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The school psychologist's primer on childhood depression: a review of research regarding epidemiology, etiology, assessment, and treatment.

The recent increase in prevalence of childhood depression highlights that depression is a debilitating public health burden that continually impacts individuals and families, with millions of children and adolescents facing the challenges of depression at school each day (Gotlib & Hammen, 2002; National Institute of Mental Health [NIMH], 2008). Research reveals that childhood depression is associated with subsequent maladjustment and challenges later in life (Mash & Barkley, 2003). Thus, there is a clear need for further understanding childhood depression among education professionals, as well as further awareness of support strategies for children and adolescents (Whittington, Kendall, Fonagy, Cottrell, Cotgrove, & Boddington, 2004).

As it is important to establish an understanding of the contemporary conceptual foundations underlying, the following begins with a brief summary of the transactional-ecological developmental perspective. Next, this article delineates contemporary empirical insights related to the epidemiology, etiology, assessment, and treatment of childhood depression, with particular consideration of information relevant to school-based professionals. Finally, reputable and informative Internet resources are described to facilitate access to additional online resources.

Contemporary Transactional-Ecological Developmental Perspective

It is important to begin with a discussion of the conceptual foundation underlying the contemporary understanding of childhood depression. Broadly, a developmental perspective provides a framework to understand the range of processes and mechanisms that underlie how and why psychopathology emerges in children, how it changes over time, and how it is influenced by developmental capacities and the contexts in which development occurs (Cicchetti & Richters, 1993).

As a school psychologist, it is vital to take into account the array of factors that promote positive development, including but not limited to psychological, physiological, and social factors (Stormshak & Dishion, 2002); there is no sole determinant of positive outcomes. The transactional-ecological developmental perspective elucidates the dynamic processes by which children and contexts shape each other (Sameroff, 2009). This developmental perspective emphasizes the "progressive, mutual accommodation between an active, growing human being and the changing settings in which the developing person lives" (Bronfenbrenner, 1979, p. 21) and the interplay with processes in the individual's context over time (Sameroff, 2009). Throughout the lifespan, development, whether negative or positive, can be understood by examining the impact of interdependent contextual influences. When there is discord at any level of development or transactions are non-normative, psychopathology may result and intervention may be necessary (Sameroff & Fiese, 2000).

Specifically, this model posits that all human development is shaped by three primary levels: the (a) genotype (i.e., genetic and biochemical makeup), (b) phenotype (i.e., phenomenological experience and current developmental expressions), and (c) environtype (i.e., multilevel nested environments; Sameroff, 2000). No particular constellation of personal or environmental variables determines behaviors among youth; rather, individual, families, and contextual have dynamic and reciprocal influences over time, forming interactive feedback loops throughout time that fuel human development and ultimately manifest in maladaptive behaviors (Sameroff, 2009).

Development and Psychopathology

Psychopathology is a complex phenomenon. Messick (1983) argues psychopathology must consider three sets of contextual variables: (1) the unique child characteristics, predispositions and traits that influence the course of development; (2) the interrelatedness of various backgrounds (e.g., family, peer, classroom teacher, school, community, culture); and (3) an individual is a dynamic entity that is continuously changing. The notion that reciprocal transactions between the developing child and the multiple social and environmental contexts in which development occurs has become increasingly relevant to research and practice (Cicchetti & Aber, 1998).

Viewing depression through this developmental lens necessitates consideration of both the child and environment over time (Cicchetti & Toth, 1998). Research reveals that there are developmental differences in the expression of depression across the lifespan (Mash & Barkley, 2003). Most specifically, symptoms are typically age-specific, and several symptoms are particularly salient during specific developmental periods. Furthermore, from a developmental perspective, depression during childhood may be particularly deleterious; the cumulative impact of chronic psychological and social stress could alter biological processes and drastically affect healthy adjustment. This highlights the need for prevention and early intervention efforts.

Epidemiology and Prevalence

Mood disorders are among the most prevalent and debilitating psychiatric disorders plaguing the United States today (Hollon, Thase, & Markowitz, 2002). Depression, the most common mood disorder and one of the most frequent psychiatric disorders, is the number one cause of disability and a leading cause of suicide worldwide (Gotlib & Hammen, 2002; Hollon et al., 2002). Over the last decade, the rate of depression in the general population has increased substantially (Gotlib & Hammen, 2002). In fact, due to the elevated rate of depression worldwide, the World Health Organization Global Burden of Disease Study ranked it as the single most burdensome disease in the world (World Health Organization [WHO], 2008).

Depression affects approximately 15 million adults in the United States, about 7% of the population, every year (NIMH, 2011). Only in recent years has sound epidemiological surveys of childhood depression been utilized (Mash & Barkley, 2003). Still, few reports include both children and adolescents as separate entities.

Depression is common in childhood and adolescence (Vannest, Reynolds, & Kamphaus, 2008). Approximately 8-10% of school-aged children have depression, and it is the leading cause for suicide in adolescents. Epidemiological data suggest that the average age of onset has been decreasing in recent years (APA, 2000). In fact, approximately 1% of preschool-aged children are showing signs and symptoms (Vannest et al., 2008). In 2002, researchers found a 23% rate increase in depression among children (Harvard Medical School, 2002). Gender differences have been reported regarding depressive diagnoses and symptoms (Mash & Barkley, 2003). Whereas childhood rates are balanced across genders, adolescent females have been found to have higher (roughly 2-1) rates of depression than their male peers. Theories addressing why the prevalence among females is higher have typically focused on hormonal changes, stress and coping processes, changing social roles, and interactions among these variables. In a meta-analysis, Maag and Reid (2002) found that children with learning disabilities have significantly higher depression scores than students without learning disabilities, but not necessarily to the extent of clinical depression. Furthermore, the association of socioeconomic status (SES) and depression has been well-documented. It has been found that low income is associated with significantly more depressive disorders in children (Costello et al.,1996).

The symptoms and onset of Major Depressive Disorder (MDD) may begin at any age and depression is generally a perpetual and recurrent disorder. Some individuals have isolated episodes that are separated by many years without any depressive symptoms, whereas others experience multiple episodes in clusters. Evidence suggests that the number of prior episodes predicts the likelihood of recurrence. Approximately 50-60% of individuals who have a Major Depressive Episode will have a second episode. There is a 70% chance that individuals with two episodes will have a third, and a 90% chance that individuals with three episodes will have a fourth. Follow-up naturalistic studies suggest that a year after the diagnosis of a Major Depressive Episode, 40% of individuals still have symptoms that are characterized as being severe.

