The context of depression in clinic-referred youth: neglected areas in treatment

Teenage Blues: Predictors of depression among adolescents in Nigeria

BACKGROUND

Depressive disorders, with a prevalence of 15-21%, are among the most common disorders in children and adolescents, and increases the risk of suicide, the second leading cause of death in children aged 10 to 19.

AIM

To determine the prevalence and correlates of depressive disorders among senior students attending secondary schools in Abeokuta.

METHOD

The study was conducted in five schools randomly selected from a representative sample and was carried out in 2 phases. In the first phase, students were selected via systematic random sampling and given consent forms and GHQ-12 to administer to the parents. In the second phase, students who returned a signed informed consent form and filled out GHQ-12 were interviewed using MINI-KID, Rosenberg's Self-Esteem Scale, Family-APGAR, and sociodemographic questionnaire. Multivariate regression analyses were conducted with p-value <0.05 as level of significance.

RESULTS

The mean age was 15.3 years (SD = 1.27); 48.8% were male. The twelve-month prevalence of major depression was 11.3% and dysthymia was 1.4%. In the final regression analysis, female gender [OR = 4.3, p = 0.046], the experience of bullying [OR = 7.96, p = 0.004], difficulty getting along with friends, [OR = 7.5, p = 0.004], history of sexual abuse [OR = 8.1, p = 0.01], and perceived family dysfunction [OR = 4.9, p = 0,023] were found to be independent predictors of depressive disorders.

CONCLUSION

Depressive syndromes are a significant health burden in adolescents. Being female, being bullied, having a history of sexual abuse, and family dysfunctionality are risk factors associated with depression among these population.

A study on the correlation between family dynamic factors and depression in adolescents

Objectives

To evaluate the relationship between systemic family dynamics and adolescent depression.

Methods

An offline survey was distributed to 4,109 students in grades 6-12, with the final analysis including 3,014 students (1,524 boys and 1,490 girls) aged 10-18 years. The questionnaire included the Self-Rating Scale of Systemic Family Dynamics (SSFD), the Self-Rating Depression Scale (SDS), and demographic characteristics.

Results

Family dynamics were negatively correlated with depressive symptoms, with better family dynamics (high scores) associated with lower levels of depression based on the SDS score. After adjusting for sociodemographic characteristics, an ordinal multiclass logistic regression analysis identified family atmosphere (OR = 0.952, 95% CI: 0.948-0.956, p < 0.001) as the most important protective family dynamic against depression, followed by individuality (OR = 0.964, 95% CI: 0.960-0.968, p < 0.001). Latent class analysis (LCA) created the low family dynamic and high family dynamic groups. There were significant differences in the mean SDS scores between the two groups (45.52 ± 10.57 vs. 53.78 ± 11.88; p < 0.001) that persisted after propensity matching. Family atmosphere and individuation had a favorable diagnostic value for depression, with AUCs of 0.778 (95% CI: 0.760-0.796) and 0.710 (95% CI: 0.690-0.730), respectively. The diagnostic models for depression performed well.

Conclusion

Poor family dynamics may be responsible for adolescent depression. A variety of early intervention strategies focused on the family may potentially avoid adolescent depression.

[Research on adolescent depression associated with parental depression]

At the crossroads of a global pandemic, here and there where public discourse misuses the concepts of depression, research has begun on a public health issue, that of adolescent depression. The Adodesp study (adolescent depression associated with parental depression) aims to study the interest of a preventive identification of adolescent depression, based on that of parental figures, while evaluating the orientation towards a care system articulated between primary care and mental health devices. To date, this study has included 42 adolescents based on the identification of 30 depressed parents. Preliminary results show that 45% of adolescents are depressed and support the need for systematic identification of adolescent depression in children of depressed parents. They also underline the difficulties and pitfalls of this identification by general practitioners and conclude that it would be useful to strengthen the link between primary care and mental health services.

COVID-19-Specific Suicidal Thoughts and Behaviors in Psychiatrically Hospitalized Adolescents

This study examined the presence and correlates of COVID-specific suicidal thoughts and behaviors (i.e., thoughts of or engaging in intentional COVID-19 exposure with associated suicidal intent) among psychiatrically hospitalized adolescents. Adolescents (N = 143) completed study measures as part of the standard intake process between March 13th and August 14th, 2020. Participants answered questionnaires assessing COVID-specific passive and active suicidal ideation (SI) and suicidal behavior, as well as COVID-related stressors and emotions, and public health guidance compliance. Findings highlights that COVID-specific SI is common in high-risk youth. COVID-specific SI was associated with COVID-19-related negative emotions, elevated stress, and decreased public health guidance compliance. Results suggest that COVID-specific suicidal thoughts and behaviors, and risk correlates, should be assessed within high-risk populations to facilitate prevention of risky behavior associated with intentional COVID-19 exposure.

Learning to BREATHE "Plus": A Multi-Modal Adaptive Supplement to an Evidence-Based Mindfulness Intervention for Adolescents

Incorporating technological supplements into existing group mindfulness-based interventions (MBIs), particularly for use with adolescents, is an important next step in the implementation of MBIs. Yet there is little available content. Herein we present the development and content of a technological supplement for MBIs, which incorporates multiple technological elements to support (a) skill transfer from the group MBI to daily life, (b) the establishment of a formal mindfulness practice, and (c) the use of mindfulness during periods of high stress. A mixed-methods approach was used to develop this multi-method adaptive supplement. Findings about the use of this supplement will be disseminated scientifically and/or publicly as appropriate.

Acculturative Stress among Arab Students in Israel: The Roles of Sense of Coherence and Coping Strategies

BACKGROUND

In Israeli colleges and universities, many Arab students experience acculturative stress. Such stress arises from the need to learn new cultural rules, manage the overarching conflict inherent in maintaining elements of their culture of origin (i.e., Arab culture) while incorporating elements of the host culture (i.e., Jewish academic culture), and deal with experiences of prejudice and discrimination present in the host culture.

