Depression in Children and Adolescents: Intervention Approaches June 2 nd, 2008 Prepared By: Polly Chan

Depression in Children and Adolescents:

Intervention Approaches

June 2nd, 2008Prepared By: Polly Chan

Agenda

I. Introduction

II. What Is Depression?

III. Prevalence

IV. Diagnosis

V. Causes

VI. In-School Assessment Methods

VII. Intervention Approaches

VIII. Merits & Drawbacks

IX. Future Direction

X. References

I. Introduction

Teen Depression: A General Introduction

II. What Is Depression?

Depression

is one type of internalizing disorder (i.e. inappropriate regulation of their internal emotional and cognitive state)

is a primary triad of cognitive patterns (Beck, 1976): A negative view of the world; A negative view of the self; A negative view of the future

has been referred to as secret illnesses (Reynolds, 1992) because it is difficult to detect through external observation

III. Prevalence

About 5% of adults in the United States and Canada are experiencing major depressive disorder a given point in time 18, 16

the age groups that are at risk for depression are adolescents and young adults (between the ages of 14 and 35) 5, 7, 10, 12

More women than men experience depression during adolescence and adulthood, with a ratio of about 2 to 1; there is no gender difference in childhood 5, 17

Once depression has begun; its course is similar for men and women 21

Depression often co-occurs with anxiety disorders 11

III. Prevalence

Merrell (1999) 4-6% would be a conservative estimate of the percentage of

children who suffer from the symptoms of depression, and would benefit from further assessment and intervention

Girls seem to report the presence of depression to a greater extent than boys.

During and after adolescence (by ages 13-14), this difference between the sexes becomes noticeable, with about twice as many girls as boys experiencing the symptoms of depression at a significant level

IV. Diagnosis

Major Depressive Disorder (or Major Depressive Episode) exists when a collection of symptoms meets specific diagnostic criteria, according to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)1

Criterion A Five of the following nine symptoms are present for at least two weeksDepression mood, nearly every dayLoss of interest or pleasure in most activitiesSignificant changes in weight or appetiteDifficulty getting enough sleep, or sleeping too much Slow talking, delayed response to others, or slow movementFeeling tired, nearly every dayFeeling guilty and worthless Difficulty concentrating, planning, and making decisionsThoughts about suicide, or a plan, or a suicide attempt

Criterion B The symptoms must include either depressed mood (No.1) or loss of pleasure (No. 2)

IV. Diagnosis

Criterion C The symptoms must be causing significant distress and disruption in day-to-day functioning

Criterion D There are some symptoms and signs that must not present, such as obvious periods of mania (i.e. another type of disorder characterized by wild energy, inappropriately happy mood, irrational thinking, and implusive decision making) or mixed episode

Criterion E Symptoms are not due to medical condition or substance abuse, or bereavement (i.e. grief)

Note: Grief and depression are not exactly the same. Individuals can grieve but are not depressed. But, they can become depressed eventually if they suffer from bereavement without seeking counselling.

IV. Diagnosis

A mnemonic may be useful to recall these criteria: Depression is worth seriously memorizing extremely gruesome criteria, sorry (DIWSMEGCS)8.

These initials stand for: D_ _ _ _ _ _ _ _ mood I _ _ _ _ _ _ _ W _ _ _ _ _ S _ _ _ _ M_ _ _ _ activity E_ _ _ _ _ G_ _ _ _ C _ _ _ _ _ _ _ _ _ _ _ _ S_ _ _ _ _ _

IV. Diagnosis

DSM-IV Disorders

It is important to realize that several other mood or adjustment disorders include depression as a major feature

Table 1 includes a list of disorders from DSM-IV in which depression is a key element of the symptom presentation.

Making accurate psychiatric diagnoses requires training, skills, and care.

