Childhood Depression

1. Childhood Depression Laura Williams September 27, 2005 PSY 4930

2. The History of Childhood Depression • Before 1970's childhood depression was rarely discussed • Many clinicians seriously questioned whether children were even capable of exhibiting depressive disorders • Psychoanalytic view = pre-adolescent children lack the degree of superego development necessary to have true depressive disorders • Children thought to be cognitively unsophisticated

3. History • Clinical experience and early descriptive studies suggested that children display: • depressed mood • loss of interest in activities • problems in eating and sleeping • feelings of helplessness and hopelessness • 1980’s: childhood depression best characterized as: • a prevailing mood state • a syndrome (with a specific set of symptoms) • a true psychological disorder (with specific etiology, course, and outcome)

4. Depression as a Child Disorder • Research during the last 20 years has clearly suggested that children 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

5. DSM IV CRITERIA: Major Depressive Episode • A. Five (or more) of the following present during same 2-week period and represent a change from previous functioning; at least one symptom is either (1) depressed moodor (2) loss of interest or pleasure.

6. Major Depressive Episode • depressed mood most of the day, nearly every day, as indicated by subjective report (e.g., feels sad or empty) or observation by others (e.g., appears tearful). - In children and adolescents, can be irritable mood • 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)

7. 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--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

8. Major Depressive Episode (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (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, or a suicide attempt or a specific plan for committing suicide

9. Major Depressive Episode • B. The symptoms do not meet criteria for a Mixed Episode. • C. The 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).

10. Major Depressive Episode • E. Symptoms are not accounted for by Bereavement; or 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

11. 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..

12. Major Depressive Disorder • Specify (for current or most recent episode):Severity/Psychotic/Remission Specifiers      Chronic      With Catatonic Features      With Atypical Features      With Postpartum Onset • Specify      Longitudinal Course Specifiers (With and Without Interepisode Recovery)       With Seasonal Pattern

13. Childhood Depression:Prevalence • Prevalence estimates vary depending on the criteria employed in making the diagnosis. • Carson and Cantwell (1980). • In a random sample of 210 child inpatient cases, these researchers found: • 60% displayed depressive "symptoms" at intake • 49% were judged depressed, based on scores on a depression inventory • 28% met DSM-III criteria for MDD

14. Prevalence • Kashani and Simonds (l981) suggested a general population rate of approximately 2 % based on DSM-III criteria • More recent findings place MDD prevalence figures at 2% for children and 4-8% for adolescents • The prevalence of Dysthymic Disorder has been found to be as high as 8% in adolescents. • Male to female sex ratio is 1:1 for children and 1:2 for adolescents

15. Comorbidity • (Nottelmann and Jensen (1995) • Dysthymia: 30 – 80% • Anxiety Disorder: 30% - 80%. • CD/ODD: 42% - 100% (in one study) • ADHD: 47.9% - 57.1% • Lewinsohn, et al (1991) assessed the lifetime probability of having a disorder other than depression in adolescents • with MDD: 42% • With Dysthymic Disorder: 38% • With both disorders: 61% • Overall, 40 – 90% have some type of comorbidity

16. Prognosis: Initial Recovery • There is less known about the prognosis of child depression than in the case with adult depression. • index episode of the disorder vs. risk ofrecurrence • Kovacs, et al. (1984) found that the probability of recovery from a major depressive episode in children/adolescents is: • 74% after one year • 92% two years post onset • Strober, et al (1992) found 92% of their adolescent inpatients with major depression to have recovered after two years

17. Prognosis: Recurrence • Kovacs et al., found that 70% of children with MDD have a recurrence within 5 years • Long term prognosis is less than favorable.

18. Etiology:Theories of Depression • Psychoanalytic Perspectives • The Role of Life Stress in Childhood Depression • Behavioral and Cognitive Behavioral Views • Biological Perspectives

19. Psychoanalytic Views • There are varied psychoanalytic positions regarding the development of depressive disorders • Generally tend 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

20. Psychoanalytic Views • Depression occurs as a result of an individual (who has suffered loss) identifying with the lost object • The individual has ambivalent feelings toward the lost object, as a result of identification, he or she may turn the feelings of hostility against the self and experience depression. • 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

21. Psychoanalytic Views • More often been used to account for depression in adults rather than children • Very little empirical data on their relevance to childhood depression, although psychoanalytic approaches to therapy for depression is not uncommon in some places

22. The Role of Life Stress • A number of studies have suggested that depression may result from major life changes • Usually negative events such as separation, divorce, and death in the family • Johnson and McCutcheon (1980) , Siegel (1981), Compas, Grant, & Ey (1994): • documented significant relationships between cumulative negative life changes experienced by children and depression. • Cohen-Sandler, et al (1982) provided data suggestive of a relationship between life stress and suicidal behavior in children

23. Specific Life Stressors • Relationships between specific stressors and the development of depression (Downey, Feldman, Khuri & Friedman, 1994) • Stressful family circumstances (e.g., marital conflict, divorce, problems in parent-child relationships, maternal rejection) and childhood depression (Kaslow & Racusin, 1994)

