(p. 3) Introduction to Preadolescent Depression
Prior to the 1970s, the existence of childhood depression was not widely accepted in the psychiatric community. The prevailing view was that children’s immature cognitive, social, and emotional development protected them from experiencing depressive symptoms that required more introspection and psychological orientation, such as melancholia, worthlessness, hopelessness, and suicidality. Depression in children was hypothesized to be “masked” and was expected to manifest in more age-appropriate disturbances of behavior as opposed to other symptoms of depression. Early epidemiological and clinical studies examined depression in children and adolescents (Graham & Rutter, 1968; Kovacs, Feinberg, Crouse-Novak, Paulauskas, Pollock, et al., 1984; Kovacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein, 1984; Puig-Antich, Blau, Marx, Greenhill, & Chambers, 1978; Rutter & Graham, 1968). Sir Michael Rutter’s epidemiological studies of psychopathology in the Isle of Wright (Rutter & Graham, 1968) revealed the existence of depressive symptoms in children that were similar to adult depression in the presence of mood disturbance and neurovegetative symptoms. Puig-Antich (1982) presented some of the first pilot data demonstrating that depression in prepubertal children could be indexed using unmodified research diagnostic criteria for diagnosing major depressive disorder (MDD) in adults. The majority of children endorsed symptoms of dysphoric mood, sleep disturbances, inappropriate guilt, and thoughts of suicide, similar to presentation of depression in adults. These studies validated the existence of a depressive phenotype in children.
(p. 4) Phenomenology and Clinical Presentation
Decades of subsequent research on depression in children consistently support these early findings regarding the similarity of depressive symptoms in children and adults. Depression in children and adolescents manifests in
■ a persistent low mood or lack of interest or enjoyment in usually pleasurable activities (anhedonia);
■ sleep disturbance (trouble falling asleep, staying asleep, or early morning wakening);
■ impaired or distorted cognitive ability (such as poor concentration and thoughts of guilt and hopelessness);
■ a negative sense of self (such as low self-esteem); and
■ a range of suicidal ideation, from passive death wish to suicidal ideation with method and intent. Recent studies indicate that preschool children and school-age children experience rates of suicidal ideation similar to those of adolescents (Bridge et al., 2015; Bridge, Greenhouse, Weldon, Campo, & Kelleher, 2008; Whalen, Dixon-Gordon, Belden, Barch, & Luby, 2015).
However, depressive symptoms in youth differ from those observed in adults in several significant ways:
■ Youth often demonstrate irritability when experiencing a significant disturbance in mood rather than a melancholic depression often described by adults (Birmaher & Rozel, 2003).
■ Depressed mood and anhedonia in youth also appear to be more reactive to external situations than in adults, with periods of euthymic mood occurring during a depressive episode (Williamson et al., 2000).
■ Early clinical studies on childhood-onset depression do not reflect the 2:1 female preponderance evident in adult and adolescent-onset depression. Rather, childhood-onset depression affects both girls and boys equally, with some studies citing higher rates of depression in boys (Kovacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein, 1984; Puig-Antich et al., 1985a).
■ Suicidal behavior and completed suicide are typically low among preadolescent children, and reach rates similar to those seen in adults by adolescence (Dervic, Brent, & Oquendo, 2008).
(p. 5) Prevalence
Depression affects between 0.4% to 2.5% of preadolescent children (Birmaher & Rozel, 2003). However, these prevalence rates may underestimate the number of preadolescents who present for outpatient treatment with clinically significant depressive symptoms and functional impairment but who do not meet full diagnostic criteria for MDD. Angold, Costello, Farmer, Burns, and Erkanli (1999) argue that preadolescents with impairing subthreshold depression have psychiatric illnesses that are often underdiagnosed and untreated.
Joaquim Puig-Antich (1978) once noted that finding a “pure” case of MDD in children was “a futile effort.” More than 30 years of research has emphatically documented that comorbidity in depressive disorders in children and adolescents is the rule, rather than the exception. Up to 70% of children and adolescents with depression have comorbid psychiatric disorders (Avenevoli, Stolar, Li, Dierker, & Ries Merikangas, 2001; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Kessler, Avenevoli, & Ries Merikangas, 2001), with anxiety and disruptive behavior disorders being the most common.
