Family-Focused Treatment for Childhood Depression: Model and Case Illustrations

Longitudinal associations of depressive symptoms in father-mother-child triads: A cross-lagged panel network analysis

BACKGROUND

The current study aimed to test symptom-level associations underlying the concordance of depressive symptoms in father-mother-child triads. We used network analysis to examine central and bridge symptoms in the contemporaneous depressive network of triads and additionally assessed prospective relationships in temporal depressive networks.

METHODS

We included 881 father-mother-child triads with children aged 10 to 14 years from the China Family Panel Studies. Depressive symptoms were assessed by the short version of the Center for Epidemiologic Studies Depression Scale (CESD) across three different time points from 2012 to 2018. Contemporaneous and temporal networks (2012 → 2016 and 2016 → 2018) were estimated to examine the cross-sectional and longitudinal relationships between symptoms.

RESULTS

Within the contemporaneous network, "feeling depressed" was the most central symptom. Parental "could not get going" was identified as the bridge symptom across almost all cross-sectional networks. In the temporal network (2012 → 2016), fathers' symptoms were likely to influence mothers' symptoms. Over time (2016 → 2018), offspring symptoms (such as "could not get going") began to affect their parents. Certain symptoms were more influential than others: for instance, fathers' "could not get going" significantly predicted mothers' "bad life" and feeling that "everything was an effort" in 2016. Fathers' "could not get going" in 2016 significantly predicted children's "bad life" and "lack of happiness" in 2018.

LIMITATIONS

A self-reported scale other than clinical diagnosis was used to assess depressive symptoms.

CONCLUSIONS

The current study demonstrates that family members mutually influence each other in specific depressive symptoms. Therefore, family-based treatments that combat depression in youth should also involve both parents and target core depressive symptoms to disrupt the cycle of depression within the family context.

Evidence-Base Update of Psychosocial and Combination Treatments for Child and Adolescent Depression

OBJECTIVE

This evidence-based update (EBU) builds on three previous reviews (1998, 2008, 2017) sponsored by the Society of Clinical Child and Adolescent Psychology with the aim of evaluating the empirical support for psychosocial interventions for depression in youth.

METHOD

In the current review period (2014-2022), 25 randomized controlled trials (RCT) were identified: four in children and 21 in adolescents. Descriptive effect sizes and number-needed-to-treat (NNT) ratios were calculated for primary outcomes. Results were integrated with prior reviews, and cumulative evidence used to classify treatments as well-established, probably efficacious, possibly efficacious, or experimental. Published secondary analyses of predictors, moderators, and mediators were examined.

RESULTS

For adolescents, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT-A), CBT in combination with antidepressant medication, and collaborative care programs were all classified as well-established. The evidence was considerably weaker for children, with no treatments achieving well-established or probably efficacious status. New developments include greater exploration of parent- and family-mediated treatment models and increasing evidence on technology-assisted interventions. Data on predictors, moderators, and mediators continued to be focused on adolescent depression samples and drawn from a limited number of RCT datasets.

CONCLUSION

Since the prior EBU, there has been incremental progress in youth depression treatment research. There is an urgent need to: (a) develop innovative approaches to substantially improve on the modest effects seen in most RCTs, (b) expand the evidence base for children and other underserved groups, (c) craft evidence-based guidelines for choosing between interventions when multiple efficacious treatments do exist, and (d) address issues of treatment effectiveness and scalability to ameliorate the wide prevalence and high impact of depression in youth.

Relationships between family functioning, parenting and peer victimization in adolescent depression: A cross-sectional study

OBJECTIVE

Major depressive disorder (MDD) in adolescence is a prevalent mental health problem with a complex etiology and a rising incidence. The aim of the study investigated functioning of family, attitudes of parents, and peer victimization in adolescents with MDD and to compare those with healthy adolescents.

