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224 Chapter 12 Depressive Disorders, Bipolar Disorders, and Suicidality
adolescents, we need to consider mania in the context of
the variability in positive emotion and positive mood
observed in typically developing children and adolescents
(Gruber et al., 2016). Clinically salient episodes of mania
are associated with experiences of both joy and contempt,
an atypical, all-consuming focus on pursuing rewards and
ambitious goals, and emotion dysregulation (Gruber et al.,
2016; Vogel et al., 2022). The increasing prevalence across
adolescence of manic symptoms is associated with greater
severity of bipolar disorder and suicidality (Merikangas
et al., 2012). Rates in late adolescence are assumed to be
similar to rates observed in adults, approximately 4 percent
of the population (Carlson & Klein, 2014). The median
range for age of onset is between late adolescence and age
30, but the first high-risk period is between 15 and 19 years
of age (Alloy et al., 2015).
Developmental Course
Continuity of Depressive Disorders
As with all types of child psychopathology, developmental
continuity is often observed for youth with major depressive
disorder. That is, struggles in childhood are associated with
struggles in adolescence, and struggles in adolescence are
associated with struggles in adulthood (Garber & Rao,
2014; Rutter et al., 2006). Although continuity is common,
other pathways are also possible. These pathways include
a low stable pathway, a pathway involving less severe early
symptoms, a pathway with more severe early symptoms,
and a late-onset pathway (Arizaga et al., 2020; Ellis et al.,
2017; Weavers et al., 2021). Many episodes of adolescent
depression are brief and well-resolved. Compared to later
adolescent-onset, early adolescent-onset trajectories are
associated with greater persistence (Weaver et al., 2021).
Individual differences in developmental pathways and
outcomes depend on a variety of factors. Repeat episodes
and worse outcomes are linked to sex/gender, early
diagnosis, severity of depression, history of maltreatment,
parent mental illness, and poor peer relationships (Garber
& Rao, 2014). Thinking back to the case of Rebecca earlier
in the chapter, there are several risk factors that predict
long-term difficulties. First, she is a girl. While sex/gender
ratios for depression are relatively equal in early and middle
childhood, being a girl may further complicate the clinical
presentation as she transitions into adolescence. Rebecca’s
depression is also identified before puberty. And Rebecca’s
depression is severe, accompanied by suicidal ideation. But
there are also protective factors that may balance or moderate
the developmental course of the disorder. Rebecca’s parents
are aware and involved, and she has a history of good
friendships. With this mixed set of risk and protective
factors, a range of outcomes for Rebecca are possible.
Many children and adolescents who experience
depression deal with multiple episodes. In addition to
the ongoing experiences of depression, it is necessary to
understand how repeat episodes interfere with everyday
challenges. For example, major depressive disorder has
a negative impact on school achievement, especially for
boys (Weaver et al., 2021). To the extent that children
take pride in academic success and criticize themselves
when they do poorly, additional cycles of depression,
failure, and despair may exacerbate the initial depressive
symptoms and contribute to a poor self-image that
lasts years longer than treated, time-limited episodes
of depression. Peer difficulties, including poor-quality
relationships and peer rejection, also worsen depressive
symptoms and likely interfere with typical peer-related
developmental achievements (Garber & Rao, 2014;
Griffith et al., 2019).
We also need to consider the distinction between an
episode of major depressive disorder emerging for the first
time in adolescence (that is, as initial psychopathology) and
depression that emerges in adolescence following another
disorder (that is, as a complicating comorbid disorder).
This distinction may have even more relevance given the
earlier discussion of the development of self and identity
during adolescence. Adolescents diagnosed with depression
may have difficulties reconciling joyful and successful
childhoods with their current difficulties and may have a
much harder time constructing a sense of self characterized
by self-worth and self-efficacy.
The experience of stigma, discrimination, and adversity
contribute to ongoing depressive episodes for LGBTQ+
and gender-diverse individuals as well as more problematic
mental health outcomes, including suicidality (Chodzen
et al., 2020; Livingston et al., 2020; Rivas-Koehl et al.,
2022). Protective factors associated with better outcomes
include the presence of supportive adults and peers, safe
spaces, and mental health treatment (Johnson et al., 2019;
Rivas-Koehl et al., 2022).
Disruptive mood dysregulation disorder is often persistent
with impairments in multiple domains (Brotman et al., 2017;
Wiggins et al., 2021). Many researchers and clinicians have
emphasized the need to focus on the presence of DMDD
in preschool children rather than waiting until age 6 to
make a diagnosis (consistent with the DSM-5-TR criteria).
Data suggest that young adults with a history of DMDD
are more likely to struggle with depressive disorders, anxiety
disorders, and difficulties in many personal, interpersonal,
and educational domains (Copeland et al., 2014; Leibenluft
& Stoddard, 2013).
A number of professionals have noted that mood disorders
in children and adolescents may also be linked with special
strengths. For example, some children “may learn to be
especially attuned to others’ feelings and sensitivities, which
in some contexts may be especially adaptive and valuable”
(Cummings et al., 2000, p. 335). These children may
focus their talents on animal care, artistic endeavors, or
volunteering and community involvement.
Comorbidity is another influential factor. Major depressive
disorder combined with other internalizing disorders (such as
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Etiology 225
anxiety disorders) or externalizing disorders (such as ADHD
or conduct problems) is associated with increased impairment,
substance use and abuse, and suicidality (Garber & Rao, 2014).
In a 2016 review, two specific trajectories were described. The
first is a depression-only pathway and is more common in girls.
