DEPRESSION IN CHILDREN AND ADOLESCENTS: NATURE,
DIAGNOSIS, ASSESSMENT, AND TREATMENT
ABSTRACT
Depression in youngsters may be one of the most
overlooked and undertreated psychological disorders of childhood and
adolescence. A number of formal and informal systems of classification are
described. In general, these systems view depression in children and adolescents
as similar in symptom expression to depression in adults. This article describes
the significant gains that have been made over the past decade in the
development of measures for the assessment of depression in children and
adolescents. Although only a few control-group psychological treatment studies
have been published, results of these studies are summarized and suggest that
psychotherapeutic interventions with moderately depressed children and
adolescents are effective. New directions in research on the nature of
depression in children and adolescents are delineated, and in particular the
findings of significant comorbidity existing in depressed children and
adolescents. The need for school psychologists to understand the nature, issues
in diagnosis, assessment procedures, and therapeutic methods specific to
depression in children and adolescents is discussed.
Depression in children and adolescents represents a
serious mental health problem. Depressive disorders are of particular relevance
to school psychologists who, in many instances, may be the professional in the
best position for identification, referral, or treatment. Depression represents
what may be viewed as a prototypic internalizing disorder of childhood and
adolescence. In young people depression is particularly insidious, in that,
without active procedures for identification, it may go undetected. Research
also suggests that for some youngsters their depression may last for many years
(Kovacs et al., 1984).
Depression is more than just a mood such as feeling
sad, blue, or down in the dumps. Depression as a syndromal disorder typically
affects multiple areas of personal functioning, including behavioral, emotional,
somatic, and cognitive domains. Depressive disorders represents one of the more
serious forms of psychopathology of childhood and adolescence, given that some
depressive episodes may lead to potential life-threatening outcomes if not
identified and treated. Furthermore, depressive disorders experienced in
childhood or adolescence, may also be a precursor or risk-factor for mental
illness in adulthood (Kovacs, 1985). The perspective of the adolescent who is
"just going through a moody stage" is no longer a viable conceptualization of
depressed youngsters given the large numbers of depressed and suicidal youth, a
significant number of whom do not survive to adulthood.
Silver (1988) citing recent survey data indicated that
17.9% of all youngsters under the age of 18 years admitted to psychiatric
settings and nonfederal hospitals had an intake diagnosis of an affective
disorder. With approximately one out of six youngsters seen in psychiatric
settings having a formal diagnosis of a depressive disorder, it is reasonable to
view depression as one of the most prevalent and pervasive forms of
psychopathology in this age group.
CURRENT
FORMULATIONS
In the past 15 years there has been a growing interest
by clinicians and researchers in the examination and study of depression in
children and adolescents. In particular, interest has been shown by
psychologists in school settings, where depression in children and adolescents
is likely to be first identified. This recent attention is indeed fortunate, and
follows a relatively lengthy period in which depression in children was
considered to be either nonexistent, masked, or expressed in symptomatology
quite different from that of adults (Reynolds, 1985). The latter perspective
typically was expressed via the construct of depressive equivalents (Glaser,
1967; Hollon, 1970; Rie, 1966), in which overt negative behaviors such as
acting-out, aggression, hyperactivity, and delinquency were considered symptoms
of childhood depression.
Depression currently is conceptualized within formal
and informal systems of classification as quite similar in its symptom
expression in children, adolescents, and in adults (American Psychiatric
Association, 1980, 1987; Carlson & Cantwell, 1980, 1982; Cytryn, McKnew,
& Bunney, 1980; Poznanski, Mokros, Grossman, & Freeman, 1985; Reynolds,
1984, 1985), with minor differences due to developmental considerations (Carlson
& Garber, 1986). However, the validity of this perspective has not been
adequately tested, and remains an area of concern (Reynolds, in press a).
Depression in children and adolescents, as in adults,
is not expressed as a single symptom (e.g., manifest sad mood), but as a cluster
of symptoms that may include anhedonia, dysphoria, lowered self-esteem, social
withdrawal, fatigue, impaired school performance, crying spells or tearfulness,
problems in sleeping and eating, and self-destructive cognitions or behaviors
(American Psychiatric Association, 1987; Carlson & Cantwell, 1982;
Poznanski, 1982; Poznanski, Cook, & Carroll, 1979). Within the school
setting, depressive symptoms in children may also be expressed by a decreased
ability to effectively deal with the demands of the classroom, and an inability
to interact effectively with peers (Straw, 1988). Thus, school psychologists
need to be knowledgeable about this disorder, and cognizant that other
school-related difficulties may be an outcome or symptomatic of depression in
children and adolescents.
Depression in youngsters may be one of the most
overlooked, and undertreated psychopathologies of childhood and adolescence.
Estimates of prevalence of diagnostic cases and youngsters who demonstrate a
"clinical" level of depressive symptomatology, range from roughly 6% to 12% of
adolescents in regular school settings (Kashani, Rosenberg, & Reid, 1989;
Reynolds, 1987a), with lower levels found in children (Anderson, Williams,
McGee, & Silva, 1987; Kashani et al., 1983). These figures suggest an
enormous number of school-aged youngsters in need of psychological attention and
services.
Depression in children and adolescents may also exist
concurrently with other psychiatric diagnoses. Both, conduct disorders and
anxiety disorders have been found to occur along with depression in youngsters
(Alessi & Magen, 1988; Puig-Antich, 1982; Puig-Antich & Rabinovich,
1986; Strauss, Last, Hersen, & Kazdin, 1988). This is an important
consideration, since as Kovacs (1985,1989) suggests, the presence of concomitant
disorders with depression in children and adolescents may increase the potential
for long-term mental health problems.
It is important to note the relationship between
depression and suicidal behaviors in youngsters is far from perfect. Although a
large proportion of depressed youngsters can be considered not at risk for
suicidal behaviors, and a number of youngsters are depressed and suicidal, a
significant proportion of youngsters are at risk for suicidal behavior but are
not depressed (Reynolds, 1988a; in press b). For instance, Reynolds and Mazza
(1989) in a study of 330 adolescents reported a correlation of .47 (p <
.0001) between the Reynolds Adolescent Depression Scale (RADS) (Reynolds, 1986a)
and the Suicidal Behaviors Interview (SBI) (Reynolds, 1988b). Specific to
youngsters' scores on these measures, 35% of the sample who were above the
cutoff score on the SBI were not depressed according to their RADS scores. This
suggests a conceptualization of depression and suicidal behaviors as two
related, but somewhat distinct forms of psychopathology. Psychologists examining
depression in children and adolescents should not overlook the possibility that
a youngster may be suicidal. For the latter problem, formal self-report
(Reynolds, 1987b) and clinical interview measures (Reynolds, 1988b, in press c)
have been developed which allow for a comprehensive evaluation of the suicidal
youngster.
