Depressive disorders are characterized by sadness or irritability that is severe or persistent enough to interfere with functioning or cause considerable distress. Diagnosis is by history and examination. Treatment is with antidepressants, supportive and cognitive-behavioral therapy, or a combination of these modalities.

The term depression is often loosely used to describe the low or discouraged mood that results from disappointment (eg, serious illness) or loss (eg, death of a loved one). However, such low moods, unlike depression, occur in waves that tend to be tied to thoughts or reminders of the triggering event, resolve when circumstances or events improve, may be interspersed with periods of positive emotion and humor, and are not accompanied by pervasive feelings of worthlessness and self-loathing. The low mood usually lasts days rather than weeks or months, and suicidal thoughts and prolonged loss of function are much less likely. Such low moods are more appropriately called demoralization or grief. However, events and stressors that cause demoralization and grief can also precipitate a major depressive episode.

The etiology of depression in children and adolescents is unknown but is similar to its etiology in adults; it is believed to result from interactions of genetically determined risk factors and environmental stress (particularly early life stress such as abuse, injury, natural disaster, domestic violence, death of the family member, and deprivation.

Symptoms and Signs of Depressive Disorders

Basic manifestations of depressive disorders in children and adolescents are similar to those in adults but are related to typical concerns of children, such as schoolwork and play. Children may be unable to explain inner feelings or moods. Depression should be considered when previously well-performing children do poorly in school, withdraw from society, or commit delinquent acts.

In some children with a depressive disorder, the predominant mood is irritability rather than sadness (an important difference between childhood and adult forms). The irritability associated with childhood depression may manifest as overactivity and aggressive, antisocial behavior.

In children with intellectual disability, depressive or other mood disorders may manifest as somatic symptoms and behavioral disturbances.

Disruptive mood dysregulation disorder

Disruptive mood dysregulation disorder involves persistent irritability and frequent episodes of behavior that are very out of control, with onset at age 6 to 10 years. Many children also have other disorders, particularly oppositional defiant disorder, attention-deficit/ hyperactive disorder (ADHD), or Anxiety Disorder. The diagnosis is not made before the age of 6 years or after the age of 18 years. As adults, patients may develop unipolar (rather than bipolar) depression or an anxiety disorder.

Manifestations include the presence of the following for ≥ 12 months (with no period of ≥ 3 months without all of them):

A. Severe recurrent temper outbursts (eg, verbal rage and/or physical aggression toward people or property) that are grossly out of proportion to the situation and that occur ≥ 3 times/week on average

B. Temper outbursts that are inconsistent with developmental level

C. An irritable, angry mood present every day for most of the day and observed by others (eg, parents, teachers, peers)

The outbursts and angry mood must occur in 2 of 3 settings (at home or school, with peers).