METHODS

This study investigated the association between acculturative stress and depressive symptoms among 170 Arab undergraduates from northern and central Israel. It also explored the roles of sense of coherence and coping strategies in the relationship between acculturative stress and depressive symptoms. Participants completed questionnaires on acculturative stress, depressive symptoms, sense of coherence, coping strategies, and demographics.

RESULTS

The findings reveal gender differences in the use of different coping strategies and in levels of depressive symptoms. However, academic-year differences were found only in levels of sense of coherence and depressive symptoms. Specifically, female students expressed higher levels of both active and avoidant coping. Moreover, female students and those in their first and second years of university studies reported higher levels of depressive symptoms. Among the male students, acculturative stress was related to depressive symptoms indirectly via sense of coherence and active coping. In contrast, among the female students, acculturative stress was related to depressive symptoms both directly and indirectly via sense of coherence and avoidant coping. Among first- and second-year students, acculturative stress was related to depressive symptoms indirectly via sense of coherence and avoidant coping. However, among third- and fourth-year students, acculturative stress was related to depressive symptoms both directly and indirectly via sense of coherence.

CONCLUSIONS

This article underscores the significance of gender and academic-year differences in pathways involving acculturative stress.

Family-Based Interpersonal Psychotherapy: An Intervention for Preadolescent Depression

Family-based interpersonal psychotherapy (FB-IPT) is an evidence-based psychosocial intervention for depression in preadolescents (ages 8-12 years). Adapted from interpersonal psychotherapy for adolescents with depression and modified for younger children, this therapy includes structured dyadic sessions with preadolescents and their parents, guidance for parents in supporting their children and decreasing negative parent-child interactions, and a focus on preadolescents' comorbid anxiety and peer relationships. This article reviews the conceptual foundations and risk factors related to preadolescent depression and the rationale for focusing on improving preadolescents' interpersonal relationships to decrease depressive symptoms and risk for depression during adolescence. The structure and goals for the initial, middle, and termination phases of FB-IPT are described, as well as the specific communication and problem-solving strategies presented to preadolescents and parents. Last, research on the efficacy of FB-IPT is summarized, as are future directions for implementing this promising psychosocial intervention for preadolescent depression in community settings.

Mindfulness Interventions to Reduce Impact of Interparental Conflict on Adolescents

Exposure to frequent, intense, and poorly resolved interparental conflict puts adolescents at risk for problems in many domains, including internalizing and externalizing problems, and stress physiological dysfunction. Existing intervention strategies to target these adolescents focus almost solely on improving marital dynamics, for example, through relationship education or couples therapy. However, interventions that aim to enhance marital communication require high levels of parental commitment and motivation for change, and may be expensive and time-consuming. In the current paper, we argue that it is essential to also apply intervention strategies that directly promote the regulatory capabilities of adolescents to improve outcomes for youth from high-conflict homes. Mindfulness, or present-moment, nonjudgemental awareness, is associated with myriad positive outcomes in adults (e.g., lower levels of depression and anxiety, and greater emotion regulation). We propose that mindfulness interventions are an ideal intervention strategy for adolescents from high conflict homes. Mindfulness interventions may target the mechanisms whereby destructive marital interaction impacts youth, by providing distance between experiences and evaluations, training regulation of attention, and enhancing self-compassion and nonjudgement, as well as by enhancing relationships. We also provide an example of a specific intervention model designed to increase mindfulness in youth, Learning to Breathe (L2B).

Life stress moderates the effects of preschool behavioral inhibition on anxiety in early adolescence

BACKGROUND

Although a robust body of literature implicates temperamental behavioral inhibition (BI) as a prominent risk factor for anxiety disorders, many children with heightened BI do not develop anxiety. The current study examines the role of two forms of life stress (life events and natural disaster exposure) in moderating the relationship between BI in preschoolers and anxiety in early adolescence.

METHOD

A community sample of 392 3-year-old children was administered a laboratory observational assessment of temperament. When children were a mean age 10, the region was struck by a devastating hurricane and exposure to disaster-related stress was assessed. In early adolescence, youth and a parent were administered the UCLA Life Stress Interview (LSI) to assess behaviorally independent and dependent negative life events during the prior year and youth completed the Screen for Child Anxiety Related Emotional Disorders (SCARED).

RESULTS

The association between early childhood BI and anxiety symptoms in early adolescence was moderated by both independent life events and disaster-related stress. Children high in BI at age 3 reported greater anxiety symptoms at age 12 after exposure to higher levels of both forms of stress.

CONCLUSIONS

Stress moderated the association between early BI and later anxiety. Importantly, this was evident for two different kinds of stressors that were independent of the child's behavior that increases confidence in the causal role of stress in the development of anxiety in high BI children.

New Avenues for Promoting Mindfulness in Adolescence using mHealth

There is a large evidence base supporting the efficacy of mindfulness interventions in adulthood, and growing support for the efficacy of these interventions in adolescence. Historically mindfulness interventions have been delivered in person and in groups, with recommendations for home practice being a critical part of the intervention. However, compliance with these practice recommendations in adolescence is very poor. Past studies indicate that using mobile technology to promote skill transfer to real life can be an effective strategy, particularly when used as a supplement to an in-person intervention strategy. To date, however, mobile technology has largely been used to create stand-alone mindfulness interventions. The goals of the current paper are to discuss the potential opportunities and challenges with a mobile-technology-enhanced mindfulness intervention, and to present the rationale that such an approach is not only theoretical and empirically sound but also a critical next step to increase the efficacy and developmental appropriateness of mindfulness interventions for adolescents. This discussion is grounded in a specific example of a mindfulness intervention supplemented by momentary interventions we are developing.

