Indonesia Child and Adolescent Depression - A Review of Theories, Evaluation Instruments, Prevention Programs, and Treatments

TINJAUAN
diterbitkan: 20 Maret
2019 doi:
10.3389/fpsyg.2019.00543
Perawatan
Elena Bernaras 1, Joana Jaureguizar 2* dan Maite
Garaigordobil 3
1
Departemen Perkembangan dan Pendidikan, Universitas Negara Basque,
Donostia/San Sebastián, Spanyol, 2 Departemen Psikologi Perkembangan dan
Pendidikan, Universitas Negara Basque, Lejona, Spanyol, 3 Departemen
Kepribadian, Evaluasi dan Perawatan Psikologis, Universitas Negara Basque ,
Donostia/San Sebastián, Spanyol
Depresi adalah penyebab utama penyakit dan

kecacatan di dunia. Studi memetakan prevalensi
depresi di kalangan anak-anak dan remaja melaporkan
persentase yang tinggi dari anak-anak di kedua
kelompok dengan gejala depresi. Tinjauan ini
menganalisis konstruk dan teori penjelasan tentang
depresi dan menawarkan gambaran singkat tentang
instrumen evaluasi utama yang digunakan untuk
mengukur gangguan ini pada anak-anak dan remaja,
serta program pencegahan yang dikembangkan untuk
lingkungan sekolah dan berbagai jenis perawatan klinis
yang diberikan. Analisis mengungkapkan bahwa dalam
klasifikasi mental, konstruksi depresi anak tidak
berbeda dengan konstruksi dewasa, dan bahwa banyak
Diedit oleh: teori penjelasan harus diperhitungkan untuk sampai
Elena Vegni,
pada pemahaman penuh tentang depresi. Akibatnya,
Departemen Ilmu Kesehatan, Fakultas Kedokteran dan Bedah, Universitas
Milan, Italia pengobatan dan pencegahan juga harus bersifat
Diulas oleh: multifaktorial. Meskipun program universal mungkin
Dianna Theadora Kenny, lebih tepat karena cakupan aplikasinya yang luas,
Universitas Sydney, Australia Martina Smorti,
hasilnya tidak meyakinkan dan gagal menunjukkan
University of Pisa, Italia
kemanjuran jangka panjang yang solid. Kesimpulannya,
*Korespondensi:
Joana Jaureguizar kita dapat menyatakan bahwa: (1) Ada faktor biologis
joana.jauregizar@ehu.eus (seperti tryptophan—sebuah blok bangunan untuk
penipisan serotonin, misalnya) yang sangat
Bagian khusus:
Artikel ini dikirim ke Educational Psychology, mempengaruhi munculnya gangguan depresi; (2) Saat
bagian dari jurnal ini, hubungan interpersonal negatif dan hubungan
Frontiers in Psychology
dengan lingkungan seseorang, ditambah dengan
Diterima: 13 Maret 2018
perubahan sosial-budaya, dapat menjelaskan
Diterima: 25 Februari 2019 Diterbitkan: 20 Maret 2019
peningkatan yang diamati pada prevalensi depresi; (3)
Kutipan:
Bernaras E, Jaureguizar J dan Garaigordobil M (2019) Depresi Anak dan Banyak instrumen yang dapat digunakan untuk
Remaja: Tinjauan Teori, Instrumen Evaluasi, Program Pencegahan, dan mengevaluasi depresi, tetapi perlu untuk terus
Perawatan. Depan. Psiko. 10:543. doi: 10.3389/fpsyg.2019.00543
mengadaptasi tes untuk mendiagnosis kondisi tersebut
Depresi Anak dan Remaja: pada usia dini; (4) Program pencegahan harus
dikembangkan dan dilaksanakan sejak usia dini; dan (5)
Tinjauan Teori, Instrumen Sebagian besar perawatan menjadi semakin ketat dan
Evaluasi, Program efektif. Mengingat bahwa manifestasi awal depresi

dapat terjadi sejak usia sangat dini, penelitian lebih
Pencegahan, dan lanjut dan lebih mendalam diperlukan untuk faktor

biologis, psikologis dan sosial yang, dengan cara yang Kata kunci: depresi, remaja, anak, instrumen, pencegahan, pengobatan
saling terkait, dapat menjelaskan penampilan,
perkembangan, dan pengobatan depresi.
Frontiers in Psychology | www.frontiersin.org 1 Maret 2019 | Jilid 10 | Pasal 543

Bernaras dkk. Depresi Anak dan Remaja
kognitif (misalnya, Seligman, 1975; Abramson et al., 1978;
Beck, 1987), model pengendalian diri (misalnya, Rehm,
PENDAHULUAN 1977; Rehm et al., 1979), teori interpersonal (misalnya,
Markowitz dan Weissman, 1995; Milrod et al., 2014),
Depresi adalah penyebab utama penyakit dan kecacatan peristiwa kehidupan yang penuh tekanan (misalnya,
di dunia. Organisasi Kesehatan Dunia (WHO) telah Reinherz et al., 1993; Frank et al., 1994), dan model
mengeluarkan peringatan tentang patologi ini selama sosiokultural (Misalnya, Lorenzo-Blanco et al., 2012;
bertahun-tahun, mengingat hal itu mempengaruhi lebih Chang et al., 2013; Reeves et al., 2014).
dari 300 juta orang di seluruh dunia dan ditandai dengan Mengevaluasi depresi secara akurat telah menjadi
risiko bunuh diri yang tinggi (penyebab kematian paling perhatian lain yang menjadi fokus psikologi, dengan
umum kedua pada mereka yang berusia antara 15 dan perhatian dipusatkan secara khusus di sekitar
29) [Organisasi Kesehatan Dunia (WHO), 2017]. Studi mendiagnosis patologi ini pada masa kanak-kanak dan
pada populasi anak yang menggunakan laporan diri untuk remaja. Meskipun banyak instrumen diagnostik telah
mengevaluasi gejala depresi berat, khususnya dikembangkan dan divalidasi, terutama untuk
Inventarisasi Depresi Anak (CDI, Kovacs, 1992) dan Skala tahap kehidupan remaja dan dewasa, masih sulit untuk
Depresi Anak (CDS, Lang dan Tisher, 1978), telah menemukan tes diagnostik untuk mengevaluasi depresi
mengamati tingkat prevalensi, untuk contoh, 4% di pada anak-anak. Mencegah depresi adalah aspek lain
Spanyol (Demir et al., 2011; Bernaras et al., 2013), 6% di yang sangat penting dilampirkan oleh Organisasi
Finlandia (Puura et al., 1997), 8% di Yunani (Kleftaras dan Kesehatan Dunia (WHO) (2017), yang berpendapat
Didaskalou, 2006), 10% di Australia (Mccabe et al., 2011), bahwa program sekolah, intervensi yang ditujukan untuk
dan 25% di Kolombia (Vinaccia et al., 2006). Klasifikasi orang tua dan latihan khusus untuk populasi lansia
utama gangguan jiwa adalah Diagnostic and Statistical membantu mengurangi prevalensi patologi ini. Program
Manual of Mental Disorders, DSM 5 (American Psychiatric pencegahan depresi memang ada, tetapi mereka
Association, 2014), diterbitkan oleh American Psychiatric terutama ditujukan pada remaja dan sangat sedikit yang
Association, yang telah menjadi acuan utama dalam berfokus pada anak-anak di bawah usia 10 tahun
praktik klinis, dan versi 10 dari International Classification . Perawatan depresi adalah aspek lain yang tidak boleh
of Diseases (ICD-10, 1992), diterbitkan oleh WHO, yang diabaikan. Pada tahun 2016, WHO dan Bank Dunia
mengklasifikasikan dan mengkodifikasi semua penyakit, mengumumkan bahwa berinvestasi dalam pengobatan
meskipun awalnya tujuannya adalah untuk memetakan depresi dan kecemasan menghasilkan pengembalian
tingkat kematian. Klasifikasi ICD-11 yang baru akan empat kali lipat, karena patologi ini merugikan ekonomi
diajukan untuk disetujui kepada Negara-negara Anggota global satu triliun dolar AS setiap tahun. Lebih jauh,
di Majelis Kesehatan Dunia pada Mei 2019, dan mereka mengklaim bahwa keadaan darurat dan konflik
diharapkan mulai berlaku pada 1 Januari 2022 [Organisasi kemanusiaan menyoroti kebutuhan mendesak untuk
Kesehatan Dunia (WHO), 2018]. Kedua klasifikasi memperluas pilihan terapi saat ini. Dalam pengertian ini,
menawarkan kategorisasi yang berbeda dari gangguan berbagai teori penjelas depresi yang berbeda telah
depresi, meskipun kesamaan tertentu memang ada, dan memunculkan sejumlah besar perawatan yang berbeda
harus diingat juga bahwa keduanya telah dikritik karena (psikoterapi, perilaku, perilaku kognitif, interpersonal, dll.)
hampir tidak membedakan sama sekali antara depresi Yang saat ini sedang dianalisis dengan tingkat presisi dan
anak dan dewasa. ketelitian ilmiah yang tinggi.
