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Title: Depression: A Brief Overview of the Disorder in Childhood


1
Depression A Brief Overview of the Disorder in
Childhood
  • James H. Johnson, Ph.D., ABPP
  • University of Florida

2
Case Examples (NYU Child Study Center)
  • Alex, l0-years-old, lives with his mother and
    grandmother. His parents separated when he was
    six. Alex's teacher reports that he is in danger
    of failing, that he becomes preoccupied, often
    staring out the window, and seldom finishes his
    work. Alex has stated that the other children in
    the class are much smarter than he is. He seldom
    attends Boy Scout meetings or plays baseball,
    which he used to enjoy. When he gets home each
    afternoon, he watches television and eats all the
    cookies he can find. He usually telephones his
    mother to make sure she's all right and then goes
    to bed until his mother comes home. "I don't have
    any reason to stay up nothing good is going to
    happen," he said.

3
Case Examples (NYU Child Study Center)
  • Cheryl usually went to school and to her
    part-time job, and then came home and played with
    her cats, rather than go out with her two best
    friends, as she used to. Looking back, her mother
    realized that Cheryl hadn't gone to the movies or
    shopping for the past month and seemed to have
    lost weight. Then her mother found a bottle of
    sleeping pills on Cheryl's dresser.

4
Childhood DepressionHistory
  • Prior to the late 1970's the inclusion of a
    discussion of childhood depression in a course
    like this one would have been a rarity.
  • Many clinicians at that time seriously questioned
    whether children were even capable of exhibiting
    depressive disorders.
  • This notion was heavily influenced by the
    psychoanalytic view that, prior to adolescence,
    children lack the degree of superego development
    necessary to have true depressive disorders.

5
History
  • Despite this view, clinical experience and early
    descriptive studies suggested that children did
    in fact show features like those seen in
    depressed adults.
  • depressed mood,
  • loss of interest in activities,
  • problems in eating and sleeping,
  • feelings of helplessness and hopelessness.
  • Nevertheless, controversy continued into the
    1980s regarding whether these features were best
    characterized as
  • a prevailing mood state,
  • a syndrome (with a specific set of symptoms), or
  • a true psychological disorder (with specific
    etiology, course, and outcome)

6
Acceptance of Depression as a Child Disorder
  • Research during the last two and one-half decades
    has clearly suggested that children and
    adolescents often display evidence of
    psychopathology where depression is the most
    prominent feature.
  • It is now accepted that the depressive features
    displayed by children/adolescents are often
    consistent with DSM IV criteria for Major
    Depressive Disorder.

7
Continuity of Child and Adult Depression
  • There is good evidence of continuity between
    adolescent depression and adult depression.
  • Depressed adolescents are high risk for MDD in
    adulthood (Klein, et al 2005).
  • This link is not as strong with child depression.
  • Higher rates of MDD are found in the families of
    both children and adolescents with depression.

8
Child Depression Lite
  • As childhood depression represents a significant
    problem for many children and adolescents, it
    seems important to consider it along with other
    childhood disorders.
  • However, given time limitations, and the fact
    that depressive disorders are covered in the
    adult portion of this course, only a cursory
    overview will be provided here.
  • This can be supplemented by the readings found in
    the syllabus.

9
DSM IV CRITERIA Major Depressive Episode
  • A. Five (or more) of the following symptoms are
    present during the same 2-week period and
    represent a change from previous functioning
  • At least one symptom is (1) depressed mood or (2)
    loss of interest or pleasure .
  • (1) depressed mood - most of the day, nearly
    every day, as indicated by subjective report or
    observation by others. - In children and
    adolescents, can be irritable mood.
  • (2) Diminished interest or pleasure in all, or
    almost all, activities - most of the day, nearly
    every day (as indicated by subjective account or
    observation made by others)

10
Major Depressive Episode
  • (3) significant weight loss when not dieting or
    weight gain (e.g., a change of more than 5 of
    body weight in a month), or decrease or increase
    in appetite nearly every day. Note In children,
    consider failure to make expected weight gains.
  • (4) insomnia or hypersomnia nearly every day
  • (5) psychomotor agitation or retardation nearly
    every day (observable by others, not merely
    subjective feelings of restlessness or being
    slowed down).
  • (6) fatigue or loss of energy nearly every day

