Depression: A Brief
Overview of the Disorder
in Childhood
James H. Johnson, Ph.D., ABPP
University of Florida
Case Examples (NYU Child Study
Center)
“Alex, l0-years-old, lives with his mother and grandmother. His
parents separated when he was six. Alex's teacher reports
that he is in danger of failing, that he becomes preoccupied,
often staring out the window, and seldom finishes his work.
Alex has stated that the other children in the class are much
smarter than he is. He seldom attends Boy Scout meetings
or plays baseball, which he used to enjoy. When he gets
home each afternoon, he watches television and eats all the
cookies he can find. He usually telephones his mother to
make sure she's all right and then goes to bed until his
mother comes home. "I don't have any reason to stay up;
nothing good is going to happen," he said. “
Case Examples (NYU Child Study
Center)
“Cheryl usually went to school and to her
part-time job, and then came home and
played with her cats, rather than go out
with her two best friends, as she used to.
Looking back, her mother realized that
Cheryl hadn't gone to the movies or
shopping for the past month and seemed
to have lost weight. Then her mother
found a bottle of sleeping pills on Cheryl's
dresser.”
Childhood Depression:
History
Prior to the late 1970's the
inclusion of a discussion of
childhood depression in a course
like this one would have been a
rarity.
Many clinicians at that time
seriously questioned whether
children were even capable of
exhibiting depressive disorders.
This notion was heavily influenced
by the psychoanalytic view that,
prior to adolescence, children
lack the degree of superego
development necessary to have true
History
Despite this view, clinical experience and
early descriptive studies suggested that
children did in fact show features like
those seen in depressed adults.




depressed mood,
loss of interest in activities,
problems in eating and sleeping,
feelings of helplessness and hopelessness.
Nevertheless, controversy continued into
the 1980’s regarding whether these features
were best characterized as



a prevailing mood state,
a syndrome (with a specific set of symptoms), or
a true psychological disorder (with specific
etiology, course, and outcome)
Acceptance of Depression
as a Child Disorder
Research during the last two and
one-half decades has clearly
suggested that children and
adolescents often display evidence
of psychopathology where depression
is the most prominent feature.
It is now accepted that the
depressive features displayed by
children/adolescents are often
consistent with DSM IV criteria for
Major Depressive Disorder.
Continuity of Child and
Adult Depression
There is good evidence of continuity between
adolescent depression and adult depression.
Depressed adolescents are high risk for MDD
in adulthood (Klein, et al 2005).
This link is not as strong with child
depression.
Higher rates of MDD are found in the families
of both children and adolescents with
depression.
Child Depression Lite
As childhood depression represents a significant
problem for many children and adolescents, it
seems important to consider it along with other
childhood disorders.
However, given time limitations, and the fact that
depressive disorders are covered in the “adult”
portion of this course, only a cursory overview
will be provided here.
This can be supplemented by the readings
found in the syllabus.
DSM IV CRITERIA: Major
Depressive Episode
A. Five (or more) of the following symptoms are present
during the same 2-week period and represent a change
from previous functioning;
At least one symptom is (1) depressed mood or (2) loss of
interest or pleasure .


(1) depressed mood - most of the day, nearly every
day, as indicated by subjective report or observation by
others. - In children and adolescents, can be
irritable mood.
(2) Diminished interest or pleasure in all, or almost all,
activities - most of the day, nearly every day (as
indicated by subjective account or observation made by
others)
Major Depressive Episode




(3) significant weight loss when not dieting
or weight gain (e.g., a change of more than
5% of body weight in a month), or decrease
or increase in appetite nearly every day.
Note: In children, consider failure to make
expected weight gains.
(4) insomnia or hypersomnia nearly every
day
(5) psychomotor agitation or retardation
nearly every day (observable by others, not
merely subjective feelings of restlessness or
being slowed down).
(6) fatigue or loss of energy nearly every
day
Major Depressive Episode



(7) feelings of worthlessness or excessive or
inappropriate guilt nearly every day
(8) diminished ability to think or concentrate,
or indecisiveness, nearly every day (either by
subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear
of dying), recurrent suicidal ideation without a
specific plan, a suicide attempt or a specific
plan for committing suicide
Major Depressive Episode
B. Symptoms do not meet criteria for a
Mixed Episode.
C. Symptoms cause significant distress or
impairment in social, occupational, or
other important areas of functioning.
D. Symptoms are not due to the direct
effects of a substance (e.g., a drug of
abuse, a medication) or a general
medical condition (e.g., hypothyroidism).
Major Depressive Episode
E. Symptoms are not accounted for by
Bereavement; the symptoms persist
for longer than 2 months or are
characterized by marked functional
impairment, morbid preoccupation
with worthlessness, suicidal ideation,
psychotic symptoms, or psychomotor
retardation.
Major Depressive Disorder
A. Presence of single or recurrent Major
Depressive Episode(s)
B. The Major Depressive Episode(s) is (are)
not better accounted for by Schizoaffective
Disorder and is not superimposed on
Schizophrenia, Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder
Not Otherwise Specified.
C. There has never been a Manic Episode, a
Mixed Episode, or a Hypomanic Episode.
Anxiety Versus Depression
Before focusing on child depression is
important to comment on differences
between child anxiety and depression.
Often difficult to distinguish as both result in
distress
Indeed prior factor analytic studies have
often failed to find define independent
factors related to these symptoms.
This may be especially difficult with
relatively young patients
Anxiety Versus Depression
May be useful to consider a tripartite
model by highlighting the three distinctive
and overlapping features of anxiety and
depression (Clark & Watson, 1991,
Lonigan, et al, 2003).
General distress
 Anhedonia
 Physiological hyperarousal

