ABSTRACT
Assessment of depression in children and adolescents requires an understanding of developmental issues that contribute to the expression of depression as well as a firm knowledge of assessment practices. The aim of this chapter is threefold. First a discussion of the models of depression is presented to provide a theoretical framework for understanding depression in children and adolescents. Second, a brief overview of developmental issues that can contribute to depression is provided. Finally, a discussion of the assessment measures as well as their applicability to children and adolescents with depression is presented.The diagnosis and assessment of childhood depression rests on the symptoms listed in DSM-IV-TR (American Psychiatric Association, 2000), using generally the same symptoms as those used to diagnose adult depression. DSM-IV-TR provides a framework for diagnosing depression in adults. To qualify for a diagnosis of depression under this framework, the child/adolescent must show a depressed mood or loss of interest in pleasurable activities for at least two weeks. In addition, there must be at least four additional symptoms that may include changes in appetite/weight, sleep, or activity level; feelings or worthlessness and/or guilt as well as suicidal ideation; and/or problems with concentration and work completion. In addition to these DSM-IV-TR symptoms, social withdrawal, somatic symptoms, a negative body image, and bodily complaints have been found in children and adolescents with depression (Hammen & Rudolph, 2003). Cantwell (1983) suggests that children can show a unique presentation of depression and that depression in children may be characterized by restlessness and irritability rather than the sad mood and apathy frequently seen in adults. This suggestion is now present in DSM-IV-TR (American Psychiatric Association, 2000).There are several models of depression that can help to inform the assessment of children and adolescents. The cognitive-behavioral model combines the child’s behavior and how the environment shapes this behavior with how the child perceives his/her environment. In 485
contrast, the behavioral model suggests that depression is the result of the child not receiving sufficient reinforcement from his/her environment. This dearth of reinforcement may be due to few reinforcers in the environment or difficulty in obtaining these reinforcers, possibly due to off-putting behaviors. Interpersonal models stress the relationships the child has with peers and parents. Difficulties are found in establishing friendships and connections to others and most particularly with peers (Rudolph, Hammen, & Burge, 1994). In these models the child has difficulty with problem-solving, coping, and emotional regulation (Rudolph, Kurlakowsky, & Conley, 2001). Children with these types of difficulty often ruminate on their difficulties, and this rumination in turn interferes with their ability to utilize active and effective problem-solving strategies. Psychodynamic theories of depression in childhood stress a disruption in caregiving relationships. Object relations theory suggests that the experience of a loss places the child in a vulnerable position for developing depression. This loss may be either literal or figural (death or emotional deprivation/poor parenting). In this model depression stems from anger about the lost object, which is then converted into an internal schema that usually takes the form of self-criticism (Davis & Wallbridge, 1983). Attachment theory can also be a model for depression. When the child is unable to form an attachment to the primary caregiver, a sense of security and trust is not present, and the infant becomes vulnerable to future problems with mood and self-acceptance (Bowlby, 1980).The psychosocial and developmental contexts in which depression occur are important variables that need to be evaluated when a child or adolescent is being assessed for possible depression (Cicchetti, Gaiban, & Barnett, 1991; Cicchetti & Schneider-Rosen, 1986; Sroufe & Rutter, 1984). Thus, depression in childhood and adolescence is a combination the child’s temperament, coping skills, biological heritage, and environmental experiences. A lack of openness to change, often required by environmental demands, and an inability to easily assimilate new experiences may overwhelm a child and are likely associated with depression in early childhood. In addition, difficulties with attachment may contribute to depressive feelings, particularly if there is a disruption in early attachment (Cicchetti & Schneider-Rosen, 1986; Cummings & Cicchetti, 1990; Kobak, Sudler, & Gamble, 1991; Kopp, 1989; Nurcombe, 1994).The prevalence of depression appears to be increasing with a concomitant decrease in the age when depression is first noted (Stark, Sander, Yancy, Bronik & Hoke, 2000). The estimated rate of depression is approximately 2% of children and 4% of adolescents (American Academy of Child and Adolescent Psychiatry, 1998). Prior to adolescence, there are no gender differences, but during adolescence, girls show an increase; the incidence almost doubles by adulthood (Stark et al., 2000).The duration of depression in children also varies depending on age. Major depression appears to last for 32 to 36 weeks, whereas dysthymia can last from 3 to 4 years (Kovacs, Akiskal, Gastonis, & Parrone, 1994; Strober, Lampert, Schmidt, & Morrell, 1993). Risk factors include not only the level of severity of depression but also the duration, with those children from dysfunctional families and girls showing more severe and longer episodes of depression (McCauley et al., 1993, Stark et al., 2000). In addition, depression in children and adolescents appears to be recurrent, with a 20% to 60% chance of returning within 1 to 2 years of remission (AACAP, 1998). Risk factors for a relapse include early age of onset, comorbid disorders, and psychosocial stressors (Birmaher et al., 2002; Emslie, Rush, Weinberg, & Gullion, 1997).Cormorbidity is an important issue during an evalution of a child for depression. Approximately 40% to 70% are reported to have one comorbid disorder, and 20% to 50% have two or more (Birmaher et al., 1996). Common comorbid disorders include anxiety, ADHD, oppo
sitional defiant disorders, and possibly posttraumatic stress disorder (Birmaher et al., 1996; Kilpatrick et al., 2003). Moreover, in late adolescence, personality disorders may arise and complicate the depression assessment as well as treatment (Lewinsohn, Rohde, Seeley, & Klein, 1997). When comorbidity is present, there is more severe impairment, a poorer response to treatment, and an increased risk for suicide (Lewinsohn, Rohde, & Seeley, 1998). How depression expresses itself differs, depending on the developmental level of the child or adolescent (Luby et al., 2002; Weiss & Garber, 2003).A meta-analysis of 11 empirical studies found developmental effects in 18 of 29 (62%) core and associated depressive symptoms (Weiss & Garber, 2003). Another analysis of empirical research found that some symptoms of depression were consistent across age groups, including depressed mood, decreased concentration, sleep disturbance, and suicidal ideation. The presentation of other symptoms varied by age. Anhedonia (or a depressed mood), variation of symptom severity throughout the day, hopelessness, psychomotor retardation, and delusions increased with age, whereas depressed appearance, low self-esteem, somatic complaints, and hallucinations decreased with age (Borchardt & Meller, 1996; Carlson & Kashani, 1988). The extent to which developmental effects moderate the presentation of depression and the nature of those effects are not yet entirely understood (Goodyer, 1996), but developmental considerations appear to be useful in the assessment of depression. A brief description of empirical knowledge highlighting developmental issues important for the assessment of depression from infancy through early adulthood follows.