Sepanjang sejarah, ada banyak teori penjelasan yang Mengingat berbagai aspek terkait depresi yang
berbeda tentang depresi. Teori-teori biologis dan diuraikan di atas, penelitian ini memiliki tujuan sebagai
psikologis adalah yang terutama mencoba menjelaskan berikut: (1) Untuk menganalisis konstruksi depresi yang
asal mula gangguan mental ini. Teori biologis memiliki, ditawarkan oleh dua klasifikasi gangguan mental utama
dari berbagai perspektif yang berbeda, mendalilkan bahwa (DSM-5 dan ICD-10); (2) Untuk memberikan gambaran
depresi dapat terjadi karena defisit noradrenalin (misalnya, tentang teori-teori penjelas utama depresi; (3) Untuk
Schildkraut, 1965; Narbona, 2014), gangguan endokrin menguraikan instrumen evaluasi depresi anak dan remaja
(misalnya Birmaher et al., 1996), gangguan terkait tidur yang paling umum digunakan dalam literatur ilmiah; (4)
(misalnya , Sivertsen et al., 2014; Pariante, 2017), Memberikan gambaran singkat tentang program
perubahan struktur otak (Whittle et al., 2014), atau pencegahan depresi pada anak dan remaja di lingkungan
pengaruh genetika (Scourfield et al., 2003). Teori psikologi sekolah; dan (5) Untuk menggambarkan perawatan klinis
telah berusaha untuk menjelaskan depresi berdasarkan yang paling ketat dan efektif secara ilmiah untuk
psikoanalisis dan, lebih khusus, dalam hal teori lampiran gangguan mental ini.
(misalnya, Bowlby, 1976; Ainsworth et al., 1978; Blatt, Basis data yang digunakan untuk melakukan pencarian
2004; Bigelow et al., 2018), model perilaku (misalnya, adalah PubMed, PsycINFO, Web of Science, Scopus,
Skinner, 1953; Ferster, 1966; Lewinsohn, 1975), model Science Direct dan Google Scholar, bersama dengan
berbagai manuskrip yang berbeda. Dengan kata kunci menguraikan perawatan klinis utama yang digunakan saat
yang konstan adalah depresi, pencarian informasi juga ini untuk mengobati depresi anak dan remaja.
merujuk pada rangkaian kata kunci lainnya, yaitu: masa
kanak-kanak, remaja, teori penjelas, etiologi, instrumen
evaluasi, program pencegahan, dan pengobatan. KONSTRUKSI DEPRESI: DSM-5 DAN
Pencarian dilakukan untuk informasi yang diterbitkan ICD-10
antara tahun 1970 dan 2017.
Jadi, pertama-tama kami menggambarkan konstruksi Depresi memiliki dua klasifikasi global yang paling
depresi dan merangkum teori-teori penjelas utama. penting: DSM-5 dan ICD-10. Sebagaimana dinyatakan
Selanjutnya, kami menyajikan instrumen evaluasi utama sebelumnya dalam pendahuluan, klasifikasi ICD-11 yang
yang digunakan untuk mengukur depresi anak dan remaja baru akan dipresentasikan untuk disetujui oleh
dan melaporkan hasil tinjauan bibliografi program Negara-negara Anggota diMajelis Kesehatan Dunia
pencegahan di lingkungan sekolah. Akhirnya, kami
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Gangguan bipolar pediatrik. Prevalensi gangguan ini
diperkirakan antara 2 dan 5%, dengan anak-anak laki-laki
TABEL 1 | Gangguan depresi menurut DSM-5 dan ICD-10. DSM-5 dan remaja laki-laki lebih mungkin menderita daripada
rekan-rekan perempuan mereka.
ICD-10
Gangguan Depresi Mayor
Gangguan depresi Gangguan mood (afektif) F32, F33, F34, dan F38
- Gangguan disregulasi mood yang mengganggu - penambahan berat badan yang
Gangguan depresi beratGangguan depresi Gangguan depresi mayor ditandai signifikan, insomnia atau hipersomnia,
-persisten (dysthymia) - Gangguan disforik dengan suasana hati yang tertekan agitasi atau keterbelakangan
pramenstruasi - Gangguan depresi akibat zat/obat - hampir sepanjang hari, hampir setiap
Gangguan psikomotor, kelelahan atau kehilangan
hari, meskipun pada anak-anak dan energi, perasaan tidak berharga. , atau
depresi karena kondisi medis lain
- Gangguan depresi tertentu lainnyaGangguan
remaja suasana hati ini mungkin mudah rasa bersalah yang berlebihan atau
depresi tidak spesifik lainnya tersinggung daripada depresi. tidak pantas, berkurangnya
-- Episode tunggal (F32) Gangguan tersebut menyebabkan kemampuan untuk berpikir atau
- Gangguan depresif berulang (F33)Gangguan penurunan minat atau kesenangan berkonsentrasi, pikiran kematian yang
-mood (afektif) yang persisten (F34) yang nyata pada semua, atau hampir berulang, ide bunuh diri yang berulang
-mood (afektif) lainnya
semua, aktivitas sepanjang hari, hampir tanpa rencana tertentu, atau
Gangguan(F38)
setiap hari, penurunan atau
pada Mei 2019, dan diharapkan mulai berlaku pada 1 risiko bunuh diri, yang menurut Organisasi Kesehatan
Januari 2022. Presentasi yang baru klasifikasi pada tahun Dunia (WHO) (2017), penyebab kematian paling umum
2019 akan memungkinkan negara-negara untuk kedua di kalangan anak muda berusia antara 15 dan 29
merencanakan implementasinya, menyiapkan terjemahan tahun
yang diperlukan dan melatih para profesional yang sesuai . Kebaruan utama yang ditawarkan oleh DSM- 5 di
[Organisasi Kesehatan Dunia (WHO), 2018]. Dalam teks bagiannya tentang gangguan depresi adalah pengantar
yang diterbitkan oleh kolaborator WHO (Luciano, 2017), gangguan disregulasi mood
telah disarankan bahwa ICD-11 akan memasukkan yang mengganggu (yang tidak boleh
gangguan mood dalam kategori gangguan mental dan didiagnosis sebelum usia 6 tahun atau setelah usia 18
perilaku. Namun, hingga versi final diterbitkan, informasi tahun). Gangguan ini ditandai dengan ledakan amarah
ini tidak dapat diverifikasi sepenuhnya. berulang yang parah yang dimanifestasikan secara verbal
Kedua klasifikasi (DSM-5 e IDC-10) menawarkan (misalnya, kemarahan verbal) dan/atau perilaku
kategorisasi yang berbeda dari gangguan depresi, seperti (misalnya, agresi fisik terhadap orang atau properti).
yang ditunjukkan pada Tabel 1. WHO memasukkan Ledakan ini sering terjadi sebagai akibat dari frustrasi dan
gangguan depresif dalam kategori gangguan mood, untuk dianggap sebagai kriteria diagnostik harus tidak
meskipun tinjauan ini hanya berfokus pada Bagian F32, konsisten dengan tingkat perkembangan individu, terjadi
F33, F34, dan F38, yang termasuk gangguan depresi tiga kali atau lebih per minggu selama setidaknya satu
yang paling sering dan yang, pada gilirannya, berisi tahun di sejumlah pengaturan yang berbeda (di rumah, di
subbagian yang akan dijelaskan lebih lanjut nanti. sekolah, dll.) dan menjadi parah dalam setidaknya salah
Menurut DSM-5, semua gangguan depresi memiliki satu dari ini. Gangguan ini ditambahkan ke DSM-5 karena
satu ciri umum, yaitu adanya suasana hati yang sedih, keraguan yang timbul sehubungan dengan bagaimana
kosong atau mudah tersinggung, disertai dengan mengklasifikasikan dan merawat anak-anak yang
perubahan somatik dan kognitif yang secara signifikan mengalami iritabilitas kronis yang persisten dibandingkan
mempengaruhi kapasitas individu untuk berfungsi dengan gangguan terkait lainnya, khususnya
(DSM-5). Mereka dapat menjadi masalah kesehatan yang upaya bunuh diri atau rencana khusus untuk bunuh diri.
serius jika dibiarkan bertahan untuk jangka waktu yang Gejala-gejala ini menyebabkan penderitaan yang
lama dan terjadi dengan tingkat intensitas sedang hingga bermakna secara klinis atau hendaya dalam fungsi sosial,
berat. Salah satu konsekuensi penting dari depresi adalah pekerjaan, atau fungsi penting lainnya. Di Amerika
Serikat, prevalensi 12 bulan adalah 7%, meskipun tiga kali atau kelelahan, harga diri rendah, konsentrasi yang buruk,
lebih tinggi di antara mereka yang berusia antara 18 dan atau kesulitan membuat keputusan. dan perasaan putus
29 daripada di antara mereka yang berusia 60 atau lebih. asa. Prevalensi gangguan ini di Amerika Serikat adalah
Selain itu, tingkat prevalensi untuk wanita adalah 1,5-3 0,5%.
kali lebih tinggi daripada pria.