Predictors of Internalizing Behaviors in Ukrainian Children

OBJECTIVE

To (a) estimate the level of child internalizing problems in a sample of Ukrainian school-age children and (b) examine the relationships between child internalizing psychopathology and parenting practices, depression, alcohol use, and sociodemographics.

BACKGROUND

Most research on child internalizing behaviors has used samples from high-income countries, but there is a lack of information about children's behaviors and associated risk and protective factors from low- and middle-income countries such as Ukraine. An ecological-transactional model framework was used in this study to examine maternal and family-level factors associated with child internalizing behavior problems.

METHOD

Data were gathered from a community-based sample of Ukrainian mothers and children between 9 and 16 years of age (n = 251) using face-to-face interviews. Multiple linear regression analysis was used to examine the relationship among the independent variables (e.g., alcohol use, depression, and parenting behaviors) and children's internalizing behaviors.

RESULTS

Older children, especially boys, reported fewer internalizing problems. Increased internalizing symptomatology was associated with mothers' older age, higher level of depression, lower use of positive parenting, and poor child monitoring and supervision.

CONCLUSION

These results raise awareness about the importance of child familial backgrounds while trying to address child mental health problems in Ukraine.

IMPLICATIONS

Family practitioners may want to help mothers learn and apply positive parenting and effective supervision and monitoring skills to help reduce their children's depression and anxiety symptoms. Additionally, helping to decrease maternal depression may have a positive trickle-down effect on their children's internalizing behaviors.

Socratic Questions With Children: Recommendations and Cautionary Tales

This clinically focused article offers cognitive behavior therapists recommendations and cautionary tales for using the Socratic method when working with children. The importance of the therapeutic relationship in combination with developmental considerations is discussed. The use of Socratic method in various cognitive behavioral modules is illustrated by means of case examples. Dialogues provide examples of how the cognitive specificity hypothesis and downward arrow technique can be used to support young clients in eliciting negative automatic thoughts. The importance of pacing, the mixing of closed and open-ended questions, and behavioral experiments to aid cognitive restructuring are also highlighted through extracts from clinical conversations. Finally, the article emphasizes that the purpose of the Socratic method is to broaden thinking and to access new knowledge rather than just giving young clients new thoughts and problem solving strategies.

Meeting the complex needs of urban youth and their families through the 4Rs 2Ss Family Strengthening Program: The "real world" meets evidence-informed care

Youth living in poverty face compounding familial and environmental challenges in utilizing effective community mental health services. They have ongoing stressors that increase their dropout rate in mental health service use. Difficulties also exist in staying engaged in services when they are involved with the child welfare system. This study examines the 4Rs 2Ss Family Strengthening Program, developed across four broad conceptual categories related to parenting skills and family processes that form a multiple family group service delivery approach. A total of 321 families were enrolled in this randomized intervention study, assigned to either the 4Rs 2Ss Family Strengthening Program or standard care services. Caregivers and their children randomly assigned to the experimental condition received a 16 week multiple family group intervention through their respective outpatient community mental health clinic. Data was collected at baseline, midtest (8 weeks), posttest (16 weeks), and 6 month follow-up. Major findings include high engagement in the 4Rs 2Ss Family Strengthening Program, compared to standard services. Although child welfare status is not related to attendance, family stress and parental depression are also related to participant engagement in this multiple family group intervention. Involvement in the 4Rs 2Ss Family Strengthening Program resulted in improved effects for child behaviors. Lastly, no evidence of moderation effects on family stress, child welfare involvement, or parental needs were found. The 4Rs 2Ss Family Strengthening Program appeared able to engage families with more complex "real world" needs.

Taming the adolescent mind: a randomised controlled trial examining clinical efficacy of an adolescent mindfulness-based group programme

BACKGROUND

Mindfulness interventions with adolescents are in the early stages of development. This study sought to establish efficacy of a mindfulness-based group intervention for adolescents with mixed mental health disorders.

METHOD

One hundred and eight adolescents (ages 13-18) were recruited from community mental health clinics and randomised into two groups (control vs. treatment). All participants received treatment-as-usual (TAU) from clinic-based therapists independent of the study. Adolescents in the treatment condition received TAU plus a 5-week mindfulness-training programme (TAU+Mi); adolescents in the control group received only TAU. Assessments including parent/carer reports were conducted at baseline, postintervention and 3-month follow-up.

RESULTS

At postintervention, adolescents in the mindfulness condition experienced significant decrease in mental distress (measured with the DASS-21) compared to the control group (Cohen's d = 0.43), and these gains were enhanced at 3-month follow-up (Cohen's d = 0.78). Overall outcomes at 3 months showed significant improvement for adolescents in the mindfulness condition; in self-esteem, mindfulness, psychological inflexibility and mental health, but not resilience. Parents/carers also reported significant improvement in their adolescent's psychological functioning (using the CBCL). Mediation analyses concluded mindfulness mediated mental health outcomes.

CONCLUSIONS

Increase in mindful awareness after training leads to improvement in mental health and this is consistent with mindfulness theory. The mindfulness group programme appears to be a promising adjunctive therapeutic approach for clinic-based adolescents with mental health problems.

Increasing Understanding in Children of Depressed Parents: Predictors and Moderators of Intervention Response

We evaluated predictors and moderators of differential response to two family-based depression prevention programs for families with a depressed parent: a clinician-facilitated intervention and a lecture group intervention. Individual and family level variables were examined using regression analyses with generalized estimating equations. For the outcome of child understanding of depression, parental changes in child-related behaviors and attitudes predicted greater child understanding (p < 0.001). For the parent outcome of behavior and attitude change, across intervention conditions, younger parent age (p < 0.05), female parent gender (p < 0.01), more chronic and severe parental depression history (p < 0.05), lower SES (p < 0.05), and single-parent status (p < 0.05) were associated with better outcomes across conditions. Effect sizes were moderate, ranging from 0.4 to 0.7 SD. Family and marital functioning were not found to be predictors of any outcomes. When both parents were depressed at baseline, there was no difference in the clinician- versus lecture-based approach, and when only the father was depressed, families reported more changes with the clinician condition than with the lecture condition (p < 0.05). Findings from this study can help identify intervention strategies that are appropriate for different types of at-risk individuals and families.

