Depression in Children and Adolescents

Harold S. Koplewicz, Emily Klass, Harold S. Koplewicz, Emily Klass

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317358121
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Originally published in 1993, this title has contributions from many internationally respected experts from this field. The book covers the following areas: theories of development and etiology of depression; medical illness and depression; depression and other psychiatric conditions; treatment approaches to depression. The book has been written in such a way that research, clinical and psychiatric issues are easily understood. It will still be of interest and value to paediatricians, mental health practitioners and researchers in the field.

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Psychotherapy of Depression in Childhood and Adolescence

Clarice J. Kestenbaum and Ian A. Canino

Division of Child and Adolescent Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.

Introduction

Depression has long been one of the neglected syndromes of the psychopathology of childhood. Full depressive disorders as in adults were rarely thought to occur in children partly due to the belief that children lacked the necessary intrapsychic, maturity for depression to occur (Rie, 1966) and partly, if it did occur, it took a “masked” form. Toolan (1962), for example, discussing the interaction of developmental levels and the manifestation of depressive feelings, coined the term “depressive equivalents” including temper tantrums, disobedience, and accident proneness. Other authors (i.e. Wolfenstein, 1966) contended that even normal mourning could not occur until mid-adolescence when certain developmental tasks had been completed.

The past decade, however, has brought in its wake a renewed interest in depressive reactions in children, and there has been a marked change in the psychiatric view of affective disorders of early life. Depressive conditions meeting adult criteria have now been shown to occur in childhood.

Depression in Early Childhood

One definition of depression as compared to sadness, grief and mourning in the psychoanalytic literature is “an experience of loss that triggers rage and hostile responses directed at the self… and transformed consequentially to a mood sta^e” (Milrod, 1988). Themes of childhood sadness and grief reactions date back to the writings of Anna Freud and Dorothy Burlingham (1944) who described the responses of infants and children to the loss of parental affection and need gratification caused by death, foster care placement, illness and divorce. Rene Spitz in 1945 designated the term “hospitalism” to specify the destructive effects of institutional care on infants. He coined the term “anaclitic depression” for the syndrome occuring in children over six months of age as a result of separation from their mothers after the mother-child tie had been established. In the emotionally deprived children he studied he encountered severe withdrawal, apathy, and regression. In a two-year follow-up study of these children in a foundling home, Spitz (1946:113-117) found them to be severely delayed in their gross motor development, capacity to handle materials, toilet training, language development, and social relations. Their height and weight fell below the normal ranges and he postulated that their resistance to physical illness had been severely impaired. This clinical picture was to later become the “failure to thrive” syndrome often seen in many pediatric wards.

John Bowlby (1973), in his work with hospitalized children, stated that there is a causal relationship between loss of maternal care in early life and disturbed personality development. The pathogenic factor, he believes, is loss of the mother (or primary caretaker) during the period between six months and three years, the period considered optimal for the establishment of object permanence (6 to 18 months) in the Piagetian sense of cognitive stages of development and object constancy (6 to 36 months) when the internal representation of a familiar person is complete. The child becomes closely attached to the mother and is distressed by her absence. Most children do not suffer disruption of the primary attachment in the early years, but if the mother should die or if a series of short term caretakers are employed as substitutes in the total absence of the mother, or if the child is hospitalized for long periods of time, a clinical picture resembling adult mourning may indeed result. Bowlby (1973) through observations of hospitalized children described a series of specific stages the child underwent after maternal loss and mentioned the time limits beyond which lost object restoration would not reverse the reaction. He described the children as undergoing three stages: protest, despair, and detachment. He postulated that protest may result in subsequent separation anxiety, that despair could lead to grief and mourning, and that detachment was a defensive maneuver which protected the child from emotional pain.

