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Chapter 8
Mood Disorders
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Overview of Mood Disorders
 Mood disorders run the spectrum from severe depression to
extreme mania and involve extreme, persistent, or poorly
regulated emotional states
 DSM-IV-TR divides mood disorders into two general
categories:
 depressive disorders: excessive unhappiness
(dysphoria) and loss of interest in activities
(anhedonia)
 irritability is one of the most common symptoms,
occurs in 80% of clinic-referred, depressed
children
 bipolar disorder: mood swings from deep sadness to
high elation (euphoria) and expansive mood (mania)
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Depression
 A pervasive unhappy mood disorder more severe than the
occasional blues or mood swings everyone gets from time to
time
 The symptoms are so universal that it is sometimes called
“the common cold of psychopathology”
 Children who are depressed can’t shake their sadness
and it interferes with their daily routines, social
relationships, school performance, and overall functioning
 often accompanied by anxiety or conduct disorders
 often goes unrecognized and untreated
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Depression (cont.)
 History
 In the past, it was mistakenly believed that depression did
not exist in children in a form comparable to that in adults
 We now know that children do experience depression,
and that depression in children is not masked, but rather
may be overlooked because it frequently co-occurs with
other more visible disorders
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Depression (cont.)
 Depression in Young People
 5% of children and 10-20% of adolescents experience
significant depression at some time
 They display lasting depressed mood in face of real or
perceived distress with disturbances in thinking,
physical functioning, and social behavior
 Suicide among teens is a serious concern
 90% show significant impairment in daily functions
 Depression in young people is a serious concern
because of long-lasting emotional suffering, problems
in everyday living, heightened risk for suicide,
substance abuse, bipolar disorder, poor health
outcomes, and higher health care costs
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Depression (cont.)
 Depression and Development
 Experience and expression of depression change with age
 In children under age 7 (as young as 3-5) it tends to be diffuse
and less easily identified
 Anaclitic depression (Spitz): infants raised in a clean but
emotionally cold institutional environment displayed reactions
resembling depression, sometimes resulting in death
 Similar symptoms can occur in infants raised in severely
disturbed families
 Depressed preschoolers may appear extremely somber and
tearful, lacking exuberance, bounce, and enthusiasm; may
display excessive clinging and whiny behavior around mothers
and fear of separation or abandonment; irritability
 Depressed school-aged children show similar symptoms, plus
increasing irritability, disruptive behavior, tantrums, and
combativeness
 Preteens show similar symptoms, plus self-blame and low selfMash/Wolfe Abnormal Child Psychology, 4 edition
esteem
© 2009 Cengage Learning
th
Depression (cont.)
 Anatomy of Depression
 As a symptom: feeling sad or miserable
 occurs in 40% or more of children and adolescents; for
most, symptoms are temporary
 As a syndrome: a group of symptoms that occur together more
often than by chance; mixed symptoms of anxiety and
depression that tend to cluster on a single dimension of
negative affect
 As a disorder:
 major depressive disorder (MDD): minimum duration of 2
weeks; associated with depressed mood, loss of interest,
other symptoms, and significant impairment in functioning
 dysthymic disorder: depressed mood, generally less severe
but longer lasting symptoms (a year or more), and
significant impairment in functioning
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Major Depressive Disorder (MDD)
 Key features: sadness, loss of interest or pleasure in nearly all
activities (anhedonia), irritability, and other specific symptoms that
are present for at least 2 weeks
 Symptoms must represent change from previous functioning
 Diagnosis requires the presence of a major depressive episode,
exclusion of other conditions (e.g., prior occurrence of a manic
episode), and ruling out physical factors, normal bereavement, or
underlying thought disorder
 Diagnosis in children:
 same criteria for school-age children and adolescents
 depression is easily overlooked because other behaviors attract
more attention
 some features (e.g., irritable mood) are more common in
children and adolescents than in adults
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Major Depressive Disorder (cont.)
 Prevalence:
 2-8% of children ages 4-18
 Rare among preschool (<1%) and school-age children (2%),
increases two- to threefold by adolescence and adulthood
 Rates vary with length of time in which symptoms are
assessed; prevalence is about 3% if assessed at a single point
in time and 8% if assessed over a 1-year period; lifetime
prevalence in adolescents may be as high as 20% for 14-18year-olds, although this may be underestimated
 The modest increase from preschool to elementary school may
reflect growing self-awareness and cognitive capacity, verbal
ability to report symptoms, and increased performance and
social pressures
 The sharp increase in adolescence may result from biological
maturation at puberty interacting with developmental changes
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Major Depressive Disorder (cont.)
