Major Depressive Disorder Among Preadolescent
Canadian Children: Rare Disorder or Rarely
Detected?
(Re—
Daphne J. Korczak, MD, MSc; Marianna Ofner, PhD, RN; John LeBlanc, MD, MSc;
Sam Wong MD; Mark Feldman, MD; Patricia C. Parkin, MD
.
From the Department of Psychiatry, University of Toronto, Toronto, Ontario (Dr Korczak); Department of Pediatrics, University of Toronto,
Toronto, Ontario (Drs Feldman and Parkin); The Hospital for Sick Children, Toronto, Ontario (Drs Korczak, Feldman, and Parkin); Dalla Lana
School of Public Health, Toronto, Ontario (Drs Ofner and Parkin); Bloomberg Faculty of Nursing, Toronto, Ontario (Dr Ofner); Department of
Pediatrics, Dalhousie University, Halifax, Nova Scotia (Dr LeBlanc); Stanton Hospital, Yellowknife, Northwest Territories (Dr Wong); and
Department of Pediatrics, University of Alberta, Edmonton, Alberta (Dr Wong)
Conflict of Interest: The authors declare that they have no conflict of interest.
Address correspondence to Daphne J. Korczak, Department of Psychiatry, The Hospital for Sick Children, 555 University Ave, Toronto, ON
M5G1X8, Canada (e-mail: daphne.korczak@sickkids.ca).
Received for pub ication May 24, 2016; accepted October 22, 2016.
A bstract
OBJECTIVE: Despite agreement that preadult onset of depres­
sion is associated with greater illness severity, and that children
can meet the diagnostic criteria for major depressive disorder
(MDD), few studies have examined the presentation of MDD
among young children. This is the first nationwide study of
MDD among preadolescent children in Canada.
M ETHO DS: Pediatrician members (2500) of a Canadian pediat­
ric surveillance network were surveyed monthly over 3 years to
report new cases of MDD among 5- to 12-year-olds. Survey
response and questionnaire completion rates were 80% and
85%, respectively. Symptom presentation and duration, impair­
ment, medical and psychiatric history, and management were
reported.
RESULTS: Twenty-nine new cases of MDD were identified by
pediatricians. Of these, 23 (79%) experienced symptoms for >6
months before presentation with global functional impairment.
Parental depression or anxiety, commonly maternal, was pre­
sent in 21 cases (72%). Twenty-two children (76%) reported
suicidal ideation; 6 (21%) had attempted suicide. Twentythree children (79%) were treated with medication. Thirteen
children (45%) were treated with 2 or more medications.
CONCLUSIONS: Children with MDD frequently had a parental
history of mood disorders, experienced long-standing symptom
presence, high symptom burden and functional impairment
prior to presentation; and commonly treatment with polyphar­
macy.
W hat’s New________________________
impairment.6 Current epidemiologic data estimate that
childhood (preadolescent) depression occurs in 1% to 2%
of children.11-13 However, research regarding the onset
and course of childhood depression has typically been
collected from adult participants, thereby relying on the
retrospective recall of age at onset that is subject to recall
bias.
Despite general agreement that children and adolescents
can meet diagnostic criteria for major depressive disorder
(MDD), few studies have used prospective data collection
of preadolescent MDD. Accurate identification of MDD in
young children is important in order to facilitate early
detection and employ effective interventions to reduce
morbidity and mortality. Twenty-five years ago, a critical
review of 14 studies regarding the epidemiology of child
and adolescent depressive disorders concluded that
although MDD appeared to be uncommon in prepubertal
children, the shortcomings of the literature, including mea­
surement inconsistencies, suggested the need for further
research in this area.14 Subsequent research addressing
K eywords: children; community practice; early-onset depres­
sion; pediatrics; treatment
A cademic Pediatrics 2017;17:191-197
Diagnosis of major depressive disorder (MDD) among
preadolescent children is uncommon in Canada. Pread­
olescent children identified with MDD have severe and
long-standing symptoms and functional impairment
before presentation. Among young children with
MDD, a parental history of mood disorders is frequently
present.
THERE IS NOW compelling evidence that preadolescentonset depression can be severe and can lead to serious
consequences.1-4 Population-based studies have reported
that the onset of depression at a young age, particularly
before adolescence, is a risk factor for an increased number
and severity of depressive episodes,5,6 increased
suicidality,'1'6 increased emergency department visits and
hospitalizations,3,5 increased psychiatric and medical
comorbidity,5,7'8 higher health care costs,9 lower educa­
tional attainment,10 and greater social and occupational
Academic Pediatrics
Copyright © 2016 by Academic Pediatric Association
191
Volume 17, Number 2
March 2017
192
A c a d e m ic P e d ia tr ic s
KORCZAK ET AL
these questions has unfortunately been limited. Research in
your.g children has suggested that current Diagnostic and
Statistical Manual o f Mental Disorders (DSM) criteria
require modification in order to be applicable to pre­
schoolers.15 Similarly, several small studies in diverse clin­
ical populations16”18 and one large study of children in
Hungary19 have reported differences in symptom presenta­
tion of depressed children compared to adolescents with
depression. As such, questions regarding the appropriate­
ness of MDD diagnostic criteria, the degree of MDDrelated impairment, and the management of MDD for pre­
adolescent children remain largely unanswered.
