Child and adolescent

Depression
Kristina Baglo, Kelly DeCoste, and
Danni Kerr

What is Depression?

Depression is a mood disorder that involves a

severe despondency and dejection that is
followed by feelings of hopelessness and
inadequacy
Though we all feel sad at times, depression
and feelings of sadness persist for an extended
period impacting your day-to-day activities
Depression has an impact on growth and
development, peer/family relationships, and
school performance.

(Pfizer, 2012)

Depressive Disorders

1) Major Depressive Disorder

Clinical

course is characterized by 1 or more Major

Depressive Episodes

2) Dysthymic Disorder
At

least 1 year of depressed mood (more days than

not)
Additional depressive symptoms (that do not meet the
criteria for a Major Depressive Episode)
Early onset of DD is a precursor to Major Depressive
Disorder

3) Depressive Disorder Not Otherwise Specified

Depressive features that do not meet criteria for

MDD, DD, or adjustment disorders
(APA, 2000)

Prevalence

6 month prevalence rate of depressive

disorders:
1-3%

in school aged children, with even

distribution by gender
5-6% in adolescence, with females 2 times
more likely to have it

Lifetime prevalence in adolescents is 1520%

Major depressive disorders in
adolescents: 5-28%

Etiology

Uncertainties surrounding etiology of

childhood depression
Psychosocial theory: depression is the
result of limited rewards or life satisfaction,
parental resentment or rejection of the child,
deficits in self-regulatory skills for coping
with stress, negative thinking about self
Biological theory: deficit in or imbalance of
neurotransmitters and genetic transmission

Case Study
Jack is a 11-year-old boy, in grade five, who lives with
his mother. His parents separated when he was six.
Jack's teacher reports that he is in danger of failing, that
he becomes preoccupied, often staring out the window,
and seldom finishes his work. Jack has stated that the
other children in the class are much smarter than he is.
He makes excuses to get out of his soccer practices and
games, which he used to enjoy. Afterschool, Jack eats
anything he can find in the cupboard or fridge. He then
goes to bed until his mother comes home from work,
claiming that "I don't have any reason to stay up
because nothing good is going to happen."

Case Study
1.

2.

3.

4.

What red flags do you think warrant

further assessment? What else could
account for these?
What historical information and areas of
functioning should be evaluated?
What types of questions, techniques, and
measures would be useful to use with Jack?
Who would you want to interview to confirm
or refute a diagnosis of depression? What
would you expect to learn from each rater?

Approach
Client presents with
emotional concerns

Yes

Suicide risk?
Diagnosti
c criteria?

Seek
emergency
services

Communicati
ng results

Literature
review

Diagnostic
decision
making

Interviews,
rating
scales,
cognitive,
neuropsychologi
cal &
academic
measures

No

Proceed with
assessment
Differenti
al
diagnosis
?
Assessme
nt
approach

Presentation

Symptom expression may vary as a

function of cognitive and social
development
Symptoms may occur in typically
developing children and adolescents

Must ensure the change is maintained over

time and a negative impact on functioning

Developmental Factors

Symptoms fairly similar across childhood,

adolescence, and adulthood

Presentation

Gender Differences
Boys
Externalizing behaviors
e.g., anger, irritability

Girls
Internalizing behaviors
e.g., quiet, keep to themselves
Twice as likely to become
depressed after age 15 due to
cognitive vulnerabilities

??

??

Cultural Considerations

Presentation may vary based on culture

Some symptoms may be of more concern than

others

May combine symptoms of Depressive,

Anxiety, and Somatoform Disorders
Must distinguish between culturally
distinctive experiences and hallucinations
or delusions
Do not dismiss symptoms because they are
viewed as normal for that culture

Risk Factors
Childhoo
d abuse
History
of
depressi
on
Social
Difficulti
es
Poor
functioning in
multiple areas
of life

Temperam
ent

Risk
Factors
Negative
Attachme
nt

Personal
ity Type

Life
Stress
Poor
parental
supervision
/family

Resilience Factors
Biological
Factors

Environmental
Factors

High Self-esteem

Positive social
relationships

High feelings of selfworth

Feelings of high family

connectedness
Connections to school
environment and staff

Case Study
1.

2.

3.

4.

What red flags do you think warrant

further assessment? What else could
account for these?
What historical information and areas of
functioning should be evaluated?
What types of questions, techniques, and
measures would be useful to use with Jack?
Who would you want to interview to confirm
or refute a diagnosis of depression? What
would you expect to learn from each rater?

