History
The recognition of depressive symptoms and disorders in school-aged children is a relatively new phenomenon
During the mid-twentieth century, psychologists rarely diagnosed children with depression
More recently, researchers began noting similarities and differences observed in children and adults with depression
Slightly different criteria are now being used to diagnose depression in children
Obstacles in Diagnosis in Childhood
some of the obstacles and criticisms in diagnosing young children with depression include:
- Distinguishing between developmentally appropriate and adaptive states
- Transitory nature
- Diagnostic classification systems that fail to take into account developmental variations
- Shortages of evidence-based psychometrically sound measures
Depression in children
- Depression in school-aged children is often associated with depressed or irritable mood
- It is also frequently associated with social withdrawal and somatic complaints (stomach ache, headache etc)
- Depressed children often exhibit impairment in family, school and peer functioning
Understanding depression in Youth
- Depressed mood or loss of interest are hallmark characteristics of depression
- May sometimes be differentiated from adult presentation of depression by irritability, physical complaints, & lack of making expected weight gains (rapid changes)
- Girls tend to exhibit more symptoms than boys, particularly after onset of adolescence
- Many definitions lack developmental perspective (cognitive, affective, & interpersonal competencies)
Understanding depression in Youth
Symptoms include:
- Sadness
- Difficulties concentrating and making decisions
- Lack of productivity
- Lack of desire to do things that once were interesting
- Appetite changes
- Sleep changes
- Suicidal ideation
- Weariness
- Irritable mood
- Fatigue
- Psychomotor disturbance
Additional Diagnosis of Disruptive Mood Dysregulation Disorder
- A diagnosis reserved for children between 6 and 18 years of age who show persistent irritability and frequent episodes of extremely out-of-control behavior.
- This new diagnosis was added to address concerns about the potential over-diagnosis and over-treatment of bipolar disorder in children
- Chronic, severe persistent irritability
- Must be distinguished carefully from pediatric bipolar disorder
- Prevalence Rate: 2% - 5%
- Rates are expected to be higher in males and school-aged children than in females and adolescents
rule out pediatric bipolar disorder
- Severe recurrent temper outbursts manifested verbally or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation
- Temper outbursts are inconsistent with developmental level
- Temper outbursts occur, on average, three or more times per week
- The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others
- Temper outbursts/and irritable or angry mood must be present in at least two of three settings and should be considered severe in at least one of these settings
- Temper outbursts/and irritable or angry mood has been present for 12 or more months
- There has never been a distinct period lasting more than 1 day during which full symptom criteria is met for a manic or hypomanic episode (makes it bipolar again)
- Behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another disorder (Autism Spectrum Disorder, Posttraumatic Stress Disorder, Separation Anxiety Disorder)
Major Depressive Disorder:
Symptoms
- Must cause impairment
- Must reflect a change from baseline
- Cannot be secondary to -general medical condition
- Have 5 out of the following symptoms for at least 2 weeks. One has to be depressed mood or loss of pleasure
- -Depressed most of the day, nearly every day
- -Anhedonia
- -Significant weight change
- -Sleep disturbance
- -Psychomotor agitation or retardation
- -Fatigue or loss of energy
- -Feelings of worthlessness or inappropriate guilt
- -Diminished ability to think or concentrate/indecisiveness
- -Recurrent thoughts of death or suicide without a plan, or suicide attempt or a specific plan for attempting suicide
Three levels of severity in Major Depressive Disorder
Mild: Few in any symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in mind impairment in social or occupational functioning
Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe”
Severe: The number of symptom is substantially in excess of that required for the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning
Major Depressive Disorder Specifiers
- In Partial Remission: Symptoms of the immediately previous major depressive episode are present, but full criteria are not met, or there is a period lasting less than 2 months without any significant symptom of major depressive episode following the end of such an episode
- In Full Remission: During the past 2 months, no significant signs or symptoms of the disturbance were present
- With Psychotic Features: Delusions and/or hallucinations are present
—With Mood-Congruent Psychotic Features: The content of all delusions and hallucinations are consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment
—With Mood-Incongruent Psychotic Features: The content of the delusions or hallucinations does not involve the typical depressive themes, or is a mixture of mood-incongruent and mood-congruent themes.