 Comorbidity: As many as 90% of youngsters with depression
have one or more other disorders; 50% have two or more
 Most common comorbid disorders in clinic-referred
youngsters are anxiety disorders (especially GAD),
specific phobias, separation anxiety disorders
 Depression and anxiety are more visible as separate, cooccurring disorders as severity of disorder increases and
child gets older
 Other common comorbid disorders are dysthymia,
conduct problems, ADHD, substance-use disorder
 60% have comorbid personality disorders, especially
borderline personality disorder
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Major Depressive Disorder (cont.)
 Onset, Course, and Outcome
 May be gradual or sudden; usually a history of milder episodes
that do not meet diagnostic criteria
 Age of onset usually between 13-15 years
 Average episode lasts 8 months (longer if a parent has history
of depression)
 Most children eventually recover, but the disorder does not go
away
 Chance of recurrence: 25% within 1 year, 50% within 2
years, 70% within 5 years
 About 1/3 develop bipolar disorder within 5 years after onset
of depression
 Overall outcome is not optimistic: even after recovery, children
often continue to experience adjustment and health problems
and chronic stress
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Major Depressive Disorder (cont.)
 Gender, Ethnicity, and Culture
 No gender differences until puberty; then females are 2-3 times
more likely to suffer from depression; also, more susceptible to
milder mood disorders, and more likely to experience recurrent
episodes
 Symptom presentation is similar for both sexes, although
correlates of depression differ for the sexes
 Physical, psychological, and social changes are related to the
emergence of sex differences in adolescence
 Low birth weight predicts depression in adolescent girls, but not
boys
 Sex differences partly rooted in biological differences in brain
processes that regulate emotions
 Relationship between depression and race and ethnicity during
childhood is not well studied
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Dysthymic Disorder (DD)
 Dysthymic Disorder (DD), or dysthymia, is characterized by
depressed mood for most of the day, on most days, for at
least 1 year
 It is less severe but more chronic than MDD
 Symptoms include poor emotion regulation: constant
feelings of sadness and of being unloved and forlorn, selfdeprecation, low self-esteem, anxiety, irritability, anger,
and temper tantrums
 Children with both MDD and DD have “double
depression”
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Dysthymic Disorder (cont.)
 Prevalence & Comorbidity
 Rates of DD are lower than MDD, with approximately 1% of
children and 5% of adolescents affected
 Most common comorbid disorder is MDD; about one-half of
dysthymic children also have one or more co-occurring
nonaffective disorders that preceded dysthymia, such as
anxiety disorders, conduct disorder, or ADHD
 Onset, Course, and Outcome
 Most common age of onset 11-12 years
 May be a precursor to MDD for some children
 Average episode length 2-5 years
 Most recover, but are at high risk for developing other
disorders, especially MDD, anxiety disorders, and conduct
disorder
 Adolescents with DD receive less social support than those with
MDD
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Associated Characteristics of Depressive Disorders
 Intellectual and Academic Functioning: Difficulty concentrating, loss
of interest, and slowness of thought and movement are likely to
have a harmful effect on intellectual and academic functioning,
resulting in lower scores on tests, teacher ratings, and levels of
grade attainment
 Interference with academic performance, but not necessarily
related to intellectual deficits; may have problems on tasks
requiring attention, coordination, and speed
 Cognitive disturbances: Deficits and distortions in thinking; feelings
of worthlessness, attributions of failure, self-critical automatic
thoughts, depressive ruminative style, pessimistic outlook, negative
thinking and faulty conclusions generalize across situations,
hopelessness, and suicidal ideation
 Negative Self-Esteem: Low or unstable self-esteem; may be related
to body image
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Associated Characteristics (cont.)
 Social and Peer Problems: Few close friendships, feelings of
loneliness and isolation, social withdrawal, ineffective coping in
social situations
 Family Problems: Less supportive/more conflictual relationships with
parents and siblings; feel socially isolated from families and prefer to
be alone
 Depression and Suicide
 Profound feelings of hopelessness, helplessness, and despair
may lead to suicide attempt
 Most youngsters with depression think about suicide; as many
as one-third attempt it
 Most common methods: drug overdose and wrist cutting
 Most common methods for those who complete suicide are
firearms, hanging, suffocation, poisoning, overdose
 Strongest risk factors worldwide are having a mood disorder and
being a young female
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Theories of Depression
 Psychodynamic
 Depression is the conversion of aggressive instinct into
depressive affect and results from the actual or symbolic loss of
a love object that is loved ambivalently
 Attachment
 Parental separation and disruption of an attachment bond are
predisposing factors for depression
 Behavioral
 Emphasizes the importance of learning, environmental
consequences, and skills and deficits in the onset and
maintenance of depression
 Depression is related to a lack of response-contingent
positive reinforcement
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Theories of Depression (cont.)
