Child and Adolescent Depressive Disorders



Child and Adolescent Depressive Disorders


Elizabeth McCauley PhD, ABPP,

Gretchen R. Gudmundsen PhD,

Carol Rockhill MD, PhD, MPH,

My Banh PhD



Introduction

It is now recognized that depressive disorders represent a serious mental health risk for children and adolescents. Depression can present along a wide continuum stretching from brief episodes of low mood, which resolve spontaneously, to a disabling complex of symptoms that persist over time. Community-based research suggests that 20% of youth report having experienced a clinically significant depressive episode by age 18, while 65% of adolescents report experiencing transient or less severe depressive symptoms. Even subclinical levels of depressive symptomatology can, however, derail the normal developmental process, interfering with academic and social functioning and increasing risk for both substance use and suicide. Moreover, the sequelae of early-onset depression include a host of later psychosocial deficits, including poor global and adaptive functioning, academic and occupational impairment, disrupted interpersonal relationships, early childbearing, reduced life satisfaction, and substance abuse or dependence. These far-reaching consequences underscore the importance of improving our ability to identify and intervene with depressed youth.

Given the scope of the problem of depression in children and adolescents, the lack of adequate mental health resources, and the issues of stigma, clinicians in a variety of community settings including primary care offices and schools are faced with taking increasing responsibility for detection and management of these mental health problems. When symptoms of depression occur, youth and families are likely to turn first to known providers or institutions for direction and support. In many cases, primary care medical providers are contacted first as for many children and adolescents somatic complaints may be the first signs of depression and less stigma is attached to seeking medical rather than mental health care. In other cases, schoolbased care providers are called upon for help as declines in school performance and attendance may herald the onset of depression.

Evidence-based guidelines for the management of depression across the severity continuum within community-care settings underscore the need for varied approaches that range from “watchful waiting” in youth with mild symptoms to multimodal interventions in more severe cases. Determining how best to recognize each child’s level of need remains a challenge. This chapter will summarize recent findings about depressive disorders in children and adolescents and review practical strategies that can be used to provide effective identification, assessment, and management within primary care or community-based settings.


Background

Historically, depression was considered a phenomenon that only adults experienced. Before the 1980s children were seldom given a diagnosis of depression as it was widely believed that they were not cognitively or emotionally mature enough to experience or comprehend the
sense of loss or the internalization of aggression that many thought were essential elements underlying a clinically significant depressive reaction. Young people, especially preadolescent children, also tended to present with a mixture of mood-related symptoms like sadness coupled with somatic symptoms and/or noncompliance and acting out. In the late 1970s, the term “masked depression” was coined and used to describe youth whose clinical presentation included a variety of mood and behavioral disorder symptoms, but depression was thought to be a central component of the underlying problem.

During this time, efforts were being made to standardize the diagnostic process to provide a reliable method to ascertain a diagnosis across research groups and parts of the country. In this context, semi-structured diagnostic interviews were developed, which outlined strict criteria for making a diagnosis. This movement began with studies of adult psychopathology but soon trickled down to work with children and adolescents. In 1980, two landmark studies presented data indicating that using structured diagnostic interviewing and the existing adult criteria (DSM-III) was a valid way to diagnose depression in children. With this, masked depression fell by the wayside and a new wave of research on the development, course, and treatment of depression in children and adolescents was ushered in. This research has confirmed that children and adolescents experience a range of depressive disorders that are qualitatively similar in nature to those experienced by adults. Ironically, we have now come full circle as today we recognize that depression in young people typically presents as part of a complex constellation of emotional and behavioral problems, with anxiety and disruptive behavior disorders frequently presenting along with depressive symptoms.


Clinical Features

Depressive disorders involve individuals experiencing a change from their normal mood (euthymia) to a depressed state. These episodes may vary in number, type, and duration of depressive symptoms. Developmental level accounts for some differences in symptom presentation. Anhedonia, or the lack of enjoyment of activities, is a hallmark symptom of depression in very young children. Preadolescents are also more likely to report somatic complaints such as stomachache or headache more frequently than adolescents who report more hopelessness, fatigue, weight loss, and suicidal ideation and attempts.

