Chapter 9: Depressive Disorders in Children

Winnie W. Chung

Mary A. Fristad

Overview

Childhood depression can lead to lifelong physical and mental health concerns

Major Depressive Disorder (MDD): affects 2.8% of children under 13 years old

Children experiencing depressive symptoms or disorders are at greater risk for: Attention and behavioral problemsDisruptions in family functioningAcademic difficultiesSocial problemsSuicideAlcohol or drug abuse

Depression in Childhood

Longer depressive episode duration and relapse/recurrence predicted by: Greater depression severityConflict with parentsComorbid conditionsLower socioeconomic statusFamily history of mood disordersNegative patterns of cognition

80–85% of children with MDD experience a comorbid condition (e.g., anxiety or behavioral disorder)

Evidence-Based Approaches

All child treatment studies are downward extensions of adult approaches

Cognitive behavioral therapy (CBT): well-established treatment approachChild-only group CBT and child group CBT with parent

component are well-established

Behavior therapy as a theoretical approach is considered probably efficacious

Nondirected support, psychoeducational, and family systems are deemed experimental

Child-Only Group CBT

Penn Prevention Program: designed to prevent depressive symptoms, and relates impairment in at-risk children with elevated depressive symptoms and perception of parental conflict 12-week group treatment in schoolCognitive component and social problem solvingDecreases in depressive symptoms post intervention; results maintained

at 6-month follow-up; 3 years post treatment effects diminished

Primary and Secondary Control Enhancement Training program (PASCET): designed to reduce elementary-aged children’s elevated depressive symptoms by increasing primary and secondary coping strategiesSchool settingChildren with mild to moderate depressive symptoms showed

improvement in depressive symptoms, psychosocial functioning, coping, and the caregiver-child relationship

Group CBT

Coping with Depression: purpose is to treat moderate to severe depressive symptoms in 6th to 8th-grade students12 sessions, small groupSelf-change skills, pleasant activities scheduling, cognitive

techniques

Self-Control Therapy: group CBT with parental involvement

Stress-Busters Intervention: 10-session after-school group intervention that includes general skill-building, depression-specific CBT, creation of a videotape

Parent-Child CBT

CBT via Videoconferencing (CBT-VC)8-week CBT protocol using videoconferencingTherapist meets with target child and his/her parent

separately Children (8 to 14 years old) in CBT-CV showed

significantly greater rate of decline in symptoms than children in traditional CBT

Individual Therapy With Parent Component

Contextual Emotion-Regulation Therapy (CERT)30-session problem-focused and developmentally

sensitive treatment targeting children’s self-regulation distress and dysphoria

Parents serve as “assistant coaches” and improve their relationship with their child

Children’s depressive and anxiety symptoms decreased significantly post treatment

Family-Based Therapy

Family-Focused Treatment for Childhood Depression (FFT-CD): treat school-aged children with depressive disorders in the clinic settingIncludes family systems and cognitive-behavioral approaches to

interrupt and reverse negative emotional spirals 9 to 14-year-old children diagnosed with depressive disorder had

significant reduction in depression severity and improvements in global functioning

Multi family Psychoeducational Psychotherapy (MF-PEP): 8-session manualized intervention to use as an adjunctive treatment for children with unipolar depressive or bipolar disordersRCT with 165 8 to 12-year-olds diagnosed with MDD, DD, or bipolar

spectrum exhibited lower levels of mood severity over a year long follow-up period compared to TAU

Parenting-Based Treatment

Parent-Child Interaction Therapy Emotion Development (PCIT-ED): treat depression in 3 to 7-year-old childrenParents and children attend sessions: child-directed

interaction and parent-directed interactionImprove and strengthen parent-child relationship through

in-vivo coaching

Emotionally Attuned Parenting: improve parents’ empathy toward children with severe depression and anxiety disorders

Psychodynamic Approaches

Systems Integrative Family Therapy: emphasizes interpersonal relationships, stressful life events, and problematic attachments using psychodynamic principles

Psychodynamic Psychotherapy: identify core conflictual themes and point out their relations to target children’s symptoms as well as to their parents’ representational world

Parental Involvement

AACAP recommends that families be centrally involved in the treatment of their child with depressionParents serve as gatekeepers for the types and levels of care their

child receivesThey play a vital role in monitoring their child’s progress and acting

as a safety net

Parental characteristics/behaviors hypothesized to contribute to children’s depressive symptoms: Inconsistent and hostile parentingInsecure attachmentInattentiveness to the child’s needsHigh maternal criticismPoor interpersonal skillsIneffective coping styles

Adaptations and Modifications

Adaptations made for different cultural backgrounds

ACTION: for 9 to 13-year-old girls diagnosed with depressive disorder and their parents; positive results with an ethnically diverse sample

PRP: adapted for low-income Latino and African American 5th- to 8th-grade children; content adapted for children in low-income communities and urban settingsAlso has been adapted for Chinese children

Measuring Treatment Effects

K-SADS: semi structured interview that incorporates information from parents, children, and clinical judgment to determine pre- and post-treatment diagnoses based on DSM-IV

Preschool Age Psychiatric Assessment: parent interview to determine psychiatric diagnoses in children ages 2 to 5 years old

ChiPS: structured interview with child and parent forms; assesses 20 behavioral, anxiety, mood, and other syndromes according to DSM-IV

Assessing Symptoms and Global Functioning

CDI: self-report measure of children’s depressive symptoms in the previous 2 weeks

Mood and Feelings Questionnaire: parent- and child-report rating scale that assesses symptoms of depression

CBCL: parent-, child-, teacher-report checklistCDRS-R: semi-structured interview that combines

parent and child inputCGAS: overall summary score that ranges from 0

to 100. Clinicians rate children’s functioning.

Assessing Targeted Treatment Outcomes

CASQ: child-report measure to assess children’s explanatory styles

ATQ: self-report measure to assess the frequency at which children make negative self-statements and have negative automatic thoughts

FES: used to assess family functioning on three dimensions: interpersonal relationship, personal growth, and system maintenance

Clinical Case Example: Janelle

9-year-old girl

Symptoms: dysphoric mood, irritable mood, withdrawn behavior, fatigue, feelings of worthlessness

Diagnosis: Depressive Disorder Not Otherwise Specified (D-NOS)

Treatment goals: 1) Reduce the frequency and intensity of Janelle’s depressed and

irritable moods2) Improve Janelle’s self-esteem3) Equip Janelle with coping skills to manage her moods4) Improve Janelle’s social relationships

Clinical Case Example (Cont’d)

Therapy: 18 sessions over 4 monthsResults: Steady improvements in Janelle’s moods

and behaviors; Janelle no longer exhibited frequent periods of dysphoric and irritable moods, seldom made negative self-statements, but rather began describing positive characteristics of herselfBecame engaged in extracurricular activities