Diagnosing depression in the young is no child’s play.

Among other requirements, it takes specialized skills, clinical practice, extended time and an understanding of the differences that separate the pediatric patient from his more developed counterpart - elements that in too many cases are sadly lacking, specialists say.

They advise parents who suspect serious trouble to make an appointment with their child’s doctor to rule out medical conditions - such as thyroid deficiency, mononucleosis, anemia or sleep disorders - that can cause depressive symptoms.

When physical causes have been eliminated, the child may be referred to a psychiatric specialist. However, these days, in a major - and to many mental-health experts troubling - shift, up to 75 percent of emotionally disturbed youngsters are seen in primary-care settings, where, studies suggest, an average visit has shrunk to 13 minutes.

‘Children really need a comprehensive evaluation, an accurate diagnosis and an individualized treatment plan ... you can’t (make a diagnosis) in a five-to-10-minute office visit,’ cautioned Dr. David Fassler, a trustee of the American Psychiatric Association who has researched and practiced child and adolescent psychiatry for more than two decades and written extensively on the topic.

‘You must understand the child, understand the developmental history, family history, medical history, how the child is doing in school, how he’s doing at home, how he spends time with the family and at home,’ he said.

It takes an expert to make the right call, and a specialized one at that, mental-health providers say.

‘People who aren’t used to dealing with (depressed children) can easily miss it; (even) people who treat depression in adulthood may not necessarily know how to evaluate a child,’ said Dr. Julio Licinio.

He is professor of psychiatry, behavioral sciences, medicine and endocrinology at the David Geffen School of Medicine at the University of California, Los Angeles; director of the UCLA Center for Pharmacogenomics and Clinical Pharmacology; author of ‘Biology of Depression: From Novel Insights to Therapeutic Strategies’ (Wiley, 2005) and researcher at the UCLA Neuropsychiatric Institute.

‘I can’t imagine people are being adequately treated because even experienced psychiatrists can miss depression in children, (and) there’s a great shortage of child experts,’ Licinio said. ‘There is a different way to ask questions of children than of adults and differences in what to look for.’

That’s one reason research of depression and other psychiatric disorders in the very young is in its infancy, say early-childhood investigators from the Washington University School of Medicine in St. Louis, who took a rare look into the mental health of 3-to-5-year-olds.

Only recently have researchers learned how to ask preschoolers about their feelings, the investigators said.

In their studies, they observed 174 tykes at play and used puppets to assess their emotions. Even at this normally fun-loving age, they surmised, depression can break in and rob life of its pleasures.

Anhedonia, as this joyless state is known to psychiatrists, is a defining symptom of the disorder in the not-ready-for-primary-school players, the infant and preschool researchers reported.

They said they found depressive symptoms in the tots followed in the footsteps of those seen in their elders, but their duration skipped all over the map in the naturally more volatile younger group. This observation needs further elucidation and elaboration, they wrote.

Using the interview and puppet technique that had helped them identify clinical depression in preschoolers for the first time, Dr. Joan Luby, associate professor of child psychiatry, and her colleagues said they subsequently detected signs of bipolar disorder in a small group of 3-to-6-year-olds.

The condition is characterized by wild mood swings that alternate between euphoria and despair.

In presenting their findings at an annual meeting of psychiatrists, the researchers noted diagnosing such young children presents extraordinary challenges.

The marks of mania - hyperactivity, irritability and distractibility - mimic not only those of attention-deficit / hyperactivity disorder but also of normal behaviors and emotions of this age group, they acknowledged.

The investigators defined three features they said set bipolar children apart from the rest: elation, grandiosity and hypersexuality. As an ‘extreme’ example of a manic preschooler, Luby cited the case of a little girl who thought she made the sun rise and set.

Concerned about seeing mental illness in children where there is none, critics contend such musings are nothing more than a normal part of a child’s creative imagination.

Distinguishing bipolar illness from ADHD, major depression and other disorders is critical because their treatments are not interchangeable and, in fact, could prove harmful if wrongly applied.

The Food and Drug Administration warns, for example, that use of ‘an antidepressant alone may increase the likelihood of precipitation of a mixed-manic episode in patients at risk for bipolar disorder.’

Thus, the regulatory agency advises, ‘prior to initiating treatment with an antidepressant, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder.’

Until recently, such screening was scarce among very young children, who, as a group, have not been considered serious candidates for mental illness, specialists say.

That notion has started to crumble, at least in psychiatric circles, under evidence piling up to the contrary, researchers say. For example, Duke University investigators say they detected adult-like rates of psychiatric disorders in preschoolers.

