Depression in Children and Adolescents: Linking Risk Research and Prevention

doi:10.1016/j.amepre.2006.07.007

American Journal of Preventive Medicine

Volume 31, Issue 6, Supplement 1, December 2006, Pages 104-125

https://doi.org/10.1016/j.amepre.2006.07.007 Get rights and content

Abstract

The National Institute of Mental Health has called for translational research linking basic knowledge about vulnerabilities that underlie mood disorders to the development of effective preventive interventions. This paper highlights research about risk factors for depression in children and adolescents and links it to current knowledge about interventions aimed at preventing depression in youth. Basic epidemiologic and clinical research indicates that increased risk for depression is associated with being female; a family history of depression, particularly in a parent; subclinical depressive symptoms; anxiety; stressful life events; neurobiological dysregulation; temperament/personality (e.g., neuroticism); negative cognitions; problems in self-regulation and coping; and interpersonal dysfunction. These vulnerabilities both increase individuals’ chances of encountering stress and decrease their ability to deal with the stress once it occurs. Although several existing depression-prevention studies have targeted one or more of these risk factors, the efficacy of these various prevention programs for youth with different combinations of these risk factors needs to be investigated further. Most existing depression-prevention programs in youth have used cognitive–behavioral techniques, with some success. Other depression-prevention strategies have included training in coping, social problem solving, social skills, communication skills, and parenting. A comprehensive prevention program is recommended that includes multiple intervention components, each of which addresses risk and protective factors across different domains and levels of analysis.

Introduction

The “road map” outlined by the National Institutes of Health¹ calls for translational research that enhances bi-directional communication between basic science and clinical application. New knowledge discovered by basic researchers then should be used to develop interventions that can prevent or reduce the suffering of individuals with mental disorders. In turn, clinical trials testing the efficacy of these interventions can be used to provide further insights into the mechanisms underlying and maintaining the disorders.

Regarding depression in particular, the National Institute of Mental Health (NIMH) Strategic Plan for Mood Disorders Research² stated that research that provides a “detailed account of how cognitive, behavioral, and affective vulnerabilities influence the onset and prolongation of mood disorders can contribute to the development of effective preventive interventions.” In addition, prevention trials can “provide an opportunity to test theories regarding the mechanisms that lead to onset and the strategies that avert it.” Thus, developmental theory and basic research should guide the design of prevention trials, which then should generate results that can be used to inform and revise the theory.³

The distinction between risk factors and causal risk mechanisms4, 5, 6 is relevant to the present discussion. Risk factors are antecedents that increase the probability of an outcome over the population base rate. They do not, however, explain the processes through which these factors influence the likelihood of the condition. In contrast, risk mechanisms describe the intervening paths that link the risk factor to the outcome of interest. Altering these mechanisms will affect the likelihood of the condition. Indeed, these are the processes that interventions aim to affect. In addition, fixed markers are risk factors that are not considered changeable (e.g., gender, genotype), although they may influence more proximal risk factors that can be altered (e.g., responses to stress, levels of neurotransmitters). Variable markers change (e.g., age) or can be changed.⁵ With regard to depression in particular, potential risk factors include such fixed markers as gender7, 8 and genes,9, 10 and such variable markers as parental depression,11, 12 anxiety,13, 14 subsyndromal levels of depressive symptoms,15, 16 neurobiological dysregulation,17, 18 temperament/personality,19, 20 negative cognitions,21, 22 problems in self-regulation and coping,²³ stressful life events,24, 25 and interpersonal difficulties.26, 27 These variables have been particularly linked with subsequent depression, although this list is not exhaustive.

Depression has a complex, multifactorial causal structure. Therefore, it is unlikely that any one risk factor will explain its development, nor will reducing the chances of the occurrence of a single risk factor be sufficient to prevent depression. Rather, it is more likely that the accumulation28, 29 and/or interaction among multiple risk factors30, 31 will lead to depression.