The second is a depression plus conduct problems pathway. This
second pathway is not sex/gender-specific and is associated with
lower cognitive ability (Riglin et al., 2016). Youth diagnosed with
DMDD exhibit higher rates of ADHD and anxiety disorders as
well as major depressive disorder (Brotman et al., 2017).
Continuity of Bipolar Disorders
With respect to bipolar disorders, a chronic pattern has been
observed for children and adolescents. Ongoing difficulties
include both subclinical symptoms and full episodes
(Birmaher et al., 2009). Mild forms of bipolar disorder
increase the risk for more severe disorder. Approximately
20 to 25 percent of children and adolescents convert from
bipolar II to bipolar I over time. Conversion of cyclothymia
to bipolar II is also common (Alloy et al., 2015). Similar to
adults, recovery rates are high, but recurrences are frequent
(Carlson & Klein, 2014). Factors associated with worse
outcomes include difficult temperament, rapid cycling of
episodes, psychotic features, low SES, comorbid disorders,
and poor adherence to treatment (Alloy et al., 2015).
For individuals at high risk (because their parents were
diagnosed with bipolar disorder), there was variability in the
display of subclinical symptoms that led to later disorder
as well as in adolescent anxiety disorders that preceded
later bipolar disorder (Axelson et al., 2015). A history of
maltreatment is also associated with early onset of bipolar
disorder, greater symptom severity, increased comorbidity,
and worse outcomes (Agnew-Blais & Danese, 2016).
Etiology
Depressive Disorders
There are many causes, many pathways, and many outcomes
for children and adolescents with depressive disorders.
As with other types of psychopathology, it is necessary
to construct risk models that include multiple factors, in
various combinations, that lead to disorder. One such model
provides a multilevel developmental framework, with both
direct and interactive effects among types of risk factors
(Garber, 2007; refer to Figure 12.4).
Genes and Heredity
Estimates of heritability for depressive disorders for
children and adolescents are moderate and similar to adult
estimates. Additive genetic effects (many genes, small
impacts) are observed (Jami et al., 2022). The genetic
impact on depressive symptoms appears to increase as
children age. This increase in heritability is likely linked to
gene-by-environment-by-time processes, with individuals
at high genetic risk experiencing more adverse life events
than individuals at low genetic risk (Garber & Rao, 2014;
Gotlib et al., 2020). Family studies of depressive disorder
indicate that “having a depressed parent is one of the most
powerful predictors of depression in children, which likely
is due to both genetic and environmental influences”
(Garber, 2007, p. 202). Multigenerational studies,
where parents and grandparents are both diagnosed
with depressive disorders, provide additional evidence
for increased risk of early-onset (prepuberty) depression
across sex/gender, race/ethnicity, and SES levels (van Dijk
et al., 2021).
Figure 12.4 A multilevel biopsychosocial model of depression
Individual Diatheses
Genes
Neurobiology
Temperament
Cognitive Style
Self-Regulation
Context
Stressful life events
Interpersonal relationships
Source: Garber (2007). Depression in youth: A developmental psychopathology perspective.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Response
to Stress
Biological
Cognitive
Behavioral
Emotional
Depression
226 Chapter 12 Depressive Disorders, Bipolar Disorders, and Suicidality
Genetic influences are also observed for disruptive mood
dysregulation disorder. DMDD is associated with a family
history of depression (not bipolar disorder) (Propper et al.,
2017). Many genetically informed studies include a focus on
genetic variants believed to be involved in emotion regulation
and stress reactivity, such as the serotonin transporter linked
promoter region gene (5-HTTT) (Garber & Rao, 2014).
In addition, in an example of differential susceptibility to
depression, at-risk adolescent boys with a 5-HTTT genetic
variant do better in the presence of positive family support
and worse in the presence of poor family support (Li et al.,
2013).
Physiological Factors
Physiological investigations have identified a number of
structural, functional, and biochemical differences that
contribute to the emergence and maintenance of depressive
disorders. Atypical structure and function of brain regions
involved in the experience and regulation of negative mood
(e.g., the amygdala, the insula) have been observed (Garber
& Rao, 2014; Nielsen et al., 2020). There are also data
relating to decreased blood flow and reduced activation
patterns in the left frontal regions of the brain. These
electroencephalograph (EEG) asymmetries continue into
adulthood (Garber & Rao, 2014; Goldstein et al., 2016).
Atypical patterns of brain connectivity have also been
observed (Ellis et al., 2017; Garber & Rao, 2014). Taking
these types of physiological factors into account, Pennington
(2002, p. 117) describes an “imbalance between top-down
(prefrontal) and bottom-up (amygdala) components of the
affect regulation system.” Additional research highlights
the dysregulation of neurotransmitters, norepinephrine
and serotonin in particular (Garber & Rao, 2014).
Dysregulation of physiological threat systems may lead to
chronic overactivity of the hypothalamic-pituitary-adrenal
(HPA) axis and stress responsivity (McEwen & Akil, 2020).
Young children with difficult temperaments, with
increased irritability, and with negative emotions and
decreased flexibility are at higher risk for the development
of depressive disorders (Beauchaine & Tackett, 2020). Sleep
disturbances are also commonly described, with variable
patterns related to sleep architecture (e.g., types of sleep and
arousal patterns) and sleep EEG rhythms. Decreased sleep is
associated with increases in negative mood and risk-taking
behaviors. Better sleep may be a protective factor in children
and adolescents (Gregory & Sadeh, 2015; Kelly et al., 2021).
