Lecture 24 Childhood Psychopathology: Depression Lecture Outline I. Introduction II. Depression in Infancy A. Anaclitic Depression B. Protest-Despair-Detachment C. Controversy III. Depression in Childhood A. Self-Report B. Masked Depression C. The Developmental Context IV. Depression in Adolescence A. Puberty B. Learned Helplessness C. Cognitive Development V. Course VI. Conclusions ------------------------------------------- I. Introduction In today's lecture we will examine an example of an "internalizing disorder": childhood depression. Earlier in the course we examined adult depression - and perhaps you wonder why we return to the topic of depression once again. Is not depression depression...whether or not it occurs in adulthood or childhood? For many years, many psychologists presumed this to be the case: adult concepts of the disorder were merely extended downward (Rutter, 1986). The DSM-III-R is consistent with this approach: There is no separate diagnostic category for childhood depression. The manual simply states that depression "may begin at any age, including infancy" (APA, 1987, p.220) However, in more recent years, there has been growing recognition that, although adult concepts may be applicable to childhood psychopathology, it is equally likely that disorders in childhood will have their own distinctive features. Today we will look at the nature of depression as it applies to childhood, and attempt to identify the uniqueness of the disorder as well as some the controversies involved in its study. II. Depression in Infancy Can an infant be depressed? This question, simple at first glance, turns out to be the heart of considerable controversy. Let's look first at some of the evidence supporting the view that "yes, young children do develop depression". A. Anaclitic Depression In 1946, Spitz (1946) described a syndrome he termed "anaclitic depression" which he observed in children confined to institutions and thus separated for extended periods of time from their parents. These children, especially around 6-12 months of age, began to exhibit symptoms such as weeping, withdrawal, apathy, weight loss, and sleep disturbance (Rutter, 1986). This sounds very much like the symptoms of depression listed in the DSM-III-R. Spitz hypothesized that these children were responding to the loss of their mother. He even suggested that such loss or prolonged separation can lead to death for the child. B. Protest-Despair-Detachment Other researchers have further investigated the effects of separation on the child. Bowlby (1980) has documented a protest- despair-detachment sequence that children go through when separated from their parents, behaviors that appear to overlap with depression to a great extent. Protest: the child is very upset, tries to initiate contact with the parent by crying, screaming etc. Despair: quickly after the initial protest, the child seems to lose hope of being reunited. S/he becomes quieter until eventually silent and withdrawn. Detachment: the child seems to overcome the loss and becomes responsive, sociable and even cheerful again. However, at this point s/he no longer will seek out his/her parents and may even ignore them if they return. Hetherington and Martin (1972) describe the child's reaction to prolonged separation in this way: First there is a period of "protest" during which the child cries a great deal, asks for parents if he can talk, shows restless hyperactivity, and is easily agitated. After about a week some children decrease their overt protests and manifest what has variously been called despair, depression or withdrawal. They become unresponsive and lose interest in the environment. The facial muscles sag and the face presents the generally accepted features of sadness and dejection. Loud wailing and crying may be replaced with low intensity whimpering or sobbing (p.62). C. Controversy Whether or not these reactions are the "same" as depression seen in adulthood or even later in childhood remains a matter of controversy. Reasons to suspect that these reactions are not depression, at least in the sense that they indicate a disorder, include: a) such reactions are very common and apparently "natural" in young children separated from their parents b) research has shown that in many cases the symptoms spontaneously disappear or there is rapid recovery upon return to the family. These facts have led many researchers to question whether the symptoms seen in these young children can be considered an actual disorder (Lefkowitz & Burton, 1978; Raskin, 1977; Rutter, 1986). To the extent that psychopathology indicates abnormal behavioral responses, the reactions seen in infants faced with separation are in fact quite normal. Nevertheless, "it can scarcely be disputed that it constitutes some form of affective response, which, at least in some children, can be relatively persistent and disabling" (Rutter, 1986, p.19). It should also be noted that not all psychopathology indicates abnormal behavioral responses: stress reactions are quite normal as a consequence of a traumatic experience, as you have seen with Post Traumatic Stress Disorder. III. Depression