The present paper highlights basic research findings on depression in youth to identify who is at risk and therefore should be targeted for prevention, and notes potential mechanisms of risk, which can inform the content of such programs. Studies testing the efficacy of depression-prevention programs have varied with regard to which, if any, of these risk factors they have targeted. Appendix A outlines several risk factors, basic findings, and relevant prevention programs. Appendix B provides descriptive information about these prevention programs categorized by the populations to whom the interventions were directed.³² Whereas universal preventive interventions are administered to all members of a target population, selective programs are provided to a subsample who are at above average risk, and indicated prevention is given to individuals who manifest subclinical signs or symptoms of the disorder. (For a review of depression-prevention studies in children and adolescents, see a recent meta-analysis.³³)

Section snippets

Gender

Being female is significantly associated with depression in adolescents and adults. Prior to adolescence, the rate of depressive disorders is about equal in girls and boys,34, 35 or even higher among boys36, 37; during early to middle adolescence, the rate of depressive symptoms and disorders in girls rises to two to three times that of boys.7, 38 Explanations for this gender difference have included hormonal changes, increased stress, differences in interpersonal orientation, tendencies toward

Genes

Depression clearly is familial,11, 54 but family data alone cannot distinguish environmental from genetic causes of the transmission of depression across relatives. Family, twin, and adoption studies have provided evidence of both genetic and environmental effects for unipolar depression.9, 10 Estimates of heritability of depressive symptoms tend to be moderate, although these estimates vary as a function of informant, age, and severity of depressive symptoms.55, 56 Nonshared environmental

Offspring of Depressed Parents

Parental depression is one of the strongest risk factors for depression in children, which likely is the result of both genetic and environmental influences.11, 12 Compared to children of nondepressed parents, offspring of depressed parents are about three to four times more likely to develop a mood disorder,⁷² and are at increased risk for high levels of medical utilization, other internalizing disorders, behavior and school problems, suicide attempts, substance abuse disorders, and lower

Subsyndromal Depression

Subsyndromal levels of depressive symptoms significantly increase risk of having a full major depressive episode in adults,15, 16 adolescents,86, 87 and children.⁸⁸ For example, in a prospective study, Pine et al.⁸⁷ showed that a difference of two standard deviations from the mean in depressive symptoms predicted a two- to three-fold greater risk of an episode of major depression in adulthood; the symptoms of anhedonia and thoughts of death were particularly predictive of subsequent depressive

Anxiety

Anxiety is the most common comorbid disorder with depression, with estimates ranging from 30% to 75% in preadolescents and between 25% and 50% in adolescents.13, 51, 94 There also is increasing evidence that anxiety precedes the onset of mood disorders and thus might be a risk factor for depression.94, 95, 96, 97 Therefore, children with anxiety also should be targeted for depression-prevention programs.

Two studies have explicitly examined anxiety as a potential moderator of the effects of

Neurobiology

Psychobiological studies of depression in youth have focused on dysregulation in neuroendocrine and neurochemical systems, sensitization of biological stress mechanisms, and disturbances in sleep architecture.17, 101, 102 Studies of growth hormone, prolactin, and cortisol levels after pharmacologic stimulation in currently depressed, remitted, and at-risk youth have shown in all three groups abnormalities in the secretion of these hormones, such as blunted growth-hormone secretion after the

Temperament/Personality

Temperament is thought to have a genetic/biological basis, although experience and learning, particularly within the social context, also can influence its development and expression,¹¹⁴ and therefore interventions may be able to affect trait expression. Negative emotionality, the propensity to experience negative emotions, is conceptually related to negative affectivity,115, 116 neuroticism,¹¹⁷ the behavioral inhibition system,¹¹⁸ stress reactivity,¹¹⁹ “difficult temperament,”¹²⁰ behavioral

Negative Cognitions

Cognitive theories of depression assert that when confronted with stressful life events, individuals who have negative beliefs about the self, world, and future, and make global, stable, and internal attributions for negative events will appraise stressors and their consequences negatively, and hence are more likely to become depressed than are individuals who do not have such cognitive styles.21, 22 A growing convergence of evidence from correlational, predictive, and offspring studies

Stress

Considerable empirical evidence exists of a link between stressful life events and depression in children and adolescents.²⁵ The stress exposure model posits that individuals who have experienced stress will be more likely to become depressed than those who have not.¹⁶⁴ Support for this model has been provided by prospective studies showing that stress temporally precedes increases in depressive symptoms,165, 166 and the onset of depressive disorders in youth.167, 168 Interestingly, the

