Week 10 Flashcards
Depressive states vs. Depressive Disorders
Depressive states:
Feeling in low spirits, “sad”, “down”, “feeling blue”
Appropriate response to loss or other painful life events
May feel tired, irritable, and have changes to sleep, eating, and concentration
Depressive disorder:
Significant distress and/or interference with functioning
Emotion vs Mood vs Affect
Emotions:
shorter term response that is evaluative in nature
and involves physiological arousal, subjective experience,
and behaviours
Mood:
pervasive and sustained emotions
Affect:
observed by others (remarkable affect would be quite noticeable)
Depressive Disorders in Children
In decades past, depression in children was not recognised
Previously, children were described as showing other behaviours in response to traumatic losses, e.g.,
rebelliousness, restlessness, and somatic symptoms (“masked depression”)
Now widely recognised that children can exhibit same
characteristics of depression as adults
Behaviour problems can accompany depression (rather than masking it)
MDD and Persistent Depressive Disorder: Common Features
Depressed mood (or irritability in children)
Accompanying symptoms:
Changes in appetite and/or eating behaviour
Changes in sleep
Changes in energy level
Low self-esteem (PDD)
Poor concentration, indecisiveness
Feelings of hopelessness (PDD)
Diminished interest or pleasure (MDD)
Worthlessness, guilt (MDD)
Recurrent thoughts of death or suicide (MDD)
Clinically significant distress and/or impairment in social, occupational or other important areas of functioning
Differential diagnosis: the basics
Major Depressive Disorder:
5 or more symptoms in 2 week period
Persistent Depressive Disorder: persists for at least one
year in children (2 years in adults); can have periods of MDD (“double depression”)
Bipolar disorder:
presence of manic or hypomanic episodes
Adjustment Disorder with Depressed Mood:
essential feature is reaction to a recent identified stressor
Disruptive Mood Dysregulation Disorder (DMDD):
New category for children under 12
Chronic, severe, persistent irritability, which may take the form of aggressive outbursts or angry mood
Aggressive outbursts or angry mood not limited to discrete episodes (as in Bipolar Disorder)
Inconsistent with child’s developmental level
Lasts for at least 12 months
MDD Point prevalence
1-2% pre-schoolers
1-3% school-age children
5-6% adolescents
MDD Lifetime prevalence
15-20% adolescents
Course and gender differences
Marked increase in prevalence at adolescence
Females»_space; Males
Prevalence: Other Depressive Disorders
Important point: Less research for these categories Disruptive Mood Dysregulation Disorder Estimated at 2-5% in youth Expected to be more common in children compared to adolescents More common in boys than girls
Persistent Depressive Disorder
Not as common as MDD
Gender disparity seen in MDD not seen in PDD
Aboriginal and Torres Strait Islander people:
Aboriginal and Torres Strait Islander people are nearly twice as likely to die by suicide.
Indigenous Australians are nearly three times more likely to be psychologically distressed than non-Indigenous Australians.
Racism, both perceived and actual experiences, is increasing which affects wellbeing
Dramatic increase in adolescence, esp. for girls
Proposed explanations
Gender-specific life stressors
Early developing girls exposed to interpersonal stressors, sexual harassment
Onset of puberty
Girls more likely to see changes of adolescence as negative
Girls may more sensitive to peer pressure
Girls may more sensitive to interpersonal stressors in family
Also limited opportunities for girls compared to boys?
Depressive Disorders in Children: Comorbidity
Commonly comorbid with anxiety
Also comorbid with CD, eating disorders, substance abuse
Associated problems
suicide (can be suicidal without depression)
Recovery and Recurrence
High rates of recovery paired with high rates of recurrence
Child and Adolescent Suicide
Suicide can occur in children and adolescents with
depression
In 2015, suicide was the leading cause of death of children between 5 and 17 years of age (HeadSpace website, based on ABS stats)
Suicidal ideation needs to be monitored in children and adolescents with depression
Individual risk assessment by health professional is essential
Child and Youth Suicide in Australia
Total deaths per year 306 in 2006 to 405 in 2015. in the 0-14 range gone from 8 in 2006 to 22 in 2013
Child and Adolescent Suicide, Who is at risk?
