Theoretical explanations of depression in children (Childhood Mental Health)

Introduction

Over recent years, there has been an extreme attention in the concept of depression in childhood. The issue is particularly complex because sadness and tears are common parts of all children’s lives and so cannot form any true basis for a diagnosis of a depressive illness. In addition, the term itself has become so much part of common usage that it has begun to lose value as a description of a particular illness process. Even within professional circles the word ‘depression’ is used synonymously to describe three discrete levels known as depressed mood, depressive syndrome and depressive disorder (Kadzin 1990).

The depressed mood of a child is a state of profound unhappiness and sense of dejection (dysphoria) that is more than normal sadness. The child cannot see any real bright spots to his or her life, and there is a loss of emotional involvement with either other children or activities. Repeatedly it is associated with negative styles of thinking about the young people themselves (giving rise to feelings of failure and guilt) or about the future (giving a sense of hopelessness).  Table 1 shows how much thoughts create a wider shift in mood, which then becomes attributed to all aspects of life. The presence of such feelings is a normal reaction to a distressing event, but they are in proportion to the importance of the event, and the overall intensity is not great (Elliott and Place 1998).

Table 1 (Thoughts creating a shift in mood)

When reflecting upon:      personal achievements              ability to influence events

The past                         feeling of guilt and shame         fearful of acting in case of repeats

The present                    believes self to be a failure        feels helpless

The future                      experts the worst to happen       feels hopeless

(Elliott and Place 1998).

The depressive syndrome as part of the concrete levels is a cluster of symptoms including depressed mood, tearfulness and petulance, loss of appetite, sleep disturbance and interruption, poor concentration and loss of energy. While depressive disorder can be viewed as a psychiatric diagnosis of depression, such as the one given in the diagnostic and statistical Manual (DSM-IV) of the American Psychiatric Association (1994), is based on typical symptoms but they must be present for a specific time, and clearly impair the person’s functioning, persistence and impairment are what distinguishes the disorder from the syndrome (Elliott and Place 1998).

The world depression has been used in different ways, to describe somewhat different issues. Since it usually relates to affects, it belongs to the class of Affective Disorders in DSM-III (American Psychiatric Association, 1980).  Depressed individuals undergo mood changes, thus depression is included in DSM-III-R (American Psychiatric Association, 1987) in the class of mood disorders (Wolman and Stricker, 1990). Depression, in general terminology, can refer to severe mood swings or to mild variations in effect. In the clinical context, depression refers not only to a state of depression but to a syndrome with psychomotor and somatic/vegetative state lasting weeks or months. Additionally, clinically significant depression generally affects the person’s ability to live a normal life. Persons may lose interest in school, friends, television programs, and other activities previously enjoyed. Unlike other disorders, such as schizophrenia, that adversely affect thought, the principal symptoms of depression are mood and effect. Typical of these symptoms are sadness, low self-esteem, and loss of interest in activities. The disorder occurs so frequently that it is referred to as the “common cold of emotional problems” (Matson, 1989).

The concept of childhood depression is still a matter of considerable controversy. Until recently the prevailing view was that depressive disorders rarely occurred in children or that if they did occur they took a “masked” form. In the previous fifteen years, however, there has been an in recognition that depressive conditions resembling adult depression can and do appear in childhood (Rutter, 1988a; Angold 1988a; Harrington, 1990). Indeed, it has been suggested that they are quite common in clinical samples. Nevertheless, there are continuing uncertainties about the comparability of depressive disorders in adults and many writers remain doubtful about the true frequency of depressive syndromes in prepubertal children (Lefkowitz and Burton, 1978; Graham, 1981; Shaffer, 1985).

There is no best way of diagnosing or classifying depression in children. Several systems of classification have been developed with considerable overlap among them. The most popular of these systems is the Diagnostic and statistical Manual (DSM-III-R) (American Psychiatric Association 1987). The ICD-10 has also been used in classifying the diagnostic criteria for depressive disorder and it’s been commonly used in Europe for diagnosing depression. However, to confirm that a depressive syndrome is present, the young person must not only appear miserable and unhappy, but demonstrate a negative style of thinking and present a daily routine which illustrate a loss of interest and concentration. For some clinicians, there must be clear anhedonia which means that the young person has lost all enjoyment of life and now portrays a picture dominated by gloom and despondency (Elliott and Place, 1998).

Recently, it has been established that the definitions of the depressive syndrome and disorder which are used in adults are also the ones to use when try to assess children. With the acceptance that adult-type depression is present in children, there has been an increasing interest in whether the mixture of depression and mania, which is seen in adults, can occur in childhood. Having confirmed that the adult diagnosis can be used in children, the next problem is to determine how often such illness in young people. The summary of results from such studies has pointed to about 2 percent of children developing a depressive illness before they reach puberty (Kashani et al. 1983), with perhaps as many as 30 per cent of those who present with depression before puberty going on to show the bipolar illness in later life (Geller et al. 1994). The presence of depressive symptoms does not mean that the disorder of depression is actually present. Indeed, up to 25 per cent of the general adolescent population show some symptoms of depression at some point (Roberts et al. 1990), and although only a small proportion of these will go on to develop the full disorder, this group is more likely to show the full disorder in the following two years than the general population (Weissman et al. 1992).