Case Study
Jack is a 11-year-old boy, in grade five, who lives with
his mother. His parents separated when he was six.
Jack's teacher reports that he is in danger of failing, that
he becomes preoccupied, often staring out the window,
and seldom finishes his work. Jack has stated that the
other children in the class are much smarter than he is.
He makes excuses to get out of his soccer practices and
games, which he used to enjoy. Afterschool, Jack eats
anything he can find in the cupboard or fridge. He then
goes to bed until his mother comes home from work,
claiming that "I don't have any reason to stay up
because nothing good is going to happen."

Case Study
What red flags warrant further assessment?
What else could account for these?

1.

Sleeping more and increased appetite

Medical

problem?

Frequent staring out window

Inattention?

Seldom finishing work

Learning

disability?

"I don't have any reason to stay up because nothing

good is going to happen"
Anhedonia?

Case Study
1.

2.

3.

4.

What red flags do you think warrant

further assessment? What else could
account for these?
What historical information and areas of
functioning should be evaluated?
What types of questions, techniques, and
measures would be useful to use with Jack?
Who would you want to interview to confirm
or refute a diagnosis of depression? What
would you expect to learn from each rater?

Case Study
Jack is a 11-year-old boy, in grade five, who lives with
his mother. His parents separated when he was six.
Jack's teacher reports that he is in danger of failing, that
he becomes preoccupied, often staring out the window,
and seldom finishes his work. Jack has stated that the
other children in the class are much smarter than he is.
He makes excuses to get out of his soccer practices and
games, which he used to enjoy. Afterschool, Jack eats
anything he can find in the cupboard or fridge. He then
goes to bed until his mother comes home from work,
claiming that "I don't have any reason to stay up
because nothing good is going to happen."

Case Study
What historical information and areas of
functioning should be evaluated?

2.

Medical conditions ruled out?

Substance abuse?
Relationship with father before and after
divorce?
When did his academic difficulties begin?
Has he always been inattentive?

Differential Diagnosis
Adjustme
Major
Depressiv
e
Episode?

Mood Disorder
due to a
General
Medical
Condition?

Bipolar
Disorder
?

Anxiet
y?

nt
Disorder?

Normal
moodines
s?
Medicatio
n effects?
SubstanceInduced
Mood
Disorder?

ADHD
?

Eating
Disorder
?

CD?

PTSD
?

Associated Disorders

Approximately two thirds of children and

adolescents with major depressive
disorder also have another mental
disorder (Bhatia & Bhatia, 2006)

Anxiety disorders (30-80%)

Disruptive disorders (i.e., ODD and CD; 1080%)
ADHD (5-50%)
Substance abuse (20-30%)

Depression and Anxiety

Tripartite Model of
Anxiety and
Depression (Clark &
Watson, 1991)

Anxious Arousal
somatic

tension,
shortness of breath,
dizziness,
lightheadedness, and dry
mouth

Negative Affect
upset,

angry, guilty,
afraid, sad, scornful,
disgusted, and worried

Low Positive Affect

tired,

fatigued, and
sluggish

DSM-5
Mixed Anxiety/Depression
3 or 4 symptoms of Major Depression
accompanied by anxious distress, lasting
at least 2 weeks
2 or more symptoms of anxious distress
Not suffering from any other DSM-5
mental disorders
Marked distress/significant impairment

Symptom Overlap
Irritable/angry mood

PTSD

Insomnia/hypersomn
ia

Adjustment
Disorder

Substance
Abuse

Dysphoria

Uncomplicat
ed
Bereavement

Feelings of
worthlessness/hopel
essness

Approach
Client presents with
emotional concerns

Yes

Suicide risk?
Diagnosti
c criteria?

Seek
emergency
services

Communicati
ng results

Literature
review

Diagnostic
decision
making

Interviews,
rating
scales,
cognitive,
neuropsychologi
cal &
academic
measures

No

Proceed with
assessment
Differenti
al
diagnosis
?
Assessme
nt
approach

Semi-Structured Interviews

(from Sattler & Hoge, 200

Family
history
Learning
difficulties?

Possible
trigger?

Recent
physical
examination?

*Inquire about suicidal thoughts/atte

Diagnostic Interviews
Name

Age

Administratio
n Time

Reliability/Vali
dity

K-SADS

6-18 years

35 minutes
2.5 hours

- Fair to
excellent
interrater
reliability Convergent
validity
supported

DICA-IV

6-12/1317/parents

1-2 hours

- Poor to good
interrater
reliability Some evidence
of convergent
validity

CAPA

9-17 years

1-2 hours

- Limited data
on associations
with other

Rating Scales
Name

Age

Completion
Time

CDRS

6-12 years

15-20 minutes

Issue with
discriminant
validity

MFQ

8-18 years

5-10 minutes

Acceptable

RCDS-2*

7-13 years

10-15 minutes

Acceptable

RADS-2

11-20 years

5-10 minutes

Acceptable

BDI-Y

7-14 years

5-10 minutes

Minimally
adequate
construct
validity

BDI-II

13-80 years

5 minutes

Acceptable

CDI*

7-17 years

10-20 minutes

Use with
caution

* Short form available

Reliability/Vali
dity

Now What?
Yes

Not a
depressive
disorder

Comorbid
conditions?