in Childhood Interestingly, children between the toddler years and adolescence appear remarkably free of depressive symptoms (Arieti & Bemporad, 1978; Rutter, 1986). For example, in one large scale study, only 1.4 children (per 1000) aged 10 - 12 were diagnosed with a depressive disorder (Rutter, 1980) There may be a number of reasons for this: A. Self-Report One possible explanation for why children are rarely diagnosed with depression is the young child's inability to label and verbalize how s/he feels. The activity and general exuberance of young children make him/her a poor candidate for a diagnosis of depression (Arieti & Bemporad, 1978). Indeed, parents and teachers often fail to notice even severe depression (eg: a child who is suicidal) (Rutter, 1986). B. Masked Depression Other authors have argued that many children are in fact depressed and that we can infer this depression from their behaviors if we realize that the overt behaviors associated with childhood depression are different from the behaviors seen in adult depression. Children, it is hypothesized, do not exhibit their depression in the same manner as adults. Children's depressions may be masked by a set of diverse behaviors such as aggression, hyperactivity, enuresis (bed-wetting), learning disabilities, somatic complaints, and delinquency (Arieti & Bemporad, 1978; Cantwell, 1983). The theory is that an underlying, unexpressed depression is responsible for these overt behaviors. Perhaps what is occurring is that the child, unable to tolerate prolonged feelings of sadness, shifts his/her attention to other activities. There are a number of problems with this theory. Perhaps the major problem is that the behaviors cited as masking depression cover the entire range of childhood psychopathology! It is not made clear how these numerous behaviors are linked to the hypothesized underlying depression. It is also not clear how one decides whether a symptom is or is not masking depression (Cantwell, 1983). Such problems have led different psychologists to mean very different things by depression. All sorts of symptoms have been considered as evidence of depression. In one study, from the 1970's, that looked at the frequency with which different investigators made a diagnosis of depression, it was found that the frequency ranged from 1.8 % to 25 % (Annell, 1971). Because the concept of "masked depression" has been so vaguely and loosely defined, it has lost credibility in recent years (Achenbach, 1982; Cantwell, 1983), although it is not completely dismissed (eg: Schwartz & Johnson, 1985). C. The Developmental Context Another reason depression is so infrequently diagnosed in children may be due to the very nature of childhood. The numerous and swift developmental changes that occur in childhood make it difficult to determine the significance of any particular set of symptoms. Indeed, the behavior and moods of children are very flexible and volatile - they tend to be transient and especially responsive to the environment. Some have argued that this doesn't fit with what we usually think of as a depressive disorder, which should be relatively stable and immune from the environment (certainly more so than is seen in children) (Arieti & Bemporad, 1978; Cantwell, 1983; Costello, 1980). In addition, other investigators have argued that children are simply not psychologically developed enough to even have true depression. (Psychoanalytic theorists have been making this claim for many years now). For example, if some form of relatively well- developed self-reflection is necessary for one to feel depressed, then young children who have not yet developed such a cognitive ability would not be able to experience depression. Basically, the concern is that we may be attributing to children a more complex psychological makeup than is justified (Arieti & Bemporad, 1978). What's more, and similar to what we noted with infant depression, almost all children exhibit depressive-like symptoms at some time, and these symptoms will spontaneously go away. Such symptoms may simply be normal aspects of growing up, and not indicate psychopathology (Lefkowitz & Burton, 1978). But more on this in a few minutes. IV. Depression in Adolescence In contrast to the debate over childhood depression, there is little doubt that depression is experienced by adolescents (Arieti & Bemporad, 1978; Cantwell, 1983; Rutter, 1986). The problem with this stage of development is not whether depression exists or not, but in differentiating the truly depressed adolescent from the normally moody adolescent (Arieti & Bemporad, 1978). There are numerous possible reasons for this increase in depressive emotions: it is a time of ambiguity: ties with the past must be broken and a new image of the self must be developed - one is neither a child any more, nor fully an adult. experimentation with new social roles takes place; there is pressure to conform, yet to conflicting roles. This can lead to feelings of inadequacy, shame and guilt. Whatever the reason, adolescence is often a turbulent time for the youth, with extensive mood swings and transient depression (Arieti & Bemporad, 