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Chapter 8

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Psychology 2042A/B
Scott Wier

Child Psychology Chapter 8: Mood Disorders Introduction  Mood Disorder: a disturbance in mood is the central feature  Children with mood disorders suffer from extreme, persistent, or poorly regulated emotional states  Mood disorders are one of the most common, chronic, and disabling illnesses in young people Overview of Mood Disorders  Dysphoria: a state of prolonged bouts of sadness  Anhedonia: feelings of little joy in anything you do and lose interest in nearly all activities  Many youngsters with depression express these combined feels of sadness and loss of interest  However, some never report feeling sad. Rather, they express their depression through their irritable mood  Irritability is one of the most common symptoms of depression  Mania an abnormally elevated or expansive mood, and feelings of euphoria which is an exaggerated sense of well-being  Bipolar Disorder (BP): highs may alternate with lows or they may feel both extremes at about the same time  DSM-IV-TR divides mood disorders into depressive disorders and bipolar disorder Depression  Depression refers to a pervasive unhappy mood  Clinical depression is more severe than the occasional blues or mood swings that everyone gets from time to time  Children’s symptoms tend to be short lived  For a long time it was thought that children didn’t get depressed, and when they did, it would be short-lived  Children who are depressed can’t seem to shake their sadness, and it begins to interfere with their daily routines, social relationships, school performance and overall functioning  Often have accompanying problems such as anxiety or conduct disorder  Depression often goes unrecognized and untreated because parents may not recognize the child’s underlying subjective negative mood Depression: History  Because children lacked sufficient superego development to permit aggression to be directed against the self, it was believed that they were incapable of experiencing depression  In another view, symptoms of depression were considered normal and passing expressions of certain stages of development  View emerged that children express depression much differently than adults in ways that are often indirect and hidden known as masked depression  Notion of masked depression has been rejected  Depression is simply overlooked because it frequently co-occurs with more visible disorders, such as conduct problems Depression in Young Children  Almost al youngsters experience some symptoms of depression  Display lasting depressed mood while facing real or perceived distress and disturbances in their thinking, physical functioning, and social behaviour  Suicidal behaviour among teens, which is frequently associated with depression  Even when children recover from their depression, they are likely to experience recurrent bouts and continued impairments  Heightened risk for suicide, substance abuse, BP disorder, poorer health outcomes, and higher health care costs make depression in young people a significant concern Depression and Development  Children express and experience depression differently at different ages  No one pattern fits all children within a particular age group or developmental period, and not until children are older is depression clearly recognizable to as clinical disorder using DSM criteria  May be used to identify clinical depression in children as young as 3-5  Under age of 7 are less easily identified  Anaclitic depression in which infants raised in a clean but emotionally cold institutional environment displayed reactions that resembled depression  Spitz attributed this depression to an absence of mothering and the lack of opportunity to form an attachment, physical illness and sensory deprivation may also have played a role  These infants experience sleep disturbances, loss of appetite, increased clinging, apprehension, social withdrawal, crying and sadness  Preschool children who are depressed may appear extremely somber and tearful  Irritable for no reason and negative and self-destructive verbalizations may occur, and physical complaints are common  School age children with depression display many of the symptoms of preschoolers in addition to increasing irritability, disruptive behaviour, temper tantrums, and combativeness  Often unwilling to talk about their sad feelings, physical complaints may include weight loss, headaches, and sleep disturbances, academic difficulties, and peer problems, and suicide threats  Preteens show increasing self-blame and expressions of low self-esteem, persistent sadness, and social inhibition  Inability to sleep or may sleep excessively, disturbances in eating are also common, increased irritability, loss of feelings of pleasure or interest and worsening school performance  Negative body image and self-consciousness, physical symptoms such as excessive fatigue and energy loss, feelings of loneliness, guilt, and worthlessness, and suicidal thoughts and attempts  Presence of sad mood, loss of interest or irritability is essential for diagnosing depression  In addition, regardless of the child’s age, the symptoms must reflect a change in behaviour, persists over time, and cause significant impairment in functioning Anatomy of Depression  Different types of depression: o Depression