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Maastricht University, Department of Clinical Psychological Science, Postbox 616, 6200 MD, Maastricht, The Netherlands
University of Amsterdam, Department of Education, PO Box 94208, 1090GE Amsterdam, The Netherlands
a r t i c l e
i n f o
Article history:
Received 30 May 2008
Received in revised form 16 January 2009
Accepted 13 February 2009
Keywords:
Depression
Youth
Family processes
Family systems
Treatment
a b s t r a c t
There is strong evidence that family factors play a role in the development, maintenance and course of youth
depression. However, to date few clinical trials of psychotherapy for youth depression employ family therapy
interventions or target the known family risk factors. This is surprising given recent meta-analytic ndings
showing only modest effect sizes for psychotherapy for youth depression, and that cognitive therapies do not
outperform non-cognitive therapies. The aim of this review is to 1) use a developmental systems approach to
review empirical evidence on family risk factors for youth depression to identify potential targets for
treatment, 2) examine the extent to which these family risk factors have been targeted in clinical trials for
youth depression, and 3) provide a road map for the development of empirically validated family-based
interventions for youth depression.
Strong evidence was found supporting a relationship between family factors at multiple system levels and
depressive symptoms or disorders. Support for several different hypothesized causal mechanisms as well as
bidirectional effects was found. A comparison of the identied risk factors and psychotherapy trials for youth
depression indicated that few RCT's target family factors; among those that do, only a few of the family risk
factors are targeted. Recommendations for translation of empirical knowledge of family risk factors and
mechanisms to develop empirically valid family-based interventions to enhance existing treatments for
youth depression are provided.
2009 Elsevier Ltd. All rights reserved.
Contents
1.
2.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1.
A systems approach to the evidence . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2.
Why use a systemic model for youth depression? . . . . . . . . . . . . . . . . . . .
Part I. Risk factors and mechanisms in the development of youth depression . . . . . . . . . .
2.1.
Methodological note: Levels of evidence required for causal models . . . . . . . . . . .
2.1.1.
Cross-sectional vs. longitudinal design . . . . . . . . . . . . . . . . . . . . .
2.1.2.
Self-report vs. observational assessment. . . . . . . . . . . . . . . . . . . .
2.2.
Level 1: Individual factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.1.
Child factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.2.
Parent factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.3.
Hypothesized risk mechanisms. . . . . . . . . . . . . . . . . . . . . . . .
2.3.
Level 2: Parentchild subsystem . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.1.
Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.2.
Level 2: Parental rearing, conict and support, autonomy and relatedness . . .
2.3.3.
Parental care and control in children and adolescents: Non-observational studies
2.4.
Level 3: Marital relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5.
Level 4: Whole family system . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5.1.
Global family environment . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5.2.
Relationships between multiple family subsystems . . . . . . . . . . . . . .
Corresponding author. Tel.: +31 43 388 1593; fax: +31 43 388 4155.
E-mail addresses: k.restifo@dmkep.unimaas.nl (K. Restifo), s.m.bogels@uva.nl (S. Bgels).
0272-7358/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2009.02.005
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2.5.3.
Interaction patterns in families with a depressed member . . . . . . . . . . . . . . . . .
2.5.4.
Summary of whole family level . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.6.
Level 5: Extra-familial context: stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.7.
Summary of empirically supported family risk factors for youth depression . . . . . . . . . . . . .
3.
Part II. Targeting family risk factors in psychotherapy of youth depression: Evidence from clinical trials . . .
3.1.
Who is the target of treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.
Which risk factors are targeted in psychotherapy for youth depression? . . . . . . . . . . . . . .
3.3.
Which family risk factors are targeted? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.4.
What kinds of treatments have been tested in RCT's for youth depression? . . . . . . . . . . . . .
3.5.
Efcacy of interventions targeting family factors . . . . . . . . . . . . . . . . . . . . . . . . .
3.6.
