Depression Child & Adolescents
Behavioral/Interpersonal Models
depressed individuals react and contribute to interpersonal difficulties Interpersonal Relationships -depression linked with decreased perceptions of competence in social situations and relationships -increased impulsivity and aggression in relationships -decreased social activity, passivity, and withdrawal -impairments in the ability to form high quality friendships Achievement and School-Related Functioning -lower perceived cognitive competence and negative academic self concept -less positive relationships with peers -more behavior problems at school
Criticisms of Cognitive Models
may not be an etiological indicator, but rather a result of depression research has not established that these cognitions are stable traits that operate regardless of mod state how are these attributions made when discussing depression in children that have yet to fully develop their cognitive functions?
Cognitive Model: Information Processing
depressed individuals are believed to engage in systematic biases or errors in thinking, which lead to idiosyncratic interpretations of situations and events=negative automatic thoughts exhibit negative cognitive schemas which guide information processing and stimulate the self-critical beliefs "negative triad"=negative beliefs about self, world, and the future adolescents have been found to seek out experiences which verify the above, that is they seek out negative feedback
Associated Features and Comorbidity
ADHD or other Conduct Disorder: 14-36%, Anxiety: 80 to 90% of individuals with MDD also have anxiety symptoms. Separation anxiety. 1/3 of individuals with MDD also have a full-blown anxiety disorder. Anxiety in a person with major depression leads to a poorer response to treatment, poorer social and work function, greater likelihood of chronicity and an increased risk of suicidal behavior. Higher in depressed girls., Eating Disorders:, Psychosis: Mood congruent delusions or hallucinations may accompany severe MDD, Substance Abuse: common (Alcohol and Cocaine). Alcohol or street drugs are often mistakenly used as a remedy for depression. Depression may also be a consequence of drug or alcohol withdrawal and is commonly seen after cocaine and amphetamine use., Medical Illness: 25% of individuals with severe, chronic medical illness (e.g., diabetes, myocardial infarction, carcinomas, stroke) About 5% of individuals initially diagnosed as having MDD subsequently are found to have another medical illness which was the cause of their depression. Medical conditions often causing depression are: Endocrine disorders: hypothyroidism, hyperparathyroidism, Cushing's disease, and diabetes mellitus. Neurological disorders: multiple sclerosis, Parkinson's disease, migraine, various forms of epilepsy, encephalitis, brain tumors. Medications: many medications can cause depression, especially antihypertensive agents such as calcium channel blockers, beta blockers, analgesics and some anti-migraine medications. Mortality: Up to 15% of patients with severe MDD die by suicide. Over age 55, there is a fourfold increase in death rate., Premorbid History: 10-25% of patients with MDD have preexisting Dysthymic Disorder. These "double depressions" (i.e., Dysthymia + Major Depressive Disorder) have a poorer prognosis. Gender: Males and females are equally affected by MDD prior to puberty. After puberty, this disorder is twice as common in females as in males. The highest rates for this disorder are in the 18-29-year-old age group . Women at this age range have a diagnostic rate 3x all other groups.
Age Differences
Adolescents: Depressed boys are at the greatest risk of suicidal behaviors in late adolescence. Depressed girls are at the highest risk in middle adolescence. More weight loss in girls especially. More hypoersomnia. Children: Younger children report more somatic symptoms. More irritability in younger children. Report less dysphoria than adolescents. More weight gain.
Family Dynamics
Adversarial family climate (high stress/low support) creates ongoing stress with little relief or support Negative reinforcement wherein a child's depression is reinforced Cognitive attributions (negative thinking) become a self-fulfilling prophecy Family climate doesn't foster emotion regulation
Onset
Average age at onset is 25, but this disorder may begin at any age. Average duration of an episode is 4 months and of dysthymic disorder 2-4 years For adolescents diagnosed with MDD, age of onset is typically age 11 to 14 Episodes of major depression in children and adolescents have a median duration of 7-9 months 20% of adolescents have episodes lasting 15 months or longer Adolescents with dysthymia, have a typical duration of symptoms for 4 years Approx 70-80% of adolescents recover from MDD after 1 year, increasing to 86-98% after 2 years However 70% experience a recurrence within five years After the first episode of Major Depressive Disorder, there is a 50%-60% chance of having a second episode, and a 5-10% chance of having a Manic Episode (i.e., developing Bipolar I Disorder). After the second episode, there is a 70% chance of having a third. After the third episode, there a 90% chance of having a fourth. The greater number of previous episodes is an important risk factor for recurrence.