The objectives of this study were to prospectively
collect and summarize details regarding the detection
of MDD in preadolescent children and their associated
characteristics and management in a national sample of
pediatrician offices. Consistent with previous research,
we hypothesized that first, children with MDD would
experience considerable functional impairment; and
second, that treatment strategies would be similar to
those used for adolescents. We also suspected that a
diagnosis of MDD among preadolescent children would
be uncommon, but we recognized that our study was not
designed to assess MDD incidence.
We undertook what is to our knowledge the first nation­
wide prospective study of MDD in Canadian children by
using an established disease surveillance system, the Cana­
dian Pediatric Surveillance Program (CPSP). Although
large surveys of children’s mental health have previously
been conducted in Canada,20'21 respondents in these
surveys
(primarily parents)
have
completed
questionnaires on behalf of their children, which
included information about the child’s feelings and
behaviors but did not include clinical assessments. As
such, past surveys have been unable to confirm clinical
diagnoses of MDD, examine clinical comorbidities, or
accurately report on the current management of
childhood MDD. The present study examined physician
assessment of MDD including their reports on
comorbidities, management strategies, and family history
of children with MDD, thus addressing some of the
methodologic limitations of previous studies.
M ethods
Through the CPSP,22 approximately 2500 pediatricians
across Canada were asked each month from January 1,
2012, to December 31, 2014, to submit information on
any case that they had seen in their practice meeting the
case definition of very early onset (VEO) MDD,23 as
defined in the monthly survey.24'25 Briefly, the CPSP is
an active surveillance system in which 2500 Canadian
pediatrician participants are contacted each month to
inquire about the presentation in their clinic of the
condition (VEO-MDD) under active surveillance during
the previous month. If they respond “yes,” then they are
provided with a full case definition and are asked to
report sufficient demographic information to allow the
surveillance system to detect duplicate cases in the event
that families sought help from more than one
pediatrician. Participants also report pertinent clinical
and treatment information. To improve compliance with
surveillance, only a limited number of pediatric
conditions are surveyed at any one time, usually 6 to 8,
and at least one condition is dropped and a new one
added each year. Although active surveillance is more
costly and time-consuming than passive surveillance,
which relies on clinician-initiated reporting rather than reg­
ular contact, reminders, and feedback to stimulate report­
ing, active surveillance methods provide better case
identification than passive surveillance of health condi­
tions.25 Prior CPSP studies indicate a mean reporting rate
of 80%, with an average 85% to 90% response rate for
detailed questionnaire completion22'26 once a case had
been reported.
C ase A scertainment
Cases were included as follows: any child aged 5 to 12
years (inclusive, from the fifth to the 13th birthday) seen
in the previous month with a newly identified VEO major
depressive episode (MDE), as defined by the DSM-IVTR23 (Table 1). Pediatrician participants were provided
with the case definition on the data form, which included
the depressive symptoms that comprise a depressive
episode. MDEs may occur within the broader context of
either unipolar (MDD) or bipolar illness. Exclusion criteria
were the presence of or history of hypomanic or manic
symptoms, substance use, or general medical conditions
to which the MDE might be attributed, such that the
MDE reflected the presence of MDD, and not bipolar dis­
order or other underlying illness.
For each case identified, the physician was asked to
complete a nonnominal case report form detailing the
patient’s demographic data, depressive symptoms
(including suicidality), duration of symptom onset, initi­
ated or planned treatments, domains of functional impair­
ment, presence of medical or psychiatric comorbidities,
history of abuse or neglect, and family history of mental
illness in a first-degree relative (Online Appendix). Using
the information available to them, pediatricians were
asked to report whether the case had required emergency
department services or hospitalization, and whether the
case or family member had sought advice or care from
school officials, community agencies, or allied health pro­
fessionals. The case report form required 5 to 10 minutes
to complete.
Data A nalyses
Descriptive analyses (means, standard deviations, and
proportions) were used to describe the study participants.
Box-and-whisker plots were used to display data regarding
age at symptom onset and VEO-MDD diagnoses in order
to visually present the range of these data (median, inter­
quartile range) and allow for further examination of the
relative patterns of skewness for these factors.