Despite the findings of Spitz and Bowlby there is still controversy about the existence of depression in children under five. Kovacs and Beck (1977) contend that depression is rare and difficult to diagnose before age seven when communication skills become fully developed. Poznanski and Zrull (1970) disagree and have described children as young as three who displayed lack of appetite, failure to gain weight, withdrawal and lack of attachment to the caretaker. Depression in the mother has been implicated, along with separation and loss, as highly significant risk factors (Weissman 1972). A depressed mother who is unable to meet the needs of an infant or young child does not provide a healthy emotionally stable environment. In order to fulfill the developmental tasks of the preschool age—separation and individuation according to Margaret Mahler (1952), a firm attachment bond to the primary caretaker must be established first.

O’Brien (1983) observes “Maternal depression disrupts the mutual activation and regulation that characterizes a healthy mother-child relationship… preschool children of depressed mothers have a high incidence of behavioral disorders, difficulty in eating, difficulty in obtaining bladder control and a high accident rate”

Depression in Middle Childhood

As previously noted, the psychoanalytic literature underscores the importance of development in determining the timing of particular symptoms (Bemporad and Won Lee, 1986). Developmental tasks of middle childhood include acquisition of new motor skills, such as bike riding and language skills. Cognitive development proceeds by leaps and bounds. In terms of socialization the child develops a number of peer relationships, frequently a best friend and participates actively in groups. Self-esteem is dependent in most part on a feeling of success academically and socially. The middle years are also the period for conscience development and a deepening sense of values. Behavioral problems as the child matures frequently indicate underlying depressive feelings. Children may appear sullen, complain of fatigue and behave in a provocative, negativistic or bored manner. Just as loss of the mothering figure may lead to depressive reactions in infancy, losses of loved ones or friends by separation and divorce can lead to overt or covert depressive symptoms. Some children experiencing a loss might defend against the feelings engendered by the loss by fighting or refusing to conform to academic requirements in school.

Anthony (1967) noted that the difference between child and adult depression stems from “the child’s inability to verbalize his affective state, the incomplete development of the superego (i.e. conscience) and the absence of a consistent self representation.” His studies of depressed children describe weepiness, flattened affect, fear of death, irritability, somatic complaints, loss of appetite, difficulties in school and hostility directed toward the parents. Some of these children, Anthony felt, had a constitutional predisposition to depression and often came from families with a history of depression or manic-depressive illness.

Sandler and Joffee (1965) observed that the children they studied did not display the psychomotor retardation of adult depressives but did display sad affect, withdrawal, feelings of rejection, passivity and insomnia. They contend that depression can be the “result of the loss of a prior state of well-being rather than solely as the deprivation of a love object.”

Poznanski and Zrull (1970) focused on the negative self-image or loss of self esteem as being of primary importance in understanding the psychopathology of childhood depression. Glaser (1967) utilized the phrase “masked depression” as did Cytryn and McKnew (1972).

Bemporad (1988) concentrated his work on children and adolescents and defines depression somewhat more generally as the “deprivation of some aspect of psychic life that was necessary to the individuals’ sense of esteem or worth.” He describes the individuals’ vulnerability to severe dysphoria as due to (a) the individual’s inordinate need for nurturance or affirmation from others in order to secure a sense of self-esteem and/or (b) the individuals’ inability to substitute or create new sources of worth subsequent to such a loss. He states that the possible precipitant of depression are experiences that can influence negatively the self-concept in relation to important others and/or the loss of relationships, achievements, or ideas that have been utilized to support a needed self-regard.

Depression in Adolescence

Adolescence is a period of physiological and psychological change. According to Bios (1968) character formation will proceed optimally only if the following conditions are met:

1) Loosening of Parental Ties: Adolescents must increasingly seek new models for themselves in teachers, counselors, friends, and heroes of sport, television, and films, with whom they can identify, and by whose example they shape their own efforts at individuation and independence.

2) Resolution of Earlier Traumas: Adolescents must come to terms with certain traumatic childhood events. These may involve only early disappointment with one or both parents, who are seen to have human frailties, or something as severe as the death of a parent.

3) Establishment of Continuity: Adolescents seek to establish a sense of continuity with respect to their previous feelings, remembered experiences, and their own family history. One cannot have a future without having a past.