Comorbid anxiety disorders affect an estimated 30% to 58% of children and adolescents with depression (Costello et al., 2003; Kovacs, Gatsonis, Paulauskas, & Richards, 1989). The most common anxiety disorders in children with depression are separation anxiety disorder followed by generalized (overanxious) anxiety disorder (Kovacs et al., 1989). Although comorbid separation anxiety disorder decreases with age, generalized anxiety disorder continues to remain a significant comorbidity for children with depression (Costello et al., 2003). Comorbid anxiety disorders complicate and, in many cases, worsen the prognosis for treatment and recurrence. Children and adolescents with depression (p. 6) and anxiety disorders demonstrate increased severity and duration of depressive symptoms, increased suicidality and psychosocial problems, and poor response to psychotherapy (Brent et al., 1998; Cheung et al., 2010; Goodyer, Herbert, Secher, & Pearson, 1997).
It is not surprising that anxiety and depressive disorders are highly comorbid in children. Indeed, both depression and anxiety disorders in children share some of the same symptoms, such as fatigue, difficulty concentrating, and sleep disturbances. Community, clinical, and school populations repeatedly demonstrate high correlations between self-report measures of childhood depression and anxiety, ranging from .40 to .80 (Brady & Kendall, 1992; Muris, Van Brakel, & Meesters, 1998). More recent studies on childhood depression and anxiety have found that anxiety disorders often precede depressive disorders in children and adolescents and may serve as a “gateway” to depression in affected children (Axelson & Birmaher, 2001; Silk, Davis, McMakin, Dahl, & Forbes, 2012).
Disruptive Behavior Disorders
Disruptive behavior disorders, such as conduct, oppositional defiant, and attention deficit hyperactivity disorders, are also common in children and adolescents with depression, and affect an estimated 21% to 83% of depressed youth (Angold & Costello, 1993). In an early paper, Puig-Antich (1982) identified a diagnostic subgroup of children with depression and conduct disorder (roughly one-third of the sample) in a cohort of prepubertal boys clinically referred for treatment for depression. Kovacs, Paulauskas, Gatsonis, and Richards (1988) documented a prevalence rate of 16% for co-occurrence of depression and conduct disorder in their sample of depressed children. However, conduct disorder occurred secondary to depression in children, possibly developing as a complication to the mood disorder. Comorbid disruptive behavior disorders are significant predictors of a more persistent course of psychiatric disorder in children (Goodyer et al., 1997).
(p. 7) Course of Childhood Depression
Longitudinal studies that have tracked clinic and community samples of children across the lifespan have informed our knowledge-base about the course of childhood depression. Long-term follow-up studies of clinic samples of children diagnosed with depression have been important for understanding whether or not childhood depression predicts depression in adolescence and adulthood. Kovacs’ groundbreaking studies of childhood depression (Kovacs, Feinberg, Crouse-Novak, Paulauskas, Pollock, et al., 1984; Kovacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein, 1984) were among the first to outline the course and correlates of depressive disorders in children, as well as to investigate rates of recovery in children diagnosed with major depression, dysthymia, double depression, and adjustment disorder with depressed mood. In their sample, an earlier age of onset for depression predicted a longer recovery from the initial episode; hence, older children recovered from their depression more rapidly than did younger children. This finding suggested that early-onset depression in children was associated with a more protracted course of the disorder and was a deleterious marker for severe psychiatric outcomes in adolescence and adulthood (more so than later onset of depression in children and early adolescents). These studies demonstrated that depression in children was not a relatively benign and transient problem and suggested the continuity between childhood-onset and depression into adolescence and adulthood.
The Maudsley Hospital studies of early-onset depression in a sample of clinically identified children and adolescents with depression followed these youth into young adulthood to determine whether childhood-onset or adolescent-onset depression was more likely to predict depression in adulthood (Fombonne, Wostear, Cooper, Harrington, & Rutter, 2001a, 2001b; Harrington, Fudge, Rutter, Pickles, & Hill, 1990, 1991; Harrington et al., 1993, 1997). Although both childhood-onset and adolescent-onset groups were at high risk for depression as adults, those diagnosed with depression in childhood did not experience higher rates of depression as adults when compared to nondepressed children or depressed adolescents. Indeed, there was a trend for the adolescent-onset (p. 8) depression group to have an increased likelihood of depression in adulthood. Methodological problems related to the retrospective diagnosing of childhood depression from medical records and the small number of identified cases have complicated the implications from the Maudsley Hospital studies. Nevertheless, these investigations were significant in furthering debate about the discontinuity of early-onset depression and suggesting an etiological distinction between childhood and adolescent-onset depression.