Normal moodiness?

No

Physical
exam?
Medication
effects?
Underlying
medical
cause?
Substance
use?
Medication
effects?

Assessme
nt process

Criteria for
Mood Disorder
met

Communicating Results

Be sensitive while acknowledging the

seriousness of the disorder

Alternatives for treatment

Suicide rate??
Life changes
Psychotherapy
Medications*

Will fix later

* Adverse side effects for
children/adolescents?

Case Study
1.

2.

3.

4.

What red flags do you think warrant

further assessment?
What historical information and areas of
functioning should be evaluated?
What types of questions, techniques, and
measures would be useful to use with Jack?
Who would you want to interview to
confirm or refute a diagnosis of depression?
What would you expect to learn from each
rater?

Case Study
What types of questions, techniques,
and measures would be useful to use
with Jack?

3.

Clinical interview

History
Symptoms

Diagnostic interview

K-SADS, DICA-IV, CAPA

Rating scales

CDRS, MFQ, RCDS-2, RADS-2, BDI-Y, CDI

Case Study
1.

2.

3.

4.

What red flags do you think warrant

further assessment?
What historical information and areas of
functioning should be evaluated?
What types of questions, techniques, and
measures would be useful to use with Jack?
Who would you want to interview to
confirm or refute a diagnosis of depression?
What would you expect to learn from each
rater?

Case Study
Jack is a 11-year-old boy, in grade five, who lives with
his mother. His parents separated when he was six.
Jack's teacher reports that he is in danger of failing, that
he becomes preoccupied, often staring out the window,
and seldom finishes his work. Jack has stated that the
other children in the class are much smarter than he is.
He makes excuses to get out of his soccer practices and
games, which he used to enjoy. Afterschool, Jack eats
anything he can find in the cupboard or fridge. He then
goes to bed until his mother comes home from work,
claiming that "I don't have any reason to stay up
because nothing good is going to happen."

Case Study
Who would you want to interview to
confirm or refute a diagnosis of depression?
What types of data would you require?

4.

Child
Parent
Teacher
Diagnostic

interview red flags?

Rating scales elevated?
What impact is it having on his academics?
Socially? Family life?

Discussion Questions

It is common for parent rating scale results to

differ significantly from each other and from
those of their child. As a psychologist, how
would you interpret these discrepancies? What
additional information might you need to help
with your decision?

Childhood depression is a mental health

disorder that often goes undiagnosed or
misdiagnosed. What factors do you think
contribute to this?

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of

mental disorders
(4th ed., text rev.). Washington, DC: Author.

Clark, L.A. & Watson, D. (1991). Tripartite Model of Anxiety and Depression:
Psychometric Evidence and Taxonomic Implication. Journal of Abnormal
Psychology, 100, 316-336.
doi: 10.1037/0021-843X.100.3.316

de Mesquita, P. B., & Gilliam, W. S. (1994). Differential diagnosis of childhood

depression:
Using comorbidity and symptom overlap to generate multiple
hypotheses. Child
Psychiatry and Human Development, 24, 157-172. doi:

Klein, D. N., Dougherty, L. R., & Olino, T. M. (2005). Toward guidelines for
evidence-based
assessment of depression in children and adolescents.
Journal of Clinical Child and
Adolescent Psychology, 34, 412-432. doi:
10.1207/s15374424jccp3403_3

Mash, E. J., & Barkley, R. A. (2007). Assessment of childhood disorders. New York,
NY: Guilford
Press.

McCauley, E., Pavlidis, K., & Kendall, K. (2001). The depressed child and
adolescent. Cambridge,
UK: Cambridge University Press.

Pfizer. (2012). http://www.pfizer.ca/local/files/en/yourhealth/Depression.pdf

References

Sattler, J. M., & Hoge, R. D. (2006). Assessment of children: Behavioral,

social, and clinical
foundations (5th ed.). La Mesa, CA: Jerome M.
Sattler, Publisher.

Stewart, D. & Sun, J. (2007). Resilience and depression in children: Mental

health promotion in
primary schools. International Journal of Mental
Health Promotion, 9, 37-46. doi: