Family processes in the development of youth depression: Translating the evidence to treatment

Abstract

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 findings 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 identified 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.

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 and Gotlib, 1999, Sander and McCarty, 2005, Sheeber et al., 2001).

Surprisingly, the direct translation of these research findings into specific 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 specific family risk factors identified in the research literature (Sander and McCarty, 2005, Weisz et al., 2006).

Furthermore, the evidence for efficacy 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 significantly better than non-cognitively based treatments. Taken together, these findings 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 and McCarty, 2005, Weisz et al., 2006). This is in contrast to clinical trials research on externalizing disorders, substance abuse and eating disorders, in which efficacy of family interventions has been demonstrated (Diamond & Josephson, 2005).

The aim of this review is to address the gap in the translation of research findings on family processes in depression and treatment of youth depression. The first goal is to examine the empirical evidence on family risk factors and mechanisms in the development of youth depression, in order to identify potential targets for treatment. The second goal is to examine the extent to which these family risk factors have been targeted in randomized controlled psychotherapy trials for youth depression. The third goal is to provide a road map for the development of family-based treatments for youth depression to target the broad array of family risk factors identified in the empirical literature.

Several considerations guide our approach. First, there is a need to move beyond identifying separate risk factors, to developing models of causal risk mechanisms (Garber, 2006). Research on family and parental factors related to depression have tended to view parental psychopathology, rearing styles, marital functioning and family structure as separate domains, and often research is conducted on only one of these variables at a time. Researchers are increasingly using developmental and family systems theory to integrate diverse findings into models, which can describe the complex interrelationships between risk factors and specify possible causal pathways from risk to outcome (Cowan and Cowan, 2002, Davies and Cummings, 2006, Goodman and Gotlib, 1999, Sheeber et al., 2001). While developmental and interpersonal models have been available for decades in the developmental literature (Cicchetti & Toth, 1998), the adult literature on depression (Gotlib, 1990), and within family therapy research (Steinglass, 1987) these models have less frequently been applied to the treatment of child and adolescent depression, where cognitive models have been predominant.

While the terms “family systems” or “systemic” have been used in various ways in the literature, in this review, “systemic” refers to an approach which views the individual in the context of his environment. Individual characteristics such as genes, temperament and personality are assumed to unfold within, and in interaction with, a particular environment. Environmental influences can be conceived as operating at varying degrees of proximity to the child, from the immediate family (parents and siblings), to extended family, to the broader social context outside the family (e.g., school, work, socio-cultural factors) (Bronfenbrenner, 1986). It is important to note that this approach makes no further assumptions about etiology or treatment of depression. Rather, the only assumption is that examining multiple factors at various systemic levels will give a more complete picture of the mechanisms involved in the development of youth depression. Within this approach, the term subsystem refers to any part of a larger system: for example, the individual child subsystem refers to the child, the marital subsystem refers to the spousal relationship, the whole family subsystem refers to the mother, father and child(ren) unit.

Systemic models allow for the integration of multiple types of data and theories by viewing each as occurring at different levels of analysis: individual, family, community and culture (Bronfenbrenner, 1986). The literature on family factors in depression has drawn from several populations (depressed parents, depressed youth, and community samples), and includes diverse factors such as parental rearing style, family environment, marital conflict, attachment, support and conflict. Rather than viewing these as separate factors, organizing these factors according to the different system levels facilitates model building and clinical application. Moreover, this approach lends itself to developing hypotheses about how individual risk factors interact to produce risk mechanisms, and is consistent with current multivariate approaches to studying risk processes in youth. Furthermore, placing risk factor evidence at each level of the system generates hypotheses about potential targets for treatment, including the level at which targets should be addressed, which can be tested in clinical trials.

Fig. 1 illustrates a systemic model of risk for the development of youth depression. In contrast to models which describe hypothesized causal pathways from family factors to youth depression (Cummings and Davies, 1994, Downey and Coyne, 1990, Goodman and Gotlib, 1999), the purpose of this model is to describe the multiple factors which can influence or maintain the development of depression, the level at which each factor operates, and the ways in which each factor may interact with other factors at the same or different level of the system. The model does not specify the direction of causality, but allows for the possibility that relationships may be reciprocal and transactional rather than unidirectional. The purpose of this model is twofold: to integrate family risk factor evidence into hypothesized mechanisms of transmission which can be tested in subsequent research, and to promote the translation of this evidence into clinical interventions targeting the hypothesized mechanisms at the appropriate system level.

While several reviews of family factors in youth depression have appeared recently, this is the first to use a systemic framework to integrate the empirical findings in order to facilitate clinical application. Furthermore, we include a broader range of studies, including some studies of normal populations which have bearing on theoretical models but which have largely been ignored in the youth depression treatment literature. We also address the question of specificity of these family factors to depression, by including studies which examine other psychopathological outcomes in addition to depression.