Research on Child and Adolescent Mental Health

illness in children and adolescents. Children like
Amy, with comorbid depressive disorder and
chronic physical illness such as asthma, have
higher health care utilization, poor medical
outcome, more functional impairment, decreased
quality of life, and increased mortality (Strunk,
1987). Despite findings that children with certain
disorders (e.g., asthma, cancer, sickle cell anemia)
appear to have increased risk of depressive
symptoms compared with other disorders, physical
illness factors (e.g., type of disorder, severity or
duration of disorder) are generally poor predictors
of depressive symptoms (Bennett, 1994). This is
further complicated by difficulties defining and
measuring depression in this population due to
overlap of symptoms (e.g., insomnia, changes in
appetite and energy). Interestingly, certain
psychosocial interventions (e.g., writing about
stressful experiences, family therapy) have been
shown to improve physical disease status in adults
with asthma (Smyth, Stone, Hurewitz & Kaell,
1999) even in the absence of depression. This effect
is thought to be mediated by the improvement of
the immune response. Such studies could provide
the foundation for examining potential mediators
and moderators of treatment effect when co-morbid
depression is present, as was the case for Amy, and
suggests that psychosocial strategies to help her
cope with her asthma may have had preventive
effects on her depressive symptoms.
C. Psychosocial Factors
Cultural—Another often-neglected area in clinical
practice is the appreciation of the role of cultural
differences and similarities in the etiology,
expression, and phenomenology of depressive
disorders (Marsella, 1987). A number of risk factors
have been associated with depression in African-
American children, including higher levels of childreported
daily stress, poverty, teenage pregnancy,
lack of maternal contact, low educational level of
mother and/or head of household, high levels of
family conflict, use of corporal punishment, and
domestic violence (Marsella, 1987). <strong>Research</strong> also
suggests that culture influences the manifestations
of depressive symptoms in youth. For example,
somatic complaints and interpersonal difficulties
are common in depressed American Indian
children, whereas cognitive and affective
complaints characterize depressed European
American children (Manson, Ackerson, Dick &
Baron, 1990). An understanding of the cultural
background of Amy’s family, the context within
which her symptoms developed, and the family’s
response to them are all important issues to
consider.
Poverty—Although poverty has been shown to be a
risk factor for juvenile depression, data are mixed
regarding the link between social class and rates of
depression and depressive symptoms in youth.
There are virtually no data on the interaction of
socioeconomic status and ethnicity with depressive
symptoms/disorders and youth. Interestingly, the
effect of low socioeconomic status may be more a
function of being at the bottom of the social
hierarchy and less due to absolute income levels or
cultural differences (Goodman & Gottlib, 1999;
Keating & Hertzman, 1999). The divorce-related
change in the socioeconomic status of Amy’s
mother may have additionally contributed to
maternal unavailability (through work pressures)
and may have the potential to indirectly affect
Amy’s mental health outcome by limiting the
family’s access to mental health care.
Cumulative Life Stressors—Life events are
positively correlated with symptoms of depression,
particularly when these events are severe,
numerous, and/or related to key interpersonal
relationships (Birmaher et al., 1996; Compas,
Grant, & Ely, 1994; Garber & Hilsman, 1992;
Williamson, Birmaher, Anderson, al-Shabbout &
Ryan, 1995). Negative life events most likely to
precipitate depression in adolescents relate to
structural changes in the family (e.g., divorce) and
rejection from peers (Bell-Dolan, Last & Strauss,
1990; Brent et al., 1993; Reinherz et al., 1993;
Weller, Weller, Fristad & Bowes, 1991). Although
most research suggests that depression is a familial
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