Childhood depression has grabbed a lot of headlines recently, with major news media devoting ample space to the question, “Why are so many kids depressed, and what are we doing about it?”
And few if any of these headlines have been bigger or louder than the recent ones addressing the possible association between suicide risk and antidepressant use in children and adolescents, and the Food and Drug Administration's directive that a black box label be placed on selective serotonin reuptake inhibitors warning of this possible association.
The news behind these headlines has forced child and adolescent health care providers to ask themselves not only what is being done about depression in kids, but also, in light of the potential dangers of drug therapy, what can be done differently? For many children, the answer may lie with their parents' depression.
Studies have shown that parents with untreated depression are likely to have depressed children. “The odds of a child suffering from depression are at 25% if one parent suffers from depression. If both parents suffer from depression, the child has a 75%,” said David Fassler, M.D., of the University of Vermont, Burlington.
Children of depressed parents are also at higher risk for substance abuse, antisocial behavior, and a cascade of problems associated with attachment, anxiety, physical health, academic performance, self-esteem, aggression, behavior, and language (Psychol. Bull. 1990;108:50-76).
The problems can begin in infancy and grow along with the child. The younger a child is when the parent becomes depressed, the greater the impact will be, said Dr. Fassler, who is also coauthor of the book “'Help Me, I'm Sad': Recognizing, Treating, and Preventing Childhood and Adolescent Depression” (New York: Little, Brown and Co., 2003).
Several studies have shown that depressed mothers have trouble bonding with their newborns, are less sensitive than nondepressed mothers to their babies' needs, and are less consistent in how they respond to their babies' behavior. The behavior of their babies—listless, unhappy, hard to comfort—reflects those deficits, as does defiant, out-of-control behavior in a toddler.
Pair the difficulty dealing with their children with depressed parents' irritability, fatigue, pessimism, and social/emotional withdrawal, and the cycle is perpetuated into adolescence, where it manifests as poor academic performance, lack of motivation, social withdrawal, a sense of hopelessness and, potentially, suicidal thinking.
Although parental depression is not the only risk factor for depression in children, it is a major—and changeable—one. “There are certain steps you can take to reduce the risks for a child with a family history of mental illness,” Dr. Fassler said. These include monitoring the child for possible signs and symptoms of depression, as well as modifying the environmental contributors, which sometimes includes treating the parents' depression.
The first step toward effective intervention is to develop a treatment plan specific to the child and the family. Often, this might include individual and family therapy, school involvement, and, if necessary, adjunctive medication. Medication should only be used as part of a comprehensive, individualized treatment plan,” Dr. Fassler said.
Applying a family-based approach to the prevention of depressive symptoms does work. In a 2003 study, William Beardslee, M.D., head of psychiatry at Children's Hospital Boston, and his colleagues at the affiliated Judge Baker Children's Center, tested the effectiveness of two cognitive, psychoeducational, preventive interventions in children of depressed parents (see related story).
Preliminary results from the first-of-its-kind longitudinal primary prevention study of healthy kids at risk for psychopathology showed that the interventions, which addressed parental depression, resulted in a significant reduction in risk factors and increase in protective factors in the participating families over more than 2 years.
The case for preventive intervention among depressed families is a strong one. Several studies on children who were depressed before puberty show that they had a higher rate of antisocial behavior, anxiety, and major depression as adults than adults who experienced their first depressive episode as teens. Often, these children have little understanding of depression and feel like outsiders in their own world.
On the other hand, children who receive support and reassurance that their depression has a name and is treatable—and that their parents' depression is not a reflection on them but an illness to be overcome—are less likely to get caught in the intractable cycle and become depressed parents themselves.
Models Build Resilience in Children of Parents With Depression
Helping children understand a parent's mood disorder through open, honest communication fosters resiliency in those who might otherwise succumb to mental illness, according to Dr. Beardslee.
For children living in homes with depressed parents, promoting resilience through communication is the central component of a family-based intervention developed by Dr. Beardslee and his colleagues at the Judge Baker Children's Center in Boston.