as a symptom  Feeling sad or miserable  Often occur without the existence of a serious problem, and are relatively common to all ages  Symptoms of depression are temporary o Depression as a syndrome  More than sad mood  A group of symptoms that occur together more often than by chance  Less common than isolated depressive symptoms, and often includes missed symptoms o anxiety and depression, which tend to cluster on a single dimension of negative affect  May occur following certain life events o Depression as a disorder  Comes in two types, major depressive disorder and dysthymic disorder  May be associated with common causes, associated features, and a characteristic course, outcome, and response to treatment Major Depressive Disorder (MDD)  Key features of MDD: sadness, loss of interest or pleasure in nearly all activities, irritability, plus a number of additional specific symptoms that are present for at least 2 weeks  A diagnostic MDD depends on the presence of a major depressive episode plus the exclusion of other conditions, such as the prior occurrence of a manic episode  It also requited ruling out physical factors that may have caused or prolonged the depression, a depression that is part of normal bereavement, and underlying thought disorders  Three important points about the diagnosis of MDD: o Same criteria used to diagnose children and adolescents as to diagnose adults o Depression in children can be easily overlooked o Some features of depression are likely more common in children and adolescents than in adults  Children and adolescents with MDD frequently display similar symptoms and have comparable rates of comorbidity and recurrence as adults  Clinic-referred children will recover somewhat faster from their depressive episode, and are at greater risk for developing bipolar disorder  Children suffer from their disorder for many years longer than adults Major Depressive Disorder (MDD): Prevalence  Rare among preschool and school age children but increases by adolescence  Prevalence estimates vary with the length of the time in which symptoms are assessed  The estimates using DSM diagnosis of MDD might be lower than the self- reported symptoms of depression  Many children who just barely fail to meet diagnostic criteria for MDD still show significant impairments in their social competence, cognitive attributions, coping skills, family relations and experience stress  Increase in depression from preschool to elementary school is likely a reflection of the school-age child’s growing self-awareness and cognitive capacity, verbal ability to report symptoms, and increased performance and social pressures  Increase in depression in adolescence appears to be the result of biological maturation at puberty interacting with important developmental changes that occur during this tumultuous time period Major Depressive Disorder (MDD): Comorbidity  The most frequent co-occurring disorders in clinic-referred children with MDD are anxiety disorders, particularly generalized anxiety disorders, specific phobias, and separation anxiety disorders  Dysthymia, conduct problems, ADHD, and substance use disorder are also common in clinic referred children with depression  Comorbid personality disorder, which is most commonly borderline personality disorder – instability of interpersonal relationships, self-image, affects, and marked impulsivity  Most co-occurring disorders are present before depression and are likely to persist after the child is no longer depressed  Co-occurring disorders can increase the risk for recurrent depression, the duration and severity of the depressive episode, and suicide attempts  Presence of another disorder decreases the children’s response to treatment and is related to less effective outcomes Major Depressive Disorder (MDD): Onset, Course, and Outcome  Onset of depression in adolescence may be gradual or sudden  Age of onset is 13-15  The average episode of MDD lasts about 8 months, with longer episodes if a parent has a history of depression  A significant number of children develop chronic, relapsing disorder that persist into young adulthood  Onset of depression prior to age 15 and a recurrent episode prior to age 20 display more severe, chronic, suicidal depressions, greater co-occurring anxiety and worse social functioning at age 15 and poorer psychosocial outcomes at age 20  First episode may sensitize the children to future episodes  The first episode may be linked to a specific stressor, and is accompanied by lasting changes in biological processes that heighten future reactivity to stress  The initial externally produced changes in the brain can be conditioned so that followed the first depressive episode may result in depression. This phenomenon is known as kindling  Even after recovery from their depressive episode many youths continue to show milder symptoms of depression and experience adjustment and health problems and chronic stress  Adolescences who are depressed have a greater than normal risk for delinquency, arrest and conviction, dropping out of school, and unemployment  Also increases the risk for later tobacco use, substance use disorder, suicidal behaviour, impairment, poor work record, marital problems, and health services  Although almost all recover from their depression, they continue to be at high risk for later episodes of mood and other disorders and for impaired social