Mood Problems

Mood Problems: Depression in Childhood and Adolescence

Depression during childhood or adolescence can be a challenging experience for both the young individual and their family members. Although most young people will recover from a depressive episode within the year, depression tends to recur; as such, adolescents are more likely to develop episodes of depression as adults.

Factors such as ongoing persistent mood disorder (dysthymia), episodic major depressive condition, severe depressive symptoms, maternal depression, co-morbid conduct or drug misuse, family problems, and social adversity can predict worse outcomes.

A Case of Adolescent Depression: Maire

The O’Connors requested an urgent appointment due to Maire's shoplifting, lying, and truancy. Maire's parents discovered bottles of perfume in her room. Maire admitted to stealing them. The school principal then phoned to ask about her whereabouts. Maire admitted to truanting with Julie, who was known as a troublemaker in the school. After another incident, Maire locked herself in her room for 24 hours and wailed or cried periodically and made threats of self-harm.

Developmental History

Maire was born in Sligo but then moved to Dublin 12 months before the referral. Maire's mother suffered post-partum depression for about six months following her birth. During this period Maire was cared for by her aunt Aoife in Sligo. Maire's pre-school development was unremarkable but she did have trouble settling into junior school. In junior school Maire was in the top half of the class and on the school junior hockey team. The transition to secondary school was relatively uneventful but realized that she was physically maturing more rapidly than her two friends and felt awkward about this. During her first 2 years at secondary school she formed a close friendship with Tricia, an older girl who was particularly wild. Following the move to Dublin, Maire would confide that she had few close friends at school and felt excluded by her classmates, would cry, express strong feelings of loneliness and stay in bed for whole days at the weekend. However, after she met Julie the gap between herself and her mother widened and began to display tantrums and would not keep house rules.

Family History

Sarah and Seamus had been married for 16 years. After each child, Sarah experienced post-partum depression. The move to Dublin was prompted by a lucrative job offer for Seamus. Seamus became relatively unavailable for family life. This isolation led to a recurrence of her depression and she was on antidepressants at the time of referral. Sarah found herself having to manage the crisis with Maire without input from Seamus because of his work commitment and oscillated between being harsh and empathic. Seamus criticized her for adopting such an ambiguous position.

Maire’s Presentation

Maire's scores on the Child Behaviour Checklist and Childhood Depression Inventory indicated clinical range scores. She reported suicidal ideation without intent, loneliness, and a dislike for living in Dublin. She admitted to shoplifting and felt excluded at school. She considered herself ugly, boring, and horrible, and found concentrating difficult. She had difficulty sleeping through the night and often awoke at 5.00 am and couldn’t go back to sleep. Maire showed affective, cognitive, behavioral, and somatic features consistent with a diagnosis of depression, having lasted about a year. In addition she had a variety of conduct problems which began in early adolescence and had fluctuated since then.

The episode of depression was precipitated by moving from Sligo to Dublin, combined with genetic predisposition and an early separation experience during her mother’s post-partum depression, Maire’s depression was maintained by her self-defeating thinking style and problematic relationships with her parents. For Seamus the main stresses were work related and for Sarah, isolation was the main source of stress.

Treatment

Treatment in this case involved family work to improve the level of support offered to Maire by her parents; liaison with the school which aimed to increase Maire’s involvement in structured activities such as sports and drama; and individual cognitive therapy which aimed to help Maire challenge her negative beliefs and improve her problem-solving skills. Over a period of 3 months Maire’s mood, family relationships, and school-based adjustment improved.

Diagnosis and Classification

Diagnostic criteria for Major Depressive Episode from the DSM-5 and ICD-10 classification systems include:

  • Depressed mood
  • Loss of concentration and attention
  • Reduced self-esteem and confidence
  • Ideas of guilt and unworthiness
  • Bleak, pessimistic views of the future
  • Disturbed sleep
  • Diminished appetite

The DSM and ICD systems also include vegetative or somatic features, which are absent from the Achenbach system.

DSM-5 Criteria for Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

  1. Depressed mood most of the day, nearly every day.
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
  3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
  4. Insomnia or hypersomnia nearly every day.
  5. Psychomotor agitation or retardation nearly every day.
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
  9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

ICD-10 Criteria for Depressive Episode

In a typical depressive episode, the individual usually suffers from depressed mood, loss of interest and enjoyment and reduced energy leading to increased fatigue, ability and diminished activity. Marked tiredness after only slight effort is common.

Other common symptoms are:

a. reduced concentration and attention
b. reduced self-esteem and confidence
c. ideas of guilt and unworthiness
d. bleak and pessimistic views of the future
e. ideas or acts of self harm or suicide
f. disturbed sleep
g. diminished appetite.

Types of Mood Disorders

DSM and ICD make distinctions between unipolar and bipolar mood disorders, and between episodic disorders and the milder but more persistent conditions of dysthymia and cyclothymia.

  • Major depressive disorder and bipolar disorder: Episodic conditions.
  • Dysthymia and cyclothymia: Less severe, non-episodic chronic and continuous conditions.