Weissman and colleagues (1999) conducted a follow-up study of Puig-Antich’s original sample of children with prepubertal-onset depression (Puig-Antich et al., 1985a, 1985b) when they were young adults. Although they evidenced increased social impairment, psychiatric treatment utilization, and suicide rates compared to controls, individuals who experienced prepubertal depression were generally not at an increased risk for depression in adulthood. Closer examination of the sample revealed heterogeneity in cases based upon comorbidity and family history of depression. A subgroup of children with depression experienced recurrent episodes of depression into adulthood. These cases were more likely to have a family history of depression. A second subgroup, those with childhood-onset depression and conduct disorder, evidenced adult psychiatric outcomes marked by a twofold increased risk for alcohol abuse/dependence and a fourfold increased risk for conduct disorder compared to controls. Childhood cases with depression and comorbid conduct disorder also had a significantly higher rate of antisocial personality disorder than cases with childhood-onset depression alone. Thus results from Weissman et al.’s follow-up study supported earlier findings on the course of childhood-onset depression being moderated by comorbid conduct disorder and family history of depression.
A 10- to 15-year follow-up of Puig-Antich et al.’s (1989) sample of children with prepubertal-onset depression presented additional evidence that childhood-onset depression can be continuous or discontinuous with adult depression based upon family psychiatric history (Wickramaratne, Greenwald, & Weissman, 2000). While the majority of children with prepubertal-onset depression did not have recurrent MDD into adulthood, those children who went on to have recurrent depression had significantly higher rates of MDD in their first-degree relatives than those who did not. That is, the continuity of MDD from (p. 9) childhood to adulthood was associated with a strong family history of MDD. Similar to findings from high-risk studies, these data support the continuity of course for childhood-onset depression in cases where there is significant familial loading for depression.
The handful of prospective longitudinal studies that have tracked the course of depression across different phases of development provide some of the best evidence regarding the course of childhood-onset depression. For example, the Oregon Adolescent Depression Study prospectively assessed a community sample of youths over a 12-year period to identify antecedents, correlates, and course of MDD in children and adolescents (Lewinsohn, Rohde, Seeley, Klein, & Gotlib, 2000; Rohde, Lewinsohn, Klein, Seeley, & Gau, 2013). Their findings suggested a strong degree of continuity for depression across childhood, adolescence, and early adulthood. Incident of childhood depression doubled the risk of experiencing depression in adolescence, and adolescent depression strongly predicted depression in early adulthood. In the Great Smoky Mountains Study, preadolescent girls who met diagnostic criteria for MDD, minor depression, or dysthymia between the ages of 9 and 13 were approximately 20 times more likely to manifest a diagnosis of MDD by age 16 (Copeland, Shanahan, Costello, & Angold, 2009; Costello et al., 1996; Shanahan, Copeland, Costello, & Angold, 2011). Thus these two separate population-based studies provide support for the continuity of childhood-onset depression into adolescence and early adulthood and further the case for the predictive validity of childhood-onset depression.
