Prevention of Depression in At-Risk Adolescents: Moderators of Long-term Response.

In a randomized controlled trial, we found that a cognitive behavioral program (CBP) was significantly more effective than usual care (UC) in preventing the onset of depressive episodes, although not everyone benefitted from the CBP intervention. The present paper explored this heterogeneity of response. Participants were 316 adolescents (M age = 14.8, SD = 1.4) at risk for depression due to having had a prior depressive episode or having current subsyndromal depressive symptoms and having a parent with a history of depression. Using a recursive partitioning approach to baseline characteristics, we (Weersing et al. 2016) previously had identified distinct risk clusters within conditions that predicted depressive episodes through the end of the continuation phase (month 9). The present study used the same risk clusters that had been derived in the CBP group through month 9 to reclassify the UC group and then to examine group differences in depression through month 33. We found that in this overall very high-risk sample, the CBP program was superior to UC among youth in the low-risk cluster (n = 33), characterized by higher functioning, lower anxiety, and parents not depressed at baseline, but not in the middle (n = 95) and high-risk (n = 25) clusters. Across conditions, significantly more depression-free days were found for youth in the low-risk cluster (M = 951.9, SD = 138.8) as compared to youth in the high-risk cluster (M = 800.5, SD = 226.7). Identification of moderators, based on purely prognostic indices, allows for more efficient use of resources and suggests possible prevention targets so as to increase the power of the intervention.

Impact of severity and chronicity of parental affective illness on adaptive functioning and psychopathology in children.

We report on the impact of specific indexes of the severity and chronicity of parental depression, measures of familial discord, and demographic variables as predictors of impaired adaptive functioning and psychopathology in children. Seventy-two children and their mothers from 37 families were interviewed in person. At least one biological parent in each family had a depressive disorder but neither parent had a history of mania, schizophrenia, or schizoaffective disorder. Almost every measure of severity and chronicity of depression in the biological parents has a statistically significant association with currently impaired adaptation and the presence of a DSM-III-diagnosed disorder in the children, as do the measures of increased discord among married or separated parents. Depression in the mother is more strongly associated with increased psychopathology in the children than is depression in the father.

Prevention of childhood depression: recent findings and future prospects.

Traditionally, research on childhood mood disorders has focused on clinical trials and longitudinal course and outcome studies, rather than on prevention. Recently, however, advances in the design, methodology, and evaluation of prevention approaches and progress in understanding what factors predispose children to depression have made possible the development of theoretically driven, empirically justified approaches to the prevention of depression in youngsters who are at high risk, either because of elevated symptom levels or parental mood disorder. In this review, we outline recent empirical findings on risk factors for depression in nonreferred samples of youngsters and also in children of depressed parents. Additionally, we review three trials of preventive interventions for childhood depression that yield promising initial findings. We emphasize the need to understand both risks for depression and factors that protect youngsters at risk from succumbing to depression in guiding the development of prevention programs. We also argue that consideration of prevention of depression requires addressing broader social adversity influences that lead to poor mental health outcomes in children, even beyond the effects of parental mood disorder. We conclude with an emphasis on the importance of a developmental-transactional perspective that highlights opportunities for intervention at different points across the lifespan.

Increased orbitofrontal cortex levels of choline in depressed adolescents as detected by in vivo proton magnetic resonance spectroscopy.

BACKGROUND: The frontal lobe has been implicated in the pathology of depression in adults. Through the use of magnetic resonance spectroscopy, altered brain choline levels have also been linked to the pathophysiology of affective disorders. METHODS: To identify possible alterations in orbitofrontal cortex levels of cytosolic choline in adolescents with and without depression, 22 depressed and 43 control adolescents were recruited. Of those recruited, usable proton magnetic resonance spectra were acquired from a voxel in the left anterior medial frontal lobe of 17 depressed (mean age 15.8+/-1.6) and 28 healthy adolescents (mean age 14.5+/-1.7). RESULTS: Orbitofrontal cytosolic choline/creatine (Cho/Cr) ratios (p =.032) and cytosolic choline/N-acetyl aspartate (Cho/NAA) ratios (p =.043) were significantly higher in the depressed subjects than in the control subjects. There were no significant differences between depressed and control subjects in gray or white matter content within the voxel. CONCLUSIONS: These findings suggest that brain cytosolic choline may be increased in depressed adolescents in comparison with control subjects and independent of a corresponding structural change. These results are consistent with similar, previously reported findings in adults and suggest that depression in adolescents is associated with alterations in orbitofrontal metabolism.

