Major depressive disorder in children and adolescents: diagnosis and treatment

Mental Disorder

Major Depressive Disorder in Children and Adolescents

Research on childhood and adolescent mood disorders has advanced significantly in recent years. It is now no longer common to find those who say that depression is an adult mental disorder alone. While there is not much debate about the definition and diagnosis of childhood depression, there are questions still to be answered regarding the best treatment outcome for children and adolescents who display symptoms of depression. This paper will outline a view of Major Depressive Disorder (MDD) as it relates to children, starting with a discussion of the diagnostic criteria for defining its symptoms. Then it will limit itself to synthesizing the research on childhood depression and treatment intervention styles from a cognitive standpoint. The cognitive perspective is probably the one most used in research, understanding and treating children who suffer from MDD. It is often in treatment combined with behavioral elements to improve treatment success. Finally, some of the ethical issues involved in working with depressed children will be thought out.

Diagnostic Criteria and Definition

The DSM-IV-TR lists Major Depressive Disorder (MDD) under the heading of mood disorders (American Psychiatric Association, 2000). There is no reason for not accepting this manual's definition and diagnostic criteria as a guideline. Important for the DSM-IV-TR's definition of MDD is an understanding of Major Depressive Episodes (MDE). The manual characterizes an MDE as "a period of at least two weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities" (APA, 2000, p. 349). However, the prolonged period of downturned mood must be accompanied by at least four additional symptoms, such as appetite or weight change, sleep disruption, decreased energy, feelings of worthlessness or guilt, difficulty thinking and concentrating, or suicidal thoughts and intentions. Such symptoms, combined, must persist most of the day, all day, for at least two consecutive weeks. Further, they must show serious distress or social impairment of functioning. It is important to note that according to the manual, the childhood and adolescent symptoms for a MDE are considered the same as the adult symptoms (APA, 2000, p. 353).

To properly diagnose MDD, the psychotherapist must interpret symptoms. These may include somatic complaints, reports of hostility or irritability, statements about loss of interest and care for anything, or reports about appetite loss. In addition, many physical symptoms may suggest MDD, such as brooding, tearfulness, worry, abdominal pains, headaches, and even panic attacks. The therapist can read facial features and body language to determine the symptoms. Insomnia or over-sleeping may be noted. There might be increased agitation (pacing, tapping) or increased slowing of motor and speech functions. Heightened fatigue is typical. Loss of intimate relations or less satisfying social interactions are common. The therapist may notice the patient taking more responsibility for events, thus blaming themselves and attributing greater defect to the self than is natural. Along with these potential diagnostic symptoms, the person may be distractible, lacking memory or concentration, as well as wishing to be dead. A combination of four of these, or related symptoms, in addition to the general joyless loss of interest in life are good cause for considering a diagnosis of MDD.

Many of the additional factors that have been identified for diagnosing MDD are not that relevant for children. Individuals with chronic or severe medical conditions are at higher risk for developing MDD. There is an average onset in the mid-20s, but this age is decreasing in the younger population and it is important to realize that MDD can begin at any age. After one single episode, there is a 60% chance of having another. The more episodes someone has, the more likely they are to experience other episodes, as well as to develop a Manic Episode. While difficult to predict, MDD in a young person can evolve into Bipolar Disorder.

The diagnosis of MDD should not be made, however, if the MDE is linked together with a recurring pattern that includes Manic Episodes. The episode or episodes must occur without a history of Manic, Mixed, or Hypomanic Episodes in order to be properly considered constitutive of Major Depressive Disorder. In addition, the MDE(s) can be confused with Schizoaffective Disorder, so care must be taken to analyze clearly the difference. Further, the occurrence of Substance-Induced Mood Disorder or of Mood Disorder Due to a General Medical Condition cannot be part of the diagnosis of Major Depressive Disorder.