4) Solidification of Sexual Identity: Early adolescence is characterized by a growing capacity to make a sexual object choice and to solidify one’s sense of gender identity, an aspect of self-awareness that had begun in infancy. Most often the goal of the mature individual is to find an intimate relationship with a partner of the opposite sex. Failure to complete these developmental tasks may lead to subsequent depression.

Mood swings in adolescence are common manifestations of this developmental period. Usually these are transient and related to such events as dissolution of a friendship, disappointment with performance in grades or sports, or parental discipline. Bemporad (1988) observes that adolescence is a vulnerable period and notes that depressive responses in adolescence range from normative to pathological. Adolescents sense of worth often comes from relationships and achievements that are outside the family nucleus and is highly determined by the adolescents’ ability to convince themselves as well as others that they are no longer children. Feelings of inadequacy, disappointment, or shame are dependent on socially-related activities especially those related to heterosexual coupling. At a cognitive level, the adolescent develops self-consciousness, a sense of consequences of his or her behavior, and a more realistic grasp of their abilities and liabilities both intellectual as well as physical. They must relinquish their childhood fantasies and thus deal with their feelings of loss and resignation.

Bemporad furthermore describes two types of depression in adolescence—anaclitic and introjective. Anaclitic depression is that occurring in adolescents who have not emancipated themselves from their familial role (being too gratified or protected): thus, they cannot form a separate satisfactory sense of worth. It also includes those coming from dysfunctional families in which the adolescents assume pseudoparental roles, therefore having difficulty forming allegiances and relationships outside the household. Introjective depression, Bemporad believes, is observed in adolescents who are more individualized but have unrealistic demands and expectations internalized from familial relationships. They feel they must live out some parental aspiration and this precludes feelings of pleasure and/or freedom. Serious depressive symptoms in adolescence include school refusal, avoidance of former friends, lack of interest in sports or hobbies, or reckless behavior, alcoholic or drug abuse. Self reproach, expressions of worthlessness and of course, suicidal preoccupation are all important warning signs that should not be ignored.

Clearly, there is a wide spectrum of what may be considered depression; from normal sadness to depressive feelings secondary to grief reactions, physical illness, and psychosocial stress to the full syndrome of major depression.

In each case of childhood or adolescent depression, strengths, vulnerabilities, and the developmental level must be considered. The child’s ability to report, express, and experience depressive feelings has to be understood within the context of the family and of the environment. The strengths and vulnerabilities, self-image, defensive style, as well as temperamental traits and genetic predisposition will certainly effect symptom expression and resolution as well as level of dysfunctionality and prognosis.

Psychotherapeutic Interventions for Preschool Children with Depressive Reactions

It is obvious from the foregoing discussion that depression in childhood and adolescence has multiple determinants and that a psychiatric evaluation should be done in order to choose the best kind of therapeutic intervention. If a seven year old is dysthymic and cannot learn to read dynamic psychotherapy would not be the first line of intervention, even if the child is able to discuss his frustration with an understanding adult. He would need a special class placement, and language and learning therapy; only if the mood disorder persisted after appropriate academic help was instituted should the consultant consider a course of psychotherapy. Psychosocial distress due to poverty, homelessness or family turmoil needs environmental manipulation, social service intervention or family therapy in addition to individual counselling or psychotherapy.

Psychiatric Consultation and Brief Intervention

The sine qua non of the psychiatric consultation is the evaluation. Brief therapeutic intervention is sometimes enough to allow the depressed child to get back on the path of normal development.

Case I–Maria, age 4

Maria was referred for a psychiatric consultation by her preschool principal because of apathy and withdrawal. The teacher had tried to engage her in a variety of activities without success. Maria’s mother, Mrs. S., a sad young woman from the Dominican Republic, told the consultant that Maria did not love her any more; she described Maria as having been...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• Introduction
• Theories of Development and Etiology
• Medical Illness and Depression
• Depression and Other Psychiatric Conditions
• Treatment Approaches
• INDEX