Gangguan Dysphoric Pramenstruasi Kriteria
Depresi Persisten diagnostik untuk gangguan dysphoric pramenstruasi
Gangguan(Dysthymia) menyatakan bahwa, di sebagian besar siklus menstruasi,
Gangguan depresi persisten (dysthymia) adalah setidaknya lima gejala harus ada selama minggu terakhir
konsolidasi dari gangguan depresi mayor kronis yang sebelum dimulainya menstruasi, dan individu harus mulai
didefinisikan DSM-5 dan gangguan distimik, dan ditandai merasa lebih baik beberapa hari kemudian, dengan
dengan suasana hati yang tertekan hampir sepanjang semua gejala menghilang sepenuhnya atau hampir
hari, selama lebih dari beberapa hari, selama beberapa sepenuhnya selama seminggu setelah menstruasi.
hari. minimal 2 tahun. Pada anak-anak dan remaja, mood Karakteristik yang paling penting dari gangguan ini adalah
dapat menjadi iritabel dan durasinya harus minimal 1 labilitas afektif, iritabilitas atau kemarahan yang intens,
tahun. DSM-5 menetapkan bahwa pasien yang atau konflik interpersonal yang meningkat, suasana hati
menunjukkan gejala yang memenuhi kriteria diagnostik yang sangat tertekan dan / atau eksitasi yang berlebihan,
untuk gangguan depresi mayor selama 2 tahun juga harus dan gejala kecemasan yang mungkin disertai dengan
didiagnosis dengan gangguan depresi persisten. Ketika gejala perilaku dan somatik. Gejala harus ada selama
individu tersebut mengalami episode mood depresi, sebagian besar siklus menstruasi selama setahun terakhir
mereka juga harus menunjukkan setidaknya dua dari dan harus berdampak negatif pada fungsi pekerjaan dan
gejala berikut: nafsu makan yang buruk atau makan sosial. Estimasi paling ketat dari prevalensi gangguan ini
berlebihan, insomnia atau hipersomnia, energi rendah mengklaim bahwa 1,8%
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depresi lain yang tidak
ditentukan, di sisi lain, perbedaannya adalah
wanita memenuhi kriteria tetapi tidak memiliki gangguan bahwa dokter lebih memilih untuk tidak menentukan
fungsional, sementara 1,3% memenuhi kriteria dan alasan mengapa presentasi gagal memenuhi semua
menderita gangguan fungsional dan gejala penyerta lain kriteria gangguan tertentu dan termasuk presentasi yang
dari gangguan mental lainnya. informasinya tidak cukup untuk diberikan. diagnosis yang
lebih spesifik.
Zat / Obat-Induced Dalam ICD-10, gangguan depresi termasuk dalam
Disorderdepresi kategori gangguan mood. Gangguan berikut dianalisis di
bahan / obat-induced gangguan depresiditandai oleh bawah ini: episode depresi tunggal, gangguan depresi
adanya gejala gangguan depresi, seperti gangguan berulang, dan gangguan mood (afektif) persisten.
depresi mayor, yang disebabkan oleh konsumsi, inhalasi
atau suntikan zat, dengan mengatakan gejala bertahan Episode Depresi Tunggal
setelah efek fisiologis atau efek keracunan atau penarikan Klasifikasi Episode depresif tunggal membedakan antara
telah hilang. Beberapa obat dapat menimbulkan gejala episode depresi dengan berbagai tingkat keparahan:
depresi, oleh karena itu penting untuk menentukan ringan, sedang, dan berat tanpa gejala psikotik.
apakah gejala tersebut benar-benar disebabkan oleh Karakteristik umum dari mereka semua termasuk
penggunaan obat atau apakah gangguan depresi muncul penurunan mood, pengurangan energi, dan penurunan
begitu saja selama periode penggunaan obat. Prevalensi aktivitas sehari-hari. Ada hilangnya minat dalam
gangguan ini di Amerika Serikat adalah 0,26%. pengejaran yang sebelumnya menyenangkan, penurunan
kapasitas konsentrasi, dan peningkatan kelelahan, bahkan
Gangguan Depresi Karena Kondisi selama aktivitas yang membutuhkan usaha minimal.
Perubahan terjadi pada nafsu makan, tidur terganggu,
Medis Lain harga diri dan kepercayaan diri turun, gagasan bersalah
Gangguan depresi akibat kondisi medis lain ditandai
atau tidak berharga hadir dan gejalanya sedikit berbeda
dengan munculnya suasana hati yang tertekan dan minat dari hari ke hari. Dalam bentuknya yang paling ringan, dua
atau kesenangan yang sangat berkurang dalam semua atau tiga gejala yang dijelaskan di atas mungkin ada, dan
aktivitas dalam konteks kondisi medis lain. DSM-5 tidak pasien dapat
memberikan informasi tentang prevalensi gangguan ini. melanjutkan sebagian besar aktivitas sehari-hari mereka.
Kategori Gangguan depresi Ketika episode sedang, biasanya ada empat atau lebih
tertentu lainnya digunakan ketika gejala gejala dan pasien mungkin mengalami kesulitan untuk
karakteristik gangguan depresi muncul dan menyebabkan melanjutkan aktivitas biasa. Dalam bentuknya yang paling
penderitaan yang signifikan atau gangguan dalam fungsi parah, beberapa gejala ditandai dan menyedihkan,
sosial, pekerjaan atau fungsi lainnya tetapi tidak biasanya kehilangan harga diri dan gagasan tentang
memenuhi semua kriteria gangguan depresi, dan dokter ketidakberhargaan atau rasa bersalah. Pikiran dan
memilih untuk mengomunikasikan alasan spesifik untuk tindakan bunuh diri sering terjadi dan sejumlah gejala
ini. Dalam kategori gangguan
somatik biasanya muncul. Jika episode depresif disertai yang persisten dan biasanya berfluktuasi di mana
gejala psikotik, ditandai dengan adanya halusinasi, delusi, sebagian besar episode tidak cukup parah untuk
retardasi psikomotor, atau stupor yang begitu parah menjamin didiagnosis sebagai episode hipomanik atau
sehingga aktivitas sosial biasa tidak mungkin dilakukan; depresi ringan. Karena mereka bertahan selama
mungkin ada bahaya bagi kehidupan dari bunuh diri, bertahun-tahun dan mempengaruhi kehidupan normal
dehidrasi, atau kelaparan. pasien, mereka melibatkan penderitaan dan kecacatan
yang cukup besar. Bagian ini juga mencakup siklotimia
Gangguan Depresi Berulang Gangguan dan distimia. Siklotimia adalah ketidakstabilan suasana
depresi berulang ditandai dengan episode depresi hati yang persisten yang melibatkan banyak periode
berulang yang serupa dengan yang dijelaskan di atas depresi dan kegembiraan ringan, tidak ada yang cukup
untuk episode depresi tunggal tanpa mania. Mungkin ada lama untuk membenarkan diagnosis gangguan afektif
episode singkat peningkatan mood ringan dan aktivitas bipolar atau gangguan depresi berulang. Gangguan ini
berlebihan (hipomania) segera setelah episode depresi, sering ditemukan di antara kerabat pasien dengan
kadang-kadang dipicu oleh pengobatan antidepresan. gangguan afektif bipolar dan beberapa pasien dengan
Bentuk yang lebih parah dari gangguan ini sangat mirip siklotimia akhirnya berkembang menjadi gangguan afektif
dengan depresi manik-depresi, melankolis, depresi vital, bipolar. Untuk bagiannya, distimia adalah depresi suasana
dan depresi endogen. Episode pertama dapat terjadi pada hati kronis, yang berlangsung setidaknya beberapa tahun,
usia berapa pun, dari masa kanak-kanak hingga usia tua. yang tidak cukup parah, atau di mana episode individu
Onsetnya bisa akut atau berbahaya dan dapat tidak cukup berkepanjangan, untuk membenarkan
berlangsung dari beberapa minggu hingga berbulan-bulan. diagnosis gangguan depresi berulang ringan, sedang,
Gangguan depresi rekuren bisa ringan atau sedang, tetapi atau berat.
tidak ada riwayat mania. Bagian ini juga mencakup
gangguan depresi berulang yang saat ini dalam remisi, di Gangguan Mood (Afektif) Lainnyagangguan
mana pasien mungkin pernah mengalami dua atau lebih Akhirnya,mood (afektif) lainnya termasuk gangguan mood
episode depresi di masa lalu, tetapi telah bebas dari gejala yang tidak termasuk dalam kategori yang dijelaskan di
depresi selama beberapa bulan. atas karena tidak memiliki tingkat keparahan atau durasi
yang cukup. Mereka mungkin tunggal, berulang (singkat),
Gangguan Mood [Afektif]Gangguan atau episode tertentu.
