Book Review

The Depressed Child and Adolescent: Developmental and clinical perspectives

N Engl J Med 1996; 334:1410-1411May 23, 1996

Article

The Depressed Child and Adolescent: Developmental and clinical perspectives
(Cambridge Monographs in Child and Adolescent Psychiatry.) Edited by Ian M. Goodyer. 354 pp. New York, Cambridge University Press, 1995. $79.95. ISBN: 0-521-43326-6

In their contribution to this excellent monograph, Kovacs and Bastiaens may have sensed the growing impatience as the reader struggles with the mountain of studies presented. They write: “Although, over the past 15 years, considerable advances have been made in clinical and psychometric assessment, specification of diagnostic criteria, and phenomenologic description of depressed youths, no novel or comprehensive theories of early-onset depressions have been proposed.” It seems that the false surety of the previously dominant view, psychoanalysis, has evaporated and that, perhaps in reaction to its excesses, the scientific hard core of psychiatry has tried to exist in a sea of empirical findings without theory — to strap itself, so to speak, to the mast of a rigorous empiricism and resist the siren song of comprehensive theorizing. This book is a good example.

Ian Goodyer has assembled an internationally recognized group of researchers as authors. The stage is set by a historical account of the evolution of concepts of mood disorders in children that demonstrates the episodic and sometimes retrograde progress in this area. Each of the current scientific perspectives on depression in children is then examined, and to each the dissecting scalpel of the controlled study is applied. The entire span of development, from prepuberty to adolescence, is addressed. In the resulting tour de force, we are taken from an exposition of the development of emotional behavior and understanding, through the contributions of temperament, attachment, and personality development, to depressive vulnerability. What is known of the effect of physiologic variables on the development of depression is detailed, as well as physiologic correlates of depression. Phenomenologic, epidemiologic, and family-genetics aspects of the disorder are reviewed, as is the contribution of life events. The clinical perspectives are completed by chapters on suicidality, pharmacologic treatment and psychotherapy, and the findings of longitudinal studies of depressed children and adolescents.

Each chapter contains a depth of information not found in usual textbooks and a subtlety of understanding that only experts of international standing who are reviewing the areas of their own research can provide. A consistent theme is that while standard diagnostic criteria derived from the study of adults has brought us thus far, future advances will depend on our developing ways of detecting and tracking depression as the development of children unfolds and exerts marked influences on their emotional and behavioral repertoire. One example of the complexities involved is Terwogt and Stegge's description of the development of children's ability to display emotions. By the age of 3, they may be able to conceal disappointment spontaneously but will believe the examiner knows how they truly feel. By the age of 6, children will know that facial expressions can be misleading, and by the age of 7 to 11 they will be able to feign emotions for self-protection or out of consideration for others. It is not a surprise, then, when Kolvin states in chapter 5 that parents are often unaware of their children's depression and that for a generation psychoanalysis denied that there was such a thing as childhood depressive disorder.

This book is remarkable for the consensus of its authors on standards for the admissibility of evidence across the many perspectives they review. By and large, they rely only on the results of controlled studies on populations of subjects. Unlike most psychiatric textbooks, this one offers no case studies. Connecting the abstract descriptions of research findings and the clinical picture of a depressed child is an act of synthesis and reconstruction that the clinicians reading this book will need to undertake on their own. When they do so, however, their formulation of the child's problems and treatment will be richer, and they will proceed on a sounder scientific footing for having made the effort. They will bring to their work the newest scientific and developmental information. To the researcher in childhood depression, this book documents, with references, the great strides child and adolescent psychiatry and psychology have made in the past 30 years.

Like any true milestone, this book indicates not only how far we have traveled but how much farther there is to go. It also makes clearer the limitations of the method of inquiry. It is striking how tremendously difficult it is to establish by controlled clinical trials relations that seem obvious to the practitioner. Thus, it is as hard to imagine reaching a true understanding of childhood depression by applying the rating scales and other measures cited to populations as it is to imagine understanding the activity of the brain by applying thermodynamics alone. The problem is that when a population is studied the individual becomes the gaussian noise and is lost. By contrast, with the paradigm used 30 years ago, when the case history was the focus, generalizability and falsifiability were sacrificed. The way out of this predicament has not yet been found. In his preface, Goodyer states the hope that this book will stimulate further scientific research. I believe he and his contributors will accomplish that goal. Perhaps also by having summarized the product of our current technique so skillfully, they will even spur the development of ways to bridge the gap between the population and the individual, between science and existence. Then maybe the call by Kovacs and Bastiaens for a comprehensive theory of childhood depression will be truly heeded.

Joseph Gonzalez-Heydrich, M.D.
Children's Hospital, Boston, MA 02115