METHODS

The study was designed as a multi-center, cross-sectional, case-control study. 98 adolescents diagnosed with MDD and 99 healthy controls were recruited for the study. Beck depression inventory, parental attitude research instrument (PARI) tool, family assessment device (FAD), and multidimensional peer victimization scale (MPVS) were applied to all participants. Descriptive, correlational, and bivariate group comparisons were used in analyses.

RESULTS

The average ages of adolescents with MDD and control adolescents were 14.7 (S.D.=1.5) and 15.0 (S.D.=1.6) years, respectively. Females formed 74.5% of youth with MDD (vs. 70.3% of controls). The groups were similar in terms of socio-demographic features (all p>0.05). Adolescents with MDD had significantly elevated scores in FAD subscales except problem solving, PARI rejection of homemaking, marital conflict, and authoritarian subscales, and all MPVS subscales. Adolescents with MDD also displayed significant positive correlations between all MPVS subscales and FAD subscales except FAD problem-solving.

CONCLUSION

This cross-sectional, multi-center study suggests that family dysfunction and peer victimization may be higher in youth with MDD. Although cross-sectional design precludes evaluation of causality, it may be prudent to evaluate family functions as well as peer victimization of depressed youth.

Network dynamics of momentary affect states and future course of psychopathology in adolescents

BACKGROUND

Recent theories argue that an interplay between (i.e., network of) experiences, thoughts and affect in daily life may underlie the development of psychopathology.

OBJECTIVE

To prospectively examine whether network dynamics of everyday affect states are associated with a future course of psychopathology in adolescents at an increased risk of mental disorders.

METHODS

159 adolescents from the East-Flanders Prospective Twin Study cohort participated in the study. At baseline, their momentary affect states were assessed using the Experience Sampling Method (ESM). The course of psychopathology was operationalized as the change in the Symptom Checklist-90 sum score after 1 year. Two groups were defined: one with a stable level (n = 81) and one with an increasing level (n = 78) of SCL-symptom severity. Group-level network dynamics of momentary positive and negative affect states were compared between groups.

RESULTS

The group with increasing symptoms showed a stronger connections between negative affect states and their higher influence on positive states, as well as higher proneness to form 'vicious cycles', compared to the stable group. Based on permutation tests, these differences were not statistically significant.

CONCLUSION

Although not statistically significant, some qualitative differences were observed between the networks of the two groups. More studies are needed to determine the value of momentary affect networks for predicting the course of psychopathology.

Development and efficacy of a family-focused treatment for depression in childhood

BACKGROUND

Depression in childhood frequently involves significant impairment, comorbidity, stress, and mental health problems within the family. Family-Focused Treatment for Childhood Depression (FFT-CD) is a 15-session developmentally-informed, evidence-based intervention targeting family interactions to enhance resiliency within the family system to improve and manage childhood depression.

METHODS

We present the conceptual framework underlying FFT-CD, the treatment development process, the intervention strategies, a case illustration, and efficacy data from a recent 2-site randomized clinical trial (N = 134) of 7-14 year old children randomly assigned to FFT-CD or individual supportive psychotherapy (IP) conditions.

RESULTS

Compared to children randomized to IP, those randomized to FFT-CD showed higher rates of depression response (≥50% Children's Depression Rating Scale-Revised reduction) across the course of acute treatment (77.7% vs. 59.9%, t = 1.97, p = .0498). The rate of improvement overall leveled off following treatment with a high rate of recovery from index depressive episodes in both groups (estimated 76% FFT-CD, 77% IP), and there was an attenuation of observed group differences. By final follow-up (9 months post-treatment), one FFT-CD child and six IP children had suffered depressive recurrences, and four IP children attempted suicide.

LIMITATIONS

Without a no treatment control group it is not possible to disentangle the impact of the interventions from time alone.

CONCLUSIONS

While seldom evaluated, family interventions may be particularly appropriate for childhood depression. FFT-CD has demonstrated efficacy compared to individual supportive therapy. However, findings underscore the need for an extended/chronic disease model to enhance outcomes and reduce risk over time.

