depression affects a person's physical, cognitive, emotional/affective, and motivational well-being, no matter their age. For example, a child with depression between the ages of 6 and 12 may exhibit fatigue, difficulty with schoolwork, apathy and/or a lack of motivation. An adolescent or teen may be oversleeping, socially isolated, acting out in self-destructive ways and/or have a sense of hopelessness. (See table 1.)

Prevalence and Risk Factors

While only 2 percent of pre-teen school-age children and 3-5 percent of teenagers have clinical depression, it is the most common diagnosis of children in a clinical setting (40-50 percent of diagnoses). The lifetime risk of depression in females is 10-25 percent and in males, 5-12 percent.

Children and teens who are considered at high risk for depression disorders include:

• children referred to a mental health provider for school problems
• children with medical problems
• gay and lesbian adolescents
• rural vs. urban adolescents
• incarcerated adolescents
• pregnant adolescents
• children with a family history of depression

Diagnostic Categories

Transient depression or sadness is not uncommon in children. For a diagnosis of clinical depression, however, it must be causing an impairment in the child's ability to function. Two primary types of depression in children are dysthymic disorder and major depressive disorder.

Dysthymic disorder is the less severe of the two, but lasts longer. The child exhibits chronic depression or irritability for more than a year, with a median duration of three years. Onset typically occurs at about 7 years of age with the child exhibiting at least two of six symptoms (see table 2). A majority of these children go on to develop a major depressive disorder within five years, resulting in a condition known as "double depression." However, 89 percent of pre-teens with untreated dysthymic disorder will experience remission within six years.

Major depressive disorders have a shorter duration (greater than two weeks, with a median duration of 32 weeks) but are more severe than dysthymic disorders. A child with major depressive disorder exhibits at least five of nine symptoms, including a persistent depressed or irritable mood and/or a loss of pleasure. Typical onset for major depressive disorder is 10-11 years of age, and there is a 90 percent rate of remission (for untreated disorders) within one and a half years.

The prevalence of depression increases with age, affecting as many as 5 percent of all teenagers, and as many as one-in-four women and one-in-five men in adulthood. Fifty percent of those with a major depressive disorder will have a second episode in their lifetime.

In many cases, depressive disorders overlap with other diagnoses. These may include: anxiety disorders (in one-third to two-thirds of children with depression); attention deficit hyperactivity disorder (in 20-30 percent); disruptive behavior disorders (in one-third to one-half of patients); learning disorders; eating disorders in females; and substance abuse in adolescents.

continue: The Risk of Suicide in Children