Pennington (2002, pp. 116–117), investigating the
physiological consequences of social stress, emphasizes the
roles of “behavioral sensitization and electrophysiological
kindling” and states that “social stress causes a permanent
vulnerability in the HPA axis.” He suggests that over time,
the increasingly sensitive neurological response system
requires lower thresholds of stimulation to trigger a new
episode. This kindling model explains, in part, why later
episodes of depression occur in the context of less severe
stress. The kindling model may be further understood in
the social context of brain development. That is, changes
in the microstructures of the brain take place in continuous
transaction with the environment. With the rapid production
of neurons in early life, followed by neuronal pruning,
stabilization, and sensitization, the experience of social
distress and dysfunction has both immediate and long-term
negative impacts (Curley et al., 2011; Dougherty et al., 2011).
Finally, given the dramatic increases in rates of depressive
disorders in adolescence, puberty changes and the timing
of puberty are a frequent focus of study. Some research
emphasizes the transdiagnostic risks associated with early
puberty, with increases in rates of both internalizing and
externalizing disorders (Hamlat et al., 2019). Other research
emphasizes the specific contribution of early puberty to
depressive disorders in both girls and boys, although the
effects are strongest for girls (Hamlat et al., 2020; Stumper
& Alloy, 2021). Physiological challenges include increasing
hormone concentrations and body changes. For some girls,
physical development outpaces cognitive and emotional
development. Social pressures may also increase, as peers
and adults expect more adultlike behavior from those
whose appearance suggests greater maturity. For boys, early
maturity has a mix of positive and negative impacts, with
higher levels of self-esteem balanced by engaging in more
frequent risk behaviors.
Child Factors
Emotion theories focus on emotion dysregulation as the core
deficit (Beauchaine & Cicchetti, 2019; McQuillan et al.,
2018). Intense, prolonged, and poorly controlled experiences
with emotion lead to the development of an affective bias.
The bias or tendency to feel sad is usually most prominent,
but there may also be biases related to anxiety, guilt, and
shame. Having fewer emotion-regulation strategies, less
effective strategies, or believing that strategies are ineffective
also contributes to the development of depressive disorders
(Compas et al., 2017; Lennarz et al., 2019). Irritability
(involving a predisposition to frustration and anger) and
dysregulation are the focus of emotion research related to
DMDD (Stringaris et al., 2018; Wiggins et al., 2021).
With respect to temperament, the combination of
high negative emotionality and low positive emotionality
increases the risk for depressive disorders. This particular
risk is especially salient for girls who also experience harsh
or punitive parenting (Garber & Rao, 2014). Although
most emotion research examines the dysregulation of
negative emotion, there are investigations that explore the
dysregulation of positive emotions. These studies focus
on surgency, the temperamental characteristic including
tendencies to experience positive emotions, excitability and
approach behaviors, reward seeking, and high activity levels
(Vogel et al., 2022). Children who display very high levels
of surgency are at increased risk for problematic outcomes
including DMDD (Vogel et al., 2022).
Attachment status has a far-reaching impact, with an
emphasis on the association between insecure attachment
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Etiology 227
patterns and the emergence of internalizing disorders such
as depression (Khan et al., 2020). Feelings of emotional
security are the primary concern. Emotional security is
central to the regulation of many kinds of behavior and is
tied to three underlying processes: the child’s emotional
reactivity, representations of family relationships (i.e., the
internalized working models), and regulation of exposure to
family emotion (Cummings et al., 2000). Lack of emotional
support in early development may also lead to cognitive
consequences, including negative self-concept and negative
beliefs about the self. Dysfunctional cognitions that develop
early may become even more established and difficult to
change if there are ongoing or additional negative events.
Cognitive theories include Beck’s information-processing
theory of depression, Bandura’s work on self-efficacy,
Seligman’s theory of learned helplessness, and Abramson’s
and Alloy’s work on hopelessness. Cognitive explanations
of depression focus on the cognitive triad—negative beliefs
about the self, negative beliefs about the world, and negative
beliefs about the future—as well as problematic information
processing and cognitive errors (Beck, 1987; 1996).
Cognitive constructs and depressive symptoms influence
each other over time.
The hopelessness model emphasizes that negative
inferences about the causes and consequences of events
increase the risk for depression (Abramson et al., 1989; Liu et
al., 2021). In numerous studies, children and adolescents who
display negative automatic thoughts, dysfunctional attitudes,
and low self-efficacy and self-esteem are more likely to develop
depressive disorders (Beck & Bredemeier, 2016; Garber &
Rao, 2014). According to Sonuga-Barke et al. (2016, p. 335),
a distinctive pattern of dysfunctional cognitive processing
in depressed children and adolescents involves “disengaged,
perseverative, and pessimistic decision making.” Negative
beliefs may develop because of problematic early experiences,
additional life stressors, difficult interpersonal relationships
(e.g., with peers), or modeling others’ beliefs (Garber & Rao,
2014; Sonuga-Barke et al., 2016).
The role of self-concepts (including self-esteem, selfefficacy, locus of control and mastery) are the focus of
detailed analysis (Reed-Fitzke, 2020). Self-esteem has
received the most attention with clear links to the emergence
and maintenance of depression. Other work has identified
low authenticity (feeling that one’s true self is unknown
or unacceptable to others) as a contributing factor to
depression. The experience of hiding one’s self is relevant to
many LGBTQ+ youth (refer again to Box 12.1) as well as
to minority or marginalized individuals such as observed in
some Asian American youth (Luthar et al., 2021).