Note: Although these classification categories were developed primarily from research with adults, they may also apply to children and adolescents in many cases.15

IV. Diagnosis

Table 1 DSM-IV Disorders with Depression as a Major Feature_________________________________________________

Major depressive disorder Dysthymic disorder Depressive disorder, not otherwise specified Bipolar disorders Cyclothymic disorder Mood disorder due to medical condition or substance abuse Adjustment disorder with depressed mood

IV. Diagnosis

V. Causes

The Family and Other Social Causes6

Separations from loved persons or places Sudden and permanent loss of a much loved person as a result of

death, divorce, or a movement away from the environment the child has gotten used to

Depreciated or rejected by their parents or loved ones at least over a period of many years

Physical Stressors Physical disability (e.g. enduring hospitalization, immobilization,

pain or disfigurement) Chronic disabilities (e.g. paralysis, kidney disease, severe allergies,

heart disease)

Nature of the Biological Abnormality Neurotransmitters, namely dopamine, norepinephrine, and

serotonin, have been studied intensively in psychiatry Evidence in genetic and biochemical research on depression

strongly points to a biological component in some forms of depression19

The Genetic Risk If you are a close relative (i.e., parent, a brother or sister, or a son

or daughter) of a patient with a major depression, you have about a 25-30% chance of developing the condition sometime in your lifetime

V. Causes

Merrell (2001) Potential sources of social-emotional assessment information are

varied and include: the student who is being evaluated his or her parents other family members teachers school personnel the peer group the community-based informants (e.g. youth group leaders)


Assessment Methods Observation – manifestations in classroom22 and at home Social-Emotional Assessment and the Childhood History Form

Initial screening and intervention planning Depression Symptom Checklist Interview and questionnaires Beck Depression Inventory (BDI)3

is a measure of depression which consists of 21 items with four levels of severity for each symptoms

has been used with adolescent populations and has been proved to be valid and reliable 13, 23, 24

establishes the baseline for measuring change


Psychological Methods of Treatment9 Insight-oriented therapy

Focus on gaining an understanding and awareness of the subconscious forces and conflicts which result in depressed mood and behaviour.

Cognitive therapy Change the maladaptive ways of thinking as a means of

changing resulting emotions and behaviour. Behaviour therapy or modification

Directly target changing “depressed” behaviour by changing the consequences which are believed to strengthen and weaken behaviour.

Interpersonal psychotherapy and family therapy Emphasize improving the depressed individual’s interpersonal

communication skills and the relationships with others.


Medical Treatment of Depression Use of antidepressant medications9

Tricyclic antidepressants (since 1950s) Monoamine oxidase inhibitors (MAOIs) Lithium


Cognitive Therapy Based on the theory that dysfunctional thinking styles and the

consequent maladaptive behaviours The general collection of techniques upon which cognitive theory

for depression is built can be traced primarily to the work of Aaron Beck. He first articulated a comprehensive cognitive model for depression (1967) and, with his colleagues, developed an extensive intervention manual for use in treating depressed adults3

Cognitive treatment approach for depression was later modified for use with adolescent26

Focus on learning to recognize and challenge negative automatic thoughts, generate more realistic alternative thoughts and increase positive statements about oneself25


Stage 1: Developing Awareness of Emotional Variability15 Aid the process of helping older students become aware of

their emotional states and mood variability◊ The Emotional Pie

Stage 2: Detecting Automatic Thoughts and Identifying Beliefs

Change maladaptive thinking patterns◊ Thought Chart

Stage 3: Evaluating Automatic Thoughts and Beliefs After automatic thoughts have been detected and corresponding

underlying beliefs have been identified, the next step in cognitive therapy is to determine whether thoughts and beliefs are realistic or unrealistic, adaptive or maladaptive

◊ Identifying Thinking Errors◊ Examining the Evidence: Three Questions◊ Evaluating Positives and Negatives


Step 4: Changing Negative Automatic Thoughts and Maladaptive Beliefs

Changing Negative Automatic Thoughts Increasing Positive Self-Statements Basic Steps to Self-Control and Self-Monitoring Interventions for