11
Major Depressive Episode
  • (7) feelings of worthlessness or excessive or
    inappropriate guilt nearly every day
  • (8) diminished ability to think or concentrate,
    or indecisiveness, nearly every day (either by
    subjective account or as observed by others)
  • (9) recurrent thoughts of death (not just fear of
    dying), recurrent suicidal ideation without a
    specific plan, a suicide attempt or a specific
    plan for committing suicide

12
Major Depressive Episode
  • B. Symptoms do not meet criteria for a Mixed
    Episode.
  • C. Symptoms cause significant distress or
    impairment in social, occupational, or other
    important areas of functioning.
  • D. Symptoms are not due to the direct effects of
    a substance (e.g., a drug of abuse, a medication)
    or a general medical condition (e.g.,
    hypothyroidism).

13
Major Depressive Episode
  • E. Symptoms are not accounted for by Bereavement
    the symptoms persist for longer than 2 months or
    are characterized by marked functional
    impairment, morbid preoccupation with
    worthlessness, suicidal ideation, psychotic
    symptoms, or psychomotor retardation.

14
Major Depressive Disorder
  • A.  Presence of single or recurrent Major
    Depressive Episode(s)
  • B. The Major Depressive Episode(s) is (are) not
    better accounted for by Schizoaffective Disorder
    and is not superimposed on Schizophrenia,
    Schizophreniform Disorder, Delusional Disorder,
    or Psychotic Disorder Not Otherwise Specified.
  • C. There has never been a Manic Episode, a Mixed
    Episode, or a Hypomanic Episode.

15
Anxiety Versus Depression
  • Before focusing on child depression is important
    to comment on differences between child anxiety
    and depression.
  • Often difficult to distinguish as both result in
    distress
  • Indeed prior factor analytic studies have often
    failed to find define independent factors related
    to these symptoms.
  • This may be especially difficult with relatively
    young patients

16
Anxiety Versus Depression
  • May be useful to consider a tripartite model by
    highlighting the three distinctive and
    overlapping features of anxiety and depression
    (Clark Watson, 1991, Lonigan, et al, 2003).
  • General distress
  • Anhedonia
  • Physiological hyperarousal

17
Anxiety Versus Depression
  • Depression and anxiety are both characterized by
    a high level of distress
  • Depression is uniquely related to anhedonia
  • Anxiety is more associated with high
    physiological hyperarousal
  • The distinction between anxiety depression can
    thus be enhanced by emphasizing the dimensions
    that separate the two conditions anhedonia and
    hyperarousal (Klein, et al 2005)

18
Childhood DepressionPrevalence
  • Prevalence estimates vary depending on the
    criteria employed in making the diagnosis.
  • This relationship is nicely illustrated by the
    results of an early study by Carson and Cantwell
    (1980).
  • In a random sample of 210 child inpatient cases,
    seen at the UCLA Neuropsychiatric Institute,
    these researchers found that
  • 60 per cent displayed depressive "symptoms" at
    intake
  • 49 per-cent were judged depressed, based on
    scores on a depression inventory,
  • 28 per-cent met DSM III criteria for Major
    Depressive Disorder

19
Prevalence
  • The earliest findings using DSM III criteria
    suggested a general population rate of 2
    (Kashani and Simonds, l981).
  • More recent, findings have a suggested MDD 6
    month prevalence rate to be 13 for school age
    children 5 to 6 for adolescents.
  • Adolescent lifetime prevalence rates may be as
    high as 15 20 (Klein, et al, 2005)
  • The prevalence of Dysthymic Disorder has been
    found to be as high as 8 in adolescents.
  • Male to female sex ratio is approximately 1-1 for
    children 1-2 for adolescents.

20
Comorbidity
  • Findings suggest most comorbidity with Dysthymia,
    Anxiety Disorders, ODD/CD, and ADHD (Nottelmann
    and Jensen (1995).
  • Dysthymia 30 80
  • Anxiety Disorder 30 to 80.
  • CD/ODD 42
  • ADHD 47.9 to 57.1
  • Lewinsohn, et al (1991) assessed the lifetime
    probability of having some psychiatric disorder
    other than depression in adolescents with MDD,
    Dysthymic Disorder, or both.
  • Probability estimates for these groups were .42
    (MDD), .38 (Dysthymic), and .61 (Both),
    respectively.
  • The majority of children with MDD or DD have some
    type of comorbidity (Klein, et al 2005).