Research on Assessing Depression in Infancy
Biological correlates related to research of vagal tone (heart rate variability). Decreased in depressed infants or infants of depressed mothers. Almost all research has focused on the dyadic relationship. High correlation with maternal depression. These children are found to be temperamentally more difficult, difficult to soothe, higher irritability, and lower level of physical activity. Preschoolers are more likely to feel excessive guilt, increased inhibition in unfamiliar situations, preoccupation with sad themes in play, extreme emotional withdrawal, and empathic over-involvement in the problems of others. Infant response to flat affect-distress, protest, averted gaze, increased drooling, wary expression Very young infants are able to discern meaning from affect.
9 Assessment Instruments
Child Depression Inventory (CDI) Children's Depression Rating Scale Revised (CDRS-R) The Depression Scale of Beck Youth Inventories Depression and Anxiety in Youth Scale The Hopelessness Scale for Children Inventory of Suicide Orientation Moods & Feelings Questionnaire Reynolds Adolescent Depression Scale Reynolds Child Depression Scale
Other Etiological Indicators
Consequence of stressful, disruptions in family life, school, and/or social circumstances that are created by a behavior disorder Parental conflict Low parental education (in females only) Parental mental illness
New DSM diagnosis
Created to distinguish these children from ODD and BD. DMDD is characterized by severe and recurrent temper outbursts that are far beyond what context would expect. Occurs frequently at least 3 or more times per week. Outside of these tantrums the irritability is extremely and enduring, however this irritability is required to appear in at least 2 settings. Cannot diagnose before age 6 or after age 18. Symptom threshold is much higher than that for ODD If a child meets criteria for ODD and DMDD, give DMDD diagnosis. There was also the need to address high levels of children diagnosed with BD who did not experience symptoms in an "episodic" way that is characteristic of BD.
Contextual Family Variables
Discord in relationships Families are perceived to be less cohesive and adaptable, less open to emotional expressiveness, less democratic, more hostile, and more rejecting. They are perceived to be more conflictual and disorganized and are less likely to engage in pleasant activities. Parental and child depression also occur in the context of increased family stressors.
HPA axis
Elevated cortisol levels, elevated corticotropin releasing hormone, and impaired negative feedback control of the HPA axis The causal risk here being early ongoing chronic stress Sensitized stress response system implicated
Recovery
For patients with severe Major Depressive Disorder, 76% on antidepressant therapy recover, whereas only 18% on placebo recover. For these severely depressed patients, significantly more recover on antidepressant therapy than on interpersonal psychotherapy. For these same patients, cognitive therapy has been shown to be no more effective than placebo.
Poor Outcome
Inadequate treatment Severe initial symptoms Early age of onset Greater number of previous episodes Only partial recovery after one year Having another severe mental disorder (e.g. Alcohol Dependency, Cocaine Dependency) Severe chronic medical illness Family dysfunction Suicidal thoughts or actions
Brain and Neurochemistry
Increased amygdala activation Volume abnormalities in the hippocampus, prefrontal cortex, orbitofrontal cortex and anterior cingulate cortex In adults have found abnormalities in the hypothalamic-pituitary-adrenal axis, related to responses to stress In adults have also found three related abnormalities-higher levels of cortisol, abnormal cortisol regulation, and abnormalities of corticotropin releasing factor. Similar patterns have not yet been found in child and adolescent samples. Low levels of growth hormone EEG findings in adolescents similar to adults. Reduced REM sleep. Not yet found in children. Left frontal lobe hypoactivation
Risk factors: individual, family, school, SES
Individual (difficult temperament, low self esteem, low positive mood); family (conflict, level of expressed emotion, parenting style, maternal depression); peer and school (peer rejection, aggression); and socioeconomic (poverty, stressful life events)
Other Signs and Symptoms in Children
Irritability or anger Continuous feelings of sadness, hopelessness Social withdrawal Increased sensitivity to rejection Changes in appetite -- either increased or decreased Changes in sleep -- sleeplessness or excessive sleep Vocal outbursts or crying Difficulty concentrating Fatigue and low energy Physical complaints (such as stomachaches, headaches) that do not respond to treatment Reduced ability to function during events and activities at home or with friends, in school, extracurricular activities, and in other hobbies or interests Feelings of worthlessness or guilt Impaired thinking or concentration Thoughts of death or suicide
Gender Differences
More common in females from adolescence forward Girls report more frequent interpersonal stress Boys are more susceptible to academic and other school related stress than females Some findings that boys experience more overall chronic stress, but don't react with depression
Parent-Child Relationships: Parents of Depressed Children
Parents of depressed children reveal higher levels of criticism and emotional overinvolvement. Disruptions in family relationships are also common. Depressed children evidence less effective problem solving, fewer supportive and positive behaviors, less positive communication, and less autonomous assertion during parent-child interactions. Parenting exchanges with the child lead to less rewarding interactions with their depressed child.
