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Understanding Childhood Depression 1

Running Head: UNDERSTANDING CHILDHOOD DEPRESSION

Understanding Childhood Depression through a Family Model Lens John Laing University of Calgary APSY 651

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Introduction The goal of this paper is to review literature pertaining to childhood mood disorders. Specifically, this paper will outline the characteristics and symptoms of childhood depression with a focus on major depressive disorder. Although it is likely that other forms of mood disorders and depression have similar pathways, a review of such literature is beyond the scope of this paper. In my review of the literature regarding major depressive disorder in children, I focused my literature search on family models and characteristics regarding childhood depression. This paper will outline familial factors related to the onset of childhood depression. Utilizing a family model perspective I will present several key familial factors that may increase the risk of childhood depression including: familial history of mental health and depression; environmental factors and interpersonal support; paternal influences; and cognitive styles. Lastly, I will focus on attachment theory as a useful explanation for how depression can be passed through families, as well as to explain the development of distorted cognitions in children with depression. Definition and Characteristics of Childhood Depression Mood can be defined as a feeling or emotion, for example, anger, happiness, and sadness (Mash & Wolfe, 2005). According to Costello et al., 2002, approximately 6% of children suffer from a mood disorder. Children with mood disorders exhibit poor emotional self-regulation and often feel unhappy, sad or excessive elation (Mash & Wolfe, 2005). Depression is one of the major types of mood disorders affecting children. Specifically, major depressive disorder affects between 2% and 8% of all children between the age of 4 and adulthood (Mash & Wolfe, 2005). Depressed children experience feelings of sadness that are more pronounced than typical feelings of sadness and can often experience irritability, guilt and shame (Hammen & Rudolph, 2003; Mash & Wolfe,

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2005). Depression can affect children in several areas of functioning. According to Mash and Wolfe (2005), depressed children can appear restless, agitated, display low levels of activity, slowed speech or cry excessively. They can show a change in attitude marked by feelings of worthlessness and low self-esteem. Also, children with depression may suddenly stop caring about things they once enjoyed such as school or extracurricular activities. Risk of suicide may increase as the childs change in attitude may leave them feeling hopeless or dreading the future. Often times they are consumed with their inner thoughts and tensions leading them to be overly critical of themselves or extremely self-conscious. Furthermore, depressed children can experience physical changes as well. For example, disruptions in eating and sleeping are common. They often experience loss of appetite, awake early in the morning or frequently throughout the night, or feel tired all the time. Physical complaints such as headaches and stomachaches are also common. Childhood depression can often present in different ways depending on the childs age and developmental stage (Davison, Neale, Blankstein, & Flett, 2002). According to Mash and Wolfe (2005), preschool children can often appear somber and tearful as a result of depression. Somatic complaints are common in preschool children with depression, as well as fear of separation or abandonment by their mothers. Furthermore, preschool children may seem irritable and are often less energetic and playful than their peers. In addition to the depressive symptoms preschool children can display, school-aged children with depression can exhibit increased irritability, disruptive behaviour and temper tantrums (Hammen & Rudolph, 2003; Mash & Wolfe, 2005). Difficulties with peer interactions and academics are also common for school-aged children with depression. Although physical complaints such as weight loss, headaches and sleep disturbances are common, school-aged

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children seldom want to talk about their feelings. Furthermore, suicidal ideation may begin to occur at this age (Mash & Wolfe, 2005). Many of the depressive symptoms exhibited by younger children are also displayed by preteens who are depressed (Davison et al., 2002; Mash & Wolfe). However, preteens with depression begin to blame themselves, tend to have low self-esteem and feel sad much of the time. Social inhibition and feelings of isolation from family members are also common. Furthermore, depressed preteens are at increased risk for disturbances in eating and sleeping patterns. Teenagers display much of the same symptomology, however, teenagers who suffer from depression are more likely to display the following: irritability; a decrease in the ability to feel pleasure or interest; a decrease in academic achievement; anger toward their parents rules and expectations; negative body image and increased self-consciousness; fatigue and energy loss; feelings of loneliness and worthlessness; and suicidal ideation and attempts (Mash & Wolfe, 2005). Some differences exist between the manifestation of major depressive disorder in children and adults (Hammen & Rudolph, 2003). Anhedonia, psychomotor retardation, impairment in daily functioning and suicidal attempts appear to increase with age. However, somatic complaints, behavioural problems, separation anxiety and phobias appear more prevalent in depressed children than in adults (Mash & Wolfe, 2005). Because many of the symptoms displayed by children with depression are also likely to be displayed by typically developing children at some point, the presence of a sad mood, loss of interest, or irritability is critical for diagnosing childhood depression (Hammon & Rudolph, 2003). Also, the symptoms must be a change in the childs typical presentation, they must persist and they must cause significant impairment to the childs daily functioning (Mash & Wolfe, 2005).