Depression 19


Behavioural Intervention Techniques Most strategies require the responsibilities of teachers or parents

to implement and monitor the intervention The approaches include the use of social and tangible reinforcers,

fading and modeling Activity Scheduling

◊ should start out simple and gradually increase the amount and complexity of tasks or events

◊ monitors closely the activity schedule◊ provides a high rate of social reinforcement (e.g., praise,

encouragement, and other positive statements) whenever the child is engaged in the scheduled activities

Weekly Planning Form for Scheduling Positive Activities Baseline Record for Positive Activities

Incentives - movie tickets, tokens, or small prizes Best implemented in conjunction with monitoring mood levels


Operant Conditioning Techniques To reduce symptoms of depression by increasing behavioural

responses that are incompatible with feeling depressed ◊ e.g., reinforcement of desired behaviour and extinction of

undesired behaviour are widely used in treating externalizing conduct problems

Positive reinforcement is to make behaviour more likely to occur in the future, by presenting a reinforcer (i.e., praise, recognition, token, a desired object, or access to a desired activity or food) immediately following the behaviour

Negative reinforcement is to strengthen behaviour by terminating an aversive or annoying stimulus following the occurrence of a desired behaviour (e.g., successfully nagging the child to leave his/ her room to engage in a positive activity because the child is tired of the annoying nagging, finding it reinforcing to get out of the room).


It is important to find out from the child what might be most reinforcing to them, and to encourage parents or teachers to have a variety of reinforcers available

Immediately delivery of the reinforcer following the desired behaviour is essential

It is essential to start off the reinforcement program by delivering the positive consequences most times or every time the desired behaviours occur and then gradually fade out the reinforcement schedule

Differential reinforcement of other behaviour (DRO) Differential reinforcement of alternative behaviour (DRA )


Types of non-depressed behaviours that might be targeted in a differential positive reinforcement intervention:

Smiling Making eye contact with other persons Delivering a positive social greeting Interacting with peers in a positive manner Appropriate speech volume, tone, or clarity Actually participating in various positive activities Volunteering to participate in activities or to assume

responsibilities for tasks Making positive self-statements Making positive statements regarding other persons or events Engaging in physical exercises



Merits Cognitive therapy techniques

can result in positive changes through having a teacher or a parent implement the treatment. This is extremely helpful if the children with depression are resistant to become involved in group or individual counselling programs15

Behavioural intervention approaches reduce behaviours that maintain depression and to increase

the behaviours that help in overcoming depression do not require cognitive maturity

Both the long-term benefits that are resulting from successful

psychological intervention reduce the likelihood of relapse because of the development of alternative methods of coping with potential precipitants and with symptoms25

Drawbacks Cognitive therapy requires cognitive maturity (applicable for

children at least 8 to 12 years old but might be best used with typically developing students who are 13 or older)15

Psychotherapy is a labour-intensive service provided by highly trained professionals9

Rates for a 45- to 50-minute session range from $60 to more than $200

Insurance plan


XI. Future Research

Future Research on Classroom or Clinical Practice

Embed the social-emotional aspects in the existing curriculum

More large-scale studies are needed to determine the proportions of the population that suffer from psychological or psychiatric disorders in children and youth15

New methodology is needed to resolve the dilemma: lack of adequate control group vs. the ethnical concerns in using no treatment control groups in depression research4

Research on how biological variables interact with psychotherapy processes

X. References

1. American Psychiatric Association. (2000a). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author.

2. Beck, A. T. (1976). Depression: Clinical, experimental, and theoretical. New York: Hoeber.3. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York:

Guilford Press. 4. Beckham, E. E. (1990). Psychotherapy of Depression Research at a Crossroads: Directions for the 1990s.

Clinical Psychology Review, 10, 207-228.5. Blazer, D. G., Kessler, R. C., McGonagle, K. A., & Swartz, M. S. (1994). The prevalence and distribution of

major depression in a national community sample: The National Comorbidity Survey. American Journal of Psychiatry, 151, 979-986.