The current psychiatric diagnostic manual, the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR), discusses a number of depressive diagnoses, as described in Table 11-1, that can be useful when assessing children and adolescents with major depressive disorder (MDD), dysthymic disorder (DD), depression not otherwise specified (NOS), and depression secondary to a general medical condition. Diagnostic criteria for core depressive disorders for youth parallel adult criteria, with a few exceptions. In youth MDD, irritability can be the primary emotion rather than sadness, and a child or an adolescent who experiences depressive symptoms for 1 year qualifies for a diagnosis of DD, whereas a 2-year duration of symptoms is required for adults.

Depressive disorder NOS best characterizes young people who report periods of low mood accompanied by low self-esteem or loss of interest in normally enjoyable activities, but either do not demonstrate all of the symptoms necessary to warrant a diagnosis of MDD or show a relatively recent onset of difficulties with depressed mood. In some cases their periods of low mood wax and wane. This diagnosis can be useful as a “working diagnosis” when depressive symptoms are present, but the potentially causal role of an underlying medical condition is still being evaluated.

Within the diagnosis of MDD, some young people have variant presentations. Specifically, adolescents, more frequently than adults, present with what has been termed “atypical depression.” This variant of MDD is characterized by increased reactivity to rejection, lethargy, increased appetite, craving for carbohydrates, and hypersomnia. Some children and adolescents present with
psychotic symptoms. In young children these tend to be brief, transient auditory hallucinations in which the child may hear a voice telling them to hurt themselves or others. Delusional thinking is more common in adolescents who may be troubled by persistent and intrusive beliefs that they are dying or controlled by some outside power. Efforts to clearly identify a group of young people with seasonal mood disorder have met with mixed results. Because the shorter, darker days of northern climates correspond with the school year, it can be difficult to disentangle the stressors related to school from the impact of reduced light exposure. Other variants in the presentation of depression may reflect ethnocultural differences; for instance, Asian American girls are more likely to describe depression as part of a relational problem (e.g., being misunderstood), having low selfesteem (e.g., “feeling insecure, useless, and insufficient”), and feeling stressed.








TABLE 11-1 Characteristics of DSM-IV Depressive Disorders




















Diagnosis


Key Clinical Features


Major depressive disorder (MDD)




  • Depressed, sad, or irritable mood or anhedonia



  • One cardinal symptom (listed above) in concert with at least four additional symptoms



  • All symptoms must be present during the same 2-week period and must represent a change from previous functioning


Dysthymic disorder (DD)




  • Depressed, sad, or irritable mood for most of the day for more days than not for 1 year (must not have gone for more than 2 months without experiencing two or more symptoms)



  • More protracted, less severe course than MDD (mean episode length of 33-48 months)



  • Heightens risk for development of MDD


Depressive disorder not otherwise specified (NOS)




  • Depressed, sad, or irritable mood or anhedonia, but mood disturbance does not meet DSM-IV criteria for full episodes


Depression secondary to a general medical condition




  • Depressed or irritable mood or anhedonia in most or all activities



  • Symptoms are determined to be directly related to the presence and physiologic consequences of a medical condition.


Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Text Revision). Washington, DC: Author, 2000.


Many youth also present with depressive symptoms in the context of significant or chronic health conditions. When depressive symptoms appear only in the context of significant illness, a diagnosis of depression secondary to a general medical condition should be used. Many of these youths have no history of mental health concerns prior to the onset of their illness but become overwhelmed or demoralized in the face of loss of function, pain, and in some cases lifethreatening circumstances. For others, significant depressive symptoms may have predated their health concerns or have been significant even when physical symptoms are in remission, suggesting the need for a diagnosis of depression independent of their medical diagnosis.


Differential Diagnoses

Given the variability in how depression can present, it is critical to consider whether there is another more central problem to address. Thus, whenever considering a depression diagnosis, the first step is to rule out the presence of an underlying medical condition (see the section “Assessment”) with care to also determine whether the young person is exhibiting depressive symptoms secondary to another emotional or behavioral disorder. In addition, youth with undetected eating disorders (bulimia, early stages of anorexia nervosa) and anxiety sometimes first present with depressive symptoms.