Etiology, Symptomatology, and Course

The increasing prevalence of depression raises the question of etiology. Three major areas seem to contribute to the cause of depression: biological factors, psychological factors, and environmental factors (Watts & Markham, 2005). In an attempt to identify causal factors, the synthesis and interaction of specific biological and psychological vulnerabilities and stressful life events have been examined.

Childhood Depression

Depression in young children is relatively rare, but becomes more frequent in school-aged children (Mash & Barkley, 2003). According to the Behavior Assessment System for Children (BASC-2; Reynolds & Kamphaus, 2004), depression in children is characterized by unhappiness, sadness, and stress that may result in an inability to carry out everyday activities or may bring on thoughts of suicide.

Historical models of etiology for childhood depression largely originated as adaptations of adult models (Mash & Barkley, 2003). Recently, a multidimensional, developmental, transactional perspective has been adopted (Mash & Barkley, 2003), highlighting the importance of considering the influences in and between each of the child's ecologies. Thus, prominent models include biological (e.g., neurochemistry), cognitive (e.g., attributions), behavioral/interpersonal (e.g., interpersonal relationships, social problems), family (e.g., parent-child dyad, attachment theory), and life stress (e.g., stress exposure, diathesis-stress). Through this lens, the onset of depression in childhood is understood to result from the dynamic, reciprocal transactions between the above mentioned factors over time (see Figure 1).

Perhaps as a function of their cognitive developmental level, young children with depression do not frequently report feelings of hopelessness or a preoccupation with death (Merrell, 2001; Ryan et al, 19873). Rather, young children typically reveal signs of depression via their outward appearance and through somatic complaints (Carlson & Kashani, 1988; Ryan et al, 1987). Children's most common psychosomatic complaints include: stomachaches or nausea, headache, pain in the eyes, pain in the limbs or joints, and tingling sensations or numbness (Merrell, 2001). They also tend to demonstrate more disruptive and irritable behavior than adults (Kashani, Holcomb, & Orvaschel, 1986). Finally, the failure to make developmentally appropriate weight gain is associated with childhood depression (Merrell, 2001).

Adolescent Depression

Middle to late adolescence is the most common age at onset of first major depression or significant symptoms (Mash & Barkley, 2003). The presentation of depression tends to change as children enter adolescence. Instead of somatic complaints and depressed appearance, adolescents with depression tend to present with more withdrawn behaviors, including anhedonia (lack of interest in activities), psychomotor retardation ("moving slow"), and sleep disturbances (Carlson & Kashani, 1988). Further, instead of separation-related problems, adolescents with depression have higher levels of comorbid eating disorders and substance abuse disorders (Fleming & Offord, 1990).

After onset, individuals suffering from depression oftentimes experience a number of difficulties (Beck, 1967). The symptoms of depression can generally be divided into four main categories, including emotional manifestations, cognitive manifestations, motivational manifestations, and physical/vegetative manifestations. Emotional manifestations refer to changes in the child's feelings or overt behavior (e.g., dejected mood, negative feelings toward self, loss of gratification). Cognitive manifestations refer to maladaptive and oftentimes irrational thoughts (e.g., low self-evaluation, negative expectations, self-criticism, distorted self-image). Prominent features of motivational manifestations in a depressed child include a regressive nature, lack of positive motivation, avoidant behavior, and increased dependency. Vegetative and physical manifestations include fatigue, sleep disturbances, loss of libido, weight loss, and weight gain.

There is growing evidence that an early onset of depression foreshadows a potentially lifelong course, with continuity between childhood depression, adolescent depression, and adult depression (Mash & Barkley, 2003). Although findings on the continuity of child depression and adult depression are mixed, research has found strong evidence demonstrating the continuity of adolescent depression into adulthood (Weissman et al., 1999). Depression is typically chronic, with about 50% to 67% of people who have ever been clinically depressed experiencing relapse over the remainder of their lives (Gotlib & Hammen, 2002).

Diagnosis and Assessment Strategies

According to the DSM-IV-TR (APA, 2000), a Major Depressive Episode is diagnosed by the presence of at least 5 of the following symptoms during the same 2-week period: a depressed mood most of the day, markedly diminished pleasure or interest in activities, significant weight loss or weight gain, recurrent insomnia or hypersomnia, psychomotor agitation or retardation, recurrent fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished concentration or indecisiveness, or thoughts of death and suicide ideation. The symptoms must cause significant distress in social, occupational, or other areas of functioning and must not be part of the physiological effects of bereavement or an external substance. Major Depressive Disorder (MDD) is characterized as the presence of two or more Major Depressive Episodes. Table 1 provides education professionals with a list of important emotional, behavioral, and cognitive signs of depression during childhood and adolescence.

In schools, students exhibiting depressive symptoms may be identified as having an emotional disturbance under the Individuals with Disabilities Education ct (IDEA, 2004). To qualify for services, the general pervasive mood of unhappiness or depression must be over a long period of time and to a marked degree that adversely affects the student's education performance (Council for Exceptional Children, 2011).

There are several assessment instruments marketed to measure child and adolescent depression. On a global level, the Behavioral Assessment System for Children (BASC-2; Reynolds & Kamphaus, 2004) is an integrated system designed to facilitate the differential diagnosis and classification of a variety of emotional and behavioral disorders of children and to aid in the design of treatment plans. The BASC-2 has a depression subscale that specifically assesses for the key symptoms of childhood and adolescent depression, as determined by parent, teacher, and student report forms. School psychologists can examine the depression subscale separately or in a more comprehensive manner with all the other subscales to determine the clinical and relative severity of the depression items compared to the other assessment components.