Other prospective longitudinal studies using community samples of youths have also examined subthreshold symptoms of depression in preadolescent children—elevated depressive symptoms that are not extensive or severe enough to warrant a diagnosis—as predictors of later MDD diagnoses in adolescence and early adulthood. Keenan and colleagues’ (2008) study of depressive symptoms in preadolescent girls provides strong evidence for subthreshold symptoms of depression during the preadolescent period predicting a later onset of MDD. Using diagnostic interviews, researchers studied depressive symptoms and depressive disorders in a cohort of preadolescent girls across a three-year period, from ages 9 to 11. Not only did they find a high (p. 10) degree of stability of subthreshold and threshold levels of depressive symptoms in girls during this developmental period; they found that higher depressive symptoms at ages 9 and 10 significantly predicted a nearly twofold increase in risk for a later depressive disorder in these preadolescent girls. In fact, 78% of all girls meeting criteria for minor or major depression at age 11 had at least one depressive symptom at age 9 (Keenan et al., 2008). Other studies have also found that elevated symptoms of depression at earlier developmental periods were strong predictors of a later MDD diagnosis in both children and adolescents (Johnson, Cohen, & Kasen, 2009; Rohde, Beevers, Stice, & O’Neil, 2009; Wesselhoeft, Sorensen, Heiervang, & Bilenberg, 2013). Taken together, these studies support the more continuous course of depression across development, including during the preadolescent period.
Significant developmental changes in physical appearance, cognitive processes, and reciprocal interpersonal relationships occur during the preadolescent period, roughly defined as between the ages of 7 and 12 years. It has been a more highlighted aspect of “middle childhood” over the past decade primarily due to the well-established trend that puberty, particularly in girls, is occurring at earlier ages than in previous generations (Graber, 2013). Pubertal maturation has been associated with an increased interest in and gravitation toward social relationships. During puberty, the human brain undergoes a significant shift in the social, affective, and attentional processes that underlie this increased orientation toward interpersonal relationships (Dahl & Gunnar, 2009; Dorn et al., 2006; Forbes & Dahl, 2010). Brain regions associated with socioaffective processes undergo a period of increased plasticity (Nelson & Guyer, 2011; Nelson, Leibenluft, McClure, & Pine, 2005), specifically those involved in the regulation of social distress, including the amygdala, subgenual cingulate, anterior insula, as well as the ventromedial/ventrolateral and dorsolateral prefrontal cortical regions (Silk et al., 2014). Preadolescents’ interpersonal experiences shape and strengthen neural pathways in these regions of the brain associated with social and affective processing. Preadolescents begin to engage in interpersonal relationships that require new and more sophisticated (p. 11) social and problem-solving skills as they develop closer relationships with peers and begin to individuate from their parents.
In both community and clinical samples, more preadolescents are presenting with issues associated with the “storm and stress” once attributed to adolescents. Parent–child conflict may increase during this time, as preadolescents begin to assert independence and experiment with individuating from parents (Steinberg & Silverberg, 1986). Increased sensitivity to peer rejection accompanies this developmental period, and unstable peer relationships can contribute to high levels of interpersonal stress (Connolly, 2000; Degirmenicioglu, 1998).
Why “Preadolescent” Depression?
Depression during the preadolescent period is an increasingly recognized public health concern. Preadolescent depression interferes with normative social and emotional development at a sensitive developmental period that increases the risk for recurrent depression into adolescence (Asarnow et al., 1988; Emslie et al., 1997; Goodyer et al., 1997) and adulthood, particularly when there is a strong family loading for depression (Weissman et al., 1999; Wickramaratne et al., 2000). Marked interpersonal impairment has been associated with depression in preadolescents (Birmaher & Rozel, 2003; Geller, Zimerman, Williams, Bolhofner, & Craney, 2001; Hammen, Rudolph, Weisz, Rao, & Burge, 1999; Hammen & Rudolph, 1996) and appears to be one of the mechanisms for recurrent depression in adolescence and adulthood. Depressed preadolescents experience frequent negative interactions and more distant relationships with parents, as well as more problematic (e.g., teasing) and fewer close peer relationships as compared to nondepressed preadolescents (Puig-Antich et al., 1985a). Unfortunately, depressed preadolescents remain at risk for interpersonal and social impairment even after their symptoms remit (Kovacs, Feinberg, Crouse-Novak, Paulauskas, Pollock, et al., 1984; Puig-Antich et al., 1985b), as they continue to experience significantly more difficulties in interpersonal relationships with parents and peers than do preadolescents with no history of depression. Hence preadolescent depression appears to (p. 12) not only interfere with normative social development during a formative period but also results in residual impairments in preadolescents’ interpersonal functioning, which may increase their risk for recurrent depression into adolescence and adulthood.