Another cognitive characteristic that has received a lot
of research attention is rumination, a “relatively stable
maladaptive coping strategy” that involves repeated
focus on problems or symptoms and the causes and
consequences of those problems or symptoms (Burwell
& Shirk, 2007, p. 56). Rumination appears to prolong
episodes of depression, especially in girls and young
women (Essau et al., 2010; Jose & Weir, 2013; NolenHoeksema, 2002). Further, a “cost of caring” has been
described in girls’ friendships, in which the rumination of
one friend is associated with increased empathic distress
in the other (Smith & Rose, 2011).
Integrations of multiple cognitive models may provide a
better understanding of the complexity and heterogeneity
of depressive disorders in youth and more specific cognitive
targets for intervention (Liu et al., 2021; Pössel & Smith,
2020). It is also important to keep in mind that cognitive
models are not only relevant for depressive disorders.
Cognitive risks are transdiagnostic risks and cognitive
vulnerabilities increase the likelihood of both internalizing
and externalizing disorders. Across disorders, core features
of common cognitive risk include dysfunctional attitudes
and self-criticism. Additional specific cognitive risks
include negative inferential style and rumination/brooding
(Schweizer et al., 2020).
Parent and Family Factors
There have been numerous investigations of the children
of depressed parents. Longitudinal data provides clear
iStock.com/Sheryl Griffin
Along with other risk factors, having depressed parents
significantly increases the likelihood that a child will
develop depression or another form of psychopathology.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
228 Chapter 12 Depressive Disorders, Bipolar Disorders, and Suicidality
Birth Parent
Rearing Parent
Stress
Child Emotion
evidence that depressed parents, in addition to their genetic
and physiological impact, have children who struggle with a
variety of internalizing and externalizing disorders (Garber
& Rao, 2014; Gotlib et al., 2020). But not all children
with depressed parents are depressed themselves. If they do
have problems, not all of them are similar. Most research
on depressed caregivers focuses on mothers. The results of
research on fathers are mixed.
In the “launch and grow” model of depression, a set of
cascading effects (related to self-worth, family environment,
and stressful life events) is set into motion for children who
experienced maternal depression by age 12 and predicted
the trajectory of depression across adolescence (Garber
& Cole, 2010). Another model focused on caregivers is
a dynamic stress-regulation model in which caregiver
depression increases the child’s stress sensitivity and leads
to the development of both internalizing and externalizing
disorders (Laurent, 2014; refer to Figure 12.5).
Several pathways of parental impact on child and
adolescent depressive disorders have been described
(Cummings et al., 2000): (1) parent depression affects
parent–child relationships and interactions and leads to
child psychopathology; (2) parent depression affects family
relationships and interactions and causes family disruptions,
which lead to child psychopathology; and (3) parent
depression affects relationships with romantic partners, and
this leads to child psychopathology.
With respect to the parent–child relationship, parental
depression is associated with lower quality parenting
(Cicchetti et al., 1997; Gotlib et al., 2020). The sadness,
social withdrawal, and reduced activity that are hallmarks
of adult depression often interfere with the typical positive
emotional and behavioral exchanges that characterize
interactions with infants and young children. The
emotional unavailability and insensitivity sometimes seen
in depressed caregivers may also hinder the development
of secure attachment relationships. Older children and
adolescents may experience a range of negative interactions
as well as inconsistent or ineffective parenting. Some
depressed caregivers express irritability or hostility or hold
negative beliefs about their children (Goodman et al., 2011).
The timing, severity, and chronicity of caregiver depression
may moderate or intensify these patterns. Children with
additional risk factors, such as higher rates of irritability or
negative emotion, may be particularly vulnerable to poorquality care (Whelan et al., 2015).
Overall, many of these risk factors are consistent with a
reinforcement model of depression (Pennington, 2002) in
which parents offer fewer rewards and more punishments
to their children. This model is sometimes viewed as more
consistent with the maintenance of depression in children
rather than the emergence of depression. Mental health
services that support effective parenting for mothers and
fathers with depression are essential.
Even as we discuss the caregiving difficulties experienced
by depressed parents, we need to remember that many
depressed parents exhibit average or even excellent
parenting. “For example, a girl’s father, despite being
alcoholic and depressed, may remain very loving and caring
toward her. While she may experience the negative sequelae
of the father’s problems, she may also firmly understand
that she is loved and may treasure and benefit from those
experiences that are supportive and special” (Cummings
et al., 2000, p. 301). It is also the case that there is specificity
observed in children’s interactions with a depressed parent,
so a child’s relationships with nondepressed adults may serve
as important protective factors.
With respect to family relationships and family
atmosphere, family conflict is an important risk factor
(Garber & Rao, 2014). But specific family factors may have
Figure 12.5 A model of parent–child emotion regulation via stress sensitivity
Influences
Inherited risk
Source: Laurent (2014). Clarifying the contours of emotion regulation: Insights from parent-child stress research.
Prenatal maternal
depression
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Postnatal maternal
depression
Influences
Postnatal paternal
depression
Sensitivity
HPA Activation
(calibrating
over time)
Current
environmental
context
Regulation
Internalizing,
externalizing
problems
Etiology 229
differential impacts depending on ethnicity or sex/gender.
High conf lict, for exa mple, appears to have a disproportionate
impact on adolescent girls (Lewis et al., 2015). Finally,
parent psychopathology influences child psychopathology
via mechanisms related to adult conflict. Depressed parents
are negative and critical toward their partners as well as
their children. Warmth and emotional support from the
well partner is critical in helping the struggling partner
both with the disorder and with parenting (Cummings
et al., 2000).
