The Development of Depression in Children
and Adolescents
Dante Cicchetti and Sheree L. Toth
University of Rochester
In recent decades, research on child and adolescent de-
pression has proliferated. Currently, attention in the field
is directed toward examining the epidemiology, causes,
course, sequelae, and treatment response of children at
risk for developing or presently experiencing depressive
disorders. In this article, a developmental psychopathol-
ogy approach is used to elucidate the development of
depressive disorders, the diverse pathways that evolve,
and the processes that contribute to varied outcomes. The
developmental psychopathology perspective underscores
the importance of moving beyond the identification of
isolated aberrations in psychological and biological
components of depressive presentations to the under-
standing of how those components have evolved and how
they are integrated within and transact across biological,
psychological, and social systems. Implications for pre-
vention and intervention are addressed as is the impor-
tance of increasing the public awareness of depressive
disorders and reducing the social stigma that interfere
with the attainment of treatment for depressed persons.
I
n this article, we present a developmental psychopa-
thology conceptualization of the depressive disorders
of childhood and adolescence. Such an approach es-
pouses the viewpoint that to comprehend human develop-
ment, it is essential to understand the integration of devel-
opmental processes at multiple levels of biological, psy-
chological, and social complexity within individuals over
the life course. Thus, multidisciplinary efforts to unify
and integrate the advances that have taken place in the
fields of developmental psychology, clinical psychology,
psychiatry, epidemiology, sociology, neurobiology, genet-
ics, and the neurosciences within a developmental psy-
chopathology perspective are essential to address the crit-
ical issues involved in the development of depressive
disorders.
Depressive disorders are conceived as heterogeneous
conditions that are likely to eventuate through a variety
of developmental pathways. Single risk factors can rarely
be conceived as resulting in depressive outcomes. Rather,
the organization of biological, psychological, and social
systems as they have been structured over development
must be fully examined. We consider a depressotypic
developmental organization to be a potential precursor
to depressive illness, and we argue that the concept of
February 1998 • American Psychologist
Copyright 1998 by the American Psychological Association, Inc. 0003-066X/98152.00
Vol. 53, No, 2, 221-241
this organization has much heuristic value in guiding
thinking about the diverse processes that underlie symp-
tom expression and depressive outcomes. The develop-
mental position challenges us to move beyond identifying
isolated aberrations in cognitive, affective, interpersonal,
and biological components of depressive presentations,
to understand how those components have evolved devel-
opmentally, and to understand how they are integrated
within and across biological and psychological systems
of the individual embedded within a multilevel social
ecology.
We begin by discussing the nature of depressive
illness and then examine epidemiological data on and
clinical characteristics of depression in children and ado-
lescents. We then articulate concepts from the field of
developmental psychopathology and present a model that
addresses the development of depression and its manifes-
tation in children and adolescents. As there is a paucity
of longitudinal investigations on the development of de-
pression, we draw on research that includes studies that
used epidemiological (e.g., representative of the commu-
nity under investigation), high-risk (e.g., children with
depressed parents), and clinical (e.g., hospitalized clini-
cally depressed youngsters or clinically referred children)
samples. Of course, our model is necessarily speculative
because studies have not examined the emergence and
evolution of a depressotypic organization over time. We
focus on unipolar depression because the majority of
research that has occurred on mood disorders and their
development has been conducted with either the offspring
of mothers with unipolar depression or on depressed chil-
dren and adolescents. Accordingly, we examine the
emerging insights that a developmental psychopathology
perspective provides for comprehending the etiology,
course, and sequelae of depressive disorders in childhood
and adolescence. We also discuss the treatment and social
policy implications derived from this perspective.
Dante Cicchettiand ShereeL. Toth,Mt. HopeFamilyCenter,University
of Rochester.
Work on this article was supportedby grants from the Lifecourse
Prevention Branch of the National Institute of Mental Health
(MH45027) and from the Spunk Fund, Inc.
Correspondence concerning this article should be addressed to
Dante Cicchetti,Mt. Hope FaihilyCenter,Universityof Rochester, 187
Edinburgh Street, Rochester,NY 14608.
221

Dante Cicchetti
Definitional Parameters and Nature of
Impairment
Over the past several decades, remarkable scientific prog-
ress has occurred in our understanding of the mental
disorders of childhood, adolescence, and adulthood (In-
stitute of Medicine [IOM], 1985, 1989). Despite these
advances, mental illness continues to challenge millions
of individuals and families as well as to place major
stress on the service delivery system and on the research
community that strive to better comprehend psychopa-
thology and thereby contribute to improved treatment and
prevention efforts (IOM, 1985, 1989, 1994).
Among adults, depressive disorders are quite com-
mon and tend to co-occur with other serious mental disor-
ders, including substance abuse, anxiety disorders, and
schizophrenia. Perhaps most significantly, they are
strongly associated with suicide, one of the leading
causes of death in adolescents and adults. Depressive
disorders also are associated with far-reaching impair-
ments in functioning not only for the depressed individual
but also for family members.
With respect to the financial burden to society ac-
companying the treatment of depression as well as the
costs associated with the suffering experienced by those
who have or are confronted with the illness, depressive
disorders are among the most serious psychopathological
disorders. The annual cost of depressive disorders in the
United States has been estimated at $43 billion, 85% of
which is attributed to expenditures for major depressive
disorder (MDD), including costs of treatment as well
as absenteeism from work, losses of productivity, and
premature death (Hirschfeld et al., 1997). Additionally,
because of its chronicity, depression can remain burden-
222
some for a significant period of time. Given the substan-
tial economic drain on individuals, families, and society,
and the long-term suffering, the risk for suicide, and the
impairment in occupational, interpersonal, and family re-
lationships, it is not at all surprising that, since antiquity,
depression and its impact on the human condition have
constituted a prominent area of inquiry for philosophers,
physicians, psychiatrists, and psychologists alike (Jack-
son, 1986). Children with clinical depression, similar to
adult depressives (Hirschfeld et al., 1997; Robins & Re-
gier, 1991), are undertreated (Beardslee, Keller, Lavori,
Staley, & Sacks, 1993; IOM, 1989). In fact, 70% to 80%
of depressed teenagers do not receive treatment (Keller,
Lavori, Beardslee, Wunder, & Ryan, 1991; Rohde, Lew-
insohn, & Seeley, 1991).
Depression has typically been operationalized in
three ways, including depressed mood, depressive syn-
dromes, and depressive disorders (Angold, 1988). De-
pressed mood is delimited by a single symptom or group
of symptoms that involve dysphoric affect. Most com-
monly, self-report measures have been used to identify
depressed mood. Depressive syndromes involve sets of
symptoms that have been shown to co-occur empirically.
Depressive disorders are reflected by categorical diagno-
ses, such as those proffered in the Diagnostic and Statisti-
cal Manual of Mental Disorders (DSM IV; American
Psychiatric Association [APA], 1994) or in the Interna-
tional Classification of Diseases (ICD-IO; World Health
Organization, 1996).
Stated simply, depressive disorders, also referred to
as mood disorders, involve disturbances of emotion that
affect an individual's entire psychic life (IOM, 1994).
There are two types of mood disorder. These are bipolar
disorder, which we do not address in this article, and
depressive disorder, which has two major subtypes:
MDD, marked by a single episode or recurrent episodes
of depression; and dysthymia (DD), which involves a
chronic disturbance of mood. Depressive disorders are
characterized by a pervasive mood disturbance that in-
volves feelings of sadness and loss of interest or pleasure
in most activities in conjunction with disturbances in
sleep, appetite, concentration, libido, and energy. Efforts
have been made to recognize that symptoms of these
disorders may be manifested differently in children and
adolescents than in adults (APA, 1994; Birmaher, Ryan,
Williamson, Brent, Kaufman, Dahl, et al., 1996; Kovacs,
1996). However, most often the criteria associated with
adult depression have been applied to children, and devel-
opmental considerations that may affect the etiology,
course, and outcome of depression in children and ado-
lescents have been minimized or disregarded entirely.
Depressive Disorders in Childhood and
Adolescence
Although the mood disorders of children and adolescents
have been investigated for a shorter period of time than
the mood disorders of adults, nonetheless, in recent de-
cades there has been a proliferation of research activity
February 1998 • American Psychologist

Sheree L. Toth
in the area of childhood and adolescent depression. In
contrast to earlier beliefs that called into question whether
or not veridical depressive illness could occur before
puberty (Rie, 1966), contemporary emphases have
shifted from a focus on debating which criteria should
be used to diagnose childhood mood disorders to more
sophisticated examinations of the epidemiology, causes,
course, sequelae, and treatment responses of depressed
and/or dysthymic children as well as of children who are
considered to be at risk for depression because they have
one or more relatives with a mood disorder (Birmaher,
Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996;
Cicchetti & Schneider-Rosen, 1986; Downey & Coyne,
1990; Kovacs, 1996; Puig-Antich, 1986; Todd, Newman,
Geller, Fox, & Kickock, 1993; Weissman et al., 1987).
Epid_em!qlogy and Clinical Characteristics of Child
and Adolescent Depression
Estimates of the point prevalence of MDD range from
0.4% to 2.5% for children and from 0.4% to 8.3% for
adolescents (Birmaher, Ryan, Williamson, Brent, Kauf-
man, Dahl, et al., 1996). However, developmental con-
straints on cognition, language, memory, and self-under-
standing may compromise the accuracy of the assessment
of MDD in children (Cicchetti & Schneider-Rosen, 1986;
Kovacs, 1989). The lifetime prevalence estimate of MDD
in adolescence is between 15% and 20%, a rate compara-
ble to the lifelong rate of adult MDD and suggestive that
depression in adults may have its origins in adolescence
(Harrington, Rutter, & Fombonne, 1996; Kessler et al.,
1994). Point prevalence rates of DD have ranged from
0.6% to 1.7% in children and from 1.6% to 8.0% in
adolescents. Moreover, although MDD in childhood oc-
curs at approximately the same rate in girls and boys, in
February 1998 • American Psychologist
adolescence MDD occurs twice as frequently in teenage
girls, paralleling the gender ratio obtained for adult MDD
(Fleming & Offord, 1990; Lewinsohn, Clarke, Seeley, &
Rohde, 1994).