Anxiety Versus Depression
Depression and anxiety are both
characterized by a high level of distress
Depression is uniquely related to anhedonia
Anxiety is more associated with high
physiological hyperarousal
The distinction between anxiety & depression
can thus be enhanced by emphasizing the
dimensions that separate the two conditions;
anhedonia and hyperarousal (Klein, et al
2005)
Childhood Depression:
Prevalence
Prevalence estimates vary depending on
the criteria employed in making the
diagnosis.
This relationship is nicely illustrated
by the results of an early study by
Carson and Cantwell (1980).
In a random sample of 210 child inpatient
cases, seen at the UCLA Neuropsychiatric
Institute, these researchers found that

60
per
cent
displayed
depressive
"symptoms" at intake
 49
per-cent were judged depressed,
based
on
scores
on
a
depression
inventory,
 28 per-cent met DSM III criteria for
Major Depressive Disorder
Prevalence
The earliest findings using DSM III
criteria suggested a general
population rate of 2 % (Kashani and
Simonds, l981).
More recent, findings have a suggested
MDD 6 month prevalence rate to be 1–3
% for school age children & 5 to 6 %
for adolescents.
Adolescent lifetime prevalence rates
may be as high as 15 – 20% (Klein, et
al, 2005)
The prevalence of Dysthymic Disorder has
been found to be as high as 8% in
Comorbidity
Findings suggest most comorbidity with
Dysthymia, Anxiety Disorders, ODD/CD, and
ADHD (Nottelmann and Jensen (1995).
 Dysthymia: 30 – 80%
 Anxiety Disorder: 30% to 80%.
 CD/ODD: 42%
 ADHD: 47.9% to 57.1%
Lewinsohn, et al (1991) assessed the
lifetime probability of having some
psychiatric disorder other than depression
in adolescents with MDD, Dysthymic
Disorder, or both.
Probability estimates for these groups were
.42 (MDD), .38 (Dysthymic), and .61 (Both),
respectively.
The majority of children with MDD or DD
Prognosis: Initial Recovery
There is less known about the prognosis
of child depression than in the case of
depression with adults.
Here, outcome must be evaluated both
with
regard
to
the
likelihood
of
recovery from the index episode of the
disorder and the risk of recurrence.
Regarding initial recovery, Kovacs, et
al.
(1984a),
have
found
that
the
probability of recovery from a major
depressive
episode
in
children/adolescents is 74% after one
year and 92% two years post onset.
Strober, et al (1992) found 92% of their
adolescent
inpatients
with
major
depression to have recovered after two
Prognosis: Recurrence
Findings related to the probability
of
later
recurrence
are
less
encouraging.
Here,
Kovacs
et
al.,
found
approximately 70% of children with
major depression to a recurrence
within five years.
Although
most
children
and
adolescents with major depressive
disorder
will
recover
to
a
significant degree, most of these
will experience subsequent episodes
of significant depression.
The long term prognosis is less
than favorable.
Etiology: Conceptual
Models of Depression
Psychoanalytic Perspectives
The Role of Life Stress in Childhood
Depression
Behavioral and Cognitive Behavioral
Views
Biological Perspectives
Psychoanalytic Views
No one psychoanalytic position
regarding the development of
depressive disorders.
Psychoanalytic perspective have,
however, generally tended to
highlight the role of object
loss.
The loss may be real, as in the
loss of a parent through death,
divorce, or separation or may be
more symbolic, as in the
withdrawal of attention,
Psychoanalytic Views
Depression occurs as a result of an
individual (who has suffered loss)
“identifying” with the lost love
object.
Because the individual is likely to
have ambivalent feelings toward the
lost object he or she may turn the
feelings of hostility against the
self and thus experience depression.
This type of reaction to loss is
thought to occur in persons who are
fixated
at
the
oral
stage
of
psychosexual development, who are
overly
dependent,
and
who
Psychoanalytic Views
Psychoanalytic views most
often invoked to account for
adult depression.
Little empirical data on
their relevance to childhood
depression, although
psychoanalytic approaches to
therapy for depression are
used to treat depression by
some clinicians
The Role of Life Stress
A number of studies have suggested that
depression may result, in part, from the
experiencing of major life changes;
The focus here is usually on negative
events such as separation, divorce, and
death in the family.
Research by Johnson and McCutcheon (1980) ,
Siegel (1981), (Compas, Grant, & Ey (1994)
and many others have documented significant
relationships between cumulative negative
life changes experienced by children and
depression.
This relationship may be moderated by other
variables (Johnson & Sarason, 1978)
Cohen-Sandler, et al (1982) have likewise
provided data suggestive of a relationship
between lifetime life stress levels and
suicidal behavior in children.
Specific Life Stressors
Other studies have documented
relationships between specific
stressors such as child abuse and
neglect and the development of
depression (Downey, Feldman, Khuri &
Friedman, 1994).
Research has also found relationships
between stressful family
circumstances (e.g., marital
conflict, divorce, problems in
parent-child relationships, maternal
rejection) and childhood depression
(Kaslow & Racusin, 1994).
Taken together, such findings are
Cognitive/Behavioral Views
Beck (1974) has been among the more
prominent individuals who has highlighted
the role of cognitive factors in the
development of depression.
Here, depression is seen as being related
to the way individuals perceive events in
their environment.
It
is
assumed
that
the
depressed
individual,
as
a
result
of
his/her
learning
history,
displays
cognitive
distortions or cognitive schematas that
contribute to a negative view of the
self,
the world,
and the future.
These views are, in turn, seen as
contributing to feelings of self-blame,
failure, and hopelessness which impact on
mood and other behaviors associated with
Examples of Cognitive
Distortions
Filtering
 Looking at only 1 element, tunnel vision, selective
memory for negative events
Catastrophizing
 What if Statements, Assuming the worst
Polarized Thinking
 Black/white, either/or thinking - no room for mediocrity
Mind Reading
 Snap judgments: assumptions about what others are
thinking, feeling, what motivates them, how reacting to
you, projecting
Cognitive/Behavioral Views
Other cognitive views include Rehm's
(1977) self-control model of depression
which involves a blending of cognitive &
operant views of behavior.
Depression is seen as being related to
cognitive-behavioral deficits in the areas
of self-monitoring, self-evaluation, and
self-reinforcement.
Thus, depression is thought to result from