Practitioner review: Dysphoria and its regulation in child and adolescent depression

BACKGROUND

By emphasizing the importance of emotions, the 'affect revolution' in how human behavior is conceptualized has inspired a new generation of studies on dysphoric experience and its regulation in clinical depression, and novel efforts to characterize the precursors of affective disorders in juveniles at familial risk for depression.

METHOD

We review clinical, behavioral, and functional neuroimaging studies of dysphoric experience and its regulation in depressed children and adolescents, and in juvenile offspring of parents with histories of clinical depression. We discuss the implication of the literature in the context of maternal depression.

RESULTS

Findings confirm the high rate of clinically significant dysphoria in depressed children and adolescents and reveal notable affective lability in daily life as a function of context and activity. Findings also show that depressed youngsters have problems in attenuating dysphoria. Similarly, never-depressed offspring at familial risk for depression display problems in mood repair and impaired mood repair mechanisms. Brain neuroimaging findings indicate that, overall, depressed, and high-risk youngsters differ from never depressed controls in neural functioning (activation, connectivity) both at rest and in response to emotion triggers.

CONCLUSION

The evaluation of depressed youngsters should include questions about reactivity of dysphoric mood to the changing contexts of daily life and about how they manage (respond to) their own sadness and distress. The resultant information may help the clinician to restructure a young patient's day for the better and identify helpful mood repair responses. Evidence of impaired mood repair mechanisms in youngsters at high-risk for depression suggests the need for early intervention. But interventions must consider that many depressed and high-risk children have depressed mothers, who may be constrained in their ability to help offspring's emotion regulation efforts. To optimize treatment response of offspring, mothers of depressed children should therefore be routinely screened for depression and treated, as warranted.

An analysis of stakeholder views on children's mental health services

The purpose was to examine the perspectives of mental health stakeholders as a means to guide the adaptation of evidence-based treatments. The Mental Health System Ecological (MHSE) model was used to organize therapist, administrator, and parent perspectives gathered using qualitative methods. The MHSE model posits the influences of client-level, provider-level, intervention-specific, service delivery, organizational, and service system characteristics on implementation. Focus groups and interviews were conducted with community mental health stakeholders and included parents, therapists, and administrators (N = 21). Participants included 11 primarily Caucasian (90.48%) female participants, ranging in ages between 31 and 57 years. Data were analyzed according to the MHSE model. Frequency counts were tabulated for each theme and stakeholder group differences were determined using the Mann-Whitney test. Stakeholder groups mentioned needs at each level of the MHSE model. Stakeholder group differences most notably emerged with child and family themes, which included complexity of mental health issues, parenting differences, and family stressors. Stakeholders identified challenges for optimal mental health services for children across multiple levels of an ecological model. Implications of the findings are discussed, including the continued relevance of adapting mental health interventions by increasing their flexible application across multiple target problems and the promise of partnership approaches.

The prevalence of different kinds of child abuse and the characteristics that differentiate abused from nonabused male adolescents

Child abuse has proved to be one of the most important social challenges. The present study attempts (a) to determine the prevalence of child abuse in an urban area in Iran and (b) to differentiate abused from non-abused adolescent boys using parental and child characteristics. A survey was conducted to determine the prevalence of different types of child abuse. The prevalence sample comprised 2,100 students selected through a multistage random sampling procedure. Data were collected using the Childhood Trauma Questionnaire (CTQ), Beck Depression Inventory, II (BDI-II), State Trait Anxiety Inventory (STAI), modified Hazan & Shaver Attachment Style Questionnaire (ASQ) and Symptom Check List 90 (SCL-90-R). Descriptive statistics and discriminant function analysis were used to analyze the data. The results showed that 14.85% of the subjects were exposed to child abuse, with emotional abuse being most prevalent (52.09%). Also, it appeared that variables such as parental depression and anxiety and children's attachment styles, anxiety, and aggression can help discriminate abused boys from their non-abused counterparts.

Anxious youth in research and service clinics

With the current focus on increasing utilization of empirically supported treatments, knowledge of sample differences and similarities has increasing importance. The present study compared anxiety-disordered youth (age 7-13) from (a) five Norwegian service clinics (SC, N = 111) to (b) a university research clinic (RC) in Philadelphia, USA (N = 144) on pre-treatment characteristics measured by the Multidimensional Anxiety Scale for Children, Child Behavior Checklist, Teacher Report Form, Anxiety Disorders Interview Schedule, and Children's Global Assessment Scale (CGAS). SC youth demonstrated higher levels of anxiety based on child- (d = 0.42-1.04) and parent-report (d = 0.53) and conduct problems based on parent-report (d = 0.43) compared to RC youth. SC youth was more functionally impaired on the CGAS (d = 0.97), whereas RC youth evidenced a greater number of diagnoses (d = 0.63). The two samples were equivalent regarding parent-reported symptoms of affective, somatic, attention-deficit/hyperactivity, and oppositional problems. Future directions and clinical implications are discussed.

Contextual emotion regulation therapy: a developmentally based intervention for pediatric depression

For this special issue about child and adolescent depression, the authors were asked to describe contextual emotion regulation therapy as an example of a developmentally informed psychosocial intervention. The article begins with the authors' definition of the elements that should comprise such an intervention. A succinct summary of this contextual emotion regulation therapy is then provided, including its explanatory paradigm of depression, followed by an exposition of how it addresses the various definitional criteria of a developmentally informed intervention. The article concludes with a brief overview of the challenges of implementing a developmentally sensitive psychotherapy for depressed children and adolescents.