Persistenmood [afektif] yang persisten adalah gangguan
Perbatasan dalam Psikologi | www.frontiersin.org 4 Maret 2019 | Jilid 10 | Pasal 543

dipelajari dengan melakukan pencarian di PubMed, Web
of Science, Science direct, dan Google Scholar. Dengan
Manifestasi dan gejala depresi bervariasi sesuai kata kunci yang konstan adalah depresi, depresi anak dan
dengan usia dan tingkat perkembangan. Namun, jelas depresi remaja, pencarian informasi secara silang
bahwa DSM-5 dan ICD-10 tidak membedakan antara mengacu pada rangkaian kata kunci lain yang juga sesuai
depresi orang dewasa dan anak, meskipun dengan dengan teori spesifik yang dimaksud. Karena pentingnya
memasukkan gangguan disregulasi mood yang beberapa karya mani dalam kaitannya dengan
mengganggu, DSM-5 memperhitungkan fakta bahwa pengembangan teori psikologis depresi, penulis tertentu
anak-anak dan remaja berusia antara 7 tahun. dan 18 tetap menjadi referensi utama selama beberapa dekade.
dapat mengekspresikan kesusahan mereka dengan cara Sebanyak 64 referensi bibliografi digunakan. Berikut ini
lain, melalui iritabilitas kronis, parah, dan berulang yang adalah rangkuman dari berbagai penjelasan timbulnya
dimanifestasikan secara verbal dan/atau perilaku. depresi, menurut kerangka teori yang berbeda.
Demikian pula, gangguan depresi mayor menentukan
bahwa pada anak-anak suasana hati mungkin mudah Teori Biologis
tersinggung daripada depresi. Namun, tidak ada Jika gangguan mood tidak dapat dijelaskan oleh riwayat
perbedaan semacam ini yang ditemukan dalam ICD-10, keluarga atau peristiwa kehidupan yang penuh tekanan,
ketidakhadiran yang dapat menyebabkan kesimpulan yang maka mungkin anak atau remaja tersebut menderita
salah bahwa karakteristik depresi anak dan remaja mirip penyakit saraf. Dalam kasus seperti itu, gejala depresi
dengan depresi orang dewasa. dapat bermanifestasi lebih awal pada anak-anak dan
remaja seperti sindrom epilepsi, gangguan tidur, sefalalgia
berulang kronis, beberapa penyakit neurometabolik, dan
TEORI PENJELASAN tumor intrakranial (Narbona, 2014).
DEPRESI
Defisit Noradrenalin
Gangguan depresi tidak dapat dijelaskan dengan teori Serotonin adalah monoamina terkait dengan adrenalin,
tunggal, karena banyak variabel yang berbeda terlibat norepinefrin, dan dopamin yang memainkan peran kunci,
dalam onset dan persistensinya. Oleh karena itu, terutama di otak, karena terlibat dalam fungsi pengaturan
teori-teori biologis dan psikologis utama diambil sebagai kehidupan yang penting (nafsu makan, tidur, memori,
referensi utama untuk bagian ini. Selanjutnya, kontribusi belajar, pengaturan suhu, dan perilaku sosial, dll), serta
yang dibuat oleh masing-masing teori mengenai depresi banyak patologi kejiwaan (Nique et al., 2014). Serotonin
memodulasi neuroplastisitas, terutama selama Tidur Masalah tidur sering dikaitkan dengan situasi
tahun-tahun awal kehidupan, dan disfungsi pada kedua kekurangan sosial, pengangguran, atau peristiwa
sistem berkontribusi pada fisiopatologi depresi (Kraus et kehidupan yang penuh tekanan (perceraian, kebiasaan
al., 2017). Tes MRI pada hewan telah mengungkapkan hidup yang buruk, atau kondisi kerja yang buruk)
bahwa pengurangan kepadatan dan ukuran neuron, serta (Garbarino et al., 2016). Tampaknya juga, bagaimanapun,
pengurangan volume hipokampus di antara pasien bahwa gangguan tidur terkait dengan perkembangan
depresi depresi. Hubungan ini terjadi sebagai akibat dari
mungkin disebabkan oleh perubahan neuroplastisitas bagaimana kurang tidur mempengaruhi hipokampus,
serotonergik. Branchi (2011), bagaimanapun, berpendapat meningkatkan sensitivitas saraf terhadap penghinaan
bahwa meningkatkan kadar serotonin dapat meningkatkan eksitotoksik dan kerentanan terhadap tantangan
kemungkinan berkembang dan pulih dari psikopatologi, neurotoksik, mengakibatkan penurunan bersih materi
dan menggarisbawahi peran yang dimainkan oleh abu-abu di hipokampus di korteks orbitofrontal kiri (Novati
lingkungan sosial dalam proses ini. Dalam pengertian ini, et al., 2012). .
Curley et al. (2011) menunjukkan bahwa kualitas Untuk bagian mereka, Franzen dan Buysse (2008)
lingkungan sosial dapat mempengaruhi perkembangan menyatakan bahwa hubungan dua arah antara gangguan
dan aktivitas sistem saraf, yang pada gilirannya tidur (terutama insomnia) dan depresi membuat lebih sulit
berdampak pada respons perilaku, fisiologis, dan untuk membedakan hubungan sebab-akibat di antara
emosional. mereka. Oleh karena itu tidak jelas apakah depresi
menyebabkan gangguan tidur atau apakah gangguan tidur
Perubahan Endokrin Perubahan kronis menyebabkan munculnya depresi. Apa yang
terkait usia dan adanya faktor risiko biologis, termasuk tampak jelas, bagaimanapun, adalah bahwa mengobati
faktor endokrin, inflamasi atau kekebalan, kardiovaskular gangguan tidur (baik insomnia dan hipersomnia) dapat
dan neuroanatomi, membuat orang lebih rentan terhadap membantu mengurangi keparahan depresi dan
depresi (Clarke dan Currie, 2009). Memang, beberapa mempercepat pemulihan (Franzen dan Buysse, 2008).
penelitian menunjukkan bahwa depresi mungkin terkait Studi longitudinal telah mengidentifikasi insomnia
dengan perubahan endokrin: sekresi kortisol nokturnal sebagai faktor risiko untuk timbulnya atau kambuhnya
(Birmaher et al., 1996), sekresi hormon pertumbuhan depresi pada orang muda dan orang dewasa (Sivertsen et
nokturnal (Ryan et al., 1994), sekresi hormon perangsang al., 2014). Dibandingkan dengan populasi non-klinis,
tiroid (Puig-Antich, 1987) , sekresi melatonin dan prolaktin anak-anak dan remaja yang depresi melaporkan kesulitan
(Waterman et al., 1994), kadar kortisol yang tinggi tidur dan durasi tidur yang lebih lama (Acardo et al.,
(Herane-Vives et al., 2018), atau penurunan produksi 2012).
hormon pertumbuhan (Dahl et al., 2000). Pubertas dan Untuk bagian mereka, Foley dan Weinraub (2017)
perubahan hormonal dan fisik yang menyertainya mengamati bahwa, di antara gadis-gadis praremaja,
memerlukan perhatian khusus karena telah diusulkan masalah tidur awal dan kemudian secara langsung atau
bahwa mereka dapat dikaitkan dengan peningkatan tidak langsung memprediksi berbagai gangguan
insiden depresi (Reinecke dan Simons, 2005). penyesuaian sosial dan emosional (gejala depresi,
Gangguan
Frontiers in Psychology | www.frontiersin.org 5 Maret 2019 | Volume 10 | Pasal 543

langsung dari neurotransmisi glutamatergik yang
berlebihan. Namun, bertentangan dengan temuan pada
, kompetensi sekolah yang rendah, regulasi emosi yang orang dewasa dengan depresi, tidak ada defisit
buruk, dan perilaku pengambilan risiko). penghambatan kortikal yang ditemukan pada anak-anak
dan remaja dengan gangguan depresi mayor (Croarkin et
Perubahan Neurotransmisi al., 2013).