Ethics approval was granted by the research ethics board
of the Hospital for Sick Children, Toronto.
A cademic Pediatrics
Very Early O nset MDD
193
Table 1. Case Definition for Very Early Onset Major Depressive Episode
Report any child aged 5 to 12 years of age inclusively, seen in the previous month, with newly diagnosed early-onset major depressive episode,
including children with unipolar mood disturbances sufficient to cause a disruption to social, family and/or academic functioning.
“Major depressive episode” is defined in the DSM-IV-TR as:
1) Depressed or irritable mood, most of the day, nearly every day,
OR
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
which is either newly present or has clearly worsened compared to the child's pre-episode status.
AND
At least 4 of the following 7 symptoms that are present during the same 2-week period as either (1) or (2) above. These symptoms occur daily or
nearly daily and represent a distinct change from previous functioning.
1) Significant weight change, failure to make expected weight gains, or significant appetite change.
2) Insomnia (difficulty falling asleep, night-waking, or waking too early) or hypersomnia.
3) Psychomotor agitation or retardation: observable by others and does not represent subjective feelings.
4) Fatigue or loss of energy.
5) Feelings of worthlessness or excessive or inappropriate guilt (not merely guilt about being sick).
6) Diminished ability to think or concentrate, or indecisiveness.
7) Recurrent thoughts of death, recurrent suicidal ideation, or a suicide attempt.
AND
Impairment in social functioning (social withdrawal, family or peer conflicts) or academic functioning (school refusal, decreased school
performance), which is either newly present or worsened compared to pre-episode status.
Exclusion Criteria
1) Symptoms due to the direct physiologic effects of a substance or a general medical condition.
2) Symptoms occurring exclusively during acute bereavement period (within 2 months after the loss of a loved one).*
3) A previous diagnosis of a manic episode or bipolar disorder.
*This exclusion does not apply to palliative care patients.
Results
Thirty-eight children were reported to have had newly
identified MDD during the study period. Nine were
excluded because they were age 13 or older (n = 7), they
had subsequent revision of their diagnosis by a child psychi­
atrist (n = 1), or because they had subsequent determination
of depressive symptoms resulting from substance use rather
than MDD (n = 1). Twenty-nine children aged 5 to 12 years
(up to the 13th birthday) were thus identified as newly diag­
nosed MDD cases identified during the study period.
D emographics
and
was also positive for paternal MDD (n = 4; 14%), paternal
alcohol or substance use (n = 3; 10%), maternal bipolar
disorder (n = 2; 7%), paternal ADHD, and maternal obses­
sive compulsive disorder (one case each). In addition to
receiving pediatric care, 22 children (76%) had also
received care for these symptoms from other physicians,
and 19 (66%) were receiving care from allied health pro­
fessionals including social workers, child and youth coun­
selors, and psychologists. School officials for liaison or
assistance were involved in 12 cases (41%) at the time of
MDD diagnosis.
C linical C haracteristics
Boys comprised 16 (55%) of the 29 confirmed cases. At
the time of diagnosis, children had a median age of 11.1
years (range 7.3-12.9 years), and 23 (79%) had been expe­
riencing depressive symptoms for at least 6 months (Fig.).
Eighteen children (62%) were globally impaired in all
functional domains at the time of presentation. Comorbid
medical conditions were present in 5 children (17%); 2
children had diagnoses of asthma, and 1 child each had a
seizure disorder, migraine headaches, and type 1 diabetes
mellitus. Comorbid psychiatric conditions were present
in many children before MDD onset (Table 2). Of comor­
bid psychiatric disorders, attention-deficit/hyperactivity
disorder (ADHD) and anxiety were the most common,
each occurring in 13 children (45%) with MDD, with all
3 disorders (anxiety, ADHD, and MDD) occurring in 8
children (28%). Twenty-three children (79%) had a history
of a psychiatric disorder in a first-degree relative. Family
psychiatric history of children with MDD was positive
for maternal history of psychiatric disorder in 19 cases
(66%), most commonly MDD or anxiety disorder
(n = 17; 59%). Psychiatric history of first-degree relatives
S ymptom P resentation
The frequency of specific depressive symptoms that was
reported by children with MDD is outlined in Table 3. The
14
6 ■
5 --------------------------- ----------------------Symptom Onset
,
Diagnosis o f MDD
Figure. Box-and-whisker plot depicting age at onset of depressive
symptoms and age at which MDD diagnosis was made. MDD indi­
cates major depressive disorder.
194
KORCZAK ET AL
A c a d e m ic P e d ia tr ic s
Table 2. Demographic and Presenting Characteristics of 29 Chil­
dren With Very Early Onset Major Depressive Disorder
Characteristic
Male sex
Race
White
Aboriginal
Asian
Not specified
Durat on of symptoms before presentation
<6 mo
6-12 mo
>12 mo
No. o" domains of functional impairment*
2
3
4
History of abuse (confirmed or suspected)
Comorbid psychiatric disorder!