The consequences of depression during childhood
and adolescence cannot be minimized. Depressive disor-
ders are neither normal developmental occurrences nor
short-lived problems that dissipate with time (Kovacs,
1989). Even when episodes remit, they commonly recur
and interfere with children's ability to function compe-
tently (Kovacs, Feinberg, Crouse-Novak, Paulauskas, &
Finkelstein, 1984; Kovacs, Feinberg, Crouse-Novak, Pau-
lauskas, Pollock, & Finkelstein, 1984). Moreover, when
DD as compared to MDD is the first to emerge in chil-
dren, there is a greater risk for developing subsequent
mood disorders. For example, Kovacs and colleagues
(Kovacs, Akiskal, Gatsonis, & Parrone, 1994) found that
76% of children with earlier onset DD developed a subse-
quent MDD, and 69% of the children with DD as the
first emergent mood disorder developed a combined DD
and depression (i.e., double depression). In a recent re-
view of the literature, Birmaher and colleagues (Bir-
maher, Ryan, Williamson, Brent, Kaufman, Dahl, et al.,
1996) concluded that the average length of an episode of
MDD in children and adolescents was seven to nine
months. Approximately 90% of MDD episodes remit
within two years post onset, whereas the remaining epi-
sodes last for a more protracted period of time. Addition-
ally, MDD frequently recurs in children and adolescents.
As compared to MDD, DD has a much more pro-
longed course, with the average length of an episode
being four years. Children with DD generally experience
their first MDD episode two to three years after the onset
of DD. Because the development of DD is one of the
major pathways to recurrent depressive disorder, early
identification and treatment and the implementation of
preventive interventions for DD are critical strategies that
should be used (Kovacs et al., 1994).
With respect to comorbidity, 40% to 70% of de-
pressed children and adolescents develop an additional,
or comorbid, disorder, with 20% to 50% estimated to
have two or more comorbid diagnoses. The most frequent
comorbid diagnoses include DD, anxiety disorder, dis-
ruptive disorder, and substance abuse (Harrington et al.,
1996; Kovacs, 1989, 1996). In children and adolescents,
the majority of anxiety disorders (typically separation
anxiety disorder) precede the depressive episode, whereas
in adults, depression usually predates the anxiety disorder
(Kovacs, 1996). MDD typically precedes the onset of
alcohol or substance abuse by approximately four and a
half years, thereby providing an important time window
for the prevention of substance abuse in depressed ado-
lescents (Birmaher, Ryan, Williamson, Brent, Kaufman,
Dahl, et al., 1996). In general, comorbid diagnoses appear
to enhance the risk for recurrent depression and to affect
the duration of the depressive episode, suicide attempts,
functional outcome, response to treatment, and the use
223
of mental health services (Birmaher, Ryan, Williamson,
Brent, & Kaufman, 1996; Kovacs et al., 1994).
Gender Differences
From a developmental perspective, gender differences in
depression are especially important because knowledge
of gender-specific pathways may enhance our understand-
ing of the etiology of depression as well as help to guide
preventive approaches (Gjerde, 1995). Although not all
studies of depressed youth have revealed gender differ-
ences (cf. Leadbeater, Blatt, & Quinlan, 1995), research
suggests that at some point in early-to-middle adoles-
cence, the overall prevalence of depressive symptoms
increases significantly for both sexes, but that girls begin
to manifest significantly higher rates of depressive symp-
toms (Angold & Rutter, 1992; Nolen-Hoeksema & Gir-
gus, 1994). In moving beyond studies of depressed symp-
tomatology to actually examining clinically relevant de-
pression, three longitudinal investigations of community
samples found age and gender effects consistent with
expectations that, beginning in adolescence, girls are
more likely to experience depression than boys (Giaconia
et al., 1993; Kashani et al., 1987; McGee et al., 1990).
A number of explanations have been proffered to explain
this gender difference. One obvious hypothesis has in-
voked the role of biological changes associated with pu-
berty. However, Angold and Rutter (1992) found that pu-
bertal status did not predict depression beyond the effect
of age. Nolen-Hoeksema and Girgus (1994) suggested
that gender differences in personality or behavioral style
(e.g., more rumination among girls) that may exist prior
to adolescence interact with increased developmental
challenges for girls in adolescence, resulting in the ob-
served gender differences in rates of depression. Al-
though more work is needed to gain a better understand-
ing of the mechanisms that may contribute to these age
and gender effects, a consensus regarding increases in
depression during adolescence, especially in girls, has
emerged.
Concepts in a Developmental
Psychopathology Approach to
Depression in Children and Adolescents
Given the prevalence of depressive disorders across ex-
tensive periods of development and the various risk fac-
tors associated with depression and other forms of psy-
chopathology, it is essential to gain a firm grasp of the
developmental processes that contribute to the emergence
and perpetuation of depressive disorders. Depressive dis-
orders are of particular interest to developmentalists be-
cause of the complex interplay of psychological (e.g.,
affective, cognitive, socioemotional, social-cognitive),
social (e.g., community, culture), and biological (e.g.,
genetic, neurobiological, neurophysiological, neuro-
chemical, neuroendocrine) components that are involved.
Further, depressive conditions may be viewed as forming
a spectrum of severity from transient and universally ex-
224
perienced dysphoria, to elevated levels of depressive
symptoms that do not meet the diagnostic criteria for
disorder, to extended periods of DD and episodes of
MDD (Gotlib, Lewinsohn, & Seeley, 1995). Even within
more narrowly defined disorders (e.g., MDD), there are
likely to be heterogeneous conditions with phenotypic
similarity despite differences in etiology. There are di-
verse pathways to depressive disorder, and potential risk
factors for depression may result in a multitude of out-
comes of which depression may be one. Moreover, de-
pressive phenomena and disorders are present throughout
the life span from early childhood through senescence.
To structure our understanding of depression in childhood
and adolescence, we next discuss major developmental
principles central to both normal and abnormal patterns
of development.
Developmental psychopathology seeks to unify di-
verse disciplinary perspectives to provide an understand-
ing of multiple levels of individual adaptation and devel-
opment, the interrelations and integrations of these varied
systems across the life course, the spectrum of potential
developmental pathways that evolve, and the causal pro-
cesses contributing to these varied trajectories (Cicchetti,
1993). Depressive disorders constitute a particularly im-
portant area of study because of the diverse systems that
influence these disorders. Aberrations in cognitive, soci-
oemotional, representational, and biological domains are
present to varying degrees among individuals with mood
disorders (see Figure 1). Notably, these varied systems
do not exist in isolation. Rather, they are complexly inter-
related and mutually interdependent. In adaptively func-
tioning individuals, there is a coherent organization
among these domains. In contrast, in depressed individu-
als, there is either an incoherent organization among these
systems or an organization of pathological structures,
that is, a depressotypic organization. Depressotypic orga-
nizations evolve developmentally and may eventuate in
depressive disorders at different points across the life
course. Thus, understanding the interrelations among
these systems is vital for delineating the nature of these
disorders as well as for elucidating how these systems
also promote adaptive functioning.
Given the multiplicity of systems affected by de-
pressive disorders, the developmental approach serves to
direct attention to the early developmental attainments
that may be related to later appearing patterns of de-
pressive symptomatology. For example, an understanding
of the deviations in affective regulation or the core nega-
tive attributions about the self observed in depressed per-
sons may emerge through an examination of the early
development of these features, their developmental
course, and their interrelations with other psychological
and biological systems of the individual.
Organizational Approach to Development
In this regard, an organizational perspective on develop-
ment has provided developmental psychopathologists
with a valuable framework for conceptualizing develop-
February 1998 • American Psychologist
Figure 1
Integration of Biological and Psychological Systems in the Emergence of a Depressolypic Organization
Cognitive
Ie.g., Social Cognition, Ce.g., Affect Regulation,
Information Processing,
Attributional Style)
I X
Biological
(e.g., Genetics, (e.g., InternalRepresentationalModels,
Physiological Processes,
Brain Structural Anomalies
Neuroendoerine Dysregulation,
Neurotransmitter Anomalies,
Hemispheric Activation
Asymmetries)
mental phenomenon as they relate to the evolution of
depressive disorders. At each stage, children are con-
fronted with new developmental challenges (i.e., stage-
salient developmental issues; Cicchetti & Schneider-
Rosen, 1986; Sroufe, 1979; Sroufe & Rutter, 1984). The
quality of the resolution of these stage-salient tasks in-
fluences how the particular developmental issue is incor-
porated into psychological and biological systems as re-
organization occurs. Positive adaptation to a develop-
mental challenge contributes to competence and better
preparedness for adaptively resolving subsequent tasks
of development. In contrast, compromised or inadequate
resolution of a stage-salient developmental challenge,
which is also integrated as reorganization proceeds, re-
suits in a decreased likelihood of positive adaptation to
later developmental demands. Thus, although not inevita-
ble, early competence tends probabilistically to foster
later competence, and similarly, early incompetence tends
to promote later incompetence.