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According to Fombonne (1999), the occurrence of depression in children is increasing while the age of onset is decreasing. According to Kessler et al. (2001), there is clear evidence of increasing prevalence of major depressive episode since 1960 (as cited in Hammen & Rudolph, 2003, p. 242). Although the cause of the increase is not known, it is likely that social change since the 1960s may have contributed to the increased susceptibility of children to depression (Hammen & Rudolph, 2003; Mash & Wolfe, 2005). Disturbances in family functioning and increased family disharmony may play key factors in the increased development of major depressive disorder in children. Psychosocial factors within a family and other family influences may contribute to the etiology of depression (Hammen & Rudolph, 2003). Familial Influences Family histories of mental health and parental depression have been linked to a childs risk for developing depression (Sander & McCarty, 2005). Fendrich, Warner, and Weissman (1990) found parent depression to be the most important risk factor for the development of childhood depression. Furthermore, parent depression was found to be a greater risk factor than family discord, low family cohesion or overprotection and low affection toward the child. Goodman and Gotlib (1999) explain the link between parental depression and childhood depression as involving: genetics; neuroregulation difficulties that influence mood regulation; exposure to negative maternal mood and behaviour; and stress within the childs environment. Although parental depression plays a key role in the development of childhood depression, other factors must be considered. According to Sander and McCarty (2005), maternal depression alone may not place children at greater risk for depression. However, maternal depression, emotionally unavailable mothers, high maternal control and low self-esteem in the child are likely

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to increase the risk of childhood depression. Also, Hammen and Rudolph (2003) argued that both environmental stress and interpersonal support play a role in the onset of childhood depression. Furthermore, maternal depression was linked to more symptoms of depression and poor interpersonal functioning in teenagers. However, teenagers who displayed depressive symptoms, but had non-depressed mothers were more inclined to feel stress associated with environmental factors and did not display the same interpersonal deficits as depressed teens with depressed mothers. According to Hammen and Rudulph (2003), teenagers with depression, but who have non-depressed mothers, are more likely to exhibit social and interpersonal skills. This suggests that different forms of teenage depression may have different interpersonal impairments associated with them (Sander & McCarty, 2005). Recently, research has begun to include paternal factors in childhood depression rather than maternal factors alone (Hammen & Rudolph, 2003; Sander & McCarty, 2005). Sanford et al. (1995) studied parent variables and their influence on the development of depression in children. Results suggested that paternal variables increased the likelihood of childhood depression in different ways than maternal variables. For example, depressed children who had less positive relationships with their fathers were at higher risk for persistent depression than depressed children with positive relationships with their fathers. At one year follow-up depressed children with positive relationships with their fathers were more likely to see a reduction in their depressive symptoms, whereas, depressive symptoms remained persistent for those children with negative relationships with their fathers. Furthermore, fathers depression was related to youth depression and increased family conflict. Also, fathers depression was more likely to increase the risk of childhood depression in families with a depressed mother.

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Parental cognitive style may also influence the development of childhood depression (Hammen & Rudolph, 2003; Mash & Wolfe, 2005; Sander & McCarty, 2005). According to Sander and McCarty (2005), childrens negative views of self, the world, and the future are similar to their parents views of self, the world and the future. Furthermore, child depression was related to the cognitive style and parenting dimensions of their mother and father in a study conducted by Alloy et al., (2001). Cognitive theories posit that depression is a result of negative and deficient thinking that is automatic to the individual (Hammen & Rudolph, 2003). Also according to this theory, people who are depressed hold negative schemas about the world, the future, as well as their self-worth. Depressed individuals may hold pessimistic expectations regarding the future and tend to attribute negative outcomes to internal, environmental and stable factors (Hammen & Rudolph, 2003). Cognitive theories provide insight into the thinking and underlying processes of depression, however, family models provide a useful explanation for how distorted cognitions can be transmitted from family member to family member and generation to generation. Goodman and Gotlib (1999) suggest that negative family interactions also increase the risk for childhood depression. For example, low parental support and family conflict has been linked to childhood depression (Hammen & Rudolph, 2003; Sander & McCarty, 2005). Also, youth who lack positive coping strategies to manage stressful family relations are less well adjusted and show deficits in both emotional and psychological functioning (Sander & McCarty, 2005). According to Bowlby (1988) attachment to a positive caregiver early in life is important to the healthy development of children. Parenting practices such as harsh discipline and negative parent-child interaction may also increase a childs risk for depression (Davison et al., 2002; Mash & Wolfe; Sander & McCarty, 2005). Specifically, children develop internal working models of how they view and interpret the world based on their early childhood experiences.

