2015-07-07

Presentation Outline

Research facts about Depression (What is Childhood

Depression)
DSM-IV & DSM-V (Changes)
What are the symptoms of Childhood Depression
Implication of Childhood Depression
Examine risk factors
Teen Suicide
Interventions case study
Implications of the types of interventions
Compare two types of interventions
Conclusion (choosing the right intervention)
References

CHILDHOOD DEPRESSION
By Leora Volodarsky

Childhood Depression
ANSWERS

1)

2 % of children and 5% of adolescent are currently clinically diagnosed with

depression.
Research suggests that 80 of children and adolescents with some type of
depression receives no treatment (what are the implications?)
3)Rates of depression are similar in boys and girls prior to puberty, however the rate of
depression is twice as high in teenage girls as it is in teenage boys.
4) Yes
5) Risk of depression increases as a child gets older
6)Having depression increases a persons risk for heart disease, diabetes , and many
other diseases
2)

Case reports on childhood depression date to the early 17th century

Melancholia in children was first reported in the mid-19th century

(Miller et al., 2002)

Research from Europe and NIMH funded American studies in the 1970s increased the awareness &
acceptance of childhood depression

DSM-IV

DSM-V Criteria for Depression

Need to have five or more symptoms over the past two weeks
q
q
q
q
q
q
q
q
q

Depressed mood or irritable

Decreased interest or pleasure
Significant weight change (5 %) , or change in in appetite
Change in sleep : Insomnia or hypersomnia
Change in activity: Psychomotor agitation or retardation
Fatigue or loss of energy
Feeling of guilt/ worthlessness
Concentration
Suicidal: Thoughts of death or suicide

Theories of Depression
Psychodynamic: anger turned inward; severe
superego
n Attachment: insecure early attachment
n Behavioral: inability to obtain reinforcement
n Cognitive: depressive mindset
n Self-Control: deficits in self-monitoring, self-evaluation,
and self-reinforcement
n Interpersonal: characteristic to individual, roles and
events
n Socioenvironmental: stressful life circumstances
exacerbate vulnerabilities
n Neurobiological: neurochemical, endocrine, and
receptor abnormalities
(Miller et al., 2002)
n

DSM-V
What are the changes?
Two new disorders
- Disruptive Mood Dyregulation Disorder
- Premenstrual Dysphoric Disorder

(American Psychiatric Association, 2013)

2015-07-07

What Is Childhood
Depression

Lets test our knowledge

1. How common is Childhood Depression ?
2. Research suggests that ___ of children and adolescents with
some type of depression receives no treatment
3. Rates of depression are similar in boys and girl (T/F)
4. Depression tends to run in families (T/F)
5. Risk of depression increases as a child gets older (T/F)
6. What are some implications of depression
7. The existence of depression prior to 1960 was seriously
doubted because it was felt that childrens immature
superego would not permit the development of depression
(T/F)
8. What do you think increased the awareness of childhood
depression

Epidemiology (3)

Prevalence increases during adolescence, possibly due to:

1. Biological factors (e.g., sexual maturation)
2. Environmental factors (e.g., increased social/academic
expectations, more chance of exposure to negative events)
3. Psychological & cognitive factors (e.g., increased autonomy
and abstract thinking)
4. Studies in specialized populations show increased incidence,
such as 40% among children on neurology wards with
unexplained headaches (Ling et al, 1970); 7% of general
pediatric inpatients (Kashani et al, 1981); 28% of children in
psychiatric clinics (Carlson & Cantwell, 1980); 59% of child
psychiatry inpatients (Petti, 1978); and 27% of adolescent
inpatients (Robbins et al, 1982)

Epidemiology
Varying rates have been reported; no large, well accepted
epidemiologic studies
Generally accepted 1-year incidence is:
*Preschool age 1%
*School age 2%
*Adolescent age 4 - 8% (why an increase? )

Gender ratio of 1:1 in childhood and 2:1 (female to male)

by adolescence
Lifetime prevalence of depression among adolescents is
15 20% (similar to adults); 15.3% per NCS
Kashani & Sherman, 1988; Fleming & Offord, 1990; Lewinsohn et al, 1993 & 1994;
Kessler & Walters, 1998

What Are The Symptoms?