Characteristics of anxious and depressed youth seen in two different clinical contexts

Previous research has revealed that youth seen at community clinics present with a higher frequency of externalizing problems and are demographically different from youth seen at research clinics. This study extends findings on these discrepancies by examining differences between youth at research and community clinics meeting criteria for two different primary disorders (anxiety and depression). Consistent with prior research, community clinic youth reported lower incomes, were more ethnically diverse, and had higher rates of externalizing problems compared to research clinic youth, regardless of primary diagnosis. Findings are discussed in terms of enhancing dissemination of evidence-based treatments for internalizing disorders in community settings.

Conceptualizing the prospective relationship between social support, stress, and depressive symptoms among adolescents

The goal of the current study is to examine the relationship amongst social support, stress, and depressive symptoms within a transactional and diathesis-stress framework using a multi-wave, longitudinal design. At the initial assessment, adolescents (n = 258) completed self-report measures assessing social support (peer, classmate, parent, and total), dependent interpersonal stress, anxious symptoms, and depressive symptoms. Additionally, participants reported stress and symptomology in each of the four waves spanning six months. Results of time-lagged, idiographic, multilevel modeling indicated that stress mediated the relationship between lower parental, classmate, and total social support and subsequent depressive, but not anxious, symptoms. In contrast, lower levels of peer support were not associated with higher levels of stress and subsequent depressive symptoms. Additionally, only classmate support deficits significantly moderated the relationship between stress and depressive symptoms. Overall, the results suggest that deficits in parental and classmate support may play a greater role in contributing to adolescent depression as compared to deficits in peer support.

The prevention of adolescent depression

This article provides a conceptual framework for research and outlines several new directions for the same on the prevention of depression in youth and reviews the recent literature on prevention efforts targeting children and adolescents. Prevention efforts should target both specific and nonspecific risk factors, enhance protective factors, use a developmental approach, and target selective and/or indicated samples. A review of the literature indicates that prevention programs using cognitive-behavioral and/or interpersonal approaches and family-based prevention strategies are the most helpful. Overall, it seems that there is reason for hope regarding the role of interventions in preventing depressive disorders in youth.

Clinician and Parent Perspectives on Parent and Family Contextual Factors that Impact Community Mental Health Services for Children with Behavior Problems

The present study employed qualitative methods to examine multiple stakeholder perspectives regarding the role of parent and family contextual factors on community child mental health treatment for children with behavior problems. Findings suggest agreement between clinicians and parents on the number, types and importance of parent and family factors in children's mental health services; however, stakeholders differed in reports of which factors were most salient. Specifically, clinicians endorsed most factors as being equally salient, while parents described a few salient factors, with parental stress and inadequate social support being the most frequently discussed. These qualitative data further elucidate the context of community services and have implications for evidence-based practice implementation and improving community care.

Implementing Interventions with Families in Schools to Increase Youth School Engagement: The Family Check-Up Model

This study examined outcomes associated with the Family Check-Up (FCU), an adaptive, tailored, family-centered intervention to enhance positive adjustment of middle school youth and prevent problem behavior. The FCU intervention model was delivered to families in 3 public middle schools. The study sample comprised 377 families, and participants were randomly assigned to receive either the intervention or school as usual. Participation in the intervention was relatively high, with 38% of the families receiving the FCU. Participation in the intervention improved youth self-regulation over the 3 years of the study. Self-regulation skills, defined as effortful control, predicted both decreased depression and increased school engagement in high school, with small to medium effect sizes. The results have implications for the delivery of mental health services in schools that specifically target family involvement and parenting skills.

Longitudinal course of adolescent depression: neuroendocrine and psychosocial predictors

OBJECTIVE

The study examined whether cortisol measures are associated with the clinical course of depression in adolescents. Furthermore, the study evaluated whether the relationship between cortisol and clinical course is moderated by environmental stress and/or social support.

METHOD

Fifty-five adolescents with depression (age range 13-18 years) were recruited. In addition to a systematic diagnostic assessment, information was obtained on environmental stress and social support. Urinary free cortisol measures were collected on three consecutive nights during the index episode. Clinical follow-up evaluations were conducted at regular intervals over a 5-year period, documenting recovery from the index depressive episode and recurrent episodes. Information on environmental stress and social support also was gathered during each follow-up assessment.

RESULTS

Consistent with prior reports, the majority of adolescents (92.2%) recovered from the initial depressive episode. A substantial proportion of the recovered youth (42.6%) experienced a subsequent episode during the follow-up period. Higher cortisol levels were associated with a longer time to recovery from the index depressive episode. The effect of cortisol on recovery was moderated by social support. The combination of elevated cortisol and recent stressful experiences predicted recurrence, whereas a higher level of social support was protective against recurrence.

CONCLUSIONS

These data, in conjunction with prior literature, suggest that depression reflects an underlying neurobiological vulnerability that may predispose individuals with high vulnerability to chronic, recurrent episodes. Psychosocial factors, independently or in combination with an underlying neurobiological vulnerability, also play an important role in determining the clinical course of depression.

Characteristics, correlates, and outcomes of childhood and adolescent depressive disorders

Depressive illness beginning early in life can have serious developmental and functional consequences. Therefore, understanding the disorder during this developmental stage is critical for determining its etiology and course, as well as for deveiopinq effective intervention straieqies. This paper summarizes current knoviedqe reqardinq the etiology, phenomenoiogy, correlates, natural course, and consequences of unipolar depression in children and adolescents. Using adult depression as a framevork, the unique aspects of childhood and adolescence are considered in order to better understand depression within a developmental context. The data suggest that the clinical presentation, correlates, and natural course of depression are remarkably similar across the lifespan. There are, however, important developmental differences. Specifically, the familial and psychological context in which depression develops in youngsters is associated with variability in the frequency and nature of depressive symptoms and comorbid conditions among children and adolescents. Maturational differences have also been identified in the neurobiological correlates of depression. These developmental differences may be associated with the observed variability in clinical response to treatment and longitudinal course. Characterization of the developmental differences will be helpful in developing more specific and effective interventions for youngsters, thereby allowing them to reach their full potential as adults.