Family and Interpersonal Risk Factors
Studies of depressed preadolescents and preadolescents at risk for developing depression identify several psychosocial factors that are commonly associated with depression in preadolescent children. Understanding family and interpersonal risk factors that accompany preadolescent depression can inform treatment strategies and may suggest antecedents for future episodes of depression.
Family Risk Factors
Adverse family environments marked by high levels of family discord, conflict, and criticism are more strongly associated with preadolescent depression than with adolescent depression (Fendrich, Warner, & Weissman, 1990; Nomura, Wickramaratne, Warner, Mufson, & Weissman, 2002). Clinical studies of depressed preadolescents revealed that their families were significantly less cohesive and more disengaged compared to the families of nondepressed children (Puig-Antich et al., 1985b). Preadolescent depression is associated with high rates of depressive disorders in parents (Harrington et al., 1990; Weissman et al., 1984). This finding is consistent with studies documenting the increased risk for developing depressive disorders during childhood and adolescence in children of depressed parents (Beardslee, Versage, & Gladstone, 1998; Weissman et al., 1997). Children of depressed parents experience severe and recurrent courses of depression, with high rates of interpersonal impairment and suicide (Beardslee, 1993; Weissman & Klerman, 1992; Weissman et al., 1997). The high rates of parental depression in these preadolescents’ families are likely to contribute to negative family processes. Negative family interactions, such as poor parenting behavior and harsh/critical interactions with children, are factors related to parental depression that may increase children’s (p. 13) risk for depression (Campbell, Cohn, & Meyers, 1995; Goodman & Gotlib, 1999). When parents are depressed, they may model maladaptive strategies for controlling emotional distress and coping with problems. Preadolescents socialized in these families may develop poor emotional regulation skills and passive coping strategies that place them at higher risk for depressive disorders, complicating their adjustment to loss and life transitions, and creating problems within their interpersonal relationships (Keenan & Hipwell, 2005).
Preadolescent depression is associated with impairments in social interactions, poor emotion processing, and difficulties taking the perspective of others in social interactions. These difficulties in interpersonal relationships may precede the onset of preadolescent depression and are consistent with profiles of children of depressed parents. For example, children at high risk for developing depression are more likely than low-risk children to demonstrate heightened negative affect in distress inducing protocols (Forbes, Cohn, Allen, & Lewinsohn, 2004), lower positive affect when engaging in pleasurable tasks (Dietz, Birmaher, et al., 2008; Olino et al., 2011), and difficulties regulating negative emotions (Silk, Shaw, Skuban, Oland, & Kovacs, 2006). High-risk children also demonstrate difficulties correctly identifying emotion in others (Joormann, Gilbert, & Gotlib, 2010; Joormann, Talbot, & Gotlib, 2007) and may demonstrate a bias toward negatively interpreting others’ affect and behavior. These difficulties in emotional processing may further impair communication and problem-solving with parents and peers, increasing the preadolescents’ experience of conflict in their relationships with others.
Although depression in preadolescents is associated with social withdrawal, anhedonia, and increased sensitivity to rejection, the high rates of comorbid anxiety disorders further complicate depressed preadolescents’ interpersonal relationships. Similar to the effects of depression, comorbid anxiety may impair depressed preadolescents’ ability to engage in social situations or interpersonal relationships (Allen & Badcock, 2003; Brown & Harris, 1978; Coyne, 1976; Gilbert, 1992). Because preadolescent depression and anxiety often co-occur, (p. 14) it is difficult to distinguish the independent effects each has on social withdrawal and loneliness. However, continued anxiety symptoms may contribute to preadolescents’ residual interpersonal impairment in relationships with family members and peers and their ongoing social isolation even after their depressive symptoms remit (Cyranowski, Frank, Young, & Shear, 2000; Leadbeater, Blatt, & Quinlan, 1995; Ruble, Greulich, Pomerantz, & Gochberg, 1993; Rudolph, 2002).
