Chapter 9Depressive Disorders in Children
Winnie W. Chung and Mary A. Fristad
OVERVIEW OF THE DISORDER
Childhood depression is an impairing condition and can lead to lifelong physical and mental health concerns. Major depressive disorder (MDD) is estimated to affect 2.8% of children under age 13, with 12-month prevalence rates ranging from approximately 1% to 3% in school-age children (Costello, Erkanli, & Angold, 2006) and 1% to 2% in preschoolers (Egger et al., 2006). An additional 5% to 10% of youth experience significant depressive symptoms that do not meet diagnostic criteria for MDD (Birmaher, Brent, & the American Academy of Child and Adolescent Psychiatry [AACAP] Work Group on Quality Issues, 2007). The review of adolescent depression appears elsewhere in this book; this chapter primarily focuses on the assessment and treatment of depressive disorders and symptoms in children age 12 years and under.
In the treatment outcome studies presented later in this chapter that focus on children with depressive spectrum disorders (DSDs), diagnoses are based on criteria described in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) (American Psychiatric Association [APA], 1994). DSD diagnostic categories in the DSM-IV include MDD, dysthymic disorder (DD), and depressive disorder not otherwise specified (D-NOS). MDD requires the presence of depressed or irritable mood, or loss of interest in activities for most of the time during a 2-week period, along with symptoms including appetite changes, sleep disturbances, fatigue, feelings of worthlessness, concentration difficulties, and suicidal thoughts and behaviors. DD has a more chronic and pervasive presentation, with depressed or irritable mood and associated symptoms lasting most days for at least 1 year. Finally, a D-NOS diagnosis is reserved for depressive symptoms and features that do not meet criteria for MDD, DD, or an adjustment disorder. In the fifth edition of the DSM (DSM-5), bereavement is no longer an exclusion criterion for MDD (APA, 2013). A new diagnostic category, persistent depressive disorder, replaces the former DD diagnosis, and allows for the continuous presence of MDD in the first year of depressive symptoms, thereby consolidating the DSM-IV chronic MDD and DD diagnoses. Further, the multiaxial system used in the DSM-IV is replaced by a nonaxial approach in the DSM-5 to document diagnoses.
Children experiencing depressive symptoms or disorders are at greater risk for attention and behavioral problems; disruptions in family, academic, and social functioning; and suicide and drug or alcohol abuse (Birmaher, Arbelaez, & Brent, 2002; Birmaher et al., 2007). While most recover from an index episode, 30% to 70% will experience a relapse or recurrence (Birmaher et al., 2002). Early age of onset, greater depression severity, conflict with parents, and various comorbid conditions predict longer episode duration and relapse or recurrence (Birmaher et al., 2002). Other influences include low socioeconomic status, family history of mood disorders, and negative patterns of cognition. Most (80%–95%) children diagnosed with MDD experience a comorbid condition, often an anxiety or behavior disorder, which are also of significant concern (Kovacs, 1996). Children with MDD who also exhibit psychotic symptoms, psychomotor retardation, have a family history of bipolar disorder (BD), or exhibit pharmacologically induced mania symptoms are at risk for subsequent development of BD (e.g., Akiskal et al., 1983; Birmaher et al., 2002, 2007; Geller, Fox, & Clark, 1994). Careful monitoring of symptom development and responses to pharmacological interventions (e.g., antidepressant medications) is of particular importance with these children. Additionally, sex and age differences are notable. In childhood, girls and boys are equally likely to have MDD (Birmaher et al., 1996); by adolescence, girls are twice as likely to have MDD.
EVIDENCE-BASED APPROACHES
Psychotherapeutic approaches, for both prevention and intervention, have received increasing attention. More research has focused on adolescents than children (Weisz, McCarty, & Valeri, 2006). Two reviews using the Task Force on the Promotion and Dissemination of Psychological Procedures criteria (Chambless et al., 1996; Chambless et al., 1998; Chambless & Hollon, 1998) have evaluated the evidence base for youth depression treatments (David-Ferdon & Kaslow, 2008; Kaslow & Thompson, 1998). In the first review (Kaslow & Thompson, 1998), seven studies involved 13- to 18-year-old adolescents only while seven studies focused exclusively on children in grades 3 to 8. The latter included children with “elevated symptoms of depression” determined by children’s self-reported symptoms on measures such as the Children’s Depression Inventory (CDI) (Kovacs, 1985). No studies reported on children with a DSD diagnosis. These child studies all used treatments that were downward extensions of adult approaches, primarily based on cognitive behavioral principles, and typically administered in group formats. Only Stark and colleagues’ school-based Self-Control Therapy (SCT) (Stark, Reynolds, & Kaslow, 1987; Stark, Rouse, & Livingston, 1991) emerged as a probably efficacious treatment; no treatments met criteria and standards for a well-established intervention.