 Cognitive theories focus on the relationship between negative
thinking and mood, and emphasize “depressogenic” cognitions--the
negative perceptual and attributional styles and beliefs associated
with depressive symptoms
 Hopelessness theory: Depression-prone individuals tend to
make internal, stable, and global attributions for the cause of
negative events (negative attributional style)
 Beck’s cognitive model: Depressed individuals make negative
interpretations about life events because they use biased and
negative beliefs as interpretive filters
 Cognitive problems:
 information-processing biases (negative automatic
thoughts)
 negative outlook regarding oneself, the world, and the
future (“cognitive triad”)
 negative cognitive schemata
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Theories of Depression (cont.)
 Self-control theories: view depression as associated with
difficulties in organizing behavior in relation to long-term
goals
 Deficits in self-monitoring, self-evaluation, selfreinforcement
 Interpersonal models: view disruptions in relationships as the
basis for the onset and maintenance of depression
 Socioenvironmental models: emphasize the relationship
between stressful life events and depression
 Diathesis-stress model of depression: the impact of stress
may be moderated by individual risk factors (e.g., genetic
risk)
 Neurobiological models: emphasize the role of genetic
vulnerabilities and neurobiological abnormalities
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Causes of Depression
 Due to the many interacting influences, multiple pathways to
depression are likely
 Genetic risk influences neurobiological process and is
reflected in early temperament characterized by
 oversensitivity to negative stimuli
 high negative emotionality
 disposition to feeling negative affect
 These early dispositions are shaped by experiences in
the family and negative family experiences may create an
inconsistent emotional and social environment that create
difficulties for the child with regulating emotion,
interpersonal behavior, and coping with stress
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Causes of Depression (cont.)
 Genetic and Family Risk
 Twin studies suggest moderate genetic influence, with
heritability estimates ranging from 35-75%
 Children of parents with depression have about 3 times the risk
of having depression; higher when both parents have mood
disorders
 What is inherited is likely a vulnerability to depression and
anxiety, with certain environmental stressors needed for these
disorders to be expressed
 Neurobiological Influences
 Abnormalities in the structure and function of several brain
regions that regulate emotional functions
 Amygdala and hippocampus, HPA axis dysregulation, sleep
abnormalities, growth hormone, and neurotransmitters
(serotonin, dopamine, and norepinephrine) have been
implicated
 Heightened sensitivity to stress
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Causes of Depression (cont.)
 Family Influences
 When children are depressed:
 Families display more critical and punitive behavior toward
the depressed child than toward other children
 Compared with other families, they display more anger and
conflict, greater use of control, poorer communication, overinvolvement, less warmth and support, more
disorganization, higher levels of stress, and a lack of social
support
 When parents are depressed:
 Depression interferes with the parent’s ability to meet the
child’s needs.
 Children experience increased rates of depression before
puberty, and higher rates of phobias, panic disorder, and
alcohol dependence as adolescents and adults
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Causes of Depression (cont.)
 Stressful life events
 Depression is associated with severe stressful life events
 Triggers for depression may involve
 life changes (e.g., moving to a new neighborhood)
 violent family environment
 daily hassles and other nonsevere stressful life events
 interpersonal stress and actual or perceived personal
losses
 Although sadness and depression following these events
are common, they are not inevitable
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Causes of Depression (cont.)
 Emotion regulation: the processes by which emotional
arousal is redirected, controlled, or modified to facilitate
adaptive functioning; the balance maintained among positive,
negative, and neutral mood states
 Children who experience prolonged periods of emotional
distress and sadness and have problems regulating
negative emotions may be prone to depression
 Avoidance or negative behavior may be used to regulate
distress, rather than problem-focused and adaptive
coping strategies
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Treatment of Depression
 Fewer than 50% of children with depression receive help for
their problem
 Cognitive-behavioral therapy (CBT) has shown the most
success in treating children and adolescents with
depression
 Interpersonal Psychotherapy for Adolescent Depression
(IPT-A) has also been effective
 With the exception of SSRIs, which have problematic side
effects, medications have been less effective than CBT
and IPT-A
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Treatment of Depression (cont.)
 Psychosocial Interventions
 Cognitive therapy
 Teaches depressed youngsters to identify, challenge,
and modify negative thought processes, such as
misattributions, negative self-monitoring, short-term
focus, excessively high performance standards, and
failure to self-reinforce
 Behavior therapy
 Focuses on increasing pleasurable activities and
events, and providing the youngster with the skills
necessary to obtain more reinforcement
 Social skills training is an integral component
(assertiveness, communication skills, etc.)
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Treatment of Depression (cont.)
 Psychosocial Interventions, cont.