Since the late 1970s, a significant body of research
on depression in young people has emerged, with descriptions of epidemiology;
psycho-social, individual difference, and biological correlates; and
classification, diagnosis, and assessment (Reynolds, 1985). However, unlike the
study of depression in adults, which encompasses numerous experimental
investigations of psychological intervention procedures, there have been only a
few experimental studies of psychological treatments for depression in children
and adolescents. Most of the controlled psychological treatment studies of
depression in children and adolescents have been conducted in school settings,
and are therefore of potential value to school psychologists.
School psychologists should be aware that it is not
unusual to find affective disorders in parents of children who are depressed
(e.g., Reid & Morrison, 1983). Depression (as well as many other
psychopathologies) in one or both parents is a potential complicating factor in
the assessment (i.e., when using parent reports of children's depression) and
treatment of depression as well as other psychological problems in youngsters.
DIAGNOSIS
OF DEPRESSION IN CHILDREN AND ADOLESCENTS
Diagnosis is an evaluation process which involves the
comparison of an individual's symptoms with prespecified criteria for one or
more disorders. The outcome of this process typically is whether or not an
individual meets the classification criteria In most cases a decision is made
based on the symptoms presented as well as those not in evidence.
Diagnosis may also be viewed as a type of measurement.
Thus, measurement error, or reliability, is an important consideration when we
make a diagnosis. As in other measurement procedures, multiple sources of
measurement error are possible in making a diagnosis including error due to the
diagnostician and the diagnostic system. Described below are a number of systems
that have been used to formulate a diagnosis of depression in children and
adolescents. Classification systems should not be viewed as static or immutable
in their description of inclusion and exclusion criteria for specific disorders.
As we learn more about specific disorders, modifications in systems of
classification become necessary. This process is exemplified by ongoing
revisions in the Diagnostic and Statistical Manual of Mental Disorders and the
International Classification of Diseases.
Diagnostic Systems and Approaches
A number of diagnostic systems are used by researchers
and clinicians for the delineation and description of depression in children and
adolescents. Current classification systems generally utilize a taxonomic
approach for the differentiation of subtypes of depression based on symptom
clusters and employ both inclusion and exclusion criteria. In the United States,
the primary system for the classification of depressive disorders in children,
adolescents, and adults is the Diagnostic and Statistical Manual of Mental
Disorders--3rd Edition Revised (DSM-IIIR; American Psychiatric Association,
1987). The DSM-IIIR classification of depressive disorders in children and
adolescents is similar to that in adults. The widespread, although not total,
acceptance of the DSM-IIIR taxonomy by psychologists and psychiatrists has
provided common, formal criteria for the diagnosis of depression in children.
Another classification system, the Research Diagnostic Criteria (RDC) (Spitzer,
Endicott, & Robins, 1978), was designed for research purposes and provides
greater specificity of distinct subtypes of depression than does DSM-IIIR.
Weinberg, Rutman, Sullivan, Penick, and Dietz (1973)
proposed what generally is considered to be the first contemporary diagnostic
description of symptoms and criteria for depression in children. Although not in
general use today, the Weinberg Criteria (Weinberg et al., 1973) is noteworthy
as the first formal system for classifying depressive disorders in children and
adolescents. By suggesting that depressive symptoms evident in adults are also
found in developmentally modified form in children, the Weinberg Criteria was
instrumental in advancing the recognition of depression in children as a
phenomenologically similar disorder as found in adults. In addition, Petti
(1978,1985) developed the Bellevue Index of Depression (BID) as a systematic
clinical interview for the evaluation of Weinberg specified symptomatology in
children. Although somewhat less structured as formal criteria, Poznanski and
her colleagues (Poznanski, 1982; Poznanski, Mokros et al., 1985) have also
described clinical symptomatology for depression in children, and also developed
a clinical interview for the assessment of depression in children (Poznanski et
al., 1979; Poznanski, Freeman, & Mokros, 1985).
Diagnostic and Statistical Manual of Mental Disorders
As noted, the diagnostic system most often used for
clinical purposes as well as some research investigations is the DSM-IIIR
(American Psychiatric Association, 1987). Depressive disorders in the DSM-IIIR
fall under the category of Mood Disorders, and include Major Depression, Bipolar
Disorders, Cyclothymia, and Dysthymia. Disorders are differentiated by specific
clusters of symptoms, age of onset, and the duration of symptoms. Disorders that
are most likely to be found in schoolaged youngsters are Major Depression and
Dysthymia, although Adjustment Disorder with mood should also be considered
diagnostically relevant for some youngsters (e.g., Kovacs, 1985). The depressive
disorders subsumed under the domain of Mood Disorders in the DSM-IIIR are
illustrated in Table 1.
Major Depression. In DSM-IIIR Major Depression denotes
a relatively severe, acute form of depression. Major Depression as a diagnostic
syndrome is defined by the following criteria and symptomatology, the presence
of five of the following symptoms, one of which is either dysphoric mood (can be
irritable mood in children and adolescents) or anhedonia (loss of interest or
pleasure in all or almost all activities). Other symptoms include sleep problems
as manifested by insomnia or hypersomnia; complaints or other evidence of
diminished ability to think or difficulty concentrating; loss of energy or
general fatigue; eating problems as manifested by decreased or increased
appetite or significant weight loss or gain (in young children failure to make
expected weight gains is symptomatic); psychomotor retardation or agitation;
suicidal or morbid ideation, death wishes, or suicide attempts; and feelings of
self-reproach, worthlessness, or excessive or inappropriate guilt (which may be
delusional). Symptoms need to be present nearly every day for a period of at
least 2 weeks. A number of exclusion criteria are also specified that preclude a
number of other pathologies, such as Organic Mental Disorder as concomitant
problems, to make a diagnosis of Major Depression.
Dysthymia. Dysthymia is a chronic disorder somewhat
less severe in symptom distress as compared to Major Depression, but typically
of greater duration. Dysthymia may be especially relevant to the study of
depression in children and adolescents. Kovacs et al., (1984) in a longitudinal
study found that Dysthymia was a longlasting problem for some children and
adolescents, with the disorder lasting 5 years or longer in some youngsters.
Diagnostic criteria for Dysthymia in children and
adolescents is depressed or irritable mood for most of the day, and manifested
most of the time over a period of at least 1 year, although there may be periods
of up to 2 months where symptoms are not present. In addition, at least two of
the following symptoms must be present when depressed: appetite loss or gain,
insomnia or hypersomnia, fatigue or low energylevel, low-self-esteem, poor
concentration or problems making decisions, and feelings of hopelessness.