Randomized controlled trial of family-focused treatment for child depression compared to individual psychotherapy: one-year outcomes

OBJECTIVE

Childhood-onset depression is associated with increased risk of recurrent depression and high morbidity extending into adolescence and adulthood. This multisite randomized controlled trial evaluated two active psychosocial treatments for childhood depression: family-focused treatment for childhood depression (FFT-CD) and individual supportive psychotherapy (IP). Aims were to describe effects through 52 weeks postrandomization on measures of depression, functioning, nondepressive symptoms, and harm events.

METHODS

Children meeting criteria for depressive disorders (N = 134) were randomly assigned to 15 sessions of FFT-CD or IP and evaluated at mid-treatment for depressive symptoms and fully at roughly 16 weeks (after acute treatment), 32 weeks, and 52 weeks/one year. See clinicaltrials.gov: NCT01159041.

RESULTS

Analyses using generalized linear mixed models confirmed the previously reported FFT-CD advantage on rates of acute depression response (≥50% Children's Depression Rating Scale reduction). Improvements in depression and other outcomes were most rapid during the acute treatment period, and leveled off between weeks 16 and 52, with a corresponding attenuation of observed group differences, although both groups showed improved depression and functioning over 52 weeks. Survival analyses indicated that most children recovered from their index depressive episodes by week 52: estimated 76% FFT-CD, 77% IP. However, by the week 52 assessment, one FFT-CD child and six IP children had suffered recurrent depressive episodes. Four children attempted suicide, all in the IP group. Other indicators of possible harm were relatively evenly distributed across groups.

CONCLUSIONS

Results indicate a quicker depression response in FFT-CD and hint at greater protection from recurrence and suicide attempts. However, outcomes were similar for both active treatments by week 52/one year. Although community care received after acute treatment may have influenced results, findings suggest the value of a more extended/chronic disease model that includes monitoring and guidance regarding optimal interventions when signs of depression-risk emerge.

Indirect effect of parental depression on school victimization through adolescent depression

BACKGROUND

While a link between parental depression and adolescent school victimization is frequently hypothesized, studies on this association have shown mixed results. In addition, adolescent depression has been considered a potential psychosocial mechanism underlying the link between parental depression and adolescent school victimization. However, studies to support this proposition are lacking. This paper examines the direct effect of parental depression on adolescent victimization by peers and teachers in school as well as indirect effect through adolescent depression in an Asian context (Taiwan) and further examines differences in the interrelationships of parental depression, adolescent depression, and school victimization by peers and teachers across gender and school age groups.

METHODS

Data were obtained from a random sample of 2,419 students (grades 7-12) and their parents in one of the largest metropolitan areas in Taiwan.

RESULTS

Parental depression did not have a significant direct association with either type of school victimization. However, parental depression showed a significant indirect association with both types of school victimization through adolescent depression. These findings applied to both males and females and both junior and senior high school students.

LIMITATION

The study utilized cross-sectional data, and the findings cannot be used to build causal relationships.

CONCLUSION

Our findings provide empirical support that parental depression has indirect associations with school victimization by peers and teachers through adolescent depression. The results support the importance of including family-based approaches for depression targeting parents and adolescents in future victim intervention/prevention school programs.

Psychosocial risk factors associated with depressive symptoms among adolescents in secondary schools in mainland china: A systematic review and meta-analysis

BACKGROUND

The objective of the study is to systematically estimate the effect size of psychosocial risk factors for depressive symptoms among adolescents in secondary schools in mainland China.

METHOD

A literature search was conducted in both English and Chinese databases. This meta-analysis used a random-effects model to estimate the effect size.

RESULTS

Fifteen psychosocial risk factors were identified in a total of 164 articles. The results revealed the absolute value of effect size ranging from 0.16 to 0.43. Among them, poor parent-child communication (r = 0.43), negative life events (r = 0.40), academic pressure (r = 0.40), abuse (r = 0.33), poor family functioning (r = 0.33), bullying (r = 0.32), and poor family cohesion (r = 0.32) were associated with depression with a medium to large effect. Moderator analysis shows that grade, study quality, mean age, and gender were significant moderators of at least one factor for depression.