A Multilevel Analysis of Gender Differences in Psychological Distress Over Time

Females have higher rates of depression than males, a disparity that emerges in adolescence and persists into adulthood. This study uses hierarchical linear modeling to assess the effects of school context on gender differences in depressive symptoms among adolescents based on two waves of data from the National Longitudinal Study of Adolescent Health (N = 9,709 teens, 127 schools). Analysis indicates significant school-level variation in both overall symptom levels and the average gender gap in depression net of prior symptoms and individual-level covariates. Aggregate levels of depressive symptomatology were positively associated with contextual-level socioeconomic status (SES) disadvantage. A cross-level contingency emerged for the relationship between gender and depressive symptoms with school SES and aggregate perceived community safety such that the gender "gap" was most apparent in contexts characterized by low SES disadvantage and high levels of perceived safety. These results highlight the importance of context to understanding the development of mental health disparities.

Cognitive-behavioral therapy versus usual clinical care for youth depression: an initial test of transportability to community clinics and clinicians

Community clinic therapists were randomized to (a) brief training and supervision in cognitive-behavioral therapy (CBT) for youth depression or (b) usual care (UC). The therapists treated 57 youths (56% girls), ages 8-15, of whom 33% were Caucasian, 26% were African American, and 26% were Latino/Latina. Most youths were from low-income families and all had Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) depressive disorders (plus multiple comorbidities). All youths were randomized to CBT or UC and treated until normal termination. Session coding showed more use of CBT by CBT therapists and more psychodynamic and family approaches by UC therapists. At posttreatment, depression symptom measures were at subclinical levels, and 75% of youths had no remaining depressive disorder, but CBT and UC groups did not differ on these outcomes. However, compared with UC, CBT was (a) briefer (24 vs. 39 weeks), (b) superior in parent-rated therapeutic alliance, (c) less likely to require additional services (including all psychotropics combined and depression medication in particular), and (d) less costly. The findings showed advantages for CBT in parent engagement, reduced use of medication and other services, overall cost, and possibly speed of improvement--a hypothesis that warrants testing in future research.

The prevention of depression in children and adolescents: a review

OBJECTIVE

To review the recent literature on the prevention of clinical diagnoses of depression in children and adolescents.

METHOD

Several preventive intervention programs targeting depressive diagnoses in youth were reviewed. These programs based their prevention strategies on cognitive-behavioural and (or) interpersonal approaches, which have been found to be helpful in the treatment of depression. In addition, family-based prevention strategies were reviewed. Also, nonspecific risk factors for youth depression, including poverty and child maltreatment, were discussed as important considerations in prevention programs targeting youth depression.

RESULTS

In general, successful prevention programs targeting youth depression are based on evidence-based treatment programs for youth depression, structured and outlined in manuals, involve careful training of personnel implementing the protocols, and include assessment of fidelity to the intervention protocols. The programs were consistent with cognitive-behavioural and (or) interpersonal psychotherapy traditions. Overall, it appears that there is reason for hope regarding the role of interventions in preventing depressive disorders in youth.

CONCLUSIONS

Several new directions for future research on the prevention of depression in youth were outlined. Future research is needed to establish an empirical base for the prevention of depression in high-risk youth and should: focus on targeted and indicated prevention approaches, attend to moderators of intervention effects, include approaches that aim to enhance the family environment, attend to nonspecific risk factors for disorder, and focus on the dissemination phase of prevention research.

Pharmacogenetics of selective serotonin reuptake inhibitors in pediatric depression and anxiety

Selective serotonin reuptake inhibitors (SSRIs) are now an accepted and widely used first-line treatment for pediatric depression and anxiety. However, the data indicate that SSRI treatment achieves a clinical response in only 55-60% of children, and some may develop drug-induced suicidal behavior. Clinicians have no reliable tools to help them identify in advance those youths who are not likely to respond to an SSRI, or who are likely to develop SSRI-induced suicidality. Pharmacogenetic research attempts to identify genetic markers that are associated with response and side-effect profile. This review covers all the pharmacogenetic studies conducted as yet on pediatric samples and compares them with available data on adult samples. An emphasis is put on serotonergic genes such as the serotonin transporter (5-HTT) and additional genes known to be active in the CNS.

Ethnic differences in electroencephalographic sleep patterns in adolescents

The purpose of the study was to evaluate ethnic differences in polysomnography measures in adolescents. Ninety-six volunteers from four ethnic groups (13 African-American, 18 Asian-American, 19 Mexican-American, and 46 Non-Hispanic White) were recruited. The subjects were in good physical and psychological health, and were asymptomatic with respect to sleep/wake complaints or sleep disorders. Polysomnography measures were collected on three consecutive nights. African-Americans manifested lower sleep efficiency, spent proportionately more time in stage 2 sleep, and had less stage 4 sleep compared to the other ethnic groups. In contrast to this, Mexican-Americans had more rapid eye movement (REM) sleep than their counterparts. The observed sleep patterns in the different ethnic groups persisted after controlling for specific demographic, clinical and psychosocial variables that are known to influence sleep measures. Gender had a differential effect on sleep patterns in the various ethnic groups. For instance, differences in non-REM sleep were more evident in African-American males, whereas increased REM sleep was most notable in Mexican-American females. At present, the clinical implications of the observed cross-ethnic differences in sleep physiology among adolescents are not clear. In previous studies, reduced sleep efficiency and stage 4 sleep, as well as increased REM sleep, were associated with psychopathology. It is not known whether the traditionally described sleep profiles, based largely on Non-Hispanic White populations, will generalize to other racial or ethnic groups. In addition to a systematic investigation of this issue, future research should attempt to identify the underlying causes for cross-ethnic variations in sleep physiology.