Exclusion criteria include no evidence of Major Depressive Episode during
initial year of the disorder, has never had a Manic or Hypomanic Episode, and is
not superimposed on a chronic psychosis, nor due to or maintained by an organic
factor.
In addition to the symptoms noted above for diagnosis
of either Major Depression or Dysthymia, other symptoms of depression are found
in youngsters as well as adults. These may include crying, anxiety or worry,
social withdrawal, and other symptoms associated with depression, but which are
not viewed as core symptoms specific to the diagnostic criteria for Major
Depression or Dysthymia. Table 2 presents a listing of symptoms of depression
that includes both the core and secondary symptoms noted by the DSM-IIIR. This
listing is modified to encompass symptom expression in children and adolescents.
School psychologists should be observant for these and other associated symptoms
in children and adolescents.
ASSESSMENT
OF DEPRESSION IN CHILDREN AND ADOLESCENTS
Assessment is basic to the identification and study of
depression in children and adolescents and as a means for determining the
efficacy of treatment. The assessment of depression in young persons is
complicated by the availability of different measures using different
perspectives and sources of information (e.g., parent, child, teacher, peer), as
well as different assessment methods (e.g., checklists versus clinical
interview). A majority of the research on assessment and diagnosis of depression
in youngsters indicates minimal concordance across sources (raters), but
relatively high within-rater relationships (Reynolds, in press a). Given the
internalizing nature of depression in youngsters, there is reason to believe
that children and adolescents are viable reporters of their symptom distress
(Reynolds & Graves, 1989a). This section describes five representative
measures, three self-report and two clinical interviews, which have been used
for the assessment of depression in children and adolescents. Although typically
not used by school psychologists, clinical interviews generally are considered
to be one of the most sensitive methodologies for the assessment of depression
(Pulg-Antich & Gittelman, 1982). Clinical interviews generally allow for
detailed evaluation and probing of children's symptoms, and the determination of
whether symptom endorsement is a function of depression or extraneous factors.
Because the clinical interview is individualized to each child, it can also
accommodate developmental and cognitive restrictions in children (Kovacs, 1986).
Assessment Measures
Five measures are described which utilize the child or
adolescent as the primary source of information regarding their level of
depressive symptomatology. These instruments are presented as examples of
appropriate measures that can be used by psychologists in school settings. It
should be noted that other measures also have been used for the assessment of
depression in youngsters. A recent review of assessment measures by Kazdin
(1987) is recommended for additional readings.
Children's Depression Inventory. The Children's
Depression Inventory (CDI)(Kovacs, 1979) is a 27-item forced-choice measure of
depressive symptomatology in children. Items use a 3-alternative format, where
the child selects the symptom level that best characterizes how he or she is
feeling. There is a large amount of research on the CDI. Studies typically
report internal consistency reliability coeffcients in the mid to upper .80s
(e.g., Nelson, Politano, Finch, Wendel, & Mayhall, 1987), and somewhat lower
test-retest reliability coefficients depending on the interval between testings
(e.g., Kovacs, 1981, 1983; Smucker, Craighead, Craighead, & Green, 1986).
Although not designed as a diagnostic measure, the CDI
is useful in assessing the severity of depressive symptomatology. One question
on the clinical use of the CDI is what cutoff score represents a clinically
relevant level of depressive symptoms? Kovacs (1983) suggests a cutoff score of
13 be used to delineate a clinical level of depression, although this score will
over-identify a significant number of nondepressed youngsters. Overall, the CDI
is a useful self-report measure of depression in children, although the lack of
a test manual, normative information, and guidelines for interpretation of
scores limits the clinical use of this scale in school settings.
Reynolds Child Depression Scale. The Reynolds Child
Depression Scale (RCDS; Reynolds, 1989a), previously called the Child Depression
Scale (e.g., Bartell & Reynolds, 1986; Reynolds, Anderson, & Bartell,
1985; Stark Reynolds, & Kaslow, 1987) is a brief, 30-item self-report
measure of depressive symptomatology in children, ages 8 through 12 years. The
RCDS is designed for the assessment of clinically relevant levels of depressive
symptomatology in children. It can be individually or group administered. The
RCDS consists of 29 items that utilize a 4-point liken-type response format, and
one item for which the response format is five smiley-type faces ranging from
happy to sad.
Normative information based on over 1,600 children
representing heterogeneous ethnic and socioeconomic backgrounds is reported in a
detailed manual, along with procedures for administration, scoring and
interpretation, and extensive data on reliability and validity. Internal
consistency reliability for the standardization sample was .90. Reynolds and
Graves (1989a) reported a test-retest reliability coefficient of .86 for the
RCDS using a 4-week interval between testing with an ethnically diverse sample
of 220 children from grades 3 through 6. Validity data are presented in the form
of high correlations with other self-report and clinical interview measures of
childhood depression, as well as content validity, factor analysis, discriminant
validity and clinical utility (Reynolds, 1989b).
Children's Depression Rating Scale --Revised. The
Children's Depression Rating Scale-Revised (CDRS-R) (Poznanski et al., 1984;
Poznanski, Freeman, & Mokros, 1985) is a frequently used outcome measure in
psychiatric studies of childhood depression. The CDRS-R is a semi-structured
interview schedule, designed for use with children ages 6 through 12 years, and
requires about 20 to 30 minutes to administer. The CDRSR consists of 17 items
each specific to a symptom of depression and rated on a 5 or 7 point scale.
Pozaanski (Poznanski et al., 1979; Poznanski et al, 1984) reported adequate
test-retest and inter-rater reliability, and high correlations between the CDRS
and psychiatrists' global ratings of depression.
Reynolds Adolescent Depression Scale. The Reynolds
Adolescent Depression Scale (RADS; Reynolds, 1986a, 1987a) is a 30-item,
paper-and-pencil self-report measure of depression designed for use with
adolescents ages 13 through 19 years. The RADS uses a four-point response format
with items reflecting most symptomatology specified by the DSM-III for major
depression and dysthymic disorder. Item content includes somatic, motivational,
cognitive, mood and vegetative components of depression, with items worded at a
third-grade reading level.
The RADS manual reports data on over 11,000
adolescents from the midwestern, as well as southeastern and western portions of
the country. For screening and clinical applications, a cutoff score has been
validated to designate a clinically relevant level of symptom severity. Internal
consistency reliability estimates have been uniformly high (ranging from .92 to
.96) with different samples of normal and depressed adolescents ranging in size
from 126 to 2,240. (Reynolds, 1987a; Reynolds & Miller, 1989). In a study of
26 mildly retarded adolescents (Reynolds & Miller 1985), the internal
consistency reliability was .87. Test-retest reliability with a 6-week interval
between testings was .80 with a sample of 104 adolescents.
