Depression in childhood is rare (Figure 1).1 It is not too early to look for it in preschool-aged children, however, and pediatricians are likely to be the first to suspect the condition. Detection requires understanding of the presenting features of depression in preschool-aged children combined with an age-adjusted approach to evaluation. Knowledge of associated risk factors also can enable recognition of depression in a preschool-aged child and will direct appropriate intervention that is important for optimizing the child’s well-being and his or her developmental and mental health trajectory.
The idea that depression occurs in preschool-aged children may be difficult to fathom considering that childhood is often regarded as a happy and carefree period. The idea also may be discarded based on the idea that such young children lack the developmental maturity to experience the core cognitions associated with depression. In fact, however, several studies document that clinically significant depression can occur in children aged as young as 3 years.2
There is limited information about the prevalence of depression in preschool-aged children. Available research indicates that boys and girls are equally affected and report that the rate ranges between 0.08% and 2%.3,4 It has been suggested, however, that because of underrecognition, the prevalence of preschool-aged depression may be underestimated.2
Although genetics may increase a child’s vulnerability to depression, depression in preschool-aged children most often develops because of an environmental issue that causes psychosocial stress. These problems can include a negative home environment, a caregiver with depression or other serious illness, problematic peer relations, and stressful life events, such as loss of a parent or a separation involving a person of significance to the child.3
Identifying preschool-aged children affected by depression can be challenging. Very young children are less able to articulate their internal emotional state and therefore are unlikely to verbalize feelings of sadness that raise suspicion of the diagnosis.5 Age-adjusted questioning may identify sadness and other diagnostic findings including excessive guilt, lack of pleasure in activities and play, and decreased energy.5,6
Most commonly, however, young children with depression exhibit somatic symptoms, such as frequent headaches or stomachaches, and they may develop changes in sleep, appetite, and social interactions. Changes in sleep can include both difficulties going to sleep, staying asleep, and sleeping too much, whereas appetite issues in preschool-aged children usually involve not eating enough rather than overeating. Their mood may appear more irritable than outright sad.
1. Lieb R, Isensee B, Höfler M, Pfister H, Wittchen HU. Parental major depression and the risk of depression and other mental disorders in offspring: a prospective-longitudinal community study. Arch Gen Psychiatry. 2002;59(4):365-374.
2. Luby JL, Gaffrey MS, Tillman R, April LM, Belden AC. Trajectories of preschool disorders to full DSM depression at school age and early adolescence: continuity of preschool depression. Am J Psychiatry. 2014;171(7):768-776.
3. Whalen DJ, Sylvester CM, Luby JL. Depression and anxiety in preschoolers: a review of the past 7 years. Child Adolesc Psychiatr Clin N Am. 2017;26(3):503-522.
4. Ghandour RM, Sherman LJ, Vladutiu CJ, et al. Prevalence and treatment of depression, anxiety, and conduct problems in US children. J Pediatr. 2019;206:256.e3-267.e3.
5. Luby JL. Treatment of anxiety and depression in the preschool period. J Am Acad Child Adolesc Psychiatry. 2013;52(4):346-358.
6. Luby JL. Preschool depression: the importance of identification of depression early in development. Curr Dir Psychol Sci. 2010;19(2):91-95.
7. Luby JL, Heffelfinger A, Koenig-McNaught AL, Brown K, Spitznagel E. The Preschool Feelings Checklist: a brief and sensitive screening measure for depression in young children. J Am Acad Child Adolesc Psychiatry. 2004;43(6):708-717.
8. Little M, Murphy JM, Jellinek MS, Bishop SJ, Arnett HL. Screening four- and five-year-old children for psychosocial dysfunction: a preliminary study with the Pediatric Symptom Checklist. J Dev Behav Pediatr. 1994;15(3):191-197.
9. Belden AC, Thomson NR, Luby JL. Temper tantrums in healthy versus depressed and disruptive preschoolers: defining tantrum behaviors associated with clinical problems. J Pediatr. 2008; 152(1):117-122.
10. Zisook S, Lesser I, Stewart JW, et al. Effect of age at onset on the course of major depressive disorder. Am J Psychiatry. 2007;164(10):1539-1546.
11. Korczak DJ, Goldstein BI. Childhood onset major depressive disorder: course of illness and psychiatric comorbidity in a community sample. J Pediatr. 2009;155(1):118-123.
12. Centers for Medicare and Medicaid Services. Fact Sheet. Antidepressant medications: use in pediatric patients. Available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Pharmacy-Education-Materials/Downloads/ad-pediatric-factsheet11-14.pdf. Published October 2015. Accessed September 4, 2019.
13. Gleason MM, Egger HL, Emslie GJ, et al. Psychopharmacological treatment for very young children: contexts and guidelines. J Am Acad Child Adolesc Psychiatry. 2007;46(12):1532-1572.
14. Zuckerman ML, Vaughan BL, Whitney J, et al. Tolerability of selective serotonin reuptake inhibitors in thirty-nine children under age seven: a retrospective chart review. J Child Adolesc Psychopharmacol. 2007;17(2):165-174.
15. University of South Florida. 2018-2018 Florida Best Practice Psychotherapeutic Medication Guidelines for Children and Adolescents (2019). University of South Florida, Florida Medicaid Drug Therapy Management Program sponsored by the Florida Agency for Health Care Administration (AHCA). Available at: http://www.medicaidmentalhealth.org/_assets/file/Guidelines/2018-19 FL Best Practice Medication-Child-Adolescent_Online1.pdf. Published January 2019. Accessed September 4, 2019.