Core components of therapy in youth: do we know what to disseminate?

Bridging the gap between lab and clinic has become a rallying cry for a generation of treatment researchers, and identifying and overcoming barriers to successful dissemination of best-practice treatment has become a major public mental health priority. In this review, the authors argue that a key limit to accomplishing this goal may be found back in the original research laboratories where these treatments were developed. Despite 50 years of research and 1,500 clinical trials, there are surprisingly little data on what makes youth psychotherapy therapeutic. To illustrate the problem this poses for dissemination, the adolescent depression literature is reviewed in terms of (a) critical core components of intervention and (b) basic processes through which these techniques operate. Process-outcome relationships in cognitive-behavioral, interpersonal, and family therapy models are examined with descriptive meta-analytic techniques. Discussion of treatment dissemination follows, focusing on the value of basic research on core psychotherapeutic techniques and processes.

Adapting evidence-based mental health treatments in community settings: preliminary results from a partnership approach

This article describes the application of a university-community partnership model to the problem of adapting evidence-based treatment approaches in a community mental health setting. Background on partnership research is presented, with consideration of methodological and practical issues related to this kind of research. Then, a rationale for using partnerships as a basis for conducting mental health treatment research is presented. Finally, an ongoing partnership research project concerned with the adaptation of evidence-based mental health treatments for childhood internalizing problems in community settings is presented, with preliminary results of the ongoing effort discussed.

Family-based interpersonal psychotherapy for depressed preadolescents: an open-treatment trial

AIM

To conduct an open-treatment trial to evaluate the feasibility, acceptability and clinical outcomes of using a family-based adaptation of Interpersonal Psychotherapy for Depressed Adolescents with a sample of preadolescents (ages 9-12) presenting for outpatient treatment for depression.

METHODS

Sixteen preadolescents who met criteria for a depressive disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition participated in this open-treatment trial of family-based interpersonal psychotherapy (FB-IPT). Parents chose whether their preadolescents should receive FB-IPT only (n = 10) or FB-IPT with antidepressant medication (n = 6). Pre- and post-treatment assessments included clinician-administered measures of depression and global functioning, and parent- and child-reported anxiety symptoms.

RESULTS

FB-IPT was associated with high treatment compliance rates (88%) and was associated with significant decreases in preadolescents' depressive and anxiety symptoms. Preadolescents who received FB-IPT only were as likely as those receiving FB-IPT and medication to have significant reductions in depressive symptoms and anxiety symptoms, and to experience significant improvement in global functioning. Parents were more likely to choose combination treatment when their depressed preadolescents had a comorbid anxiety disorder.

CONCLUSIONS

Further research on FB-IPT is needed to establish its efficacy as compared with usual outpatient treatment, its ability to be disseminated to child clinicians with varying levels of training and in adequately powered randomized controlled trials that can detect group differences.

Who Stays in Treatment? Child and Family Predictors of Youth Client Retention in a Public Mental Health Agency

The present study examined possible predictors of youth client retention in therapy in a large community-based sample. We used several conceptualizations of retention, including (a) "intake retention" (i.e., returned to treatment after intake session); (b) "mutual termination" (i.e., termination agreed upon by family and therapist), (c) "mean treatment duration" (i.e., completing the mean number of sessions in the agency), and (d) "total treatment duration" (i.e., total number of sessions). Archival data from over 400 children and adolescents who sought treatment at a large public mental health clinic were analyzed using regression analyses. Although different predictors were identified across the various conceptualizations, a few robust predictors emerged including ethnicity and client symptom severity. Clinical implications and future research directions are discussed.

Evidence-Based Psychotherapy for Children and Adolescents: Data from the Present and a Model for the Future

What is the best way to help children cope with behavioural and emotional problems? This question has been a focus of concern - to children and the adults who care for them - across many centuries and in cultures around the world. In this article we examine the current state of efforts to help children by means of an array of non-medical interventions designed to alleviate psychological distress, reduce maladaptive behaviour, and/or increase adaptive behaviour. We refer to these interventions, collectively, as 'psychotherapy'. In the article, we will note some accomplishments of the effort to develop effective interventions through clinical research. Then we will note some concerns about these efforts, and suggest ways to address the concerns through an alternate model of intervention development and testing.

Texas Children's Medication Algorithm Project: update from Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder

OBJECTIVE

To revise and update consensus guidelines for medication treatment algorithms for childhood major depressive disorder based on new scientific evidence and expert clinical consensus when evidence is lacking.

METHOD

A consensus conference was held January 13-14, 2005, that included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review, update, and incorporate the most current data to inform and recommend specific pharmacological approaches and clinical guidance for treatment of major depressive disorder in children and adolescents.

RESULTS

Consensually agreed on medication algorithms for major depression (with and without psychosis) and comorbid attention-deficit disorders were updated. These revised algorithms also incorporated approaches to address issues of suicidality, aggression, and irritability. Stages 1, 2, and 3 of the algorithm consist of selective serotonin reuptake inhibitor and norepinephrine serotonin reuptake inhibitor medications whose use is supported by controlled, acute clinical trials and clinical experience. Recent studies provide support that selective serotonin reuptake inhibitors in addition to fluoxetine are still encouraged as first-line interventions. The need for additional assessments, precautions, and monitoring is emphasized, as well as continuation and maintenance treatment.