Studi yang dilakukan selama 20 tahun terakhir telah
menunjukkan bahwa peningkatan peradangan dan Faktor Genetik
hiperaktivitas aksis hipotalamus-hipofisis-adrenal (HPA) Studi lain telah menyoroti pentingnya genetika dalam
dapat menjelaskan depresi berat (Pariante, 2017). timbulnya depresi (40%) (Scourfield et al., 2003). Penting
Beberapa mekanisme patofisiologi depresi termasuk untuk diketahui bahwa kecenderungan genetik terhadap
neurotransmisi yang berubah, kelainan sumbu HPA yang respons amigdala yang berlebihan terhadap stres, atau
terlibat dalam stres kronis, peradangan, pengurangan sumbu HPA yang hiperaktif (hiperfenilalaninemia sedang)
neuroplastisitas, dan disfungsi jaringan (Dean dan karena stres selama masa kanak-kanak dapat memicu
Keshavan, 2017). Studi lain melaporkan perubahan dalam efek yang berlebihan atau mengubah sistem psikologis
struktur otak: hipokampus yang lebih kecil, amigdala, dan yang sehat (Dean dan Keshavan, 2017).). Kaufman dkk.
lobus frontal (Whittle et al., 2014). Namun demikian, (2018) support a potential role for genes related to the
mekanisme molekuler dan klinis yang mendasarinya homeobox 2 gene of Orthodenticle (OTX2) and to the
belum ditemukan (Pariante, 2017). Gangguan depresi OTX2-related gene in the physiopathology of
mayor pada anak-anak dan remaja telah dikaitkan dengan stress-related depressive disorders in children.
peningkatan fasilitasi intrakortikal, akibat neurofisiologis Furthermore, genetic anomalies in serotonergic
transmission have been linked to depression. The adolescence have been reported (Armsden et al., 1990;
serotonin linked polymorphic region (5-HTTLPR) is a Koback et al., 1991; Kenny et al., 1993; Roelofs et al.,
degenerate repeat in the gene which codes for the 2006; Allen et al., 2007; Chorot et al., 2017). Relationships
serotonin transporter (SLC6A4). The s/s genotype of this between secure attachment and depression seem also to
region is associated with a reduction serotonin expression, be mediated by the development of maladaptive beliefs or
in turn linked to greater vulnerability to depression (Caspi schemas (Roberts et al., 1996; Reinecke and Rogers,
et al., 2010). 2001).
For their part, Oken et al. (2015) claim that Thus, attachment theory has become a useful construct
psychological disturbances may trigger changes in for conceptualizing many different disorders and provides
physiological parameters, such as DNA transcription, or valuable information for the treatment of depression
may result in epigenetic modifications which alter the (Reinecke and Simons, 2005).
sensitivity of the neurotransmitter receptor. Ainsworth described three attachment styles, in
accordance with the child's response to the presence,
absence, and return of the mother (or main caregiver):
Psychological Theories secure, anxious-avoidant, and anxious-resistant
This section outlines the different psychological theories (Ainsworth et al., 1978). The least secure attachment
which have attempted to explain the phenomenon of styles may give rise to traumatic experiences during
depression. Depression is a highly complex disorder childhood, which in turn may result in the appearance of
influenced by multiple factors, and it is clear that no single depressive symptoms.
theory can fully explain its etiology and persistence. It is Similarly, Hesse and Main (2000) argued that the
likely that a more eclectic outlook must be adopted if we central mechanism regulating infant emotional survival
are to make any progress in determining the origin, was proximity to attachment figures, ie, those figures who
development, and maintenance of this pathology. help the child cope with frightening situations. Using
Attachment-Informed Theories Ainsworth's strange situation procedure,
Attachment theory was the term used by Bowlby (1976) to Main (1996) found that abused children engaged in more
refer to a specific conceptualization of human beings' disorganized, disruptive, aggressive, and dissociative
propensity to establish strong and long-lasting affective behaviors during both childhood and adolescence. Main
ties with other people. Bowlby (1969, 1973) proposes that (1996) also found that many people with clinical disorders
consistency, nurturance, protectiveness, and have insecure attachment and that
responsiveness in early interactions with caregivers psychological-disoriented and disorganized children are
contribute to the development of schemas or mental more vulnerable.
representations about the relationships of oneself with For his part, Blatt (2004) explored the nature of
others, and that these schemas serve as models for later depression and the life experiences which contribute to its
relationships. Bowlby's ethological model of attachment appearance in more depth, identifying two types of
postulates that vulnerability to depression stems from early depression which, despite a common set of symptoms,
experiences which failed to satisfy the child's need for nevertheless have very different roots: (1) anaclitic
security, care and comfort, as well as from the current depression, which arises from feelings of loneliness and
state of their intimate relations (Bowlby, 1969, 1973, abandonment; and (2) introjective depression, which
1988). Adverse early experiences can contribute to stems from feelings of failure and worthlessness. This
disturbances in early attachments, which may be distinction is consistent with psychoanalytical formulations,
associated with vulnerability for depression (Cummings since it considers defenselessness/dependency and
and Cicchetti, 1990; Joiner and Coyne, 1999). desperation/negative feelings about oneself to be two key
Associations between insecure attachment among issues in depression.
children and negative self-concept, sensitivity to loss, and
an increased risk of depression in childhood and
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Bernaras et al. Child and Adolescent Depression
attachment needs, giving rise to disorganized attachment,
with all the psychological consequences that this may
Brazelton et al. (1975) found that at age 3 weeks, involve. Similarly, Beeghly et al. (2017) found that among
babies demonstrate a series of interactive behaviors infants aged between 2 and 18 months, greater maternal
during face-to-face mother-infant interactions. These social support was linked to decreasing levels of maternal
behaviors were not found to be present in more disturbed depressive symptoms over time, and that boys were more
interactions, which may trigger infant anxiety. vulnerable than girls to early caregiving risks such as
In a longitudinal study focusing on the relationship maternal depression, with negative consequences for
between risk of maternal depression and infant attachment mother-child attachment security during toddlerhood.
behavior, Bigelow et al. (2018) analyzed babies at age 6 Authors such as Shedler and Westen (2004) have
weeks, 4 and 12 months, finding that mothers at risk of attempted to find solutions to the problems arising in
depression soon after the birth of their child may have relation to the DSM diagnostic categories, developing the
difficulty responding appropriately to their infant's Shedler Westen Assessment Procedure (SWAP-200) to
capture the wealth and complexity of clinical personality
descriptions and to identify possible diagnostic criteria make external, unstable, and specific attributions for
which may better define personality disorders. success (Abramson et al., 1978; Peterson et al., 1993), a
For their part, Ju and Lee (2018) argue that peer cognitive style also present in children and adolescents
attachment reduces depression levels in at-risk children, with depression (Gladstone and Kaslow, 1995).
and also highlight the curative aspect of attachment The Information Processing model (Beck, 1967; Beck et
between adolescent peers. al., 1979) postulates that depression is
caused by particular stresses
Behavioral Models that evoke the activation of a
The first explanations proposed by this model argued that schema that screens and codes
depression occurs due to the lack of reinforcement of the depressed individual's
previously reinforced behaviors (Skinner, 1953; Ferster, experience in a negative
1966; Lewinsohn, 1975), an excess of avoidance fashion (Ingram, 1984, p. 443). Beck suggests that
behaviors and the lack of positive reinforcement (Ferster, this distortion of reality is expressed in three areas, which
1966) or the loss of efficiency of positive reinforcements he calls the “cognitive triad”: negative views about oneself,
(Costello, 1972). A child with depression initially receives a the world and the future as a result of their learning history
lot of attention from his social environment (family, (Beck et al., 1983). These beliefs are triggered by life
friends...), and behaviors such as crying, complaints or events which hold special meaning for the subject (Beck
expressions of guilt are reinforced. When these depressive and Alford, 2009).
behaviors increase, the relationship with the child
becomes aversive, and the people who used to Self-Control Model
accompany the child avoid being with him, which
This theory assumes that depression is due to deficits in
contributes to aggravating his depression (Lewinsohn,
the self control process, which consists of three phases:
1974). Low reinforcement rates can be explained by
self-monitoring, self-evaluation, and self-administration of
maternal rejection and lower parental support (Simons and
consequences (Rehm, 1977; Rehm et al., 1979). In the
Miller, 1987), by a lower rate of reinforcement offered to
self-monitoring phase, individuals attend only to negative
their children by mothers of depressed children (Cole and
events and tend to recognize only immediate, short-term
Rehm, 1986), or by low social competence (Shah and
consequences. In the self-evaluation phase, depressed
Morgan, 1996).
individuals establish unrealistic evaluation criteria and
Depression is mainly a learned phenomenon, related to
inaccurately attribute their successes and failures. If
negative interactions between the individual and his or her self-evaluation is negative, in the self-administration of
environment (eg, low rate of reinforcement or consequences phase the individual tends to engage very
unsatisfactory social relations). These interactions are little in self-reinforcement and very frequently in
influenced by cognitions, behaviors and emotions self-punishment.
(Antonuccio et al., 1989).
Both Rehm's self-control model (Rehm, 1977) and
Bandura's conception of child depression (Bandura, 1977)
Cognitive Models assume that children internalize external control
The attributional reformulation of the learned helplessness guidelines. These guidelines are related to family
model (Abramson et al., 1978) and Beck's cognitive theory interaction patterns and both may contribute to the
(Beck et al., 1979) are the two most widely-accepted etiology or persistence of depression in children.
cognitive In a study conducted with children aged between 8 and
theories among contemporary cognitive models of 12 years, Kaslow et al. (1988) found that depressed
depression (Vázquez et al., 2000). children had a more depressive attributional style and
Learned helplessness is related to cognitive more self control problems.
attributions, which can be specific/global, internal/external,
and stable/unstable (Hiroto and Seligman, 1975;
Abramson et al., 1978). Global attribution implies the Interpersonal Theory
conviction that the negative event is contextually This model, which is closely linked to attachment theories,
consistent rather than specific to a particular circumstance. aims to identify and find solutions for an individual's
Internal attribution is related to the belief that the aversive problems with depression in their interpersonal
situation occurs due to individual conditions rather than to functioning. It suggests that the difficulties experienced are
external circumstances. Stable attribution is the belief that linked to unresolved grief, interpersonal disputes,
the aversive situation is unchanging over time (Miller and transition roles and interpersonal deficits (Markowitz and
Seligman, 1975). People prone to depression attribute Weissman, 1995).
negative events to internal, stable and global factors and

relationships.
