Childhood and Adolescent Depression
    Major depression is a common and serious disorder in adolescents. Early parenthood, divorce, work, difficulties, and substance abuse can affect or trigger this disorder.  Depression can also increase the risk for suicidal behavior and ideation  (Hibbs, Jensen, 1997).
    The Diagnostic and statistical manual of mental disorders (4th ed.).  Defines a major depression episode as having five or more symptoms appearing during the same two week period.  One of the symptoms must be a depressed mood or loss of interest or pleasure.  The symptoms consist of: 1) depressed mood majority of the day, almost every day.  This can also be observed as irritability in children or adolescents.  2) significant loss of interest or pleasure in all or most of daily activities.  3) weight loss or gain when not dieting.  4) hypersomnia or insomnia majority of the nights.  5) psychomotor agitation, a retardation almost every day.  6)  lack of energy or fatigue.  7) Feeling of worthlessness or excessive guilt.  8) lack of concentration, or indecisiveness.  9) recurrent thoughts of death, suicidal ideation (APA).
    Another depressive disorder is the Dysthymic Disorder.  The DSM-IV (1994), defines this as having a depressed mood the majority of the day, more days then not.  This can be observed as irritability in children and adolescents but must be present for at least one year (APA).
    The person must have two or more symptoms while depressed from the following list:  poor appetite or overeating, insomnia or hypersomnia, lack of energy or fatigue, low self-esteem, lack of concentration or indecisiveness, and feelings of hopelessness.  The symptoms and criteria need to be present without ceasing for more then two months at a time.  Major depression must first be ruled out for this disorder  (APA).
    Diagnostic Classification: 0-3 (1994) included the following criteria for depression in children: young children with a pattern of depressed or irritable mood and lack of interest in developmentally appropriate activities, diminished capacity to protest, excessive whining, a lack of social interactions and initiative.  Disturbances in their sleep or eating may accompany these symptoms.  The symptoms need to be present for at least two weeks.  Reactive Attachment Deprivation / Maltreatment Disorder and Adjustment Disorder must be ruled out for a diagnosis of depression with these symptoms.  (0-3, 1997).

Treatment for depression:
    There are many different treatment plans for children and adolescents with depression due to the fact that depression varies in each youth.  For example; situational depression may not require therapy.  Healthy children and adolescents do not want to remain depressed.  They want these sad feelings to go away quickly.  A relationship with a concerned and supportive adult figure may be all that the youth needs.  If the depression continues on for more than two weeks, outside help needs to be sought  (Meeks, 1988).
    Youth that suffer from chronic depression need long-term treatment.  Therapy must focus on the positive through individual therapy with a therapist. Within the therapy, the youth needs consistent reminding of the success they tend to ignore.  They need support and a feeling of security within the therapy.  The therapist should help the youth resolve any underlying conflicts in order for them to deal with their feelings better  (Meeks, 1988).
    A major affective disorder can be biologically based, therefore, medication is effective in stabilizing the highs and lows as well as the episodes in balance.  Individual therapy is used for extra support and educating the youth on their illness.  Skill training can be used to teach them better coping skills with their disabilities as well as with others.  This can improve self-esteem and confidence  (Meeks, 1988).
    Two models of therapy this paper will focus on are, cognitive-behavior therapy and systemic-behavioral family treatment.  Both are used successfully in treating depressed children and adolescents.