Resilient adolescents whose parents have serious affective and other psychiatric disorders: importance of self-understanding and relationships.

Eighteen young men and women whose parents had major affective disorders, often in combination with other serious psychiatric disorders, were selected from a larger sample on the basis of their good behavioral functioning as adolescents at initial assessment. When they were reassessed an average of 2 1/2 years later, 15 of the 18 were still functioning well. Considerable self-understanding, a deep commitment to relationships, and the ability to think and act separately from their parents characterized these young people. Many of them were taking care of their ill parents. The implications of these findings for preventive and clinical intervention are discussed.

Children of parents with major affective disorder: a review.

The authors review published studies of the children of parents with major affective disorder and report the rates of diagnosable disorder in the children, their clinical symptoms and other behavioral disturbances, and the differing impact of parental illness at different ages and stages of development. There is significant risk to children in having parents with major affective disorder, and considerable impairment is evident in these children. The authors discuss the methodological issues in the studies and offer suggestions for future investigations.

Initial findings on preventive intervention for families with parental affective disorders.

OBJECTIVE: The purpose of this study was to develop a clinician-based cognitive, psychoeducational, preventive intervention for families with parental affective disorder that would be suitable to widespread use, test its feasibility and safety, and define the areas affected by the intervention. The intervention was designed to increase understanding of parental illness and resilience in the children. METHOD: The authors studied the first seven families (14 parents) to receive the intervention. Enrollment criteria included affective disorder during the preceding year in at least one parent, presence of at least one child between the ages of 8 and 14 years who was not psychiatrically ill at the time of participation, and willingness to participate in the research study. The intervention consisted of parent, child, and family sessions. Assessment included semistructured interviews with parents about affective disorders, standard ratings of marital satisfaction and therapeutic alliance, and a recently developed semistructured interview to assess response to the intervention. RESULTS: Overall satisfaction with the intervention was rated moderate to high by parents. No harm was reported. Ten of 14 parent subjects reported five or more behavior and attitude changes that they attributed to the intervention. The most frequent behavior and attitudinal changes reported were increased discussion of the illness and related issues and increased understanding of information about affective illness. CONCLUSIONS: The authors conclude that the intervention is safe and feasible in families with parental affective disorder.

But are they cases? Validity of DSM-III major depression in children identified in a family study.

The authors examine the validity of the diagnosis of major depression in nine children and adolescents assessed as part of a study of offspring of parents who had affective disorders. The authors conclude that these nine children were suffering from valid cases of affective disorder because disruptions in multiple domains of functioning accompanied the major depression. The seriousness of the impairment and the finding that few of these children received any treatment at all strongly suggest the need for a heightened awareness among clinicians about the seriousness of depression in children whose parents have affective disorders.

Sustained change in parents receiving preventive interventions for families with depression.

OBJECTIVE: The purpose of this study was to compare the sustained effects of two cognitive, psychoeducational preventive interventions for families in which a parent had an affective disorder. METHOD: Thirty-seven families, in which there was a child between the ages of 8 and 15 years (mean = 11.5 years) and at least one parent who had experienced a recent episode of affective disorder according to the Research Diagnostic Criteria, were studied 1.5 years after enrollment in the study. The families were randomly assigned to one of two interventions, clinician-facilitated or lecture. The two interventions were similar in content but differed in the degree of involvement of the children and the linking of information to the families' life experiences. Nineteen families participated in the clinician-facilitated intervention, which consisted of six to 10 sessions. Eighteen families were assigned to the lecture condition, which consisted of two lectures attended only by parents. Family members were interviewed both before and after the interventions with diagnostic interviews and semistructured measures designed to assess response to the interventions. RESULTS: Sustained effects of the interventions were reported 1.5 years after enrollment. The clinician-facilitated intervention was associated with more positive self-reported and assessor-rated changes than the lecture intervention. CONCLUSIONS: These short-term preventive interventions, particularly the clinician-facilitated one, have long-term benefits for families with parental affective disorder.

Childhood abuse and lifetime psychopathology in a community sample.