Similarly, various different studies have highlighted the
Milrod et al. (2014) argue that pathological attachment fact that one of the variables that best predicts depression
during early childhood has serious consequences for in children is peer relations (Bernaras et al., 2013;
adults' ability to experience and internalize positive Garaigordobil et al., 2017).
unrealistically thin ideal body predicted disordered eating
attitudes through body dissatisfaction, dietary restraint and
Stressful Life Events
depression.
Studies focusing on the adult population have reported
Finally, the importance of family interactions in the
that between 60 and 70% of depressed adults
onset of depressive symptoms cannot be overlooked.
experienced one or more stressful events during the year
Parenting style has been identified as a key factor in
prior to the onset of major depression (Frank et al., 1994).
children's and adolescents' psychosocial adjustment
In children and adolescents, modest associations have
(Lengua and Kovacs, 2005). Parental behavior has been
been found between stressful life events and depression
studied from two different perspectives: warmth and
(Williamson et al., 1995). For their part, Shapero et al.
control. Warmth is linked to aspects such as engagement
(2013) found that people who had suffered severe
and expression of affection, respect, and positive concern
emotional abuse during childhood experienced higher
by parents and/or principal caregivers (Rohner and
levels of depressive symptoms when faced with current
Khaleque, 2003). In this sense, prior studies have
stressors. Sokratous et al. (2013) argue that the onset of
identified a significant association between parental
depression is not only triggered by major stressful events,
warmth and positive adjustment among adolescents
but rather, minor life events (dropping out of school, your
(Barber et al., 2005; Heider et al., 2006). Rohner and
father losing his job, financial difficulties in the family,
Khaleque (2003) argue that children's psychological
losing friends, or the illness of a family member) may also
adjustment is closely linked to their perception of being
influence the appearance of depressive symptoms.
accepted or rejected by their principal caregivers, and
Events such as the loss of loved ones, divorce of
other studies have found that weaker support from parents
parents, mourning or exposure to suicide (either is associated with higher levels of depression and anxiety
individually or collectively) have all been associated with among adolescents (Yap et al., 2014).
the onset of depression in childhood (Reinherz et al.,
Similarly, Jaureguizar et al. (2018) found that a low level
1993). Factors such as a history of additional interpersonal
of perceived parental warmth was linked to high levels of
losses, added stress factors, a history of psychiatric
clinical and school maladjustment, and that the weaker the
problems in the family and prior psychopathology
parental control, the greater the clinical maladjustment.
(including depression) increase the risk of depression in
These authors also found that young people with negligent
adolescents (Brent et al., 1993). Birmaher et al. (1996)
mothers and authoritarian fathers had higher levels of
found that prior research into stressful life events in
clinical maladjustment.
relation to early-onset depression had been based on data
In short, according to the different theories, depression
obtained from self-reports, making it difficult to determine
may be due to (1) biological reasons; (2) insecure
the causal relationship, since events may be both the
attachment; (3) lack of reinforcement of
cause and consequence of depression.
previously-reinforced behaviors; (4) negative interpersonal
However, not everyone exposed to this kind of
relations and relations with one's environment and the
traumatic experience becomes depressed. Personality
resulting negative consequences; (5) attributions made by
and the moment at which events occur are both involved
individuals about themselves, the world and their future;
in the relationship between depression and stressful life
and (6) sociocultural changes. It is likely that no single
events, although biological factors such as serotonergic
theory can fully explain the genesis and persistence of
functioning (Caspi et al., 2010) also exert an influence.
depression, although currently, negative interpersonal
relations and relations with one's environment and
Sociocultural Models sociocultural changes (economic, political, and
These models postulate that cultural variables are demographic) may explain the observed increase in the
responsible for the appearance of depressive symptoms. prevalence of depression.
These variables are mainly acculturation and
enculturation. In acculturation, structural changes are
observed (economic, political, and demographic), along EVALUATION INSTRUMENTS
with changes in people's psychological behavior (Casullo,
2001). Some studies link increased suicide rates with Many different evaluation instruments can be used to
economic recession (Chang et al., 2013; Reeves et al., measure child and adolescent depression. Tables 2, 3
2014). Enculturation occurs when the older generation outline the ones most commonly used in scientific
invites, induces or forces the younger generation to adopt literature. Table 2 summarizes the main self-administered
traditional mindsets and behaviors. tests that specifically measure child and adolescent
In an attempt to better understand the influence of depression, while Table 3 presents tests that measure
culture and family on depressive symptoms, child and adolescent depression among other aspects (ie,
Lorenzo-Blanco et al. (2012) tested an acculturation, broader or more general tests). Finally, Table 4
cultural values and family functioning model with Hispanic summarizes the main hetero-administered psychometric
students born in the United States. The tests for assessing this pathology.
results revealed that both family conflict and family As shown in the tables above, there are several self
cohesion were related to depressive symptoms. administered instruments that can be used with children
Another study carried out with girls aged 7–10 years from age 6 to 7 onwards, although their duration should be
(Evans et al., 2013) observed that internalizing an taken into
Frontiers in Psychology | www.frontiersin.org 8 March 2019 | Jilid 10 | Article 543
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Frontiers in Psychology | www.frontiersin.org 10 March 2019 | Volume 10 | Article 543

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how a child feels, ask the child”
(Reynolds et al., 1985, p. 524).
consideration in order to avoid overtiring subjects. While it Depending on the specific aim of the evaluation or
is clear that an effort has been made to design shorter research study, a broader diagnostic measure, such as
measures (compare, for example, the 66 items of the CDS those outlined in Table 3, may also provide valuable
with the 16 items of the longest version of the KADS), the information. Finally, it is worth noting that only two
duration of the test should not be the only aspect taken hetero-administered instruments were found for teachers,
into account when selecting an evaluation instrument. with all others being clearly oriented toward the clinical
One of the most widely used instruments to measure field. In this sense, special emphasis should be placed on
child depression in the scientific literature is the Children's the need to develop valid and reliable instruments for
Depression Inventory-CDI (Kovacs, 1985), which is based teachers, since they may be key agents for detecting
on the Beck Depression Inventory-BDI (Beck and symptoms among their students. While it is important to
Beamesderfer, 1974). Thus, it is based on Beck's cognitive train teachers in this sense, it is also important to provide
theory of depression. Following this same theoretical line, them with instruments to help them assess their students.
the Children's Depression Scale CDS (Lang and Tisher, The instruments that are currently available have
1978) was designed, but in this case, this instrument was produced very different results as regards their correlation
not created based on another instrument previously with students' self-reported symptoms, although in
designed for adult population (as in the case of the CDI), general, teachers tend to underestimate their students'
but instead from its beginnings, it was conceived depressive symptoms (Jaureguizar et al., 2017).
exclusively to assess child depression. Chorpita et al.
(2005) explain that the CDI measures a broader construct
of negative affectivity rather than depression as a separate CHILD AND ADOLESCENT DEPRESSION
construct, and that it may be useful for screening for trait PREVENTION PROGRAMS IN THE
dimensions or personality features, whereas other SCHOOL ENVIRONMENT
instruments, such as the Revised Child Anxiety and
Depression Scale-RCADS (Chorpita et al., 2000), Extant scientific literature was reviewed in order to
measure a specific clinical syndrome. summarize the main depression prevention programs for
Table 2 describes many other instruments that are very children and adolescents in school settings. The
useful as screening tests for depression and depressive databases used for conducting the searches were
disorder, such as the Center for Epidemiological Studies PubMed, PsycINFO, Web of Science, Scopus, Science
Depression Scale for Children-CES-DC (Weissman et al., Direct, and Google Scholar, along with a range of different
1980) (based on the Center for Epidemiological Studies manuscripts. With the constant key word being
Depression Scale for Adults, CES-D; Radloff, 1977), the depression, the search for information cross-referenced a
Mood and Feelings Questionnaire MFQ (Angold et al., series of other key words also, namely: “child OR
∗
1995), or the Depression Self-Rating Scale for ∗ ∗
adolescent ,” “prevent program,” and “school OR
Children-DSRS (Birleson, 1981). This last one, for
example, is useful to measure moderate to severe school-based.” Searches were conducted for information
depression in childhood and is based on the operational published between January 1, 1970 and December 31,
definition of depressive disorder, that is, a specific 2017.
affective-behavior pattern that implies an impairment of a First, articles were screened (ie, their titles and
child's or adolescent's ability to function effectively in abstracts were read and a decision was made regarding
his/her environment (Birleson, 1981). their possible interest for the review study). The inclusion
The cognitive and affective component of depression is criteria were that the study analyzed all the research
the one that is most present in the instruments described subjects of the review study (depression, childhood, or
in Table 2. In fact, for example, the Short Mood and adolescence and prevention programs in school settings),
Feelings Questionnaire (SMFQ) includes the cognitive and that study participants were aged between 6 and 18, that
affective items from the original MFQ item pool, in addition the study was published in a peer-reviewed journal and
to some items related to tiredness, restlessness, and poor that it was written in either English or Spanish. Review
concentration (Angold et al., 1995). In the SMFQ, more studies and their references were also analyzed. Studies
than half of the items from the MFQ were removed, and focusing mainly on psychiatric disorders other than
even so, high correlations between the MFQ and the depression were excluded.
