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Some experiences of sadness, grief, or depressed mood arise during the course of most children’s lives. Divorces, the death of a grandparent, the departure of a close friend, or a failed hope—all are common and upsetting. However, there has been increasing recognition that some children and adolescents suffer from serious and pervasive disorders related to their mood and that these disorders are associated with significant morbidity (ie, impairment in psychosocial function, low self-esteem) and mortality (ie, intended suicide or “accidental” death secondary to an impulsive behavior such as driving while intoxicated). Consequently, the critical clinical task is to differentiate children and adolescents with serious disorders from the larger group of children and adolescents who have some symptoms of sadness or grief but who are not clinically depressed. Since the diagnosis and risk assessment depends on emotional information gleaned from an interview, it can be extremely difficult for a clinician to differentiate between those children and adolescents with serious mood disorder and those who are profoundly and acutely upset in response to a combination of adverse circumstances.

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Because our understanding of the pathophysiology of emotional dysregulation is just emerging, diagnosis of major depressive disorders relies primarily on clinical history and observed mental status. There are few reliable tests to assist or to confirm a diagnosis. Current knowledge is based on the best available data from clinical studies, epidemiological research, and careful observations of longitudinal course.

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Currently, depressive illnesses are classified into three broad categories: depressive disorders, dysthymic disorder, and bipolar affective disorder or cyclothymic disorder (see Table 93-1). Estimates of the point prevalence of major depression are approximately 1.5% to 2.5% in prepubertal children, increasing to 3% to 8% during adolescence. Bipolar affective illness is estimated at a point prevalence of 0.2% to 0.4% among prepubertal children, increasing to approximately 1% among adolescents. Depressive illnesses do not show gender differences in prepubertal children; however, at puberty, there is a significant increase in major depression among females, resulting in a female-to-male ratio of 3:1 during adolescence. Some research suggests that early onset of puberty increases the risk of depression in girls.1 Bipolar disorders are equally common in males and females throughout the life cycle.

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Table 93-1. DSM-IV Criteria for Depression, Dysthymia, Mania, and Mixed Mood State

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