Severity Continuum

It is also useful to categorize depressive disorders by levels of severity as this helps guide immediate treatment planning. Categorization is based on the presence or absence of the nine key symptoms (depressed mood/irritability, anhedonia, as well as difficulties with fatigue, sleep disturbance, appetite disturbance, thoughts of death or suicide, decreased concentration, self-blame/hopelessness/down on self, and psychomotor retardation/agitation) coupled with duration of symptoms and degree of impairment in psychosocial functioning. Thus, mild depression is defined as five to six or fewer symptoms of short duration with limited impairment, moderate depression as seven to eight symptoms of longer duration with moderate impairment, and severe depression as persistent presentation of most symptoms with marked impairment. If impairment is marked and suicidal ideation or psychotic symptoms are present, the depression is considered severe regardless of the number of symptoms present.


Epidemiology

Depression can vary in terms of severity, but most of the epidemiologic research has focused on clinically significant depression, or MDD with a subset of studies including youth with DD as well as those with MDD. Few epidemiologic studies have included very young children, but an epidemiologic study completed in the 1980s identified nine young children who met criteria for MDD from a community sample of 1000 preschoolers. More recently, Luby and her research team have conducted a series of studies to validate developmentally modified criteria for depression in preschool-aged children, which should lay the groundwork for further epidemiologic work with this age group.

Within the diagnostic context outlined earlier in the text, in 2002 the National Institutes of Mental Health estimated that approximately 6 million children and adolescents between the ages of 9 and 17 experience an episode of clinically significant depression over the course of their childhood and adolescent years. MDD is considered somewhat rare in children, with a 12-month prevalence of less than 3% in the sixth- to ninth-grade years. However, as reviewed by Hankin and colleagues, the rate of depressive disorders escalates over fivefold in the adolescent years reaching 17% during the 18th year of life, while 65% of adolescents report experiencing transient or less severe depressive symptoms. While rates of depression increase during this period for both boys and girls by middle to late adolescence, depressed females outnumber depressed males by a ratio of 2 to 1. A growing body of research suggests some variation in prevalence of depression across different ethnocultural groups, with Hispanic American youth demonstrating higher rates of depression and Asian American reporting lower levels of depression. Finally, between 5% and 10% of young people present with subsyndromal symptoms that do not meet criteria for MDD or dysthymia, but are associated with concerning outcomes, including considerable psychosocial impairment and increased risk for suicide and the development of more significant depression.


Risk Factors

Depression is most likely to develop when a number of risk factors converge. Inherited or biologic vulnerabilities may contribute to risk for depression. Family and twin studies suggest heritability estimates for depression of up to 50%, and descriptive research indicates that having a parent with depression is one of the strongest and most reliable risk factors for depression in children. Children may also learn depressive coping styles from observing a depressed parent and being exposed to more stressors when living with a depressed parent. Young people may also inherit temperamental qualities such as sensitivity to negative emotions, which can contribute to risk for depression.


It is widely believed that depression affects a vulnerable person (based on biologic, cognitive, or a combination of risk factors) when he or she is faced with stressful life events. For young people, major life events such as parental separation or divorce or exposure to abuse or neglect as well as peer and school pressures, loss of a friendship or romance, or a geographic move can trigger depression. Depression that first presents in childhood has been strongly associated with exposure to stressful environments. Goodyer and colleagues suggest that depressed youth may be born with dysfunctional neuroregulatory mechanisms or develop atypical responses when exposed to early stressors. In their studies, youth with hypersecretion of stress-related hormones (salivary Cortisol and dehydroepiandrosterone) and recent losses were the most likely to develop a depressive disorder.

Although heritability estimates are high, researchers consistently underscore the importance of the gene-environment interaction in the development of depressive disorders. For example, there is a wealth of evidence implicating dysfunction in serotonergic signaling in depression, a process controlled in part by the serotonin transporter (SERT) gene. Initial studies suggested that the 5-HTTLPR polymorphism of SERT coupled with exposure to stress during childhood increased the risk of depression in adulthood. Although a recent meta-analysis by Risch and colleagues casts doubt on the specific role of the 5-HTTLPR polymorphism of SERT in mediating depression, the SERT gene itself remains an important candidate gene for depression.