The researchers identified more than one mental illness in 11.3 percent of the 2-to-5-year-olds they studied, including ADHD in 3.3 percent and depression in 2 percent.

These tykes were singled out for their unusual sadness and irritability, negative play themes, poor sleeping and eating habits, lack of confidence and self-blame when things went wrong, the researchers said.

The team reported detecting disruptive disorders in 8.4 percent of the little ones, who refused to follow instructions or obey rules, were highly irritable, fought and lied, among other symptoms.

Another 9.5 percent was found to suffer from anxiety disorders that could take the form of special fears or difficulty in separating from parents, the researchers said.

As an evolutionary mechanism intended to avert danger, most infants develop a healthy degree of fear of strangers and of distress at being apart from mom and dad that culminate when the child is 9 months to 13 months old before starting to decline at about 30 months, research indicates.

Early developmental studies also show a perfectly natural arousal of apprehensions, most often of dogs and the dark, which peak between the ages of 2 and 6, affecting 62 percent of 3-year-olds.

Because these slippery symptoms can so easily slide across the line dividing appropriate and abnormal behavior, there has been little consensus on how to identify mental disorders at such a young age.

Child psychiatrist and Duke researcher Dr. Helen Egger said she hopes to bring increased uniformity and reliability to the task with the diagnostic tool she and colleagues developed specifically for this age group.

Most previous studies have relied on imprecise, open-ended measures which offer a yes/no ratings scale or symptom checklist that asks parents to subjectively judge whether, say, a temper tantrum, occurs ‘very often’ or ‘often,’ leading to ill-defined results, she said.

In contrast, the more narrowly focused Preschool Age Psychiatric Assessment pioneered by the Duke team focuses on such specifics as the exact number and nature of the fits, taking some of the guesswork out of what constitutes a disorder in the very young, Egger said.

‘We can look at behaviors across the population and see where the extremes fall, for example in terms of the frequency of temper tantrums,’ Egger said. ‘We can look at our data and set points empirically to determine how many temper tantrums are too many and to establish guidelines that everyone else can follow.’

The team reports observing, for example, that a child who hits, bites, kicks or breaks things during a tantrum is eight times more likely to have a disorder than one who has a less physically destructive fit.

‘We’ve got a pretty darn good screen ... to figure out who are the children we don’t need to worry about and who aren’t,’ Egger said.

Nailing that critical distinction can hammer home more accurate assessments of the prevalence and causes of psychiatric problems in preschoolers - two big question marks at the moment, researchers say.

‘Our current understanding of preschool psychopathology is rather like that of older child and adolescent psychiatry around 1970,’ Egger said. ‘Until recently, we’ve had no reliable or valid measures for diagnosing psychiatric disorders in very young children.’

‘Most studies have examined emotional and behavioral symptoms using checklists that ask, ‘Does your child have this a lot or a little?’ on a three-point scale, but you can’t make a diagnosis that way,’ she added.

Rather, their method uses a comprehensive, structured interview with clear criteria taken from the formal diagnostic manual, Egger said. A key consideration is whether the behavior impairs the child’s ability to function at home or school.

‘I know toddlers and preschoolers are hyperactive, impulsive and intensive,’ said Egger, mother of 3-year-old twin boys. ‘It is common for children to have two or three symptoms, but when you get clusters of six or more, and that applies to only a small percentage of children, they’re highly impaired already.’

The behavior becomes a burden not just for the child but also for the parents, Egger said, adding that 44 percent of the children found to have disorders had been suspended from preschool.

‘If your child gets kicked out of preschool, you might not be able to work and support your family,’ Egger said. ‘If the child is so disruptive, he can’t go out to dinner or church with you, that has a huge impact on the family.’

There is indication the symptoms can persist, and maybe worsen, over time in some 50 percent to 60 percent of youngsters, so the efforts to catch the problem early when it’s easier to manage and before it can cause significant damage have important implications for the future of children’s mental health, Egger said.

‘I can understand the concerns of those who think we’re pathologizing normal behavior, but for me as a practicing clinician who sees these deeply troubled children on a regular basis, I can only ask if young children have the same symptoms as older children and adults and if they’re impaired, why wouldn’t we recognize that as a disorder and want to alleviate their distress and their parents’ distress?’ she said.

She considers the Duke researchers’ work a critical first step to bringing some order to the chaos surrounding the identification and treatment of troubled tykes.

‘How can you have treatment studies when you don’t know what you’re treating?’ she said.

‘I see children who have had multiple consultations before they come to me, and I’ve seen preschoolers on the most incredible, appalling combinations of medications you can imagine,’ the child psychiatrist observed. ‘The lack of evidence, the lack of knowledge produces a lot of bad treatments.’