Environmental Factors
Even with the myriad factors related to genes, individual
characteristics, and family functioning, we should not
overlook the impact of larger events (such as trauma) and
larger environments (such as culture and socioeconomic
background) on the development of mood disorders
(Garber & Rao, 2014). However, we should also be
thinking about the emergence of psychopathology in
more complex ways. For example, as we have frequently
noted in discussions of differential susceptibility, children
at high genetic risk may be more vulnerable to the effects
of adverse environments. Also, individual children, even
those in the same family, may respond differently to a
stressor. Distinctions need to be made between shared
risk factors (affecting all siblings) and nonshared risk
factors (affecting only one sibling or affecting one or more
siblings disproportionately).
Both specific negative life events (such as a parent
losing a job or a serious illness in the family) and chronic
hassles have been associated with depression in children,
especially in the early years (Garber & Rao, 2014; Kim
et al., 2021). With increasing age, interactions between
negative events and the child’s cognitive abilities and
tendencies (such as pessimistic explanatory styles) become
more important (Riglin et al., 2015) as well as interactions
between environmental factors (such as between negative
events and social support) (Petti et al., 2004). Parental
depression is associated with increases in negative life
events and environmental stressors, increasing further
youth risk for depression via cascading effects (Gotlib
et al., 2020).
In addition to major life events, chronic hassles can
contribute to high levels of stress. Problematic peer
relationships, and romantic difficulties in particular, may
also be extremely stressful for adolescents. Depressed youth
often have various peer problems including social skills
deficits, poorer-quality friendships, and experiences with
rejection (Garber & Rao, 2014). Perceived rejection, in fact,
is a more salient risk factor than actual rejection (Garber &
Rao, 2014). Youth with bipolar disorder also report fewer
close friendships and more victimization than typically
developing peers (Siegel et al., 2015).
Evidence that girls are exposed to more episodic stressors,
and more total stressors, may provide additional perspective
on observed sex/gender differences in rates of depression
(Frost et al., 2015). Further, the timing and severity of
adverse experiences appears to differentially influence the
emergence and course of depression in adolescent girls
compared to adolescent boys. Early preschool exposure
to high-impact adversity, for example, is associated with
depression in adolescent girls, but not adolescent boys.
Adolescent girls also display more depression following lowerimpact exposure in elementary school (St. Clair et al., 2015).
Excessive pressure to excel in and out of school settings is
increasingly linked to depressive symptoms and problematic
outcomes. Chronic stress related to academic achievement
and parental criticism are important risk factors (Luthar
et al., 2020; Stiles et al., 2020).
As an everyday, environmental risk factor, poverty
exerts a number of deleterious effects. In addition, it
appears to “be a broad-scale enhancer of risk in relation
to depression in mothers” (Goodman et al., 2011, p. 15).
That is, findings related to the effects of maternal
depression on children are magnified in the presence
of poverty. Neighborhood adversity also constrains the
benefits of available protective factors (Silk et al., 2007).
Discrimination and racism also increase youth risk for
depression, with clear evidence across groups of Black,
Latino, Asian American, and LGBTQ+ youth (Arizaga
et al., 2020; Chodzen et al., 2020; Luthar et al., 2021).
Positive parenting behavior may be a protective factor
in some families. Data suggest that protective parenting
buffers the impact of racial discrimination for Black youth
(Lei et al., 2021).
Maltreatment, including physical abuse, sexual abuse,
emotional abuse, and neglect, long understood to be
precursors of insecure attachment, are also predictably
related to later mood disorders in children and
adolescents (Cicchetti & Toth, 1995, 2003). Individual
and developmental factors, the specific form, severity,
and chronicity of abuse, and other environmental factors
all influence children’s outcomes (VanZomeren et al.,
2020).
Bipolar Disorders
As with major depressive disorder, genes are important
determinants of risk for bipolar disorder. Bipolar is
highly heritable, with many genetic variants having
small effects (Hasin et al., 2022; Mahon et al., 2015;
Oquendo et al., 2013). Many of the genetic variants that
are associated with increased risk for bipolar disorder
also increase the risk for other forms of psychopathology.
Although many individuals with bipolar disorder
experience both manic and depressive episodes, research
findings from the National Institute of Mental Health’s
Family Study of Affective Spectrum Disorders suggest
that genetic transmission of risk for mania and for
depressive episodes is largely independent (Merikangas
et al., 2014).
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
230 Chapter 12 Depressive Disorders, Bipolar Disorders, and Suicidality
Stress
Stress
essive pathway
Brain regions implicated in bipolar disorder include the
amygdala, ventral striatum, and ventral prefrontal cortex.
These regions are involved in emotional and motivational
processes. Both atypical structure and function are observed,
including atypical white matter microstructure trajectories
(Linke et al., 2020; Russo et al., 2015). Other researchers
have emphasized the extensive dysfunction of both affective
and cognitive circuits and atypical neural reward circuit
processing (Bart et al., 2021; Pavuluri, 2015). Atypical white
matter microstructure trajectories are observed in youth at
risk for bipolar disorder (Linke et al., 2020).
Two physiological risk factors receiving special
attention are reward hypersensitivity and social/circadian
rhythm disruption (Alloy et al., 2019; McCarthy
et al., 2021). In the reward hypersensitivity model, the
biobehavioral system that regulates motivation and goalseeking behaviors is hypothesized to be hyperreactive to
goal- and reward-relevant cues. Enthusiastic, excited, and
often agitated pursuit of rewards is part of the hypomanic
or manic symptom pattern. Failure to achieve goals or
rewards leads to depressive symptoms (refer to Figure 12.6).