Summary of family risk factors targeted in youth depression treatment . . . . . . . . . . . . . . .
4.
Part III. Road map for the development of empirically supported family treatments for depression . . . . .
4.1.
Which family factors should be targeted? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.
Steps in the development and validation of family-based interventions for youth depression. . . . .
4.2.1.
Developing a model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.2.
Developing a manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.3.
Evidence for validation of family-based interventions for youth depression . . . . . . . . .
4.2.4.
Further research directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.
Why have the ndings from family process research gone largely unheeded in clinical trials for youth
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction
An extensive body of evidence supports the role of family
processes in the development, course and maintenance of depression
in children and adolescents (Sander & McCarty, 2005). Family
environment, marital and family relationships (Cummings, Keller, &
Davies, 2005), parenting behavior (Alloy, Abramson, Smith, Gibb, &
Neeren, 2006) and attachment (Sexson, Glanville, & Kaslow, 2001)
have been related to the development and maintenance of childhood
and adolescent depressive symptoms and disorders, as well as
treatment response and relapse among depressed adolescents
(Birmaher et al., 2000). This evidence comes from diverse research
traditions and populations, employing diverse methodologies, and
examining varying aspects of family relationships (Goodman & Gotlib,
1999; Sander & McCarty, 2005; Sheeber, Hops, & Davis, 2001).
Surprisingly, the direct translation of these research ndings into
specic techniques for treatment of depressive disorders has been
limited (Davies & Cummings, 2006). Few treatment studies of youth
depression include family-based interventions; those that do target
only a few of the specic family risk factors identied in the research
literature (Sander & McCarty, 2005; Weisz, McCarty, & Valeri, 2006).
Furthermore, the evidence for efcacy of current treatments for
youth depression may not be as strong as it once appeared (Weersing &
Brent, 2006). In a recent meta-analysis of treatments for youth
depression, Weisz et al. (2006) reported a modest overall effect size for
current treatments for youth depression, which was considerably
lower than effect sizes found for treatments of other child and
adolescent disorders. Cognitively based treatments, which make up
the majority of empirically tested treatments, were not signicantly
better than non-cognitively based treatments. Taken together, these
ndings suggest not only that there is considerable room for
improvement in the treatment of youth depression, but also the
possibility that treatment effects could be increased by also targeting
non-cognitive risk factors. Family factors would seem to be an obvious
candidate, given the strong evidence for family factors in depression.
Despite this, few treatment studies of youth depression have included
family interventions which target the wide variety of family risk factors
for youth depression (Sander & McCarty, 2005; Weisz et al., 2006). This
is in contrast to clinical trials research on externalizing disorders,
substance abuse and eating disorders, in which efcacy of family
interventions has been demonstrated (Diamond & Josephson, 2005).
The aim of this review is to address the gap in the translation of
research ndings on family processes in depression and treatment of
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depression?
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Risk factor
Parental factors
2. Parentchild subsystem
Attachment
Rearing behaviour and style
Conict and support
Autonomy and relatedness
Expressed emotion
3. Marital subsystem
Marital discord
Marital conict
Marital satisfaction
Partner support
5. Extra-familial subsystem
Stress
Poverty
Ses
Culture, ethnicity
Community
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problems when the husband was angry and withdrawn (Katz &
Gottman, 1993). Avoidant conict tactics have been found to be
related to higher rates of internalizing, but not externalizing problems
in children (Marchand & Hock, 2003).
Finally, conict resolution has been shown to ameliorate children's
distress in the face of interparental conict in experimental analogue
studies, in which children are exposed to videotapes depicting
parents (i.e. actors) ghting, with varying degrees of conict resolution (Davies & Cummings, 1994). Complete resolution of conict has
been shown to bring children's distress levels back to baseline levels,
but even partial resolution of conict reduces children's distress
(Cummings, 1994). Children's distress is also reduced when parents
resolve their conict off screen, or when they tell children that the
conict has been resolved (Cummings, Simpson, & Wilson, 1993).