When depression is combined with hostility, impulsiveness, substance abuse, personality disorders
Indigenous youth
Sexual minority youth
Protective factors include family support
Intervention:
Crisis intervention, CBT, Family Therapy
Suicide Prevention
Suicide prevention is important
Media reporting of suicide: recommendations to reduce contagion effects (Kerig, et al. 2012, p. 338)
School-based programs should focus on risk and protective factors
Depression presentation Infancy and Toddlerhood
Loss of developmental accomplishments, e.g., toilet training
Self-harming behaviours, e.g., head-banging, self-biting
Self-soothing behaviours, e.g., thumb-sucking
Depression presentation Preschool
Inability to enjoy play activities Social withdrawal, separation anxiety Vague somatic complaints, irritability, sleep problems, nightmares
School Age depression presentation
Presentation becomes more similar to adults, i.e., depressed mood, low self-esteem, self-criticism, guilt, loss of pleasure
Eating and sleep disturbances
Disruptive and aggressive behaviours may impair peer relationships and academic performance
Adolescence depression presentation
More likely to verbalise their sad feelings and distress
Sharp mood swings, negativity
Hypersomnia (sleeping too much); changes in eating behaviour
More likely to show anhedonia (loss of pleasure), hopelessness, and social withdrawal compared to younger children
Etiology: Integrative Model of Depression in
Children and Adolescents
(Fig. 5.1, Hammen, et al., 2014)
Early adverse experiences
Genetics
->
Biological, emotional, cognitive, interpersonal
->
Proximal stressors
->
Depression
Biological context etiology
Genetic risk
Temperament
Brain structure and function
HPA dysregulation
Etiology Individual context:
Cognitive factors
Internal working models of
attachment
Beck’s cognitive theory of depression
- Worthlessness, helplessness, hopelessness
- Negative thoughts about self, world, future
Low self-efficacy
Rumination: dwelling on negative thoughts and feelings
Seligman – Learned Helplessness
Perceived competence and control – underestimate
competence
Attentional bias – towards negative stimuli
Etiology - Individual context:
Emotional factors
High negative emotionality
Low positive emotionality
Emotional responding – rumination
Emotion regulation – failure to regulate emotional
responses
Emotional processing – deficits in identifying and
understanding emotions
Etiology Family context:
Interpersonal
Family support?
Family conflict?
Loss of parent
Depressed parent/s
- Impact parent-child relationships
- Impact on development of emotion regulation skills
- Effects partly mediated by parenting style
Social / Peer relationships Etiology
Transactional relationship between peer relationships,
social difficulties, and depression
May be antecedents or consequences of depression
Romantic relationships – risk factor for subsequent depression
Cultural
Poverty? (query whether it is a factor for youth)
Life stress, e.g., racial discrimination
Empirically Supported Treatment
Pharmacotherapy
Cognitive-Behavioural Treatment
Interpersonal Therapy
Pharmacotherapy
SSRIs
For severe depression
For moderate depression where psychological therapy is not available, or is refused, or does not lead to improvement
Within context of therapeutic relationship and management plan
Thorough ongoing monitoring, particularly for increased suicidal ideation
Combined with CBT and/or IPT
Cognitive-Behavioural Treatment
Psychoeducation and lifestyle information
Behaviour monitoring and behavioural activation
Development of skills that promote competence
Problem solving skills training
Identify, challenge and restructure maladaptive thoughts and beliefs
Skill development in distress tolerance and emotion
regulation (mindfulness)
Interpersonal Therapy
Focus on development of communication and social skills
To assist young people to establish or re-establish meaningful, supportive and enjoyable peer relationships