21
Prognosis Initial Recovery
  • There is less known about the prognosis of child
    depression than in the case of depression with
    adults.
  • Here, outcome must be evaluated both with regard
    to the likelihood of recovery from the index
    episode of the disorder and the risk of
    recurrence.
  • Regarding initial recovery, Kovacs, et al.
    (1984a), have found that the probability of
    recovery from a major depressive episode in
    children/adolescents is 74 after one year and
    92 two years post onset.
  • Strober, et al (1992) found 92 of their
    adolescent inpatients with major depression to
    have recovered after two years.

22
Prognosis Recurrence
  • Findings related to the probability of later
    recurrence are less encouraging.
  • Here, Kovacs et al., found approximately 70 of
    children with major depression to a recurrence
    within five years.
  • Although most children and adolescents with major
    depressive disorder will recover to a significant
    degree, most of these will experience subsequent
    episodes of significant depression.
  • The long term prognosis is less than favorable.

23
Etiology Conceptual Models of Depression
  • Psychoanalytic Perspectives
  • The Role of Life Stress in Childhood Depression
  • Behavioral and Cognitive Behavioral Views
  • Biological Perspectives

24
Psychoanalytic Views
  • No one psychoanalytic position regarding the
    development of depressive disorders.
  • Psychoanalytic perspective have, however,
    generally tended to highlight the role of object
    loss.
  • The loss may be real, as in the loss of a parent
    through death, divorce, or separation or may be
    more symbolic, as in the withdrawal of attention,
    support, or approval by parents (e.g. 17 year old
    female custody hearing).

25
Psychoanalytic Views
  • Depression occurs as a result of an individual
    (who has suffered loss) identifying with the
    lost love object.
  • Because the individual is likely to have
    ambivalent feelings toward the lost object he or
    she may turn the feelings of hostility against
    the self and thus experience depression.
  • This type of reaction to loss is thought to occur
    in persons who are fixated at the oral stage of
    psychosexual development, who are overly
    dependent, and who subsequently experience a
    significant loss.

26
Psychoanalytic Views
  • Psychoanalytic views most often invoked to
    account for adult depression.
  • Little empirical data on their relevance to
    childhood depression, although psychoanalytic
    approaches to therapy for depression are used to
    treat depression by some clinicians

27
The Role of Life Stress
  • A number of studies have suggested that
    depression may result, in part, from the
    experiencing of major life changes
  • The focus here is usually on negative events such
    as separation, divorce, and death in the family.
  • Research by Johnson and McCutcheon (1980) ,
    Siegel (1981), (Compas, Grant, Ey (1994) and
    many others have documented significant
    relationships between cumulative negative life
    changes experienced by children and depression.
  • This relationship may be moderated by other
    variables (Johnson Sarason, 1978)
  • Cohen-Sandler, et al (1982) have likewise
    provided data suggestive of a relationship
    between lifetime life stress levels and suicidal
    behavior in children.

28
Specific Life Stressors
  • Other studies have documented relationships
    between specific stressors such as child abuse
    and neglect and the development of depression
    (Downey, Feldman, Khuri Friedman, 1994).
  • Research has also found relationships between
    stressful family circumstances (e.g., marital
    conflict, divorce, problems in parent-child
    relationships, maternal rejection) and childhood
    depression (Kaslow Racusin, 1994).
  • Taken together, such findings are compelling in
    providing support for the view that life
    stressors are indeed associated with childhood
    depression.

29
Cognitive/Behavioral Views
  • Beck (1974) has been among the more prominent
    individuals who has highlighted the role of
    cognitive factors in the development of
    depression.
  • Here, depression is seen as being related to the
    way individuals perceive events in their
    environment.
  • It is assumed that the depressed individual, as a
    result of his/her learning history, displays
    cognitive distortions or cognitive schematas that
    contribute to a negative view of the self, the
    world, and the future.
  • These views are, in turn, seen as contributing to
    feelings of self-blame, failure, and hopelessness
    which impact on mood and other behaviors
    associated with depression.