Ten years after Kaslow and Thompson’s review (1998), David-Ferdon and Kaslow (2008) examined randomized controlled trials (RCTs) conducted subsequent to the previous review. Eighteen adolescent-only, five child-only, and five mixed-aged studies were identified. Of the 10 new studies that included child participants, 3 included those diagnosed with a DSD; the remainder focused on children with elevated depressive symptoms. Treatments examined in the child studies were more developmentally informed than those in the prior review. Most included cognitive behavioral principles, although treatments utilizing psychodynamic, family systems, and a combination of psychoeducational and supportive approaches were also represented. In addition to Stark and colleagues’ SCT, the Penn Prevention Program (including the modified Penn Optimism Program) (e.g., Jaycox, Reivich, Gillham, & Seligman, 1994; Yu & Seligman, 2002) was deemed a probably efficacious intervention. As a group, cognitive behavioral therapy (CBT) is considered a well-established treatment approach, and specifically, child-only group CBT and child-group CBT with a parent component are well-established treatment modalities. Behavior therapy as a theoretical approach is considered probably efficacious; nondirected support, psychoeducational, and family systems approaches are deemed experimental. Parent–child and individual video self-monitoring modalities are also considered experimental, reflecting the limited research on these modalities.
Since the 2008 review, two additional RCTs have been published (Fristad, Verducci, Walters, & Young, 2009; Luby, Lenze, & Tillman, 2012). Fristad and colleagues (2009) evaluated the efficacy of Multi-Family Psychoeducational Psychotherapy (MF-PEP), which incorporates CBT and family systems therapy techniques, in children diagnosed with either a DSD or bipolar spectrum disorder. Luby and colleagues (2012) examined the efficacy of a modified version of Parent-Child Interaction Therapy (PCIT) among preschool-age children diagnosed with MDD. While both RCTs demonstrated favorable results, they remain in the experimental stage, given their initial evaluation status.
A recent meta-analysis examining the effects of psychotherapy in treating youth depression revealed positive though modest effects (Weisz et al., 2006). Weisz et al. (2006) also found that both cognitive and noncognitive (e.g., behavioral activation techniques) approaches demonstrated similar effects, and self-report outcome data from youth were more favorable than that provided by parents. Weisz and colleagues (2012) conducted an RCT to examine the Modular Approach to Therapy for Children with Anxiety, Depression, or Conduct Problems in children and adolescents. This approach includes techniques from various evidence-based approaches, with flowcharts directing the sequence of modules to guide clinicians as they target specific symptoms of concern. Results suggest that youth who received modular treatment demonstrated steeper improvement trajectories compared to those who received usual care or standard evidence-based treatment and had fewer diagnoses posttreatment than those in usual care. Future studies to further elucidate the unique contributions of these elements to treatment outcomes, specifically with children, would be highly informative.
SPECIFIC TREATMENT APPROACHES
Reviews suggest that psychotherapy has some efficacy in ameliorating children’s depressive symptoms; brief descriptions of such interventions, including child-only group CBT, group CBT with parental involvement, parent–child CBT, individual therapy with parent component, family-based therapy, parenting-based treatment, and psychodynamic therapy, are discussed next.
Child-Only Group CBT
The following describes child-only interventions employing CBT techniques delivered in a group format.
Penn Prevention Program
The Penn Prevention Program (PPP) was developed to prevent depressive symptoms and related impairment in at-risk children with elevated depressive symptoms and perception of parental conflict (Gillham, Reivich, Jaycox, & Seligman, 1995; Jaycox et al., 1994). This 12-week group treatment conducted in schools includes a cognitive component (e.g., identifying and accurately evaluating negative beliefs, engaging in flexible thinking, and adopting a more optimistic explanatory style) and a social problem-solving component (e.g., learning perspective-taking and problem-solving skills). Other techniques to cope with family conflict and stressful events are also introduced. PPP has been evaluated in 143 at-risk 10- to 13-year-old youth, randomized to treatment and control conditions by school (Jaycox et al., 1994). Those who received PPP self-reported significantly greater decreases in depressive symptoms postintervention compared to those in the control group; results were maintained at 6-month follow-up. Although children who participated in PPP did not demonstrate significant changes in overall explanatory style, they were less likely than those in the control condition to make stable and enduring attributions to negative events postintervention. Effects were maintained 2 years postintervention (Gillham et al., 1995). By 3 years posttreatment, effects on depressive symptoms had diminished, although effects on explanatory style were maintained (Gillham & Reivich, 1999). PPP has also been evaluated in an RCT of 189 seventh-grade students with elevated symptoms of depression in rural Australia (Roberts, Kane, Thomson, Bishop, & Hart, 2003). While there were no intervention effects on depressive symptoms at posttreatment and 6-month follow-up, children who participated in PPP showed lower levels of anxiety symptoms at both time points.