In summary, marital discord, particularly marital conict, has been
related to both internalizing and externalizing problems in children in
cross-sectional, longitudinal and experimental studies, has been
found to be elevated in families of depressed children and depressed
parents, and may partially account for the relationship between
parental depression and child psychopathology, including depression.
How parents ght seems to matter, with actual or threatened physical
aggression, anger combined with withdrawal, and avoidant tactics
having particularly deleterious effects on children, and calm discussion, humor and problem solving decreasing negative effects.
Resolution of the conict, whether directly observed or only explained
by parents, has been found to ameliorate the negative impact of
interparental conict in analogue experiments. The bulk of this
research has been conducted in nonclinical populations, and stronger
relationships have been found between interparental conict and
externalizing symptoms than internalizing symptoms.
2.5. Level 4: Whole family system
In this section, we turn to studies which have examined interconnections between the above subsystems within the context of the broader
family system. Thus we move from consideration of the individual, dyadic
relationships (spouse-spouse or parentchild) to triadic relationships, that
is mother, father and child(ren). The shift from dyadic to triadic
relationships allows interrelationships between various subsystems to
be examined, which may impact on dyadic and individual processes
(Bronfenbrenner, 1986; Minuchin, 1974). By examining a broader level of
the system, transactional processes may be revealed which might
otherwise go unnoticed. For example, if a depressed mother is observed
to be withdrawn from and critical of her children, a causal relationship
may be hypothesized:
Maternal depressionYCritical withdrawn parentingYChild depression:
305
306
Table 2
Family risk factors targeted and effect sizes in randomized controlled trials for youth depression1,2.
Level of family
system
Authors
1 Individual
parent
Maternal depression3
Sample
Study design
Billings and Moos (1986); 249 b18 year old children of depressed
Timko et al. (2002)
parents already receiving treatment
and children of nondepressed parents
Depressed parents
Dysthymic mothers
Depressed mothers
Depressed mothers
Depressed, psychiatric or
medically ill mothers
No randomization; child
outcomes examined after
mothers began treatment
Depressed mothers
Depressed mothers
Depressed mothers
Depressed mothers
Depressed mothers
Medication treatments
Target of treatment
308
Table 2 (continued)
Family risk factor
targeted
Authors
Sample
Target of treatment
Study design
Support
Conict
Autonomy
Communication
Youth
Youth
Overall ES 4
.61 IPT
Depression ES
.54 IPT
.45 IPT
.44 IPT
Youth
.11 CBT
.47 IPT
.37 CBT
.72 IPT
Parents + youth
.68 ABFT
.72 ABFT
.32 CBT
.15 SBFT
.36 CBT
.18 SBFT
2 Parentyouth
Attachment
Diamond et al. (2002)
Parental warmth/control
Support
Conict
Autonomy
Communication
Parenting style
Conict
Communication
Problem solving
Communication
Problem solving
High expectations
Pos. reinforcement
Attachment
107 1318 year old depressed adolescents Family (SBFT) youth (CBT)
(clinic referred and via advertisement)
Treatment of Adolescent
Depression Study
(TADS; March et al., 2004)
.09 CBT
.07 CBT
Conict
Communication
Problem solving
.32 CWD-A
.15 CWD-A + parent
group
.18 CBT
.14 CWD-A + parent
group
Conict
Communication
Problem solving
Support
.53 CWD-A
.73 CWD-A + parent
group
.41 CBT + MFT
.68 CWD-A
1.31 CWD-A + parent
Group
.25 CBT + MFT
Level of family
system
Family
Marital conict
4 Entire family
system
Dysfunc. interactions
107 1318 year old depressed adolescents Family (SBFT) youth (CBT)
(clinic referred and via advertisement)
.32 CBT
.15 SBFT
.36 CBT
.18 SBFT
Expressed emotion
Cohesion/
disengagement
Parents + youth
.68 ABFT
.72 ABFT
Treatment of Adolescent
Depression Study
(TADS; March et al., 2004)
.09 CBT
.07 CBT
Family
Youth
.61 IPT
.54 IPT
Youth
.45 IPT
.44 IPT
Youth
.11 CBT
.47 IPT
.37 CBT
.72 IPT
Parents + youth
.68 ABFT
.72 ABFT
5 Extra-familial
Communication
Expressed emotion
Problem solving
Stressful life events
IPT = Interpersonal Therapy; IPTA = Interpersonal Therapy Adolescent; M-ITG = MotherInfant Therapy Group; CBT = CognitiveBehavioral Therapy; TAU = Treatment As Usual; SBFT = Systematic Behavior Family Therapy; CWD-A =
Coping With Depression Adolescent; MFT = Multiple Family Therapy.