Responses to Stress

How individuals respond to stress can significantly affect their future adjustment and psychopathology. Several perspectives on coping with stress in children and adolescents have been suggested.135, 190, 191 Earlier theories differentiated between problem-focused and emotion-focused coping.¹⁹² Whereas problem-focused coping involves responses that act on the source of stress, emotion-focused coping involves attempts to palliate negative emotions that arise from a stressful event through such

Interpersonal Relationships

Two important findings emerge regarding the link between interpersonal vulnerability and depression. First, families with a depressed member tend to be characterized by problems with attachment, communication, cohesion, social support, childrearing practices, chronic criticism, harsh discipline, and inappropriately peer-like relationships.204, 205, 206 Moreover, low levels of parental warmth, high levels of maternal hostility, and escalating parent–adolescent conflict significantly predict

Summary and Future Directions

In summary, basic epidemiologic and clinical research has helped to identify who is at risk for developing depression, and thus who should be the target of prevention programs. Risk factors particularly associated with an increased likelihood of depression include being female, anxious, offspring of depressed parents, having subclinical levels of depressive symptoms, and being exposed to stress or trauma. The specific number, combination, or weighting of these or other risk factors for

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Risk and protective factors for depression: Implications for preventionDepression in Children and Adolescents: Linking Risk Research and Prevention

Abstract

Introduction

Section snippets

Gender

Genes

Offspring of Depressed Parents

Subsyndromal Depression

Anxiety

Neurobiology

Temperament/Personality

Negative Cognitions

Stress

Responses to Stress

Interpersonal Relationships

Summary and Future Directions

Clin Psychol Rev

Biol Psychiatry

Am J Prev Med

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Clin Psychol Rev

J Am Acad Child Adolesc Psychiatry

Behav Res Ther

Biol Psychiatry

J Am Acad Child Adolesc Psychiatry

Strategic plan and priorities

Breaking ground, breaking through: the strategic plan for mood disorders research

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

Am Psychol

Prevention and early intervention for depression in adolescence and early adult life

Eur Arch Psychiatry Clin Neurosci

Coming to terms with the terms of risk

Arch Gen Psychiatry

Development of depression from preadolescence to young adulthood: Emerging gender differences in a 10-year longitudinal study

J Abnorm Psychol

Gender differences in depression

Genetics of depression

Genetic epidemiology of major depression: review and meta-analysis

Am J Psychiatry

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

J Am Acad Child Adolesc Psychiatry

Risk for psychopathology in the children of depressed mothers: a developmental model for understanding mechanisms of transmission

Psychol Rev

Comorbidity of anxiety and depression in children and adolescents

Psychol Bull

The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders

Arch Gen Psychiatry

The role and clinical significance of subsyndromal depressive symptoms (SSD) in unipolar major depressive disorder

J Affect Disord

A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders

Arch Gen Psychiatry

Biological aspects of depression

Depression and personality

Temperament, stress reactivity, and coping: implications for depression in childhood and adolescence

J Clin Child Adolesc Psychol

Hopelessness depression: a theory-based subtype of depression

Psychol Rev

Depression: clinical, experiential, and theoretical aspects

Coping during childhood and adolescence: problems, progress, and potential

Psychol Bull

The effects of stressful life events on depression

Ann Rev Psychol

Stressors and child and adolescent psychopathology: measurement issues and prospective effects

J Clin Child Adolesc Psychol

Psychological aspects of depression: toward a cognitive–interpersonal integration

Protective factors in children’s responses to stress and disadvantage

Contributions of risk research to the design of successful interventions

Toward a comprehensive developmental model for major depression in women

Am J Psychiatry

Diathesis-stress theories in the context of life stress research: implications for the depressive disorders

Psychol Bull

The prevention of depressive symptoms in children and adolescents: a meta-analytic review

J Consult Clin Psychol

Prevalence of childhood and adolescent depression in the community

Br J Psychiatry

Effects of age and pubertal status on depression in a large clinical sample

Dev Psychopathol

DSM-III disorders in preadolescent children

Risk and protective factors for depression: Implications for prevention
Depression in Children and Adolescents: Linking Risk Research and Prevention