A number of studies have established the validity of
the RADS using bivariate and multivariate procedures to examine relationships
with other depression scales and measures of related constructs. To summarize,
the RADS has been found to be highly correlated with other self-report measures
of depression (r's ranging from .70 to .89). A correlation of .83 was found
between the RADS and the HDRS with a sample of 111 adolescents, substantiating
criterion-related validity.
Hamilton Depression Rating Scale. The Hamilton
Depression Rating Scale (HDRS) (Hamilton, 1960; 1967) is a clinical interview
for the assessment of severity of depressive symptoms. The HDRS has been found
to demonstrate a high degree of clinical utility in distinguishing between
adults with formal RDC diagnoses of Major Depression, Minor Depression, and
nondepressed controls (Kobak, Reynolds, Rosenfeld & Greist, in press). The
Hamilton Depression Rating Scale-High School Adaptation (HDRS-HS) (Reynolds,
1982) assesses the same 17 symptoms as evaluated on the adult version of the
HDRS, with modifications for school-age appropriate activities and developmental
level. The 17 item HDRS-HS does require a trained interviewer and typically
requires between 20 and 30 minutes to administer. Reynolds and Bartell (1983) in
a longitudinal study of depression in 111 adolescents found high internal
consistency reliability (rAlpha = .91), and adequate test-retest
reliability over 12 weeks (rtt = .77) and interrater reliability (r [sub
rr = .83) for the HDRS-HS.
School-Based Idenfitication of Depressed Youngsters
It has been suggested that the identification of
depressed children and adolescents in school settings should be conceptualized
as a proactive procedure (Reynolds, 1986b). Because of the low numbers of
youngsters who self-refer for depression, and difficulty in accurate
identification by significant others, a school-based procedure for the
identification of depressed youngsters may be viewed as an important component
in the provision of services to children and adolescents. A viable strategy to
accomplish this is the use of a multiple-stage screening procedure for the
identification of depressed youngsters.
The identification of depressed children and
adolescents is hampered by limited self-referral evidenced in this population.
There is also a tendency by some parents to deny or reject information that
their child may be suffering from an affective disorder. To some extent, the
constellation of symptoms of depression, many of which are internalizing such as
cognitive and somatic features, limits the identification of depressed children
and adolescents by parents or teachers (Leon, Kendall, & Garber, 1980;
Reynolds et al., 1985; Reynolds & Graves, 1989b). Thus, the direct
assessment of the child may provide the best procedure for the initial
identification of potentially depressed children. The school therefore provides
an optimal setting for the early identification of depressed children and
adolescents.
The identification of depressed youngsters requires a
systematic evaluation of individuals potentially at risk. The screening
procedure described here consists of three assessment stages for identifying
clinically depressed youngsters in school settings and has been elaborated in
greater detail by Reynolds (1986b). The multiple-stage screening is important
owing to the number of false positives which may occur with a single
administration of a self-report depression measure.
Stage 1. The initial stage is the large group
assessment (i.e., classrooms) with a self-report, paper-and-pencil measure of
depression, such as the RCDS or RADS. An enhanced procedure for adolescents at
this stage is the inclusion of a measure specific to the identification of
youngsters at risk for suicidal behaviors, such as the Suicidal Ideation
Questionnaire (Reynolds, 1987b, 1988a). This assessment of an entire school,
including administration, directions, and distribution of the questionnaires,
can be carried out in 16 to 20 minutes.
A significant proportion of youngster (8 to 15%
depending on age-level) typically are identified on a single administration. To
some extent, this is an over-identification of youngsters, due to such potential
factors as acquiescence, poor metacognitive understanding of symptom severity,
noncompliance with directions, or a transient mood disturbance or a reaction to
minor stressors. Conducting clinical interviews as a follow-up on a potentially
large number of children can be costly in terms of time and resources. The over
identification at Stage 1 is considered appropriate since this will result in a
decrease in false negatives (i.e., missing a youngster who is depressed).
Stage 2. To reduce the number of false positives, the
second stage of the screening consists of re-administration of the self report
depression measure to identified youngsters. This can be accomplished by the
assessment of small groups of 6 to 10 students at a time. Youngsters identified
as reporting significant depressive symptomatology on both assessments (Stages 1
and 2) should then be individually assessed by qualified school psychologists or
mental health professionals with a structured or semi-structured clinical
interview.
Stage 3. For the systematic and clinical evaluation of
depression in youngsters, an individual clinical interview for depression should
be conducted by a school psychologist, or other health professional
knowledgeable about depression in youngsters and trained on the interview
procedure used. This interview should be conducted with all students who meet
the depression criteria at both Stage 1 and Stage 2, as well as youngsters who
may have met criteria at only one stage, but who for other reasons may be viewed
as potentially at-risk.
A clinical interview with the youngster and possibly
parents typically is warranted to confirm a diagnosis, or clinical level of
depression. A number of clinical interview measures for children are available,
including measures of severity, such as the CDRS-R (Poznanski et al., 1984) and
the BID (Petti 1978), both of which have been used in treatment outcome studies
of depression in children and adolescents (Kahn, 1988; Reynolds & Coats,
1986; Stark, Reynolds, & Kaslow, 1987), as well as interview measures used
for diagnosis (i.e., Puig-Antich & Chambers, 1978).
Youngsters who meet the criteria for clinical levels
of depression at all stages of the screening model should be seen or referred
for active treatment and intervention. Children who meet criteria at the first
two, but not the third stage, should be considered nondepressed, but in need of
re-evaluation at a later date.
TREATMENT
OF DEPRESSTON IN CHILDREN AND ADOLESCENTS
The treatment,of depression in children and
adolescents is not an activity which should be entered into without training and
knowledge of affective disorders, psychological models of depression, and
associated treatment modalities. There are multiple reasons for this caution.
Foremost is the nature of depression with particular reference to the distress
experienced by the youngster.Treating a disorder of childhood that is
characterized by a youngster experiencing intense subjective misery, along with
numerous somatic disturbances such as sleep disturbance and appetite loss, as
well as the potential for suicidal thoughts or intent, is a serious undertaking.
Such a case represents a distinctly different task than the treatment of a
youngster for academic problems or behavioral problems such as aggression or
acting out. In the case of depression, failure to make significant, long lasting
treatment gains within a relatively short period of time, may for some
youngsters prolong a level of unbearable psychological distress. Given treatment
failure, the condition in some youngsters may be exacerbated by increased
feelings of hopelessness, helplessness, and despondency.
