0021-7557/02/78-05/359 Jornal de Pediatria - Vol.

78, Nº5, 2002 359

Jornal de Pediatria
Copyright © 2002 by Sociedade Brasileira de Pediatria

REVIEW ARTICLE

Depression in childhood and adolescence:

clinical features
Saint-Clair Bahls*

Abstract
Objective: this study reviews clinical features, evolution, comorbidity and suicidal behavior in
childhood and adolescence depression. Its objective is to provide clear information on this common, severe
and not very easily recognized pathology.
Sources: literature searches were performed through Medline (1991-2000), with secondary-source
follow-up.
Summary of the findings: scientific concern about depression in childhood and adolescence is recent
and up to the 70’s depression was considered rare or inexistent in this period. Current diagnostic systems
define as basic features of depression in children and adolescents are the same ones found in adults for
major depression episodes; however, researches emphasize the significance of the developmental process
in the clinical manifestations, with predominant features in each phase.
Conclusions: nowadays, major depression in children and adolescents is understood to be a common,
disabling and recurrent disease, with a high level of morbidity and mortality. It is an important public health
problem.

J Pediatr (Rio J) 2002;78(5):359-66: depression, childhood and adolescence, clinical features.

Introduction
Depressive disorders consist of a group of pathologies in 2020, only losing to cardiac diseases. 1,2 Meanwhile,
with a high and growing prevalence in the general population. scientific interest in depression in children and adolescents
According to the World Health Organization, in the next is relatively recent, until the 1970s it was believed that
two decades there will be a dramatic change in health needs depression in this age group was rare or even nonexistent. 3-9
of the world population, due to the fact that diseases like The National Institute of Mental Health in the U.S. (NIHM)
depression and cardiopathies are substituting the traditional officially recognized the existence of depression in children
problems of infectious diseases and malnutrition. The and adolescents in 1975,10 and the research on depression
damage caused by diseases measured by the Disability during these life phases has attracted a growing interest
Adjusted Life Years shows that major depression, the 4th during the last two decades.3,11,12
generative cause of overload in 1990, will be the 2nd cause Many authors have called attention to the phenomena of
depression in children and adolescents that not only is it
now fully recognized, it seems to be more frequent and
* Professor, Department of Psychology, Universidade Federal do Paraná.
happening earlier and earlier. 13-19 In the Los Angeles
Master’s Degree in Childhood and Adolescence Psychology. Epidemiologic Catchment Area Project study, according to
Manuscript received Oct 08 2001. Accepted for publication Apr 24 2002. Olsson and von Knorring,20 25% of adults with major

359
360 Jornal de Pediatria - Vol. 78, Nº5, 2002 Depression in childhood and adolescence: clinical features - Bahls S-C7

depression report that the first episode of the disease occurred The majority of authors in the area of depressive
before 18 years of age. In a recent review of the epidemiology disorders in childhood and adolescence cite that
of depressive disorder in children and adolescents Bahls3 symptoms vary with age, emphasizing the importance of
found that the prevalence-year for major depression in the maturation process at the different developmental
children is 0.4 to 3.0%, and 3.3 to 12.4% in adolescents. stages of the symptoms and behaviors of depression,
Major depression in childhood and adolescence is with one predominant symptomatological
considered to exhibit a pervasive and long-lasting nature, characterization per age group. 8,16,19,26-28
affect multiple functions and cause significant psychosocial
damage. The objective of this article is to present a review Children
of depression in these age groups, emphasizing clinical
In preschool children (up to age 6 or 7) the most
status, its evolution, comorbidities and relation to suicidal
common clinical manifestations are physical symptoms,
behavior. For the purpose of this paper a search was done
such as: pains (principally head and abdominal), fatigue and
using these key words: depression, childhood and
dizziness. Goodyer4 cites that approximately 70% of the
adolescence, clinical characteristics, in the period of 1991
cases of major depression in children present physical
to 2000, and a manual survey of bibliographic references.
complaints. The complaints of physical symptoms are
followed by anxiety (especially separation anxiety), phobias,
psychomotor agitation or hyperactivity, irritability, loss of
Clinical status appetite with a failure to reach an adequate weight, and
Today depressive disorders in children and adolescents sleep disorders. Some authors also cite, with less frequency,
and those in adults are understood as the same the occurrence of enuresis and encopresis, sad facial
phenomenological entities, a fact derived from studies expressions, deficient communication skills, frequent crying,
which show the same diagnostic criteria reliably applied to repetitive movements and auto and heteroaggressiveness
these three age groups.7,8,13,21-23 According to the through aggressive and destructive behavior. The pleasure
Diagnostic and Statistical Manual of Mental Disorders24 in playing or attending preschool diminishes or disappears
(DSM-IV) the basic symptoms of a major depressive episode and the acquisition of age-appropriate social skills does not
(Table 1) are the same in adults, adolescents and children occur naturally4,8,9,18,19,29 (Table 2). Although the majority
even though there are data suggesting that the predominance of authors affirm that in this period suicidal ideation or
of characteristic symptoms can change with age, including attempts do not occur, Shafi and Shaffi8 emphasize that
very common symptoms in children (somatic complaints, self-destructive behavior in the form of severe and repeated
irritability and social withdrawal) and symptoms less head bashing, biting oneself, swallowing dangerous objects
commonly found in children (psychomotor retardation, and a propensity for accidents could be the suicidal equivalent
oversleeping and delusions). The International Classification in children that do not verbalize emotions. Meanwhile
of Diseases25 (ICD-10) presently deals with depressive suicidal ideation in this age group is considered a rare
disorders in the same way for all age groups, with only the occurrence, occurring only in special cases. North American
following specific citation “atypical presentations are studies of preschool children with depression found that
particularly common in depressive episodes in adolescence”, often parents are also depressed and are involved in serious
but it does not supply more information. social problems.19