1
Studies can be listed more than once if family factors at multiple system levels are targeted.
2
Unless noted, all studies are RCT's.
3
Reported in Gunlicks & Weissman, 2008.
4
All effect sizes (ES) for overall outcomes and for depression outcomes from Weisz et al. (2006) unless otherwise noted.
5
Effect sizes for overall and depression outcomes from Sanford et al. (2006), not Weisz et al.
3 Marital
subsystem
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retention (Wells & Albano, 2005). The parent component included two
mandatory sessions of parent psychoeducation, as well as optional
parentyouth sessions which could be drawn from ve family therapy
modules which addressed 1) family problem-solving skills; warmth
and hostility 2) family communication skills, 3) behavioral contingency schedules 4) positive reinforcement, and 5) parentadolescent
attachment.
3.5. Efcacy of interventions targeting family factors
How effective are interventions that primarily target family and
interpersonal relationships? Table 2 displays results from treatment
studies targeting family factors in order to improve youth depression,
including ten studies which treated maternal depression to reduce
child psychopathology. Effect sizes from Weisz et al.'s (2006) metaanalysis are included. Unfortunately, the small number of studies
makes it difcult to draw rm conclusions. Weisz et al.'s (2006) metaanalysis of psychotherapy of youth depression found an average
effect size of .34 for all treatments, and cognitively based interventions
fared no better than non-cognitive interventions. Effect sizes for
family or parent-based treatments of youth depression varied widely,
from .14 to 1.31 for child CBT + parent group, from .18 to .72 for family
therapy, and from .44 to .72 for Interpersonal Therapy (IPT). Since
many factors independent of type of treatment can inuence effect
size, it is difcult to directly compare effect sizes. When family or
parenting interventions have been compared to individual, cognitively
based interventions, the ndings have been mixed. In the only
randomized controlled trial which directly compared CBT to family
therapy, Brent's group found cognitivebehavioral therapy (CBT) to be
more effective in the short term than systematic behavioral family
therapy (SBFT), however, at two year follow-up the treatment effects
were the same. Furthermore, SBFT was found to reduce parentchild
conict, which was a predictor of relapse. Rossello and Bernal (1999)
found larger effect sizes for IPT compared to CBT; however these
differences were not signicant. Among the cognitivebehavioral
trials, Lewinsohn's group found evidence for a marginally signicant
increase in effect by adding a parent group to a youth CBT group
(Lewinsohn et al., 1990); however a later study failed to replicate this
nding (Clarke et al., 1999).
How effective are treatments that target a depressed parent (Level 1)
at reducing symptoms of child depression or other psychopathology?
In their review, Gunlicks and Weissman (2008) found evidence that
reduction or remission of parental depressive symptoms was associated
with reduction in child symptoms. Specically, ve out of nine studies
found that treatment of parental depression was associated with
improvements in child psychopathology, and ve out of the six studies
examining psychosocial outcomes reported that mothers' treatment
was associated with child improvement, including better academic
functioning, better global functioning, better motherchild relationship.