LIMITATIONS

Limitations included the heterogeneity which is largely unexplained, and the inability to investigate the interactions of different factors and to determine the direction of causal relationships between psychosocial factors and depression in the present meta-analysis.

CONCLUSIONS

This study suggests that family-related factors and school-related factors may be significantly associated with depressive symptoms in Chinese secondary school students. Further research is needed to develop effective strategies to modify these factors in depression prevention programmes.

Child and Adolescent Depression: A Review of Theories, Evaluation Instruments, Prevention Programs, and Treatments

Depression is the principal cause of illness and disability in the world. Studies charting the prevalence of depression among children and adolescents report high percentages of youngsters in both groups with depressive symptoms. This review analyzes the construct and explanatory theories of depression and offers a succinct overview of the main evaluation instruments used to measure this disorder in children and adolescents, as well as the prevention programs developed for the school environment and the different types of clinical treatment provided. The analysis reveals that in mental classifications, the child depression construct is no different from the adult one, and that multiple explanatory theories must be taken into account in order to arrive at a full understanding of depression. Consequently, both treatment and prevention should also be multifactorial in nature. Although universal programs may be more appropriate due to their broad scope of application, the results are inconclusive and fail to demonstrate any solid long-term efficacy. In conclusion, we can state that: (1) There are biological factors (such as tryptophan-a building block for serotonin-depletion, for example) which strongly influence the appearance of depressive disorders; (2) Currently, negative interpersonal relations and relations with one's environment, coupled with social-cultural changes, may explain the increase observed in the prevalence of depression; (3) Many instruments can be used to evaluate depression, but it is necessary to continue to adapt tests for diagnosing the condition at an early age; (4) Prevention programs should be developed for and implemented at an early age; and (5) The majority of treatments are becoming increasingly rigorous and effective. Given that initial manifestations of depression may occur from a very early age, further and more in-depth research is required into the biological, psychological and social factors that, in an interrelated manner, may explain the appearance, development, and treatment of depression.

A Randomized Clinical Trial Comparing Family-Focused Treatment and Individual Supportive Therapy for Depression in Childhood and Early Adolescence

OBJECTIVE

Despite the morbidity and negative outcomes associated with early-onset depression, few studies have examined the efficacy of psychosocial treatment for depressive disorders during childhood. Integrating family in treatment could have particularly salutary effects during this developmental period. This trial compared immediate posttreatment effects of family-focused treatment for childhood depression (FFT-CD) with those of individual supportive psychotherapy (IP) for children 7 to 14 years old with depressive disorders.

METHOD

Children were randomized to 15 sessions of FFT-CD (n = 67) or IP (n = 67) over 4 months. The primary treatment outcome was adequate clinical depression response, defined as at least a 50% decrease in score on the Children's Depression Rating Scale-Revised (CDRS-R). Additional outcomes included patient-centered outcomes (parent- and child-reported treatment satisfaction), remission (defined as CDRS-R score ≤28), change in continuous CDRS-R score, and change in child and parent reports of depressive and non-depressive symptoms and social adjustment.

RESULTS

Significant improvement was evident across groups for depressive and non-depressive symptoms, global response, and functioning and social adjustment. Compared with children randomized to IP, children randomized to FFT-CD showed higher rates of adequate clinical depression response (77.7% versus 59.9%; number needed to treat = 5.72; odds ratio 2.29; 95% CI 1.001-5.247; t = 1.97, p = .0498). Across treatments, families reported high satisfaction; compared with IP families, FFT-CD families reported greater knowledge and skills for managing depression. There were no significant differences between treatment arms on secondary outcomes.

CONCLUSION

Results support the value of psychosocial intervention, emphasize the important role that families play, and highlight the potential for FFT-CD for supporting recovery in children with depression. Clinical trial registration information-Systems of Support Study for Childhood Depression; http://clinicaltrials.gov; NCT01159041.