Because the course of development is marked by
considerable variability in outcomes, a diversity of devel-
opmental pathways is to be expected (Cicchetti & Ro-
gosch, 1996). Multifinality specifies that diverse out-
comes are likely to result from any one source of influ-
ence. For example, although children of parents with
depressive disorders are considered at risk, including at
genetic risk, for the development of depression, certainly
not all such individuals develop depressive disorders, and
a wide spectrum of adaptation is seen. Harrington and
colleagues (1996), on the basis of research they con-
ducted with clinical and epidemiological samples, con-
February 1998 • American Psychologist
Attachment Organization,
Self-Esteem,
Interpersonal Relations,
Guilt)
Degressotypi~
Renresentational
Self-Schemata,
Self-Cognitions)
J
cluded that depressive disorders represented a heteroge-
neous group of phenomena. Although children and ado-
lescents with depressive disorder were more likely than
comparable psychiatric controls to evidence depressive
disorders in adulthood, individuals who also had comor-
bid conduct disorders tended to be less likely to develop
depression in adulthood than those without conduct prob-
lems. The findings of Harrington et al. (1996) not only
demonstrate a degree of specificity in adult outcomes for
depressive disorders but also illustrate multifinality in
developmental pathways through observing alternate pat-
terns of adaptation among children and adolescents who
had experienced depressive disorders.
In contrast to multifinality, the principle of equifi-
nality suggests that the same outcome may emanate from
diverse routes. Gjerde (1995) provided an illustrative ex-
ample of equifinality in the development of chronic de-
pressive symptoms by young adulthood as predicted
through repeated assessments from the preschool years.
Strong predictive patterns were evident for young adult
men beginning in the preschool period, a time in which
undersocialization and antagonistic interpersonal behav-
ior were linked with depression in adulthood. Similar
constellations of these personality characteristics in later
childhood and adolescence also were related to chronic
depressive symptoms in young adults. Conversely, among
women this personality organization did not predict adult
depression. Moreover, early precursors of depressive
symptomatology were not identified for women, and it
was not until adolescence that patterns of oversocializa-
tion and excessive introspection were found to predict
225
depressive symptoms in young women. Thus, very differ-
ent trajectories to the same depressive outcome in adult-
hood were identified. In view of the varied pathways that
are likely to result in depressive outcomes, a model that
is sufficiently complex and comprehensive and that
allows for the explication of precursors to depressive
illness as well as for full blown depressive syndromes
and disorders is essential.
An Ecological Transactional Model
To be able to account for the diverse influences on the
emergence of depression, a transactional model that ad-
dresses the interrelations among dynamic biological, psy-
chological, and social systems is necessary (Sameroff &
Chandler, 1975). Such a model views the multiple trans-
actions among environmental forces, caregiver character-
istics, and child characteristics as dynamic, reciprocal
contributions that may exacerbate or decrease the likeli-
hood of a depressotypic organization and the emergence
of a depressive illness. The application of a transactional
model to the evolution and maintenance of depression
requires that attention be directed to the risk factors asso-
ciated with the development of the disorder. As such, the
multiple factors that have been implicated in the etiology
of depression must be understood. In accord with a trans-
Figure 2
Transaction of Multilevel Potentiating and Compensatory Processes in the Development of Depressotypic
Organization and Depressive Outcomes
J I
226
actional developmental formulation, it is likely that nu-
merous general factors across broad domains of psycho-
logical and biological development will be related to the
manifestation of depression as well as to positive adapta-
tion in the context of risk for depression. Whether depres-
sion occurs is affected not only by the presence or ab-
sence of specific vulnerability or protective factors.
Rather, the interplay that occurs between these factors
and current and previous levels of adaptation as well as
the developmental period during which risk factors are
experienced (Cicchetti & Tucker, 1994; Sroufe, Ege-
land, & Kreutzer, 1990) also are vital contributors to
depressive outcomes.
An ecological transactional model provides a frame-
work for understanding how multiple factors can influ-
ence the emergence of depression in children and adoles-
cents (see Figure 2). According to such a perspective, an
individual's ecology is seen as being comprised of a num-
ber of co-occurring levels, some of which are proximal
to and others which are more distal to the individual
(Belsky, 1993; Bronfenbrenner, 1979; Cicchetti & Lynch,
1993). Depending on how' proximal the influence is to
the individual, the role that it exerts on the emergence of
a depressotypic organization and of a depressive disorder
may be more or less evident. Processes from each level
Ongoing Transactiou of
Potentiating and Compensatory
Processes at Each Level of the
Social Ecology
Distal Outcomes
Dysthymia
'1 I Major Depressive
Disorder
Double Depression
Co-Morbid Disorders
Positive Adjustment
February 1998 • American Psychologist
of the environment as well as characteristics of the indi-
vidual mutually influence each other over time and shape
the course of child development, including whether or
not a depressotypic organization and a depressive illness
emerge.
Cicchetti and Lynch (1993) discuss the role that
potentiating and compensatory risk factors exert at vari-
ous levels of the ecology. Risk factors within a given
level of the ecology also can influence outcomes and
processes in surrounding ecological levels. The ongoing
transactions among these risk factors determine the
amount of biological and psychological risk that the indi-
vidual faces. Potentiating factors increase the likelihood
that a depressotypic organization and a depressive illness
will occur, whereas compensatory factors decrease the
probability of their occurrence. Each factor may exert
enduring or transient influences that affect the probability
of a depressive outcome. Importantly, the manner in
which children deal with the challenges that impinge on
them by family, community, and societal conditions is
seen in their own ontogenic (i.e., individual) develop-
ment. As enduring vulnerability factors and transient
challengers at various ecological levels increase, the oc-
currence of a depressotypic organization and depression
becomes more likely. Conversely, the presence of endur-
ing protective factors and transient buffers at various eco-
logical levels may help to explain why some children
deal adaptively and avert depression even in the face of
conditions seemingly linked to a depressotypic organiza-
tion and depressive illness.
The two most distal levels of an individual' s ecology
include the macrosystem, which contains the beliefs and
values of the culture, and the exosystem, which includes
aspects of the community in which children and families
live. More proximal influences are exerted by the micro-
system, or the immediate environment, most typically
the family, and ontogenic development, or those factors
within the person that affect his or her adaptation. In
accord with a transactional approach, ongoing transac-
tions of risk and protective processes within and among
each level of the ecology are conceived as contributing
to the emergence and development of a depressotypic
organization and to the onset and recurrence of depressive
disorders. To examine how depression may evolve, we
discuss illustrative research relevant to the development
of depressotypic organization and depressive illness that
has been conducted on factors operating at different levels
of the ecology.
Because the amount of research conducted at vari-
ous levels of the ecology varies, in this article we place
a greater emphasis on the ontogenic and microsystem
levels, that is, those that are most proximal to the child
or adolescent. Moreover, because we believe that it is
how the individual copes with various influences and
not any ecological factor per se that contributes to the
emergence of a depressive illness, we first discuss onto-
genic development and its relations to a depressotypic
organization. Subsequently, we describe how the individ-
February 1998 • American Psychologist
ual is embedded within progressively more distal levels
of the ecologies and how risk and protective factors op-
erating at levels of the ecology can serve to exacerbate
or diminish the likelihood of a depressotypic organization
and a depressive illness.
Onlt~denic development, The quality of the res-
olution of early stage-salient developmental tasks may
contribute to early aberrations that are hierarchically inte-
grated and portend the development of pathways to de-
pressive disorder through depressotypic organizations of
developmental structures. For heuristic purposes, four
early stage-salient developmental issues that bear theoret-
ical relevance for diverse components of evolving de-
pressotypic organizations and depressive disorders are
highlighted. These issues include (a) the development
of homeostatic and physiological regulation, (b) affect
differentiation and the modulation of attention and
arousal, (c) the development of a secure attachment rela-
tionship, and (d) the development of the self-system. As
development proceeds, each of these issues sequentially
reaches ascendancy and becomes a primary arena for
which internal resources must be elaborated and extended
to hierarchically integrate the imposed developmental
challenges to foster positive adaptation. Moreover, rather
than subsequently declining in importance, each issue
remains a lifelong component of adaptation.
The research we discuss on aberrations in these
areas is drawn from studies on the offspring of parents
with depressive disorders, from investigations on chil-
dren and adolescents with mood disorders, and from pop-
ulation-based epidemiological studies that have focused
on depressed symptoms and depressive disorders. Al-
though the majority of work has been conducted on chil-
dren with depressed parents, it is important to note that
there are clear linkages between families having a de-
pressed parent and those with a depressed child. Specifi-
cally, a significant proportion of children with a de-
pressed parent also are depressed (Downey & Coyne,
1990). In addition, relations in the time of the occurrences
between episodes of depression in mothers and children
have been found (Hammen, 1991), and one third to one
half of parents with a depressed child are themselves
depressed (Brumbeck, Dietz-Schrnidt, & Weinberg, 1977;
Puig-Antich et al., 1989).
Homeostatic and physiok~ical regulation, In
the early months of life, the infant is challenged to main-
taln homeostatic equilibrium of internal physiological
states. Homeostatic systems strive to maintain a set point
of functioning, and departure from this optimal level gen-
erates tension. Consequently, behavioral and biological
systems must be activated to reduce the tension, thereby
helping the infant to regain a state of equilibrium. Early
innate motoric reflexes allow the infant some capacity to
regain equilibrium. However, significant environmental
support must be provided for the infant to regulate physi-
ological states and maintain equilibrium. Thus, early
physiological regulation requires support from caregiv-
ers. Infants develop capacities to communicate their
227
needs to caregivers through affective responses, and sen-
sitive caregivers must be able to read these signals
accurately.
As the infant's brain develops, the infant becomes
increasingly self-sufficient in modulating arousal gener-
ated by physiological tension. This growing capacity cor-
responds to maturation of forebrain inhibitory tracts and
neurotransmitter systems, which allows increasing con-
trol of lower hindbrain and midbraln limbic structures.