In contrast, they found little evidence that treating postpartum depression has signicant positive effects on infant attachment, temperament,
and cognitive development.
3.6. Summary of family risk factors targeted in youth
depression treatment
In summary, the majority of tested treatments for youth depression do not target family factors or involve family members in the
treatment. Among those that do, the parentchild relationship (Level
2), is the main focus, particularly conict resolution, problem-solving
skills, communication and support, attachment, increasing warmth
and decreasing hostility, and increasing positive reinforcement of the
adolescent. Marital conict (Level 3) has not been targeted in RCT's for
youth depression, and whole family relations (Level 4) and stressful
life events (Level 5) are targeted in only a few studies. In a promising
trend, investigators have begun to target parental depression (Level 1)
312
Studies
Diamond et al. (2002)
Brent group
(Brent et al., 1997)
TADS Group
Wells & Albano (2005)
Sanford et al. (2006)
Lewinsohn et al. (1990)
Diamond et al. (2002)
Brent group
(Brent et al., 1997)
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314
5.1. Why have the ndings from family process research gone largely
unheeded in clinical trials for youth depression?
If the preference for individual, cognitive-based approaches is not
supported by the empirical evidence, on the one hand, and if there is
strong evidence that targeting family factors could improve treatment
of youth depression on the other, why has this been largely neglected
in the treatment literature? One explanation is that clinical applications always lag behind basic research ndings. Intervention
researchers may be less aware of the evidence from developmental
and family process research. Furthermore, whereas cognitive therapy
researchers have highlighted the importance of empirical validation,
family therapy proponents have been less concerned with empirically
demonstrating treatment efcacy or conrming hypothesized models.
However, the very success of the cognitive paradigm may also be a
factor. Scientic paradigms serve to dene the concepts and data for
inclusion in a particular eld, as well as dening what lies outside the
eld (Kuhn, 1962). The cognitive model has been tremendously inuential in the last forty years in organizing the selection and interpretation
of data about depression. During roughly the same time period, evidence
supporting family factors in depression has been accumulating. However, this evidence has not been as systematically applied to treatment of
youth depression. More than a dozen recent reviews of family factors in
depression have called for the application of these ndings to treatment
of youth depression (e.g., Alloy et al., 2006; Goodman & Gotlib, 1999;
Sander & McCarty, 2005; Sheeber et al., 2001). At the same time, recent
articles from experts within the eld of youth depression have questioned the evidence for the superiority of cognitive therapy for youth
depression compared to other therapies (Weersing & Brent, 2006;
Weersing, Iyengar, Kolko, Birmaher, & Brent, 2006; Weisz et al., 2006).
Thus the eld appears to be poised to integrate and apply these ndings
which have been available for several decades. There are promising signs
that this integration is beginning. There are manualized treatments
available to address the interpersonal and family relationships associated
with youth depression; however they need to be integrated into a developmental and family framework, and they need to be tested systematically. The fact that TADS included a comprehensive family component
as part of the rst study comparing CBT to medication indicates the
degree to which CBT researchers have incorporated concerns about
family processes into their study designs. Interventions targeting
parental depression as a means of reducing child psychopathology
represent another promising research trend. And nally, the fact that
leading CBT researchers are taking a critical look at the accumulated data
on CBT for youth depression is a welcome sign, which will improve
cognitivebehavioral treatments as well as open the eld to other
treatments for youth depression. We hope that this review, by organizing
the family evidence within a systemic framework, will contribute to the
further application of this evidence to treatment of youth depression.
The future of psychotherapy research may lie in integrative rather
than competitive models. Fortunately, there is enough to go around
for everyone interested in youth depression: from individual genetic
and cognitive factors, to the wide variety of family factors reviewed
here. Future research on psychotherapy of adolescent depression
should focus on which combination of interventions is most helpful
for which individuals and their families.
Acknowledgements
We are grateful to Marcus Huibers and David Bernstein for their
comments on earlier drafts of this article.
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