Other instruments that measure depression exclusively include; the Childhood Depression Inventory (CDI-2; Kovacs, 2010), the Reynold's Childhood Depression Rating Scale- 2nd Edition (RCDS 2; Reynolds, 2002b), and the Reynold's Adolescent Childhood Rating Scale--2nd Edition (RADS2; Reynolds, 2002a). The CDI-2, a self-report questionnaire, is essentially a downward extension of the Beck Depression Inventory, which is used to assess depression for both psychiatrically diagnosed patients and normal populations (Gotlib & Hammen, 2002). The CDI-2 includes several items that attempt to assess areas of school and social/peer relations and uses language more suitable for 8 to 13-year-old children (Kovacs & Beck, 1977). Similarly, the RCDS and RADS are self-report surveys that list key features of depression in the form of emotions and symptoms. These two questionnaires were developed specifically to screen for depression in children in schools, providing school and mental health professionals a measure for the evaluation of the severity of children's depressive symptoms (Reynolds, 2002).

Treatment

Kapornai and Vetro (2008) suggest that the main goals of treatment in childhood and adolescent depression should be two-fold: 1) to reduce the depressive symptoms and to improve individual functioning; and 2) to prevent recurrence and relapse of depressive symptoms. Most controlled clinical trials have focused on symptom reduction and generally showed that medication, notably selective serotonin reuptake inhibitors (SSRIs), evidence-based psychosocial interventions, and the combination of these two are most effective in treating depression in children and adolescents (Carr, 2008; Cheung, Emslie, & Mayes, 2005; Vasa, Carlino, Pine, 2006; Weisz, McCarty, & Valeri, 2006). However, it is important to note that there is controversy regarding whether medication alone is a safe approach for treating depression in youths, as numerous studies have found a connection between SSRIs and increased suicidal risks for adolescents (Hall, 2006; Healy, 2003; Mann, et al., 2006).

While most research on treatment efficacy use outcome studies comparing different psychotherapies, some scholars suggest further examining subprocesses (specific techniques) and microprocesses (specific broken down technique process) across these approaches (Gendlin, 1986; Sander & McCarty, 2005). McCarty and Weisz (2007) identified several effective therapeutic techniques and treatment process elements that are evidence-based: enhancing relationship, building communication skills, changing unrealistic negative cognitions and so on. Additionally, they found that effective support usually starts with an orientation to understanding depression and its course and providing clients with a sense of what treatment will entail. Indeed, scholars have recognized psychoeducational interventions as one important component in treating depression. The aims of psychoeducation are to inform the child, the family and the school about depressive symptoms, their consequences, prognosis, treatment duration and adverse effects of medication (Nobile, Cataldo, Marino, & Molteni, 2003).

Many teachers and qualified school personnel have been trained to implement interventions that target depression in children (Maag, 2002). Such interventions include social skills training, self-control training (e.g., self-monitoring, self-evaluation, and self-reinforcement), activity scheduling, cognitive restructuring, and relaxation training. Furthermore, Maag (2002) posited that manipulating the context and reframing a student's perceptions of symptoms of depression can have an effect on behavior and mitigate their impact. Table 2 provides a brief comparison of treatment modalities.

Pharmacotherapy

Antidepressants have been available for over 40 years (Gotlib & Hammen, 2002). The explosive growth and use of antidepressant medication has been among the dominant themes of psychological and psychiatric treatment over the last two decades. As of 1999, three of the 12 most prescribed medications for any type of ailment or disorder in the United States were antidepressants (Gotlib & Hammen, 2002).

Antidepressant medications are used to treat varying levels of depression (Hollon et al., 2002). They function by initiating neurochemical effects on the body. Norepinephrine, serotonin, and dopamine are neurotransmitters that are involved in the regulation of mood and other processes found in depression. Antidepressant medications work primarily by blocking the reuptake of these neurotransmitters into the presynaptic cleft, thus increasing the amount of the given neurotransmitter that is available. It is widely believed that varying types of antidepressants are equal in efficacy and therefore, selection of a particular antidepressant for a particular patient is generally based on personal treatment history, side effects, safety in overdose, and expense. SSRIs are the most commonly prescribed antidepressants used by physicians and psychiatrists. Antidepressant medications have the most extensive empirical support and generally are effective as long as their use is maintained, but they can generate an array of unpleasant side effects and do little to reduce risk of relapse after their use is discontinued (Preston & Johnson, 2012).

Antidepressant medications are the most prevalent treatment for MDD in the United States (DeRubeis et al., 2005). Although numerous studies examined the use of antidepressants for treating children and adolescents diagnosed with depression, antidepressants have not been found to be efficacious in the treatment of MDD in children and adolescents (Mandoki, Tapia, Sumner, & Parker, 1997). Thus, caution should be taken when families or children are only considering pharmacotherapy to treat childhood and adolescent depression. More research is warranted to examine the implementation of only pharmacotherapy with children.

Psychotherapy

Although the rates of depression have drastically increased in recent years, the use of psychotherapy as a treatment and management system has declined both in the number of patients treated and the number of patient visits (Ludman, Simon, Tutty, & Von Korff, 2007). Currently, the conventional treatment of depression in the United States entails the use of antidepressant medication and no formal psychotherapy. A community survey in 1997 showed that only 35% of individuals diagnosed with depression received any psychotherapy, with fewer than 20% going to four or more psychotherapy sessions. However, various forms of psychotherapy have continued to be explored (DeRubeis et al., 2005). Two such psychotherapies, cognitive therapy and interpersonal psychotherapy, have shown promise as a viable alternative to pharmacotherapy in the treatment and management of depression in children and adolescents.

Cognitive behavior therapies. The extent and impact of depression accompanied by the recent debate over the risk of medication has spurred the necessity of psychotherapy (Weisz, McCarty & Valeri, 2006). In general, the principles of psychotherapy aim to treat the psychological and/or behavioral aspects of depression as opposed to physiological aspects.

Cognitive therapy is based on the basic theoretical grounds that an individual's emotions and behavior are largely determined by the way in which they perceive the world (Beck et al. 1979). Cognitive psychotherapy is used symptomatically during depressions to help the patient gain objectivity toward automatic reactions and counteract them. During non-depressed periods, the therapy is designed to modify the idiosyncratic cognitive patters to reduce vulnerability to future depressions. On the whole, the primary function of cognitive therapeutic techniques is to help identify and correct distorted conceptualizations and dysfunctional beliefs that underlie thought and behavior.