and academic functioning  As they become adults children and adolescents with MDD continue to experience may negative long-term outcomes Major Depressive Disorder (MDD): Gender, Ethnicity, and Culture  Females twice as likely as males to suffer from depression, are more susceptible to milder mood disorders, and are more likely to experience recurrent episodes  This sex difference is not present among children ages 6-11, where depression is equally common in boys and girls  Girls reporting significantly more of these symptoms than boys  Sex differences begin between 13-15  Symptoms presentation is quite similar for both sexes  The correlates of depression may differ for the sexes  Depression may differ for the sexes  Depression is more highly related to school-related to school-related stress in boys than in girls  Physical, psychological, and social changes during adolescence may heighten the risk for depression in girls  Hormonal changes in estrogen and testosterone may affect brain function, increasing sexual maturity may affect social roles, interpersonal changes and expectations may result in heightened exposure to stressful life events, and non-normative changes such as early maturation may lead to isolation from one’s peer group  Thought that females may be at higher risk than males because they have a greater orientation toward cooperation and sociality  They also use ruminative coping styles to deal with stress  Interpersonal stress and a lack of social support are particularly salient aspects of depression for adolescent girls  Low birth weight has been found to predict expression in adolescent girls but not boys  Research also suggests that increased levels of testosterone and estrogen at puberty, particularly when they occur in combination with social stress, increase the risk fro depression in girls  Hormones and sleep cycles, which can alter mood, differ dramatically between males and females  Sex differences in depression may be partly rooted in biological differences in the brain processed that regulate emotions  African American and Hispanic youths both had significantly higher rates of depression  However, only Hispanic youths with depression showed an elevated risk for impaired functioning  Pubertal status was found to be better predictor of depressive symptoms than chronological age in Caucasian girls, but not in African American or Hispanic girls  Found that non-white adolescents reported more symptoms of depression than white adolescents  These differences likely reflect differences in SES  In females, initial rates of depressive symptoms were highest for Hispanic and Asian teens and lowest for whites, with African American youths falling in between  Males displayed lower levels of symptoms but the findings for race-ethnic group differences were similar to those for females  All groups showed decreases in symptoms Dysthymic Disorder  Dysthymic Disorder (DD): display depressed mood for most of the day, on most days, for at least 1 year  They are unhappy or irritable most of the time  The symptoms of dysthymia are chronic, they are less severe than those for children with MDD  Children with dysthymia are characterized by poor emotion regulation  Some may experience double depression, where a major depressive episode is superimposed on the child’s previous dsythymia, causing the child to present with both disorders  One study found that children with wither MDD or dysthymia alone did not differ in their clinical features  Children with both disorders were more severely impaired than children with just one of the disorders Dysthymic Disorder: Prevalence and Comorbidity  Rates are lower than those of MDD  Most prevalent co-occurring diagnosis with dysthymia is MDD  Half of the children with dysthymic disorder also have one or more co- occurring nonaffective disorders that preceded dysthymia, including anxiety disorders, conduct disorder, and ADHD Dysthymic Disorder: Onset, Course, and Outcome  Develops about 3 years earlier than MDD, around 11-12 years old  Since dysthymia frequently precedes MDD, it could be a precursor to its development  Average episode length of 2-5 years  Almost all eventually recover from dysthymic disorder  High risk of developing other disorders, especially MDD, anxiety disorders, and conduct disorders  Receiving less social support from friends this is unique to children with dysthymia  Those who recover have the same family relationships, cognitive styles, and school functioning as other children  The only area that continues to be affected is psychosocial functioning  They may be a predisposing factor for the development of dysthymic disorder, or a lasting scar of the illness  Long-lasting episodes of dysthymia can have extremely harmful effects on development Associated Characteristics of Depressive Disorders: Intellectual and Academic Functioning  Certain depressive symptoms are most likely to have a harmful effect on a child’s intellectual and academic functioning  The association between severity of depression and children’s overall intelligence is weak, suggesting that the effects of depression on cognitive functions may be selective  Perform more poorly than others in school, score lower on standard achievement tests, lower levels of grade attainment, repeating a grade, being late or skipping school, failure to complete homework, and dissatisfaction with or refusal of