Right-brain activation has been associated with distress,
whereas left-brain activation and inhibition of right-brain
activity have been linked to positive affect (Davidson,
1991). The development of interhemispheric connections
enhances the infant's ability to self-regulate (Cicchetti &
White, 1988; Tucker & Williamson, 1984). The develop-
ment of these neurological systems is experience ex-
pectant, necessitating external input from caregivers
(Greenough, Black, & Wallace, 1987). Moreover, the
quality of caregiving received is likely to contribute to
variations in neurobiological growth and development,
resulting in long-term effects on the organization and
development of the brain.
Parents vary in how well they are able to assist their
infants in the maintenance of homeostatic regulation,
thereby indirectly influencing the process of brain devel-
opment. Further, extremely frequent, novel experiences
and an unstable environment may more routinely activate
the right brain, resulting in negative affect expression. In
contrast, stability and consistency in the environment
may support dominance of the left brain, which may
strengthen the inhibitory effects on negative arousal.
Thus, the quality of parenting may influence the develop-
ment of interhemispheric connections and the emotion
regulatory abilities that the infant develops.
Differences in homeostatic regulation have been in-
vestigated in infants of parents with mood disorders,
where as early as the neonatal period, difficulties have
been noted. These include elevated levels of epinephrine
and norepinephrine, difficulties with self-quieting, lower
activity levels, more negative affect, and attentional prob-
lems, all of which are suggestive of more difficult temper-
aments (Abrams, Field, Scafidi, & Prodromidis, 1995;
Field, 1992; Sameroff, Seifer, & Zax, 1982).
Even simulated depression portrayed by nonde-
pressed mothers has been shown to result in negative
infant affectivity and disruption in the infant's effective
self-regulation (Cohn & Tronick, 1983). In more recent
investigations, a number of problematic depressed mater-
nal interactive behaviors have been observed. Three dis-
tinct interactive profiles have been identified in depressed
mothers, including (a) a withdrawn, unavailable, and un-
derstimulating pattern; (b) a hostile-intrusive overstimu-
lating pattern; and (c) a positive pattern characterized by
the absence of depressed symptoms on maternal self-
report inventories of depression (Cohn, Matias, Tronick,
Lyons-Ruth, & Connell, 1986; Field, Healy, Goldstein, &
Guthertz, 1990). Cohn and his colleagues (1986) specu-
lated that restricted maternal affect and lack of respon-
228
siveness eventuated in increased infant distress, whereas
maternal hostility and intrusiveness were associated with
more infant avoidance.
In addition to the importance of the affective aspects
of mother-infant interaction, infants also have shown
dramatic reactions to violations of the expected temporal
relationship between their own and their mother's posi-
tive affect (Cohn & Campbell, 1992). When normal
mothers were instructed in a laboratory analogue simula-
tion to sober in response to their infant's positive affect
displays, the babies were found to manifest sober expres-
sions and to avert gaze from their mother (Cohn & El-
more, 1988). Clearly, the temporal aspects of the affective
displays of depressed mothers are likely to be quite im-
paired. Bettes (1988) examined the vocal utterances of
mothers varying from mild to moderate in their level of
depressed symptoms. She found that the vocalizations of
mothers with some degree of depressed symptomatology
were more variable and their vocalizations were of longer
duration than was the case in the nondepressed mother
control groups.
Beyond infancy, affect regulatory difficulties also
have been observed among older offspring of parents
with mood disorders. Jameson and colleagues (Jameson,
Gelfand, Kulcsar, & Teti, 1997) found that depressed
mothers were less likely to repair interrupted interactions
with their toddlers than were nondepressed mothers with
their toddlers. Additionally, the toddlers of the depressed
mothers were less likely to maintain interactions with
their mothers than were the toddlers of nondepressed
mothers. Finally, nondepressed mothers and their toddlers
displayed more interactive coordination than did de-
pressed mothers and their toddlers.
Toddlers of mothers with MDD also have been
shown to exhibit more dysregulated, out-of-control be-
havior than toddlers of nondepressed mothers (Zahn-
Waxier, Iannotti, Cummings, & Denham, 1990). These
differences predicted behavior problems as perceived by
mothers at age five and as reported by the child at age
six, and were found to occur predominantly for children
of depressed mothers who were less able to modulate,
control, and provide structure and organization during
their toddler's play.
Difficulties in the regulation of affect also may con-
tribute to problematic peer relations. Zahn-Waxler and col-
leagues (Zahn-Waxler, Denham, Cummings, & Iannotti,
1992) noted that preschool-aged children of parents with
mood disorder characteristically engage in uncontrolled
and poorly regulated social exchanges with peers. Boys of
depressed mothers have been found to generate aggressive
strategies to solve hypothetical peer conflicts (Hay, Zahn-
Waxier, Cummings, & Iannotti, 1992). Thus, these findings
suggest that early regulatory difficulties in offspring of
parents with mood disorders may continue to affect adapta-
tion as new experiences and situations are encountered.
These difficulties may portend problems in the modulation
of affective reactions that may heighten the risk for the
development of future depressive disorders. For example,
February 1998 • American Psychologist
Zahn-Waxler and Kochanska (1990), in their examination
of patterns of guilt in five- to nine-year-old children of
depressed and nondepressed mothers, found evidence for
continued affect regulatory problems. These investigators
discovered that younger children of depressed mothers
were overaroused to hypothetical situations of interper-
sonal conflict and distress, whereas the older offspring of
depressed mothers appeared to struggle against experienc-
ing guilt. Themes involving sensitivity to the problems of
others and empathic overinvolvement were evident.
Furthermore, in an investigation of 275 children be-
tween kindergarten and eighth grade, Garber and col-
leagues (Garber, Braafladt, & Weiss, 1995) found that
children with high levels of depressed symptoms reported
using affect regulatory strategies less often than did chil-
dren with low levels of depressed symptoms. Moreover,
the depressed children rated their own affect regulatory
responses as less effective in altering their negative mood.
In addition, Garber et al. (1995) discovered that de-
pressed girls rated mother-initiated affect regulatory
strategies as less effective than did nondepressed girls.
Moreover, younger children rated both self- and mother-
initi~ited affect regulation strategies as more effective
than did older children.
These exemplars illustrate emerging difficulties
from infancy in regulatory processes among infants and
children of depressed mothers that may contribute to an
evolving depressotypic organization as development
proceeds.
Affect differentiation and modulation of atten-
tion and arousal. With the foundations of internal
homeostatic regulation established, the infant becomes
more attentive and responsive to the physical environ-
ment, and abilities rapidly develop in diverse areas of
functioning. Affective expression becomes an increas-
ingly prominent means through which the infant interacts
and engages in exchanges with the caregiver, and infants
begin to regulate and adapt their affective expressions
and behaviors to those of their caregivers. Concomitantly,
neurological maturation and cognitive growth contribute
to this affect differentiation in the infant's internal experi-
ence of emotion and its external expression.
Because the infant continues to rely heavily on the
caregiver for the provision of support, the quality of care
and interactions with the caregiver contribute to experi-
ence-dependent individual differences in patterns of af-
fect differentiation, expression, and regulation that
emerge (Greenough et al., 1987; Schore, 1996). The his-
tory of interactions and exchanges with the caregiver
influences the infant's emerging interpretation and reac-
tions to external events (Bowlby, 1973). As previously
noted, caregivers continue to influence the infant's modu-
lation and management of arousal and physiological ten-
sion. However, increasingly, the infant now also evaluates
the environment on the basis of past experiences, and
tension is cognitively generated by those evaluations
(e.g., as threatening, overstimulating; Sroufe & Waters,
1976). Caregiver sensitivity and affective attunement to
February 1998 • American Psychologist
the infant's arousal states help the infant to manage in-
creasing amounts of tension and arousal (Sroufe, 1979).
Further, caregivers actively socialize affective expression
in their infants. This occurs through infant imitation of
prevailing caregiver affects, caregiver imitation of infant
affect, and selective attention and differential encourage-
ment or discouragement of the expression of different
affects by the caregiver (Hesse & Cicchetti, 1982; Ma-
latesta & Izard, 1984).
Field and her colleagues have conducted a number
of studies in this regard. Infants of depressed mothers
were found to display more frequent expressions of sad-
ness and anger and fewer expressions of interest than
were infants of well mothers (Pickens & Field, 1993).
Moreover, in face-to-face interaction, depressed mothers
and their infants displayed less positive affect. The de-
pressive style of the infants also was accompanied by
more gaze and head aversion by the infants with the
mothers, suggesting the infants used self-regulatory be-
haviors to reduce negative affect associated with maternal
unresponsiveness. Field et al. (1988) also demonstrated
that when the infants of depressed mothers interacted
with nondepressed strangers, the infants tended to elicit
depression-like behavior in the strangers, suggesting that
the nonreinforcing interactive styles of the infants could
perpetuate blunted affect in the caregiver even when de-
pression had remitted.
Additionally, the emotional socialization that is con-
veyed by depressed caregivers also may be especially
important to consider for child development. In describ-
ing the emotions depicted by photographs of infants, de-
pressed mothers tended to view infants as more fearful
and less joyous than did well mothers (Zahn-Waxler &
Wagner, 1993). Depressed mothers also were either more
or less likely to identify sorrow in infants, a finding that
suggests that depressed mothers may either deny the exis-
tence of sadness in their own infants or overattribute its
presence. In a related vein, depressed mothers who had
not received therapy also have been found to be more
inaccurate in interpreting emotional expressions than
were depressed mothers who had received psychotherapy.