Gillham, Reivich, and colleagues (2006) incorporated a six-session group parent component to PPP to equip parents with the same resiliency skills taught to the children. This revised Penn Resilience Program (PRP) reduced symptoms of depression and anxiety at 6- and 12-month follow-ups in 44 at-risk sixth and seventh graders, compared to those in a control condition. PRP has also been evaluated in primary care with 271 children 11 and 12 years of age exhibiting elevated depressive symptoms (Gillham, Hamilton, Freres, Patton, & Gallop, 2006). While there were no overall intervention effects on depressive symptoms or disorders, girls (not boys) in PRP reported lower levels of depressive symptoms, and all who participated in PRP demonstrated improvements in explanatory style for positive events over the subsequent 2 years. A PRP effectiveness study that used an active control condition (the Penn Enhancement Program) demonstrated mixed results (Gillham et al., 2007). Specifically, while PRP was effective in reducing depressive symptoms through the 30-month follow-up among 697 sixth to eighth graders with elevated symptoms of depression in two schools, no effects of PRP were found for a third school.
Primary and Secondary Control Enhancement Training
The Primary and Secondary Control Enhancement Training program (PASCET) was originally developed as an eight-session small-group treatment to reduce elevated depressive symptoms among elementary school–age children by increasing their primary and secondary control coping strategies (Weisz, Thurber, Sweeney, Proffitt, & LeGagnoux, 1997). Primary control strategies involve modifying one’s objective environment when possible to fit one’s needs and desires; secondary control strategies involve changing one’s interpretations of objective situations that are not modifiable. PASCET is also available as an 18-session individual treatment for 8- to 15-year-olds, with options for parental and school involvement (Bearman, Ugueto, Alleyne & Weisz, 2010). Practice homework is assigned between sessions, and a final project is completed to summarize and integrate skills learned throughout treatment.
An RCT of PASCET in 48 third to sixth graders with elevated depressive symptoms revealed that participation in PASCET in the school setting resulted in lowered depressive symptoms, including scores that normalized, compared to peers in a control condition (Weisz et al., 1997). Effects were maintained at 9-month follow-up. A version of PASCET plus parenting training has been developed (PASCET plus caregiver–child relationship enhancement training; PASCET-C-CRET). Children with mild to moderate depressive symptoms showed improvement in depressive symptoms, psychosocial functioning, coping, and the caregiver–child relationship after participation in PASCET-C-CRET (Eckshtain & Gaynor, 2009). PASCET appears to be promising in treating depressive symptoms in children; further evaluations are warranted.
Coping with Depression
The Coping with Depression (CWD) course, developed to address depression in adolescents (Clarke & Lewinsohn, 1984; Lewinsohn & Clarke, 1984), has been adapted to treat moderate to severe depressive symptoms among sixth- to eighth-grade students (Kahn, Kehle, Jenson, & Clark, 1990). Consisting of 12 sessions delivered in a small-group format, CWD teaches children self-change skills, pleasant-activities scheduling, cognitive techniques, communication, problem solving, social skills, and strategies to maintain and generalize treatment gains. A school-based RCT with 68 sixth to eight graders experiencing elevated depressive symptoms compared CWD, a relaxation protocol, an individual self-modeling intervention, and a wait-list control (WLC) group. Participants in all three treatment conditions had significantly lower depression scores at posttreatment and 1-month follow-up; youth who participated in CWD showed improved self-concept compared to those in the WLC group. Further, CWD participants were almost twice as likely to function in the nondepressed range compared with those in the self-modeling condition; effects were more strongly maintained at follow-up for the CWD group than for the self-modeling group, suggesting CWD helps to improve depressive symptoms.
Group CBT With Parental Involvement
The following describes group interventions for children employing CBT techniques that incorporate parental involvement.
Self-Control Therapy
Stark and colleagues’ SCT is a school-based group treatment (Stark, Brookman, & Frazier, 1990; Stark et al., 1987, 1991) that incorporates cognitive training, teaches self-control and behavioral skills, and includes ongoing consultation with children’s teachers to support their functioning at school and with peers. Parent training and education are provided in monthly family meetings. Sessions begin and end discussing homework previously assigned or to be assigned; the remaining time is spent discussing children’s personal concerns and skills training. The cognitive component involves cognitive restructuring and attribution retraining. Self-control training consists of teaching accurate self-monitoring skills, training in self-reinforcement, and accurate self-evaluations. The behavioral training component includes planning pleasant activities, and training in assertiveness, social skills, and relaxation.