 Cognitive-behavioral therapy (CBT)
 Involves an integration of cognitive and behavioral
therapies, and has shown the most success in treating
depression in young people
 Primary and Secondary Control Enhancement Training
(PASCET)
 The ACTION Program
 Adolescent Coping with Depression Program (CWD-A)
 Interpersonal Psychotherapy for Adolescent Depression
(IPT-A)
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Treatment of Depressive Disorders
 Medications
 Tricyclic antidepressant medications consistently fail to
demonstrate any advantage over placebo in treating
depression in youth and they have potentially serious side
effects
 SSRIs (e.g., fluoxetine--Prozac) are the most commonly
prescribed medication for treating childhood depression
 despite support for their efficacy, side effects include
suicidal thoughts and self-harm as well as a lack of
information about long-term effects on the developing
brain
 Up to 60% of depressed youngsters respond to placebo,
15-30% respond to brief treatment, suggesting that in
milder cases education, support, and case management
may be effective
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Treatment of Depression (cont.)
 Prevention
 CBT is most effective at lowering risk for depression and
for preventing recurrences
 School-based initiatives may provide a comprehensive
program to enhance protective factors in the environment
and to develop young people’s individual resiliency skills
 Positive Youth Development Programs provide
opportunities and support for achieving the knowledge
and skills necessary to meet the challenges of adulthood
 Large-scale prevention efforts (e.g., Teen Screen) are
directed at early detection of high school students at risk
for depression and suicide
 A high priority needs to be given to programs aimed at
preventing depression in young people
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Bipolar Disorder (BD)
 Features: a striking period of abnormally and persistently elevated,
expansive, or irritable mood, alternating with or accompanied by
one or more major depressive episodes
 Elation and euphoria can quickly change to anger and hostility if
behavior is impeded; elation and euphoria may be experienced
simultaneously with depression
 Controversy involves difficulty in identifying BP in young people,
who show extreme variability and overlap of symptoms with
other childhood disorders
 Significant impairment in functioning: previous hospitalization,
MDD, medication, co-occurring disruptive behavior, anxiety
disorders, psychotic symptoms, suicidal ideation/ attempts
 Symptoms include restlessness, agitation, sleeplessness,
pressured speech, flight of ideas, sexual disinhibition, surges of
energy, expansive grandiose beliefs
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Bipolar Disorder (BP) (cont.)
 Several DSM subtypes based on whether youngster
displays a manic, mixed, or hypomanic episode
 Youngsters with mania may present with atypical
symptoms: changes in mood, psychomotor agitation,
mental excitation, volatile and erratic, irritability,
belligerence, and mixed manic-depressive features
 Classic symptoms for children with mania include
pressured speech, racing thoughts, flight of ideas
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Bipolar Disorder (BP) (cont.)
 Prevalence
 Lifetime estimates of 0.4-1.2%, although it’s difficult to make an
accurate diagnosis
 In youngsters, milder bipolar II and cyclothymic disorder are
more likely than bipolar I; “rapid cycling” also more common
 Extremely rare in young children, but increases after puberty
(when rates are as high as for adults)
 Affects males and females equally, but boys may show more
manic mood and girls more depressed mood
 Comorbidity
 High rates of co-occurring disorders are common
 Most typical are ADHD, disruptive behavior disorders (ODD and
CD), and anxiety disorders; substance abuse is also common
 Co-occurring medical problems: cardiovascular and metabolic
disorders, epilepsy, migraine headaches
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Bipolar Disorder (BP) (cont.)
 Onset, Course, and Outcome
 60% of patients with BP have first episode prior to age 19;
onset before age 10 is rare
 Peak age of onset between 15 and 19 years of age
 Risk factors: major depressive episode (rapid onset),
psychomotor retardation, psychotic features, family
history of mood disorders
 Adolescents with mania typically include psychotic
symptoms (hallucinations, paranoia, thought disorder),
unstable moods with mixed manic and depressive
features, severe deterioration in behavior
 Early onset and course: chronic and resistant to
treatment, with poor long-term prognosis
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Bipolar Disorder (BP) (cont.)
 Causes
 Few studies have looked at the causes of BP in children
and adolescents
 Research with adults suggests that BP is the result of a
genetic vulnerability in combination with environmental
factors (e.g., life stress, family disturbances)
 Multiple genes
 Genetic predisposition does not necessarily mean a
person will develop BP
 Brain imaging studies suggest mood fluctuations are
related to abnormalities in areas of the brain related to
emotion regulation: prefrontal and anterior cingulate
cortex, hippocampal-amygdalar complex, thalamus, and
basal ganglia
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning
Bipolar Disorder (BP) (cont.)
 Treatment
 No cure
 Usually treatment can stabilize mood and allow for
management and control of symptoms
 Multimodal plan includes:
 close monitoring of symptoms
 education of the patient and the family about the
illness
 matching treatments to individuals
 medication, usually lithium
 psychotherapeutic interventions to address symptoms
and related psychosocial impairments
Mash/Wolfe Abnormal Child Psychology, 4th edition
© 2009 Cengage Learning