None
Anxiety disorder
ADHD
LD
ODD
Substance use
Eat ng disorder
Family history of mental illness! (first-degree relative)
Maiernal MDD/anxiety
Paternal MDD
Sib ing (any)
Other
Mean no. of professionals involved per child
Medical
Interprofessional
Active school collaboration
Value
16(55%)
25 (86%)
2 (7%)
1 (3%)
1 (3%)
6(21%)
12 (41%)
11 (38%)
4(14%)
7 (24%)
18(82%)
4(14%)
6(21%)
13(45%)
13(45%)
8 (28%)
5(17%)
3(10%)
1 (3%)
17(59%)
4(14%)
4(14%)
6(21%)
2.0
0.9
12(41%)
ADHD indicates attention-deficit/hyperactivity disorder; LD,
Learning Disorder; ODD, oppositional defiant disorder; and MDD,
major depressive disorder.
‘ Peer relationships, academic performance, family relationships,
extracurricular activities.
fBecause subjects may have more than 1 psychiatric comorbidity
or family member with mental illness, percentages may not sum to
100%.
most common symptoms experienced were depressed
mood, anhedonia, irritability, decreased concentration, sui­
cidal ideation, worthlessness, insomnia, and fatigue or
decreased energy. In addition, 15 children (52%) with
MDD experienced new-onset or increased anxiety at the
same time as depressive symptom onset (n = 15; 52%).
Weight change, psychomotor abnormalities, hypersomnia,
and nonspecific somatic complaints were infrequently seen
(Table 3). Six children (21%) had made a suicide attempt
before diagnosis.
M anagement
The majority of children with MDD were treated with
medication (n = 23; 79%), either as the sole management
approach (n = 6; 21%) or more frequently in combination
with a nonpharmacologic treatment (n = 17; 59%)
(Table 4). Of medications prescribed to treat depression,
selective serotonin reuptake inhibitors (SSRIs) were most
commonly initiated, with fluoxetine prescribed more
frequently than other SSRI medications. Other prescribed
SSRIs were sertraline, citalopram, escitalopram, and par­
Table 3. Frequency of Depressive Symptoms
Symptom
n (%)
Depressed mood
Diminished interest or pleasure
Irritability
Decreased concentration or indecisiveness
Suicidal ideation
Worthlessness or excessive/inappropriate guilt
Insomnia
Fatigue or loss of energy
New or increased anxiety
Non-specific somatic complaints
Psychomotor retardation
Psychomotor agitation
Suicide attempt
Weight loss
Hypersomnia
Weight gain
27 (93)
23 (79)
22 (76)
22 (76)
22 (76)
21 (72)
19(66)
17(59)
15(52)
9(31)
9(31)
6(21)
6(21)
6(21)
5(17)
4(14)
oxetine. Approximately one-third (n = 9; 31%) of children
were treated for depression with non-SSRl medications,
either singly or in combination with a SSRI medication,
including amitriptyline, venlafaxine, lamotrigine, gabapentin, valproate, quetiapine, and risperidone. Concurrent
stimulant medication was prescribed for ADHD manage­
ment for 6 children (Table 4). In total, nearly half
(n = 13; 45%) of the children with MDD were taking 2
or more medications; 6 children (21%) were prescribed
at least 3 medications after MDD diagnosis.
A nonpharmacologic treatment was undertaken in 19
cases (66%), most frequently in combination with medica­
tion (Table 4). Cognitive behavioral therapy was the most
common psychotherapy initiated (n = 12; 41%). Noncognitive behavioral therapy psychotherapies that were
used included family therapy (n = 7; 24%) and individual
therapy (n = 6; 21%). Children with MDD were also
treated with nutrition and/or exercise (n = 6; 21%) or other
Table 4. Management Strategies Used in 29 Children With Very
Early Onset Major Depressive Disorder
Treatment
n (%)
Medication only
Therapy only
Combination
No treatment
Medication
Fluoxetine
Nonfluoxetine SSRI
Non-SSRl
Concurrent stimulant
> 2 medications
> 3 medications
Therapy
CBT
Individual (non-CBT) therapy
Family therapy
Nutrition or exercise therapy
Other
> 2 therapies
> 3 therapies
6(21)
2(7)
17(59)
4(14)
13 (45)
7(24)
9(31)
6(21)
13(45)
6(21)
12(41)
6(21)
7(24)
6(21)
5(17)
12(41)
8(28)
SSRI indicates selective serotonin reuptake inhibitor; CBT, cogni­
tive behavioral therapy.