30
Examples of Cognitive Distortions
  • Filtering
  • Looking at only 1 element, tunnel vision,
    selective memory for negative events
  • Catastrophizing
  • What if Statements, Assuming the worst
  • Polarized Thinking
  • Black/white, either/or thinking - no room for
    mediocrity
  • Mind Reading
  • Snap judgments assumptions about what others are
    thinking, feeling, what motivates them, how
    reacting to you, projecting

31
Cognitive/Behavioral Views
  • Other cognitive views include Rehm's (1977)
    self-control model of depression which involves a
    blending of cognitive operant views of
    behavior.
  • Depression is seen as being related to
    cognitive-behavioral deficits in the areas of
    self-monitoring, self-evaluation, and
    self-reinforcement.
  • Thus, depression is thought to result from
  • the tendency to attend to negative rather than
    positive events (self-monitoring),
  • the tendency to consistently attribute failure to
    one's self rather than other factors
    (self-evaluation), and/or
  • the displaying of low levels of
    self-reinforcement or, alternately, high rates of
    self-punishment.

32
Behavioral Views
  • Several other behaviorally oriented views of
    depression have been proposed.
  • Here, early views of Ferster (1974) and
    Lewinsohn (1974) suggest that manifestations of
    depression result from a lack of sufficient
    positive reinforcement in the environment.
  • This lack of reinforcement can be caused by
    factors ranging from a change in residence (loss
    of social supports) to a failure to display
    appropriate social skills that decrease the
    likelihood of positive reinforcement.

33
Learned Helplessness and Depression
  • An additional perspective on depression, that
    focuses on the role of learning, has been
    presented by Seligman (Seligman, 1974 1975
    1978).
  • Here, depression is described in terms of learned
    helplessness.
  • This model suggests that depression develops in
    individuals who, as a result of their learning
    history, perceive themselves as having little or
    no control over rewards and punishments in their
    environment.

34
Learned Helplessness
  • Depression results from the individual's
    propensity to view negative events in their life
    as due to
  • Their own characteristics (internal attributions)
    Its all my fault, Im just not good with
    people, thats just who I am
  • Factors that are unlikely to change (attributions
    of stability) I keep getting fired because Im
    dumb
  • Factors that are likely to have an influence on
    the individual across situations (global
    attributions) Why bother trying to get another
    job the same thing will happen

35
Learned Helplessness
  • Abramson, et al (1989) have further highlighted
    the role of attributional style in the
    development of depression.
  • They suggest that attributions of the type just
    described (internal, stable, global), mediate the
    relationship between negative life events and
    depression (Johnson, Sarason Siegel, 1979
    LES, Locus of Control Depression).
  • Thus, hopelessness, which leads to depression, is
    seen as resulting from an interaction of life
    stress and problematic attributions regarding
    causes of these events.

36
Cognitive/Behavioral Views Child Research
Findings
  • While the views presented here were initially
    developed to account for adult rather than child
    depression, there has been some research designed
    to study the applicability of these views to
    childhood depression.
  • This child oriented research has provided some
    degree of support for many of the basic
    postulates inherent in cognitive and behavioral
    models.

37
Research Findings
  • Research has documented relationships between
    social skills deficits and both current and
    future levels of depression in children
    (consistent with Lewinsohn's model),
  • Child related research has found support for
    Beck's model in documenting relationships between
    childhood depression and indices of cognitive
    distortion.
  • Studies have also found support for a link
    between attributional styles and childhood
    depression that are consistent with the
    reformulated learned helplessness model.

38
Research Findings
  • Other studies have found links between child
    depression and
  • lowered expectations for performance,
  • more stringent standards for performance,
  • and tendencies to evaluate performance more
    negatively.
  • Such findings are supportive of Rehm's
    self-control model - that depressed individuals
    have deficits in self-monitoring, self-evaluation
    and self-reinforcement.
  • While many issues remain to be addressed,
    research appears to provide reasonable support
    for the important role of cognitive and
    behavioral factors in the development of
    childhood depression .

39
Biological Perspectives
  • Biological views of depression have focused
    primarily on the role of
  • Genetics, and
  • The role of biochemical abnormalities.
  • Of special note are biochemical abnormalities
    involving neurotransmitters (chemicals that
    facilitate the transmission of neural impulses).