Pharmacotherapy for Depression in Children and Adolescents
Most of the empirical literature on the treatment of
depression in children and adolescents has focused on the use of
psychopharmacological agents. Pharmacological interventions for the treatment of
depression in children and adolescents have been described by Petti (1983),
Puig-Antich, Ryan, and Rabinovich (1985), and Weller and Weller (1984,1986)
among others. These investigations generally have demonstrated clinical efficacy
of several tricyclic antidepressants. At least one case study has been reported
in which psychotherapy and a tricyclic antidepressant (imipramine) were used in
combination (Petti, Bornstein, Delamater, & Conners, 1980).
Psychological Intervention Research
Several single case studies for the treatment of
depression in children have been reported. The study by Petti et al., (1980)
noted above, involved in multimodal treatment of depression in a 10-year old
girl. This treatment, which included tricyclic antidepressant medication, was
effective in reducing depressive symptoms in the youngster. A case study which
was conducted by Frame, Matson, Sonis, Fialkov, and Kazdin (1982) involved a
behavioral intervention for depression in a 10-year old boy. Overall symptom
reduction was shown in four target behaviors (inappropriate body position, lack
of eye contact, poor speech, and bland affect); however, change across a range
of depressive symptoms was not presented.
Several control-group treatment studies examining the
efficacy of psychological treatments for depression in children and adolescents
have been conducted. In one of the first reported studies, Butler, Miezitis,
Friedman, and Cole (1980) compared moderately depressed 5th and 6th grade
children who received either: a treatment emphasizing social skills and social
problem solving, a cognitive restructuring treatment, or assignment to attention
or waitlist control conditions. The two active treatments and attention
condition consisted of 10 1-hour sessions conducted in small groups. A
pretest-posttest design was used, although the authors did not conduct a
follow-up evaluation to determine the maintenance of treatment gains. At the
posttest, significant decreases in depression scores on the CDI were found for
the active treatment conditions, as well as for the waitlist control. The
attention group was unchanged. Although the results of this study were somewhat
mixed, this study is noteworthy in that it was the first experimental group
intervention conducted in a school setting.
Stark, Reynolds, and Kaslow (1987) conducted a control
group treatment study, comparing cognitive-behavioral (self-control) and
behavioral problem-solving treatment conditions to a waiting list control group.
Subjects were 29 moderately depressed children, ages 9 to 12 years. Assessment
measures included the RCDS, CDI, and the CDRS-R. Treatment took place in an
elementary school and consisted of 12 50-minute sessions administered in small
groups over a 5-week period.
The cognitive-behavioral treatment relied heavily on
the self-control treatment for depression as developed by Rehm and colleagues
(Fuchs & Rehm, 1977; Rehm, 1977). Cognitive components consistent with
Beck's (1976) cognitive therapy and components of attribution retraining were
also included. The behavioral problem-solving therapy included training in
self-monitoring as a precursor to the presentation of more behavioral
components. The problem-solving therapy focused on procedures consistent with
Lewinsohn's social learning theory (Lewinsohn & Arconad, 1981; Lewinsohn,
Munoz, Youngren, & Zeiss, 1978) designed to increase children's involvement
in pleasant activities. In addition, modeling of therapist presented
problem-solving skills, with an emphasis on increasing engagement in pleasant
activities as well as improving social behavior were included.
Results at posttesting suggested both active
treatments demonstrated significant improvement in depressive symptomatology
while the difference for the waiting list control group was nonsignificant. An
8-week follow-up assessment showed a general maintenance of treatment effects,
with some children in the self-control condition continuing to improve from
posttest to follow-up. Children in the waiting list condition were treated after
the posttest and were not included in the between-group comparisons at
follow-up. Overall results indicated that the treatments were reasonably
effective, with 88% of the children in the self-control group and 67% of those
in the behavioral group nondepressed at the follow-up assessment.
The first published group treatment study of
depression in adolescents was conducted by Reynolds and Coats (1986). This
investigation compared a cognitive-behavioral treatment, a relaxation training
group, and a waiting list control group. Subjects were 30 moderate to severely
depressed high school students, with treatment administered within the high
school setting. Treatments for both active conditions were administered in 10
one-hour sessions over a 5-week period. Assessment measures included the RADS
and BID. The cognitive-behavioral therapy included elements of self-control
procedures (i.e., self-monitoring, self-evaluation, and self-reinforcement),
cognitive restructuring components consistent with Beck's cognitive therapy, and
procedures for increasing engagement in pleasant activities (Lewinsohn et al.,
1978). The relaxation training condition focused on training in progressive
relaxation procedures (Jacobsen, 1938), with some guided imagery included.
Significant treatment gains for both active treatment
conditions were found at the posttesting and were maintained at the 4-week
follow-up evaluation. Table 3 provides RADS scores for the experimental and
control groups at the pretest, posttest, and follow-up assessment points. As
shown, significant decreases in depression were reported by youngsters in the
cognitive-behavioral and relaxation groups at posttest, with minimal change in
the waiting list youngsters. Additional therapeutic effects of treatments on
subjects' self-concept and level of anxiety were also reported by Reynolds and
Coats (1986).
Kahn (1988) in a study with moderately depressed
youngsters in middle school (grades 6, 7, and 8), investigated the efficacy of
several treatments for depression, including cognitive-behavioral, relaxation
training, and a self-modeling condition, along with a waitlist control group.
The cognitive-behavioral treatment focused primarily on pleasant activity
scheduling and other behavioral components consistent with the approach of
Lewinsohn et al. (1978), with some cognitive, self-control, and social skills
training added. The relaxation training group was similar to that of Reynolds
and Coats (1986). Both of these treatments were group administered in 12
50-minute sessions. The self-modeling condition was individually administered
with subjects developing a 3-minute videotape in which they modeled behaviors
such as smiling, positive verbalizations, and appropriate eye contact which were
considered inconsistent with depression. Assessment measures included the RADS,
CDI, and BID.
All therapeutic groups demonstrated significant
treatment gains at posttesting and at a 4-week follow-up although the
cognitive-behavioral and relaxation training groups tended to show the greatest
therapeutic benefits. The results of Kahn's study specific to treatment outcome
on the RADS are presented in Table 3. It can be seen that the results of the
Kahn (1988) investigation are consistent with those of Reynolds and Coats
(1986), suggesting the clinically efficacy of these psychological treatments of
depression in youngsters. A more detailed presentation of the Kahn (1988) study
is presented in this volume (see Kahn, Kehle, Jenson, & Clark, 1990).