Academic Pediatrics
V ery Early O nset MDD
therapies including art, play, and biblio therapies and natu­
ropathic treatment. Children were commonly treated with
2 (n = 12; 41%) or 3 (n = 8; 28%) therapeutic modalities
(Table 4).
D is c u s s io n
Previous population-based studies have shown that age
at onset is a risk factor for increased MDD severity. This
compels a need for further research into the clinical picture
of children with early-onset depression. The current study
suggests that children with physician-identified VEOMDD experience long-standing symptom presence, co­
morbidity, and high levels of functional impairment before
presentation: it also suggests that management approaches
for children with VEO-MDD include polypharmacy, poly­
therapy, and engage several medical, psychosocial, and
school-based care providers.
Among children with VEO-MDD, parental mental
illness, particularly maternal mood and anxiety disorders,
was present at very high rates. This finding is consistent
with epidemiologic studies that have reported that the pres­
ence of a first-degree relative with depression is associated
with an earlier onset of illness and a more familial subtype
of the disorder.3,6,27 In this study, once a child was
identified with VEO-MDD, he or she was treated with
several concomitant interventions, both pharmacologic
and psychotherapeutic. For a small number of children
with VEO-MDD, management strategies included treat­
ments that have been shown to be nonefficacious for child­
hood depression.28-30
Despite the methodologic strengths of the study,
including use of an established national pediatric research
network with demonstrated success in reporting on phys­
ical and mental health conditions, high rates of participant
engagement and response rates, and prospective, monthly
survey administration, we identified only 29 cases during
3 years of active surveillance of 2500 pediatricians. This
is in contrast to 2 community-based surveys of parentreported depression in this age group where 1.1% of
Australian children12 and 1.7% of children in the United
States13 were identified by their parents as being depressed.
There are several possible explanations for the small num­
ber of cases detected. First, we required physician verifica­
tion of the diagnosis of VEO-MDD against a case
definition based on DSM-IV-TR criteria—a much more
specific assessment than one based on parental report of
symptoms or diagnoses. Second, children with depressive
symptoms may not seek care from a physician for medical
assistance. For example, several Canadian provinces offer
provincially funded, community-based child and family
psychosocial services (eg, parenting workshops, social
skills groups) ;hat are easily accessible. Thus, families of
children with depressive symptoms may initially be
directed to these nonmedical community centers for assistance. Alternatively, families of a depressed child may
delay seeking help because of parental symptoms of
depression or experience with treatment, or because of
misattribution of insidious depressive symptom onset to
195
an evolving child personality. Latency to treatment has
been reported to increase as age of depression onset de­
creases, with epidemiologic samples of depressed adults
reporting the longest time between symptom onset and
depression treatment for preadolescent onset of illness
(mean 12.9 years) compared to adolescent- or adult-onset
illness (6.3 and 2.4 years, respectively).3 Thus, despite
experiencing depressive symptoms, children with VEOMDD may not present for medical attention during the
age period included in this study. Delay of treatment and
resultant chronicity of depressive symptoms may be of
particular salience during childhood and adolescence, dur­
ing which time depressive symptoms may interfere with
key interpersonal and self-evaluative developmental tasks.
Failure to successfully accomplish these tasks may result in
subsequent impairment in the quality of friendships, inti­
mate relationships, and occupational achievement, as evi­
denced by the increased prevalence of personality
disorders among adults with early-onset depression3,4
and attesting to the lifelong pervasive difficulties faced in
these domains. Lengthy treatment delay has also been
associated with poorer outcomes in other psychiatric
illnesses and is associated with patient attitude,32 early
age at onset,33 insidious disease onset,34 and initial help­
seeking contact with a nonmedical professional.33
Third, it is also possible that children with depression
bypass the pediatricians’ office entirely, seeking care
initially from the family physician and either receiving
treatment in that setting or proceeding directly to specialist
care. Although pediatricians in a few urban centers across
Canada provide primary care for children, many pediatri­
cians in Canada function as consultants, serving as a
resource for family physicians, caring for children with
chronic illnesses or complex presentations, and acting as
gatekeepers for other specialty and subspecialty services.24
Thus, although it is possible that potential VEO-MDD
cases may have bypassed the pediatrician’s office in favor
of direct subspecialist (child psychiatry) consultation in
large urban centers with greater access to child psychia­
trists, it is unlikely to have occurred for the majority of
affected children, where pediatricians are generally consid­
ered the first line for consultation. 16 Fourth, for those chil­
dren who do seek care from their pediatrician, a diagnosis
of depression may not have been reported or considered.
The presence of comorbid conditions or psychosocial
stressors in the child or family may lead to underapprecia­
tion of depressive symptoms in this age group by the parent
or pediatrician and may obscure the identification of MDD.