Table 1 - Symptoms of major depressive episodes – DSM-IV

1. Depressed or irritable mood

2. Extremely diminished interest or pleasure
3. Significant weight loss or weight gain, or decreased or increased appetite
4. Insomnia or hypersomnia
5. Agitation or psychomotor retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think and concentrate, or indecisiveness
9. Recurrent thoughts of death, suicidal ideation, suicide attempt or plan
Depression in childhood and adolescence: clinical features - Bahls S-C Jornal de Pediatria - Vol. 78, Nº5, 2002 361

Table 2 - Depression symptoms in preschool children

areas, principally in Portuguese and Sciences, when
compared to children without depressive symptoms.
1. Pain (headache and stomachache) In both preschool as well as school-age children
2. Diminished pleasure in playing and going to school depression can become clear through observation of the
3. Difficulty in acquiring age-appropriate social skills themes of their fantasies, desires, dreams, games, with the
4. Anxiety predominant subjects of failure, frustration, destruction,
5. Phobias injuries, losses or abandonment, blame, excessive self-
6. Agitation or hyperactivity criticism and death.8
7. Irritability
8. Diminished appetite
9. Sleep disorders
Adolescents
The manifestation of depression in adolescents (from
age 12) normally presents symptoms similar to those of
adults, but there can exist important phenomenological
In school-age children (between six or seven to twelve characteristics that are typical of depressive disorder in this
years of age) a depressive mood can be verbalized and what phase of life. Depressed adolescents are not always sad;
is often communicated is sadness, irritability or boredom. they seem primarily irritated and unstable, and can have
They present a sad appearance, cry easily, have apathy, emotional outbursts and anger in their behavior. According
fatigue, isolation, decline in or poor school performance, to Kazdin and Marciano11 more than 80% of depressed
which could result in school refusal, separation anxiety, youths present irritable mood and also loss of energy,
phobias and death wishes. They may also report weak apathy and marked lack of interest, psychomotor retardation,
concentration, somatic complaints, weight loss, insomnia feelings of hopelessness and guilt, sleep disorders, especially
and mood-congruent psychotic symptoms (depreciative oversleeping, appetite and weight changes, isolation and
aural hallucinations and less frequently delusions of blame difficulty concentrating. Other unique characteristics of
or guilt). The decline in performance could be due to weak this group are poor school performance, low self-esteem,
concentration or interest, both characteristic of the state of suicidal ideation and attempts, and serious behavior
depression. It is common for the child not to have friends, problems, especially abusive alcohol and drug
say that classmates do not like him/her or have an exclusive use.7,14,18,19,22,30,32 The development of abstract thought
and excessive attachment to animals.8,9,14,22,29,30 Inability around age 12 brings a clearer understanding of the
to enjoy oneself (anhedonia), poor relationship with peers phenomenon of death, consequently, both suicidal ideas
and low self-esteem, describing oneself as stupid, silly or and attempts, which are normally extremely fatal, reach a
unpopular can also be present (Table 3). It is important to greater dimension in depressed adolescents, and so,
emphasize that teachers are often the first to notice the adolescents are extremely vulnerable to them (Table 4). In
emerging modifications of depression in these children. In a study on the symptoms of major depression in adolescents
a study on school efficiency in nine to ten year old children between the ages of fourteen and eighteen, in a community
with symptoms of depression, in one school in particular in sample in the Oregon Adolescent Depression Project, in the
Recife, state of Pernambuco, Bandim et al.31 found that US, Roberts et al.23 found the most prevalent symptoms to
there was a significant decrease in school performance in all be depressed mood, sleep disorders and difficulties in

