Childhood Depression

1. Childhood Depression Gregg Selke, Ph.D. September 26, 2006 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. 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; nothing good is going to happen," he said. “

4. Case Examples (NYU 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.”

5. 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)

6. 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

7. 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.

8. Major Depressive Episode • Depressed moodmost 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) – Called Anhedonia

9. 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

10. 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

11. 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).

12. 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

13. 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..

14. Major Depressive Disorder • Specify (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

15. 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

16. 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

17. 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

18. Prognosis: Initial Recovery • There is less known about the prognosis of child depression than is 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

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

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

21. 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

22. 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. • 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

23. 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

24. The Role of Life Stress • A number of studies have suggested that depression may result from major life changes • Negative 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)

25. 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 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 future • These views contribute to feelings of self-blame, failure, and hopelessness which impact on mood and other behaviors usually associated with depression

26. Cognitive Distortion Examples • Filtering • Looking at only 1 element, tunnel vision, selective memory • Catastrophizing • What if Statements, Assuming the worst • Polarized 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

27. 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

28. 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.

29. 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

30. 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)

31. 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)

32. 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

33. 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

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

35. 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

36. 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

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