Cognitive-behavioral therapy:
    Cognitive-behavioral therapy (CBT), for depression was developed from the cognitive theories of Beck, Ellis, Harper, Rhem, Seligman, and from the behavioral theories of Coyne, Fester, and Levinsohn.  The main purpose for cognitive therapy is to help the depressed person become aware of his or her unconscious pessimistic and negative thoughts, negative beliefs and biases.  It also helps the person to become aware of the self blame for failure and lack of accepting credit for the successes.  This form of therapy is based on the idea that negative ways of thinking and acting cause a person to be more depressed.  Faulty thinking patterns include: overgeneralization; castasroptrization, and jumping to conclusions.  These are very common among depressed adolescents. CBT helps the adolescent identify their thinking patterns and decide if they are reasonable (Hibbs, Jensen, 1997; Garland, 1997; Meeks, 1988).
    CBT is a model similar to Beck’s approach to depressed adults.  It is important to socialize the person to the cognitive therapy as well as monitoring and modification of automatic thoughts, assumptions, and basic beliefs.  CBT focuses on socialization to treatment, issues of autonomy and trust, acquiring of social skills, and issues of impulsively.  Problem-solving is used for issues concerning impassivity.  Some of these behaviors include; suicide attempts, substance use, and unprotected sex.  With suicidal and depressed adolescents, family involvement is very important.  Education and feedback to the family about the disorder and the progress of the adolescent being treated  (Hibbs, Jensen, 1997).
    CBT is an effective therapy for adolescents with cognitive distortions associated with the onset and recurrence of depression.  CBT targets on impulsivity and affect regulation which is associated with suicidal behavior and risk-taking common in depressed adolescents.  The main purpose of behavior therapy for depression is to increase behaviors that produce positive reinforcement and avoiding negative reinforcement from the environment.  This can be accomplished by teaching social and other copying skills.  Some of the styles of treatment a therapist may use include: Adolescent Coping With Depression (CWD-A), graded task assignment, mastery and pleasure therapy, cognitive reappraisal, alternative therapy, cognitive rehearsal and homework assignments.
    One treatment plan that uses this model is the Adolescent Coping With Depression (CWD-A), which is problematic for depressed adolescents.  This treatment also focuses on areas needing change, homework assignments, structural intervention sessions, repeated practice of skills, use of rewards and contracts, and about twenty therapy sessions  (Hibbs, Jensen, 1997).
CWD-A treatment plan is based on the theory that if adolescents learn new coping skills and strategies they will be able to counteract the commonly accepted factors that lead to their depressive episodes and deal better with everyday problems.  This treatment includes 16 two-hour sessions conducted over a eight-week period for groups of up to ten adolescents.  Workbooks are given to the adolescents which provide short readings, short quizzes, structured learning tasks, and forms for the homework assignments for each session.  Homework assignments are given at the end of each session and are reviewed in the beginning of the next session.  The CWD-A format can be used in individual therapy though group therapy is preferred  (Hibbs, Jensen, 1997).
    There is a similar treatment plan for the parents.  Parents are a part of the adolescents social system, therefore any parent-adolescent conflict can contribute to the onset, and to the maintenance, of a depressive episode.  The purpose for parent participation is to help the parent understand the adolescents’ new skills with support and positive reinforcement and to encourage the adolescent in using these skills in everyday situation.  The parents normally have a two hour weekly session with the therapist, which at this time the adolescent’s new skills are brought to their attention.  Communication and problem-solving skills that the adolescent is learning is also shred with the parents and adolescents have two joint sessions to practice these skills on issues that are important to each family.  The parents are given workbooks to help guide them through the process (Hibbs, Jensen, 1997).
    A graded task assignment may be given to the adolescent or child.  The youth observes himself reaching a set goal and increases his attitude about himself.  He is able to see that he does have some control.  The youth improves performance on one task which leads to the elevation of self-esteem leading to increased motivation and continuos improvements on performances (Beck, 1976).
    Another form of CBT is mastery and pleasure therapy.  The adolescent keeps a running account of his activities and marks each mastery experience with a “M” and a “P” for pleasure experience. This is done to help the adolescent to see the situations they had success with and situations that brought them pleasure that they normally would have forgotten (Beck, 1976).
Cognitive reappraisal utilizes a number of techniques to identify typical maladaptive cognitions and attitudes, evaluate and validate them.  This process is done with the therapist and the youth together (Beck, 1976).
    Alternative therapy is a method that consists of two different approaches.  The first approach considers an alternative explanation for experiences.  The youth has a negative bias in his interpretations, but is enabled to recognize these bias and change them to more accurate interpretations.  The youth discusses different ways of dealing with his problems and finding solutions to the problems that he thought were insoluble (Beck, 1976).
    Cognitive rehearsal is used to expose the problems that stop the youth from completing goal-directed activities.  The obstacles that he anticipates and conflicts that arise are then the focus of discussion with the therapist (Beck, 1976).
CBT is best used with adolescents due to the fact young children have immature cognition.  There are medications that can be useful with or without therapy.  It is best used in conjunction with therapy. Tricyclic antidepressants can help improve prepubertal children with major depression (Last, Hersen, 1989).
    Meichenbaum’s theory of CBT is a form of cognitive restructuring.  It focuses on changing the client’s self-verbalizations.  Self-statements and statements by other people affect a person’s behavior in the same way.  In order for CBT to be effective, the youth must notice how they think, feel, and behave and how it affects others.  In order for change to occur, the nature of their behavior so that their behavior can be evaluated in various situations (Corey, 1991).
    Coping skills are implemented within CBT for youth.  Meichenbaum discusses a five-step treatment procedure to teach these skills (Meichenbaum, 1986).  The first step is to expose the youth to situations that cause anxiety with role play and imagery.  The youth become aware of the anxiety-provoking cognitions they experience during stressful situations.  The therapist helps the youth examine those thoughts by reevaluating their self-statements.  After reevaluating their thoughts and statements, the youth notes the level of anxiety that occurred after the reevaluation.  These coping skills are good to help children with social withdrawal (Corey, 1991).
    Many times children and adolescents feel like victims of external circumstances, thought, feelings, and behaviors from which they have no control over.  Therapy teaches them to become aware of how they create their own stress.  They accomplish this by observing internal statements as well as monitoring maladaptive behaviors (Corey, 1991).  In cognitive therapy, the therapist works with both the family and the youth to help them change negative thoughts logically and rationally which in turn will change negative responses (Meeks, 1988).

Systemic-behavioral family therapy:
    Systemic-behavioral family therapy (SBFT) is a combination of two treatment approaches for the family of depressed adolescents.  One approach is from the Functional Family Therapy (FFT) where the therapist meets with the family with the goal of obtaining a commitment from each family member.  The therapist clarifies the problems and goals that the family wants to achieve (Hibbs, Jensen, 1996).
    The second is a behavioral treatment approach developed by Robin and Foster.  In the beginning of this treatment, the issues concerning; family conflict, poor communication, problem solving and structural difficulties, are assessed, identified and strategies are developed and implemented to improve these areas.  This requires positive practice at home and in the sessions with a commitment from each family member to self-monitor and have positive practice. The goal behind SBFT is to amend the problems with family conflict and communication so the patient will not have difficulties with depression in the future (Hibbs, Jensen, 1996).
    Cognitive-behavior therapy tends to be more efficacious than SBFT for adolescent MDD in clinical settings. The treatment response tends to be quicker and more complete (Brent, Holder, et al., 1997).

Conclusion:
    Treatment for depressed children and adolescent varies to each youth, according to their needs and skills.  Cognitive-behavioral therapy and systemic-behavioral family therapy are both excellent forms of therapy to help the youth to learn better coping skills and to help change their thinking process.  The family is more involved in the treatment when using SBFT, but can also be involved when using CBT.

 For references, please e-mail me at abinormal@qwest.net
 
 

More Links on Child and Adolescent Depression

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