Research to date suggests that psychological
treatments hold promise for the amelioration of depression in children and
adolescents. Guidelines and specific recommendations for school-based treatments
of depression in children and adolescents have been provided by Reynolds and
Stark (1987) and Reynolds (in press d). It should be noted that the treatment of
depression in youngsters is not a simple task. Treatment should be conducted by
a therapist with training in effective procedures along with a solid
understanding of depressive disorders in children and adolescents.
SUMMARY
AND CONCLUSIONS
Depression represents a serious and often overlooked
internalizing disorder in children and adolescents. Although we now recognize
depression in youngsters as a valid diagnostic entity, and have developed
procedures for its assessment, there is still much to be learned. In particular,
the effectiveness of various treatments for depression in youngsters is an area
in need of further study and research.
School psychologists are in a relatively unique
position for the identification of depression in children and adolescents. Given
the number of youngsters suggested by research to be experiencing clinical
levels of depression, active procedures need to be implemented in schools for
the identification and treatment of these children and adolescents. Likewise, a
concurrent focus on suicidal youth should also be considered given the
seriousness and problematic nature of this problem. If school psychologists do
not become advocates for the mental health and wellbeing of children and
adolescents, and take a proactive approach to meeting the needs of distressed
youngsters, it will be the children who suffer the consequences.
TABLE 1
DSM-IIIRa Diagnostic Classifications of Mood Disorders
Mood Disorders
Bipolar Disorder
Mixed
Manic
Depressed
Cyclothymia
Bipolar Disorder Not Otherwise Specified
Major Depression (single episode, recurrent)
Melancholic Type
Seasonal Pattern
Dysthymia
Depressive Disorder Not Otherwise Specified
[a] Diagnostic and Statistical Manual of Mental Disorders -- 3rd
Ed. Revised, American Psychiatric Association (1987).
TABLE 2
Depressive Symptomatology in Children and Adolescents
Major
Depression Dysthymia Symptom
+ + Dysphoria
+ + Insomia or hypersomnia
+ + Change in appetite/weight or in
expected weight gains
+ + Fatigue -- low energy
+ Psychomotor retardation/agitation
+ Suicidal ideation or attempt
+ + Irritability or excessive anger (possible
antisocial behavior)
+ Tearfulness or crying
+ Loss of interest in pleasurable
activities
+ Pessimistic attitude toward the
future -- hopelessness
+ + Decreased ability to think -- poor
concentration
+ + Feelings of inadequacy, loss of
self-esteem, or self-deprecation
+ + Decreased effectiveness or productivity
in school or school difficulties
+ + Social withdrawal
+ Somatic complaints
+ Excessive guilt
+ Feelings of rejection
+ Anxiety
+ Desire to leave home
+ Mood congruent hallucinations
TABLE 3
Summary of Two Adolescent Depression Treatment Studies with
Reynolds Adolescent Depression Scale (RADS) as Outcome Measure
Study Groups Pretest Posttest[a]
Reynolds & Cognitive-Behavioral 85.67 66.74
Coats (1986) Relaxation Training 80.09 65.80
Waitlist Control 80.70 81.12
Kahn (1988) Cognitive-Behavioral 85.41 53.44
Relaxation Training 83.82 61.76
Self-Modeling 84.27 62.12
Waitlist Control 86.91 80.12
Study Groups Follow-up
Reynolds & Cognitive-Behavioral 62.60
Coats (1986) Relaxation Training 54.73
Waitlist Control 72.25
Kahn (1988) Cognitive-Behavioral 54.18
Relaxation Training 61.58
Self-Modeling 64.18
Waitlist Control 74.70
Note. In both studies reported above, a screening
assessment was utilized prior to the presenting.
[a] Posttest and Follow-up RADS scores for the
Reynolds and Coast study are adjusted means based on an analysis of covariance
using pretest scores as the covariate.
Corresppondence regarding this article may be sent to
William M. Reynolds, Department of Educational Psychology, University of
Wisconsin-Madison, 1025 Johnson Street, Madison, Wisconsin 53706.
REFERENCES
Alessi, N.E., & Magen, J. (1988) Comorbidity of
other psychiatric disturbances in depressed psychiatrically hospitalized
children. American Journal of Psychiatry, 145, 1582-1584.
American Psychiatric Association. (1987). Diagnostic
and statistical manual of mental disorders-- 3rd ed. revision, Washington, DC:
Author.
Anderson, J. C., Williams, S., McGee, R., & Silva
P. ] A. (1987). DSM-III disorders in preadolescent children. Prevalence in a
large sample from the general population. Archives of General Psychiatry, 44,
69-76.
Bartell, N. P., &Reynolds, W. M. (1986).
Depression and self-esteem in academically gifted and nongifted children: A
comparison study. Journal of School Psychology, 24, 66-61.
Beck, A. T. (1976). Cognitive therapy and the
emotional disorders. New York International Universities Press.
Carlson, G. A., & Cantwell, D. P. (1980).
Unmasking masked depression in children and adolescents. American Journal of
Psychiatry, 137, 446-449.
Carlson, G. A., & Cantwell, D. P. (1982).
Diagnosis of childhood depression: A comparison of the Weinberg and DSM-III
criteria. Journal of the American Academy of Child Psychiatry, 21, 247260.
Carlson, G. A., & Garber, J. (1986). Developmental
issues in the classification of depression in children. In M. Rutter, C. E.
Izard, & P. B. Read (Eds.). Depression in young people: Development and
clinical perspectives. (pp. 399-434). New York: Guilford Press.
Cytryn, L, McKnew, D. H., & Bunney, W. E. (1980).
Diagnosis of depression in children: A reassessment. American Journal of
Psychiatry, 137, 2226.
Endicott, J., & Spitzer, R. L. (1978). A
diagnostic interview: The schedule for affective disorders and schizophrenia
Archives of General Psychiatry, 35, 837-844.
Frame, C., Matson, J. L., Sonis, W. A., Fialkov, M.
J., & Kazdin, A. E. (1982). Behavioral treatment of depression in a
prepubertal child. Journal of Behavior Therapy and Experimental Psychiatry 13,
239-243.
Fuchs, C. Z., & Rehm, L. P. (1977). A self-control
behavior therapy program for depression. Journal of Consulting and Clinical
Psychology, 45, 206216.
Glaser, K. (1967). Masked depression in children and
adolescents. American Journal of Psychotherapy, 21, 666-674.
Hamilton, M. (1960). A rating scale for depression.
Journal of Neurology, Neurosurgery, and Psychiatry, 23, 66-62.
Hamilton, M. (1967). Development of a rating scale for
primary depressive illness. British Journal of Social and Clinical Psychology,
6, 278-296.
