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Assessment of Childhood Depression

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Assessment of Childhood Depression Child and Adolescent Mental Health Volume 11, No. 2, 2006, pp. 111–116 doi: 10.1111/j.1475-3588.2006.00395.x Assessment of Childhood Depression Allan Chrisman, Helen Egger, Scott N. Compton, John Curry & David B. Goldston Box 3492, Duke University Medical Center, Durham, NC 27710, USA. E-mail: [email protected] Background: Depression as a disorder in childhood began to be increasingly recognised in the 1970s. Epi- demiologic community and clinic-based studies have characterised the prevalence, clinical course, and complications of this illness throughout childhood and adolescence into adulthood. This paper reviews two instruments for assessing depression in prepubertal children – the Dominic Interactive and The Preschool Age Psychiatric Assessment. Both instruments are useful in screening for psychiatric disorders and reliably identifying the presence of depressive symptoms in young children. Keywords: Depression; assessment; childhood; PAPA; Dominic Interactive Introduction depressive disorder, dysthymic disorder and depressive disorder not otherwise specified. The recognition that depressive syndromes and dis- In depression, children may report feeling sad, un- orders exist in young people is a relatively recent happy, bored or disinterested in usual activities, angry or development. In the mid-twentieth century, when psy- irritable, or may appear sad or tearful (APA, 1994). The choanalytic theory provided the primary conceptual diagnosis of major depressive disorder (MDD) requires at model for psychiatric disorders, clinicians rarely diag- least one episode in which the child has had five or more nosed depression in young people. Initial challenges to of the following symptoms, including one of the first two, the psychoanalytic theory that depression required full for a minimum of two weeks: (1) depressed or irritable superego development came with the recognition of mood; (2) markedly diminished interest or pleasure in ‘anaclitic’ depression in very young children (Spitz & activities; (3) weight or appetite loss or gain; (4) insomnia Wolf, 1946), a condition marked not by self-criticism or hypersomnia; (5) psychomotor agitation or retarda- but by low energy, low interest, and low mood reflecting tion; (6) fatigue or loss of energy; (7) feelings of worth- unmet basic dependency needs. By the 1970s, there lessness or excessive guilt; (8) decreased ability to think, was acknowledgment that depression might be ‘under- concentrate or make decisions; (9) recurrent thoughts of lying’ disruptive behaviour problems in children, and death or suicide or a suicide attempt or plan. clinicians began to search for ‘masked’ depression The diagnosis of dysthymic disorder (DD) according (Cytryn & McKnew, 1972). This theory, however, could to DSM-IV criteria is given if depressed or irritable mood not be substantiated. is present most days for a year or more and is accom- Researchers began noting the similarities and panied by two or more of six key symptoms. The one- differences between childhood and adult depression year duration of dysthymic disorder for children and including sadness, anhedonia, low self-esteem, adolescents is a contrast to the two-year duration re- and other vegetative signs and symptoms uniquely quired for adults. The two unipolar mood disorders are occurring in children such as somatic complaints, not mutually exclusive, and some children or adoles- social withdrawal, aggression, and school refusal. cents will experience MDD during the course of DD. Lewinsohn et al. (1993) proposed that the study of Luby and colleagues (2002) proposed developmen- affective disorders in children and adolescents began tally modified DSM-IV criteria for diagnosis of depres- in earnest in the 1970s when several sets of investi- sion in preschool children. The prominent symptoms of gators demonstrated that such disorders exist and their modified criteria were sad or irritable mood, an- can be reliably assessed in young people. Objective hedonia, low energy, eating and sleeping problems, and documentation of affective phenomenology in children low self-esteem. Their developmental modification also similar to that in adults was made possible by the included a reduction in the duration requirement for standardization of operational criteria in research and persistence of depressed or irritable mood. Namely, epidemiological studies. depressed or irritable mood must be present but not necessarily persistently present over a two-week period. Diagnostic criteria/nosology Another modification was that persistent death and Depressive disorders are now commonly diagnosed in suicide themes in play were included in the assessment accordance with DSM-IV or ICD-10 criteria. Similar of suicidal ideation. A full description of the modified criteria are used for children and adults. Depressive depression criteria can be found in Luby et al. (2002). disorders have disturbed mood as the core-defining characteristic for children. Categories of depressive Epidemiology and course disorders under the DSM-IV (American Psychiatric The rate of depressive disorders in preschoolers varies Association, 1994) nomenclature include major significantly across the few community studies of Ó 2006 Association for Child and Adolescent Mental Health. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA 112 Allan Chrisman et al. preschool depression. A recent study of psychopatho- follow the onset of other disorders, except for substance logy in a sample of children (n ¼ 307) aged 2–5 (Angold abuse and panic disorder, which have their onset in et al., 2005) is the first non-clinical study to use a adolescence. A meta-analysis by Angold and Costello reliable structured interview specifically developed for (1993) found that anxiety disorders, conduct and op- preschool children (the PAPA, see description that positional disorders, and attention deficit hyperactivity follows). The cohort was selected from a sample of 1073 disorder are 8.2, 6.6, and 5.5 times more common in children screened in a large primary care paediatric depressed children and adolescents, respectively. medical practice. The rate of depressive disorders, including major depression, dysthymia, and minor Treatments depression, was 2.1%. There was no significant differ- Developing and evaluating effective psychosocial and ence in rates of depression between boys and girls, but psychopharmacological treatments for childhood and there was a non-significant trend suggesting that older adolescent MDD has been a significant focus of re- preschoolers (4 and 5 year olds) were more likely than search. The National Institute for Health and Clinical toddlers (2 and 3 year olds) to be depressed. Excellence (NICE) and the National Collaborating Cen- Fleming and Offord’s (1990) review of studies showed tre for Mental Health have released a clinical guideline that the prevalence of MDD in preadolescent children is on the treatment and management of depression in roughly 2%, with an increase to 4% to 8% in adoles- children and young people (NICE, 2005). The guideline cents. The onset of puberty is now thought to be asso- recommends that children and young people with ciated with this increase. moderate to severe depression should be offered, as a Rates of depression are associated with gender and first-line treatment, a specific psychological therapy puberty (Birmaher et al., 1996). Among depressed chil- (such as cognitive behavioural therapy, interpersonal dren, there is equal gender representation, but in ado- therapy or family therapy of at least 3 months dur- lescents (post pubertal), the ratio of depression is about ation). Antidepressant medication should not be offered two females to one male, similar to the pattern among to children or young people with moderate to severe adults. The phenomenology of the disorder also differs by depression except in combination with a concurrent puberty, with postpubertal adolescents with MDD more psychological therapy and should not be offered at all to likely than children to have anhedonia, hypersomnia, children with mild depression. weight change, or more lethal suicide attempts. Cognitive-behavioural therapy (CBT) involves work- Despite the differences in likelihood of some symp- ing with the young person to understand and to modify toms, Birmaher and colleagues (2004) have found that thoughts and behaviours that are likely contributing to depressed children and adolescents have largely similar depression. Interpersonal psychotherapy (IPT) involves symptom patterns, course, patterns of comorbidity, and working with the young person to understand the im- parental histories. They also have similar pharmaco- pact of relationship or role conflicts on depression and logical treatment responses (Emslie et al., 2002) and to modify interpersonal patterns. There is considerable biological findings related to depression (Birmaher evidence to support the efficacy of CBT both for child- et al., 1996; Kaufman et al., 2001). hood and for adolescent depression (Curry, 2001), and of IPT for adolescent MDD (Mufson et al., 1999). Stud- Consequences ies of tricyclic antidepressant medications did not Depression during childhood or adolescence increases demonstrate efficacy in children or adolescents (Hazell the risk of depression during adulthood four-fold et al., 1995). Emslie and his colleagues (Emslie et al., (Harrington et al., 1990). Depression is associated with 1997) using fluoxetine, a selective serotonin reuptake multiple impairments in functioning,
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