Peer exclusion and rejection are consistent predictors of elevated depressive symptoms from middle childhood to early adolescence (Brendgen, Wanner, Morin, & Vitaro, 2005; Hazel, Oppenheimer, Technow, Young, & Hankin, 2014); chronic experiences of peer rejection and peer victimization (e.g., bullying) have been associated with poor mental health outcomes in young adulthood and suicidality (Copeland, Wolke, Angold, & Costello, 2013). These stressful experiences evoke feelings of loneliness and low self-esteem that may intensify depressive symptoms (Joiner, 1997; Joiner, Lewinsohn, & Seeley, 2002) and increase social withdrawal. Rejection sensitivity, anxious expectations of interpersonal rejection (Downey & Feldman, 1996), may increase depressed youths’ attention bias to negative affective cues in peer relationships and increase their fear of peer rejection. However, positive parent–child relationships may buffer preadolescents from the stress in peer relationships. In close parent–child relationships, parents actively model effective communication skills and problem-solving strategies (Alloy, Abramson, Smith, Gibb, & Neeren, 2006). The quality of parent–child relationships appears to moderate the effects of peer rejection on preadolescents. For example, preadolescents were more negatively affected by peer rejection when they felt less accepted by their parents and were less sensitive to peer rejection when parental acceptance was high (McLachlan, Zimmer-Gembeck, & McGregor, 2010). Similarly, studies find a stronger relationship between peer stress in middle childhood and depressive symptoms in early adolescence among preadolescents who report poor relationships with their parents (Hazel et al., 2014).
(p. 15) The accessibility and use of technology and social media also present new stressors regarding peer relationships in preadolescents. Since cell phones have become increasingly affordable, accessible, and necessary, the age of first acquisition has been steadily decreasing—a trend that will no doubt continue. Many preadolescents, especially those between the ages of 10 and 12, routinely use cell phones to engage and interact with peers, both individually and in groups. Having a cell phone allows the preadolescents access to social media (e.g., Facebook, Instagram, Snapchat, FaceTime) that provides further opportunities to interact with peers outside of school or extracurricular activities. Peer interactions on social media can be sources of stress for the preadolescent. There are increased opportunities for conflict, oversharing sensitive information, and feeling excluded by peers (e.g., friends posting pictures of a get-together to which the preteen was not invited). Developmentally, preadolescents may be at increased risk for impulsivity when texting/ posting pictures and may have trouble disengaging from interacting with peers on social media (e.g., FOMO = fear of missing out). They may also feel pressure to present themselves as older or more sexualized on social media to appear “cool” or garner positive feedback and attention from peers (e.g., Likes, Followers, Friend Requests). Parents differ in their degree of monitoring and in their knowledge of how to monitor their preadolescents’ activities on social media. This generation gap can often leave preadolescents with tremendous amounts of freedom in their cyber interactions.
Treatments for Preadolescent Depression
Although there is extensive research on psychosocial treatments for adult and adolescent depression, clinical interventions for preadolescent depression are less studied. At present, the field lacks usable and effective treatments for depressed preadolescents. While there is well-established support for the efficacy of cognitive behavior therapy (CBT) relative to no-treatment control conditions for treating community samples of preadolescents with elevated depressive symptoms (David-Ferdon & Kaslow, 2008), the few studies of depressed preadolescents randomized to either CBT or to an active treatment comparator have found no differences between CBT and relaxation training ( (p. 16) Kahn, Kehle, Jenson, & Clark, 1990) or supportive, nondirected therapy (Vostanis, Feehan, & Grattan, 1998; Vostanis, Feehan, Grattan, & Bickerton, 1996). Two CBT treatment protocols, Taking Action (Stark, Streuand, Krumholz, & al., 2010) and Primary and Secondary Control Enhancement Training (PASCET; Weisz, Thurber, Sweeney, Proffitt, & LeGagnoux, 1997), have demonstrated promise in effectively treating children with elevated depressive symptoms as compared to wait-list control groups, but studies have yet to compare these interventions to active control conditions. However, a recent efficacy trial comparing PASCET and client-centered therapy, a supportive and nondirective treatment that closely approximates the standard of care for pediatric depression in community mental health, in preadolescents with irritable bowel disorder and elevated depressive symptoms found no differences between the two treatment groups on posttreatment outcomes (Szigethy et al., 2014).
