Kelly Brey Love . Susan M Swearer
It
has only been within the past two decades that the majority of clinicians and researchers
reached agreement that children can experience a
depressive disorder. Initially, researchers believed children’s lack of
psycho-sexual development prohibited development
of depression in childhood.
There
has also been disagreement regarding which symptomatology comprises childhood depression, and how it differs from depression in adults. Many clinicians
and researchers shared the belief that depression in
children was ‘‘masked’’ by other symptoms (e.g.,
aggression, enuresis, anxiety, among others).
More
recent research has
identified and emphasized the similarities between
depressive symptoms experienced by adults and
children. Cohort data suggest that the age-of onset of depression has decreased,
and prevalence has increased as compared to
children born in the first half of the 20th century.
Prevalence
While depression does occur in childhood, it is more likely to manifest in adolescence and adulthood. Estimates vary, but it appears that between 0.3-2.5% of prepubertal children may be diagnosed with Major Depressive Disorder, and between 0.6-2.5% with Dysthymic Disorder.
Depression in preschoolers is less common
than in older children, and is typically associated with instances of extreme
abuse and neglect.
Depression
is equally present in both males and females in childhood, however, a gender
difference does appear after onset of puberty,
with more females reporting depressive disorders
than males.
Assessment
Childhood depression can be assessed via several different strategies. Self-report scales, semi-structured clinical interviews, peer report or nomination, parent/teacher/ caregiver rating scales, behavioral observation, and biological and/or psycho-physiological measures have all been utilized to assess depression in young children. The most commonly used methods of assessment are self-report and parent/teacher/caregiver rating scales.
An obvious difficulty affecting
both diagnosis and treatment of depression is that young children often prove
to be poor informants of their feelings, and in
particular, have difficulty identifying the temporal and causal relationships between their moods and events.
Course
A Major Depressive Episode is a period lasting a minimum of two weeks consisting of either depressedmood or anhedonia. In children and adolescents, the mood may be irritable rather than sad.
A Major Depressive Disorder is a clinical course characterized
by one or more major depressive episodes, without
history of manic, mixed or hypomanic episodes.
Dysthymic mood is described as a generally ‘‘low’’ mood, infrequently experiencing joy or excitement. Those experiencing dysthymic mood are often described as feeling ‘‘down in the dumps.’’
Dysthymic
Disorder is
comprised of a chronically depressed mood that occurs
most of the day (more days than not) for at
least two years. For children, the duration only needs to be one year, and their mood may be irritable rather than sad or depressed. The initial one to two years (depending on age) of the Dysthymic Disorder must be free from a Major Depressive Disorder.
The
course of a major depressive episode and dysthymia in children present differently than in adults. A major depressive episode typically lasts for 32–36
weeks in children or adults, and has a maximal recovery
rate of 92%. Recovery
for a major depressive episode is relatively protracted, with the greatest improvement in reduction of depressive symptomatology occurring between the 24th and 36th week.
The average length of Dysthymic Disorder is much longer than a major depressive episode, at 3 years. The younger the child is at
onset, the more likely they are to experience a
relapse, and are more likely to have recurrent
episodes of depression as adults.
Comorbidity
It is well established that children who are depressed often experience additional psychological disorders. Anxiety is the most commonly diagnosed comorbid disorder with depression in children, with 25–50% of depressed youth also diagnosed with an anxiety disorder. On average, children who experience comorbid psychological disorders report more severe impairment and often suffer more long-term consequences.Criteria
The Diagnostic and Statistical Manual of Mental Disorders: Text Revision (DSM-IV TR) outlines the criteria for the different mood disorders. Diagnostically, there is little difference in adult and child criteria for a diagnosis of depression with the exception that the duration of dysthmia is 1 year for children instead of 2 years, and ‘‘irritability’’ can be considered a manifestation of dysphoric mood.
The
DSM-IV TR criteria for a
major depressive disorder requires persistent depressed
(or irritable) mood or a marked decrease in
interest or pleasure in most or all daily activities for at least two weeks. In addition, four of the following
features must be present during the same two week
period: weight loss or gain, sleep disturbance, psycho-motor
agitation or retardation, fatigue, feelings of
worthlessness or guilt, reduced concentration, or recurrent thoughts of death. Symptoms must lead to significant distress or impairment of functioning and must not be due to substance misuse, physical illness, or bereavement.