1978). The problem: when does one make a diagnosis of depression? How severe do the symptoms need to be? How long do they need to last? Or should a diagnosis never be made, because these symptoms are perfectly normal adolescent reactions. It seems unlikely, however, that adolescent depression is a myth. Indeed, adolescence is accompanied by a "massive increase in the frequency of suicide" (Rutter, 1986; see also Shaffer, 1986) (See Handout 24-1). [Note: depression is not the only reason children commit suicide. Conflict with parents, interaction with psychotic parent, even the approach of a birthday have been linked to suicide (Shaffer, 1986)]. There is also a growing recognition that alcohol and drug use is a problem for many adolescents. Unfortunately, the use of drugs can obscure the existence of depression - it is usually much more apparent and of immediate concern to parents and school officials than the person's mood state. But it is clear that drug use can be linked to depression (among other factors), both as a cause and as a result. A. Puberty The fact that this increase in depressive symptoms coincides with puberty raises the possibility that hormonal changes are responsible for the increase. There is some evidence that hormones can play a part in emotional experiences in adults; for example: -some women develop depression when taking oral contraceptives -menopause Such findings do not lead to any clear-cut conclusions about the role of hormones, but hormonal changes may be responsible for the depression experienced by certain people (Rutter, 1986). B. Learned Helplessness We discussed the concept of learned helplessness when we looked at adult depression. The theory is equally applicable to childhood depression. If you recall, learned helplessness refers to a "mind-set" if you will, where the individual "gives up" even though success is possible because of previous experiences in which success was impossible. The symptoms of this learned helplessness, as we noted before, are remarkably similar to the symptoms of depression. A child who has grown up in a chaotic, coercive, and confusing world may have learned over the years that his/her actions have little to do with success or failure and have little impact upon the world. Such experiences may, at least, predispose the adolescent to a depressive disorder in adulthood (Dweck, 1977, Seligman & Peterson, 1986). C. Cognitive Development Adolescents are entering a stage of cognitive development where abstract, hypothetical thought is possible. Before this time, a child is not able to ponder and manipulate cognitively - s/he deals solely in the realm of concrete reality. Abstract thinking now makes possible the ability to question the very meaning of life, to contemplate one's self worth - and paves the way for an "identity crisis and all the ensuing depressive and despairing affect (Dweck, 1977). In any event, the adolescent is better able to express, label and perhaps thus experience deeper forms of depression than before (Rutter, 1986). V. Course Given the debate over the existence of childhood depression, there are few studies that have looked at the long-term prognosis for depressed children (Schwartz & Johnson, 1986). The few studies that do exist are not altogether consistent in their findings. There does seem to be some evidence, however, that adults with depressive symptoms also had depressive symptoms during childhood, although, as children their depression was often obscured by other nondepressive symptoms (eg: enuresis, fire-setting, aggression) (Rutter, 1986). In particular, early age of onset seems to be predictive of a more protracted course (Schwartz & Johnson, 1986). VI. Conclusions Childhood depression is a controversial topic. Some investigators argue that it does not even exist (eg: Lefkowitz & Burton, 1978). However, such a position seems based on certain assumptions which some people have taken exception to (eg: Costello, 1980). The assumptions: 1. Because the behaviors thought to constitute the syndrome of depression are prevalent in normal children, they cannot be considered pathological; therefore the syndrome does not exist. 2. Because these behaviors are found to disappear as a function of time, they cannot be considered pathological. 3. Problems that remit spontaneously do not need clinical intervention. And now, the Reply (Costello, 1980): 1. Just because a symptom is common does not mean it has no diagnostic significance. One must look at the symptom in context. So, while crying is common in all children, in conjunction with other symptoms it may indicate depression. Similarly a common behavior may occur with greater intensity or frequency in children with a disorder. 2. Data on prevalence as a function of age are not a sufficient base on which to judge normality or abnormality. On the one hand, symptoms may indeed fade away, but this does not mean there is not a problem which remains. The expression of the disorder has changed, that is all. 3. Even if a problem eventually fades away, it is a worthy thing to try to lessen the duration of that problem, and thus lessen the suffering experienced by the child.