Childhood Depression

Question 1

The Diagnosis of Childhood Depression

Answer 1

 Diagnostic criteria are essentially the same as for adult major depression

 Need for different intervention strategies

Question 2

Developmental Variations to Childhood Depression

Answer 2

CHILDREN:
 More symptoms of anxiety (e.g., exaggerated fears)

 Somatic complaints (e.g., headaches)

 Irritability & behavior problems (e.g., school refusal)

 Fewer suicide attempts

ADOLESCENTS:
 More sleep and appetite disturbances

 More suicidal ideation & acts

 Increased impairment of functioning

 Compared to adults, more behavioral problems

Question 3

Assessment of Childhood Depression (e.g., K-SADS-PL)

Answer 3

 Importance of multiple methods due to limited cross-informant agreement

 Self-report measures and individual interviews are essential

Question 4

Psychological theories to childhood depression

Answer 4

 In general, the theoretical approaches used to explain adult depression have also been applied to this disorder in childhood and adolescence

 For e.g., behavioural, cognitive, social skills etc

 However, the developmental application of such theories currently lacks a sound empirical basis (Lakadawalla et al., 2007)

Question 5

Developmental Research on Childhood Depression

Answer 5

• Emerging research studying how cognitive theories might be applied to children and adolescents (e.g., Beck’s Theory, 1967, 1987; Hopelessness Theory, Abramson et al., 1978)
• As cognitive development proceeds, the child develops a pessimistic inferential style which interacts with negative life events and maintains depressive symptomatology

Question 6

However…

Answer 6

• Cognitive theory is most valid for adolescents (Lakdawalla et al., 2007)
• For young children, depressive symptoms are more likely to be a direct response to current life events
• Prior to formal operational functioning (approx age 12) children may lack the single, stable negative cognitive style that adults display

Question 7

Treatment of Childhood Depression

Answer 7

 Treatment research is relatively sparse for depression in children and adolescents

 Initial choice for treatment depends upon a wide variety of factors (e.g., severity of symptoms, motivation etc)

 Stepped care approach through Child and Adolescent Mental Health Service (CAMHS)

Question 8

Pharmacological Treatments of Childhood Depression

Answer 8

 Provision of antidepressants for: bipolar disorder, psychotic depression and severe depression (7-10 symptoms) that prevents effective psychotherapy or that fails to respond to adequate psychotherapy

 Consider that due to environmental factors, pharmacotherapy alone may not be effective

 Also, few treatment studies with children and adolescents, particularly longitudinal

Question 9

Efficacy of Treatment with SSRI’s

Answer 9

 Limited research suggests that SSRI’s are most helpful at relieving depressive symptoms (particularly in adolescence)

 However, efficacy is modest:(e.g., fluoextine Prozac )
Emslie et al (1997): fluoxetine 58%, placebo 32%

Emslie et al (2002): fluoxetine 41%, placebo
20% (& not all outcome measures were
significantly different than placebo)

Question 10

Concerns over SSRI’s

Answer 10

 Long term effects are relatively unknown

 Side effects, interaction with other medication and withdrawal effects

 Small number of case reports (King et al, 1991; Teicher et al., 1990) described association between SSRI’s treatment and increased suicidal tendencies

Question 11

Depression in Children and Young People: NICE (2005) Guidelines

Answer 11

 Antidepressant medication should only be prescribed following assessment by a psychiatrist

 Should only be offered in combination with psychological treatments

 First-line treatment is fluoxetine

 Monitor for agitation, hostility, suicidal ideation and self-harm and advise urgent contact with prescribing doctor if detected

Question 12

Psychological Therapies

Answer 12

 Therapeutic approaches for older children and adolescents similar to adults.

For example:
- Social skills training (e.g., Clarke, BeBar, & Lewinsohn, 2003)

• Interpersonal (e.g., Mufston & Dorta, 2003)
• Cognitive, behavioural or cognitive behavioural

Question 13

Treatment of Pre-school depression

Answer 13

 Limited research into treatment of preschool depression

 Given the importance of parent-child interaction for socio-emotional development, dyadic psychotherapy is an important first line of treatment (Luby, 2009)

Question 14

Parent Child Interaction Therapy – Emotional Development (PCIT-ED)

Answer 14

 Focus upon emotional recognition and regulation, and strengthening of the parent-child relationship

 Methods include observation, play, direct coaching and homework tasks

 Initial research suggests significant improvements in child’s mood, behaviour and executive functioning as well as in maternal stress and depression (Luby, Lenze & Tillman, 2012)

Question 15

Combined Treatment

Answer 15

 NIMH Research on Treatment for Adolescents with Depression Study (TADS): (March et al., 2004)

 A clinical trial of 439 adolescents with major depression found a combination of medication and psychotherapy to be the most effective treatment

 Response rate of 60.6% for Fluoxetine compared to 70% for Fluoxetine and CBT combined

Question 16

Evaluation of Treatment

Answer 16

 While medications can be of value, they do not negate the need for psychotherapy

 Combined treatment seems best

 Requires multidisciplinary review and a change of approach if symptoms deteriorate

 More child-specific research is needed

 Often need for continuous treatment due to the risk of relapse and reoccurrence

 Risk factors for relapse and reoccurrence:

• Earlier age of onset
• Comorbidity
• Negative life events / psychosocial stressors
• Level of engagement with therapy