Depression in children is often missed or attributed to other causes: difficult behaviour, physical symptoms, reluctance to go to school, or simply a phase. Unlike adult depression – where the predominant presentation is sadness and withdrawal – depressed children are often irritable, angry, or physically unwell. The child who is repeatedly getting headaches and stomach aches before school, who has become explosive and difficult at home, who has lost interest in activities they used to love and whose school performance has declined, may be describing depression through behaviour rather than words.
Early recognition matters because childhood depression affects not only wellbeing in the short term but also longer-term risk of recurrence, educational attainment, and relationship development. And it is treatable.
Healthbooq (healthbooq.com) covers children's emotional health and mental wellbeing.
How Childhood Depression Presents
The DSM-5 and ICD-11 diagnostic criteria for major depressive disorder in children require at least two weeks of depressed or irritable mood most of the day, or loss of interest or enjoyment in activities, plus at least four additional symptoms from: changes in sleep (insomnia or sleeping more); changes in appetite or weight; psychomotor agitation or slowing; fatigue or loss of energy; feelings of worthlessness or inappropriate guilt; difficulty concentrating; and recurrent thoughts of death or suicidal ideation.
Critically, for children, irritable mood (not just depressed mood) satisfies the core criterion. This is important because irritability – persistent, explosive, disproportionate – is often the most prominent presentation in primary school-age children with depression.
Physical symptoms are common: recurrent headaches and stomach aches, particularly before school or social situations, in the absence of medical cause, are frequently somatic expressions of emotional distress. Waking early and being unable to get back to sleep is more specific to depression than other childhood distress.
Changes in function: declining school performance, withdrawal from friendships and hobbies, reluctance or refusal to attend school, and a change in the child's characteristic demeanour noticed by teachers or parents are important signals.
Risk Factors
A family history of depression is one of the strongest risk factors – the heritability of depression is estimated at 37-40% (Sullivan et al., 2000, American Journal of Psychiatry). Adverse childhood experiences (abuse, neglect, parental mental health problems, significant loss), bullying, chronic illness, neurodevelopmental conditions (ADHD, ASD, learning differences), and life transitions (parental separation, school change, bereavement) all increase risk.
What to Do If Concerned
A first conversation with the child, calmly and without pressure, exploring how they are feeling, what they enjoy, and whether anything is worrying them. Children are often relieved to be asked directly.
Contact with the school: teachers see children for large portions of the day and notice changes in mood, engagement, and function. A referral to the school counsellor may be available.
GP: a clinical assessment of the child's mental state, consideration of physical causes (anaemia, hypothyroidism, or other medical conditions can mimic depression), and referral to CAMHS.
Treatment
For mild depression in children, psychosocial interventions, support in school, and watchful waiting with monitoring are appropriate first steps (NICE NG134).
For moderate-to-severe depression, CBT (ideally adapted for the child's developmental level and involving parents) is the first-line psychological treatment. Family therapy may also be appropriate, particularly where family factors are contributing.
NICE does not recommend antidepressants as first-line treatment in children under 12. Fluoxetine is the only SSRI with a UK licence for depression in children (from age 8 for children who have not responded to psychological treatment). It is used with specialist oversight, with monitoring for increased suicidal ideation in the early weeks of treatment.
If a child expresses thoughts of self-harm or suicide at any point, this requires urgent assessment – contact the GP, call 111, or in cases of immediate risk, call 999 or go to A&E.
Key Takeaways
Depression in children under 12 is less common than in adolescents but does occur, affecting approximately 1-2% of primary school-age children. The presentation in younger children differs significantly from adult depression: rather than appearing sad, depressed children may present as irritable, angry, or somatic (physical complaints without medical cause). The diagnostic criteria for a depressive episode in childhood include at least two weeks of depressed or irritable mood, loss of interest or enjoyment, and associated symptoms. Psychosocial treatments (CBT, family therapy) are first-line for mild-to-moderate childhood depression. NICE does not recommend antidepressants as first-line treatment in children under 12; they are used with specialist oversight for moderate-to-severe depression when psychological treatment has not been effective.
