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 Depression:History • 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 1980’s 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 moodor (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 orhypersomnia 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 bothcharacterized 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 Depression:Prevalence • 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 1–3 % 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 hopelessnesswhich 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) “It’s all my fault, I’m just not good with people, that’s just who I am” • Factors that are unlikely to change (attributions of stability) “I keep getting fired because I’m 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 can’t 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 it’s 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 SSRI’s). • clomipramine (Anafranil) • flouxetine (Prozac), • fluvoxamine (Luvox), • paroxetine (Paxil) • sertraline (Zoloft).

46. Psychotropic Medications • There are suggestions that response to SSRI’s 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. • SSRI’s are less lethal and seem to have fewer side effects than TCA’s • There is, however, concern over a possible link between these medications and suicide. http://www.nimh.nih.gov/research-funding/scientific-meetings/2005/assessing-suicidality-during-antidepressant-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 child’s depression. • Combined treatment seems best. • Fortunately there are empirically supported treatments for child/adolescent depression that can be used along with medication, when needed.