Alternatively, pediatricians may recognize depressive
symptoms but may be hesitant to make a diagnosis of
depression in a preadolescent child. Research examining
pediatricians’ perspectives has repeatedly shown mental
health to be an area in which pediatricians feel less than
adequately trained and less confident in their knowledge
and skills compared to other content areas,36-39 leading
to the development of mental-health tool kits and resources
aimed specifically at assisting pediatricians in the identifi­
cation and initial management of children with psychiatric
disorders.40,41 Fifth, pediatricians in this study were not
196
KORCZAK ET AL
screening children for depression using a standardized
approach but rather were asked to report cases in this age
group on the basis of clinical assessment and using the
DSM-IV-TR-based definition of MDE for reference. In
contrast with recommendations for adolescents aged 12
years and older, for whom screening for depression has
been recommended by the US Preventive Services Task
Force (USPSTF),42 the USPSTF has concluded that a
lack of sufficient evidence is available to make depression
screening recommendations for children younger than 12
years old. In Canada, the Canadian Task Force on Preven­
tive Health Care has recommended against routine
screening for depression among adults 18 years of age
and older and has not published recommendations
regarding depression screening for children and adoles­
cents. It is possible that the relative absence of a culture
of routine depression screening in Canada, compared to
that of the United States, may also have contributed to
the small number of cases identified. Routine use of vali­
dated screening measures for depression is likely to have
led to an increased number of VEO-MDD cases reported
in this study. However, their use may have also led to
greater inaccuracies in case identification, as recently sug­
gested by a systematic review of the use of depression
screening tools in childhood.43 In contrast to the uncertain
role of routine depression screening for children in this age
group, however, the use of validated screening tools for
case finding may be helpful in the comprehensive assess­
ment of children in which the clinician suspects an under­
lying M DD." The use of depression screening measures
for case finding may also have led to an increased number
of VEO-MDD cases reported in our study.
Finally, current diagnostic criteria may not adequately
capture the clinical presentation of MDD in younger chil­
dren Children identified as having MDD in the present
study experienced severe and long-standing symptoms
and considerable functional impairment, suggesting either
the potential presence of diagnostic hesitation or the use of
a high diagnostic threshold. In this respect, our findings are
cons.stent with those previously reported by Luby et al,15
who noted that DSM-defined MDD identified only the
most severely depressed preschool-age children. The re­
sults of the present study are also consistent with those re­
ported in a large sample of children and adolescents in
child psychiatry subspecialty clinics in Hungary,19 in that
the atypical neurovegetative symptoms commonly experi­
enced among depressed adolescents (eg, hypersomnia, hyperphagia, weight gain, psychomotor retardation) were
less frequently reported among depressed younger chil­
dren. Rather, insomnia, weight loss, and psychomotor
agitation were more common among younger children,
as in our study. Also consistent with prior research,19 chil­
dren with VEO-MDD in our study commonly reported so­
matic complaints and either increased or new-onset anxiety
symptoms, although neither is included in the diagnostic
criteria for depression. It is therefore possible that current
DSM-based diagnostic criteria have inadequate content
validity in that they do not accurately capture the pheno­
typic presentation of preadolescent depressive illness. To
A c a d e m ic
p e d ia t r ic s
note, diagnostic criteria for MDE/MDD did not undergo
significant revision in DSM-5.44 As such, it is unlikely
that applying DSM-5 criteria to our study would have
altered our findings.
Conclusions
We report on the results of a national pediatric surveil­
lance study that elucidated the clinical features and treat­
ment of incident cases of DSM-defined MDD in
preadolescent children reported by pediatricians in Canada
over the 3-year study period. Children with MDD experi­
enced prolonged duration of symptoms, considerable func­
tional impairment, and required intensive management
programs delivered by multiple service providers. Future
research should focus on more accurately determining
the clinical phenotype of emerging depressive illness in
preadolescent children in order to facilitate improved
parent education regarding the early symptoms of MDD.
greater physician recognition and opportunities for inter­
vention among high-risk groups, and to better inform diag­
nostic criteria for this age group. There is also a need for
population-based epidemiologic surveys of mood symp­
toms in preadolescent children that include diagnostic veri­
fication of suspected cases using DSM-5 criteria.
Acknowledgments
This study was supported by the Public Health Agency of Canada and
the Canadian Paediatric Society. The funding source had no involvement
in the collection of the data, analyses, or interpretation. The authors grate­
fully acknowledge the participating Canadian pediatricians. They also
thank M. Laffin and Dr C. Moore for their reviews. This study was based
on information gathered through the CPSP. The views, opinions, and/or
conclusions expressed by the authors are their own and do not necessarily
reflect the views, opinions, and/or conclusions of the Canadian Paediatric
Society, the Public Health Agency of Canada, or the CPSP.
