How Young is Too Young to Diagnose Depression?

Any parent can attest that the “Terrible 2’s” are a moody, temperamental time in the life of a toddler. Many kids are irritable and seem to throw temper tantrums for no reason, and some engage in more destructive behaviors like biting, hitting, and kicking themselves or others. Unfortunately, for some children, this phase lasts well beyond their third birthday. Are these kids just demonstrating the outward signs of emotional immaturity, or are they suffering from clinical depression? A new study funded by the National Institute of Mental Health and published in Archives of General Psychiatry suggests it may be the latter.

The provocative new research presents evidence that depression in preschool-aged children can be a chronic condition, not just a passing grumpy phase. The study evaluated more than 200 preschoolers, aged 3 to 6 years, for 2 years and included 4 mental health exams during the study period.  At baseline, 75 children were diagnosed with major depression. This subset of children had the highest risk of subsequent depression at 12- and 24-month follow-up exams. Of the initially depressed children, 64% were either still depressed or experienced a recurrence of depression at the 6-month point, and 40% experienced continuing or recurring depression at 24 months. Nearly 20% of the children had symptoms of depression at all 4 exams.

Depression was most likely in children of mothers with depression or other mood disorders, as well as children who had experienced a traumatic event, such as the death of a parent or abuse. While most preschoolers are happy-go-lucky most of the time, depressed children are often sad and tend to play games with somber themes. A persistent lack of appetite, frequent temper tantrums, and sleep problems are also symptoms seen in depressed children. Further, excessive guilt and shame is an indicator of preschool-onset depression. Despite investigation, no evidence has shown that depressed preschoolers show developmental delays.

Treating depression in young children is controversial, though a growing number of young children are being prescribed powerful psychiatric medications. Many antidepressant medications contain warnings for adolescents, and most drugs have not been carefully examined in preschoolers. Most experts support psychotherapy as first-line treatment in children. The current study did not examine treatment in the study population.

Experts are wary of labeling preschool-aged children with depression, since the diagnostic tools for this age group are not well established. However, early identification of depression may save a child from a lifetime of social and emotional consequences. Many adolescents and adults present to health care providers for mental health treatment, indicating that their symptoms started at an early age, and most adults with depression did, in fact, meet diagnostic criteria for depression in childhood. However, if children are labeled as “depressed” so early in life, are they set up for a lifetime of medications and treatments and stigmatization?

Despite the controversy, and accuracy, of diagnosing depression in children as young as 3, new research highlights the need for communication among parents, teachers, and caregivers about a child’s emotional development. Early intervention may be the key to preventing depression later in life.


Copeland, W., Shanahan, L., Costello, E., & Angold, A. (2009). Childhood and Adolescent Psychiatric Disorders as Predictors of Young Adult Disorders Archives of General Psychiatry, 66 (7), 764-772 DOI: 10.1001/archgenpsychiatry.2009.85

Luby, J., Belden, A., Sullivan, J., Hayen, R., McCadney, A., & Spitznagel, E. (2009). Shame and guilt in preschool depression: evidence for elevations in self-conscious emotions in depression as early as age 3 Journal of Child Psychology and Psychiatry DOI: 10.1111/j.1469-7610.2009.02077.x

LUBY, J., BELDEN, A., PAUTSCH, J., SI, X., & SPITZNAGEL, E. (2009). The clinical significance of preschool depression: Impairment in functioning and clinical markers of the disorder Journal of Affective Disorders, 112 (1-3), 111-119 DOI: 10.1016/j.jad.2008.03.026

Luby, J., Si, X., Belden, A., Tandon, M., & Spitznagel, E. (2009). Preschool Depression: Homotypic Continuity and Course Over 24 Months Archives of General Psychiatry, 66 (8), 897-905 DOI: 10.1001/archgenpsychiatry.2009.97

  • becca

    Childhood depression – even depression in infancy is very real.

    We adopted my daughter at birth – in fact, her birth mother was staying with us when Tori was born. It was a very traumatic pregnancy, and Tori was born 5 weeks premie in an emergency c-section. I believe that she was depressed from birth. She went into the “terrible twos” early, and never got out of it, being subject to sudden rages and depressions. At age 7, we took her to a child psychologist, who put her on zoloft. It was a godsend. When Tori was 13, the zoloft stopped working, and we spent several years trying to find a medication that would work without too many bad side effects. We’re still not happy with her current cocktail, but at least it’s allowing her to attend school (3/4 time: full time is too stressful for her) and to function. She’ll probably need to be on antidepressants all her life. We’re resigned to this.

    I can understand people wanting to be cautious about over diagnosing depression too early, and being cautious about powerful medications… but sometimes it’s necessary.

  • J. S.

    The problem is when the parents are the only source of the depression… There are not enough resources to take care of both the children and the parents, which is what would be needed. Compare to bullying in school: The victims need help, but so do the bullies. Because no sane, happy person would do such a disgusting thing. And just ignoring and relocating the bullies would be like sweeping crap under the carpet. Problems will pop up again, unless a long-term solution is used.

    As someone who has suffered from depression as far back as I can remember, any daily pill-popping would just have made me feel worse as a kid. I had enough of that as it was, because of other problems.

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  • Theodore A, Hoppe

    It doesn’t surprise me to find depressed mothers have depressed children. Dr. Stuart Brown, of the National Institute for Play, came to research play through research on criminals who had committed murder. What he discovered in those individuals was a lack of play in childhood. This is also true of some people who suffer from addiction. Play is not just joyful and energizing it is deeply involved with human development and intelligence. The article states that depressed child “tend to play games with somber themes,” an indication of low self esteem. It is not uncommon for children to blame themselves for the problems of the parents. The good news is that this can be reversed in children, without medication, due to the plasticity of the brain. Fixing the parents is the difficult part.

Jennifer Gibson, PharmD

Jennifer Gibson, PharmD, is a practicing clinical pharmacist and medical writer/editor with experience in researching and preparing scientific publications, developing public relations materials, creating educational resources and presentations, and editing technical manuscripts. She is the owner of Excalibur Scientific, LLC.

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