Stark and colleagues (1987) compared a 12-session version of SCT with behavioral problem-solving therapy and a WLC group among 29 fourth to sixth graders with elevated depression symptoms. Children in both active treatments reported decreases in depression and anxiety posttreatment; those in SCT reported lower levels of depressive symptoms than those in the WLC condition. Improvements in depressive symptoms were maintained at 8-week follow-up, and children in the SCT group showed reduced depression scores and greater self-concept scores than those in the behavioral problem-solving condition. In a second study, Stark and colleagues (1991) examined an expanded, 24- to 26-session version of SCT. Twenty-six fourth to seventh graders with elevated depressive symptoms were randomly assigned to this expanded SCT or a counseling control condition. While children in both conditions showed reduced depressive symptoms at posttreatment and 7-month follow-up, those in SCT reported lower levels of depression and depressive cognitions than those in the control group postintervention.
Stress-Busters Intervention
The Stress-Busters program is a 10-session after-school group intervention that includes general skill building, depression-specific CBT, the creation of a videotape summarizing therapeutic skills, and a family education session to facilitate skills generalization and to foster positive parent–child interactions (Asarnow, Scott, & Mintz, 2002). Skills taught include problem solving, relaxation, social skills, scheduling pleasant activities, cognitive restructuring, and developing a personal coping plan. Therapists also discuss the notion of emotional spirals and how one’s thoughts and actions can influence the direction of spirals. Twenty-three fourth to sixth graders with tentative depression diagnoses (based on symptoms endorsed on the CDI [Kovacs, 1985]) who were randomly assigned to Stress-Busters demonstrated greater reductions in depressive symptoms, negative automatic thoughts, and internalized coping than those in the WLC group. Participants expressed high satisfaction with the treatment, also supporting the promise of this intervention in reducing children’s depressive symptoms.
Parent–Child CBT
The following describes an intervention employing CBT techniques that incorporates individual child and family sessions delivered in a videoconferencing format.
CBT via Videoconferencing
Nelson, Barnard, and Cain (2003, 2006) implemented an 8-week CBT protocol using videoconferencing. During each session, the therapist meets with the target child and his/her parent separately. Content covered in child sessions includes scheduling positive activities, monitoring feelings, cognitive-behavioral techniques, as well as training in social, problem-solving, anger management, and relaxation skills. Similar content is presented in parent sessions, with additional material relating to positive parenting, discipline strategies, and family activities. Comparing CBT via Videoconferencing (CBT-VC) with CBT delivered in the traditional face-to-face format in the clinic setting, Nelson and colleagues (2003, 2006) found that 8- to 14-year-old children diagnosed with depression who were randomized to either version of CBT demonstrated decreased depression scores posttreatment; 82% of participants no longer met criteria for a depression diagnosis. Those in CBT-VC showed a significantly greater rate of decline in symptoms than children in traditional CBT, suggesting that CBT-VC is a promising mode of treatment delivery.
Individual Therapy With Parent Component
The following describes an individual child intervention incorporating parental involvement.
Contextual Emotion-Regulation Therapy
Kovacs and colleagues’ (2006) contextual emotion-regulation therapy (CERT) is a 30-session problem-focused and developmentally sensitive treatment targeting children’s self-regulation of distress and dysphoria. Presented individually in a clinic, the core goals of CERT include reducing depressive symptoms, increasing effective regulation of negative emotions, and enabling children to adaptively respond to upsetting events. Didactic training in and practice of emotion-regulation responses are key treatment components. Other strategies presented include tracking symptoms, improving sleep hygiene, and scheduling social activities. As mentioned, parents are asked to play a significant role in CERT, by serving as “assistant coaches” and improving their relationship with their child. An open-label evaluation of CERT was conducted among 20 7- to 12-year-old children with a diagnosis of DD (Kovacs et al., 2006). Children’s depressive and anxiety symptoms decreased significantly posttreatment; effects were maintained 6 and 12 months later. For children with superimposed MDD, 80% of MDD diagnoses remitted posttreatment. Over half (53%) of the DD diagnoses remitted posttreatment; by the end of the 12-month follow-up, an additional 40% of DD cases remitted. CERT is currently being investigated in an RCT, which will provide further data regarding its efficacy.
Family-Based Therapy
The following describes family-based interventions for children with diagnosed depressive disorders.
Family-Focused Treatment for Childhood Depression
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