Transcript Childhood Depression

Childhood Depression
Gregg Selke, Ph.D.
September 26, 2006
PSY 4930
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 = preadolescent children lack the
degree of superego development
necessary to have true depressive
disorders
Children 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;
nothing good is going to happen," he said. “
Case Examples (NYU Study Center)
“Cheryl usually went to school and to her parttime 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.”
History
Clinical experience and early
descriptive studies suggested
that children display:
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depressed mood
loss of interest in activities
problems in eating and sleeping
feelings of helplessness and
hopelessness
1980’s: childhood depression best
characterized as:
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a prevailing mood state
a syndrome (with a specific set of
symptoms)
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 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
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 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
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
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 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..
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
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:
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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 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
Comorbidity
(Nottelmann and Jensen (1995)
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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
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with MDD: 42%
With Dysthymic Disorder: 38%
With both disorders: 61%
Overall, 40 – 90% have some type of
comorbidity
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
of recurrence
Kovacs, et al. (1984) found that the
probability of recovery from a major
depressive episode in
children/adolescents is:
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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
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.
Etiology: Theories of
Depression
Psychoanalytic Perspectives
The Role of Life Stress in Childhood
Depression
Behavioral and Cognitive Behavioral
Views
Biological 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
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.
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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
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
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Johnson & McCutcheon, 1980; Siegel, 1981; Compas,
Grant, & Ey, 1994
Difficult parent-child relationships &
maternal rejection
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Kaslow & Racusin, 1994
Life stress and suicidal behavior
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
Cognitive Distortion Examples
Filtering
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Looking at only 1 element, tunnel vision,
selective memory
Catastrophizing
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What if Statements, Assuming the worst
Polarized Thinking
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Black/white, either/or, no room for mediocrity
Mind Reading
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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:
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tendency to
rather than
monitoring)
tendency to
self rather
evaluation)
attend primarily to negative
positive events (selfattribute failure to one's
than other factors (self-
Behavioral Views
Ferster (1974) and Lewinsohn
(1974):
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Depression may result from a
lack of sufficient positive
reinforcement in the environment
Lack of reinforcement can be
caused by:
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change in residence
failure to display appropriate
social skills
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
Learned Helplessness
Depression results from the
individual's propensity to view
negative events in their life as
due to:
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their own characteristics (internal
attributions)
 “it’s all my fault, I’m just not good
with people, that’s just who I am”
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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”
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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 Factors
Kashani, et al. (1981):
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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
Other Biological Findings
Neurobiology of depression:
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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
Treatment of Childhood Depression
3 treatments classified as empirically
based:
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2.
3.
Interpersonal Therapy (Empirically Supported)
Cognitive-Behavior Therapy (Probably
Efficacious)
Psychotropic Medications (Probably Efficacious)
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”
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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 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
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 cognitivebehavioral therapy (CBT) with fluoxetine (Prozac).
Fluoxetine is currently the only antidepressant approved
by the Food and Drug Administration for use in children
and adolescents.