The impacts of depressive disorder on young people are persistently miserable, gloomy and unhappy. They may feel so bad that the effort to express such negative emotions is too much, and they then become inert and withdrawn. There is often an associated slowing of speech and movement which can sometimes be mistaken by the uniformed as disinterest. Not surprisingly, such behaviours cause these young people to have impaired peer and family relationships, and there is usually deterioration in school performance (Puig-Antich et al. 1993). In some cases these features rather than the depressive symptoms themselves may be more evident to the casual observer (Kent et al. 1995). A particular problem can occur in adolescence because this period of development does tend to exaggerate existing psychological traits such as needing to tidy or compulsively checking that lights are switched off. If the young person was already prone to be gloomy, then adolescence itself may make this more marked, but such symptoms still fall short of the features that would allow it to be called a depressive illness. The nature of the disorder can have a significant impact on trying to find out details of history from the young person. The withdrawal and general slowing up of thought processes mean that they are unlikely to volunteer information and any answers they do give are likely to be slowly given. Many questions will be met with ‘don’t know’, but since this is almost a universal adolescent reply, it is not very helpful diagnostically (Elliott and Place 1998).

Cognitive-behavioural model

Among investigators of childhood depression probably the most influential of the psychological approaches have been the so called cognitive-behavioural models. There is much overlap between the ideas behind these models, but three stands out:

1.  Seligman’s theory of depression

2.  Beck’s cognitive theory of depression

3.  Lewinsohn’s behavioural view point of depression

Seligman (1975) theories of depression are rooted in animal experiments. Seligman and his co-workers observed that dogs exposed to uncontrollable electric shocks failed subsequently either to learn the response to terminate the shock or to initiate as many escape attempts. In human terms, there was an expectation of helplessness that was generalized to the new situation. These findings were thought to have direct implications for the development of depression. Seligman suggested that reactive depression in humans is a state of learned helplessness. The individual has learned expectations that external events are largely beyond his control and that unpleasant outcomes are probable. It is the expectation of loss of control rather than the event that is crucial. This state can produce many of the features of depression, such as some of the cognitive deficits and motivational difficulties (e.g. psychomotor retardation). However, a particular problem for learned helplessness theory was to explain why depressed people so often had guilt. If depressed subjects thought they were unable to control events then why did they so often experience guilt? (Harrington 1993).

The theory of learned helplessness was criticised because it failed to address the issue of why some depressed people tend to blame themselves for their depression, whilst others blame the external world, and the observation that depressed people tend to attribute their successes to luck rather than to their own ability. Abramson et al.’s (1978) revised version of the theory of ‘learned helplessness’ went further than talking about a lack of control. The revised theory was based on the attributions or interpretations people make of their experiences. According to Abramson and his colleagues, people who attribute failure to internal (It’s my fault’), Stable (‘It’s going to last forever’) and global (‘It’s to affect everything I do’) causes and attribute their successes to luck are more likely to become depressed, because these factors lead to the perception that they are helpless to change things for the better (Gross and MclLveen, 1996).

The researchers argue that this attributional style derives from learning histories, especially in the family and at school. Support for the learned helplessness theory of depression comes from research which indicates that questionnaires assessing how people interpret adversities in life predict (at least to a degree) their future susceptibility to depression. However, although cognitions of helplessness often do acceptance accompany depressive episodes, the pattern of cognition has been shown to change once the individual’s depressive episode ends. According to Barnett & Gottlib (1988), people were formerly depressed are actually no different from people who have never been depressed in terms of their tendency to view negative events with an attitude of helpless resignation. This finding could be interpreted as indicating that an attitude of helplessness is a symptom rather than a cause of depression (Gross and MclLveen, 1996).

A similar account to that advanced by Seligman’s has been proposed by Beck (1974), whose cognitive model of emotional disorders state that ‘an individual’s emotional response to an event or experience is determined by the conscious meaning placed on it’. Beck believes that depression is based is based in self-defeating negative beliefs and negative cognitive sets (or tendencies to think in certain ways) that develop as a result of experience. According to Beck, certain experiences in childhood and adolescence (such as the loss of a parent or critics from teachers and other adults) lead to the development of a cognitive triad consisting of three interlocking negative beliefs. These concern the self, the world and the future, and cause people to have a distorted and constricted outlook on life. These beliefs lead people to magnify their bad experiences and minimise their good experiences. The cognitive trait is maintained by several kinds of distorted and illogical thinking that can contribute to depression (Beck and Freeman, 1990).