-With Catatonia: Apply to an episode of depression if catatonic features (psychomotor disturbance including decreased motor activity, excessive/peculiar motor activity, motor agitation) are present during most of the episode
–With Peripartum Onset: The onset of most recent episode of major depression occurs during pregnancy or in the 4 weeks following delivery
–With Seasonal Pattern: Recurrent major depressive disorder that has a regular temporal relationship between onset and a particular time of the year
- Full remissions may also occur at a characteristic time of the year
- Seasonal major depressive episodes substantially outnumber the non-seasonal major depressive episodes that may have occurred over the individual’s lifetime
Persistent Depressive Disorder
Symptoms
- Depressed mood for most of day, for more days than not, as indicated by subjective account or observations made by others, for at least 2 years
- ** For children and adolescents, mood can be irritable and duration must be at least 1 year**
- Must have 2 or more of the following symptoms
- -Poor appetite or overeating
- -Insomnia or hypersomnia
- -Low energy or fatigue
- -Low self-esteem
- -Poor concentration or difficulty making decisions
- -Feelings of hopelessness
- During 2 year period (or 1 year for children/adolescents), never been without a symptoms for more than 2 months at a time
Never been a manic or hypomanic episode
Not better explained by schizoaffective disorder, schizophrenia, delusional disorder, or other psychotic disorder
Not due to substance abuse or medication
Significant impairment
Persistent Depressive Disorder Specifiers
–With Anxious Distress: at least 2 of the following: feeling keyed up or tense; feeling unusually restless; difficulty concentrating because of worry; fear that something awful might happen; feeling individual will lose control of self.
–With Mixed Features: At least 3 of following: elevated/expansive mood; inflated self-esteem or grandiosity; more talkative/pressured speech; flight of ideas/racing thoughts; increase in energy or goal directed activity; increased involvement in risky activities; decreased need for sleep
–With Melancholic Features: At least 1 of the following: Loss of pleasure in most or almost all activities; lack of reactivity to usually pleasurable stimuli; At least 3 of the following: Profound despondency/despair; depression worse in morning; early morning wakening; psychomotor agitation or retardation; significant anorexia or weight loss; excessive/inappropriate guilt
–With Atypical Features: Mood reactivity (Mood brightens in response to actual or potential positive events) and two or more of the following: Significant weight gain or increase in appetite; hypersomnia; leaden paralysis (heavy feelings in arms or legs); long standing pattern of interpersonal rejection sensitivity that results in significant social or occupational impairments
–With Psychotic Features: Same as Major Depressive Disorder
With Catatonia: Same as Major Depressive Disorder
–With Peripartum Onset: Same as Major Depressive Disorder
–With Seasonal Pattern: Same as Major Depressive Disorder
ICD-10-CM F33 Major Depressive Disorder
Key symptoms: at least one of these, most days, most of the time for at least 2 weeks
persistent sadness or low mood;and/or
loss of interests or pleasure
fatigue or low energy
if any of above present, ask about associated symptoms:
disturbed sleep poor concentration or indecisiveness low self-confidence poor or increased appetite suicidal thoughts or acts agitation or slowing of movements guilt or self-blame
The 10 symptoms then define the degree of depression and management is based on the particular degree not depressed (fewer than four symptoms) mild depression (four symptoms) moderate depression (five to six symptoms) severe depression (seven or more symptoms, with or without psychotic symptoms)
Prevalence of Depressive Disorders in Children/Adolescents
Prevalence estimates for depression with school-age children are highly variable with prevalence rates varying as a function of age & developmental level.
- -Early childhood: 0.9% to 2.7%
- -Adolescents: 15-20%
Gender Differences
No evidence for gender differences in early childhood
Gender differences in adolescence (more common in females due to sociotal stressors, or puberty)
Ethnicity
Mixed prevalence rates
Some no difference; others more symptoms reported for minorities
Cultural & linguistic considerations: norms & language to describe depression
Developmental Course
-The onset of Disruptive Mood Dysregulation disorder must be before age 10 years, and the diagnosis should not be applied to children with a developmental age of less than 6 years
- Major Depressive Disorder may first appear at any age, but the likelihood of onset increases markedly with puberty
- —In US, incidence peaks in 20s
- Persistent Depressive Disorder often has an early insidious onset (in childhood/adolescence or early adult life) and a chronic course,
- –Early onset: Before age 21
Etiology and Risk Factors
Risk factors may predict the onset, severity, and duration of psychopathology
- Genetic
- Biological
- Social-Cognitive
- Interpersonal
- Contextual
Etiology: Genetics
Genetic predisposition of internalizing disorders.