In particular, depressed mothers not in treatment had dif-
ficulty recognizing negative emotions such as anger and
sadness (Free, Alechina, & Zahn-Waxler, 1996).
Thus, infants growing up with depressed mothers
are likely to experience aberrant affective interchanges
that contribute to divergences in their early affect devel-
opment. These early affect differences provide further
impetus for an evolving depressotypic organization.
The development of a secure attachment rela-
tionship. The development of an attachment relation-
ship with the primary caregiver during the latter half of
the first year is a fundamental achievement that organizes
evolving affect, cognition, and behavior in relation to
the quality of physical and emotional availability of the
caregiver. On the basis of evolutionary needs to maintain
safety from environmental threats, the caregiver provides
a secure base that helps the infant to modulate arousal
229
and maintain internal security (Bowlby, 1969/1982).
Variation in the quality of caregiving, particularly in
terms of sensitivity and responsivity, contributes to indi-
vidual differences in the manner in which the infant nego-
tiates the attachment relationship with the primary care-
giver. Although infants may experience different types
of relationships with various caregivers, the attachment
relationship with the primary caregiver, typically the
mother, is very important in influencing the way in which
affect, cognition, and behavior are organized. Ainsworth
and colleagues (Ainsworth, Blehar, Waters, & Wall,
1978), using a laboratory procedure involving a sequence
of separations and reunions between the infant and the
caregiver, identified three major types of attachment orga-
nization that can differentiate between securely and inse-
curely attached infants. The traditional classifications in-
clude Type B, securely attached, and two types of inse-
curely attached infants, Type A, insecure-avoidant, and
Type C, insecure-ambivalent. Further investigation, par-
ticularly involving high-risk samples, led to the identifi-
cation of additional atypical insecure attachment patterns
involving a blending of both avoidant and resistant be-
haviors (Type A/C; Crittenden, 1988) or a disorganized-
disoriented pattern (Type D; Main & Solomon, 1990),
including a variety of undirected behavioral responses
and unusual behaviors such as freezing, stilling, hand
flapping, and other stereotypies exhibited in the presence
of the caregiver. The traditional and atypical attachment
classifications represent individual differences in the
strategies that infants use to regulate emotions and behav-
ior and are related to the history of distress remediation
and emotional synchrony experienced with the caregiver.
The differences in attachment types are important
for understanding early forms of divergent organization
of socioemotional, cognitive, representational, and bio-
logical systems that may relate to an emerging depresso-
typic organization. As development proceeds beyond in-
fancy, the experience of the attachment relationship in-
creasingly becomes internally represented. As such,
representational models serve to channel the manner in
which interpersonal relations are perceived and negoti-
ated as well as the accompanying affects and cognitions
that are exhibited.
Children of depressed caregivers are at risk of expe-
riencing deviations in care as a consequence of their care-
givers' struggles with depression. Additionally, these
children may experience a sense of loss akin to the actual
loss of a parent (Bowlby, 1980) during periods of care-
giver depression. Resultant insecure representational
models may make it more difficult for these children to
cope with the experience of psychological unavailability
of the caregiver during depressive episodes. Prolonged
anxiety, sustained grieving, and difficulty in resolving the
loss may further contribute to problems in the organiza-
tion of cognitive, affective, representational, and biologi-
cal systems. Subsequent loss experiences, either real or
symbolic, may precipitate depressive episodes (Beck,
1967).
230
The quality of attachment in infants and children of
parents with mood disorders has been examined in a
number of studies (DeMulder & Radke-Yarrow, 1991;
Radke-Yarrow, Cummings, Kuczynski, & Chapman,
1985; Teti, Gelfand, Messinger, & Isabella, 1995). Over-
all, investigations have found that offspring of depressed
caregivers are significantly more likely to develop inse-
cure attachments with their caregivers. Importantly, those
studies that have not found increased rates of insecurity
in offspring of mood-disordered mothers have empha-
sized the role of severity and chronicity of maternal de-
pression in affecting child outcome (Cohn & Campbell,
1992), with offspring of mothers who had more transient
depressive episodes appearing to be more comparable
to offspring with well mothers. Issues associated with
sampling also have been raised as accounting for variabil-
ity of results, with differences being associated with
hospitalized versus community samples of depressed
mothers.
Studies that followed offspring into later childhood
found that children who continued to evidence insecure
attachments with their caregivers were more likely to
exhibit behavior problems (Easterbrooks, Davidsbn, &
Chazan, 1993). Insecure attachments among children of
depressed mothers also have been found to contribute
to interpersonal difficulties as these offspring negotiate
relationships with peers. Rubin and colleagues (Rubin,
Booth, Zahn-Waxler, Cummings, & Wilkinson, 1991)
found that insecurely attached offspring of depressed
mothers exhibited withdrawal, passivity, and inhibited
behavior when observed with a familiar peer in free play
at age five.
During adolescence, clinically depressed teenagers,
as compared with normal or nondepressed psychiatric
controls, have been found to express less secure attach-
ments to their parents (Armsden, McCauley, Greenberg,
Burke, & Mitchell, 1990). Similarly, Kandel and Davies
(1986) found that depression in adolescence was related
to problems in the emotional relationship with parents,
difficulties in forming an opposite-sex relationship, and
spousal difficulties in young adulthood. In late adoles-
cence, an insecure attachment organization has been
linked to higher levels of depressive symptomatology
(Kobak, Sudler, & Gamble, 1991) and to more interper-
sonal difficulties during the transition to college (Ko-
bak & Sceery, 1988). Among mildly depressed college
women and those recovering from major depression, Car-
nelley, Pietromonaca, and Jaffe (1994) found insecure
relationships with parents were frequent and romantic
relationships were often characterized by preoccupation,
fearful avoidance, or both. The attachment organization
of these women more strongly predicted relationship
functioning than did their depression status alone.
In summary, there is growing evidence of insecure
attachment organizations among offspring of parents with
mood disorders as well as among youth with depressive
disorders. The quality of early attachment relationships
contributes to internal representational models of self and
February 1998 • American Psychologist
other that organize cognition, affect, and behavior, and
these models serve to canalize perceptions and experi-
ence as development proceeds. In the case of individuals
with insecure attachment organizations, their internal
representational models are likely to contribute to a de-
pressotypic organization of psychological and biological
systems. Affective regulation and expression are less op-
timal, and significant others are perceived as unavailable
or rejecting while the self is regarded as unlovable. These
attachment-related aspects of a depressotypic organiza-
tion may contribute to a proneness to self-processes that
have been linked to depression (e.g., low self-esteem,
helplessness, hopelessness, negative attributional biases).
The self-system: Self-awareness and self-other
difiFarenlialion. Toddlerhood may be a particularly
sensitive period for the formation of a depressotypic orga-
nization because many of the social, emotional, and cog-
nitive competencies implicated in the development of
later depressive disorder are at crucial stages of develop-
ment during toddlerhood (e.g., the development of auton-
omy, the emergence of the affect of shame, and the con-
struction of an internal representational model of the
availability of the self and of the self in relation to others).
Building on the quality of the attachment relationship
that has evolved, toddlers begin to develop a sense of
themselves as separate and independent entities in the
second half of the second year (Lewis & Brooks-Gunn,
1979). Growing capacities for language and play during
the second and third years of life constitute a means
through which children symbolically represent the self
and relationships. Increasingly, children are able to use
symbolic means to communicate needs and feelings and
evidence increased abilities to label emotion states, inten-
tions, and cognitions of self and others (Kagan, 1981).
These representational attainments also correspond to in-
creased capacities for self-regulation.
Emotional and cognitive components are integrated
into internal representational models in which the self
becomes represented as does the self's relation to the
attachment figure (Bretherton, 1987; Sroufe, 1990). Al-
though the growing toddler increasingly acquires capaci-
ties for self-regulation, parental involvement remains vi-
tal, and parental availability and responsivity influence
how the self is represented. Caregiver accessibility and
responsivity correspond to self-representations as accept-
able and valued, whereas parental unavailability or rejec-
tion relate to self-representations as unlovable and
unworthy.
Evidence has been obtained that demonstrates diffi-
culties in self-development and corresponding affective
functioning in toddlers of mothers with mood disorders.
The self-critical styles of depressed caregivers appear
to be transmitted to their offspring. One such mode of
transmission relates to the speech used by depressed
parents. Murray and colleagues (Murray, Kempton,
Woolgar, & Hooper, 1993) found that the speech used by
depressed women to their infants expressed more nega-
tive affect, was less focused on infant experience, and
February 1998 • American Psychologist
evidenced less acknowledgement of infant agency. Even
in adolescence, increased irritability has been observed
in the verbal interchanges between affectively ill mothers
and their adolescents (Tarullo, DeMulder, Martinez, &
Radke-Yarrow, 1994).
In addition, maternal attribution patterns may affect
the types of self-attributions that children make. For ex-
ample, Radke-Yarrow and colleagues (Radke-Yarrow,
Belmont, Nottelmann, & Bottomly, 1990) found that
mood-disordered mothers conveyed significantly more
negative affect in their attributions, particularly in regard
to negative attributions about child emotions. Moreover,
among the mood-disordered mothers and their toddlers,
there was a higher correspondence in the affective tone
of attributions and statements about the self (e.g., mother
says, "I hate myself," child says, " I ' m bad"). This sug-
gests a heightened vulnerability among these children for
negative self-attributions, with negative implications for
risk for later depressive tendencies.