6. Cytryn, L., & McKnew, D. H. (1996). Growing Up Sad. Childhood Depression and Its Treatment. New York: W. W. Norton & Company, Inc.

7. Cyranowski, J. M., Frank, E., Young, E., & Shear, M. K. (2000). Adolescent onset of the gender differences in lifetime rates of major depression: A theoretical model. Archives of General Psychiatry, 57, 21-27. 8. David, A. A., Johnson Jr., T. A., Phillips, D. M., & Scherger, J. E. (2003). Family Medicine: Principles and Practice (6th ed.). New York: Springer-Verlag New York, Inc.

9. Ingersoll, B. D., & Goldstein, S. (1995). Lonely, Sad and Angry. A Parent’s Guide To Depression in Children and Adolescents. New York: Doubleday.

10. Jorm, A. F. (2000). Does old age reduce the risk of anxiety and depression? A review of epidemiological studies across the adult life span. Psychological Medicine, 30, 11-22.

11. Lacourse, E., & Gendreau, P. L. (2007). Boys’ Biopscyhological Difficulties during the Teenage Years. Canadian State of Affairs for the 21st Century. Government of Canada Policy Research Initiative.

12. Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1998). Major Depressive Disorder in older adolescents: Prevalence, risk factors, and clinical implications. Clinical Psychology Review, 18, 765-794.

13. Lewinsohn, P. M., Clarke, G. N., Hops, H., & Andrews, J. (1990). Congitive-Behavioural Treatment for Depressed Adolescents. Behaviour Therapy, 21, 385-401.

14. Merrell, K. W. (1999). Behavioural, social, and emotional assessment of children and adolescents. Mahwah, NJ: Erlbaum.

15. Merrell, K. W. (2001). Helping Students Overcome Depression and Anxiety A Practical Guide. New York: The Guilford Press.

X. References

16. Murphy, J. M., Laird, N. M., Monson, R. R., Sobol, A.M., & Leighton, A. H. (2000). A comparison of diagnostic interviews for depression in the Stirling County Study: Challenges for psychiatric epidemiology. Archives of General Psychiatry, 57, 230-236.

17. Nolen-Hoeksema, S., & Girgus, J. S. (1994). The emergence of gender differences in depression during adolescence. Psychological Bulletin, 115, 424-443.

18. Richards, S. & Perri, M. G. (2002). Depression. A Primer for Practitioners. California: Sage Publications, Inc. 19. Rehm, L. P. (1977). A Self-Control Model of Depression. Behaviour Therapy, 8, 787-804. 20. Reynolds, W. M. (Ed.). (1992). Internalizing disorders in children and adolescents. New York: Wiley.21. Simpson, H. B., Nee, J. C., & Endicott, J. (1997). First-episode major depression: Few sex differences in

course. Archives of General Psychiatry, 58, 225-232. 22. Stark, K. D. (1990). Childhood Depression: School-based Intervention. New York: The Guilford Press. 23. Strober, M., Green, J., & Carlson, G. (1981a). Utility of the Beck Depression Inventory with psychiatrically

hospitalized adolescents. Journal of Consulting and Clinical Psychology, 51, 331-337. 24. Strober, M., Green, J., & Carlson, G. (1981b). Reliability of psychiatric diagnosis in hospitalized adolescents.

Archives of General Psychiatry, 38, 141-145. 25. Verduyn, C. (2001). Cognitive Behaviuor Therapy in Childhood Depression. Child Psychology & Psychiatry

Review, 5 (4), 176-180.26. Wilkes, T. C. R., Belsher, G., Rush, A. J., Frank, E., & Associates. (Eds.). (1994). Cognitive therapy for

depressed adolescents. New York: Guildford Press. VideoReal Life Teens: Deep Depression & Suicide. TMW Media Group, California:

http://www.tmwmedia.com/reallifeteens.html, accessed on May 30, 2008.

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Depression in Children and Adolescents: Intervention Approaches June 2 nd, 2008 Prepared By: Polly Chan