- Heritability estimates range from 11-72% (Wambolt & Wambolt, 2000); 20-45% & 40-70% (Sullivan et al., 2000)
- Children whose parents are anxious & depressed are at a higher risk to develop mood & anxiety disorders than their peers.
- Twin & adoption studies with adult samples indicated that genetic factors account for approximately 50% of the variance in the diagnosis of depressive disorders
- Genetic liability may be coupled with environmental risks linked to parental depression
Etiology: Biological
- Dysregulation of Neuroendocrine system in adults
- -Endocrine system influences sleep, emotion, & eating
- -Hypothalimic-pitutitary thyroid (HPT)
- -Hypothalimic-pitutitary adrenal (HPA)
- Disruption in neurotransmitter processes
- -Serotonin & norepinephrine in limbic system
- -Decrease in these transmitters produces depression
- -Prolonged stress to these areas of the brain in genetically vulnerable individuals leads to reduction of these neurotransmitter levels
- Disruption of biological rhythms
- -Sleep wake cycle
- -Depressed individuals have demonstrated sleep abnormalities including reduced REM, sleep abnormalities
- Atypical activation of particular brain regions
- -Structural & functional brain studies indicate that left frontal brain regions are more active during negative emotional experiences
Etiology: Social-Cognitive
Cognitive Models
–Information-processing (Beck): negative automatic thoughts, schemas, negative perceptions of self & world, heightened by external stressors
–Depressed attributional style
–Bidirectional relationship between cognition & depression
–Association between attributional style & depression becomes stronger with age
Etiology: Interpersonal
Behavioral/Interpersonal Models
- Depressed individuals react to & contribute to disruptions in their relationship
- Interpersonal styles & social deficits elicit negative responses / encounters & rejection from others which can heighten depressed affect
–Inability to form high-quality relationships
–Impulsivity & aggression
–Passivity & withdrawal
–Ruminative, helpless, reassurance seeking
- Skill deficits & Lack of reinforcement
- Social Problem Solving, Coping, & Emotion Regulation
Etiology: Family
Disruptions in early social bonds / family adversity can undermine key development believed to create vulnerability for depression
- Caregiver loss
- Maltreatment
- Insecure parent-child attachment
- Parent styles characterized by low warmth
- Parent-child relationships
- Martial & family discord
- Parent psychopathology
- Parent behavior
Etiology: Contextual
Environmental adversity as triggers of depression in vulnerable individuals
- Acute negative life events
- Chronic stressors & daily hassles
- SES disadvantage & parental unemployment, low levels of parent education
Life Stress Models
- Diathesis-stress models: depression is a function of the interaction between personal vulnerability & external stress
- Exposure to event, triggers cognitive disposition
- Prolonged physical illness (Reinherez et al., 1993)
Comorbidity:
Findings suggest most comorbidity with Persistent Depressive Disorder/Dysthymia, Anxiety Disorders, ODD/CD, and ADHD
- Dysthymia: 30% - 80%
- Anxiety Disorders: 30% to 80%
- ADHD: 47.9 to 57.1%
-CD/ODD: 42%
Almost half of children with major depression disorder have another disorder
The majority of children with Major Depressive Disorder or Dysthymia have some type of comorbidity (Klein et al., 2005)
Assessment: Developmental Perspective
Consideration of Developmental factors
- Expression of symptoms
- Language & cognitive abilities
- Normative fluctuations of mood versus clinically meaningful depression
Consider assessing domains of functioning during life stages
Consideration of associated symptoms & comorbid conditions
Progress monitoring
Assessment
Multi-dimentional/ assessment
Purposes of assessment
-Screening
Prognosis
- Treatment planning
- Treatment monitoring & evaluation
Level of depression
- Syndrome
- Mood
- Disorder
Multi-informant, multi-dimensional approach allows clinicians opportunities to best understand a child’s behavior
Two main types of assessments: Diagnostic Interview and Behavior Rating Scales
–Interviews: PAPA, DISC, K-SADS
–Rating scales: Reynolds Child Depression Scale, BASC-2, CBCL, CDI
- Multiple Informants/ Sources
- -Self, parent, teacher
- Informant considerations
- -Reporters can give discrepant reports
- -Age of child
Direct Observations
must have
