Clinically significant depression can occur in children aged as young as 3 years. Here’s how to recognize the symptoms and identify risk factors in your young patients.
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.
General questions asked during a routine wellness visit or when a child is brought in for unexplained somatic complaints can explore concerns about possible depression and the need for further evaluation. The child’s parent/caregiver should be asked about changes in behavior or mood, but not specifically if the child is depressed because most adults would not consider that depression can occur in a preschool-aged child.
Screening instruments for use in this age group are limited. The Preschool Feelings Checklist that includes 16 “yes” or “no” questions is a quick and simple screening tool that might be used to identify young children who might warrant referral for further assessment by a mental health specialist.7 The Pediatric Symptom Checklist is another rating scale that assesses for difficulties in psychosocial functioning and has been validated for children aged as young as 4 years.8
Other risk factors
If there is concern that a child is depressed, pediatricians should look for an associated risk factor. Problems to explore include whether the child’s parent is depressed or if the child is living in a situation where there is conflict, neglect, or abuse. Maternal depression or illness resulting in inability to tend to the child’s emotional needs can be a common finding in the history of a young child who is depressed. A child or parent with a chronic medical illness has a modestly increased risk for depression, but how the family is adjusting to the illness may be the biggest determinant of the child’s mental well-being.
Bullying is another common issue, and in particular, it can lead to comorbid anxiety. Anxiety is more common than depression in early childhood, and the manifestations of anxiety can be similar to those of depression. Children with anxiety may complain of headaches or stomachaches, balk at going to school, exhibit separation issues, or express worry about bad things happening. Anxiety in young children often develops because the child is worried that something will happen to the parent/caregiver, and so practitioners should consider if the parent or caregiver was involved in a traumatic incident, suffered an illness, or was separated from the child. Because anxiety and depression can be comorbid and have overlapping symptoms, the goal should be to try to identify the underlying cause for the child’s distress rather than to identify the specific diagnosis.
A risk of suicide in children who are depressed usually does not emerge as a concern until adolescence. Among younger children, risk for suicide most often occurs in the context of attention-deficit/hyperactivity disorder (ADHD), which suggests that these children are more likely acting impulsively on a feeling of distress rather than on a cognitive appraisal of the sadness of their life situation. With that information in mind, screening and treating for ADHD is important in a child who may appear depressed.
It has been reported that preschoolers diagnosed with major depressive disorder were more likely than healthy preschoolers to cause self-injury during a tantrum episode.9 Young children may be asked questions to screen for suicidal ideation or self-harm, but the questions should be phrased using age-appropriate terms. Because young children may not know what suicide or dead means, it may be more appropriate to ask if they ever wish they could disappear or go away. To investigate self-harm, children may be asked if they ever want to hurt themselves rather than if they ever hurt themselves, which may be misinterpreted as `accidental injury.
Identifying and managing depression in young children is important considering its ramifications for the individual’s psychosocial development. Earlier onset of depression (ie, before age 12 years) has been associated with increased number of depressive episodes and greater social, educational, and quality-of-life impairment later in life.10,11 In preschoolers specifically, depression has been shown to predict a future Major Depressive Episode defined by DSM-5 criteria.2 Considering the higher neuroplasticity of the brain in early childhood, it is possible that intervention for depression in preschoolers may be particularly beneficial in terms of improving their long-term prognosis.2,6
Psychosocial intervention represents primary intervention for preschool-aged depression. The intervention should be tailored to any causative environmental issue and may involve behavioral therapy, family therapy, or dyadic therapy.
Pediatricians should not neglect the potential need for separate intervention focused on the parent(s) or other immediate family members. For example, parents or caregivers who are struggling with depression or other mental illness should be referred for appropriate care. Social service involvement is indicated in a situation where there is suspected abuse or neglect and may be needed in a situation where the child’s emotional or physical needs cannot be met.
There is very limited evidence to support the use of antidepressant medications to treat depression in preschool-aged children. No medication is approved by the US Food and Drug Administration (FDA) for treatment of depression in preschool-aged children (Figure 2).12 The agent with the lowest age of approval to treat major depressive disorder is fluoxetine, and it is indicated only for use in children aged 8 years and older. Other antidepressants have been studied in children but failed to show benefit and were associated with high rates of adverse events.5,12 Of particular concern is evidence that young children may be more susceptible to the activating adverse effects of selective serotonin reuptake inhibitors (SSRIs) antidepressant medications.13,14
Antidepressant treatment is only considered if a child has very severe depression or has failed to respond to appropriate psychotherapies. Florida Medicaid guidelines recommend that in children aged younger than 6 years, behavioral therapy, psychotherapy, or social intervention be given a trial of 6 to 9 months before considering a medication.15 If antidepressant treatment is used, it should be combined with psychotherapy. It should never be prescribed as standalone treatment because of poor access to appropriate psychotherapeutic intervention.
Due to concerns about possible adverse effects, antidepressant treatment may be best prescribed by a psychiatrist who is familiar with its dosing, safety, and monitoring needs in the pediatric population. Furthermore, antidepressants should only be prescribed to a child whose family or caregiver can be relied on to watch for possible adverse effects. In addition, parents need to be informed that psychotherapy and behavioral interventions are considered first-line treatments, and that treatment with medication is off-label and that there is little evidence regarding its efficacy and safety, including long-term effects on growth and development.
Referral and collaboration
It may initially be important to obtain information from the child’s school or daycare to determine whether the child is exhibiting any symptoms outside the home. Being able to refer children and families properly is important to accessing timely care. Therefore, pediatricians should familiarize themselves with local resources, such as community mental health centers, child advocacy centers, and social services.
Before considering an antidepressant medication for a preschool-aged child, it is important to evaluate for neglect or abuse; consider whether the parent/caregiver is suffering from a mental or physical illness and refer properly; and, if necessary, refer the child for behavior therapy or psychosocial intervention. Pediatricians should familiarize themselves with community providers and understand who provides behavioral interventions, for which age ranges of children, and who provides medication management. Forming collaborative relationships with other healthcare providers is important.
It is very rare that a preschool-aged child will be affected by depression, but pediatricians should be aware that it can occur so that they will explore the diagnosis in a child who presents with unexplained somatic symptoms or other age-related signs. Children at risk for depression can also be identified through screening for the presence of adverse experiences and distressing environmental factors. As young children’s brains are still developing, early identification and treatment of such issues could have everlasting implications on the child’s physical, emotional, social, and cognitive development.
1. Lieb R, Isensee B, HÃ¶fler 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.