Major Depressive Disorder is known to occur in children of almost every age. The DSM-IV-TR states that "the core symptoms of a Major Depressive Episode are the same for children and adolescents, although there are data that suggest that the prominence of characteristic symptoms may change with age" (APA, 2000, pp. 353-54). It gives some indications of childhood symptoms of depression, which are similar to the adult symptoms, and associated disorders:

Certain symptoms such as somatic complaints, irritability, and social withdrawal are particularly common in children, whereas psycho-motor retardation, hypersomnia, and delusions are less common in prepuberty than in adolescence and adulthood. In prepubertal children, Major Depressive Episodes occur more frequently in conjunction with other mental disorders (especially Disruptive Behavior Disorders, Attention-Deficit Disorders, and Anxiety Disorders) than in isolation. In adolescents, Major Depressive Episodes are frequently associated with Disruptive Behavior Disorders, Attention-Deficit Disorders, Anxiety Disorders, Substance-Related Disorders, and Eating Disorders. (APA, 2000, p. 354)

Elsewhere the manual says that its symptoms in children may come across as irritable rather than as sad. Significantly, it warns that MDD symptoms of crankiness should be differentiated from a "spoiled child" pattern of frustrated irritability. Furthermore, symptoms such as distractibility or difficulty paying attention can reflect in the child's suddenly poor performance at school. This would be a significant potential indicator of childhood depression, especially if it distresses the child seriously. A child with MDD may exhibit separation anxiety as well.

What seems important in trying to give a diagnosis to children is to pay close attention to their behavior. Often a child cannot express just what he or she is feeling in a verbal way. Rather he or she will act out in frustration. Children under 9-years-old express distress through behavioral problems and acting out (Schwartz, Gladstone, & Kaslow, 1998). They may be fidgety and restless in session, or, the opposite, motionlessness. Children communicate through somatic symptoms (headaches, etc.) more than adolescents (Birmaher et al., 1996), and the depressed child may miss school or visit the nurse more than other children. Assessment should gather from many sources. Friedburg & McClure (2002) speak of self-report measures, interviews, observer ratings, peer nominations, and projective techniques. There is a Children's Depression Inventory (CDI) that is a tool in long and short versions. It can be completed by children or adolescents before sessions and can be used to monitor changes. Another self report rating to assess symptoms is the Revised Children's Depression Rating Scale (CDRS-R) which includes parent, sibling, and teacher forms and has been normed on 9- to 16-year-olds.

Treatment and Interventions

The treatment approach this essay wants to explore is child cognitive therapy, including cognitive behavioral therapy or CBT. The cognitive approach sees negative feelings and behavioral patterns rooted in systemic negative thought patterns. Therefore, it focuses on modifying those distorting thought patterns (Curry & Reineke, 2003). The main assumption of cognitive approaches to therapeutic intervention is that if the thoughts can be adjusted in a positive direction, then the emotional and behavioral problems might resolve themselves. Cognitive approaches are structured, focused, and often based around building skills. CBT is a particularly helpful and successful form of therapy for children with mood disorders. All cognitive approaches use some behavioral techniques and agree with the benefits of psychoeducation about depression. They all emphasize the child's need to monitor mood, to identify and modify maladaptive cognitions, and to learn problem solving, social, and affect regulation skills (Curry and Reineke, 2003).

Interpersonal psychotherapy for adolescents (IPT-A) is one cognitive-based form for psychosocial intervention for children with major depressive disorder (Brown et al., 2008). Its primary goal is to reduce depressive symptoms through enhancement of communication and interpersonal skills (Stark, Herren, and Fisher, 2009). It targets common problem areas (grief, role disputes, interpersonal deficits) and applies a cognitive behavioral approach. It uses communication analysis, questions, affect encouragement, conflict clarification, role playing, and event linking to try to enhance self-esteem and encourage change. IPT -- A assists the child in grasping and resolving interpersonal issues. The rate of successful recovery is good.

Another cognitive approach is the Modular Therapy Model for treatment. Its components are within-session flexibility, between-session flexibility, designation of core vs. non-core modules, individualized pace of treatment, individualized sequence, flexible involvement of parents and family, and adaptations to address comorbidity (Curry and Reineke, 2003). This approach integrates personal CBT with parent session. Therefore, there is more emphasis on improving relationships within the family environment.

In all cognitive treatments, clients are "taught to identify dysfunctional thoughts and maladaptive assumptions -- either through recall or imagined situations -- that may be contributing to feelings of depression" (Maag, Swearer, and Toland, 2009, p. 237). Once this happens, techniques are used to contradict the debilitating thought. One technique is "reality checking" or "hypothesis testing." Here the child distinguishes between true and not true, reality and hypothesis, and goes out with a sleuth mentality to test this experimentally. The example these authors give is a boy who thinks his smiling peers are all teasing him. The therapist will help him "devise a system for reading context and judging peers' facial expressions and body language so that he can determine objectively if the thoughts behind his problem are indeed accurate" (Maag, Swearer, and Toland, 2009, p. 237). This is typical of cognitive approaches with children since the ideas presented in therapy require active and concrete reinforcement. This reinforcement also comes through the behavioral components of rehearsal and modeling. The child is essentially taught and trained by the therapist to monitor herself, evaluate herself, and reinforce what she has learned in practical ways at school and home. This integration of behavioral techniques is based on the premise that cognitive restructuring alone is often ineffective with children if not behaviorally reinforced.