Table 4 - Depression symptoms in adolescents

Table 3 - Depression symptoms in school age children 1. Irritability and instability

2. Depressed humor
1. Sadness, irritability and/or dullness 3. Loss of energy
2. Lack of ability to enjoy himself/herself 4. Lack of motivation and significant lack of interest
3. Sad appearance 5. Psychomotor retardation
4. Easy crying 6. Feelings of hopelessness and/or guilt
5. Fatigue 7. Sleep disorders
6. Isolation with weak relationship with peers 8. Isolation
7. Low self-esteem 9. Difficulty in concentrating
8. Diminished or weak school performance 10. Poor school performance
9. Separation anxiety 11. Low self-esteem
10. Phobias 12. Suicidal ideas and attempts
11. Death desire or ideation 13. Severe behavioral problems
362 Jornal de Pediatria - Vol. 78, Nº5, 2002 Depression in childhood and adolescence: clinical features - Bahls S-C

thinking (concentration problems and negative thinking) lack of the perception of support on the part of the parents
and the most stable symptoms to be depressed mood and is highly related to the presence of depressive symptoms in
anhedonia. youths.
Some authors28,33 call attention to the difference between
the manifestation of depression in female and male
adolescents, emphasizing that girls report more subjective Evolution
symptoms such as feelings of sadness, emptiness, boredom, On average, major depression in childhood increases
anger and anxiety. Girls normally are also more concerned around age nine and in adolescence between ages thirteen
with popularity, less satisfied with their appearance, more and nineteen. The first depressive episode usually lasts
self-conscious and have lower self-esteem, while boys between approximately five and nine months. In terms of
report more feelings of contempt, defiance and disdain, and recovery, the majority of authors cite the article written by
show conduct problems like: missing classes, running away Kovacs et al.,39 in which 74% or cases presented significant
from home, physical violence, robberies and substance improvement within a year, and 92% recovered in a period
abuse. They emphasize that alcohol abuse can be a strong of two years.5,6,8,11,15,20,22 Authors are unanimous in
indicator of depression. affirming that after recovery there normally remains some
As guidance for physicians, the following should not be degree of psychosocial damage; and the earlier the
considered normal, alerting to the probable presence of appearance of the pathology, the greater the harm is likely
depression during adolescence: states of irritability or long- to be, which was confirmed by the Rohde et al. study40 with
lasting and/or excessive depression, prolonged periods of 1,507 community adolescents in which they concluded that
isolation from or hostility towards family and friends, the early appearance of major depression is one of the most
distancing oneself from school or a significant decline in harmful forms of the disease and causes a more severe
school performance, distancing oneself from group activities, impact than in adults.
and behaviors such as substance abuse (alcohol and drugs), The risk of recurrence of major depression in childhood
physical violence, promiscuous sexual activity and running and adolescence is more frequent a few months after the
away from home.28 An adolescent is normally the best first episode, with variable rates, between 33 and 80% in
source of information as to his/her depressive suffering and five years, according to review articles. 13,22,29 In
his/her schoolmates and friends most easily notice the longitudinal studies16,39 in the US and England, rates of
modifications caused by the pathology. Many authors recurrence between 60 and 74% were found. Children and
emphasize that parents and teachers are often not aware of adolescents with depression possess a high risk of recurrence
depression in their adolescent children and students. which extends through adulthood, representing a high
vulnerability to depressive disorders.
The following factors are predictive of recurrence: early
Risk factors onset, numerous previous episodes, the severity of the
The most important risk factor of depression in children episode, presence of psychotic symptoms, presence of
and adolescents is the presence of depression in one of the stressors, comorbidity (especially dysthymia) and not
parents, the existence of a family history of depression following treatment.19 Some authors consider the appearance
increases the risk by at least three times, followed by of a depressive episode in childhood and adolescence as
environmental stressors like physical and sexual abuse and predictive of bipolar disorder in the future, meanwhile there
loss of a parent, sibling or close friend.8,14,34 In a longitudinal remains a lack of clear evidence regarding this
study, involving 550 adolescent students between ages relationship.13,20,41
eleven and seventeen, Garrison et al.,35 in the US, concluded
that at the start of adolescence, family environment is a
more important predictor of depressive symptoms than
Comorbidity
stressful life events. Abou-Nazel et al.,36 in Egypt, in a
study with 1,561 adolescent students between ages eleven Depressed children and adolescents normally present
and seventeen, found that low academic performance is a high rates of comorbidity with other psychiatric disorders,
marker for children at high risk of depression in this age found more commonly than in depressed adults. The most
group. Nunes et al.37 in a study in Londrina, state of Paraná, common comorbidities in children are anxiety disorder
Brazil, evaluated the presence of psychiatric disorders in (especially separation anxiety), conduct disorder, or
the parents of individuals between ages seven and eighteen oppositional defiance disorder and attention deficit disorder,
and found a predominance of mood disorders, especially and in adolescents, substance-related disorders and eating
major depression and dysthymia, confirming the importance disorders.5,12,16,22,24,27,40,42
of the family factor in vulnerability to depression in childhood Goodyer and Cooper26 emphasize that depressive
and adolescents. Patten et al.38 in a community study in disorders in children and adolescents present 40%
California, US, with 5,531 adolescents between ages twelve comorbidity with anxiety disorders and 15% with conduct
and seventeen with depressive symptoms, concluded that a disorders. Birmaher et al.13 describe major depression in
Depression in childhood and adolescence: clinical features - Bahls S-C Jornal de Pediatria - Vol. 78, Nº5, 2002 363