Supplementary Data
Supplementary data related to this article can be found at
http://dx.doi.Org/10.1016/j.acap.2016.10.011.
References
1. Costello EJ, Egger H, Angold A. 10-year research update review: the
epidemiology of child and adolescent psychiatric disorders: I.
Methods and public health burden. J Am Acad Child Adolesc Psychi­
atry. 2005;44:972-986.
2. Costello JE, Erkanli A, Angold A. Is there an epidemic of child or
adolescent depression? J Child Psychol Psychiatry. 2006;47:
1263-1271.
3. Korczak DJ, Goldstein BI. Childhood onset major depressive disor­
der: course of illness and psychiatric comorbidity in a community
sample. J Pediatr. 2009; 155:1 18-123.
4. Zisook S, Lesser I, Stewart JW, et al. Effect of age at onset on the
course of major depressive disorder. Am J Psychiatry. 2007;164:
1539-1546.
5. Klein DN. Schatzberg AF, McCullough JP, et al. Age of onset in
chronic major depression: relation to demographic and clinical vari­
ables, family history, and treatment response. J Affect Dis. 1999;55:
149-157.
6. Zisook S, Rush AJ, Lesser I, et al. Preadult onset vs adult onset of ma­
jor depressive disorder: a replication study. Acta Psychiatr Scand.
2007;115:196-205.
A cademic Pediatrics
7. Markkula N, Harkanen T, Perala J, et al. Mortality in people with
depressive, anxiety and alcohol use disorders in Finland. B rJ Psychi­
atry. 2012;200:143-149.
8. Osby U, Brandt L, Correia N, et al. Excess mortality in bipolar and
unipolar disorder in Sweden. Arch Gen Psychiatry. 2001 ;58:844-850.
9. Kessler RC. The costs of depression. Psychiatr Clin North Am. 2012;
35:1-14.
10. Rao U, Ryan ND, Birmaher B, et al. Unipolar depression in adoles­
cents: clinical outcome in adulthood. J Am Acad Child Adolesc Psy­
chiatry. 1995;34:566-578.
11. Birmaher B, Brent D, Bemet W, et al. Practice parameter for the
assessment and treatment of children and adolescents with depressive
disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:1503-1526.
12. Lawrence D, Johnson S, Hafekost J. et al. The Mental Health o f Chil­
dren and Adolescents: Report on the Second Australian Child and
Adolescent Survey o f Mental Health and Wellbeing. Canberra:
Department o f Health. Available at: https://www.health.gov.
au/intemet/main/publishing.nsf/Content/9DA8CA21306FE6EDCA
257E27000I6945/$File/child2.pdf; 2015. Accessed October 31,
2016.
13. Perou R, Bitsko RH, Blumberg SJ, et al. Mental health surveillance
among children— United States, 2005-2011. MMWR Suppl. 2013;
62:1-35.
14. Fleming JE, Offord DR. Epidemiology of childhood depressive disor­
ders: a critical review. J Am Acad Child Adolesc Psychiatry. 1990;29:
571-580.
15. Luby JL, Mrakotsky C, Heffelfinger A, et al. Modification of DSM-IV
criteria for depressed preschool children. Am J Psychiatry. 2003; 160:
1169-1172.
16. Mitchell J, McCauley E, Burke PM, et al. Phenomenology of depres­
sion in children and adolescents. J Am Acad Child Adolesc Psychiatry.
1988;27:12-20.
17. Ryan ND, Puig-Antich J. Ambrosini P, et al. The clinical picture of
major depression in children and adolescents. Arch Gen Psychiatry.
1987;44:854-861.
18. Yorbik O, Birmaher B, Axelson D, et al. Clinical characteristics of
depressive symptoms in children and adolescents with major depres­
sive disorder. J Clin Psychiatry. 2004;65:1654-1659.
19. Baji I, Lopez-Duran NL, Kovacs M, et al. Age and sex analyses of so­
matic complaints and symptom presentation of childhood depression
in a Hungarian clinical sample. J Clin Psychiatry. 2009;70:
1467-1472.
20. Boyle MH, Offord DR, Hofmann HG, et al. Ontario Child Health
Study. I. Methodology. Arch Gen Psychiatry. 1987;44:826-831.
21. Statistics Canada. National Longitudinal Survey o f Children and
Youth (NLSCY): cycles 1-8. Longitudinal Survey Data, 2010.
Available at: http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=
getInstanceList&Id=56797. Accessed November 28, 2015.
22. Grenier D, Doherty J, Macdonald D. Canadian Paediatric Surveil­
lance Program evaluation: an excellent report card. Paediatr Child
Health. 2004;9:379-384.