A third example of cognitive behavioral interventions for depressed children is Stark's ACTION treatment (Stark et al., 2007). This program for girls follows a workbook and is conducted in schools in small groups. This is important since it shows a school-based delivery of therapy in which teachers also receive intervention training. The focus is on developing self-control and coping skills. Through conversations, role plays, self-map building, homework, and self-monitoring diaries, the program helps girls acquire affective education (identifying feelings), goal setting, progress recognition, coping skills training, problem-solving training, cognitive restructuring, and building positive self-image. One way coping skills are developed, for instance, is to encourage the replacement of negative (maladaptive) thoughts with something fun and distracting (Stark, 2009, p. 279). All of the activities are to direct the child's attention from negative to positive information, thus restructuring maladaptive thoughts and beliefs and supporting them through more adaptive ones. Similar to the ACT and ADAPT intervention strategy (Stark, Herren, and Fisher, 2009), it teaches the child to gain control over mood through learned problem-solving for problems they can change, and to adapt to problems they cannot change. There is, in addition, a focus on externalizing negative thoughts, such as by talking back to or blaming the "muck monster" rather than the self, which creates emotional distance between the child and depressive thinking. The intervention strategy is designed to help the child see multiple perspectives and recognize self-blame and cognitive errors.

Finally, Mannasis (2008) has given a list of cognitive strategies to apply in child CBT therapy. These include teaching the child to recognize his or her own feelings, to make sharing feelings with helpful adults a treatment goal (since it reduces acting out from unacknowledged feelings), and to label emotional symptoms and externalize them concretely which encourages them to defend against 'thought bullies," "snowball thoughts" (catastrophic thinking), and "black cloud thoughts" (negative thinking). Since children often cannot provide adaptive thoughts for themselves, the therapist should, and then ask them to choose which is true for them. In addition, the therapist ought to repeat adaptive thoughts that are meaningful to the child and use them in different situations (repetition mantra) or give them cards with helpful coping strategies and reminders. Superheroes can be used to stimulate adaptive thinking (what would wonder woman do?). Since depression in children is often linked with being bullied, Mannasis suggests cognitive behavioral strategies for the child to challenge that belief with counterevidence.

While not comprehensive, this synthesis of cognitive approaches gives an idea of possible intervention strategies for treatment. What unifies and makes these approaches valuable is the combination of cognitive restructuring with behavioral reinforcement. Without being overly optimistic, cognitive psychotherapy is probably the best chance that children with depression have for receiving positive treatment. At the same time, the approach can be critiqued for being less focused on environmental, biological, or socioeconomic factors. Its philosophy is that such factors are best dealt with through mental adjustment put into practice. Unlike purely behavioral models, it works from cognition first and then connects with subsequent behavior. There is a clear prioritization of thought as both the problem and the solution. The development of healthy thought patterns is assumed to play a significant role in decreasing the chance of MDD.

Ethical Considerations

The definition of MDD in children is hard to dispute ethically. However, there are some issues that are important to address. One problem might be that giving a diagnosis of MDD unnecessarily stigmatizes the child. As a result, the child may grow into self-fulfilling prophecies that are detrimental in the long-run. Conceivably therapeutic practitioners understand this and mitigate this through proper supportive treatment of the child. It is possible, as well, that children do not understand their depressive feelings or see them as abnormal. They might consider therapy as a punishment, or bad in some way since they are being singled out from other children and since they are there involuntarily. Again, the ethical response is for the therapist to assure them that this is not the case. It is their moral obligation to dampen guilt feelings in the child and help them to see that their depression is not an innate characteristic of who they are. As such, the diagnostic criteria and definition of MDD must be carefully applied. It should not be used to label the child. Nor should it be used to segregate them from their school or home environments, thus furthering their feelings of isolation and withdrawal.