A variety of cognitive and behavioral strategies are implemented in cognitive therapy (Beck et al., 1979). Cognitive therapists work with individuals in delineating and testing specific misconceptions and maladaptive assumptions. This includes teaching an individual to monitor negative, automatic cognitions, recognize the connection between cognition, affect, and behavior, examine evidence for and against distorted automatic thought, substitute more realistic interpretations for biased cognitions, and learn to identify and alter dysfunctional beliefs which predispose distorted experiences.

Cognitive-behavioral interventions (CBI) are a major component of the successful treatment of childhood depression (Maag & Swearer, 2005). CBIs focus on two areas, cognitions and behavior. The cognitive component targets a student's private speech about him/herself, the environment, and his/ her future. Such interventions include self-instruction training, problem-solving training, attribution retraining, and cognitive restructuring as outlined by Beck's (1976) cognitive therapy and Ellis's (1962) rational emotive therapy. Behavioral components include modeling, role playing, and positive reinforcement (Maag & Swearer, 2005). In a review of the extant literature to determine the efficacy of CBI for treating depression in children, Magg and Swearer (2005) found that the interventions showed positive results across each of the studies examined.

Furthermore, cognitive behavioral therapy (CBT) has shown utility in decreasing depressive symptoms, symptom severity, and dysfunctional negative thoughts (Vannest, Reynolds, & Kamphaus, 2008). For example, Clarke and colleagues (2005) followed a group of adolescents who had been previously diagnosed with depression and prescribed SSRIs. Participants were randomly assigned to receive treatment-as-usual (TAU) or SSRIs alone or CBT plus SSRIs. CBT was delivered in five to nine 60-minute sessions followed by monthly telephone calls. Results suggested that fewer participants in the combined group remained moderately depressed at the one-year follow-up than participants in the TAU group alone.

Interpersonal psychotherapy. Interpersonal psychotherapy (IPT) was originally a treatment developed to help adults with depression learn how to manage interpersonal conflicts in their lives (Klerman, Weissman, Rounsaville, & Chevron, 1984). IPT was later modified by Mufson, Moreau, Weissman, & Klerman (1993) for adolescents with depression because adolescents commonly face interpersonal issues as well which greatly impacts their social-emotional well-being. IPT is a focused therapeutic approach that helps individuals learn how to understand, manage and resolve their identified interpersonal issues. IPT can be implemented in a group setting (Mufson, Gallagher, Dorta, &Young, 2004) or as an individualized therapy (Mufson, Weissman, Moreau, and Garfinkel, 1999). IPT has been shown to reduce depressive symptoms and increase social functioning and problem-solving skills (Mufson et al., 1999).

In an attempt to adapt IPT for use with depressed adolescents, Mufson, Moreau, Weissman, Wickramaratne, Martin, and Samoilov (1994) conducted a three phase study to establish the efficacy of such treatment. Results from the developed IPT manual demonstrated the potential effectiveness of IPT as evidenced by a significant reduction in the symptoms of depression and increase in overall functioning. In another study, Rossello and Bernal (1999) compared the effects of CBT and IPT with a control group. Students were randomly assigned to one of the conditions, with individuals in the CBT and IPT groups receiving 12 weekly, 1-hour, individual therapy sessions and the control group receiving no sessions. The CBT group learned how to identify thoughts, feelings, and actions that influence the feelings of depression. The IPT group learned how to evaluate current problems in their interpersonal relationships and addressed problematic areas. The results demonstrated that both the CBT and IPT groups showed significant reductions in depressive symptoms as compared with the control group.

Among psychosocial interventions, a recent meta-analysis has demonstrated that CBT has the greatest empirical support for treating depressed adolescents and children, while IPT is a promising approach for adolescents, with behavioral therapy suitable for children (David-Ferdon & Kaslow, 2008; Watanabe, et al., 2007). Age, along with other factors, such as severity and duration of the depressive symptoms, chronic medical problems, and family history of psychopathology, need to be considered when choosing a treatment plan. For example, medication combined with CBT is generally recommended for adolescents with severe depressive symptoms, because medication is effective in reducing severe depressive symptoms while CBT may decrease the risk for increased suicidal ideations due to the medication [Treatment of Adolescents with Depression (TADS) Team, 2006]. In terms of treatment modality, positive treatment effects are found across group, individual, or family therapy (David-Ferdon & Kaslow, 2008).

Prevention and Maintenance

Prevention and maintenance are crucial strategies in treating depression for a few reasons. For example, research shows that subsyndromal depression is very common among children and adolescents. Therefore, many depressed children may not qualify for adequate treatment. In an effort to reduce or eliminate symptomatology, prevention programs aimed to help children develop the skills necessary to manage their difficulties should be implemented to provide support to this subpopulation. Second, the high recurrence of depression has called for more effort in the development of interventions designed to reduce relapse and recurrence (Mrazek & Haggerty, 1994).

Bucy (1994) has outlined numerous preventive interventions for internalizing disorders in childhood, including depression. Primary prevention efforts that promote psychological well-being often begin in primary school or community settings. These include programs such as Developing Understanding of Self and Others (DUSO, Dinkmeyer and Dinkmeyer, 1982) which uses stories, pictures, role playing, and puppet play to improve self-awareness, increase positive self-images and facilitate relationships between self and others. Horowitz and Garber (2006) showed that selective and individually indicated preventions are more effective than universal preventive strategies. Selective prevention targets at children and adolescents who are at high risk for depression, such as those who have a family history of psychopathology, and indicated prevention are designed for individuals with sub-threshold depression.

Strategies from the field of positive psychology can also be used with children to target potential symptoms of depression and increase general well-being. Seligman, Ernst, Gillham, Reivich, and Linkins' (2009) examined the application of evidence-based positive psychology principles and strategies into the everyday practices of schools. As part of this framework, termed Positive Education, students complete exercises based on positive psychology as part of the school curriculum to learn and practice skills that promote self-empowerment and happiness. The Strath Haven Positive Psychology Curriculum is an example of such a program. The main focus of this curriculum is to help children identify signature strengths and incorporate them in their everyday lives. The results of a randomized controlled study of this program at a high school revealed that the program increased students' empathy, assertiveness and self-control. However, the direct ratings of depression and anxiety were not significantly affected. Thus, further research is necessary to measure the effectiveness of interventions based on the principles of positive psychology with youth in schools and to examine whether constructs such as empathy, assertiveness, and self-control are correlated with the reduction of depressive symptomatology.