Further evidence for self-system dysfunction in
offspring of depressed caregivers was found by Cic-
chetti and colleagues (Cicchetti, Rogosch, Toth, &
Spagnola, in press), who examined visual self-recogni-
tion in toddlers of depressed and nondepressed mothers,
by using the mirror-and-rouge paradigm (cf. Lewis &
Brooks-Gunn, 1979). In this paradigm, after toddlers
look at themselves in a mirror, an experimenter surrepti-
tiously places a dot of rouge on the toddler' s nose while
the toddler is looking away from the mirror, and the
toddler reexamines his or her rouge-altered mirror im-
age. Although self-recognition was attained similarly
in both groups, children of depressed mothers who ex-
hibited self-recognition were more likely than children
of nondepressed mothers to display nonpositive affect
and to shift affect from positive to nonpositive after
the rouge application. In addition, within the group of
children of depressed mothers, Cicchetti et al. (in press)
found that toddlers who did not evidence self-recogni-
tion and who shifted affect were lower in attachment
security and had mothers with fewer positive affect
characteristics.
As development proceeds, early representational
features of the self are further elaborated, and these as-
pects of self-representation possess implications for un-
derstanding a depressotypic organization. Self-under-
standing constitutes cognitive representations of the self
with roots in the internal representational models of the
self derived from attachment relationships. In contrast,
self-esteem represents an affective component of the self
that is positively or negatively valenced. Self-cognitions
are particular usages of the cognitive structure in refer-
ence to the self. They have both content, in terms of what
aspects of the self are the focus, and style, involving the
manner in which thoughts about the self are derived. Self-
cognitions and self-esteem mutually influence each other,
and when self-cognitions and associated affects are re-
peated over time, they contribute to representations of
the self known as self-schemata that tend to be enduring.
231
Important developmental shifts have been noted with re-
spect to the complexity of self-cognitions, with a signifi-
cant transition occurring in the seven- to eight-year-old
range (Harter, 1983). Younger children view themselves
in concrete, physical terms such as their appearance, pos-
sessions, and preferred activities, whereas older children
begin to view themselves in more abstract psychological
terms that include personal characteristics that are endur-
ing over time. These advancing abilities may have nega-
tive consequences for children who are at risk for an
affective disorder (Damon & Hart, 1982).
Nolen-Hoeksema, Girgus, and Seligman (1992) in-
vestigated children with depressed symptoms and their
negative life events, explanatory style, and helplessness
beginning in third grade and followed these children for
five years. In early childhood, only negative events were
related to depressive symptoms. However, later in child-
hood and notably after the cognitive shift previously de-
scribed had occurred, a pessimistic explanatory style (cf.
Peterson & Seligman, 1984) contributed to depressive
symptoms, alone or in combination with negative events.
In both interpersonal and achievement contexts, the de-
pressed children exhibited helplessness. Moreover, their
negative explanatory style worsened during depressive
episodes, and their pessimism persisted subsequently.
Depressed children may maintain excessively high
expectations for themselves, contributing to attributions
of failure when those expectations are not met. Lauer and
colleagues (1994) investigated memory and metamemory
abilities among nine- to twelve-year-old depressed chil-
dren. Only severely depressed children exhibited memory
impairments, but all depressed children were found to
have performance difficulties on metamemory tasks, in-
volving an overestimation of their abilities. Depressed
children appeared to be either overcompensating for feel-
ings of inferiority or setting unrealistic standards for
themselves, which would tend to confirm their negative
self-cognitions and sense of failure.
Research on the cognitive components of depression
in children has generally been consistent with findings
from the adult literature (for a review, see Garber, Quig-
gle, & Shanley, 1990). Depressed children have been
found to process negative self-referent words selectively,
to make more internal, stable, and global attributions for
failure and more external, unstable, and specific attribu-
tions for success, to perceive outcomes as being beyond
their control, and to view their futures as hopeless. More-
over, these cognitive processes have been found more
commonly in depressed children than in children with
other psychopathological conditions, suggesting that
there may be some specificity to the cognitive processing
associated with depression (Garber, Quiggle, Panak, &
Dodge, 1991). In fact, in a prospective analysis of the
relation between negative self-cognitions and depression,
Hammen (1988) found that children who had more nega-
tive self-concepts became more depressed than children
who had more positive self-views, even when initial de-
pression was controlled for.
232
A number of major psychological theories of adult
depression have focused on the cognitive processing of
depressed persons (Beck, 1967; Rehm, 1977). To inte-
grate aspects of social information processing and vari-
ous knowledge structures into a developmental frame-
work that is useful for understanding child and adolescent
depression, Dodge (1993) hypothesized that early experi-
ence and biologically based aspects of memory and neu-
ral functioning interact to form schemata for past experi-
ences, future expectations, and affectively charged vul-
nerabilities. Dodge believes that early life experiences
involving interpersonal loss and instability or excessive
pressure to achieve at an unrealistic level may lead chil-
dren to develop negative self-schemata and low self-
esteem.
Disturbances in the self-system also can contribute
to suicide in depressed individuals. In examining the
cause of adolescent suicide, Chandler (1994) proposed
that the identity formation demands accompanying the
transition to adolescence can adversely affect the sense
of identity needed to maintain an investment in the fu-
ture. Consequently, Chandler (1994) believed that this
loss of identity may contribute to suicide. To test this
hypothesis, Chandler grouped hospitalized adolescents
as being at either low or high risk for suicide. In accord
with his assumptions, Chandler (1994) found that over
80% of the high-risk adolescents were unable to identify
any means of justifying their own or others' self-conti-
nuity in the context of change as opposed to 8% and
0% of low-risk adolescents and nonpatient controls,
respectively.
Developmental Biological Systems in Depression
The development of a mood disorder, as well as the age
of its onset, is influenced not only by the emergence of
salient issues or tasks that must be confronted but also by
timed biological events that create challenges and provide
new opportunities as they figure prominently in every
developmental phase. A number of investigations have
shown that there is a greater prevalence of mood disorders
in the relatives of depressed persons than in the general
population (Weissman, Warner, Wickramaratne, Mo-
reau, & Olfson, 1997) and a higher probability of disorder
among relatives who are more closely related (McGuf-
fin & Katz, 1989; Tsuang & Faraone, 1990). Moreover,
twin studies reveal greater concordance of depressive dis-
order in monozygotic rather than dizygotic twins
(McGuffin & Katz, 1989). Adoption studies also have
been used to disaggregate shared genetic and environ-
mental influences. These studies have shown increased
rates of depression in biological relatives as compared
with adoptees (Cadoret, 1978; McGuffin, Katz, Wat-
kins, & Rutherford, 1996). Regardless, developmental
geneticists maintain that genetic contributions to psycho-
pathological disorders must be conceptualized within a
dynamic framework that considers the operation of ge-
netic factors in concert with environmental factors across
the life span (Goldsmith, Gottesman, & Lemery, 1997;
February 1998 • American Psychologist
Rutter, 1991). Genes are unlikely to operate in a static
fashion throughout development. Rather, their influence
may vary across the life course. Although some genes'
effects may be enduring, others may be transient. At vary-
ing developmental periods, genes may be turned on or
off, and diverse factors that regulate gene activation and
deactivation are likely to vary developmentally. Although
genes may influence the development of early structures
(e.g., receptors for neurotransmitters) that influence nor-
mal and pathological dispositions, later gene activation
and deactivation (as well as experience) also may modify
those structures at subsequent periods in ontogenesis
(Cicchetti & Tucker, 1994). Accordingly, the changing
relative influence of genetics and environment at different
stages of the life course within varying individuals must
be incorporated into developmental models of depressive
disorders and evolving depressotypic developmental
organizations.
A number of investigations have examined various
biological structures and processes among depressed
children and adolescents and nondepressed controls (see
Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et
al., 1996; Dahl & Ryan, 1996). Steingard et al. (1996),
using magnetic resonance imaging (MRI), found de-
creased brain frontal-lobe volume and increased lateral
ventricular volume in a sample of hospitalized children
with depressive disorder compared with a group of psy-
chiatrically hospitalized nondepressed controls. These
findings are congruent with similar results using MRI
techniques in adults with MDD.
Variations from normal patterns of growth hormone
(GH), prolactin secretion, and serotonergic functioning
also have been observed in response to various psycho-
pharmacological challenges among children and adoles-
cents with depressive disorders (Birmaher et al., 1997;
Dahl & Ryan, 1996). The change in GH secretion and
serotonergic regulation may be one component of a de-
pressotypic organization that portends an earlier onset of
depression (cf. Dahl & Ryan, 1996). Although difficulties
have been observed in hypothalamic-pituitary-adrenal
(HPA) axis regulation in adults with depressive disorder
(Gold, Goodwin, & Chrousos, 1988a, 1988b), inconsis-
tent results have been found in studies of depressed chil-
dren and adolescents (Birmaher, Ryan, Williamson,
Brent, Kaufman, Dalai et al., 1996). Despite these equivo-
cal findings, subsets of depressed children and adoles-
cents have been identified in which early alterations in
HPA functioning may predict a recurrent course of unipo-
lar depressive disorder in adulthood (Rao et al., in press).
Lateralization of neurotransmitter systems and
hemispheric asymmetries may influence arousability to
stimulation and individual differences in emotion pro-
cessing. Through the interaction of noradrenergic and
serotonergic systems, the right hemisphere is sensitive to
change, alerts the brain to novelty in the environment,
and thus is associated with general arousal and brain
activation. In contrast, through domination by dopamin-
ergic and cholinergic systems, the left hemisphere is bi-
February 1998 • American Psychologist
ased toward redundancy, being relatively influenced by
novelty to maintain behavior in the face of change
(Tucker & Williamson, 1984). Electroencephalogram
(EEG) studies suggest that negative emotional states cor-
respond to relatively less left-frontal or greater right-
frontal activation or both, whereas positive emotional
states correspond to the opposite pattern of activation.