Developmental Considerations for Psychosocial Treatments for Depressed Preadolescents
Interventions for preadolescent depression must match therapy tasks to the developmental competencies of preadolescents. There is great heterogeneity in preadolescents’ social, emotional, and cognitive development because of the developmental transition from childhood to adolescence. Despite the increased focus on interpersonal relationships, preadolescents still experience less sophisticated cognitive processing than adolescents do, particularly as it relates to metacognition or the awareness of one’s own thinking. The equivocal efficacy of CBT protocols for preadolescent depression may highlight the developmental limitations of this treatment model. CBT-based treatments emphasize cognitive restructuring to identify and modify automatic negative thoughts that affect behavior and contribute to depressive symptoms. Because younger children often have difficulties employing these more abstract skills given their developmental competencies, this approach may be less effective when treating depression in younger children. Hence, interventions such as CBT that focus on identifying and restructuring negative automatic thoughts related to depressed mood and vegetative symptoms may be less effective for this age group. Cognitive skills related to success in interpersonal relationships, such (p. 17) as perspective taking, are aspects of intervention that are accessible to preadolescents’ developmental stage and consistent with their increasing social motivation. Teaching depressed preadolescents more sophisticated communication skills and problem-solving skills, such as negotiation and compromise, may be helpful to improve relationships with family members and peers both concurrently and after remission of the preadolescents’ depressive episode.
Parental Involvement in Treatment of Depressed Preadolescents
A developmentally appropriate treatment for preadolescent depression must focus on the family environment and peer relationships, the two primary interpersonal domains where preadolescents experience stress and support. Preadolescents experiencing stress in their family or peer relationships are vulnerable to disturbances in mood and self-regulation as their age and developmental period leave them firmly entrenched in these interpersonal contexts and less able to create their own social support networks. As children are dependent upon their parents for nurturance, support, and assistance (Hammen et al., 1999), parental involvement in treatment for childhood depression is a critical developmental concern.
■ First, parent involvement in preadolescents’ treatment allows for a more nuanced understanding of stressors in the family environment that may be contributing to the preteen’s mood symptoms. Parental divorce, job loss or change, financial difficulties, the birth/illness/impairment of a sibling, a move to another location, and parental psychopathology affect preadolescents’ mood and functioning. However, preadolescents often do not explicitly understand the link between these issues and their depressed mood and symptoms. Routine meetings with parents allow therapists to gain a broader understanding of the preteen’s family context and the circumstances or issues that may be contributing to the preadolescent’s depression. Therapists can use this information to identify key issues to discuss with the parent and preadolescent, or guide parents in how to best support their preadolescent in negotiating issues with others.
(p. 18) ■ Second, routinely involving parents in their preadolescent’s treatment allows parents to have a good understanding of the focus of their preteen’s therapy, enabling them to support their child’s practice of new skills and strategies for handling stressors in his relationships. Parents are more likely to support their preadolescent’s use of new communication skills or negotiation and problem-solving skills if they understand that their child is practicing what he has learned in therapy. Similarly, parents may also model these skills and strategies in their interactions with their depressed preadolescent. Parental rehearsal of skills may improve parent–child interactions and increase preadolescents’ willingness to implement new skills in situations outside of therapy sessions. The therapist’s ability to share the new communication and problem-solving skills with parents and to obtain their “buy-in” for trying out these skills at home increases the likelihood of these skills generalizing to the preadolescent’s relationships with family members and peers.
■ Third, parents may actually benefit from learning different ways to communicate with their preadolescents. Hence, strategic parental involvement in the preadolescent’s therapy is an opportunity to intervene on both child and parent levels of influence and increase the likelihood of changing dyadic patterns of communication in the family.
■ Finally, there may be negative consequences for not involving parents in their preadolescents’ treatment. When parents are not involved in the process, they can become confused, disappointed in the efficacy of their child’s treatment, and less committed to bringing the child into sessions.