There is evidence to suggest that depressed children do describe their world in the ways that Beck outlined (White et al., 1985). However, it could be that feelings of depression and logical errors of thought are both caused by a third factor (which might be a biochemical imbalance). In addition, as Hammen (1985) has pointed out, the perception and recall of information in more negative terms might be the result of depression rather than the cause of it. Recent research has looked at the role of depressogenic schemata that is cognitions that may provoke depression, which remain latent until activated by Stress. Haaga and Beck (1992) have specified several types of stressor that may activate dysfunctional beliefs in people. For example, sociotropic individuals may be stressed by negative interactions or rejections by others, whereas autonomous individuals may be stressed by a failure to reach personal goals (quoted in Teasdale, 1988).

The explanation of depression from Lewinsohn’s (1974) behavioural viewpoint proposed that depression is the result of a low rate of response-contingent positive reinforcement. However, this low rate occurs not only because few positively reinforcing events are available in the environment, but also because people with depression do not engage in forms of behaviour that lead to pleasant consequences. In order words, depression can also be the result of a lack of the social skills necessary to obtain rewards. The whole situation can be made worse by the fact that once depressed, depressed subjects are less likely to experience positive social reinforcement (Harrington 1993).

Psychodynamic model

Psychodynamic approach to depression was first address by Abraham (1911), who was once a student of Freud. However, it was Freud himself, in Mourning and Melancholia (1917), who attempted to apply psychodynamic principles. Freud noted that there was a similarity between the grieving that occur when a loved one dies and the symptoms of depression. Freud saw depression as being excessive and irrational grief which occurs as a reaction to loss that evokes feelings associated with real or imagined loss of affection from the person on whom the individual was most dependent as a child. Freud argued that both actual losses (such as the death of a loved one) and symbolic loses (such as the loss of a job or social prestige) lead us to re-experience parts of our childhood. Thus, depressed people become dependent and clinging or, in very extreme cases, regress to a childlike state. Freud believed that the greater the experience of loss in childhood, the greater was the regression that occurred during adulthood. The evidence for this account is, however, mixed. For example, whilst some studies do suggest that children who have lost a parent are particularly susceptible to depression later on (Roy, 1981), other studies have failed to find such a susceptibility (Lewinsohn and Hoberton, 1982).

Freud also argued that unresolved hostility towards one’s parents, which has been repressed so that we are no longer consciously aware of it, was also important. The reason for this is that the outward expression of anger is unacceptable to the super ego, and so is turned inwards. The self directed hostility creates feelings of guilt, unworthiness and despair, which may be so intense as to motivate suicide (the ultimate form of inward-directed aggression). Freud further believed that grief was complicated by inevitable mixed feelings. As well as affection, Freud felt that mourners were likely to have had at least occasionally angry feelings towards the deceased. However, because such feelings are unacceptable, they too are redirected towards the self, leading to lowered self-esteem and feelings of guilt.

The above accounts explain the depression that occurs in response to some sort of environmental stress. Freud explains depression in the absence of any immediately identifiable stress as the symbolic loss of a loved one. A person might, for example, interpret a short-tempered response from a loved one as a sign that affection will no longer be returned. At least four reasons suggest that the psychodynamic model is inadequate in explaining mood disorders in general and depression in particular. First, there is no direct evidence that depressed people interpret the death of a loved one as desertion or rejection of themselves (Davison and Neale, 1990). Second, if anger is turned inward, we would not expect depressed people to direct excessive amounts of hostility towards people who are close to them. However, Weissman & Paykel (1974) reported evidence to suggest that this does occur. Third, as Crook & Eliot (1980) have observed, there is little evidence for a direct connection between early loss and the risk of depression in adult life. Finally, since symbolic loss cannot be observed, this aspect of the theory cannot be experimentally assessed (Gross and MclLveen 1996).

As with most clinical disorders of childhood and adolescence, there is no clear-cut understanding of why depression develops in children or adolescents. The most likely explanation encompasses multiple factors that put the child at risk for the development of depression. For example, one study found that depressed adolescents of depressed mothers showed higher levels of cognitive distortions and poorer interpersonal behaviours than did depressed adolescents without a history of material depression (Phares 2003). There is also no proven value in treating depression in the young with medication, and no evidence that continued usage reduces the likelihood of relapse. In young people the evidence suggests that cognitive therapy is both a positive treatment and that it may reduce the like-hood of recurrence. This therapeutic approach can be combined with the factors which seem to be protective against further relapse: encouragement in developing outside interests; assistance offered to help foster positive relationships with family and friends; teaching good coping skills; correcting any educational deficits so that the young person can experience school achievement. Such a range of measures will also strengthen self-esteem and so reduce the likelihood of further problems (Elliot and Place, 1998).

                                                                                                                     

Conclusion

Like other kinds of mental illness, childhood depression is a serious mental disorder which has a number of characteristics. Different explanations have been initiated and advanced in an attempt to explain the disorder. All of these have received some support from research studies, although they may not be a single acceptable explanation for the disorder. The existence of a number of overt symptoms of childhood depression is now largely accepted and this paper has used two major models in explaining this disorder.

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www.who.int/classifications/apps/icd/icd10online/ accessed on 10/04/2008