adolescence as normally presenting an index of 40 to 70% according to the study Office of Population Census and
psychiatric comorbidity, at least 20 to 50% of which have Surveys42 from 1990; and the suicide index in the general
two or more comorbidities; and they emphasize that conduct population for this age group is 0.01%. 47
disorders could persist after the depressive episode ends. In relation to age, suicidal ideation is common in school-
Kazdin and Marciano11 cite that depressed youths, in age children and in adolescents, however attempts are rare
community studies, present average rates of comorbidity in children. Suicide attempts and ideation increase with age,
between 40 and 50% for at least one other psychiatric becoming common after puberty. Of high-school students
diagnosis, and can reach up to 80%. Martin and Cohen43 4% presented one suicide attempt in the previous twelve
and Scivoletto et al.7 cite that 20% of depressed adolescents months and 8% had already had one previous suicide
also present alcohol and drug abuse. attempt in their life, according to the United States Youth
Kashani et al.,44 in a community study of adolescents in Risk Survey14 of 1990. And the indices of suicide ideation
the US, found the following rates of comorbidity among are even higher; community surveys found rates of 12 to
those with a diagnosis of major depression: 100% for 25% in primary school students and more than 25% in high
dysthymia; 75% for anxiety disorders; 50% for oppositional school students.14
defiant disorder; 35% for conduct disorder and 25% for Weismann et al.41 in the US, in a research follow-up
substance abuse. Roberts et al.23 in the US, in a community study in a period between ten and fifteen years with depressed
survey of 1,710 adolescents, found between sufferers of adolescents, found a suicide attempt rate of 50.7% and
major depression the rate of 66% with a history of another 7.7% for suicides. In Brazil, Feijó et al.48 in an investigation
mental disorder, and 34% with a previous depressive episode. of self-destructive behavior in adolescents in the range of
Garrison et al.45 in the US, in a longitudinal epidemiological thirteen to twenty years of age, accompanied suicide attempts
study with 3,283 participants between ages twelve and attended at the Emergency Room of the Hospital de Clínicas
fourteen, researching dysthymia and major depression, de Porto Alegre-RS daily during a period of four months
found a high rate of comorbidity, in which 58% of those and found the following results: 88% were caused by
diagnosed with dysthymia also had major depression overdose, 84.4% of the cases occurred in girls, 47% had
characterized by the presence of double depression. Also in already had a previous suicide attempt and 28% presented
the US, Kessler and Walters16 in an investigation of a a diagnosis of major depression. Mirand and Queiroz50
population of 1,769 individuals between ages fifteen and researching on suicide ideation and suicide attempts in a
twenty, which took part in the National Comorbidity Survey, sample of 875 medical students in Belo Horizonte, state of
found that 76.6% of those with major depression and 69.3% Minas Gerais, Brazil, obtained rates of 37% for suicide
of those with dysthymia presented at least one other ideation and 2.3% for suicide attempts.
psychiatric disorder during their lives, and concluded that
Approximately 80% of adolescent suicide attempts were
comorbidity for depression, in this age group, is more of a
through overdoses, followed by cutting wrists. Close to
rule than an exception.
65% of suicides are committed with guns, followed by
In relation to depression in childhood and adolescence, hanging, jumps and overdoses. Shafii and Shafii8 cite a
we know that the probability of comorbidities increases study in Louisville, US, in which 57% of the adolescent
with the severity of the state of depression; in addition, its suicides were with guns, emphasizing that 82% of the cases
presence normally indicates a more severe evolution and a had never had specialized help. The majority of adolescent
poorer prognosis.3,8,22 victims commit suicide impulsively and are often found
intoxicated (alcohol and drugs) at the time of death. Suicide
is three to four times more common in boys as it is in girls,
Suicide while suicide attempts are two to five time more common in
Child and adolescent suicide is a particularly dramatic girls.7,14,22,28,47,51,52
and severe manifestation, and is the most relevant fact in the The following are considered risk factors for suicidal
clinical status of depression. Today there is a tendency behavior in childhood and adolescence: age, presence of
among authors to call a suicide attempt deliberate self- previous attempts, family history of psychiatric disorders
harm.17,46,47 (especially with suicide attempt and/or suicide), absence of
Suicidal behavior among youths has apparently been on family support, presence of a gun in the house, serious and/
the rise in the last decades, and adolescence is calling or chronic physical disease, presence of depression and
attention to itself as the period most related to death due to comorbidity with other conduct disorders, and substance
violent causes.17,38,41,46,48,49 In a study in England and abuse. The risk of suicidal behavior in depressed adolescents
Wales with individuals between ages fourteen and twenty- is three times higher in the presence of these
four, according to Scivoletto et al.,7 a 78% rise in suicide comorbidities.22,29,46,48,50,52 A previous suicide attempt is
rates between 1980 and 1990 was found. Today suicide is the best predictor, so we calculate that 25% of adolescents
the second cause of death among youths from ages fifteen who attempt suicide and 25 to 40% of youths who commit
to twenty-four in the US, according to the National Center suicide have already had at least one previous suicide
for Health Statistics49 from 1986, as well as in England, attempt. It is estimated that up to 11% of adolescents who
364 Jornal de Pediatria - Vol. 78, Nº5, 2002 Depression in childhood and adolescence: clinical features - Bahls S-C