OBJECTIVE: The authors assessed lifetime psychopathology in a general population sample and compared the rates of five psychiatric disorder categories between those who reported a childhood history of either physical or sexual abuse and those who did not. METHOD: A modified version of the Composite International Diagnostic Interview and a self-completed questionnaire on child abuse were administered to a probability sample (N=7,016) of Ontario residents 15 to 64 years of age. RESULTS: Those reporting a history of childhood physical abuse had significantly higher lifetime rates of anxiety disorders, alcohol abuse/dependence, and antisocial behavior and were more likely to have one or more disorders than were those without such a history. Women, but not men, with a history of physical abuse had significantly higher lifetime rates of major depression and illicit drug abuse/dependence than did women with no such history. A history of childhood sexual abuse was also associated with higher rates of all disorders considered in women. In men, the prevalence of disorders tended to be higher among those who reported exposure to sexual abuse, but only the associations with alcohol abuse/dependence and the category of one or more disorders reached statistical significance. The relationship between a childhood history of physical abuse and lifetime psychopathology varied significantly by gender for all categories except for anxiety disorders. Although not statistically significant, a similar relationship was seen between childhood history of sexual abuse and lifetime psychopathology. CONCLUSIONS: A history of abuse in childhood increases the likelihood of lifetime psychopathology; this association appears stronger for women than men.

The effects of infantile malnutrition on behavioral development: a follow-up study.

Thirty-one children and young adults who had been severely malnourished in infancy due to intestinal disease, were compared with sibling controls for psychometric intelligence, academic performance as judged by teacher ratings, and developmental history as judged by parental questionnaires. Older members of the sample were also examined on the Lincoln-Oseretzky Motor Development Scale and by a brief psychiatric interview. There were no significant differences between patients and controls on any outcome measure. Furthermore, previously malnourished individuals were performing at or above age equivalent norms on all psychological tests. The findings suggest that the adverse behavioral effects of severe infantile malnutrition observed in children below the age of 5 yr are, to a large extent, compensated during development when the children are raised in supportive home and school environments.

Maternal depression: a concern for pediatricians.

Maternal depression is common in clinical experience but has not been fully addressed in the pediatric literature. Depression can refer to either depressive symptoms or a diagnosable depression. Depression among mothers occurs frequently, is persistent, and is related to other factors such as low social class and marital disharmony. Studies demonstrate an association between a mother's depression and adverse outcomes for her child including low birth weight, behavior problems, somatic complaints, poor growth, accidents, and affective illness. Affect and child-rearing characteristics of depressed mothers seem to be important factors in mediating these poor outcomes. Pediatricians have a special role in helping depressed mothers and their children.

Maternal expressed emotion and parental affective disorder: risk for childhood depressive disorder, substance abuse, or conduct disorder.

Expressed emotion (EE) refers to a set of emotional aspects of speech for which ratings have been derived. Seven independent studies have established that higher EE ratings in the relatives of patients with schizophrenia predict higher rates of relapse in these patients and two studies have established an association of higher EE in spouses with relapse of depression in their mate. There are no previous studies of parental EE as a predictor of childhood affective disorder or other disorders not in the schizophrenia spectrum. In this study we investigated the relationship between the level of maternal EE and the incidence of DSM-III affective disorder (major depression or mania or dysthymia), substance abuse, or conduct disorder in 273 children. We found that a higher degree of maternal expressed emotion was associated with a three-fold increase in a child's risk (odds multiplier) for having at least one of the following diagnoses: depressive disorder (major depression or dysthymia), substance abuse, or conduct disorder. This increased risk acts in addition to the increased risk of child diagnosis associated with parental affective illness. Research and clinical implications are discussed.

Children of affectively ill parents: a review of the past 10 years.

OBJECTIVE: To review the literature investigating the effects of parental affective illness on children over the past decade. METHOD: A computerized search of articles published over the past 10 years was completed. Articles were reviewed and relevant studies are presented. RESULTS: Over the course of the past 10 years a number of longitudinal studies have confirmed that children of affectively ill parents are at a greater risk for psychiatric disorders than children from homes with non-ill parents. Life table estimates indicate that by the age of 20 a child with an affectively ill parent has a 40% chance of experiencing an episode of major depression. Children from homes with affectively ill parents are more likely to exhibit general difficulties in functioning, increased guilt, and interpersonal difficulties as well as problems with attachment. Marital difficulties, parenting problems, and chronicity and severity of parental affective illness have been associated with the increased rates of disorder observed in these children. CONCLUSION: The presence of depression in parents should alert clinicians to the fact that their children also may be depressed and therefore in need of services. J. Am. Acad. Child Adolesc.

Adaptation of preventive interventions for a low-income, culturally diverse community.

