A Developmental Perspective of Depression

Childhood depression strongly illustrates the value of normative data and the possible implications of a developmental viewpoint. For example, some workers suggested that behaviors which led to the diagnosis of depression were only transitory developmental phenomena—common among children in certain age groups (e.g., Lefkowitz and Burton 1978). The classic Berkeley survey, for instance, found that 37 percent of girls and 29 percent of boys at age six exhibited insufficient appetite (a problem often thought to be associated with depression). By age nine these figures had dropped to 9 percent and 6 percent, respectively, and 14 percent of both sexes at age fourteen had insufficient appetites (MacFarlane, Alien, and Honzik 1954). Thus, insufficient appetite should probably not be considered a deviant behavior among six-year-olds. However, if it is present at age nine, especially in boys, it might be considered atypical. Other behaviors, such as "excessive reserve," occur too often in children of all ages to be considered abnormal. Other investigators (e.g. Lefkowitz, 1977) suggested that substantial proportions of the children in the normal population may possess symptoms judged characteristic of depressive disorder in clinical samples.
Thus, it could be held that depression in childhood may not as clinical entity different from common and transient developmental phenomena.

Lefkowitz and Burton (1978) suggested that perhaps one of the reasons why clinicians gave the diagnosis of childhood depression was the mistaken belief that behaviors (symptoms) such as insufficient appetite or excessive reserve are rare and, therefore, important when manifested.
The distinction between depression as a symptom and depression as a syndrome is important to consider here. One or two depressive behaviors of a child may be viewed as typical of that developmental stage. However, it is different to suggest that a cluster of such behaviors is also likely to occur in a large number of children at the same developmental level (Kovacs, 1989). Awareness of normative and developmental patterns, in any case, is clearly important and might change clinical impressions, leading to changes in diagnostic practices. The developmental perspective has become an important element in the study of depression (Cicchetti, Rogosch, and Toth, 1994; Compas, Hinden, and Gerhardt, 1995; Hammen, 1992).
The DSM perspective. It is not possible at this point to make definitive statements about the "correct" description or classification of childhood depression. A wide range of conceptualizations exist, from those that question the existence of a distinct disorder in childhood, to those that perceive childhood depression in terms of the adult classification, to those that subsume most of the important aspects of child psychopathology under the umbrella of this disorder (Petti, 1989). There are potential liabilities in making a priori judgments about what childhood depression is. However, it is probably fair to state that the dominant view is that childhood depression is a syndrome or disorder in which the essential features are the same as those manifested in adults.
Several factors have probably contributed to the dominance of this viewpoint. However, the principle influence appears to be the DSM, that beginning with DSM-IV, applied adult criteria for mood disorders including depression, to children. Table 7—2 presents the D.SM-IV criteria for the diagnosis of Major depression. There are no separate diagnostic categories for mood disorders in children or adolescents, however the possibility of different symptoms being-evident as a function of age is given some acknowledgment. For example, in prepubertal children .symptoms such as somatic complaints and social withdrawal may be particularly common, whereas symptoms such as psychomotor retardation and delusions are less common. Also, as indicated in Table 7-2, irritable mood may substitute for depressed mood in both children and adolescents.

Table 2
DSM-IV Criteria for Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2 week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day. Note: in children and adolescents, can be irritable mood
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
3. Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feeling of worthlessness or excessive or inappropriate guilt nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
9. Recurrent thoughts of death (not just fear dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

In addition to depression, DSM describes mood disorders that include mania. Mania refers to abnormally elevated, expansive, or irritable mood and excessive activity. Diagnoses may include mania or mania combined with depression (as in bipolar disorders). Manic disorders are thought to be rare in children, diagnosis is thought to be difficult in this age group, and in comparison to depression little information is available (Nottelmann and Jensen, 1995). There is, however, some indication that disorders including manic episodes may begin to occur in adolescence (Carlson, 1994; Poz-nanski and Mokros, 1994 ).
The dominance of the DSM system and the findings by several researchers that they could apply adult criteria in unmodified form to diagnose mood disorders in children and adolescents have contributed to the popularity of this perspective (e.g., Carl-son and Kashani, 1988; Ryan et al., 1987). The view inherent in the DSM approach, that mood disorders found in youngsters are the same as those found in adults, is also supported by some research. Many of the cognitive attributes, biological correlates, and behaviors found in depressed adults are also reported in children and adolescents (e.g., Kaslow, Rehm, and Siegel, 1984; Kazdin et al., 1985; Puig Antich, 1983). However, differences have also been found, and this has led many workers to conclude that it is premature to accept the use of the same criteria for depressive disorders across all age groups (Nurcornbe, 1994; Poznanski and Mokros, 1994). They suggest that research is not sufficient, and that certain findings require explanation. The gender ratio in prevalence is one example (Compas Hinden, and Gerhardt, 1995; Nolen Hoek-sema and Girgus, 1994). There is a greater prevalence of depression among adult females than adult males, whereas in youngsters prevalence differences between the genders are not usually reported until sometime during adolescence. In addition, some of the serious concomitants of adult depression are less evident in children, and some biological correlates appear to differ as well (Kazdin, 1986b). Also, antidepressant medications have not been demonstrated to have the same effectiveness in children and adolescents as they have in adults (Johnston and Fruehling, 1994). Finally, the high rates of additional disorders found in youngsters diagnosed as depressed also suggest continued attention to developmental differences in the expression of depression. The association of depression with other difficulties may hold important information regarding both the development of depression and its treatment (e.g., Anderson and McGee, 1994; Kovacs et al., 1984; Lewinsohn et al., 1993).
Overall, then, caution would argue against premature closure regarding our conceptualization of childhood depression. Much developmental information still needs to be obtained, and existing information requires explanation.

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