24. Cognitive/Behavioral Views • Beck (1974) has highlighted the role of cognitive factors in the development of depression • Depression is related to the way individuals perceive events in their environment • The depressed individual, as a result of his/her developmental and learning history, displays cognitive schematas that contribute to a negative view of the self, the world, and the future • These views contribute to feelings of self-blame, failure, and hopelessness which impact on mood and other behaviors usually associated with depression

25. Cognitive/Behavioral Views • Rehm's (1977) self-control model of depression which involves a blending of cognitive and 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 • Depression might result from: • tendency to attend primarily to negative rather than positive events (self-monitoring) • tendency to attribute failure to one's self rather than other factors (self-evaluation) • low levels of self-reinforcement or high rates of self-punishment

26. Behavioral Views • Ferster (1974) and Lewinsohn (1974): • depression may result from a lack of sufficient positive reinforcement in the environment • Lack of reinforcement can be caused by: • change in residence • failure to display appropriate social skills • Etc.

27. Learned Helplessness and Depression • Seligman (Seligman, 1974; 1975; 1978) • Depression is described in terms of learned helplessness • Depression develops in individuals who perceive themselves as having little or no control over rewards and punishments in their environment

28. Learned Helplessness • Symptoms of hopelessness and depression result from the individual's propensity to view negative events that befall them as the result of: • their own characteristics (internal attributions) • factors that are unlikely to change (attributions of stability) • factors that are likely to have an influence on the individual across situations (global attributions)

29. Learned Helplessness • Abramson, et al (1989) emphasized the role of attributional style in the development of hopelessness/depression • Attributions affect the relationship between negative life events and depression • Hopelessness, which subsequently leads to depression, results from an interaction of life stress and problematic attributions regarding causes of these events

30. Cognitive/Behavioral Views: Child Research Findings • C-B views were developed to account for adult rather depression, there has been research designed to study the applicability of these views to children • Kaslow, Brown, and Mee (1994) cite a range of studies that appear to provide support for many of the basic postulates inherent in these cognitive and behavioral models

31. 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 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

32. Research Findings • Other investigations have found links between child depression and • lowered expectations for performance • more stringent standards for performance • and tendencies to evaluate one's performance more negatively • Such findings support Rehm's self-control model

33. Biological Perspectives • Biological views of depression have focused primarily on: • genetic factors • biochemical abnormalities • Of special note are biochemical abnormalities involving neurotransmitters (chemicals that facilitate the transmission of neural impulses)

34. Genetic Factors • Kashani, et al. (1981): • concordance rate = 76% for monozygotic twins • 19% with dizygotic twins • concordance rate = 67% for monozygotic twins reared apart • Children with a depressed parent are 3x more likely to develop MDD than those with non-depressed parents • However, environmental factors cannot be ruled out as contributors

35. Other Biological Findings • Neurobiology of depression: • role of neurotransmitters (especially serotonin) • role of neuroendocrine abnormalities (e.g. plasma cortisol concentrations; growth hormone regulation; secretory patterns of thyroid-stimulating hormone) • Especially noteworthy are findings with adults that indices of lowered serotonin levels and serotonin dysregulation appear to be related to both symptoms of depression and suicidal behavior • More studies of these factors in children are needed

36. Treatment of Childhood Depression • 3 treatments classified as empirically based: • Interpersonal Therapy (Empirically Supported) • Cognitive-Behavior Therapy (Probably Efficacious) • Psychotropic Medications (Probably Efficacious)

37. Interpersonal Therapy • For depressed teenagers, Interpersonal therapy (IPT) is a well-established treatment • The focus of IPT is helping adolescents understand and address problems in their relationships with family members and friends assumed to contribute to depression • Involves what most of us think of when we hear the term “psychotherapy” • usually conducted in an individual therapy format, • therapist works one-on-one with the adolescent

38. Cognitive Behavior Therapy • CBT is designed to change both negative thoughts (cognitions) and behaviors • Depressed children/adolescent learn about the nature of depression and how their mood is linked to both their thoughts and actions • The focus is on developing better communication, problem-solving, anger-management, relaxation, and social skills • CBT (individual or group), is the most well-studied treatment for children and adolescents with depression • High relapse rates suggest the need for ongoing treatment

39. Psychotropic Medications • Some medications can help relieve depressive symptoms of youth (especially adolescents) • Those that appear to be most effective include selective serotonin reuptake inhibitors (SSRI’s): • clomipramine (Anafranil) • flouxetine (Prozac) • fluvoxamine (Luvox) • paroxetine (Paxil) • sertraline (Zoloft)

40. Psychotropic Medications • Successful response rates for SSRI’s is 70 – 90% • While the “response” rate appears to be high, many only show a “partial response” • Some studies suggest that only 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 suicidal ideation • Little is known about their long-term effects or effectiveness for younger children

41. Treatment: Final Comments • Medications can be of value, but 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