Lecture 24
Childhood Psychopathology:
Depression
Lecture Outline
I. Introduction
II. Depression in Infancy
A. Anaclitic Depression
B. Protest-Despair-Detachment
C. Controversy
III. Depression in Childhood
A. Self-Report
B. Masked Depression
C. The Developmental Context
IV. Depression in Adolescence
A. Puberty
B. Learned Helplessness
C. Cognitive Development
V. Course
VI. Conclusions
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I. Introduction
In today's lecture we will examine an example of an "internalizing
disorder": childhood depression. Earlier in the course we examined
adult depression - and perhaps you wonder why we return to the topic of
depression once again. Is not depression depression...whether or not it
occurs in adulthood or childhood? For many years, many psychologists
presumed this to be the case: adult concepts of the disorder were merely
extended downward (Rutter, 1986). The DSM-III-R is consistent with this
approach: There is no separate diagnostic category for childhood
depression. The manual simply states that depression "may begin at any
age, including infancy" (APA, 1987, p.220) However, in more recent
years, there has been growing recognition that, although adult concepts
may be applicable to childhood psychopathology, it is equally likely
that disorders in childhood will have their own distinctive features.
Today we will look at the nature of depression as it applies to
childhood, and attempt to identify the uniqueness of the disorder as
well as some the controversies involved in its study.
II. Depression in Infancy
Can an infant be depressed? This question, simple at first glance,
turns out to be the heart of considerable controversy. Let's look first
at some of the evidence supporting the view that "yes, young children do
develop depression".
A. Anaclitic Depression
In 1946, Spitz (1946) described a syndrome he termed
"anaclitic depression" which he observed in children confined to
institutions and thus separated for extended periods of time from
their parents. These children, especially around 6-12 months of
age, began to exhibit symptoms such as weeping, withdrawal, apathy,
weight loss, and sleep disturbance (Rutter, 1986). This sounds
very much like the symptoms of depression listed in the DSM-III-R.
Spitz hypothesized that these children were responding to the loss
of their mother. He even suggested that such loss or prolonged
separation can lead to death for the child.
B. Protest-Despair-Detachment
Other researchers have further investigated the effects of
separation on the child. Bowlby (1980) has documented a protest-
despair-detachment sequence that children go through when separated
from their parents, behaviors that appear to overlap with
depression to a great extent.
Protest: the child is very upset, tries to initiate contact
with the parent by crying, screaming etc.
Despair: quickly after the initial protest, the child seems to
lose hope of being reunited. S/he becomes quieter
until eventually silent and withdrawn.
Detachment: the child seems to overcome the loss and becomes
responsive, sociable and even cheerful again.
However, at this point s/he no longer will seek out
his/her parents and may even ignore them if they
return.
Hetherington and Martin (1972) describe the child's reaction to
prolonged separation in this way:
First there is a period of "protest" during which the
child cries a great deal, asks for parents if he can
talk, shows restless hyperactivity, and is easily
agitated. After about a week some children decrease
their overt protests and manifest what has variously been
called despair, depression or withdrawal. They become
unresponsive and lose interest in the environment. The
facial muscles sag and the face presents the generally
accepted features of sadness and dejection. Loud wailing
and crying may be replaced with low intensity whimpering
or sobbing (p.62).
C. Controversy
Whether or not these reactions are the "same" as depression
seen in adulthood or even later in childhood remains a matter of
controversy. Reasons to suspect that these reactions are not
depression, at least in the sense that they indicate a disorder,
include:
a) such reactions are very common and apparently "natural" in
young children separated from their parents
b) research has shown that in many cases the symptoms
spontaneously disappear or there is rapid recovery upon
return to the family.
These facts have led many researchers to question whether the
symptoms seen in these young children can be considered an actual
disorder (Lefkowitz & Burton, 1978; Raskin, 1977; Rutter, 1986).
To the extent that psychopathology indicates abnormal behavioral
responses, the reactions seen in infants faced with separation are
in fact quite normal.
Nevertheless, "it can scarcely be disputed that it constitutes
some form of affective response, which, at least in some children,
can be relatively persistent and disabling" (Rutter, 1986, p.19).
It should also be noted that not all psychopathology indicates
abnormal behavioral responses: stress reactions are quite normal as
a consequence of a traumatic experience, as you have seen with Post
Traumatic Stress Disorder.