Ethically, cognitive approaches have to be careful since they are effectively implanting thoughts into the child's mind. There is the potential for wrongful manipulation of the child. Obviously, most therapists recognize that they must be attuned to suitable ways of drawing the child out which are not unethical or perverse. With children, there may be issues of clarification and expectations as well. All this can mean anxiety in the child and a lack of understanding the point of therapy. It is the therapist's ethical duty to take time to allow them to adjust to the circumstances, to build trust, and to eliminate this anxiety through good explanations. The therapist should not exploit the situation in any way, nor criticize or demean the child, since a child with MDD is vulnerable and already presumably has self-esteem issues.

When working with children and adolescents, all the same ethical rules apply as used with adults. The APA Code of Ethics is a crucial guideline here. Moreover, all the basic rules about forming trust in a therapeutic relationship apply to children. It would be necessary for the therapist to enter the depressed child's unique world in order to begin understanding thought and feeling patterns. What is important is that the therapist use techniques and activities that match the child's cognitive level. This involves creativity and ensuring that the activities proposed are something they can initiate on own. It is further the ethical duty of a cognitive therapist to teach social skills through modeling, feedback, role playing, stories, games, or other means. Depressed children often do not know how to communicate or interact well, how to be assertive, how to give compliments, and other things that socially adjusted children use for granted. Participation in the process should be validated often. Ground rules should be established so that the child has an idea of what to expect and what is or is not tolerable during the session. In addition, after the therapeutic session, the child needs to be encouraged to enact what he or she has learned. This means the therapist must engage in motivational strategies.

From an ethical standpoint, a large part of therapy with children must involve interactions with the parents. While maintenance of the child's confidentiality is important, the parents require being informed of the proceedings involving their child. They must be allowed to express questions, including doubts, and to receive limited information about the sessions, especially if there is danger (e.g., suicidal plans). It is imperative that the therapist not break confidentiality, even of a child, for this is the basis of therapeutic trust.

Suicidality is one of the greatest ethical issue surrounding treatments for MDD. Although rare in young children, it is more prevalent in adolescents. The key perhaps is to empathize with child while also teaching coping skills when one addresses suicidal ideation. Best efforts should be made to help rather than exacerbate the suicidal ideation. It would be important to cast doubt on the efficacy of self-harm, but without shaming or arguing with the child. Because the main goal is the child's safety, care must be used in discerning the hidden expressions of potential self-harm in children who tend to speak in metaphors (hit by car, crawl in hole). Any actual plan for suicide that is discovery must be directly addressed and an alternative safety plan with adaptive problem-solving strategies put forward.

Finally, there is the issue of cultural difference. One of the problems is that minority youths are underrepresented in research on childhood depression (Brown et al., 2008, p. 82). Some have proposed increasing research on multicultural children's problems (Achenbach & Rescorla, 2006). It is fairly safe to assume that CBT could work as well on them as on others (Huey and Polo, 2008). It may be important to have an ethnic match between client and therapist to achieve successful treatment. However, this neither guarantees success, nor should the treatment be shaped to ethnicity specifically. What can happen is that the main parts of the treatment are bent or distorted in trying to make the sessions more culturally relevant. While ethically it is important for the therapist to recognize cultural difference and change certain aspects in favor of ethnic sensitivity, the overarching methods of CBT should not be altered. Mannasis (2009) gives a good example of the difference. She says that focusing a child's attention on taking pride in some aspect of cultural identity to enhance their self-esteem, while a good goal, may result in compromise of the technique and adversely affect outcome. By contrast, she writes, "Changing the ethnic features of cartoon characters in the manual, by contrast, should not adversely affect outcome, because it does not interfere with the child learning core CBT concepts, and may enhance engagement by increasing cultural relevance" (Mannasis, 2009, p. 81). The therapist has a moral duty to understand the racial identity of the child and cultural differences of background. Understanding multicultural factors can help in understanding adaptive and maladaptive functioning in children and needs to be considered.

Conclusion

In sum, this paper has given a general overview of the current status of research on Major Depressive Disorder in children. It has explored the definition and diagnosis of MDD. Various lines of research on the causes and treatments for childhood MDD have been shown, focusing specifically on the cognitive perspective, including cognitive behavioral approaches. It has attempted to assess the ideas and values of such a cognitive approach, as well as providing insight into some potential ethical issues involved in the research and treatment of childhood MDD. It is hoped that further research can be done so that all methods of treatment may be enhanced.