Clinical presentation, course, and outcome of childhood-onset dysthymic disorder (DD) in 55 school-age referrals were compared with a group of 60 youngsters whose first affective episode was major depressive disorder (MDD) in a prospective 3- to 12-year study at Psychiatric Departments of the University of Pittsburgh, Western Psychiatric Institute, University of California at San Diego, and Harvard Medical School. Dysthymic disorder was associated with earlier age at onset than MDD, similarly frequent symptoms of feeling unloved, friendless, irritability, anger, and self-deprecation, but relatively low rates of anhedonia (5% cf 70%), guilt (13% cf 30%), social withdrawal (8% cf 50%), impaired concentration (40% cf 67%), loss of appetite (5% cf 47%), insomnia (22% cf 62%), somatic complaints (36% cf 67%) and fatigue (22% cf 64%). Risk of affective disorders, including first-episode MDD (76%) and bipolar disorder (13%), was greater among dysthymic patients. After the first episode of MDD complicating DD, the clinical course of DD was similar to MDD in rates of recurrent major depression and bipolar disorder. In dysthymic children with subsequent MDD, the first episode of MDD is the “gateway” to recurrent affective illness. 
COMMENT. Pediatric neurologists are frequently faced with the differentiation of organic and psychiatric causes for behavioral and mood disorders and somatic complaints. The recognition of early onset childhood dysthymic disorder should permit prompt referral to colleagues specialized in child psychology and psychiatry. Early diagnosis and treatment of dysthymia may prevent the occurrence of major depressive disorders.
The distinctions between major depression without dysthymia, dysthymia without major depression, and double depression in 62 child psychiatry inpatients were evaluated at the Department of Psychology, State University of New York at Stony Brook. Externalizing disorders (oppositional defiant and conduct disorders) were present more often in the dysthymic group compared to the major depression and double depression groups, whereas major depression and double depression groups revealed higher rates of depressive symptoms. In contrast to the Pittsburgh report, this study found social functioning to be least impaired in children with major depression. 
The role of the Children’s Depression Rating Scale-Revised in assessing depression in children with sickle-cell anemia was evaluated at the University of South Alabama Children’s Medical Center, Mobile, AL. Excessive fatigue and physical complaints contributed to a high false-positive rate of depression on the standardized screening test, whereas the actual prevalence of depression in these children based on clinical interviews by a child psychiatrist was not increased.