With resiliency being a primary ingredient of prevention and maintenance, resilience-centered programs have also been considered as interventions for children with or at-risk for depression. The Penn Resiliency Program (PRP; Reivich, Gillham, Chaplin, & Seligman, 2013) works with youth to identify and manage everyday causes of stress in healthy ways. Emphasizing resiliency factors in children, PRP utilizes multiple leaders and more than 20 sessions to teach and practice the core management skills (Reivich and Shatte, 2002). Since 2006, 30 studies with diverse samples have evaluated PRP, making it among the most researched prevention programs for youth with depression (Seligman, Ernst, Gillham, Reivich, & Linkins, 2009). The results of the studies have concluded that PRP is effective at reducing depressive symptoms as well as clinical levels of depression and anxiety.

INTERNET RESOURCES FOR PROFESSIONALS

Given the prevalence and seriousness of depression in children, prevention and intervention are of utmost importance. There is an abundance of resources available to children, parents, and school psychologists to assist in the identification, treatment, and support of children with depression, but often it is difficult to identify quality materials. Thus, listed below are useful resources of varying degrees and types of information. The information provided includes support at the individual, family, and community level, as well as links to additional resources.

The American Academy of Family Physician (http://www.aafp.org/online/en/home.html)

The American Academy of Family Physician website provides information about clinical recommendations as well as supporting research on depression. The website shares information about how a primary care provider can help individuals with depression. News about current public policy and law impacting the medical field are also reported.

The National Institute of Mental Health

(http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml)

The National Institute of Mental Health website has an entire section devoted to depression. From learning what depression is to epidemiology and research, this website provides its readers with a thorough knowledge of the current understanding of depression. It also shares what current clinical trials are being conducted across the U.S. so readers can know what research is being done in the moment.

KidsHealth (http://kidshealth.org/parent/emotions/feelings/understanding_depression.html)

KidsHealth provides easy-to-read information about depression. With separate sections for parents, teens and kids, this website provides targeted information to help all members of families dealing with depression. From local doctors and hospital searches to positive parenting techniques, parents can find multiple sources of information on how to help them handle a child with depression. The teen and kid sections provide developmentally appropriate resources for all types of concerns and questions.

PsychCentral (http://psychcentral.com/disorders/depressionchild.htm)

PsychCentral's section on depression serves as another interactive source of information with articles, treatment options, and blogs about depression. Individuals can read about others living with depression as well as post questions and comments about the disorder. Another tool is the website's "Ask the Therapist" section in which individuals can post questions and concerns and receive a response by a licensed psychologist.

Parent Resources (http://www.depressedchild.org)

This website was created by a mother of an undiagnosed child with depression and is geared toward parents of children with depression or depressive symptoms. The website shares resources on depression such as mental health organizations, websites, articles, and books. As clinicians, it is important to be knowledgeable about websites geared toward parents such as this one in order to know what information is being shared with the general public in addition to current literature.

The Help Guide (http://www.helpguide.org/mental/depression_teen.htm)

The Help Guide is a non-profit organization that provides information about a variety of mental health issues including depression. The website clearly details tips and tools for individuals dealing with depression and individuals with friends with depression. It also gives tips and resources for suicidal ideation concerns.

Empowering Parents (http://www.empoweringparents.com)

The Empowering Parents website supports parents in positively and productively assisting their children with depression and other challenges. With articles on parenting techniques and ways to address problems at school, this website provides parents with information to help them navigate the best way to raise a child with depression.

Depression and Bipolar Support Alliance

(http://www.dbsalliance.org/site/PageServer?pagename=home)

The Depression and Bipolar Support Alliance provides a website that connects individuals with depression and bipolar disorder. The website enables individuals to learn about advocacy and empowerment within the depression and bipolar community. It offers services such as "Ask a Doctor" and "Find Professional Help" for people to get individualized and targeted help and answers to their questions. This website additionally provides research and information about clinical trials for both disorders.

The National Alliance on Mental Illness (http://www.nami.org)

The National Alliance on Mental Illness (NAMI) is an organization that provides information and resources to individuals and their families and friends with mental illness, including depression. With local affiliates all over the country, NAMI has support groups and trainings on various mental illness problems. The website lists resources and a calendar of events about informative presentations on the current laws and research impacting mental illness.

CONCLUSION

Depression is a debilitating disorder that impacts children worldwide, causing it to be not only an individual concern but also a public health concern. Although its societal impact has fueled researchers to examine the causes and treatments for depression, few definite answers have been revealed. From a developmental perspective, depression is a chronic, multifactorial mood disorder that can occur at any point during development. Negative cognitive, emotional, and physical symptoms are seen in individuals with depression. There are several assessment tools devoted to measuring depression at all stages of life. Although pharmacotherapy is the most common form of treatment from adolescence onward, it is a controversial treatment option. Research suggests that other forms of psychotherapy are as effective as or more effective in assisting individuals with depression to live better lives. Knowledge of the use and side effects of psychopharmacological treatments can be useful for school-based professionals supporting students with these prescriptions. Cognitive and interpersonal therapies are the two leading forms of psychotherapy shown to be effective in reducing depressive symptoms, and show particular effectiveness in child populations. Reputable internet resources for professionals pertaining to understanding depression among children and adolescents are also highlighted to encourage school-based professionals to obtain further contemporary knowledge through the use of high quality websites. Further research is warranted to better understand depression and optimal treatment plans, especially for diagnosis and treatment of childhood depression. Nonetheless, depression is a societal concern that continues to affect millions of individuals every day. Given that millions of children experiencing depression will enter the schools each day, it is important for school psychologists and other education professionals to be knowledgeable about the epidemiology, etiology, assessment, and treatment options delineated herein.

REFERENCES

Ackerson, J., Scogin, F., McKendree-Smith, N., & Lyman, R.D. (1998). Cognitive bibliotherapy for mild and moderate adolescent depressive symptomatology. Journal of Consulting and Clinical Psychology, 66(4), 685-690.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: Author.

Beck, A.T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York, NY: Harper & Row.

Beck, A.T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities.

Beck, A.T., Rush, A.J., Shaw, B F., Emery, G. (1979). Cognitive therapy of depression. New York, NY: The Guilford Press.

Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge , MA: Harvard University Press.

Bucy, J.E. (1994). "Internalising affective disorders". In R.J. Simeonsson (Ed.) Risk, resilience and prevention: Promoting the well-being of children (pp. 219-238). Baltimore: Paul H. Brookes Publishing Co.,

Carlson, G.A., & Kashani, J. (1998). Phenomenology of major depression from childhood through adulthood: Analysis of three studies. American Journal of Psychiatry, 145, 1222-1225.

Carr, A. (2008). Depression in young people: Description, assessment and evidence-based treatment. Developmental Neurorehabilitation, 11(1), 3-15.

Cheung, A., Emslie, G., & Mayes, T. (2005). Review of the efficacy and safety of antidepressants in youth depression. Journal of Child Psychology and Psychiatry, 46, 735-754.

Cicchetti, D., & Aber, J.L. (Eds.). (1998). Contextualism and developmental psychopathology. Development and Psychopathology, 10(2).

Cicchetti, D., & Richters, J.E. (1993). Developmental considerations in the investigation of conduct disorder. Development and Psychopathology, 5, 331-344.

Cicchetti, D., & Toth, S.L. (1998). The development of depression in children and adolescents.

Clarke, G., DeBar, L., Powell, J., & O'Connor, E. et al. (2005). A randomized effectiveness trial of brief cognitive behavioral therapy for depressed adolescents receiving antidepressant medication. Journal of the American Academy of Child and Adolescent Psychiatry, 44(9), 888-898.

Costello, E.J., Angold, A., Burns, B.J., Stangl, D.K., Tweed, D.L., Erkanli, A., & Worthman, C.M. (1996). The Great Smoky Mountains Study of Youth: Goals, design, methods, and prevalence of DSM-III-R disorders. Archives of General Psychiatry, 53, 1129-1136.

Council for Exceptional Children. (2011). Behavior disorders/Emotional disturbance. Retrieved from: http://www.cec.sped.org/AM/Template.cfm?Section=Behavior_Disorders_Emotional_Disturbance

David-Ferdon, C., & Kaslow, N.J. (2008). Evidence-Based Psychosocial Treatments for Child and Adolescent Depression. Journal of clinical child and adolescent psychology, 37(1), 62-104.

DeRubeis, R.J., Hollon, S.D., Amsterdam, J.D., Shelton, R.C., Young, P.R., Salomon, R.M., et al. (2005). Cognitive therapy vs medications in the treatment of moderate to severe depression. Archives of General Psychiatry, 62(4), 409-416.

Dinkmeyer, D. & Dinkmeyer, D. Jr. (1982) Developing understanding of self and others. (Rev. Ed.) Circle Pines, MN: American Guidance Service.

Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.

Fleming, J.E. & Offord, D.R. (1990). Epidemiology of depressive disorders: A critical review. Journal of the American Academy of Child and Adolescent Psychiatry, 29. 571-580.

Gendlin, E.T. (1986). What comes after traditional psychotherapy research? American Psychologist, 41(2), 131-136.

Gotlib, I. H., & Hammen, C.L. (2002). Handbook of depression. New York, NY: The Guilford Press.

Gutman, L. M., Sameroff, A.J., & Cole, R.C. (2003). Academic growth curve trajectories from 1st grade to 12th grade: Effects of multiple social risk factors and preschool child factors. Developmental Psychology, 39, 77-790.

Hall, W. (2006). How have the SSRI antidepressants affected suicide risk? Lancet, 367, 1959-1962.

Healy, D. (2003). Lines of evidence on the risks of suicide with selective serotonin reuptake inhibitors. Psychotherapy and Psychosomatics, 72, 71-79.

Hensley, P.L., Nadiga, D., & Uhlenhuth, E.H. (2004). Long-term effectiveness of cognitive therapy in major depressive disorder. Depression and Anxiety, 20, 1-7.

Hollon, S.D., Thase, M.E., & Markowitz, J.C. (2002). Treatment and prevention of depression. Psychological Science in the Public Interest, 3(2), 39-77.

Horowitz, J.L., Garber, J. (2006). The prevention of depressive symptoms in children and adolescents: A meta analytic review. Journal of Consulting and Clinical Psychology, 74, 401-415.

Kapornai, K., & Vetro, A. (2008). Depression in children. Current Opinion in Psychiatry, 21(1), 1-7.

Kashani, J., Holcomb, W., & Orvaschel, S. (1986). Depression and depressive symptoms in preschool children from the general population. American Journal of Psychiatry, 143, Psychotherapy of Depression. New York: Basic Books.

Klerman, G.L., Weissman, M.M., Rounsaville, B.J., & Chevron, E.S. (1984). Interpersonal psychotherapy for depression. New York, NY: Basic Books.

Kovacs, M. (2010). Children's Depression Inventory 2nd Edition: Technical Manual. North Tonawanda, NY: MultiHealth Systems Inc.

Ludman, E.J., Simon, G.E., Tutty, S., & Von Korff, M. (2007). A randomized trial of telephone psychotherapy and pharmacotherapy for depression: Continuation and durability of effects. Journal of Consulting and Clinical Psychology, 75(2), 257-266.

Maag, J.W. (2002). A contextually based approach for treating depression in school-age children. Intervention in School and Clinic, 37(3), 149-155).

Maag, J.W., & Reid, R. (2006). Depression among students with learning disabilities: Assessing the risk. Journal of Learning Disabilities, 39(1), 3-10.

Maag, J.W., & Swearer, S.M. (2005). Cognitive-behavioral interventions for depression: Review and implications for school personnel. Behavioral Disorders, 30(3), 259-276.

Mandoki, M.W., Tapia, M.R., Sumner, G.S., & Parker, J.L. (1997). Venlafaxine in the treatment of children and adolescents with major depression. Psychopharmacology Bulletin, 33(1), 149-154.

Mann, J.J., Emslie, G., Baldessarini, L.J., et al. (2006). ACNP Task Force report on SSRIs and suicidal behavior in youth. Neuropsychopharmacology, 31,473-492.

Mash, E.J., & Barkley, R.A. (Eds.). (2003). Child psychopathology. New York, NY: Guildford Press.

McCarty, C.A., & Weisz, J.R. (2007). Adolescents: What We Can (and Can't) Learn from Meta-Analysis and Component Profiling. Journal of the American Academy of Child & Adolescent Psychiatry, 46(7), 879-886.