Clinical Features of Depression

  • Perception: Perceptual bias towards negative events, mood congruent hallucinations.
  • Cognition: Negative view of self, world, and future; excessive guilt; suicidal ideation; mood congruent delusions; cognitive distortions; poor concentration.
  • Affect: Depressed mood, inability to experience pleasure, irritable mood, anxiety and apprehension.
  • Behaviour: Self-defeating behavior, psychomotor retardation or agitation, depressive stupor.
  • Somatic State: Fatigue, sleep disturbance, aches and pains, loss of appetite or overeating, weight change, diurnal mood variation, loss of interest in sex.
  • Interpersonal Adjustment: Deterioration in family relationships, withdrawal from peer relationships, poor school performance.

Epidemiology of Depression

  • Prevalence: About 4% in young people.
  • More common among adolescents than pre-adolescents.
  • Similar rates in pre-adolescent boys and girls, but higher in adolescent girls.
  • Very common in clinic referrals (about 25%).
  • Often occurs with other disorders (conduct disorder, anxiety disorders, attention deficit disorder).

Theories of Depression

Research and treatment of depression are guided by theories developed within neurobiological, psychoanalytic, cognitive-behavioral, and interpersonal and family systems traditions.

Biological Theories
  • Genetic theories propose that depression develops when a person with an inherited vulnerability to mood disorders is exposed to stressful life events.
  • Limbic system and pre-frontal cortex hypothesis - Depression is caused by an over-active limbic system and an under-active pre-frontal cortex.
  • Neurotransmission dysregulation theories - Inefficient neurotransmission within and between brain structures associated with depression subserves the symptoms of depression.
  • HPA axis hypothesis - Depressive symptoms are caused by over-activity of the HPA axis and associated chronically raised cortisol levels.
  • Biological rhythm hypothesis - Depression is due to abnormal circadian rhythms which govern the sleep-waking cycle, or abnormal seasonal rhythms.
Stress Theories
  • Diathesis-stress theory proposes that depression only follows exposure to stress in people who have specific biological or psychological attributes that render them vulnerable to stressful life events.
  • Stress generation theory - People with certain personal attributes inadvertently generate excessive stress which in turn leads to depression.
Psychoanalytic Theories
  • Freud’s introjected anger theory - Depression occurs when a person directs anger towards the self following loss of a valued relationship of failure to achieve a valued goal.
  • Bibring’s low self-esteem theory - Depression is due to low self- esteem arising from a large gap between the actual and ideal self.
  • Blatt’s attachment and autonomy theory - There are two types of depression associated with two distinct types of early parent–child relationships which engender vulnerability to depression when faced with two distinct types of stresses in later life.
Cognitive-Behavioural Theories
  • Cognitive theory - Depression occurs when life events involving loss occur and reactivate negative cognitive schemas formed early in childhood as a result of early loss experiences.
  • Behavioural theory - People with depression avoid situations where they can receive Response Contingent Positive Reinforcement (RCPR) because they lack the social skills required for eliciting rewarding interactions from others.
  • Self-control theory - Depression occurs when a person selectively monitors the occurrence of negative events to the exclusion of positive events; selectively monitors immediate rather than long-term consequences of actions; sets overly stringent criteria for evaluating actions; makes negative attributions for personal actions; engages in little self-reinforcement for adaptive behaviours; and engages in excessive self- punishment.
  • Learned helplessness theory - Depressions occurs when a person repeatedly fails to control the occurrence of aversive stimuli and makes internal global stable attributions for these failures and external, specific, unstable attributions for success).
Social Theories
  • Interpersonal theory - Depression is maintained by grief, role disputes, role transitions, poor social skills, and living in a single-parent family.
  • Family systems theory - Depression occurs when the structure and functioning of the family prevents the child from completing age appropriate developmental tasks.

Assessment

  1. Assess the risk of self-harm.
  2. Determine if the depression is a response to child abuse.
  3. Clarify the nature and extent of symptomatology.
  4. Establish the context within which the depression has arisen.
Predisposing Factors
  • Genetic vulnerability
  • Early loss experiences
  • Non-optimal parenting experiences
  • Parental depression
  • Personal characteristics
Precipitating Factors
  • Loss experiences associated with the disruption of significant relationships
  • Loss experiences associated with failure to achieve valued goals
Maintaining Factors
  • Personal: A depressive cognitive style, self-defeating behavioral patterns, dysfunctional coping strategies, immature defenses, neurobiological factors.
  • Contextual: Family or school environment, interactions with parents or primary carers, family circumstances, high levels of stress, lack of co-ordination and clear communication among involved professionals, cultural and ethnic beliefs and values, parents’ lack of experience in dealing with similar problems in the past.
Protective Factors
  • Less severe mood disorders
  • Physical fitness
  • An easy temperament
  • High self-esteem
  • Secure parent–child attachment
  • Authoritative parenting
  • A flexible family structure
  • Good parental adjustment
  • High levels of support
  • Low levels of stress
  • Membership of a high socio-economic group
  • Co-operative working relationships between the treatment team and the family and good co-ordination of multi-professional input

Treatment

  • Psychoeducation
  • Self-monitoring
  • Interventions focusing on activity
  • Interventions focusing on changing family relationships
  • Interventions focusing on cognition
  • Social skills and social problem-solving skills training
  • School interventions
  • Medication
  • Management of parental mood problems
  • Relapse management.