school  It is unclear whether depression has an enduring effect on school performance Associated Characteristics of Depressive Disorders: Cognitive Disturbances  Experience deficits and distortions in their thinking  Negative beliefs and attributions of failure are not part of the diagnosis but typically accompany the disorder  Often devalue their own performance by not acknowledging their accomplishments  They dismiss praise and frequently make inaccurate interpretations of their experiences  To focus narrowly on negative events for long periods is referred to as a depressive ruminative style  Negative thinking and faulty conclusions are generalized across situations  Many report hopelessness or negative expectations about the future that are related to diminished self-esteem and to suicide ideation and attempts  Pessimistic outlook also places them at greater risk for depressive symptoms Associated Characteristics of Depressive Disorders: Negative Self-Esteem  Low self-esteem is the symptom that seems most specifically related to depression in adolescents  Unstable self-esteem seem to play an important role in depression  Physical appearance and approval from peers, perceived incompetence in these areas may heighten the risk of depression  An interesting development model hypothesizes that children seek and receive feedback from others about their competence or incompetence in several domains: academics, social relations, sports, conduct, and physical appearance  Children whose self-views are negative and narrowly focused in one domain Associated Characteristics of Depressive Disorders: Social and Peer Problems  Experience significant disruptions in their relationships  They have few friends or close relationships, feel lonely and isolated, feel that others do not like them, and display extensive impairments in their social skills  Even when youngsters recover from their depression, they continue to experience some social impairment  Their social withdrawal may reflect an inability to maintain social interactions, which is possible related to negative, irritable, and aggressive behaviour toward others, and deficits in initiating conversations or making friends  Use ineffective styles of coping in social situations, they use less active and problem-focused coping, and more passive, avoidant, ruminative, or emotion- focused coping, also make poor choices in dealing with social problems  The basic understanding required for appropriate social relations appears to be relatively intact in children with depression Associated Characteristics of Depressive Disorders: Family Problems  Experience less supportive and more conflictual relationships with their mothers, fathers, and siblings  They feel socially isolated from their families and prefer to be alone rather than with them  Their isolation may be due to a desire to avoid conflict  During interactions, they may be quite negative toward their parents, and their parents in turn may respond in a negative, dismissing, or harsh manner Associated Characteristics of Depressive Disorders: Depression and Suicide  Most children with depression report suicidal thinking and many actually attempt it  Drug overdose and wrist cutting are the most common methods for adolescents who attempt suicide  For children who complete suicide, the most common methods are firearms, hanging or suffocation, and poisoning or overdose  Two strongest risk factors for suicidal behaviour are consistent worldwide – having a mood disorder and being a young female  Suicidal ideation is common across may different types of disorders actual suicide attempts are much more common during depression  Suicide attempts of children with depression almost never occur during times when they are symptom free  Young females with depression show more suicidal ideation and attempt suicide much more often than young males  However, they are usually less successful in completing suicide than boys  Ages 13-14 are peak periods for a first suicide attempt and decline after age 17-18  Strategy for reducing suicide in young people is to increase the availability of effective treatments for depression Theories of Depression: Psychodynamic  Early psychodynamic theories viewed depression as the conversion of aggressive instinct into depressive affect  Depression is presumed to result fro the loss of a love object that is loved ambivalently  This loss can be actual or symbolic  The individual’s subsequent rage toward the love object is then turned against the self  Since children and adolescents were believed to have adequate development of the superego or conscience, the hostility directed against internalized love objects that have disappointed or abandoned them does not produce guilt so they do not become depressed  The fact that not every child experiences depression casts doubt on this model Theories of Depression: Attachment  Attachment theory focuses on parental separation and disruption of an attachment bond as predisposing factors for depression  Bowlby hypothesized that a child confronted with unresponsive and emotionally unavailable caregiving goes through a typical sequence involving protest, despair, and detachment  A parents consistent failure to meet the child’s needs is associated with the development of an insecure attachment, a view of self as unworthy and unloved, and a view of others as threatening or undependable  These