McCarty, C.A., & Weisz, J.R. (2007). Effects of Psychotherapy for Depression in Children and Adolescents: What we can (and can't) learn from meta-analysis an component profiling. Journal of American Academy of Child and Adolescent Psychiatry, 46(7), 879-886.

Merrell, K. (2001). Helping students overcome depression and anxiety. Guilford: NY

Messick, S. (1983). Assessment of children. In P.H. Mussen (Ed.) & W. Kessen (Ed.), Handbook of child psychology: Vol. 1 History, theory, and methods (4th ed., pp. 477-526). New York, NY: Wiley.

Mrazek, P.J. & Haggerty, R.J. (Eds.) (1994). Reducing the risks for mental disorders: frontiers for preventive intervention research. Washington, D.C.: National Academy Press.

Mufson, L., Gallagher, T., Dorta, K.P., & Young, J.F. (2004). A group adaptation of interpersonal psychotherapy for depressed adolescents. American Journal of Psychotherapy, 58, 220-237.

Mufson, L., Moreau, D. Weissman, M.M., Wickramaratne, P., Martin, J., & Samoilov, A. (1994). Modification of interpersonal psychotherapy with depressed adolescents (IPT-A): Phase I and II studies. Journal of the American Academy of Child and Adolescent Psychiatry, 33(5), 695-705.

Mufson, L., Moreau, D., Weissman, M.M., & Klerman, G. (1993). Interpersonal psychotherapy for depressed adolescents. New York: Guildford Press.

National Institute of Mental Health. (2008). The numbers count: Mental disorders in America. Retrieved February 18, 2009, from: http://www.nimh.nih.goV/health/publications/the-numbers-count-mental-disorders-inamerica/index.shtml#MajorDepressive

Nobie, M., Cataldo, G.M., Marino, C., & Molteni, M. (2003). Diagnosis and treatment of dysthymia in children and adolescents. CNS Drugs, 17, 927-946.

Reivich, K., Gillham, J.E., Chaplin, T.M., & Seligman, M.E.P. (2013). From helplessness to optimism: The role of resilience in treating and preventing depression in youth. New York, NY, US: Springer Science + Business Media, New York, NY. doi: http://dx.doi.org/10.1007/978-1-4614-3661-4_12

Reivich, K., & Shatte, A. (2002). A resilience factor: Seven essential skills for overcoming life's inevitable obstacles. New York: Broadway.

Reynolds, C.R., & Kamphaus, R.W. (2004). Behavior Assessment System for Children Second Edition (BASC-2). Circle Pines, MN: AGS.

Reynolds, W.M. (2002a). Reynolds Adolescent Depression Scale--2nd Edition. Professional Manual. Odessa, FL: Psychological Assessment Resources.

Reynolds, W.M. (2002b). Reynolds Child Depression Scale--2nd Edition. Professional Manual. Odessa, FL: Psychological Assessment Resources.

Rossello, J., & Bernal, G. (1999). The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of Consulting and Clinical Psychology, 67(5), 734-745.

Ryan, N.D., Puig-Antich, J., Ambrosini, P., Rabinovich, H., Robinson, D., Nelson, B., Iyengar, S., & Twomey, J. (1987). The clinical picture of major depression in children and adolescents. Archives of General Psychiatry, 44, 854-861.

Sameroff, A.J. (2000). Dialectical processes in developmental psychopathology. In A.J. Sameroff, M. Lewis, & S. M. Miller (Eds.), Handbook of developmental psychopathology (2nd ed., pp. 23-40). New York, NY: Kluwer Academic/Plenum.

Sameroff, A.J. (Ed.). (2009). The transactional model of development: How children and contexts shape each other. Washington, DC: American Psychological Association.

Sander, J.B., & McCarty, C.A. (2005), Youth depression in the family context: familial risk factors and models of treatment. Clinical Child & Family Psychology Review, 8, 203-219.

Seligman, M.E.P., Ernst, R.M., Gillham, J., Reivich, K., & Linkins, M. (2009). Positive education: Positive psychology and class-room interventions. Oxford Review of Education, 35, 293-311.

Skaer, T.L., Sclar, D.A., Robison, L.M., & Galin, R.S. (2000). Trend in the use of antidepressant pharmacotherapy and diagnosis of depression in the US. CNS Drugs, 14(6), 473-481.

TADS Team. (2006). The Treatment for Adolescents With Depression Study (TADS): Methods and Message at 12 Weeks. Journal of the American Academy of Child & Adolescent Psychiatry, 45 (12), 1393-1403.

Vannest, K.J., Reynolds, C.R., & Kamphaus, R.W. (2008). Intervention guide for behavioral and emotional issues. Bloomington, MN: Pearson.

Vasa, R., Carlino, A., & Pine, D. (2006). Pharmacotherapy of depressed children and adolescents: Current issues and potential directions. Biological Psychiatry, 59, 1021-1028.

Watanabe, N., Hunot, V., Omori, I.M., Churchill, R., & Furukawa, T.A. (2007). Psychotherapy for depression among children and adolescents: A systematic review. Acta Psychiatrica Scandinavica, 116, 84-95.

Watts, S.J., & Markham, R.A. (2005). Etiology of depression in children. Journal of Instructional Psychology, 32(3), 266-270.

Weissman, M.M., Wolk, S., Goldstein, R.B., Moreau, D., Adams, P., Greenwald, S., Wickramaratne, P. (1999). Depressed adolescents grown up. Journal of the American Medical Association, 282, 1701-1713.

Weisz, J.R., McCarty, C.A., & Valeri, S.M. (2006). Effects of psychotherapy for depression in children and adolescents: A meta-analysis. Psychological Bulletin, 132, 132-149.

Whittington, C.J., Kendall, T., Fonagy, Cottrell, D., Cotgrove, A., & Boddington, E. (2004). Selective serotonin reuptake inhibitors in childhood depression: Systematic review of published versus unpublished data. Lancet, 363, 1341-1345.

