Childhood Depression

Childhood depression is a mood disorder that manifests in children and adolescents with clinical features that differ from the adult form. In developmental age, depressive equivalents may present with less specific symptoms, often masked by dysfunctional behaviors or oppositional attitudes.

Unlike adults, who tend to internalize distress as low mood, children may respond to psychological suffering with avoidant behavior, anger, rage, or withdrawal, which are early defensive strategies preceding full-blown depressive reactions. The absence or loss of a stable emotional reference figure can lead to feelings of insecurity and abandonment, often expressed through externalized aggression or oppositional and provocative behaviors.

The causes of depression in childhood are multifactorial. These include:

• Biological factors: genetic, neurochemical, and neuroendocrine alterations (particularly involving serotonergic and dopaminergic systems)
• Environmental and psychosocial factors: traumatic events, bereavement, abuse, parental separation, and most notably dysfunctional family dynamics (e.g., parental depression, hostility, unresolved conflict, emotional rejection)

Longitudinal studies have shown that depressed children often grow up in high-conflict family environments, where criticism, emotional rejection, or indifference prevail. The mother often plays a central role: depressed mothers tend to inadvertently reinforce regressive or passive behaviors in the child and inhibit autonomy and self-assertion. In other situations, the child may unconsciously take on the role of “regulator” of the family’s emotional balance, sacrificing personal well-being to preserve the family's stability.

It has been observed that many depressed children develop a negative internal locus of control, attributing adverse events to themselves while seeing positive outcomes as random or undeserved. This dysfunctional cognitive style is associated with guilt, low self-esteem, and learned helplessness, fostering the development of persistent depressive experiences.

Behaviorally, children with depression may exhibit:

• marked irritability or excessive passivity
• unexplained crying, social withdrawal
• oppositional or aggressive behaviors, particularly within the family
• academic difficulties and lack of interest in play activities
• sleep and appetite disturbances

During interactions with parents, depressed children often display selective and distorted perceptions of verbal and non-verbal communication, emphasizing negative messages and interpreting even neutral cues as threatening. This may create a vicious cycle of misunderstandings and escalating parental conflict, worsening the clinical picture.

The diagnosis is based on a comprehensive clinical evaluation, including interviews with the child, direct observation, standardized psychometric tools (e.g., Children’s Depression Inventory – CDI, CBCL), and assessment of the family context. It is essential to rule out secondary causes such as organic illnesses, substance use, or pervasive developmental disorders.

Treatment relies on a multimodal psychotherapeutic approach. Cognitive-behavioral therapy is currently considered the first-line intervention for mild to moderate cases. Its goals are to modify dysfunctional schemas, improve self-efficacy, reduce anxious-depressive symptoms, and enhance problem-solving skills.

A particularly effective technique in children is the use of mediated strategies, such as video-mediated recall, which involves recording family interactions and reviewing them during sessions to promote awareness and behavioral change.

In more severe, resistant, or suicidal cases, pharmacological treatment (e.g., SSRIs such as fluoxetine, which is approved for pediatric use) may be required. This should be managed by specialists with close monitoring. Education and active involvement of the parents is an integral part of the care plan, as the quality of family relationships significantly influences prognosis.

Prognosis is variable. Early, multidimensional treatment improves the chances of full remission, but the risk of chronicity or progression to mood disorders in adulthood (particularly bipolar disorder) remains significant, especially in children with a positive family history or persistent environmental risk factors.

In conclusion, childhood depression should never be underestimated. Apparently oppositional or ambiguous behaviors may signal deep distress. It is essential to interpret such signs as implicit requests for help and containment, rather than merely as manipulation or defiance.

References
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