CONCLUSIONS

Evidence and expert clinical consensus support the use of selected antidepressants in the treatment of depression in youths. The use of the recommended antidepressant medications requires appropriate monitoring of suicidality and potential adverse effects and consideration of other evidence-based treatment alternatives such as cognitive behavioral therapies.

Internalizing symptoms and disorders in families of adolescents: a review of family systems literature

Internalizing symptoms and disorders are relatively common during adolescence and impact considerably on social and emotional functioning. Using a family systems framework, this paper reviews the current literature examining the impact of internalizing symptoms and disorders on the functioning of the family system, the spouse subsystem and the parent-child subsystem. Moreover, literature examining the relationship between parents' and adolescents' internalizing symptoms and disorders is reviewed. The reviewed research demonstrates that there exists an association between internalizing symptoms and disorders and poorer functioning at various levels of the family system. Longitudinal studies have generally reported that parent internalizing symptoms and disorders predict poorer functioning in the family system as well as internalizing symptoms and disorders in adolescents. However, few longitudinal studies have examined whether adolescent internalizing symptoms and disorders predict poorer family functioning and internalizing symptoms and disorders in parents. Those that have examined such effects report mixed results. On the basis of our review, we make recommendations about future research directions. In particular, it is argued that more research on the reciprocal effects of internalizing symptoms and disorders within families is needed to better understand the antecedents and consequences of these conditions for families of adolescents.

Client Similarities and Differences in Two Childhood Anxiety Disorders Research Clinics

Some evidence suggests that research and service clinics differ on treatment-relevant dimensions, but no study has examined whether research clinics (RCs) themselves differ. We compared 2 samples of children and adolescents (ages 7 to 17 years) with anxiety disorders treated in 2 different university-based child anxiety RCs, one in Philadelphia (n = 184) and one in Miami (n = 64), on child symptom and diagnostic measures, family characteristics (e.g., income), and level of maternal depression. The samples were not significantly different on any youth symptom and diagnostic measures except 1 (parent-reported diagnoses); further, the 2 samples were statistically equivalent on 3 of 6 youth symptom measures. Although the Miami sample had significantly more parent-reported diagnoses than the Philadelphia sample, the effect size was small (Cohen's d = .44). Statistically significant differences between the samples in ethnic background and family income were observed, though the former was not significant after controlling for population differences. Findings are discussed in terms of the implications of homogeneity of RCs for treatments tested there.

Comparison of psychosocial correlates in primary school age children with attention deficit/ hyperactivity disorder- combined type, with and without dysthymic disorder

In this study, standardized assessments of maternal psychopathology, family functioning and marital adjustment were compared between 115 medication naïve, clinically referred primary school age children with Attention Deficit Hyperactivity Disorder combined type (ADHD-CT) alone and 29 children with comorbid dysthymic disorder (DD) and ADHD-CT. The mothers of children with ADHD-CT and DD reported higher rates of anxiety and depression than those of children with ADHD-CT alone. These results reinforce the need for early recognition of comorbid DD when working with children with ADHD-CT. Increased rates of maternal anxiety and depression in children with ADHD-CT and DD may contribute to the children's symptoms, require specific psychological and/or medication treatments and careful ongoing monitoring of these specific treatments.

The association of parental alcohol abuse and depression with severe emotional and behavioural problems in adolescents: a clinical study

BACKGROUND

Earlier studies have indicated associations between parental psychiatric problems, such as depression, and substance abuse and adolescent problems.

AIMS

This study aimed to determine whether parental psychiatric problems are associated with problems and problem behaviour in adolescents in a clinical sample.

METHODS

The study subjects were 70 outpatient adolescents (age 13-18 years, boys 30%) and their parents. The adolescents were assessed using the structural clinical interview for DSM-III-R (SCID) and a semi-structured questionnaire, and the parents were interviewed using a semi-structured questionnaire.

RESULTS

Maternal alcohol abuse and depression were associated with serious problems, especially among girls, and paternal alcohol abuse was associated with adolescent health-compromising behaviour. Maternal depression and alcohol abuse had no association with adolescent health-compromising behaviour. Maternal depression without alcohol abuse was associated with the diagnosis of major depressive disorder in adolescents, but not with other adolescent problems, while paternal depression without alcohol abuse was not associated with any adolescent problems.

CONCLUSIONS

Despite the small study sample, these findings indicate that parental psychiatric problems and alcohol abuse are correlated with adolescent psychological problems and should be considered and assessed when assessing adolescents.

Contextual emotion-regulation therapy for childhood depression: description and pilot testing of a new intervention

OBJECTIVE

To pilot test the acceptability and efficacy of contextual emotion-regulation therapy (CERT), a new, developmentally appropriate intervention for childhood depression, which focuses on the self-regulation of dysphoria.

METHOD

Two samples of convenience (n = 29, n = 2) served to verify some CERT constructs; it was then operationalized in a treatment manual. To pilot test CERT, 20 children (ages 7-12; 35% girls) with DSM dysthymic disorder (mean duration 24.4 months) entered an open, 30-session, 10-month, 4-phase trial, with 6- and 12-month follow-up. Assessments included independent clinical evaluations and self-rated questionnaires.

RESULTS

Fifteen children completed theraphy, four were administratively terminated and one dropped out. Completers did not clinically differ from the rest, but they were more likely to have better educated and less depressed mothers and intact families. At the end of treatment, 53% of the completers had full and 13% partial remission of dysthymia (remission from superimposed major depression was 80%). By 6- and 12-month follow-up, 79% and 92% had full remission of dysthymia (p < 0.0001). Self-reported depressive and anxiety symptoms significantly declined by the end of treatment (p < .001) and remained so throughout follow-up.

CONCLUSIONS

CERT enables clinicians to "match" the intervention to children's emotion regulatory needs and symptoms and was readily accepted by families. The promising results suggest the need for a randomized trial.