Childhood Depression

Gregg Selke, Ph.D.September 26, 2006

PSY 4930

The History of Childhood Depression

Before 1970's childhood depression was rarely discussedMany clinicians seriously questioned whether children were even capable of exhibiting depressive disordersPsychoanalytic view = pre-adolescent children lack the degree of superego development necessary to have true depressive disordersChildren thought to be cognitively unsophisticated

Case Examples (NYU 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; I don't have any reason to stay up; nothing good is going to happennothing good is going to happen,"," he said. “

“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.”

Case Examples (NYU Study Center)

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)

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

DSM IV CRITERIA: Major Depressive EpisodeEpisode

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 mood or (2) loss of interest or pleasure.

Major Depressive Episode(1) 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 moodirritable 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) – Called Anhedonia

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 failure to make expected weight gainsweight gains.

(4) Insomnia oror 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

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

Major Depressive Episode

B. The symptoms do not meet criteria for a Mixed Episode (Mania + Depression)

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).

Major Depressive Episode

E. Symptoms are not accounted for by Bereavement; or the bereavement 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

Major Depressive DisorderDisorderA.  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..

Major Depressive DisorderSpecify (for current or most recent episode)Severity/Psychotic/Remission Specifier

Chronic

With Catatonic Features

With Melancholic Features

With Atypical Features

With Postpartum Onset

Specify

Longitudinal Course Specifiers (With and Without Interepisode Recovery)With Seasonal Pattern

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

Prevalence

Kashani and Simonds (l981) suggested a general population rate of approximately 2 % based on DSM-III criteriaMore recent findings place MDD prevalence figures at 2% for children and 4-8% for adolescentsThe 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

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 Overall, 40 – 90% have some type of comorbiditycomorbidity

Prognosis: Initial RecoveryThere is less known about the prognosis of child depression than is the case with adult depression.Index episode of the disorder vs. risk of recurrenceKovacs, 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

Prognosis: Recurrence

HoweverHowever,,Kovacs et al., found that 70% of children with MDD have a recurrence within 5 years

Long term prognosis is less than favorable.

Etiology: Theories of Depression

Psychoanalytic PerspectivesThe Role of Life Stress in Childhood DepressionBehavioral and Cognitive Behavioral ViewsBiological Perspectives

Psychoanalytic Views

Varied positions

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

Psychoanalytic Views

Depression occurs as a result of an individual (who has suffered loss) identifying with the lost objectThe 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.

Hostility turned inward

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

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

The Role of Life Stress

A number of studies have suggested that depression may result from major life changesNegative events such as separation, marital conflict in parents, divorce, and death in the family experienced by children Cumulative negative life changes

Johnson & McCutcheon, 1980; Siegel, 1981; Compas, Grant, & Ey, 1994

Difficult parent-child relationships & maternal rejection

Kaslow & Racusin, 1994

Life stress and suicidal behavior Cohen-Sandler, et al (1982)

Cognitive/Behavioral Views

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

Cognitive Distortion Examples

Filtering Looking at only 1 element, tunnel vision,

selective memoryCatastrophizing

What if Statements, Assuming the worstPolarized Thinking

Black/white, either/or, no room for mediocrity

Mind Reading Snap judgments: assumptions about what

others are thinking, feeling, what motivates them, how reacting to you, projecting

Cognitive/Behavioral Views

Rehm's (1977) self-control model of depression which involves a blending of cognitive and operant views of behavior

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

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.

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

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, so why bother trying to get another job”

factors that are likely to have an influence on the individual across situations (global attributions)

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)

Genetic FactorsKashani, 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 parentsHowever, environmental factors cannot be ruled out as contributors

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 behaviorMore studies of these factors in children are needed

Treatment of Childhood Depression

3 treatments classified as empirically based:

1. Interpersonal Therapy (Empirically Supported)

2. Cognitive-Behavior Therapy (Probably Efficacious)

3. Psychotropic Medications (Probably Efficacious)

Interpersonal TherapyFor depressed teenagers, Interpersonal therapy (IPT) is a well-established treatmentThe focus of IPT is helping adolescents understand and address problems in their relationships with family members and friends assumed to contribute to depressionInvolves 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

Cognitive Behavior Therapy

CBT is designed to change both negative thoughts (cognitions) and behaviorsDepressed children/adolescent learn about the nature of depression and how their mood is linked to both their thoughts and actionsThe focus is on developing better communication, problem-solving, anger-management, relaxation, and social skillsCBT (individual or group), is the most well-studied treatment for children and adolescents with depressionHigh relapse rates suggest the need for ongoing treatment

Psychotropic Medications

NIMH Research on Treatment for Adolescents with Depression Study (TADS): Combination Treatment Most Effective in Adolescents with DepressionA 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).Fluoxetine is currently the only antidepressant approved by the Food and Drug Administration for use in children and adolescents.