A number of investigations have discovered hemi-
spheric activation asymmetries in infants of depressed
mothers. Jones and colleagues (Jones, Field, Fox,
Lundy, & Devalos, 1997) found that one-month-old in-
fants of depressed mothers exhibited greater relative
right-frontal EEG asymmetry (due to reduced left-frontal
activation) than did one-month-old infants of nonde-
pressed mothers. Moreover, the presence of right-frontal
hemispheric asymmetry was significantly related to
three-month EEG asymmetry. In addition, Field, Fox,
Pickens, and Nawrocki (1995) discovered that depressed
mothers and their three- to six-month-old infants both
displayed right-frontal EEG asymmetry. Furthermore,
Dawson and her colleagues (Dawson, Grofer Klinger,
Panagiotides, Hill, & Spieker, 1992; Dawson, Grofer
Klinger, Panagiotides, Spieker, & Frey, 1992) examined
the EEGs of 14-month-olds of mothers with elevated
depressive symptomatology and of nonsymptomatic
mothers during various emotion-eliciting situations. Evi-
dence was found that infants of the symptomatic mothers
displayed reduced left-frontal brain activation during
baseline and playful interactions. Moreover, securely
attached infants of symptomatic mothers evidenced this
left-frontal hypoactivation compared with securely
attached infants of nonsymptomatic mothers. Further,
during distress-eliciting maternal separation, the infants
of the symptomatic mothers did not display a greater
right-frontal activation or the same degrees of distress
that was seen in the infants of the nonsymptomatic moth-
ers, and these differences were observed regardless of
the attachment status of the high-risk infants. Dawson
and her colleagues interpreted these findings to suggest
that both maternal depressive symptoms and attachment
security are reflected in infant frontal lobe functioning
and emotional behavior. In tandem, the results of the
Jones et al. (1997), Field et al. (1995), and Dawson,
Grofer Klinger, Panagiotides, Spieker, and Frey (1992)
investigations support the view that a genetic diathesis
for depression and the quality of caregiving experienced
both have an impact on neurobiological development.
Convergence between biological and psychological sys-
tems is suggested, providing a window on the complexity
of developmental organization that may heighten risk for
depression.
The microsystem. Because research has found
that depression tends to run in families, it is not surprising
that a considerable amount of work has been directed
toward the family context in which depression occurs.
Although genetic factors account for some within-family
depression, it is clear that genetics alone cannot explain
fully the development of depression. Support for influ-
233
ences beyond genetics have been obtained in studies of
twins, where the heritability of severe and moderate de-
pression has been found to be only modest (Kendler,
Neale, Kessler, Heath, & Eaves, 1992). Moreover, Rende,
Plomin, Reiss, and Hetherington (1993), in an investiga-
tion of the relative contribution of genetic and environ-
mental factors to depressive symptomatology in an unse-
lected sample of adolescents participating in a combined
twin and stepfamily study, found moderate genetic influ-
ence for the full range of individual differences in de-
pressed symptoms. In addition, Rende et al. (1993) dis-
covered that there was nonsignificant genetic influence
and significant shared environmental influence on ex-
treme depression symptomatology. In view of findings
such as these, environmental contributions to depression
must not be minimized.
Because children are often very helpless to alter
the environments with which they are faced, contextual
influences may be even more significant in early-onset
depressions. The fact that many depressed children evi-
dence prompt recovery when hospitalized, even in the
absence of additional interventions, lends further cre-
dence to family influences on depression (Kashani et al.,
1987; Puig-Antich et al., 1987). Rather than seeking to
ascertain whether genetic or environmental influences
contribute to depressive illness, we must strive to under-
stand how genetic and other biological vulnerabilities
transact with contextual influences to eventuate in an
evolving depressotypic organization and in depressive
disorders during childhood and adolescence.
Investigations of family variables associated with
child and adolescent depression have focused on two
primary areas: families of depressed children and chil-
dren of depressed parents. A number of family character-
istics have been associated with the development and
maintenance of depression, including parental psychopa-
thology, family structure, and negative life events (Kas-
low, Deering, & Racusin, 1994). Specifically, a high inci-
dence of psychopathology has been found in parents and
extended family members of depressed children, with
mothers and fathers of depressed children exhibiting in-
creased levels of depression, anxiety, substance abuse,
and antisocial behavior (Kutcher & Marton, 1991; Puig-
Antich et al., 1989; Todd et al., 1993). The fact that
depressed persons tend to marry partners who also expe-
rience psychological difficulties (i.e., assortative mating)
most likely increases the incidence of psychopathology
in both parents of a depressed child or adolescent (Meri-
kangas, Prusoff, & Weissman, 1988). In examining fam-
ily structure, girls from single-parent families and chil-
dren of divorced parents have been found to exhibit in-
creased levels of depression and anxiety as well as slower
rates of recovery when they do experience a depressive
episode (Feldman, Rubenstein, & Rubin, 1988; Hoyt, Co-
wen, Pedro-Carroll, & Alpert-Gillis, 1990; Wallerstein &
Corbin, 1991). Moreover, low socioeconomic status also
has been linked with an increased risk for depression
(Garrison, Schlucter, Schoenbach, & Kaplan, 1989;
234
Gibbs, 1985). Acute and chronic life events, most typi-
cally involving significant losses through parental death,
divorce, or separation, or involving child maltreatment,
also have been associated with the occurrence of depres-
sion during childhood and adolescence (Burbach & Bor-
duin, 1986; Hoyt et al., 1990; Toth, Manly, & Cicchetti,
1992).
To gain knowledge of microcontextual influences
on depression, many investigators have studied children
reared in families with a depressed caregiver. In addition
to possible genetic influences, the overarching rationale
of such studies is based on the premise that depression
in a caregiver results in permutations in the caregiver
environment that may place a child at risk for maladapta-
tion, including depressive illness. Overall, studies have
found that children of depressed parents evidence in-
creased rates of general problems in adjustment, putative
markers of risk for depression, and clinical depression
(Downey & Coyne, 1990). However, these linkages can-
not be taken as confirmatory evidence that parental de-
pression necessarily leads to these problems or even that
it is the primary influence. Rather, the interpersonal con-
text within which a depressed caregiver resides and its
affect on children must be considered. Specifically, mari-
tal discord and family stress are much more common in
families with a depressed caregiver (Downey & Coyne,
1990). Additionally, social impairments other than diag-
nosis also are more common in depressed persons and
their spouses. Thus, co-occurring risk factors other than
depressive illness may account for the difficulties experi-
enced by children with depressed caregivers.
Although much work remains regarding the specifi-
cation of family variables that are related to a depresso-
typic organization and depressive disorder in childhood
and adolescence, it is clear that the family environment
can exert significant influences on the development and
maintenance of early-onset depression. In accord with an
ecological transactional model, the role of such factors
must be conceptualized along with other psychological,
social, and biological mechanisms that are operating at
other levels of the ecology.
The exosystem. Relative to research on onto-
genic development and microsystem influences on an
evolving depressotypic organization and on depressive
disorders, there has been a paucity of research addressing
the role of the exosystem in the etiology of depression.
However, evidence has accumulated to suggest that, in
addition to the family influences just described, schools
and neighborhoods contribute to patterns of academic
and psychological adjustment, especially during the tran-
sition from elementary to middle schools (National Re-
search Council, 1993). Therefore, the school environment
is likely to be implicated in the development of depres-
sion. This view is corroborated, at least partially, by the
fact that certain forms of psychological distress, includ-
ing depressive symptoms, increase during the middle-
school years. Perceptions of being academically compe-
tent and receiving good grades have been linked with a
February 1998 • American Psychologist
reduced risk for emotional and behavioral difficulties,
whereas low perceived academic competence is related to
depressive symptoms in children (Blechman, McEnroe,
Carella, & Audette, 1986; Cole, 1991). Moreover, adoles-
cents who do not feel a connection with school may be
more likely to engage in antisocial activities and sub-
stance abuse in efforts to boost their self-esteem and
sense of belonging (Rosenberg, Schooler, & Schoenbach,
1989). In general, it has become increasingly clear that
problems of academic alienation, poor school perfor-
mance, and minor delinquency that become more promi-
nent in early adolescence are linked to negative mental
health problems such as depression that are manifested
later in adolescence (Eccles, Lord, & Roeser, 1996). Such
negative outcomes have been related to diminished sup-
port for the development of competence, for feelings of
belongingness, and for autonomy promotion characteris-
tic of elementary school, but not of middle-school, envi-
ronments (Higgins & Parsons, 1983). Evidence such as
this suggests that the failure of the school environment
to facilitate development as children progress into middle
schools may contribute to motivational and mental health
problems. Inappropriate school environments during
early adolescence can place many young people at risk
for the negative trajectories that some lives take, includ-
ing alienation from prosocial activities and peers, depres-
sion, and involvement in antisocial pursuits. Importantly,
positive adjustment to school, including academic en-
gagement and achievement, is likely to serve as a protec-
tive factor against negative mental health outcomes (Ec-
cles et al., 1996).
The exosystem is the ecological level most directly
linked to community supports that can be mobilized when
a child or adolescent is depressed. Thus, in a supportive
exosystem, high-quality treatment services would be
readily available and their accessibility could serve to
reduce the likelihood and chronicity of depressive illness
in children and adolescents. To examine the potential
efficacy of services, we address the extant literature on
treatment for early-onset depression.
Unlike the management of adult depression, for
which professional guidelines have been issued based
on controlled treatment trials (APA, 1993; Depres-
sion Guideline Panel, 1993; Persons, Thase, & Crits-
Christoph, 1996), compelling empirical work that can
guide the recommended management of early-onset de-
pression has not yet taken place (Kovacs, 1997). Interven-
tions for depression during childhood and adolescence
include two general classes: pharmacological and
psychological.