In the social/circadian rhythm model, disruptions in daily
social rhythms (such as bedtimes, mealtimes, and school or
work time) lead to disruptions in circadian rhythms such
as sleep patterns, which, in turn, lead to mood symptoms
(refer to Figure 12.7). There is strong evidence to support
both of these models, and an integrated reward/circadian
rhythm dysregulation model to account for the emergence
and course of bipolar disorder has been proposed (Alloy
et al., 2019).
Assessment and Diagnosis
Assessment and Diagnosis in Children
With children, assessment of mood disorders is complex
because agreement between parents and children about
the presence of depression is often low (Makol & Polo,
2018). Irritability, for example, is a common complaint of
parents and teachers and may be characteristic of many
internalizing and externalizing disorders (Leibenluft, 2020;
Vidal-Ribas et al., 2016). Comprehensive assessments, then,
must include multiple measures, such as self-report, parent
report, medical exams, and observations. It is also important
to appreciate that trajectories of depressive symptoms may
vary over time, depending on the type of assessment (Long
et al., 2020).
There are many standardized interviews and checklists.
Among the most frequently used is the Children’s Depression
Inventory (Kovacs, 1985, 1992). For disruptive mood
dysregulation disorder, careful assessment involves close
attention to atypical development in preschoolers and older
children (Egger & Emde, 2011). Children who meet the
disorder and oppositional defiant disorder are diagnosed
only with the more severe disruptive mood dysregulation
disorder.
For children at risk for bipolar disorder, well-known
inventories of child and adolescent symptoms may
provide useful information (Carlson & Klein, 2014).
There continues to be considerable diagnostic confusion
Figure 12.6 The reward hypersensitivity model of bipolar disorders
Approach activation-
relevant event
(goal striving, goal
attainment, reward)
(Vulnerability)
Reward
Hypersensitivity
Approach deactivation-
relevant event
(definite failure,
irreconciliable loss)
Source: Alloy, Nusslock, & Boland (2015). The development and course of bipolar spectrum disorders: An integrated reward and circadian rhythm
dysregulation model.
Excessive reward
activation
state
Excessive reward
deactivation
state
Hypomanic/manic
symptoms or
episodes
Depressive
symptoms or
episodes
Hypomanic/manic
pathway
Depr
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Intervention 231
External Trigger
(social z
Internal Trigger
Figure 12.7 The social/circadian rhythm model of bipolar disorders
eitgeber theory)
Social
rhythm-disrupting
events
Social rhythm
disruption
Circadian pacemaker
abnormality
(suprachiasmatic
nucleus)
Source: Alloy, Nusslock, & Boland (2015). The development and course of bipolar spectrum disorders: An integrated reward and circadian rhythm
dysregulation model.
Circadian rhythm
disruption
Mood episodes/
symptoms
when trying to differentiate mania (and bipolar disorder)
from ADHD. Impulsivity and hyperactivity are certainly
part of the clinical presentation of both disorders. The
presence of distinct episodes and appropriate developmental
considerations are essential to accurate diagnosis. Early
onset bipolar disorder can be differentiated from ADHD
by the presence of typically manic symptoms such as elated
mood, flight of ideas, and grandiosity (Carlson & Klein,
2014). A child with elated mood might laugh hysterically in
inappropriate situations, with no obvious reason. Flight of
ideas may be evident in rapid and continuous jumping from
one topic to another, often with loud, pressured speech.
Children presenting with grandiosity often believe that they
have superior knowledge and abilities and behave as if rules
do not apply to them. In extreme instances, they may state
that they have supernatural powers.
Comorbid psychopathology is a critical aspect of
asses sment and d iagnosis becaus e many children with m ajor
depressive disorder also have other psychopathologies. The
most frequent are anxiety disorders, with anxiety disorders
usually preceding the mood disorder. Other internalizing
and externalizing disorders are also common.
Assessment and Diagnosis
in Adolescents
With adolescents, assessment of depressive disorders and
bipolar disorders is also complicated. Parents and clinicians,
as well as adolescents themselves, need to consider possible
symptoms in the context of a developmental period
characterized by emotional and personal challenges. In
addition, with increases in child and adolescent suicide
attempts and completions, it is imperative to screen for
suicidality. The selection of evidence-based instruments is
absolutely critical, given that there is often little agreement
among adolescents, parents, teachers, and clinicians about
the presence of psychopathology. Multiple informants may
provide valuable perspectives (Carlson & Klein, 2014).
In both screening access and testing, demographic factors
must also be addressed. Youth with various backgrounds
(e.g., low SES, LGBTQ+) may differ in access to initial care
(Davis et al., 2022). Assessment instruments must also be
carefully used. The Beck Depression Inventory, for example,
is a reliable and valid assessment for youth of various racial
and ethnic backgrounds (Mellick et al., 2019).
Diagnostic accuracy must also take into account
differential diagnosis and comorbidity. Clinicians want
to find the best explanation of the presenting symptoms
while still recognizing that some adolescents will be
appropriately diagnosed with more than one disorder. Earlyonset schizophrenia must also be considered and ruled
out. Conduct disorder needs to be separately assessed and
addressed. And substance abuse is even more common and
more problematic for adolescent-onset bipolar disorder than
earlier emerging bipolar disorder (Wilens et al., 2004).