World Health Organization [WHO]. (2008). The global burden of disease: 2004 update. Geneva, Switzerland: WHO Press. Retrieved from: http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html

Matthew A. Ruderman, Skye W. F. Stifel, Meagan O'Malley, and Shane R. Jimerson

University of California, Santa Barbara

Correspondence concerning this article should be addressed to: Shane R. Jimerson, University of California-Santa Barbara, CCSP, 2113 ED, Santa Barbara, CA 93106. Email: jimerson@education.ucsb.edu

Matthew A. Ruderman is a doctoral student in the Counseling, Clinical and School Psychology program, emphasizing in School Psychology, at the University of California, Santa Barbara. He received his B.A. in psychology from Chapman University in Orange, CA. Ruderman's research topics and presentations have included violence in the schools, bullying, defending behavior, international school psychology, and the application of positive psychology to the school setting.

Skye W.F. Stifel is a doctoral student in the Counseling, Clinical and School Psychology program, emphasizing in School Psychology, at the University of California, Santa Barbara. She received her B.A. in psychology from the University of California, Berkeley and her M.A. in Special Education from Loyola Marymount University in Los Angeles. Prior to coming to UCSB, Stifel taught special education in a variety of settings. Her research and publication topics include integrating email with counseling in schools, health crises, bullying, international school violence, and juvenile delinquency. She is currently completing her internship and will graduate in June 2013.

Meagan O'Malley, PhD, is a Research Associate in the Health & Human Development Program at WestEd. She received a BA in psychology from the University of California, Davis; an ALA in school psychology from Sacramento State University; and a PhD in counseling, clinical, and school psychology from the University of California, Santa Barbara. Dr. O'Malley is a school psychologist with experience working with diverse students and their families in a variety of education settings, including both rural and urban schools. Dr. O'Malley serves as Project Manager and Technical Assistance Coordinator for the Safe and Supportive Schools (S3) initiatives in California and Louisiana. She is also Director of Technical Assistance for the Army Youth in Your Neighborhood initiative. Dr. O'Malley conducts research in school climate measurement and intervention. She recently coauthored chapters for the Handbook of School Violence and School Safety, 2nd Edition and Best Practices in School Crisis Prevention and Intervention, 2nd Edition.

Shane R. Jimerson is a professor at the University of California, Santa Barbara. Dr. Jimerson is currently president of Division 16 (School Psychology) of the American Psychological Association (2012), and editor of the School Psychology Quarterly journal (2012-2016). His scholarly publications and presentations have provided insights regarding developmental pathways of school success and failure, the efficacy of early prevention and intervention programs (grade retention among others), school psychology internationally, developmental psychopathology, and school crisis prevention and intervention. Among over 250 publications, including 25 books, he is the lead-editor of The Handbook of School Violence and School Safety: International Research and Practice 2nd Edition (2012, Routledge), co-editor of Best Practices in School Crisis Prevention and Intervention 2nd Edition (2012, National Association of School Psychologists), lead-editor of The Handbook of Bullying in Schools: An International Perspective (2010, Routledge), The Handbook of International School Psychology (2007, SAGE Publishing), the lead editor of The Handbook of Response to Intervention: The Science and Practice of Assessment and Intervention (2007, Springer Science). He is the co-author of the book School Crisis Prevention and Intervention: The PREPaRE Model (2009, National Association of School Psychologists). He is also co-author of Identifying, Assessing, and Treating Autism at School (2006, Springer Science), co-author of Identifying, Assessing, and Treating Conduct Disorder at School (2008, Springer Science), co-author of Identifying, Assessing, and Treating PTSD at School (2008, Springer Science), and co-author of Identifying, Assessing, and Treating ADHD at School (2009, Springer Science).

TABLE 1. Emotional, behavioral, and cognitive signs of
depression during childhood and adolescence.

Emotional

Sadness or hopelessness
Irritability, anger, or hostility
Anxiety
Persistent worrying
Feelings of worthlessness and guilt

Behavioral

Tearfulness or frequent crying
Withdrawal from friends and family
Loss of interest in activities
Loss of pleasure in activities previously enjoyed
Changes in eating
Changes in sleeping habits
Restlessness
Agitation
Sluggish
Clinging and demanding
Self-harm
Activities in excess

Cognitive

Lack of enthusiasm and motivation
Negative perception of daily events and experiences
Fatigue or lack of energy
Difficulty concentrating
Thoughts of death or suicide

TABLE 2. Treatments for Children and Adolescents with Depression

Treatment         Description & Evidence

Antidepressant    Primarily block norepinephrine, serotonin, and
  Medication      dopamine neurotransmitters

                  SSRIs are most commonly prescribed

                  Not proven to be efficacious for children and
                  adolescents (Mandoki, Tapia, Sumner, & Parker,
                  1997)

Cognitive         Identify and correct distorted conceptualizations
  Behavioral      and dysfunctional beliefs that underlie thought
  Therapies       and behavior of depression

                  Techniques include delineating and testing specific
                  misconceptions and maladaptive assumptions (e.g.,
                  monitoring negative, automatic cognitions),
                  recognizing the connection between cognition,
                  affect, and behavior, and examining evidence for
                  and against distorted automatic thought

                  Dysfunctional thoughts and behaviors are then
                  substituted for more realistic interpretations and
                  functional behaviors Effective in decreasing
                  depressive symptoms, symptom severity, and
                  dysfunctional negative thoughts (Vannest,
                  Reynolds, & Kamphaus, 2008)

                  Shown to have the greatest empirical support for
                  treating depressed adolescents and children
                  (David-Ferdon & Kaslow, 2008; Watanabe, et al.,
                  2007)

Interpersonal     Aimed to help individuals learn how to understand,
  Therapy         manage and resolve their identified interpersonal
                  issues

                  Implemented individually or in group setting for
                  adolescents (Mufson, Gallagher, Dorta, & Young,
                  2004; Mufson, Moreau, Weissman, & Klerman,1993;
                  Mufson, Weissman, Moreau, and Garfinkel, 1999)

                  Proven to reduce depressive symptoms, increase
                  problem-solving skills, and increase social
                  functioning in adolescents with depression
                  (Mufson, Weissman, Moreau, and Garfinkel, 1999)
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Author:Ruderman, Matthew A.; Stifel, Skye W.F.; O'Malley, Meagan; Jimerson, Shane R.
Publication:Contemporary School Psychology
Article Type:Disease/Disorder overview
Date:Jan 1, 2013
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