Comorbidities

Having a “pure” form of a single psychiatric disorder is uncharacteristic of the majority of children with mental health conditions. Among depressed youth, the frequency of having a comorbid psychiatric diagnosis ranges across studies from 40% to 90%. The most common co-occurring problem is anxiety. Youth with a depressive disorder are up to eight times more likely than youth without depression to have a co-occurring anxiety problem. Longitudinal studies document that anxiety typically precedes the onset of depression and that anxious symptoms in childhood serve as an independent risk factor for depressive symptoms in adolescence. Significant separation anxiety in early childhood is commonly reported when gathering history of youth with comorbid depression and anxiety. Generalized anxiety disorder symptoms are most typical, as panic disorder is less common in both children and adolescents than in adults. Posttraumatic stress disorder can be associated with both generalized anxiety and depressive symptoms. Anxiety symptoms typically persist even after the depressive symptoms become apparent. In addition, McCauley and colleagues have found that depressive and anxiety disorders are more common in young people with chronic illness and add to symptom burden and functional impairment.

Depression also frequently co-occurs with externalizing behavioral problems. Clinically depressed youth are 5.5 times more likely to have attention-deficit hyperactivity disorder (ADHD) and 6.6 times more likely than youth without depression to meet the criteria for conduct disorder (CD) or oppositional defiant disorder (ODD). Externalizing behavior problems tend to be present before depressive symptoms are apparent, and persist even while depressive symptoms wax and wane. A “dual failure” model has been proposed to explain the co-occurrence of depressive and conduct problems. This model posits that the repeated academic and social failures experienced by youth with ADHD and conduct problems (ODD and CD) lead to moodiness and poor emotional control, thereby increasing vulnerability to depression.

Comorbidity with substance use or abuse is also common as youth move into adolescence. In one study, Rohde and colleagues reported a depression prevalence of 47.9% among high school students with alcohol abuse or dependence compared to about 20% in abstainers, experimenters, or social drinkers. A negative affect pathway in which youth turn to alcohol or other drugs to alleviate psychological distress has been proposed, but efforts to test this model have resulted in inconsistent findings. Depression typically precedes adolescent substance use and abuse, but substance use also exacerbates depression.



Clinical Course

Depressive episodes in children and adolescents can persist for a significant period of time with mean length of episode across samples ranging from 9 to 17 months. The persistence of depression over this kind of time period can clearly alter the developmental process. Depression is associated with a high recurrence rate, with between 40% and 69% of adolescents experiencing a relapse within 2 to 5 years.

Differential outcomes have been associated with age of onset. Depression that first presents during childhood appears to increase the risk for a number of behavioral problems later in life including both conduct- and mood-related difficulties. In contrast, depression that first presents in adolescence has been more strongly associated with a family history of depression and follows a course similar to that observed in adults, with increased risk for recurrence of depressive disorders over time.


Developmental Considerations

Recent research led by Joan Luby has documented that even preschool-aged children experience depression. In infants and toddlers, depression is most frequently associated with deprivation and can take the form of failure to thrive. In preschoolers, anhedonia or loss of interest in activities has been identified as a “highly specific symptom of depression” based on parental interviews, observations of play, and alterations in stress Cortisol reactivity. While large-scale studies of the prevalence of depressive disorders are not available for very young children, they appear to be rare. As noted earlier in the text, the prevalence of depression remains fairly low in childhood but increases markedly as youth move through adolescence.

Neurologic development, physical growth, and sexual maturation are factors thought to contribute to the increased risk for depression observed during adolescence. Changes in emotions and behavior (changes in sleep, increases in moodiness, emotional intensity, romantic interests, and risk taking) are observed at the time of pubertal development. Sexual maturation and the intensification of emotions occur while the adolescent’s nervous system is also undergoing a number of structural changes (completion of brain cell genesis, nerve myelination, and dendrite pruning in the frontal cortex) that lay the foundation for more sophisticated cognitive skills. These cognitive skills (inhibitory control, problem solving, and long-term planning), however, only become operational as the adolescent matures and gains experience. Because there is typically a developmental lag between the onset of the emotional and behavioral activation of early puberty and the mastery of cognitive and emotional coping skills, problems with affect regulation intensify during the early adolescent period. For example, because they have not mastered the cognitive and coping skills needed to handle strong emotions, adolescents are prone to biased interpretations of experiences, self-criticality, and low inhibitory control. They also use coping mechanisms that are emotion focused, such as talking about problems with friends or wishful thinking, strategies that often do not result in problem solving and can exacerbate risk for depression or prolong an existing depression.