23. American Psychiatric Association. Diagnostic and Statistical Manual
o f Mental Disorders. 4th ed. Washington, DC: American Psychiatric
Association; 1994.
24. Gauthier M, Isserman RM, Wilson I. Paediatric Human Resource
Planning Committee; Canadian Paediatric Society. A model of paedi­
atrics: rethinking health care for children and youth. Paediatr Child
Health. 2009;14:319-325.
25. Nsubuga P, White ME, Thacker SB, et al. Public health surveillance: a
tool for targeting and monitoring interventions. In: Jamison DT,
Brernan JG, Measham AR, eds. Disease Control Priorities in Devel­
oping Countries. 2nd ed. New York, NY: Oxford University Press;
2006.
V ery Early O nset MDD
197
26. Canadian Paediatric Society. Canadian Paediatric Surveillance Pro­
gram. Available at: http://www.cps.ca/English/surveillance/CPSP/
index.htm. Accessed September 15, 2015.
27. Kovacs M, Devlin B, Pollock M, et al. A controlled family history
study of childhood-onset depressive disorder. Arch Gen Psychiatry.
1997;54:613-623.
28. Berard R, Fong R, Carpenter DJ, et al. An international, multicenter,
placebo-controlled trial of paroxetine in adolescents with major
depressive disorder. J Child Adolesc Psychopharmacol. 2006; 16:
59-75.
29. Emslie GJ, Wagner KD, Kutcher S, et al. Paroxetine treatment in chil­
dren and adolescents with major depressive disorder: a randomized,
multicenter, double-blind, placebo-controlled trial. J Am Acad Child
Adolesc Psychiatry. 2006;45:709-719.
30. Hazel! P, Mirzaie M. Tricyclic drugs for depression in children and
adolescents. Cochrane Database Syst Rev. 2013;CD002317.
31. Cheung AH, Dewa CS. Mental health service use among adolescents
and young adults with major depressive disorder and suicidality. Can
J Psychiatry. 2007;52:228-232.
32. de Haan L, Peters B, Dingemans P, et al. Attitudes of patients toward
the first psychotic episode and the start of treatment. Schizophr Bull.
2002;28:431-442.
33. Bechard-Evans L, Schmitz N, Abadi S, et al. Determinants of help­
seeking and system related components of delay in the treatment of
first-episode psychosis. Schizophr Res. 2007;96:206-214.
34. Morgan C, Abdul-Al R, Lappin JM, et al. Clinical and social determi­
nants of duration of untreated psychosis in the AESOP first-episode
psychosis study. Br J Psychiatry. 2006;189:446-452.
35. Costello EJ, Bums BJ, Costello AJ, et al. Service utilization and psy­
chiatric diagnosis in pediatric primary care: the role of the gatekeeper.
Pediatrics. 1988;82(3 pt 2):435^141.
36. Lieberman L. Hilliard RI. How well do paediatric residency pro­
grammes prepare residents for clinical practice and their future ca­
reers? Med Educ. 2006;40:539-546.
37. Macnab A, Martin J, Duffy D, et al. Measurement of how well a pae­
diatric training programme prepares graduates for their chosen career
paths. Med Educ. 1998;32:362-366.
38. Committee on Psychosocial Aspects of Child and Family Health and
Task Force on Mental Health. Policy statement—The future of pedi­
atrics: mental health competencies for pediatric primary care. Pediat­
rics. 2009;124:410-421.
39. Green C, Hampton E, Ward MJ, et al. The current and ideal state of
mental health training: pediatric program director perspectives.
Acad Pediatr. 2014;14:526-532.
40. Spenser H, Ritchie B, Kondra P, et al. Collaborative mental health in
Canada. Child and Youth Mental Health Toolkits: Mood Disorders.
Available at: http://www.shared-care.ca/page.aspx?menu=65&
app=250& catl=610& tp=2& lk=no. Accessed August 10, 2016.
41. Canadian Paediatric Society; Mental Health and Developmental Dis­
abilities Committee. Mental Health: Screening Tools and Rating
Scales. Available at: http://www.cps.ca/tools-outils/mental-healthscreening-tools-and-rating-scales; 2015. Accessed August 10, 2016.
42. Siu AL. Screening for depression in children and adolescents: US Pre­
ventive Services Task Force recommendation statement. Ann Intern
Med. 2016;164:360-366.
43. Roseman M, Kloda LA, Saadat N, et al. Accurary of depression
screening tools to detect major depression in children and adoles­
cents: a systematic review. Can J Psychiatry In press.
44. American Psychiatric Association. Diagnostic and Statistical Manual
o f Mental Disorders. 5th ed. Washington DC: American Psychiatric
Association; 2013.
©2017 Elsevier