Article: Dante Cicchetti and Sheree L. Toth
This article examines depressive disorders in childhood and adolescence from the perspective of developmental psychopathology. According to this approach, understanding human development requires understanding individuals’ lifelong developmental processes (biological, psychological, and social) through the interaction of multiple dimensions. Thus, to reveal the important factors involved in the emergence of depressive disorders, it is necessary to combine developments in developmental psychology, clinical psychology, psychiatry, epidemiology, sociology, neurobiology, genetics, and neuroscience from a developmental psychopathology perspective.
According to this approach, depressive disorders are heterogeneous conditions resulting from various developmental processes, and it is rarely considered that a single risk factor leads to depressive disorder. This article proposes depressive-typical developmental organization as a possible cause of depressive disorders. This organization is important in that it suggests different processes underlying depressive symptoms and disorders. The developmental perspective compels us to understand not only the cognitive, affective, interpersonal, and biological aspects of depressive disorders, but also how these aspects change developmentally and how they integrate with the biological and psychological systems of the individual in their social environment.
This article first discusses the nature of depressive disorders, then focuses on epidemiological findings and the clinical characteristics of depression in adolescents and children. It then presents a model of the development and presentation of depression in children and adolescents, drawing on concepts from the field of developmental psychopathology. Since longitudinal studies in this area are insufficient, the findings of epidemiological research, studies with children in high-risk groups whose parents have depression, and studies with children who come to clinics for depression treatment or are hospitalized are discussed. The model proposed in this article is inevitably speculative, as there are no studies examining the emergence and change over time of the depressive prototype organization. Since much research has been conducted on unipolar depression, this article focuses on unipolar depression in understanding the etiology and process of depressive disorders in childhood and adolescence from a developmental psychopathology perspective.
Diagnostic criteria and the nature of the disorder:
Depression is typically used in three ways: depressive mood, depressive syndromes, and depressive disorders (Angold, 1988). Depressive mood is limited to a single symptom or group of symptoms that include dysphoric feeling. Methods of obtaining information from the individual themselves have been used most frequently to date to measure depressive mood. Depressive syndromes include groups of symptoms that have been empirically shown to occur together. Depressive disorders are reflected as diagnostic categories, as in DSM 4 and ICD 10.
There are two types of mood disorders. These are bipolar disorder and depressive disorder, which are not discussed in this article. There are two main subtypes of depressive disorder: Major Depressive Disorder, which manifests as single or recurrent depressive episodes, and dysthymia, which is characterized by chronic mood disorder. Although it is emphasized that the symptoms of these disorders may manifest differently in children and adolescents than in adults (APA, 1994; Birmaher et al., 1996; Kovacs, 1996), adult criteria are often applied to children and adolescents, and developmental factors that may affect etiology and progression are overlooked.
Depressive disorders in children and adolescents:
Although mood disorders in children and adolescents have been less researched than in adulthood, progress has been made in this area in recent years. Contrary to previous beliefs that questioned whether depressive disorders could occur before adolescence, recent studies have focused on which criteria should be used for diagnosis; the use of more advanced techniques in studies on epidemiology, causes, progression, and outcomes; and the responses of children with depressive, dysthymic, and risk groups to treatment.
Epidemiology and clinical features of childhood and adolescent depression
The prevalence of Major Depressive Disorder (MDD) in childhood is estimated to range from 0.4% to 2.5%, and in adolescence from 0.4% to 8.3%. However, given children’s developmental limitations in cognition, language, memory, and self-understanding, misdiagnosis of Major Depressive Disorder is possible. The lifetime prevalence of MDD in adolescence (15% to 20%) is similar to the lifetime prevalence in adults. This similarity indicates that the foundations of depression seen in adulthood are laid in adolescence. The prevalence of dysthymic disorder is 0.6% to 1.7% in children and 1.6% to 8.0% in adolescents. While MDB occurs at the same rates in girls and boys during childhood, the rate in girls is twice as high as in boys during adolescence, which parallels the rates in adulthood.
Compared to MDD, the earlier onset of dysthymic disorder in children increases the risk of subsequent mood disorders. The duration of MDD in children and adolescents is approximately 7-9 months and is often recurrent. Dysthymic disorder, on the other hand, lasts approximately 4 years. These children usually develop MDD about 2 years after the onset of dysthymic disorder. Since Dysthymic Disorder leads to recurrent depressive disorders, early diagnosis, treatment, and prevention efforts for Dysthymic Disorder should be important strategies.
Between 40% and 70% of children and adolescents with depression exhibit another disorder, and it is estimated that 20% to 50% of them exhibit two or more disorders. The most common comorbid disorders are Dysthymic Disorder, Anxiety Disorders, Conduct Disorders, and Substance Use Disorders. While Anxiety Disorders precede depressive disorders in children and adolescents, Depression precedes Anxiety Disorders in adults. MDB usually occurs approximately 4.5 years before alcohol and substance use and is an important indicator for preventing addiction in young people with depression. Comorbidity generally affects the risk of recurrence of depression, the duration of depression, the risk of suicide, functioning, response to treatment, and use of psychiatric services.
Gender differences
Research shows that the overall prevalence of depression increases in both genders during early and middle adolescence. However, the rates are higher in girls than in boys. Although there is consensus on this increase in girls, more research is needed to explain this difference.
