Depression in Childhood and Early Adolescence: Parental Expressed Emotion and Family Functioning.

Across development depression is associated with impairments in interpersonal and family functioning. In turn, these impairments may predict a more negative depression course and outcome. This study examined family functioning and parental Expressed Emotion (EE) among depressed youth during middle childhood and early adolescence and their relationship to demographic and clinical factors. Data were drawn from pretreatment evaluations of 132 depressed youth ages 7-14 and their families enrolled in a randomized clinical trial comparing family to individual treatment for youth depressive disorders. Families completed semi-structured diagnostic interviews, self-report measures of family functioning, and the Five Minute Speech Sample EE measure. High parental EE was more common in one-parent, as opposed to two-parent families, and early adolescent youth were more likely than pre-adolescent youth to have high critical EE parents. Severity and chronicity of child depression, child comorbidity, functional impairment, and maternal depressive symptoms were not associated with parental EE. Parental high EE overall and critical EE in particular were associated with reports of higher conflict and lower cohesion by both parents and children when compared to low parental EE. Similar patterns of associations were evident for youth across pre-adolescent and early adolescent developmental periods. Single parent status may be an indicator of greater family stress; and higher levels of critical EE may reflect the higher levels of parent-child conflict characteristic of the transition from late childhood to early adolescence. Among youth with depression parental EE appears to reflect potentially important impairments in family functioning.

Affective disorders in children and adolescents: addressing unmet need in primary care settings.

Affective disorders are common among children and adolescents but may often remain untreated. Primary care providers could help fill this gap because most children have primary care. Yet rates of detection and treatment for mental disorders generally are low in general health settings, owing to multiple child and family, clinician, practice, and healthcare system factors. Potential solutions may involve 1) more systematic implementation of programs that offer coverage for uninsured children; 2) tougher parity laws that offer equity in defined benefits and application of managed care strategies across physical and mental disorders; and 3) widespread implementation of quality improvement programs within primary care settings that enhance specialty/primary care collaboration, support use of care managers to coordinate care, and provide clinician training in clinically and developmentally appropriate principles of care for affective disorders. Research is needed to support development of these solutions and evaluation of their impacts.

Depression in youth: psychosocial interventions.

Witnessed over the past 20 years are major advances in knowledge regarding depression in children and adolescents. Although additional research is needed, clinicians can now turn to treatment strategies with demonstrated efficacy. In this article we review the literature on psychosocial interventions for depression in youth and offer a working model to guide the treatment of depressed youth. We begin with a brief overview of the model, followed by a review of the treatment efficacy and prevention literatures. We offer some caveats that impact the ability to move from this treatment literature to the real world of clinical practice. We conclude by considering how extant research can inform treatment decisions and highlight critical questions that need to be addressed through future research.

Is expressed emotion a specific risk factor for depression or a nonspecific correlate of psychopathology?

Five Minute Speech Sample Expressed Emotion (FMSS-EE) was examined in families of youth with depressive disorders, nondepressed youth with attention deficit/hyperactivity disorder (ADHD), and community controls screened for the absence of depression and ADHD. Consistent with the hypothesis that FMSS-EE shows some specificity as a risk factor for depression, rates of critical EE were significantly higher among mothers of youth with depression as compared to mothers of nondepressed youth with ADHD, or mothers of controls. When both mothers' and fathers' scores were used to generate family EE ratings, rates of overall EE and critical EE were significantly higher for the depressed group than the control group, but the nondepressed ADHD group did not differ significantly from the other groups. Results support the hypothesis that critical EE in mothers shows some specificity as a risk factor or correlate of depression in youth.

Social adjustment of adolescents at risk for schizophrenia: the Jerusalem Infant Development Study.

OBJECTIVE: To better understand whether poor social adjustment, a core characteristic of schizophrenic illness, may also be an indicator of vulnerability in young people who are at genetic risk for schizophrenia, but who do not have schizophrenia. METHOD: Between 1992 and 1996, 27 Israeli adolescents with a schizophrenic parent, 29 adolescents with no mentally ill parent, and 30 adolescents with a parent having a nonschizophrenic mental disorder were assessed on multiple domains of social adjustment measured using the Social Adjustment Inventory for Children and Adolescents and the Youth Self-Report. RESULTS: Young people with a schizophrenic parent showed poor peer engagement, particularly heterosexual engagement, and social problems characterized by immaturity and unpopularity with peers. These social adjustment difficulties in youths at risk for schizophrenia could not be attributed solely to the presence of early-onset mental disorders, although problems were greater in those with disorders in the schizophrenia spectrum. Young people whose parents had other disorders showed different patterns of social maladjustment characterized by difficult, conflictual relationships with peers and family. CONCLUSION: Adolescents at risk for schizophrenia have social deficits that extend beyond early-onset psychopathology and that may reflect vulnerability to schizophrenic disorder.