attempt suicide through overdose will commit suicide in the In conclusion, depression in childhood and adolescence
following years.47 The feeling of hopelessness is strongly becomes particularly important when the question of suicidal
associated with suicidal behavior and predicts future behavior is considered. There even exist reports of suicidal
attempts.7,21,49,53 It is known that at least 50% of adolescents behavior and suicide in preschool children, 8 and its
who commit suicide made threats or attempts in the past, occurrence in adolescence is rising. We estimate that
and the risk of repeating an attempt is greater in the first depression is responsible for the majority of suicides in
three months after a suicide attempt.14 youths, reaching values close to 10% in cases of major
depression. Today we know, in a relatively sure way, the
Precipitators of suicidal behavior in this age group are:
risk factors as well as the triggering factors of suicidal
losses, interpersonal crises with family or friends,
behavior in children and adolescents, which permit better
psychosocial stressors, physical and sexual abuse, legal or
strategies of addressing the problem. And if we continue to
disciplinary problems and exposure to the suicide of friends,
consider depression, due to its usually satisfactory
relatives or even through the media.7,14,22,47,51,53 Knowing
therapeutic result, as the principal preventable cause of
the risk factors associated with triggering factors provide
suicide, there is much to be done, protecting and impeding
the clinician with a necessary and useful indication of those
innumerable potential victims of suicidal behavior caused
statuses that need urgent specialist referral.
by depressive disease.
Conclusions
The study of depressive disorders in childhood and
adolescence has already shown that their presence is
sufficiently common and serious to deserve clinicians and
researchers’ attention. Especially if we consider the
possibility suggested by modern epidemiological studies of
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