Hollon, T. H. (1970). Poor school performance as a
symptom of masked depression in children and adolescents. American Journal of
Psychotherapy, 24, 268-263.
Jacobsen, E. (1938). Progressive relaxation. Chicago:
University of Chicago Press.
Kahn, J. (1988). Assessment and treatment of
depression among early adolescents. Unpublished Doctoral Dissertation,
University of Utah, Salt Lake City.
Kahn, J. S., Kehle, T. J., Jenson, W. R., & Clark,
E. (1990). Comparison of cognitive-behavioral relaxation, and self-modeling
interventions for depression among middle-school students. School Psychology
Review, 19, 196-211.
Kashani, J. H., McGee, R. O., Clarkson, S. E.,
Anderson, J. C., Walton, L A., Williams, S., Silva, P. A., Robins A. J., Cytryn,
L., & McKnew, D. H. (1983). Depression in a sample of 9-year-old children:
Prevalence and associated characteristics. Archives of General Psychiatry, 40,
1217-1223.
Kazdin, A. E. (1987). Assessment of childhood
depression: Current issues and strategies. Behavioral Assessment, 9, 291-319.
Kobak, K., Reynolds, W. M., Rosenfeld, R., Greist, J.
H. (in press). Development and validation of computer administered version of
the Hamilton Depression Rating Scale. Psychological Assessment: A Journal of
Consulting and Clinical Psychology.
Kovacs, M. (1979). Children 's Depression Inventory.
University of Pittsburgh School of Medicine. Author.
Kovacs. M. (1981). Rating scales to assess depression
in school-age children. Acta Pacdopsychiatrica, 46 305-315.
Kovacs, M. (1983). The Children's Depression
Inventory: A self-rating scale for school-aged youngsters. Unpublished
manuscript.
Kovacs, M. (1986). The natural history and course of
depressive disorders in childhood. Psychiatric Annals, 15, 387-389.
Kovacs, M. (1986). A developmental perspective on
methods and measures in the assessment of depressive disorders: The clinical
interview. In M. Rutter, C. E. Izard, & P. B. Read (Eds.), Depression in
young people: Developmental and clinical perspectives. (pp. 435-465). New York
Guilford Press.
Kovacs, M. (1989). Affective disorders in children and
adolescents. American Psychologist, 44, 209-215.
Kovacs, M., Feinberg, T. L., Crouse-Novak, M.,
Paulauskas, S. L., Pollock M., & Finkelstein, R. (1984). Depressive
disorders in childhood: II. A longitudinal study of the risk for a subsequent
major depression. Archives of General Psychiatry, 41, 229-237.
Leon, G. R., Kendall, P. C., & Garber, J. (1980).
Depression in children: Parent, teacher, and child perspectives. Journal of
Abnormal Child Psychology, 8, 221-236.
Lewinsohn, P. M., & Arconad, M. (1981). Behavioral
treatment of depression: A social learning approach. In J. F. Clarkin & A.
I. Glazer (Eds.), Depression: Behavioral and directive intervention strategies.
(pp. 33-67). New York Garland STPM Press.
Lewinsohn, P. M., Munoz, R. F., Youngren, M. A., &
Zeiss, A. M. (1978). Control your depression. Englewood Cliffs, NJ:
Prentice-HalL
Nelson, W. M., Politano, P. M., Finch, A. J., Wendel,
N., & Mayhall, C. (1987). Children's Depression Inventory: Normative data
and utility with emotionally disturbed children. Journal of the American Academy
of Child and Adolescent Psychiatry, 26, 43-48.
Petti, T. A. (1978). Depression in hospitalized child
psychiatry patients: Approaches to measuring depression. Journal of the American
Academy of Child Psychiatry, 17,49-69.
Petti, T. A. (1983). Imipramine in the treatment of
depressed children. In D. P. Cantwell & G. A. Carlson (Eds.), Affective
disorders in childhood and adolescents-An update. (pp. 376-416). Jamaica, NY:
Spectrum Publications.
Petti, T. A. (1985). Scales of potential use in the
psychopharmacologic treatment of depressed children and adolescents.
Psychopharmacology Bulletin, 21, 961-977.
Petti, T. A., Bornstein, M., Dalamater, A., &
Conners, C. K. (1980). Evaluation and multimodality treatment of a depressed
prepubertal girl. Journal of the American Academy of Child Psychiatry, 19,
690-702.
Poznanski, E. O. (1982). The clinical phenomenology of
childhood depression. American Journal of Orthopsychiatry, 52, 308-313.
Poznanski, E. O., Cook, S. C., & Carroll, B. J.
(1979). A depression rating scale for children. Pediatrics, 64, 442-450.
Poznanski, E. O., Freeman, L. N., & Mokros, H. B.
(1985). Children's Depression Rating Scale-Revised. Psychopharmacology
Bulletin, 21, 979989.
Poznanski, E. O., Grossman, J. A., Buchsbaum, Y.,
Banegas, M., Freeman, L., & Gibbons, R. (1984). Preliminary studies of the
reliability and validity of the Children's Depression Rating Scale. Journal of
the American Academy of Child Psychiatry, 28, 191-197.
Poznanski, E., Mokros, H. B., Grossman, J., &
Freeman, L. N. (1985). Diagnostic criteria in childhood depression. American
Journal of Psychiatry, 142, 1168-1173.
Puig-Antich, J. (1982). Major depression and conduct
disorder in prepuberty. Journal of the American Academy of Child Psychiatry, 21,
118-128.
Puig-Antich, J., & Chambers, W. (1978). The
Schedule for Affective Disorders and Schizophrenia for School-age Children
(Kiddie-SADS). New York New York State Psychiatric Institute.
Puig-Antich, J., & Gittelman, R. (1982).
Depression in childhood and adolescence. In E. S. Paykel (Ed.), Handbook of
affective disorders, (pp.379-392). New York: Guilford Press.
Puig-Antich, J., & Rabinovich, H. (1986).
Relationship between affective and anxiety disorders in childhood. In R.
Gittelman (Ed.),Anxiety disorders of childhood. (pp.136-166). New York Guilford.
Puig-Antich, J., Ryan, N. D., & Rabinovich, H.
(1986). Affective disorders in childhood and adolescence. In I M. Wiener (Ed.),
Diagnosis and psychopharmacology of childhood and adolescent disorders. (pp.
151-178). New York Wiley.
Rehm, L. P. (1977). A self-control model of
depression. Behavior Therapy, 8, 787-804.
Reid, W. H., & Morrison, H. L. (1983). Risk
factors in children of depressed parents. ln H. L. Morrison, (Ed.), Children of
depressed parents: Risk, identification, and intervention. (pp.33-46). New York
Grune & Stratton.