SMFQ were found (Angold and Costello, 1995), which Finally, 39 studies were selected for the review, which
may be indicating that the really important items were the explored 8 prevention programs that are outlined in Table
cognitive and affective items that were maintained. 5. In general terms, child depression prevention programs
Reynolds et al. (1985) defended that children could are divided into two main categories: universal programs
accurately report their cognitive and affective for the general population, and targeted programs aimed
characteristics, so “if one wishes to know at either the at-risk population or those with a clear
diagnosis. Although scientific literature reports that
targeted programs obtain better outcomes than universal They are all cognitive-behavioral programs implemented
ones, the latter type nevertheless offer certain advantages, either by psychologists or teachers with specialist training,
since they reach a larger number of people without the consisting of between 8 and 15 sessions. Only a few
social stigma attached to having been specially selected universal programs designed to prevent the symptoms of
(Roberts et al., 2003; Huggins et al., 2008). Thus, the ideal depression focus on younger children, since most are
context for instigating universal child depression targeted mainly at the adolescent population (Gillham et
prevention programs is the school environment. al., 1995; Barrett and Turner, 2001; Farrell and Barrett,
Table 5 outlines the most important child depression 2007; Essau et al., 2012; Gallegos et al.,
prevention programs carried out in the school context.

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suffering from depression, it has yet to be ascertained
what type of programs and what contents are the most
2013; Rooney et al., 2013). Indeed, in the present review, effective. The WHO also states that there are effective
only four universal child depression prevention programs treatments for moderate and
were found that were aimed at a younger age group severe depression, such as psychological treatments
(between 8 and 12): the Penn Resiliency Program, (behavioral activation, cognitive behavioral therapy, and
FRIENDS, the Aussie Optimism Program, and FORTIUS interpersonal psychotherapy) and antidepressant drugs
(see Table 5). (although it also warns of adverse effects), as well as
As shown in the table, the results of the various psychosocial treatments for cases of mild depression.
programs outlined are not particularly positive, since on Moreover, a study conducted with adolescents by Foster
many occasions the effects (if there are any) are not and Mohler-Kuo (2018) found that the combination of
sustained over time or are limited in scope (being cognitive-behavioral therapy and fluoxetine
dependent on who applies the program or on the sex of (antidepressant drug) was more effective than drug
the participant, etc.). Nor is the distinction between therapy alone.
universal and targeted programs particularly clear as The efficacy of treatment with antidepressants has
regards their effects, since although targeted programs been called into question for some years now. Iruela et al.
may initially appear to be more effective, their impact is not (2009) claim that tricyclic antidepressants (imipramine,
found to be sustained in the long term. clomipramine, amitriptyline) are not recommended in
Greenberg dkk. (2001) argue that researchers should childhood and adolescence since no benefits other than
explain whether their prevention programs focus on one or the placebo effect have been proven and furthermore, they
various microsystems (basically family and school), generate major side effects due to their cardiotoxicity.
mesosystems or exosystems, etc. (following the model They are therefore particularly dangerous in cases of
described by Bronfenbrenner, 1979), or are centered attempted suicide. These same authors also advise
exclusively on the individual and his or her environment, against the use of monoamine oxidase inhibitors (MAOIs)
since this will influence the results reported. These same due to dietary restrictions, interactions with other
authors conclude that programs focused exclusively on medication and the lack of clinical trials with sufficiently
children and adolescents themselves are less effective large groups which guarantee their efficacy. SSRIs or
than those which aim to “educate” subjects and bring serotonergic antidepressants are the ones that have been
about positive changes in their family and school most extensively studied in this population. The most
environments. effective is fluoxetine, the use of which is recommended in
As Calear and Christensen (2010) point out in their association with cognitive psychotherapy for cases of
review, some authors suggest that the fact that some moderate and severe child depression.
targeted programs are aimed at people with high levels of On another hand, Wagner and Ambrosini (2001)
depressive symptoms entails a broader range of analyzed the efficacy of pharmacological treatment in
possibilities for change; however, this does not help us children and adolescents and stated that, at best,
understand why these changes are not sustained over antidepressant therapy for depressed youth was
time. Thus, further research is required in this field in order moderately effective. Peiró et al. (2005) indicate that there
to identify what specific components of those programs is a great debate about the safety of selective serotonin
observed to be effective actually have a positive impact on reuptake inhibitors (SSRIs) in childhood. SSRIs, except for
the level of depressive symptoms, how these programs fluoxetine in the United States, have never been
are developed, who implements them and whether or not authorized by any agency for use in children or
their effects are sustained in the short, medium, and long adolescents, mainly because of the risk of suicide to which
term. they are associated. In 1991, the Food and Drugs
Administration (FDA) claimed that there was insufficient
evidence to confirm a causal association between SSRIs
CLINICAL TREATMENTS and suicide. Vitiello and Ordoñez (2016) conducted a
systematic review of the topic and found more than 30
FOR DEPRESSION controlled clinical trials in adolescents and a few studies
In order to draft this section, a search was conducted for with children. Most studies found no differences between
the most commonly-used therapies with proven efficacy studies that administered drugs and those that used
for treating depression. The databases used were placebo, but they did find fluoxetine to be effective. They
PubMed, Web of Science, Science direct, and Google noted that antidepressants increased the risk of suicide
Scholar. The key words used in the search were (suicidal ideation and behaviors) compared to studies that
treatment, depression, child depression, and adolescent had used placebos. The authors recommend using
depression. A total of 30 bibliographic references were antidepressants with caution in young people and limiting
used in the drafting of this summary, including the major them to patients with moderate to severe depression,
contribution made by The American Psychological especially when psychosocial interventions are not
Association's Society of Clinical Psychology (American effective or are not feasible.
Psychological Association, Society of Clinical Psychology As regards the effectiveness of psychodynamic
(APA), 2017) regarding the most effective psychological treatments, Luyten and Blatt (2012) advocate the inclusion
methods for treating depression. of psychoanalytic therapy in the treatment of child,
Although the World Health Organization (WHO) (2017) adolescent and adult depression. After conducting a
claims that prevention programs reduce the risk of review of both the theoretical assumptions of
psychodynamic treatments of depression and the psychotherapeutic treatments or pharmacotherapy, and its
evidence supporting the efficacy of these interventions, effects tend to be maintained in the longer term. They also
these authors concluded that brief psychoanalytic therapy observed that the combination of BPT and medication
(BPT) is as effective in treating depression as other active obtained better

mourning), conflicts (interpersonal disputes), change
(life transitions), and deficits in relations with others
results than medication alone. Longer-term psychoanalytic (interpersonal deficits), which generate and maintain a
treatment (LTPT) was found to be effective for patients depressive state. It uses certain behavioral strategies
suffering from chronic depression and co-morbid such as problem solving and social skills training and
personality problems. Together, the authors argue, these lasts between 12 and 16 sessions in the most severe
findings justify the inclusion of psychoanalytic therapy as a cases, and between 3 and 8 sessions in milder cases.
first-line treatment in adult, child, and adolescent – Cognitive Behavioral Analysis System of Psychotherapy
depression. (McCullough, 2000). This therapy combines
In a qualitative study carried out by Brown (2018) on components of cognitive, behavioral, interpersonal, and
parents' expectations regarding the recovery of their psychodynamic
depressed children, a direct relationship was observed therapies. According to McCullough (2003), it is the only
between said expectations and type of attachment. therapy developed specifically to treat chronic
Parents who remained more passive and expected expert depression. Patients undergoing this therapy generate
helpers to fix their child experienced reduced hope months more empathic behaviors and identify, change and heal
after finishing the program. However, when parents interpersonal patterns related to depression. Patients
changed their interactions with their child and adopted are recommended to combine the therapy with a regime
more positive expectations regarding their cure, they felt a of antidepressant medication.
more sustained sense of hope. Moreover, when parents – Behavior Therapy/Behavioral Activation (BA) (Martell et
themselves participated in therapy sessions, as part of al., 2013). Depression prompts sufferers to disengage
their child's treatment, they felt greater hope and from their routines and become increasingly isolated.
effectiveness in contributing to their child's recovery. Over time, this isolation exacerbates their depressive
The American Psychological Association's Society of symptoms. Depressed individuals lose opportunities to
Clinical Psychology [American Psychological Association, be positively reinforced through pleasant experiences or
Society of Clinical Psychology (APA), 2017] has published social activities. The therapy aims to increase patients'
a list of psychological treatments that have been tested chances of being positively reinforced by increasing
with the most scientific rigor and which, moreover, have their activity levels and improving their social relations.
been found to be most effective in treating depression. The therapy usually lasts between 20 and 24 sessions,
These treatments are as follows: with the brief version consisting of between 8 and 15
– Self-Management/Self-Control Therapy (Kanfer, 1970). sessions.