Intervention
As we think about the variety of efforts to treat and prevent
depressive and bipolar disorders, as well as the fact that many
of those treated and targeted are children and adolescents,
it is essential to consider the developmental context of
intervention. For instance, motivation is a key contributor to
treatment success. Most struggling adolescents do not refer
themselves to therapy. Once there, many remain reluctant to
participate. So immediately addressing motivational issues is
important to help adolescents develop a strong therapeutic
alliance and engage with specific therapy techniques.
Adolescents also appear to prefer active psychological
interventions. Interventions such as cognitive behavioral
therapy may increase commitment and follow-through
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232 Chapter 12 Depressive Disorders, Bipolar Disorders, and Suicidality
(Cirasola et al., 2021). Strengthening the therapeutic alliance
is also especially important for youth who experience stigma or
marginalization, challenges related to culture or background,
or who have little or no access to family support (Johnson
et al., 2019; Sheinfil et al., 2019).
The treatment of both depressive disorders and bipolar
disorders involves a number of goals. First, acute symptoms
(such as suicidality) need to be managed. The focus then
shifts to decreasing the distress and dysfunction associated
with the disorder. Finally, attention must be paid to the
maintenance of improvements. The reduction of longterm complications and the promotion of growth and
development also contribute to treatment success. A number
of meta-analytic reviews document the immediate and
long-term positive impacts of evidence-based treatments for
mood disorders (Miklowitz, 2015; Weersing et al., 2017).
Even with these available treatments, many children
and adolescents do not receive any treatment. In a large
national survey of bipolar disorder in adolescents and
treatment patterns, only half of the youth were receiving
an intervention specifically designed for bipolar disorder.
Approximately 10% were being treated for another disorder,
and 38% reported receiving no treatment (Khazanov
et al., 2015). Access to disorder-specific treatment remains
a significant public health issue. Another public health
issue is that, even when effective treatments are available
and implemented, ongoing adverse experiences increase
likelihood of poor outcomes (Weersing et al., 2017).
Pharmacological Treatments
Antidepressants are among the most frequently prescribed
medications for adolescents, with adolescent girls more
than twice as likely to use antidepressants compared to
adolescent boys and with White adolescents more likely
to use them compared to adolescents of other racial and
ethnic backgrounds (Jonas et al., 2013). Keeping this high
rate of medication use in mind, a 2016 meta-analytic review
concluded that, compared to psychosocial interventions,
there was no clear advantage to the use of antidepressants in
children and adolescents. With negative effects considered
along with likely benefits, fluoxetine was the best
medication option (Cipriani et al., 2016). For disruptive
mood dysregulation disorder, antidepressants and stimulant
medications are both used to address irritability (Brotman
et al., 2017). For bipolar disorders, mood stabilizers are the
first choice in medications. A combination of medications
may be necessary for more severe forms of bipolar disorder
(Atkins et al., 2017; Lytle et al., 2015).
For all youth receiving medications, informed consent,
support for other components of treatment (such as
psychotherapy), and monitoring of improvements and
side effects are essential. Hospitalization for those in crisis
is an important clinical option, although many children
and adolescents experience a range of difficulties following
discharge. Only 35 percent of those in outpatient treatment
following hospitalization displayed full medication
adherence. Complicating factors include symptoms severity,
comorbidity, lower SES, and the lack of a psychotherapy
component (DelBello et al., 2007).
Psychosocial Treatments
Psychosocial interventions for children with mood disorders
are effective, with cognitive-behavioral therapies and
interpersonal therapies (i.e., relationship-focused
approaches) appearing equally useful (Weersing et al., 2017).
Individual and group approaches are both associated with
good outcomes. Dialectical behavior therapy is associated
with good outcomes for adolescents with bipolar disorder
(Goldstein et al., 2015). Because sleep disturbances are
frequently observed in both depressive disorders and bipolar
disorders, strategies or techniques that target sleep are often
included as part of a comprehensive intervention (DewaldKaufmann et al., 2014). For adolescents in psychosocial
treatments, ongoing assessment of suicidality is imperative.
Interpersonal therapies for both children and adolescents
address t he salient age-related personal, socia l, and developmental
issues in the context of topics such as loss, grief, and relationship
difficulties (Weersing et al., 2017). Both cognitive behavior
therapy and interpersonal therapies must include mechanisms
designed to maintain improved functioning. In many
longitudinal outcome studies, initial gains were not maintained
over time (Weersing et al., 2017).
Another evidence-based approach involves combinations
of individual therapy with parent therapy. The combination
of CBT and parent management training, for example, is
associated with positive outcomes for youth with depressive
disorders and DMDD (Brotman et al., 2017; Vogel et al.,
2022). Computer-based interventions are increasingly
available. These may be particularly helpful for increasing
access and for addressing information processing biases
and social skills (Bansa et al., 2018; Evans et al., 2020).
Mental health monitoring apps may be a useful addition to
treatment plans, but users need to be aware of ethics and
privacy concerns (Williams & Pykett, 2022).
Family Treatments
Both mothers and fathers may be especially powerful
agents of change, with parent advocacy a key factor in
access to treatment and follow-up plans. Psychoeducational
support and family-specific techniques are associated with
decreases in children’s distress and dysfunction (Fristad &
MacPherson, 2014). Education may be especially critical for
the parents of children and adolescents with bipolar disorder
(Miklowitz et al., 2004). The role of the family is also
emphasized as we consider the ongoing need for maintenance
treatment after initial improvements (Weersing et al., 2017).