40
Genetic Factors
  • A review of early twin studies, suggest
    concordance rates of 76 for affective disorders
    in monozygotic twins as compared to 19 in
    dizygotic twins (Kashani, et al., 1981).
  • The concordance rate was 67 for monozygotic
    twins reared apart.
  • More recent studies have provided similar
    findings.
  • Research has also suggested that
  • children with a depressed parent are
    approximately three times more likely to develop
    a major depressive disorder than are children
    with non-depressed parents.
  • However, environmental factors cant be ruled out.

41
Other Biological Findings
  • In addition to genetics, other studies (primarily
    with adults) have focused on the neurobiology of
    depression.
  • Here, studies have investigated the role of
    neurotransmitters (especially serotonin) and the
    role of neuroendocrine abnormalities (e.g. plasma
    cortisol concentrations growth hormone
    regulation secretion of thyroid-stimulating
    hormone) in depression.
  • Especially noteworthy are findings with adults
    that lowered serotonin levels appear to be
    related to both symptoms of depression and
    suicidal behavior.
  • Studies of these factors in children are needed.

42
Treatment of Childhood Depression
  • While there have historically been a number of
    approaches to the treatment of childhood and
    adolescent depression, there are three that
    presently appear to be empirically based.
  • Interpersonal Therapy (Empirically Supported)
  • Cognitive-Behavior Therapy (Probably Efficacious)
  • Psychotropic Medications (Probably Efficacious)

43
Interpersonal Therapy
  • For depressed teenagers, Interpersonal therapy
    (IPT) is a well-established treatment for
    depressed adolescents.
  • The focus of IPT is on helping older children
    and adolescents understand and address problems
    in their relationships with family members and
    friends that are assumed to contribute to
    depression.
  • This approach (which may contain some elements of
    CBT) involves what most of us think of when we
    hear the term psychotherapy as it is usually
    conducted in an individual therapy format, where
    the therapist works one-on-one with the
    child/adolescent and his or her family. 

44
Cognitive Behavior Therapy
  • As noted earlier, CBT is designed to change both
    maladaptive cognitions and behaviors.
  • During CBT, depressed children/adolescent learn
    about the nature of depression and how their mood
    is linked to both their thoughts and actions.
  • The focus is often on developing better
    communication, problem-solving, anger-management,
    social skills and modifying self-defeating
    attributions. 
  • CBT is probably the most well-studied treatment
    for children and adolescents with depression.
  • While controlled studies support its efficacy,
    there are fewer studies of effectiveness (Klein,
    et al, 2005) and high relapse rates suggest the
    need for ongoing treatment.

45
Psychotropic Medications
  • Research findings suggest that some medications
    can help relieve depressive symptoms in youth
    (especially in adolescents).
  • Those that appear to be most effective include
    selective serotonin reuptake inhibitors, or
    SSRIs).
  • clomipramine (Anafranil)
  • flouxetine (Prozac),
  • fluvoxamine (Luvox),
  • paroxetine (Paxil)
  • sertraline (Zoloft).

46
Psychotropic Medications
  • There are suggestions that response to SSRIs is
    on the order of 70 90.
  • While the response rate appears to be high,
    many only show a partial response.
  • Some studies with adolescents have suggested that
    only about 1/3 show full remission.
  • SSRIs are less lethal and seem to have fewer
    side effects than TCAs
  • There is, however, concern over a possible link
    between these medications and suicide.
  • http//www.nimh.nih.gov/research-funding/scientifi
    c-meetings/2005/assessing-suicidality-during-antid
    epressant-treatment/summary.shtml

47
Combination Therapies
  • NIMH Research on Treatment for Adolescents with
    Depression Study (TADS) Combination treatment
    most effective in adolescents with depression
    (March et al., 2004)
  • A clinical trial of 439 adolescents with major
    depression has found a combination of medication
    and psychotherapy to be the most effective
    treatment.
  • Funded by the NIH's National Institute of Mental
    Health (NIMH), the study compared
    cognitive-behavioral therapy (CBT) with
    fluoxetine (Prozac).
  • Prozac is currently the only antidepressant
    approved by the Food and Drug Administration for
    use in children and adolescents.

48
Treatment Final Comments
  • While medications can be of value, they do not
    negate the need for therapy to deal with many of
    the other issues that may have contributed to the
    childs depression.
  • Combined treatment seems best.
  • Fortunately there are empirically supported
    treatments for child/adolescent depression that
    can be used along with medication, when needed.
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