Depression is due to selective attention to negative – Problem-Solving Therapy (Nezu et al., 2013). The aim is
events and immediate consequences of events, to enhance patients' personal adjustment to their
inaccurate attributions of responsibility for events, problems and stress using affective, cognitive, and
behavioral strategies. The therapy usually comprises
insufficient self-reinforcement, and excessive
around 12 sessions, although substantial changes are
self-punishment. During therapy, the patient is provided
generally observed from the fourth session onwards.
with information about depression and taught skills they This therapy is widely used in primary care. It is an
can use in their everyday life. This 10-session program adaptation that is easy to apply in general medicine by
can be delivered either in group or individual formats, at personnel working in those contexts, and can be
any age. completed in around 6 weeks (Areán, 2000).
– Cognitive Therapy (Beck, 1987). Individuals suffering
from depression are taught cognitive and behavioral The treatments that, according to the American
skills to help them develop more positive beliefs about Psychological Association, Society of Clinical Psychology
themselves, others, and the world. Méndez (1998) (APA) (2017), have modest research support and could be
argues that therapists working with depressed children used with children are as follows:
should pursue three changes: (1) Learn to value their – Rational Emotive Behavioral Therapy (Ellis, 1994). This
own feelings; (2) Replace behaviors which generate short term, present-focused therapy works on changing
negative feelings with more appropriate behaviors; and the thinking which contributes to emotional and
(3) Modify distorted thoughts and inaccurate reasoning. behavioral problems using an active-directive,
The number of sessions varies between 8 and 16 in philosophical and empirical intervention model. Using
patients with mild symptoms. Those with more severe the ABC model (A: events observed by the individual; B:
symptoms show improvement after 16 sessions. Individual's interpretation of the observed event; C:
– Interpersonal Therapy (Klerman et al., 1984). García Emotional consequences of the interpretations made),
and Palazón (2010) identified four typical focal points the aim is to bring about the cognitive restructuring of
for tension in depression, related to loss (complicated erroneous thoughts, so as to replace them with more
rational ones. The most commonly used techniques are – Short-Term Psychodynamic Therapy (Hilsenroth et al.,
cognitive, behavioral, and emotional. 2003). The aim of this therapy is to help patients
– Self-System Therapy (Higgins, 1997). Depression understand that past experiences influence current
occurs as the result of the individual's chronic failure to functioning, and to analyze affect and the expression of
achieve their established goals. During therapy, patients emotion. The therapy focuses on the therapeutic
review their situation, analyze their beliefs and, on the relationship, the facilitation of insight, the avoidance of
basis of the results, alter their regulation style and move uncomfortable topics and the identification of core
toward a new vision of themselves. Therapy generally conflictual relationship themes. It is
consists of between 20 and 25 sessions.

for depression in childhood. For example, Crowe and
McKay (2017) carried out a meta-analysis of the effects of
usually combined with pharmacological treatment to Cognitive Behavioral Therapy (CBT) on children suffering
alleviate depressive episodes. from anxiety and depression, concluding that CBT can be
– Emotion-Focused Therapy (emotion regulation therapy considered an effective treatment for child depression.
or Greenberg's experiential therapy) (Greenberg, 2004). According to these authors, the majority of protocols for
According to Greenberg et al. (2015), this therapy children have been adapted from protocols for adults, and
combines elements of client-based practices (Rogers, the most common techniques are psychoeducation,
1961), Gestalt therapy (Perls et al., 1951), the theory of self-monitoring, identification of emotions, problem solving,
emotions and a dialectic-constructivist meta-theory. The coping skills, and reward plans. Similarly, cognitive
aim is to create a safe environment in which the strategies include the identification of cognitive errors, also
individual's anxiety is reduced, thereby enabling them to known as cognitive restructuring. In another meta-analysis
confront difficult emotions, raising their awareness of conducted to analyze the efficacy and acceptability of CBT
said emotions, exploring their emotional experiences in in cases of child depression, Yang et al. (2017) observed
more depth and identifying maladaptive emotional that, in comparison with the control groups that did not
responses. The therapy is delivered in 8–20 sessions. receive treatment, the experimental groups showed
– Acceptance and Commitment Therapy (Hayes, 2005). significant improvement, although they also pointed out
This theory has become increasingly popular over that the relevance of this finding was limited due to the
recent years and is the contextual or third-generation small size of the trial groups.
therapy that is supported by the largest body of Another study carried out in Saudi Arabia concluded
empirical evidence. It is based on a realization of the that student counseling in schools may help combat and
importance of human language in experience and directly reduce anxiety and depression levels among
behavior and aims to change the relationship Saudi children and adolescents (Alotaibi, 2015).
individuals have with depression and their own Family-based treatment may also be effective in
thoughts, feelings, memories, and physical sensations treating the interpersonal problems and symptoms
that are feared or avoided. Strategies are used to teach observed among depressed children. The data indicate
patients to decrease avoidance and negative that the characteristics of the family environment predict
cognitions, and to increase focus on the present. The recovery from persistent depression among depressed
aim is not to modify the content of the patient's children (Tompson et al., 2016). In this sense, Tompson et
thoughts, but rather to teach them how to change the al. (2017) compared the effects of a family focused
way they analyze them, since any attempt to correct treatment for child depression (TCF-DI) with those of
thoughts may, paradoxically, only serve to intensify individual supportive psychotherapy among children aged
them (Hayes, 2005). 7–14 with depressive disorders. The results revealed that
incorporating the family into the therapy resulted in a
Ferdon and Kaslow (2008), for their part, in a theoretical significant improvement in depressive symptoms, global
review of the treatment of depression in children and response, functioning, and social adjustment.
adolescents, concluded that the To conclude this section, it can be stated that treatment
cognitive-behavioral-therapy-based specific programs of for depression should be multifactorial and should bear in
the Penn Prevention program meet the criteria to conduct mind the personal characteristics of the patient, their
effective interventions in children with depression. In coping strategy for problems, the type of relationship they
adolescent depression, the cognitive-behavioral therapy have with themselves and the type of relationship they
and the Interpersonal Therapy–Adolescent seem to have establish with their environment (friends, school, family,
a well established efficacy. Weersing et al. (2017), in this etc.). Thus, in order for the individual to attain the highest
same line, state that, although the efficacy of treatments in possible level of psychological wellbeing, attention should
children is rather weak, cognitive-behavioral therapy is focus on both these and other related aspects.
probably the most effective therapy. They also confirm
that, in depressed adolescents, cognitive behavioral
therapy, and interpersonal psychotherapy are appropriate CONCLUSIONS
interventions.
There are other studies also which focus on treatments The present review aims to shed some light on the
complex and broad-ranging field of child and adolescent version of the pathology. This may well be a basic error in
depression, starting with a review of the construct itself our approach to depression among younger age groups.
and its explanatory theories, before continuing on to The fact that universal prevention programs specifically
analyze existing evaluation instruments, the main designed for children are obtaining only modest results
prevention programs currently being implemented and the may indicate that we have perhaps failed to correctly
various treatments currently being applied. All these identify the key variables involved in the genesis and
aspects are intrinsically linked: how the concept is defined maintenance of child and adolescent depression.
depends on the explanatory variables upon which said The review of current child and adolescent depression
definition is based, and this in turn influences how we prevention programs revealed that the vast majority
measure it and the variables we define as being key coincide in adopting a cognitive-behavioral approach, with
elements for its prevention and treatment. contents including social skills and problem solving
It is interesting to note the low level of specificity of both training, emotional education, cognitive restructuring, and
the construct itself and the explanatory theories offered by strategies for coping with anxiety. These contents are
child and adolescent psychology, which suggest that child probably included because they are
depression can be understood on the basis of the adult

children and adolescents through student counselling in Saudi Arabia.
Prok. Soc. Perilaku Sci. 205, 18–29. doi:
10.1016/j.sbspro.2015. 09.006
important elements in the treatment of depression, as American Psychiatric Association (2014). Manual
shown in this review. But if their inclusion is important and Diagnóstico y Estadístico de los
effective in the treatment of depression, why do they not Trastornos Mentales (DSM-5)
seem to be so effective in preventing this pathology? [Diagnostic and Statistical Manual of
There are probably many factors linked to prevention Mental Disorders (DSM−5)]. Madrid: Médica
Panamericana.
programs which, in one way or another, influence their
American Psychological Association, Society of Clinical Psychology (APA)
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