Etiology-
Familial Environment/ Genetics
Familial
and environmental factors play a large role in the development of depression in young
people. High parental criticism, parental discord, and poor
parent-child communication has been associated with
onset and course of depression in youth. Both
depressive symptoms and disorders have been significantly associated with undesirable life events.
Parental
psychopathology also appears to be a significant risk factor for both the
development and the course of childhood depression. Forty-five percent of children
with mothers diagnosed with depression met criteria for
a major depressive disorder, compared to 11% of
children who were diagnosed as depressed whose mothers were not depressed. A
longitudinal study of depressed children whose parent(s) were also depressed found more
severe episodes of depression in a ten-year follow-up
than children without depressed parents.
Experiencing
single risk factors (e.g., pre-pubertal onset, familial history of depression, parental
psychopathology, stressful life events, and low family support) appears to be associated with an increase in being diagnosed with childhood depression. However,
when these risk factors are
experienced in combination, the likelihood of
impairment in the child is greater. Many researchers
have found that an increased number of risk
factors is associated with increased impairment.
Risk
factors, such as the diathesis-stress model that has been validated in studies of adult
depression have also been validated for
childhood depression. Children who have a
general negative cognitive style (irrespective to the onset of a stressor)
report higher levels of depression after a
stressor in comparison to children who do not
endorse a negative cognitive style. It
is important to note that
due to developmental considerations, few studies have examined the relationship
between cognitive style and depression in children
under the age of eight.
Etiology- Biological
There also appears to be a biological component for depression in children. Research has found that depressed children hypo-secrete growth hormones in comparison to non-depressed peers, even after the depressive episode has subsided.When a child is depressed, it is likely due to a combination of genetic vulnerability and exposure to severe trauma or stressors. Thus, the manifestation of childhood depression appears to be a mix of both ‘‘nature’’ and ‘‘nurture.’’
biological
disregulation among
depressed children is found in their neurochemistry, specifically identifying
serotonin, neorpinephrine and acetylcholine as
contributing to mood disorders.
Prevention
School based prevention programs involving pre-adolescents at risk for depression found that students participating in either a school based cognitive training program, social problem-solving program, or combined cognitive and social problem-solving program reported significantly fewer depressive symptoms than a control group.Treatment
Treatment for childhood depression has significantly lagged behind treatment for adults. It is only in the past 10–15 years that studies have been conducted testing the efficacy of psychopharmacological and therapeutic treatments.Pharmacotherapy
The use of serotonin reuptake inhibitors (SSRIs) appears to be somewhat effective in treating childhood depression. A recent study found that 56% of patients 7–17 years old receiving the SSRI fluoxetine demonstrated clinical improvement compared to 33% receiving placebo.Tricyclic antidepressants, which are frequently prescribed for treatment of depressed adults, have received mixed conclusions when used with children. This lessened success with children may stem from the developmental changes occurring in the neurotransmitter system.
Psychotherapy
Cognitive Behavioral Treatment: Individual cognitive behavioral interventions have proven effective in reduction of depressive symptomatology; lessening duration of depressive episodes, and in facilitating remission of a depressive episode in children and adolescents. Cognitive behavioral treatment typically includes pleasant events activity scheduling, self-control skills, problem solving, and cognitive restructuring. Treatment can be time limited, often between 10–12 sessions, over a five to 12 week duration.
Behavioral
Treatment: Many behaviorists believe depression occurs from a lack of
reinforcement in the environment. If a child does not receive
reinforcement (e.g., praise, interactions, touch), depressive symptoms may occur. Reinstatement
of reinforcement in the
environment will likely result in reduction of depressive
symptomatology. Little research regarding this
type of treatment has been conducted with children; however, research has found
that increasing social reinforcers is an effective
treatment with depressed adults.
Suggested Reading
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: Text revision (4th ed.). Washington D.C.: American Psychiatric Association.Ginsburg, S. D., & Twentyman, C. T. (1987). Prevention of childhood depression. In R. F. Munoz, (Ed.), Depression prevention: Research directions (pp. 93–103). New York: Hemisphere Publishing Corporation.
Kazdin, A. E. (1990). Childhood depression. Journal of Child Psychology, 31, 121–160.
Stark, K. D., Laurent, J., Livingston, R., Boswell, J., & Swearer, S. (1999). Implications of research for the treatment of depressive disorders during childhood. Applied & Preventive Psychology, 8, 79–102.
References
C.
S. Clauss-Ehlers (Ed.), Encyclopedia of Cross-Cultural School
Psychology, DOI 10.1007/978-0-387-71799-9, Springer
Science+Business Media LLC 2010
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