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Attachment Theory and Internal Working Models Internal working models hold information, expectations and feelings about other people and produce the way relationships are represented in a childs mind (Bowlby, 1988; Pearce & Pezzot-Pearce, 2007). Internal working models help a child predict how their primary caregiver and other people in their environment will behave (Goldsmith, 2007). Derived from their experiences with caregivers, internal working models guide children as they interpret situations and create plans for how to respond and behave in new environments and relationships. Relationships in the first few years of the childs life create a map for the child to navigate new relationships and environments (Bowlby, 1988; Goldsmith, 2007; Pearce & Pearce-Pezzot, 2007). Children who have not experienced available and reliable caregiving perceive their environment as unreliable; therefore, they fear exploration and engage others with aggressive and negative behaviours (Goldsmith, 2007). Children who have had poor interactions with their parents often have internal working models that hold negative information about caregivers and relationships. Children from hostile home environments often have internal working models that view people as unresponsive to their needs, untrustworthy and uncaring. This view is often reinforced by their negative and aggressive social behaviour as it often causes negative reactions by others. Specifically, internal working models derive from the childs beliefs about how acceptable they are in the eyes of their caregivers (Pietromonaco & Barret, 2000). This is achieved when the child measures and interprets the level of responsiveness of the caregiver to their needs. Children who have secure attachments develop a representation (internal working model) of themselves as acceptable and worthwhile. Conversely, children with insecure attachments develop internal working models of being unacceptable and unworthy (Pietromonaco & Barret, 2000).

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Internal working models of others include expectations about who will serve as attachment figures, how available attachment figures are and how they will respond when needed (Bowlby, 1979; Goldsmith, 2007; Pearce & Pezzot-Pearce, 1994; Pietromonaco & Barret, 2000). Through repeated use internal working models become automatic and subconscious. Internal working models automatically guide a childs attention, interpretation of situations and memory (Pietromonaco & Barret, 2000). This process generates expectations of relationships and develops strategies for how a child will deal with those relationships (Bowlby, 1979; Bowlby, 1988). In times of stress children will seek out safety and comfort from a parent or caregiver. If the child is unable to find an attachment figure to sooth their stress their level of distress increases. In times of high stress, the availability of the mother can produce a buffer for depression in children (Hammen & Rudolph, 2003; Sander & McCarty, 2005). Children who feel increased stress and perceive their caregivers to be unavailable may be more vulnerable to depression (Sander & McCarty, 2005). Furthermore, excessive reassurance seeking coupled with rejection by caregivers can create a snowballing effect, whereby the child is subjected to negative interpersonal experiences leading to an increased risk of depression. According to Betts, Gullone, and Allen (2009), adolescents whose relationships are characterized by insecurity are at increased risk for developing feelings of hopelessness, can become less independent and may have difficulties with social and personal development, leading to an increased risk of depression. Conclusion In conclusion, major depressive disorder affects approximately 2% - 8% of all children between the age of 4 and 18. Although not an exhaustive list, the key features of major depression include sadness, loss of interest or pleasure in most activities and irritability (Mash & Wolfe,

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2005). Depressed children often experience deficits and distortions in their thinking, including attributional biases and can be extremely self-critical. Although there are many theories that explain the onset and course of childhood depression, this paper reviewed depression through a family model lens. Families play an integral role in the healthy development of children, however, negative interactions between child and parent along with other familial risk factors drastically increase the risk of childhood depression. Specifically, parental mental health and depression appear to be significant risk factors of childhood depression. Furthermore, attachment theory provides a useful explanation of how important family dynamics are as both protective factors and risk factors for the development of childhood depression.

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