104 Chapter 10
they are probably the rule rather than the exception and they are not
simply due to co-existing anxiety.
Depressive equivalents
It has been suggested that many psychiatric disorders, ranging from
enuresis to behavioural disorders, are the childhood equivalents of adult
depression even if the children do not appear miserable. There is no good
evidence for this view, and children should not be diagnosed as depressed
in the absence of clear affective symptoms.
Epidemiology
The recent British national surveys cited in Chapter 3 found that around
0.2% of 5–10-year-olds were depressed, as were around 2% of 11–15-
year-olds. The rise in adolescence seems to be more closely linked to
pubertal status than to chronological age. Studies that rely primarily on
informants (parents and teachers) report lower rates of depression than
studies that rely primarily on the self-reports of children and adolescents.
The long-term significance of inner misery that is not apparent to parents
and teachers is still uncertain. The female preponderance seen in adult
depression is evident from middle or late adolescence. Before puberty, by
contrast, the sex ratio is equal or there may even be a male preponderance.
A link with social disadvantage has been suggested but the evidence is con-
tradictory. Over recent decades, the evidence suggests that the prevalence
of depression in children and adolescents has risen and the average age of
onset has fallen. These trends are probably real and not just a reflection of
improving recognition or less stringent diagnostic criteria.
Classification
Children and adolescents who have enough persistent symptoms of de-
pression to meet the criteria for a depressive episode can be assigned one
of several diagnoses, depending on how many episodes they have had
and whether they have also had any manic, hypomanic or mixed episodes
(see Chapter 11). Thus, an individual who has experienced two or more
major depressive episodes but no manic, hypomanic or mixed episodes
can be classified under DSM-IV as having ‘major depressive disorder,
recurrent’. Those with milder symptoms may meet the diagnostic criteria
for dysthymia or adjustment disorder with depressed mood. Dysthymia
involves chronic mild symptoms for at least one year (as opposed to the
two years stipulated for adults). An adjustment disorder can be diagnosed
if the symptoms occur shortly after an identifiable stressor (within one