How does depression present in pediatric patients?

How Depression Presents in Children

Depression in children manifests differently than in adults, most notably with irritability and behavioral changes often replacing the classic sad mood, and symptoms may be harder to identify because children have difficulty recognizing and describing their internal emotional states. 1

Core Presentation Differences from Adults

Mood manifestations:

• Irritability, crankiness, and explosive behavior are more common than sadness in pediatric depression, particularly in younger children 1
• Children may express depressed mood through preoccupation with song lyrics suggesting life is meaningless rather than verbalizing sadness 1
• Periods of disruptive mood lasting weeks to months may be the primary presentation rather than persistent sadness 1

Behavioral indicators:

• Loss of interest in previously enjoyed activities (sports, video games, friends) is a key marker 1
• Oppositional and negative behavior may mask underlying depression 1
• Talk of or attempts at running away from home can signal psychomotor agitation 1
• Persistent boredom despite available activities 1

Physical and Somatic Presentations

Common somatic complaints:

• Frequent headaches and stomach aches without clear medical cause 1, 2
• Excessive late-night TV watching and refusal to wake for school indicating sleep disturbance 1
• Failure to gain weight as expected rather than frank weight loss 1
• Development of anorexia or bulimia 1

Academic and Social Dysfunction

School-related changes:

• Poor school performance and frequent absences are hallmark features 1
• Decreased educational attainment and school absenteeism 3
• Diminished ability to concentrate manifesting as academic decline 1

Social impairment:

• Poor peer relationships and social withdrawal 1, 4
• Decreased social functioning across multiple domains 1

Critical Diagnostic Considerations

Age-specific challenges:

• Children often cannot identify or describe internal mood states, making diagnosis more difficult than in adults 5, 3
• Symptom expression varies significantly with developmental stage 5
• The mean age of onset is 14-15 years, with earlier onset in girls than boys 1

High-risk features requiring immediate attention:

• Recurrent suicidal ideation or behavior, including threats of suicide, writing about death, or giving away favorite belongings 1
• 10% of children aged 5-12.9 years and 19% of adolescents aged 13-17.9 years with MDD attempt suicide 1

Comorbidity and Diagnostic Complexity

Common co-occurring conditions:

• Depression in children is more frequently comorbid with other psychiatric disorders than in adults, particularly ADHD, anxiety disorders, conduct disorder, and substance abuse 1, 3
• Approximately 20% of children diagnosed with major depression will later develop bipolar symptoms, though these may not manifest until years after initial diagnosis 1, 6
• The presence of high rates of comorbid disruptive disorders can obscure the underlying depression 1

Prevalence and Recognition Gap

Epidemiology:

• Depression affects 3-5% of children and adolescents, with about 8% of adolescents reporting MDD in the past year 1, 5
• Only 36-44% of children and adolescents with depression receive treatment, indicating the majority remain undiagnosed 1
• Prevalence is higher in primary care settings than in community samples 1

Common Diagnostic Pitfalls

What to avoid:

• Never dismiss suicidal thoughts or comments as unimportant or attention-seeking 1
• Do not rely solely on the child's verbal report of sadness—look for behavioral indicators and irritability 1
• Avoid missing depression masked by oppositional behavior or somatic complaints 1, 2
• Do not overlook the possibility of emerging bipolar disorder, particularly in children with irritability and mixed features 1, 6