There are some significant differences between diagnosing a child with MDD and diagnosing an adult. First and foremost, symptom duration must be at least 1 year (as opposed to 2 for adults). Secondly, the presentation is likely to be different… with children exhibiting somatic complaints, irritability, and social withdrawal much more often their adult counterparts. In both cases, one symptom must be depressed or irritable mood and/or inability to experience pleasurable emotions from normally pleasurable life events such as eating or social interaction (anhedonia).
The likelihood that comorbid conditions will appear increases with the severity of the depression. (Netherton, Holmes, & Walker, 1999, p. 266) Often MDD is comorbid with anxiety disorders, ADHD, behavior disorders, eating disorders, and/or substance abuse. There does appear to be a distinct lack of a “developmental perspective” in the DSM-IV-TR, but that is not exclusive to this particular category or disorder… I suspect that’s just an effort to remain “atheoretical.”
I am not at all surprised that rates of depressive disorders increase with age, since frequency, duration, and severity of previous episodes seem to be an indicator of risk. Also, for lack of a better explanation, the longer you live, the more likely you are to have to endure a negative life event. I was surprised to see that by age 15, females are twice as likely as males to receive a depressive disorder diagnosis.
Theoretically speaking, I came to favor the interpersonal/cognitive/behavioral models of development for depression. There was a continued lack of a developmental model, however, for all the theories. On the whole, I got the impression that we were really selling the childhood cohort short due to lack of research (or, perhaps that’s just the Netherton text working, not sure which… will definitely check this out when I get knee deep into the journal reading).
Attachment theory rears its ugly head again, condemning insecure parental attachment as being significant in the etiology of depression related cognitive processes. (Netherton et al., 1999, p. 269) The text suggests that this leads to a more depressive perspective on self, world, and future… culminating in a sense of helplessness and hopelessness. It would appear that depression is a possible marker for RAD? I would like to see some comorbity rates.
I understand that self assessment has to be a key component for assessment, but I wouldn’t bet the house on those results alone. I really like the idea of a multi-trait, multi-method, multi-informant approach to increase diagnostic reliability and validity. I really believe that you need to take a big picture approach to the complete child, accessing cognitive, affective, interpersonal, adaptive, genetic, and environmental effects to be able to diagnose this disorder effectively. In addition to a full batter of testing and semi-structured interviews, if able we should dig into a medical history and eliminate underlying organic causes… paying special attention to drug history since many anticonvulsants and some antibiotics are associated with depressive symptoms.
Although I will give treatment only cursory coverage, at this early stage I am very much in favor of cognitive restructuring and development of more adaptive cognitions. Although the text didn’t really address it, I would also take a “top down” approach and see if I couldn’t convert this to a family intervention. I am increasingly aware that families are systems and that children tend to play a specific role in that system.
Depression is one area where I am a proponent of pharmacological intervention, despite the fact that I have come out against the pharmacological means to the end on some other diagnosis. It would appear to me that SSRI’s were made specifically for depression, success rates are relatively high, and side effects are minimal. I’m not sure I could consider TCAs and MAOIs unless SSRI+CBT failed. ECT is our last resort… but the degree of impairment would have to be pretty serious for me to suggest it.
Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.