III. Depression in Childhood
Interestingly, children between the toddler years and adolescence
appear remarkably free of depressive symptoms (Arieti & Bemporad, 1978;
Rutter, 1986). For example, in one large scale study, only 1.4 children
(per 1000) aged 10 - 12 were diagnosed with a depressive disorder
(Rutter, 1980) There may be a number of reasons for this:
A. Self-Report
One possible explanation for why children are rarely diagnosed
with depression is the young child's inability to label and
verbalize how s/he feels. The activity and general exuberance of
young children make him/her a poor candidate for a diagnosis of
depression (Arieti & Bemporad, 1978). Indeed, parents and teachers
often fail to notice even severe depression (eg: a child who is
suicidal) (Rutter, 1986).
B. Masked Depression
Other authors have argued that many children are in fact
depressed and that we can infer this depression from their
behaviors if we realize that the overt behaviors associated with
childhood depression are different from the behaviors seen in adult
depression. Children, it is hypothesized, do not exhibit their
depression in the same manner as adults. Children's depressions
may be masked by a set of diverse behaviors such as aggression,
hyperactivity, enuresis (bed-wetting), learning disabilities,
somatic complaints, and delinquency (Arieti & Bemporad, 1978;
Cantwell, 1983). The theory is that an underlying, unexpressed
depression is responsible for these overt behaviors. Perhaps what
is occurring is that the child, unable to tolerate prolonged
feelings of sadness, shifts his/her attention to other activities.
There are a number of problems with this theory. Perhaps the
major problem is that the behaviors cited as masking depression
cover the entire range of childhood psychopathology! It is not
made clear how these numerous behaviors are linked to the
hypothesized underlying depression. It is also not clear how one
decides whether a symptom is or is not masking depression
(Cantwell, 1983). Such problems have led different psychologists
to mean very different things by depression. All sorts of symptoms
have been considered as evidence of depression. In one study, from
the 1970's, that looked at the frequency with which different
investigators made a diagnosis of depression, it was found that the
frequency ranged from 1.8 % to 25 % (Annell, 1971).
Because the concept of "masked depression" has been so vaguely
and loosely defined, it has lost credibility in recent years
(Achenbach, 1982; Cantwell, 1983), although it is not completely
dismissed (eg: Schwartz & Johnson, 1985).
C. The Developmental Context
Another reason depression is so infrequently diagnosed in
children may be due to the very nature of childhood. The numerous
and swift developmental changes that occur in childhood make it
difficult to determine the significance of any particular set of
symptoms. Indeed, the behavior and moods of children are very
flexible and volatile - they tend to be transient and especially
responsive to the environment. Some have argued that this doesn't
fit with what we usually think of as a depressive disorder, which
should be relatively stable and immune from the environment
(certainly more so than is seen in children) (Arieti & Bemporad,
1978; Cantwell, 1983; Costello, 1980).
In addition, other investigators have argued that children are
simply not psychologically developed enough to even have true
depression. (Psychoanalytic theorists have been making this claim
for many years now). For example, if some form of relatively well-
developed self-reflection is necessary for one to feel depressed,
then young children who have not yet developed such a cognitive
ability would not be able to experience depression. Basically, the
concern is that we may be attributing to children a more complex
psychological makeup than is justified (Arieti & Bemporad, 1978).
What's more, and similar to what we noted with infant
depression, almost all children exhibit depressive-like symptoms at
some time, and these symptoms will spontaneously go away. Such
symptoms may simply be normal aspects of growing up, and not
indicate psychopathology (Lefkowitz & Burton, 1978). But more on
this in a few minutes.
IV. Depression in Adolescence
In contrast to the debate over childhood depression, there is
little doubt that depression is experienced by adolescents (Arieti &
Bemporad, 1978; Cantwell, 1983; Rutter, 1986). The problem with this
stage of development is not whether depression exists or not, but in
differentiating the truly depressed adolescent from the normally moody
adolescent (Arieti & Bemporad, 1978). There are numerous possible
reasons for this increase in depressive emotions:
it is a time of ambiguity: ties with the past must be broken and a
new image of the self must be developed - one is neither a child
any more, nor fully an adult.
experimentation with new social roles takes place; there is
pressure to conform, yet to conflicting roles. This can lead to
feelings of inadequacy, shame and guilt.