Family interaction styles of children with depressive disorders, schizophrenia-spectrum disorders, and normal controls.

Family interaction processes during a problem-solving task were examined in children with depressive disorders, children with schizophrenia-spectrum disorders, and a normal control group of community children screened for the absence of psychiatric disorder. Major findings were: a) children with depressive disorders were more likely than children with schizophrenia-spectrum disorders and children with no psychiatric disorder to direct guilt-inducing comments toward their parents; and b) parents of children with schizophrenia-spectrum disorders were more likely to direct harsh critical comments toward the child than were parents of depressed children or parents of normal controls. In addition, children's and mothers' use of benign criticism was linked, while children's harsh criticism was associated with intrusion from the father, and children's self-denigrating comments were related to specific paternal criticism. Implications of these results for understanding transactional processes associated with childhood-onset depressive and schizophrenia-spectrum disorders are discussed.

Evidence that the dopamine D4 receptor is a susceptibility gene in attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) is a common neurobehavioral problem afflicting 5-10% of children and adolescents and persisting into adulthood in 30-50% or more of cases. Family, twin, and adoption studies suggest genetic factors contribute to ADHD and symptoms of inattention, impulsivity, and hyperactivity. Because stimulant intervention is effective in reducing ADHD symptoms in about 70-80% of cases, molecular genetic investigations of genes involved in dopamine regulation are currently underway by many groups. In a case control study of the dopamine D4 receptor gene (DRD4) and ADHD, La Hoste and colleagues found an increase of a 7-repeat variant of a 48-bp VNTR in exon 3 among ADHD subjects compared to controls. Swanson and colleagues replicated this finding in a sample of 52 ADHD probands and their biological parents using a haplotype relative risk analysis. Here, we describe linkage investigations of the VNTR and ADHD in affected sibling pair (ASP) families and singleton families using both the transmission disequilibrium test (TDT) and a mean test of identity-by-descent (IBD) sharing. Using the TDT in the total sample, the 7 allele is differentially transmitted to ADHD children (P = 0.03) while the mean test revealed no evidence of increased IBD sharing among ASPs. In the current sample, the 7 allele attributes a 1.5-fold risk for developing ADHD over non-carriers of the allele estimated under a model described by Risch and Merikangas.

Psychological distress and treatment adherence among children on dialysis.

Among 23 pediatric renal dialysis patients, we obtained self-reported assessments of psychological adjustment and biochemical and subjective ratings of adherence. Findings indicate elevated levels of depressive symptoms and substantial nonadherence. Depressive symptoms were associated with higher levels of hopelessness, more negative self-perceptions, and more depressogenic attributional style. The psychological adjustment measures did not significantly correlate with adherence. Nonsignificant associations among different measures of adherence underscore its multifaceted nature. Implications for monitoring the adjustment of children on dialysis, assessing adherence, and future research are discussed.

Children with schizophrenia-spectrum disorders: thought disorder and communication problems in a family interactional context.

Thought disorder and communication patterns during an interactional task were examined in families of children with schizophrenia-spectrum disorders (schizophrenia and schizotypal personality disorder), depressed children, and normal controls. Children with schizophrenia-spectrum disorders showed significantly more thought disorder than their normal peers; levels of thought disorder among depressed children fell between those observed in the other two groups but did not differ significantly from either of them. Similarly, mothers of children with schizophrenia-spectrum disorders showed more thought disorder than mothers of normal control children but did not differ from mothers of depressed children. Children with schizotypal personality disorder did not differ from children with schizophrenia. These findings demonstrate that the thought disorder present in childhood-onset schizophrenia and schizotypal personality disorders is manifest in an important social context, the family.

Psychiatric comorbidity in children after the 1988 earthquake in Armenia.

OBJECTIVE: To determine current rates of posttraumatic stress disorder (PTSD), depressive disorder, and separation anxiety disorder (SAD) among children 1 1/2 years after the 1988 earthquake in Armenia; to determine current rates of comorbid PTSD and depressive disorder; and to assess the contribution of exposure, gender, loss of family members, and loss of residence. METHOD: Two hundred eighteen school-age children from three cities at increasing distances from the epicenter were evaluated using the Child Posttraumatic Stress Disorder Reaction Index, the Depression Self-Rating Scale, and the section on SAD from the Diagnostic Interview for Children and Adolescents. RESULTS: On the basis of these evaluations, high rates of current PTSD, depressive disorder, and their co-occurrence were found among victims residing in the two heavily impacted cities. SAD was comparatively less frequent, although symptoms of SAD had been pervasive throughout the region. Severity of posttraumatic stress and depressive reactions were highly correlated. Extent of loss of family members was independently correlated with each. CONCLUSION: After a catastrophic natural disaster, children are at risk for comorbid PTSD and secondary depression. Based on the findings, an interactive model is proposed of postdisaster psychopathology. Early clinical intervention is recommended to prevent chronic posttraumatic stress reactions and secondary depression.