OBJECTIVE: To describe essential elements in the adaptation of a prevention approach with a high-risk urban sample, chosen to contrast sharply with the primarily middle-class sample in which it had been originally tested. METHOD: Key elements of a preventive intervention for families with parental depression were adapted for use in the new context. RESULTS: A sequence of alliance-building events was implemented, involving engagement at three levels: community, caregivers, and family. The prevention approach was modified to include an expanded approach to defining depression and resilience; greater flexibility on the part of the clinician; more intensive engagement between clinician and family, with a focus on immediate daily concerns; as well as awareness of cultural issues and responsiveness to the subject's experience of violence. CONCLUSION: Core principles of helping family members to discuss the effects of depression and adversity on family life were affirmed.

Response of families to two preventive intervention strategies: long-term differences in behavior and attitude change.

OBJECTIVE: To explore the long-term impact of two forms of preventive intervention designed to diminish risk to children in families in which one or both parents suffered from affective disorder. METHOD: Fifty-four parents in 18 families were initially assessed and randomly assigned to one of two interventions--a clinician-facilitated, manual-based, psychoeducational preventive intervention or a standardized lecture-group discussion in which similar educational information was presented. Assessments included standard diagnostic interviews, child behavior scales, and semistructured interviews with parents about the effects of the intervention. Follow-up assessments were conducted three times over the 3-year follow-up interval. RESULTS: No harmful effects were reported for either intervention, and ratings of degree of upset about reported concerns declined across time for both conditions. Families receiving the clinician-facilitated intervention reported more behavior and attitude changes than did lecture-group families when assessed after intervention. The difference between the two groups was sustained at further follow-up assessments. CONCLUSION: Although both preventive interventions produced changes in behaviors and attitudes, parents in the clinician-facilitated intervention reported more benefit. These data support the hypothesis that linking cognitive information to the family's life experience produces long-term changes.

The impact of parental affective disorder on depression in offspring: a longitudinal follow-up in a nonreferred sample.

OBJECTIVE: This study explored the effects of parental affective disorder on offspring in a nonreferred health maintenance organization 4 years after initial examination. METHOD: The sample, average age 18.5 years, included 91% of the 153 youngsters initially studied. The main instruments were structured diagnostic interviews scored according to criterion systems for both parents and children; assessment of the youngsters was blind to the previous assessment. RESULTS: Rates of major depressive disorder were higher in the children of parents with affective disorder (26%) compared with those whose parents had no disorder (10%). CONCLUSION: Depression and other parental affective disorders, as they occur in the community in parents who often are neither recognized nor treated, are associated with serious affective disorder in offspring. Clinical and preventive approaches for these offspring are needed and should be targeted to all families in which there is serious parental affective disorder, not just those who present for psychiatric treatment.

Chronic course of anxiety disorders in children and adolescents.

In a naturalistic study that assessed the lifetime psychiatric histories of 275 children ascertained independently of diagnostic or treatment-seeking behavior, 38 (14%) of the children had a history of anxiety disorder. Rates of comorbidity of depression and other psychiatric disorders were high. Life table estimates of the duration of illness indicate a more protracted time to recover than expected, because 46% would be ill for at least 8 years. Moreover, of those who recovered from their first episode of anxiety disorder, many had experienced recurrence before interview. After conducting pooled analyses, investigators performed separate analyses for children with separation disorder and overanxious disorder. Median age of onset of these conditions was surprisingly young: 10 years of age for overanxious disorder and 8 years of age for separation disorders.

Psychiatric outcome of burned children and adolescents.

Recent medical and surgical advances allow many severely burned patients to survive who formally would have died. Assessment of psychiatric outcomes with these patients may provide ways of measuring effects of acute burn care methods on later quality of life, specify more accurately their emotional needs during rehabilitation, and stimulate further research. Thirty children, aged 7 to 19, with severe burns are compared with 30 nonburned subjects matched for age, sex, SES, and parents' marital status according to DSM-III criteria. The burned children had significantly higher levels of overanxious disorder, phobias, and enuresis, but they had the same rates of present depressive disorders.

Comparison of preventive interventions for families with parental affective disorder.

Twenty families participated in a random assignment trial of two cognitive psychoeducational preventive interventions for families with parental affective disorder. Twelve families were assigned to a clinician-based intervention and eight to a lecture-based intervention, with assessment prior to intervention and an average of 18 weeks following intervention. Both groups were satisfied and believed they received help from the intervention. The clinician-based group was significantly more satisfied overall, and reported significantly more changes in both behaviors and attitudes about their illness from pre- to postintervention. Both groups showed significant decrease in degree of upset over issues of concern from pre- to postintervention. The clinician-based group reported receiving significantly more help with their primary concern. The implications of these findings are discussed.