Depression in pediatric patients may present with either sad or irritable mood as its predominant symptom Unlike depressed adults, who tend to be consistently down or sad, depressed pediatric patients will often have moments in which they seem happy—often when they are engaged in a preferred activity Clinicians should not rule out depression based on these moments of what is referred to as mood reactivity Clinical Considerations Depression involves a pervasive sad or irritable mood, accompanied frequently by self-deprecation and suicidal ideation Depression also implies a change in functioning from an earlier state of relatively good adjustment The depressed child typically experiences a profound sense of helplessness, feeling unable to improve an unsatisfactory situation The prevalence of depression in children and adolescents is around 3% It is higher in children with anxiety and/or behavioral or significant medical problems Most children with depression present to the ED with other chief complaints (somatic symptoms, school or behavior problems); the ED clinicians must consider the possibility of depression in all children seen with recurrent or vague somatic complaints A large body of evidence suggests that a genetic predisposition exists for depression, particularly severe depression Depression manifests differently, depending on the stage of development In infancy, depression is usually the result of loss of important attachments and/or nurturance and is seen as a global interference of normal growth and physiologic functioning, including apathy, listlessness, staring, hypoactivity, poor feeding and weight loss, and increased susceptibility to infection In school-aged children key features include dysphoric mood, irritability, and self-deprecatory ideation Dysphoric mood is manifested by looking or feeling sad and forlorn, being moody and irritable, and crying easily Selfdeprecatory thoughts are reflected by low self-esteem, feelings of worthlessness, and suicidal ideation Depression in this age can also appear as other common symptoms, including multiple somatic complaints, school avoidance, or underachievement, including learning disabilities or ADHD, angry outbursts, runaway behavior, phobias, and fire setting