As noted, parent management training is often combined
with individual youth treatments to achieve better outcomes.
Parental depression should also be addressed, for both parent
and youth well-being. In addition, given the impact of poor
marital relations on children’s adjustment, marital therapy may
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Suicidality 233
be a useful adjunct intervention. Finally, recognizing that the
caregivers of youth with depressive and bipolar disorders also
struggle to remain optimistic and effective, caregiver support
is critical. There are many ways to provide that support, from
individual counseling to internet groups.
Prevention Efforts
Prevention efforts have included studies targeting children
of depressed parents as well as samples of youth with more
general high-risk profiles (such as those experiencing
multiple adversities). The Penn Resiliency Program (PRP),
which focuses on the cultivation of optimism and coping
skills in middle schoolers, has yielded positive outcomes (Ma
et al., 2020). Although overall positive effects are observed,
there is also significant variation in individual outcomes
(Brunwasser et al., 2018; Ma et al., 2020). Other types of
prevention emphasize the timing of therapeutic techniques
to coincide with developmental milestones. The hypothesis
is that youth and their families may be more accepting of
change-related opportunities when a transition period is
underway (Gladstone & Beardslee, 2002). Another agerelated option is to focus on preadolescent girls to address
sex/gender-specific challenges (Avenevoli et al., 2015).
Additional prevention efforts are focused on outreach
to youth at greater risk because of multiple adversities or
particular experiences (such as maltreatment).
Suicidality
“The young boy scrawled a note and pinned it to his shirt.
Then he walked to the far side of the family Christmas
tree and hanged himself from a ceiling beam. The note was
short—‘Merry Christmas’—and his parents never forgot or
understood it”
(Kay Redfield Jamison, 1999, p. 73).
One of the saddest developmental trajectories ends with
suicide. For most people, the idea that death is preferable to
even the most difficult of life’s struggles is hard to understand.
It is even more awful when the individual who thinks about,
attempts, or dies by suicide is a child or adolescent. Although
suicide in childhood and adolescence is not common, youth
suicide is a major public health concern. For elementary
school-aged children, suicide is not common, with stable
rates observed between the late 1990s through the early
2000s. The overall stability, however, masks important
differences in trends for White children and Black children.
Suicide rates decreased significantly for White children, but
rates increased significantly for Black children (Bridge et al.,
2015). Self-injurious thoughts and behaviors are observed in
younger youth as well (Oppenheimer et al., 2022). Additional
research on risk factors, prevention, and intervention for child
suicidality is urgently needed (Ayers et al., 2020).
For adolescents, suicide rates are increasing, with suicide
the second-leading cause of adolescent deaths (Oppenheimer
et al., 2022). According to the Centers for Disease Control
and Prevention (CDC), a survey of high school-aged
youth found that 19 percent of students reported seriously
considering suicide, 16 percent reported creating a plan, and
9 percent reported trying to ta ke their own life in the previous
year (Ivey-Stephenson et al., 2020). A meta-analytic review
of worldwide suicide rates in adolescents (from 2010 to
2016) reveals significant variation in mortality rates related
to countries and regions. Consistent with previous reports,
the highest rates are observed in New Zealand, Estonia,
and Uzbekistan. Keep in mind, however, that most of the
data comes from Western and high- and middle-income
countries. We know much less about adolescent suicidality
in low-income and non-Western countries (Glenn et al.,
2020).
In many countries, race and ethnicity contribute to
higher risk, likely connected to the experience of multiple
adversities. Among these high-risk groups are Black,
Hispanic, and Indigenous adolescents. LGBTQ+ and
nonbinary adolescents also exhibit higher rates (Glenn et al.,
2020; Oppenheimer et al., 2022; Price & Khubchandani,
2019). In all investigations, adolescent boys have much
higher rates of suicide than adolescent girls. Attempted
suicide is a much more frequent phenomenon than dying
by suicide, with adolescent girls attempting suicide at
significantly higher rates than adolescent boys.
To understand some of the factors that predispose
children and adolescents to consider suicide, it is important
to be clear about definitions related to suicidality. Suicidal
ideation involves a variety of cognitions, from transitory
thoughts about dying to detailed plans for killing oneself.
Parasuicide includes many behaviors, from less dangerous
gestures to serious suicida l actions, that do not result in death.
The term parasuicide is increasingly preferred over attempted
suicide because the motives and intentions of individuals are
often difficult to identify. Nonsuicidal self-injury (NSSI),
or self-harm, overlaps with many kinds of suicidal behavior
but can also be considered a distinct phenomenon. Many
adolescents who display self-harm report different attitudes
toward life and death and use different means of injury
(e.g., cutting versus overdosing) from adolescents who
exhibit parasuicidal behavior (Cha & Nock, 2014; refer to
Box 12.2). Self-injurious thoughts and behaviors (SITBs)
are a composite description of suicidal ideation, NSSI, and
parasuicide. Suicide involves an intentional death that is the
direct or indirect result of a positive or negative act of the
victim. Suicidality is the construct that includes suicidal
ideation, parasuicide, SITBs, and suicide.
Many different variables increase the risk for suicidality in
adolescents. Genetic effects on persistent suicidal ideation,
suicide attempts, and deaths by suicide are observed, with
concordance rates for monozygotic twins higher than rates
for dizygotic twins. Many of these genetic effects overlap
those observed for the heritability of various forms of
psychopathology. Physiological processes that contribute to
disinhibition, impulsivity, and aggression are all risk factors.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.