Involving parents in their preadolescent’s therapy allows therapists to informally assess parents for their own current depressive symptoms that may be negatively affecting their interactions with their preteen and discuss the possibility of seeking their own psychiatric treatment. Parents of depressed preadolescents are highly likely to have a history of depression or other psychiatric disorder. As a result, they may model less effective communication and problem-solving strategies (p. 19) in their interactions with their child. Oftentimes, parents’ untreated depression and impaired parenting behavior may contribute to family stressors that influence preadolescents’ depressive symptoms. Recent studies indicate the benefit of treating parental depression on the long-term improvement of psychiatric symptoms in children (Swartz et al., 2016). Therefore, identifying and supporting depressed parents is a strategy for promoting the mental health and well-being of depressed preadolescents. Although therapists can broach the issue of parental psychopathology and individual treatment without involving parents in their child’s treatment, this approach has the potential to increase parents’ defensiveness and mistrust of the therapist. In our experience, encouraging parents to pursue their own treatment is most effective when it involves a conversation that progresses over time. Parents may be more willing to consider the therapist’s suggestion of pursuing treatment for themselves when they feel that their child’s therapist understands the challenges in the family context and can link parental treatment to supporting their preadolescent’s well-being. This is possible only if the therapist has a collaborative relationship with parents.
Comorbid Anxiety Disorders
Appropriate interventions for depressed preadolescents must also address the high rates of comorbid anxiety disorders among this age group and the potential for this untreated anxiety to increase social withdrawal and interpersonal avoidance. The effects of social isolation can be detrimental to depressed preadolescents both during and after a depressive episode. Depressed preadolescents who avoid social interactions and have anxiety about initiating peer relationships may have prolonged courses of disorder and miss opportunities to rehearse, practice, and implement any new interpersonal communication and problem-solving skills learned in therapy. In the absence of depressive symptoms, continued social anxiety and interpersonal avoidance may contribute to preadolescents’ residual social impairment and social isolation—factors that may increase their risk for recurrent depression in the future. Therefore, a psychosocial intervention for preadolescent depression must address any comorbid social anxiety and work to decrease social withdrawal and reluctance toward initiating with peers.
(p. 20) Early Intervention and Secondary Prevention
The preadolescent period presents a window of opportunity for early psychosocial intervention for depressive disorders and for addressing risk factors associated with recurrence. It is important to address depressive disorders in preadolescents when treatment has the potential to be most successful, when suicide rates are low, and when comorbid substance use disorders are rare. It is also important to treat preadolescents’ depressive symptoms prior to early adolescence (ages 13–15), when dramatic increases in rates of depression occur, particularly for girls. Effective clinical intervention for depressed preadolescents could decrease the burden of illness on youth during a sensitive period of social and neural development. Treatments that target preadolescents’ interpersonal impairment with parents and peers may also reduce risk for depression recurrence during adolescence. Empirically supported treatments that target poor interpersonal functioning need to be validated for this high-risk group. The area of early psychosocial interventions for preadolescent depression remains open to the development of effective and family-based protocols that provide alternatives to pharmacotherapy and address interpersonal risk factors in preadolescents related to continued courses of depression (Tompson, 2008; Tompson, Boger, & Asarnow, 2012).
Preadolescent depression is an important public health concern because it is often a “gateway” condition that increases the risk for recurrent depression in adolescence (Asarnow et al., 1988; Emslie et al., 1997; Goodyer et al., 1997) and adulthood, particularly when there is a strong family loading for depression (Weissman et al., 1999; Wickramaratne et al., 2000). Marked interpersonal impairment has been associated with depression in preadolescents (Birmaher & Rozel, 2003; Geller et al., 2001; Hammen et al., 1999; Hammen & Rudolph, 1996) and appears to be one of the mechanisms for recurrent depression in adolescence and adulthood. Depressed preadolescents experience frequent negative interactions and more distant relationships with parents, as well as more problematic (e.g., teasing) and fewer close peer relationships (p. 21) as compared to non-depressed preteens or psychiatric controls (Puig-Antich et al., 1985a). Unfortunately, depressed children remain at risk for interpersonal and social impairment even after their symptoms remit (Kovacs, Feinberg, Crouse-Novak, Paulauskas, Pollock, et al., 1984; Puig-Antich et al., 1985b), as they continue to experience significantly more difficulties in interpersonal relationships with parents and peers than do non-depressed children. Preadolescent depression not only interferes with normative social development at a formative period but also results in residual impairments in preadolescents’ interpersonal functioning, which may increase their risk for recurrent depression into adolescence and adulthood. Effective interventions for depression in the preadolescent period that target family and interpersonal risk factors may reduce risk for depression recurrence in adolescence. (p. 22)