the tendency to attend to negative rather than
positive events (self-monitoring),
the tendency to consistently attribute failure
to one's self rather than other factors (selfevaluation), and/or
the displaying of low levels of selfreinforcement or, alternately, high rates of
self-punishment.
Behavioral Views
Several other behaviorally oriented
views of depression have been
proposed.
Here, early views of Ferster (1974)
and Lewinsohn (1974) suggest that
manifestations of depression result
from a lack of sufficient positive
reinforcement in the environment.
This lack of reinforcement can be
caused by factors ranging from a
change in residence (loss of social
supports) to a failure to display
appropriate social skills that
Learned Helplessness and
Depression
An additional perspective on
depression, that focuses on the role
of learning, has been presented by
Seligman (Seligman, 1974; 1975;
1978).
Here, depression is described in
terms of learned helplessness.
This model suggests that depression
develops in individuals who, as a
result of their learning history,
perceive themselves as having little
or no control over rewards and
punishments in their environment.
Learned Helplessness
Depression results from the individual's
propensity to view negative events in their life
as due to:

Their own characteristics (internal attributions) “It’s
all my fault, I’m just not good with people, that’s just who I am”


Factors that are unlikely to change (attributions of
stability) “I keep getting fired because I’m dumb”
Factors that are likely to have an influence on the
individual across situations (global attributions) ;
“Why bother trying to get another job – the same thing will happen”
Learned Helplessness
Abramson,
et
al
(1989)
have
further highlighted the role of
attributional
style
in
the
development of depression.
They suggest that attributions of
the type just described (internal,
stable,
global),
mediate
the
relationship between negative life
events and depression (Johnson, Sarason &
Siegel, 1979 – LES, Locus of Control & Depression).
Thus, hopelessness, which leads to
depression, is seen as resulting
from an interaction of life stress
and problematic attributions
Cognitive/Behavioral Views:
Child Research Findings
While the views presented here
were initially developed to
account for adult rather than
child depression, there has
been some research designed to
study the applicability of
these views to childhood
depression.
This child oriented research
has provided some degree of
support for many of the basic
postulates inherent in
Research Findings
Research has documented relationships
between social skills deficits and
both current and future levels of
depression in children (consistent
with Lewinsohn's model),
Child related research has found
support for Beck's model in
documenting relationships between
childhood depression and indices of
cognitive distortion.
Studies have also found support for a
link between attributional styles and
childhood depression that are
consistent with the reformulated
Research Findings
Other studies have found links
between child depression and



lowered expectations for performance,
more stringent standards for
performance,
and tendencies to evaluate performance
more negatively.
Such findings are supportive of
Rehm's self-control model - that
depressed individuals have deficits
in self-monitoring, self-evaluation
and self-reinforcement.
While many issues remain to be
addressed, research appears to
provide reasonable support for the
important role of cognitive and
behavioral factors in the development
of childhood depression .
Biological Perspectives
Biological views of depression
have focused primarily on the
role of ;
 Genetics, and
 The role of biochemical
abnormalities.
 Of special note are biochemical
abnormalities involving
neurotransmitters (chemicals
that facilitate the
transmission of neural
Genetic Factors
A review of early twin studies, suggest
concordance rates of 76% for affective
disorders
in
monozygotic
twins
as
compared
to
19%
in
dizygotic
twins
(Kashani, et al., 1981).
The
concordance
rate
was
67%
for
monozygotic twins reared apart.
More recent studies have provided similar
findings.
Research has also suggested that

children
with
a
depressed
parent
are
approximately three times more likely to
develop a major depressive disorder than are
children with non-depressed parents.
However, environmental factors can’t be
ruled out.
Other Biological Findings
In addition to genetics, other studies
(primarily with adults) have focused on
the neurobiology of depression.
Here, studies have investigated the role
of neurotransmitters (especially
serotonin) and the role of
neuroendocrine abnormalities (e.g. plasma
cortisol concentrations; growth hormone
regulation; secretion of thyroidstimulating hormone) in depression.
Especially noteworthy are findings with
adults that lowered serotonin levels
appear to be related to both symptoms of
depression and suicidal behavior.
Studies of these factors in children are
needed.
Treatment of Childhood
Depression
While there have historically been a number
of approaches to the treatment of childhood
and adolescent depression, there are three
that presently appear to be empirically
based.



Interpersonal Therapy (Empirically Supported)
Cognitive-Behavior Therapy (Probably
Efficacious)
Psychotropic Medications (Probably Efficacious)
Interpersonal Therapy
For depressed teenagers, Interpersonal therapy
(IPT) is a well-established treatment for depressed
adolescents.
The focus of IPT is on helping older children and
adolescents understand and address problems in
their relationships with family members and
friends that are assumed to contribute to
depression.
This approach (which may contain some elements
of CBT) involves what most of us think of when
we hear the term “psychotherapy” as it is usually
conducted in an individual therapy format, where
the therapist works one-on-one with the
child/adolescent and his or her family.
Cognitive Behavior Therapy
As noted earlier, CBT is designed to change both
maladaptive cognitions and behaviors.
During CBT, depressed children/adolescent learn
about the nature of depression and how their mood is
linked to both their thoughts and actions.
The focus is often on developing better
communication, problem-solving, angermanagement, social skills and modifying selfdefeating attributions.
CBT is probably the most well-studied treatment for
children and adolescents with depression.
While controlled studies support it’s efficacy, there
are fewer studies of effectiveness (Klein, et al, 2005)
and high relapse rates suggest the need for ongoing
treatment.
Psychotropic Medications
Research findings suggest that some
medications can help relieve depressive
symptoms in youth (especially in adolescents).
Those that appear to be most effective include
selective serotonin reuptake inhibitors, or
SSRI’s).





clomipramine (Anafranil)
flouxetine (Prozac),
fluvoxamine (Luvox),
paroxetine (Paxil)
sertraline (Zoloft).
Psychotropic Medications
There are suggestions that response to SSRI’s is on
the order of 70 – 90%.
While the “response” rate appears to be high, many
only show a “partial response”.
Some studies with adolescents have suggested that
only about 1/3 show full remission.
SSRI’s are less lethal and seem to have fewer side
effects than TCA’s
There is, however, concern over a possible link
between these medications and suicide.
http://www.nimh.nih.gov/research-funding/scientific-meetings/2005/assessingsuicidality-during-antidepressant-treatment/summary.shtml
Combination Therapies
NIMH Research on Treatment for Adolescents
with Depression Study (TADS): Combination
treatment most effective in adolescents with
depression (March et al., 2004)
A clinical trial of 439 adolescents with major
depression has found a combination of medication
and psychotherapy to be the most effective
treatment.
Funded by the NIH's National Institute of Mental
Health (NIMH), the study compared cognitivebehavioral therapy (CBT) with fluoxetine (Prozac).
Prozac is currently the only antidepressant
approved by the Food and Drug Administration for
use in children and adolescents.
Treatment: Final
Comments
While medications can be of value, they do not
negate the need for therapy to deal with many
of the other issues that may have contributed
to the child’s depression.
Combined treatment seems best.
Fortunately there are empirically supported
treatments for child/adolescent depression that
can be used along with medication, when
needed.