Whatever the reason, adolescence is often a turbulent time for the
youth, with extensive mood swings and transient depression (Arieti &
Bemporad, 1978). The problem: when does one make a diagnosis of
depression? How severe do the symptoms need to be? How long do they
need to last? Or should a diagnosis never be made, because these
symptoms are perfectly normal adolescent reactions. It seems unlikely,
however, that adolescent depression is a myth. Indeed, adolescence is
accompanied by a "massive increase in the frequency of suicide" (Rutter,
1986; see also Shaffer, 1986) (See Handout 24-1). [Note: depression is
not the only reason children commit suicide. Conflict with parents,
interaction with psychotic parent, even the approach of a birthday have
been linked to suicide (Shaffer, 1986)].
There is also a growing recognition that alcohol and drug use is a
problem for many adolescents. Unfortunately, the use of drugs can
obscure the existence of depression - it is usually much more apparent
and of immediate concern to parents and school officials than the
person's mood state. But it is clear that drug use can be linked to
depression (among other factors), both as a cause and as a result.
A. Puberty
The fact that this increase in depressive symptoms coincides
with puberty raises the possibility that hormonal changes are
responsible for the increase. There is some evidence that hormones
can play a part in emotional experiences in adults; for example:
-some women develop depression when taking oral contraceptives
-menopause
Such findings do not lead to any clear-cut conclusions about
the role of hormones, but hormonal changes may be responsible for
the depression experienced by certain people (Rutter, 1986).
B. Learned Helplessness
We discussed the concept of learned helplessness when we
looked at adult depression. The theory is equally applicable to
childhood depression. If you recall, learned helplessness refers
to a "mind-set" if you will, where the individual "gives up" even
though success is possible because of previous experiences in which
success was impossible. The symptoms of this learned helplessness,
as we noted before, are remarkably similar to the symptoms of
depression. A child who has grown up in a chaotic, coercive, and
confusing world may have learned over the years that his/her
actions have little to do with success or failure and have little
impact upon the world. Such experiences may, at least, predispose
the adolescent to a depressive disorder in adulthood (Dweck, 1977,
Seligman & Peterson, 1986).
C. Cognitive Development
Adolescents are entering a stage of cognitive development
where abstract, hypothetical thought is possible. Before this
time, a child is not able to ponder and manipulate cognitively -
s/he deals solely in the realm of concrete reality. Abstract
thinking now makes possible the ability to question the very
meaning of life, to contemplate one's self worth - and paves the
way for an "identity crisis and all the ensuing depressive and
despairing affect (Dweck, 1977). In any event, the adolescent is
better able to express, label and perhaps thus experience deeper
forms of depression than before (Rutter, 1986).
V. Course
Given the debate over the existence of childhood depression, there
are few studies that have looked at the long-term prognosis for
depressed children (Schwartz & Johnson, 1986). The few studies that do
exist are not altogether consistent in their findings. There does seem
to be some evidence, however, that adults with depressive symptoms also
had depressive symptoms during childhood, although, as children their
depression was often obscured by other nondepressive symptoms (eg:
enuresis, fire-setting, aggression) (Rutter, 1986). In particular,
early age of onset seems to be predictive of a more protracted course
(Schwartz & Johnson, 1986).
VI. Conclusions
Childhood depression is a controversial topic. Some investigators
argue that it does not even exist (eg: Lefkowitz & Burton, 1978).
However, such a position seems based on certain assumptions which some
people have taken exception to (eg: Costello, 1980). The assumptions:
1. Because the behaviors thought to constitute the syndrome of
depression are prevalent in normal children, they cannot be
considered pathological; therefore the syndrome does not exist.
2. Because these behaviors are found to disappear as a function of
time, they cannot be considered pathological.
3. Problems that remit spontaneously do not need clinical
intervention.
And now, the Reply (Costello, 1980):
1. Just because a symptom is common does not mean it has no
diagnostic significance. One must look at the symptom in context.
So, while crying is common in all children, in conjunction with
other symptoms it may indicate depression. Similarly a common
behavior may occur with greater intensity or frequency in children
with a disorder.
2. Data on prevalence as a function of age are not a sufficient
base on which to judge normality or abnormality. On the one hand,
symptoms may indeed fade away, but this does not mean there is not
a problem which remains. The expression of the disorder has
changed, that is all.
3. Even if a problem eventually fades away, it is a worthy thing to
try to lessen the duration of that problem, and thus lessen the
suffering experienced by the child.