Other Signs and Symptoms in Adolescents
Poor performance in school Withdrawal from friends and activities Sadness and hopelessness Lack of enthusiasm, energy or motivation Anger and rage Overreaction to criticism Feelings of being unable to satisfy ideals Poor self-esteem or guilt Indecision, lack of concentration or forgetfulness Restlessness and agitation Changes in sleeping or eating patterns Substance abuse Problems with authority
Course
Psychological stress: Stress appears to play a prominent role in triggering the first 1-2 episodes of this disorder, but not in subsequent episodes. Course: Course is variable. Some people have isolated episodes that are separated by many years, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. About 20% of individuals with this disorder have a chronic course.
Major signs for depression in adolescents
Sadness, anxiety, or a feeling of hopelessness Loss of interest in food or compulsive overeating that results in rapid weight loss or gain Staying awake at night and sleeping during the day Withdrawal from friends Rebellious behavior, sudden drop in grades, or cutting school Complaints of pains including headaches, stomachaches, low back pain, or fatigue Use of alcohol or drugs and promiscuous sexual activity A preoccupation with death and dying Hopelessness about the future Difficulty concentrating on school work and a frequent drop in grades Frequent tearfulness or crying Feelings of guilt about having caused what might be leading to the depression today Often don't see the pervasive anhedonia like you do in adults More reactivity to situational stressors than adults
Emotional Vulnerability to Depression
Temperament-high negative emotionality, low positive emotionality, and poor effortful control Poor emotion regulation and deficits in processing emotion
Bereavement Exclusion
The change has been made so that major depression is not overlooked with bereaved individuals. The death of a loved one can precipitate MDD. Differences between grief and depression include: "In grief, painful feelings come in waves, often intermixed with positive memories of the deceased; in depression, mood and ideation are almost constantly negative. In grief, self-esteem is usually preserved; in MDD, corrosive feelings of worthlessness and self-loathing are common. While many believe that some form of depression is a normal consequence of bereavement, MDD should not be diagnosed in the context of bereavement since diagnosis would incorrectly label a normal process as a disorder" APA 2013.
Familial Patterns and Genetics
There is strong evidence that major depression is, in part, a genetic disorder: Individuals who have parents or siblings with Major Depressive Disorder have a 1.5-3 times higher risk of developing this disorder. The concordance for major depression in monozygotic twins is substantially higher than it is in dizygotic twins. However, the concordance in monozygotic twins is in the order of about 50%, suggesting that factors other than genetic factors are also involved. Children adopted away at birth from biological parents who have a depressive illness carry the same high risk as a child not adopted away, even if they are raised in a family where no depressive illness exists. Interestingly, families having Major Depressive Disorder have an increased risk of developing Alcoholism and Attention-Deficit Hyperactivity Disorder.
Cultural Considerations
Very few studies done with ethnically diverse population. One study: slightly higher rates in Mexican Americans. Most studies have focused on the differences between Caucasian Americans and African Americans, finding generally no differences in prevalence High correlation with chronic medical conditions and physical disabilities. Some correlation with poverty and low SES, but findings inconsistent.
Mediation Models
basically the opposite of the diathesis-stress model. Believe that negative life events lead to the development of negative cognitions and then depression.
Stress Generation Models
depression and associated characteristics may promote dysfunction, such that depressed individuals actually generate stressful circumstances, which in turn trigger depressive reactions. Early onset of depression may interrupt normal development and the acquisition of skills, leading to stress and risk for future maladjustment. Depressive symptoms have been linked to self generated stress, particularly within interpersonal relationships. Life stress may be not only a cause of subsequent symptoms, but also a consequence of disorder-related impairment.
Diathesis-Stress Models
depression as a function of the interaction between personal vulnerability and external stress. This model is a convergence between cognitive theories and environmental stressors. Stable trait like characteristics and/or biological markers, when matched with a significant situational stressor, prove to be a good match. This match leads to depression.
Stress Exposure Models
depression is a response to the experience of negative life events
Cognitive Models: Seligman's Learned Helplessness
depression stems from the experience of uncontrollable, noncontingent events predisposition to contribute negative outcomes to internal, global, and stable factors, and positive outcomes to external, specific, and unstable factors believe that their efforts to achieve their goals will be futile
Psychodynamic Theories
focus on actual or symbolic loss as the primary vulnerability factor. Depression arises from anger or hostility toward the lost object that has become internalized as a form of self-rejection.
Parent-Child Relationships: high risk studies
maternal depression is a serious risk factor for children. Depressed mothers and their children demonstrate differing behavior patterns: withdrawal and disengagement with flat affect and lack of contingent responding and overt pattern of hostility and instrumentativeness