Download Child and Adolescent Psychopathology

Depressive Disorders
Chapter 17
Daniel N. Klein, Autumn J. Kujawa, Sarah R.
Black, and Allison T. Pennock
HISTORICAL CONTEXT
 Recognition of child and adolescent depressive
disorders did not emerge until the late 1970s.
 Before the 1970s depression was thought to be
rare in children and clinicians believed that
depression was expressed in behavioral
disturbances such as behavior problems, enuresis,
and somatic concerns.
 During the late 1970s, investigators demonstrated
that many children and adolescents met full adult
criteria for major depressive disorder (MDD).
TERMINOLOGICAL AND
CONCEPTUAL ISSUES
 Depression is a complex phenomenon and can encompass:
 A mood state
 A clinical syndrome that can be caused by a variety of nonpsychiatric
factors such as neuroendocrine disorders and psychoactive drug use
 A psychiatric disorder
 Depressive disorders are multifactorial conditions—caused by
combinations of many etiological factors.
 Depressive disorders are probably etiologically
heterogeneous, meaning that there are different subtypes of
depression that are caused by different sets of etiological
processes.
 Depressive disorders are characterized by both equifinality
and multifinality.
DIAGNOSIS AND
CLASSIFICATION
 DSM-IV (2000)
 MDD: A period of persisting depressed or irritable mood
or loss of interest or pleasure that lasts at least 2 weeks
and is accompanied by a variety of other symptoms,
including:
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Low energy and fatigue
Inappropriate feelings of guilt or worthlessness
Difficulty thinking, concentrating or making decisions
Sleep disturbance (insomnia or hypersomia)
Appetite disturbance (eating too little or too much or significant
weight loss or gain)
• Psychomotor disturbance (either retardation [extreme slowing in
movement and speech], or agitation [extreme restlessness])
• Thoughts of death or suicidal thoughts or behavior.
DIAGNOSIS AND
CLASSIFICATION
 Dysthymic disorder (DD) is a milder but more chronic
condition, characterized by a period of depressed or
irritable mood that is present for at least half the time for
at least one year and is accompanied by several other
depressive symptoms.
 Subtypes
 Unipolar-bipolar distinction, differential symptom
presentation, and course.
 Unfortunately, subtyping has largely been ignored
in child and adolescent depression.
DIAGNOSIS AND
CLASSIFICATION
 Depression in Very Young Children
 Little research exists on depression in infants and
preschool aged children
 Luby and colleagues (2003) reported that MDD can be
identified in preschool-age children using modified DSMIV criteria with a shorter duration requirement.
 Preschoolers meeting modified criteria for MDD had an
11-fold greater risk of exhibiting MDD 12 to 24 months
later compared to healthy children (Luby, Si, Belden, Tandon &
Spitznagel, 2009).
EPIDEMIOLOGY
 Prevalence
 Studies of community samples indicate that depression is
rare in early childhood, increases somewhat in
middle/late childhood, and rises sharply in adolescence.
 A meta-analysis of 26 studies estimated that the point
prevalence of MDD was 2.8% in school-age children and
5.7% in adolescents (Costello, Erkani, & Angold, 2006).
 By mid-late adolescence, the lifetime prevalence of
depression approaches adult rates (Rudolph, 2009).
EPIDEMIOLOGY
 Sex Differences
 Depressive symptoms and diagnoses in males and
females are similar in childhood but between the ages of
12 and 15 rates among females increase markedly (Hyde,
Mezulis, & Abramson, 2008; Nolen-Hoeksema & Hilt, 2009).
 Comorbidity
 Depressed children and adolescents are:
• 8.2 times more likely than nondepressed youths to meet criteria for
an anxiety disorder
• 6.6 times more likely to meet criteria for conduct disorder
• 5.5 times more likely to meet criteria for attentiondeficit/hyperactivity disorder (Angold, Costello, & Erkanli,1999).
COURSE AND OUTCOME
 Clinical samples tend to have a longer duration than community
samples:
 Mean duration of MDD episodes is approximately 7 to 8 months.
 Episodes of DD last an average of 48 months.
 40% to 70% of adolescents with MDD experience a recurrence in
adulthood (Fombonne et al., 2001).
 Predictors of increased risk of recurrence:
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Greater severity
Psychotic symptoms
Suicidality
Prior history of recurrent MDD
Subthreshold symptoms after recovery
Depressotypic cognitions
Recent stressful life events
Adverse family environments
Family history of MDD
RISK FACTORS
 Genetics
 Temperament
 Maladaptive parenting and abuse
 Biological factors
 Cognitive factors
 Peer relationships
 Life stress
PROTECTIVE FACTORS
 Little research on protective factors in youth
depression.
 Most research focuses on variables that appear to
be the absence or opposite of established risk
factors, such as high self-esteem and self-efficacy,
an “easy” temperament, and family and peer
support.
CONCLUSIONS AND FUTURE
DIRECTIONS
 Genetic factors play a role in youth depression, but
the strength of their influence varies as a function
of development, given that genetic effects increase
with age.
 Genetic influences are likely to operate through
intermediate phenotypes such as temperament
and susceptibility to stress.
 Genetic influences are also mediated and/or
moderated by a number of other risk factors.
 Two major sets of distal causes include genetic
susceptibilities and early adversities.