Although virtually all medications found to be effec-
tive in the treatment of adult depression have been tested
with children, systematic studies with clear results are
rare. The drugs most commonly used for treating depres-
sion in children and adolescents are the tricyclic antide-
pressants, including imipramine, amitriptyline, and nor-
triptyline (Stark et al., 1996). In general, the superiority
of antidepressant medication as opposed to placebo has
February 1998 • American Psychologist
not been proven as an effective treatment for children
and adolescents (Kovacs, 1997; Stark et al., 1996). How-
ever, these negative results must be tempered because
most studies have used very small samples, and this, as
well as other methodological problems, may have
clouded the findings (Birmaher, Ryan, Williamson,
Brent, & Kaufman, 1996). For example, small sample
sizes preclude controlling for the heterogeneity of de-
pressive illness and therefore subgroups of depressed
children and adolescents who may be more or less re-
sponsive to specific medications cannot be identified
(Kye & Ryan, 1995). Moreover, unlike studies on adults,
methodologically sound investigations on the relative ef-
fectiveness of antidepressants, psychotherapy, and a com-
bination of these two types of therapy have not been
conducted.
With respect to psychotherapy research with de-
pressed youth, results have been more positive than re-
search on pharmacological treatments. In general, thera-
pies for the treatment of depression in children and ado-
lescents have been found to be more effective than
treatment wait-list or various comparison conditions (cf.
Kovacs & Bastiaens, 1995; Weisz, Rudolph, Granger, &
Sweeney, 1992). However, these positive results must be
tempered because studies typically have included only
nonreferred children with mild to moderate levels of de-
pressive symptoms and not psychiatrically diagnosed pa-
tients. Moreover, almost all research has focused on mid-
dle- or upper-class nonminority youth (Lewinsohn,
Clarke, & Rohde, 1994). Because more severe depression
as well as depression accompanied by stressors associ-
ated with poverty and minority status most likely exacer-
bate difficulties encountered in the treatment of depres-
sion, much more research on treatment with diverse popu-
lations is needed. Additionally, evaluation studies have
generally been conducted with behavioral or cognitive-
behavioral approaches, and it is therefore unclear whether
other therapies that are used with depressed children and
adolescents are equally effective. Finally, much more
work on the prevention of a depressotypic organization
and of early-onset depression through psychological and
pharmacological treatments is needed.
l'he macro$¥$~am, At first glance, it may seem
that cultural values and beliefs are unlikely to be related
to an evolving depressotypic organization and to de-
pressive disorders. However, there are aspects of the mac-
rosystem that have been shown to exert influences on
the emergence of depression. Moreover, because societal
attitudes can affect the availability of resources and sup-
ports as well as the likelihood that treatment will be
sought by families with a depressed child, the macrosys-
tem can exert a significant impact on whether depression
develops as well as on how it is addressed when it is
present.
Relatively little research has been conducted on
macrosystem influences and depression during childhood
or adolescence. However, research on risk for suicide
sheds some light on the role of culture and adaptation.
235
A number of findings on ethnicity also point to the role
of culture and, specifically, to cultural changes as a risk
for suicide. In Micronesia, suicide varies greatly by geo-
graphic location, with suicide rates being the highest in
islands that have undergone a rapid transition from a
traditional culture to a Western orientation (Brent & Mo-
ritz, 1996). Similar factors appear to be operative in Na-
tive American populations, in which increased suicide is
found on reservations where traditional cultural practices
have eroded. Specifically, Levy and Kunitz (1987) found
that Hopis at increased risk for suicide included the chil-
dren of parents who had entered into traditionally disap-
proved marriages, such as marriage across tribes, mesas,
or clans of disparate social status. The resultant labelling
of parents as deviant was considered to contribute to
the stigmatization experienced by the children, thereby
contributing to the initiation of a series of stressors. Fi-
nally, although current statistics reveal that Whites have
higher rates of suicide than African Americans, this dif-
ference may diminish as a function of rapid increases in
rates of suicide among African American men in recent
decades (Centers for Disease Control and Prevention,
1990). Within African American populations, geographic
influences on suicide have been found. Suicide rates are
highest in the urbanized and industrial Northeast and
Midwest and lowest in the rural South, again suggesting
that the absence of more traditional, culturally sanctioned
supports may be operative (Shaffer & Fisher, 1981).
Summary, Intervention, and Social Policy
Implications
The developmental psychopathology perspective proffers
important insights useful for efforts to prevent depresso-
typic organization from evolving into depressive disor-
ders as well as for intervention once depression has oc-
curred (Kellam, 1990; Kellam & Rebok, 1992). Under-
standing the organization of psychological and biological
developmental domains among the offspring of depressed
parents and among depressed children and adolescents is
invaluable for conceptualizing the meaning of symptom
expression and the capacities of different depressed per-
sons to benefit from different types of treatment (Shirk &
Russell, 1996).
Given that the roots of depressotypic developmental
organizations may originate in infancy, prevention efforts
that focus on early intervention in high-risk conditions
are likely to be important for promoting competent early
developmental attainments on the sequence of stage-sa-
lient developmental issues (Cicchetti & Toth, 1992). Al-
though parental depression as a risk condition has been
a focus in this article, numerous disadvantageous family
and societal circumstances (e.g., parental psychopathol-
ogy, parental substance abuse, marital violence, child
maltreatment, persistent poverty) constitute situations
that may detract from children's ability to competently
resolve developmental challenges, thereby contributing
to risk for a depressotypic organization and depressive
outcomes. Broad-based community programs, such as
236
Head Start (Zigler & Valentine, 1979) or the Perry Pre-
school Project (Schweinhart, Barnes, Weikart, Barnett, &
Epstein, 1993), that promote child competence and sup-
port adaptive family relationships are likely to be im-
portant in preventing developmental failures associated
w i t h depressotypic organizations, thereby reducing the
prevalence of depressive disorders on a population level.
Additionally, the preventive program of Beardslee and
colleagues (Beardslee et al., 1997), in which efforts to
educate families about the effects of parental depression
have been found to result in improved illness-related
communication between parents and children and in im-
proved child understanding of parental illness, appears
to be very promising.
Because of the potential for increased genetic as
well as psychological risk with which the offspring of
depressed parents are faced, preventive interventions for
such families may be particularly important. Such pre-
vention strategies, beginning when children are very
young, should incorporate multiple foci and strategies,
including attending to the alleviation of the parental de-
pression, enhancing parent-child adaptive communica-
tion and interaction, and reducing larger family stresses,
such as marital discord. In so doing, the likelihood of
promoting competence as these children confront the uni-
versal challenges of development will be enhanced, and
depressive outcomes may be prevented (see, e.g.,
Beardslee et al., 1997). The need for and provision of
preventive services for offspring of depressed parents will
likely require changes in social and health-care policy.
All too often services are designated restrictively for the
individual with the disorder, while the larger needs of
family systems, offspring, and the functioning of de-
pressed adults as parents are neglected (Beardslee et al.,
1997).
When providing therapy for early-onset depression,
intervenors must always be mindful of how the varying
capacities of children at different developmental levels
influence their capacity to utilize various therapeutic
strategies (Shirk, 1988; Toth & Cicchetti, in press). More-
over, children continue to develop in an ongoing matrix
of potentiating and compensatory factors that influence
the course of their adaptation (Cicchetti & Aber, 1986;
Cicchetti & Toth, 1998). Interventions to alter parental,
family, and social-contextual sources of risk are neces-
sary to alleviate ongoing contributors to the difficulty
depressed children have in resolving stage-salient issues
of development. Because depressed children and off-
spring of depressed parents are likely to have experienced
maladaptive resolutions of earlier stage-salient issues
(e.g., homeostatic and physiological regulation, affect
differentiation and the modulation of attention and
arousal, the development of a secure attachment organiza-
tion, and self-awareness and self-other differentiation)
prior to the onset of a depressive disorder, attention to
reorganizing these critical domains through therapeutic
interventions is crucial (see Gillham, Reivich, Jaycox, &
Seligman, 1995; Stark et al., 1996). Moreover, helping
February 1998 • American Psychologist
c h i l d r e n to attain adaptive f u n c t i o n i n g i n c u r r e n t stage-
salient issues (e.g., peer relations, school a c h i e v e m e n t )
is likely to b e b e n e f i c i a l i n b e g i n n i n g to r e o r g a n i z e a n d
r e w o r k prior d e v e l o p m e n t a l i n c o m p e t e n c i e s .
D e s p i t e the fact that d e p r e s s i o n is a p r e v e n t a b l e a n d
treatable illness, c o n s i d e r a b l e social s t i g m a c o n t i n u e s to
b e associated with seeking t r e a t m e n t for a depressive
disorder, a n d large n u m b e r s o f i n d i v i d u a l s w h o are clini-
cally d e p r e s s e d r e m a i n untreated. I n c r e a s i n g the a w a r e -
n e s s o f the availability a n d utility o f t r e a t m e n t s for de-
pressive disorders in c h i l d r e n a n d a d o l e s c e n t s a n d r e d u c -
i n g the n e g a t i v e p u b l i c attitudes that interfere with
s e e k i n g t r e a t m e n t require social a n d health policies that
e d u c a t e the p u b l i c r e g a r d i n g depressive disorders, their
effects, a n d the i m p o r t a n c e o f i n t e r v e n t i o n as w e l l as
policies that u n d e r s c o r e the criticality o f i n c r e a s i n g the
use o f treatment. O n l y then will we t r i u m p h over c o m b a t -
ting the significant personal, family, a n d societal toll en-
g e n d e r e d b y depressive illness.
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