Assessment


Screening and Symptom Assessment

The US/Canadian and British guidelines for management of depression in young people stress the importance of early identification of at-risk youth with subsequent monitoring for the development of a depressive disorder. As part of every contact, including well-child or problemfocused medical visits, the guidelines recommend that patients and parents complete a brief screening tool that covers symptoms of depression including thoughts of self-harm and suicide, to allow the care provider to carry out a rapid check for depression and to track changes in symptom presentation over time. Screening tools flag youth in need of more follow-up
while also communicating to the young person that concerns about mood and feelings are legitimate topics for discussion. There are a number of patient/parent self-report scales and clinician’s interviews that can be incorporated readily into routine practice (Table 11-2).








TABLE 11-2 Screening and Interview Measures









































Measure


Informants


Number of Items


Depression measures


Moods and Feelings Questionnaire (MFQ; Angold and Costello 1987)


Youth (age 8-18) and parent version


32 items (complete form); 13 items (short form)


Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, and Williams, 2001)


Adolescents


9 items


Childhood Depression Inventory (CDI; Kovacs, 1992)


Youth (age 7-17)


27 items


Reynolds Child Depression Scale (RCDS; Reynolds, 1989)/Reynolds Adolescent Depression Scale (RADS; Reynolds, 1987)


Youth-Child (8-12)/Adolescent (13-18)


30 items


Beck Depression Inventory (BDI; Beck and Steer, 1993)


Adolescents


21 items


Broadband measures


Achenbach System of Empirically Based Assessment (Achenbach and Rescorla, 2001): Youth Self-Report (YSR); Child Behavior Checklist (CBCL)


Youth (age 11-18) and parent (regarding youth age 5-18)


118 items


Semi-structured interview guidelines


HEADDSSS psychosocial interview for adolescents (Goldenring and Cohen, 1988; Goldenring and Rosen, 2004)


Adolescents


Domains: home, education/employment, activities, diet, drugs, sexuality, suicidality/depression, safety


As outlined in Table 11-3, a brief psychosocial assessment should be built into each medical clinic or community-care visit, via the inclusion of brief but routine questions that ask about home, school, and social functioning.

As with a screening questionnaire, asking key questions about social and emotional adjustment communicates to the child or adolescent that these are legitimate topics to bring up and opens the door for further discussion if/when concerns arise. Inclusion of the parents’ perspective in evaluating depressive symptoms is essential for young children and useful at all ages. Assessment of adolescents, however, requires a private interview with the adolescent to discuss issues such as substance abuse and sexual activity and to assess risk for self-harm and suicidal ideation that may be difficult for the teen to reveal in front of their parents. A review of confidentiality and its limits should lead off this interview process. When assessing for self-harm risk, it is essential to ask specifically about thoughts of suicide and engagement in risky or selfharming behaviors. If the youth indicates that he or she has been thinking about suicide, determining whether he or she has a specific plan or access to means (e.g., are there guns in the home) is essential. Inclusion of a safety plan that covers who the youth can turn to for support, ways to manage stressors (e.g., listen to music and take a run), and identification of something the youth has to live for is an effective way to draw this evaluation, no matter how brief to a close. Assessment of co-occurring problems is also essential to assure a clear understanding of
the issues the young person is coping with and identifying what kind of interventions may be needed. Some of the self-report/parent report scales described in Table 11-2 are a good way to track a wide range of problem areas as well as the brief review of current status vis-à-vis substance use and trouble at home, at school, or in the community.






TABLE 11-3 Essentials of Assessment for Child and Adolescent Depression

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Jun 29, 2016 | Posted by in PSYCHIATRY | Comments Off on Child and Adolescent Depressive Disorders

Full access? Get Clinical Tree

Get Clinical Tree app for offline access