Approaching Childhood and Adolescent Depression with Developmental Psychopathology Concepts:
The occurrence of depressive disorders at different stages of development and their association with various risk factors and other pathologies make it important to gain insight into the developmental processes that cause these disorders to emerge and persist. The reason developmental psychologists are particularly interested in depressive disorders is that these disorders are based on complex structures such as psychological (e.g., affective, cognitive, socio-emotional, socio-cognitive), social (e.g., society, culture), and biological (e.g., genetic, neurobiological, neurophysiological, neurochemical, neuroendocrine) factors. There are different processes leading to depressive disorders, and potential risk factors for depression can also lead to behavioral problems other than depression.
Individuals with mood disorders exhibit impairments in cognitive (information processing, social cognition, etc.), social-emotional (self-esteem, interpersonal relationships, guilt, affect control, etc.), representational (self-schema, internal representation models, etc.), and biological (genetic, structural brain abnormalities, etc.) systems. These systems are not separate from each other but are closely related. In individuals with normal functioning, there is a consistent organization between these systems. In contrast, in depressed individuals, there is an inconsistent organization between these systems or an organization of pathological structures, in other words, a depressive-typical organization. This organization progresses developmentally and can result in depressive disorders at different stages of life. Therefore, understanding the relationships between these systems is crucial for understanding both the nature of depressive disorders and how these systems enable normal functioning.
Since different systems are affected by depressive disorders, the developmental approach directs attention to early periods that may later emerge and be associated with depressive symptoms. For example, understanding the malfunctions in emotional control mechanisms or the negative attributions that depressed individuals make about themselves can be achieved by examining the early development of these characteristics.
Organizational Approach To Development:
Children encounter different problems they must solve at each stage of development. Positive adaptation to these problems contributes to the individual’s competence, while poor solutions reduce the individual’s positive adaptation to developmental problems they may encounter in the future.
Since development can lead to a wide variety of outcomes, differences in developmental processes are to be expected. According to the principle of multifinality, a single effect can lead to different outcomes. For example, although children of depressed parents (including hereditary factors) are considered a risk group, not all of them develop depressive disorders, and some show adaptation.
According to the principle of equifinality, the same outcome can stem from different causes. For example, while depression in men in adulthood has been found to be associated with oppositional and antisocial interpersonal behavior in the preschool period, in women, excessive socialization and excessive introversion during adolescence have been found to be characteristics that can predict depression in adulthood.
Ecological Transactional Model
(An Ecological Transactional Model)
This model provides a framework for understanding how multiple factors contribute to depression in childhood and adolescence. According to this perspective, an individual’s environment consists of simultaneously existing levels that are either close to or distant from the individual. Depending on the proximity of the effect to the individual, its role in the emergence of depressive organization and depressive disorder varies. The individual’s characteristics and the processes at each level of the environment interact with each other over time and shape the child’s development process. The presence or absence of depressive organization also depends on this.
The two most distant levels in the individual’s environment are the macro-system, which includes beliefs and cultural values, and the eco-system, which includes the characteristics of the environment in which children and families live. Factors closer to the individual that can affect adaptation include the immediate environment (micro-system), particularly the family, and individual characteristics. Within the framework of the change model, the transitions of ongoing risk and protective factors within and between levels of the environment are seen as contributing to the development of depressive-typical organization and the emergence or recurrence of depressive disorders.
Individual development
(Ontogenetic Development)
Due to theoretical interest in the development of different parts of depressive disorders and depressive organization, this article focuses on four developmental points specific to early developmental stages.
a. Development of homeostatic and physiological regulation
b. Development of sensory discrimination and regulation of attention and arousal
c. Development of secure attachment
d. Development of the self system
a. Development Of Homeostatic And Physiological Regulation
In the first months of life, infants need to maintain balance in their internal physiological states. The homeostatic system seeks to remain at a point of equilibrium, and deviation from this equilibrium causes distress. Early physiological regulation seeks support from the adult caring for the infant. Infants develop ways to communicate their needs to their parents through sensory responses. Responsive parents must also be able to correctly identify these signals.
As the infant’s brain develops, the infant becomes increasingly capable of regulating the arousal caused by physiological distress. This developing capacity occurs thanks to the development of frontal lobe control functions and neurotransmitter systems. Right brain activation is associated with stress, while left brain activation and control of right brain activity are associated with positive emotions. The development of interhemispheric connections also enhances the baby’s ability to control themselves. This neurological development is experience-dependent. For this, external stimuli from parents are necessary.
Parents indirectly influence their baby’s brain development process based on the quality of support they provide to their babies in the continuity of homeostatic regulation. Frequent new experiences and an inconsistent environment can cause negative affect by regularly activating the right brain. Conversely, a consistent and coherent environment can support left-brain dominance, thereby reducing negative arousal. Thus, parents’ attitudes toward their infants can influence the development of interhemispheric connections and emotional control skills.
Studies involving mothers playing the role of a depressed mother have also demonstrated the existence of the aforementioned negative effects on infants. Studies conducted with children whose parents exhibited mood disorders after infancy have also observed that these children experienced difficulties in emotional control. Research in this area suggests that difficulties in regulation and control processes beginning in infancy may contribute to changes in depressive-type organization.
b. Emotional Discrimination And Regulation Of Attention And Arousal
With the establishment of the foundations of internal homeostatic regulation, the infant becomes more attentive to and responsive to their physical environment. They also begin to rapidly acquire skills in different functional areas. Emotional expression becomes an important tool in the infant’s relationship with their parents. The infant adapts and regulates their emotional expression and behavior according to their parents.
Since the infant needs the support of its parents, how the parent relates to and cares for the infant contributes to the emergence of individual differences in infants’ abilities to make emotional distinctions, express emotions, and regulate emotions.
Thus, the negative emotional interactions experienced by the children of depressed mothers lead to differences in their early emotional development. These early emotional differences play a driving role in the development and change of depressive-typical organization.