Family-expressed emotion, childhood-onset depression, and childhood-onset schizophrenia spectrum disorders: is expressed emotion a nonspecific correlate of child psychopathology or a specific risk factor for depression?

Expressed emotion (EE) was examined, using the brief Five Minute Speech Sample measure, in families of (1) children with depressive disorders, (2) children with schizophrenia spectrum disorders, and (3) normal controls screened for the absence of psychiatric disorder. Consistent with the hypothesis of some specificity in the association between EE and the form of child disorder, rates of EE were significantly higher among families of depressed children compared to families of normal controls and families of children with schizophrenia spectrum disorders. Within the depressed group, the presence of a comorbid disruptive behavior disorder was associated with high levels of critical EE, underscoring the need to attend to comorbid patterns and subtypes of EE in future research.

Childhood-onset schizophrenia: editors' introduction.

Descriptions of various psychotic symptoms in children began to appear in the psychiatric literature at about the same time as descriptions of psychotic symptoms in adults. For example, Kraepelin estimated that at least 3.5 percent of his cases of dementia praecox had onsets before age 10. The construct of "childhood schizophrenia" initially emerged from attempts to classify a broad range of psychotic children. By the late 1940s and 1950s, the diagnosis of "childhood schizophrenia" was given to many disturbed children who today would be considered to have infantile autism and other developmental disabilities. In the early 1970s infantile autism and its variants was differentiated from schizophrenia of childhood onset. These changes were incorporated in DSM-III, which returned to the practice before 1930 of diagnosing schizophrenia in children using the same criteria as for adults, with minor allowances for differences in the manifestations of these symptoms during childhood. The studies presented in this issue of Schizophrenia Bulletin use DSM-III, DSM-III-R, or ICD-9 criteria for schizophrenia.

Childhood-onset schizophrenia: a followup study.

This article is an overview of our studies of childhood-onset schizophrenia. Data are presented demonstrating that (1) the majority of the sample showed continuing schizophrenia as they progressed through adolescence; (2) there was considerable variability in outcome, defined by global adjustment scores, with 56 percent of the sample showing improvement in functioning during a 2- to 7-year followup period and the other 44 percent showing minimal improvement or a deteriorating course; (3) schizophrenia in childhood could be diagnosed by the same criteria used for adults and was associated with severe dysfunction; and (4) some intrafamilial attributes found to be associated with schizophrenia in adults were also associated with schizophrenia in children, but there were some differences in the family environmental correlates of childhood- and later-onset schizophrenia. These data are consistent with the hypothesis that childhood- and later-onset schizophrenia represent the same illness or illnesses. Additional research is needed, however, to clarify the etiologic and clinical significance of the atypical early onset in childhood cases.

The science of prevention. A conceptual framework and some directions for a national research program.

A conceptual framework for studying the prevention of human dysfunction is offered. On the basis of recent advances in research on the development of psychological disorders and methods of preventive intervention, generalizations about the relation of risk and protective factors to disorder are put forward, along with a set of principles for what may be identified as the science of prevention. Emerging themes from the study of human development, in general, need to be incorporated in the models for explaining and preventing serious problems of human adaptation. The article concludes with a set of recommendations for a national prevention research agenda.

One-year outcomes of depressive disorders in child psychiatric in-patients: evaluation of the prognostic power of a brief measure of expressed emotion.

The association between 1-year post-hospitalization outcome and the brief Five Minute Speech Sample (FMSS) measure of expressed emotion (EE) was examined among children with depressive disorders. Results indicated a strong association between 1-year outcome and the FMSS-EE measure. Whereas children returning to high EE homes were likely to show persistent mood disorder, recovery was more common among children returning to low EE homes. This predictive relationship was independent of possible mediating variables such as treatment regimen and clinical characteristics. Results provide the first reported demonstration that (1) the brief FMSS-EE measure predicts clinical outcome, and (2) EE measures predict 1-year outcome for children with depressive disorders.

Coping and stress in families of child psychiatric inpatients: parents of children with depressive and schizophrenia spectrum disorders.

Coping and disruption were examined in parents of children with depressive and schizophrenia spectrum disorders. Parents described disruption in their family lives, relationships, leisure time, and work functioning. High maternal disruption was associated with the absence of intimate relationships and child chronicity. Parents most frequently reported using active cognitive coping strategies, but with the advantage of hindsight, advised seeking community resources for helping their children.