Reynolds, W. M. (1982). Hamilton Depression Rating
Scale: High School Adaptation. Unpublished manuscript, University of
Wisconsin-Madison.
Reynolds, W. M. (1984). Depression in children and
adolescents: Phenomenology, evaluation and treatment. School Psychology Review,
18, 171-182.
Reynolds, W. M. (1985). Depression in childhood and
adolescence: Diagnosis, assessment, intervention strategies and research. In T.
R. Kratochwill (Ed.), Advances in school psychology, Vol. 4. (pp. 133189).
Hillsdale, NJ: Lawrence Erlbaum.
Reynolds, W. M. (1986a). Reynolds Adolescent
Depression Scale. Odessa, FL: Psychological Assessment Resources.
Reynolds, W. M. (1986b). A model for the screening and
identification of depressed children and adolescents in school settings.
Professional School Psychology, 1,117-129.
Reynolds, W. M. (1987a). Reynolds Adolescent
Depression Scale: Professional Manual. Odessa, FL Psychological Assessment
Resources.
Reynolds, W. M. (1987b). Suicidal Ideation
Questionnaire. Odessa, FL: Psychological Assessment Resources.
Reynolds, W. M. (1988a). Suicidal Ideation
Questionnaire: Professional Manual. Odessa, FL: Psychological Assessment
Resources.
Reynolds, W. M. (1988b). Suicidal Behaviors
Interview.? Unpublished clinical interview schedule. Madison: University of
Wisconsin.
Reynolds, W. M. (1989a). Reynolds Child Depression
Scale. Odessa, FL: Psychological Assessment Resources.
Reynolds, W. M. (1989b). Reynolds Child Depression
Scale: Professional Manual. Odessa, FL: Psychological Assessment Resources.
Reynolds, W. M. (in press a). Depressive disorders in
children and adolescents. In W. M. Reynolds (Ed.), Internalizing disorders in
children and adolescents. New York: Wiley.
Reynolds, W. M. (in press b). Suicidal ideation and
depression in adolescents: Assessment and research. In P. F. Lovibond and P.
Wilson (Eds.), Proceedings of the XXIV International Congress of Psychology:
Clinical volume. Amsterdam: Elsevier Science Publishers.
Reynolds, W. M. (in press c). Development of a
semistructured clinical interview for suicidal behaviors in adolescents.
Psychological Assessment. A Journal of Consulting and Clinical Psychology.
Reynolds, W. M. (in press d). Psychological
intervention for depression in children and adolescents. In G. Stoner, M. Shinn,
& H. Walker (Eds.), Interventions for achievement and behavior problems.
Washington, DC: National Association of School Psychologists.
Reynolds, W. M., Anderson, G. & Bartell, N.
(1985). Measuring depression in children: A multimethod assessment
investigation. Journal of Abnormal Child Psychology, 13, 613-626.
Reynolds, W. M., & Bartell, N. P. (1983).
Stability of depressive symptomatology in adolescents. Unpublished data.
Reynolds, W. M., & Coats, K. I. (1986). A
comparison of cognitive-behavioral therapy and relaxation training for the
treatment of depression in adolescents. Journal of Consulting and Clinical
Psychology, 54, 663-660.
Reynolds, W. M., & Graves, A. (1989a). Reliability
of children's reports of depressive symptomatology. Journal of Abnormal Child
Psychology, 17, 647
Reynolds, W. M., & Graves, A. (1989b). Depressive
symptomatology in gifted and nongifted children: Teacher and child report
comparisons. Manuscript submitted for publication.
Reynolds, W. M., & Mazza, I J. (1989). Suicidal
behavior and depressive symptomatology in adolescents. Manuscript in progress.
Reynolds, W. M., & Miller, K. L. (1985).
Depression and learned helplessness in mentally retarded and nonretarded
adolescents: An initial investigation. Applied Research in Mental Retardation,
6, 295307.
Reynolds, W. M., & Miller, K. L. (1989).
Assessment of adolescents' learned helplessness in achievement situations.
Journal of Personality Assessment, 53, 211-228.
Reynolds, W. M., & Stark, K. D. (1987).
School-based intervention strategies for the treatment of depression in children
and adolescents. In S. G. Forman, (Ed.), School-based affective and social
interventions. (pp. 69-88). New York Haworth.
Rie, H. E. (1966). Depression in childhood: A survey
of some pertinent contributions. Journal of the American Academy of Child
Psychiatry, 5, 663683.
Shaw, J. A. (1988). Childhood depression. Medical
Clinics of North America, 72, 831-846.
Silver, L. B. (1988). The scope of the problem in
children and adolescents. In J. G. Looney (Ed.), Chronic mental illness in
children and adolescents. (pp. 39-61). Washington, DC: American Psychiatric
Press.
Smucker, M. R., Craighead, W. E., Craighead, L. W.,
& Green, B. J. (1986). Normative and reliability data for the Children's
Depression Inventory. Journal of Abnormal Child Psychology, 14, 26-39.
Spitzer, R. L., Endicott, J., & Robins, E. (1978).
Research diagnostic criteria: Rationale and reliability. Archives of General
Psychiatry, 35, 773782.
Stark, K. D., Reynolds, W. M., & Kaslow, N. J.
(1987). A comparison of the relative efficacy of self-control therapy and
behavioral problem-solving therapy for depression in children. Journal of
Abnormal Child Psychology, 15, 91-113.
Strauss, C. C., Last, C. G., Hersen, M., & Kazdin,
A. E. (1988). Association between anxiety and depression in children and
adolescents with anxiety disorders. Journal of Abnormal Child Psychology, 16,
67-68.
Weinberg, W. A., Rutman, J., Sullivan, L., Penick, E.
C., & Dietz, S. G. (1973). Depression in children referred to an educational
diagnostic center: Diagnosis and treatment. Journal of Pediatrics, 83,
1065-1072.
Weller, R. A., & Weller, E. B. (1984). Use of
tricyclic antidepressants in prepubertal depressed children. In E. B. Weller and
R. A. Weller (Eds.), Current perspectives on major depressive disorders in
children. (pp. 60-63). Washington, DC: American Psychiatric Press.
Weller, R. A., & Weller, E. B. (1986). Tricyclic
antidepressants in prepubertal depressed children: Review of the literature.
Hillside Journal of Clinical Psychiatry, 8, 46-55.
~~~~~~~~
By William M. Reynolds University of Wisconsin-Madison
Copyright of School Psychology Review is the
property of National Association of School Psychologists and its content may not
be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print,
download, or email articles for individual use.