factors may place the child at risk for later depression, particularly in the context of stressful interpersonal relationships  Attachment relationships also serve to regulate biological and behavioural systems related to emotion  In support of this theory, children with insecure attachments are more likely than children with secure attachments to display symptoms of depression are more likely to experience without depression Theories of Depression: Behavioural  Emphasize the importance of learning, environmental consequences and skills an deficits during the onset and maintenance of depression  Depression is related to a lack of response contingent positive reinforcement  This occurs for three reasons: o Child may be unable to experience available reinforcement, often due to interfering anxiety o Changes in the environment may result in a lack of availability of rewards o A child may lack the social skills needed to have rewarding and satisfying social relationships  May also receive sympathy for their sadness, which produces the desired attention and concern  This sympathy is usually short-lived because even people begin to avoid him or her  This models seems incomplete in the light of what is known about other factors that may lead to a vulnerability to depression  Model highlights the importance of learning processes in the emergence, expression, and outcome of depression in young people Theories of Depression: Cognitive  Focus on the relation between negative thinking and mood  The underlying assumptions are that how young people view themselves and their world will influence their mood and behaviour, and that cognitive vulnerabilities interact with negative events to increase depressive symptoms  Depressogenic Cognitions: the negative perceptual and attributional styles and beliefs associated with depressive symptoms  Hopelessness Theory: proposes that depression-prone individuals tend to make internal, stable, and global attributions to explain the causes of negative events  When something bad happens, they think they are responsible  They attribute positive events to something outside themselves  A negative attributional style results in the individual’s taking personal blame for negative events in his or her life and leads to helplessness and avoidance of these events in the future  The cognitive model by Beck proposes that depressed individuals make negative interpretations about life events because they use biased and negative beliefs as interpretive filters for understanding these events  Depressed individuals show cognitive problems in three areas o First, they display information-processing biases or errors in their thinking in specific situations, called negative automatic thoughts  May selectively attend to negative information  Assign negative labels and react emotionally to the label rather than the event o Second, depression is believed to be associated with a negative outlook in the following three areas referred to a the negative cognitive triad  Negative views about oneself  Negative views about the world  Negative views about the future o Third, depressed children have negative cognitive schemata, which are stable structures in memory that guide information processing, including self-critical beliefs and attitudes  These schemata are rigid and resistant to change even in the face of contradictory evidence, and may heighten the children sensitivity to depression, especially when activated by stress  A well developed sense of self and a time perspective for the future are needed to experience depression; these cognitive processes are still developing in children  Many of the cognitive errors and distortions discussed do far, such as illogical thinking are normal ways of thinking in young children Theories of Depression: Other Theories  Self control theories view children with depression as having difficulty organizing their behaviour in relation to long-term goals and displaying deficits in self-monitoring, self-evaluation, and self-reinforcement  Interpersonal models view disruptions in interpersonal relationships, especially with family and peers, as the basis for the onset and maintenance of depression o Interpersonal models also propose that the child’s depression may serve a function in the family  Socioenvironmental models emphasize the relationship between stressful life events and depression o First, depression can be a direct reaction to the occurrence of stressful life events o Second, Diathesis-Stress Model of Depression: the occurrence of depression depends on the interaction between the child’s personal vulnerability and life stress o Third, negative environmental events may be internalized as negative cognitions, which then predispose the child to develop depression o Finally, depression may result in impairments in functioning that generate stressful life circumstances  Neurobiological models of depression in young people focus on genetic vulnerabilities and neurobiological processes Causes of Depression  Causes of depression interplay among genetic, neurobiological, family cognitive, emotional, interpersonal, and environmental factors  Genetic risk influences neurobiological processes, and is reflected in an early temperament characterized by oversensitivity to negative stimuli, high negative emotionality and a disposition to feeling
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