Children:
More symptoms of anxiety
(e.g., phobias, separation
anxiety), somatic complaints,
and auditory hallucinations
Depression is expressed as
temper tantrums & behavior
problems
Fewer delusions and serious
suicide attempts
By middle childhood,
preoccupations w/death,
lowered self-esteem, social
withdrawal/rejection, & poor
school performance

Adolescents:
More cognitive components to
their depression than children
Guilt and hopelessness become
apparent
More sleep & appetite
disturbances, delusions, suicidal
ideation & attempts
Compared to adults, still more
behavior problems and fewer
neurovegetative difficulties

What Are The Symptoms?

Age

Symptoms

Preschool

Increased tantrums, separation

anxiety, oppositional (may not look
sad)

Elementary

Tantrums, oppositional, grade might

be falling, avoid friends or activities,
may show some aggressive behaviour

Middle School

Grades, avoid friends and activities,

may seem bored, sad, sleep/ weight
changes, may also see drug use, self
harm

High School

Grades dropping, irritable, avoid

friends and activities, drop out of
school, drug use, running away,
suicide thoughts, self harm,

Clinical Presentation
DSM-IV Criteria do not differ for children & adolescents
Generally, children show fewer neurovegetative signs than adults
Irritability may substitute for depressed mood

2015-07-07

What Are The Risk

Factors?

Epidemiology (2)
Studies on Dysthymia suggest a wide range in point
prevalence: children from 0.6 1.7%; and adolescents
from 1.6 8.0%
o Garrison et al, 1992; Kashani et al, 1987; Lewinsohn et al 1993 & 1994

Studies in specialized populations show increased

incidence, such as 40% among children on neurology
wards with unexplained headaches (Ling et al, 1970); 7% of
general pediatric inpatients (Kashani et al, 1981); 28% of
children in psychiatric clinics (Carlson & Cantwell, 1980);
59% of child psychiatry inpatients (Petti, 1978); and 27%
of adolescent inpatients (Robbins et al, 1982)

More about Mothers

Chronic Illness
Hormonal changes
Family history
Use of certain types of medication
Neglect or abuse
Socioeconomic deprivation
Other disorders
Loss of a loved one
Increase use of drugs
Bulling

Teen Suicide

A 20-year follow-up of offspring of depressed and non-depressed

parents found that the risks for anxiety disorders, major depression,
and substance dependence were ~3x higher in the offspring of
depressed parents vs. non-depressed parents; social impairment was
also greater. The time of greatest incidence was 15 20 y/o; higher
rates of medical problems and mortality in the offspring of
depressed parents were beginning to emerge as the offspring enter
middle age (Weissman et al, 2006)

2015-07-07

Why Are Teens So Vulnerable?

Early Adolescence

Puberty stimulates changes
in brain systems regulating
arousal and appetite that
inuence intensity of
emotion and motivation

Who Young People Turn

to For Help These Days

Middle Adolescence

adolescent emotional and behavioral

problems 2nd to poor regulation

skills--particularly when gap between
pubertal arousal and consolidation of
cognitive skills is extended

Late Adolescence
With age and experience
comes maturation of
frontal lobes which
facilitates regulatory
competence

Interventions

Cognitive-Behavioural Therapy (CBT)

Psychoeducational psychotherapy (PEP)
Relaxation Training
Mindfulness-based therapy
Medication
Yoga
Traditional counselling

What is PEP?

Psychoeducational Psychotherapy (PEP)

Is the only evidence-based treatment designed for preadolescents
children with depression (developed by Mary A. Fristad for children 8-12
years old with depression)
Program Goal:
Learn about the symptoms of mood disorders
Effectively manage the symptoms of mood disorders
Improve communication
Improve problem solving
Improve emotion regulation
Decrease family tension
Improve consumer skills
Reduce symptom severity
Improve functioning
it is not your fault, but it is your challenge

How PEP Works?

Case Study

Two types of approaches

Consists of 20-24 weekly 50 minute sessions or 8 90minute sessions
Home work (i.e. toolkit)

2015-07-07

Session Outline

Goal:
1. Teach the child the difference between helpful
thoughts and hurtful thoughts
2. Teach the child how to use thoughts and actions to
manage different feelings.
Beginning the Session:
q Do check-in & have the child identify and rate feelings
(review mood)
q Medication log
q Review healthy habits and/or Taking charge sheet of
feelings
q Tool kit log

Implications for PEP

What does research show?

q High degree of consumer satisfaction
q Decreased mood severity
q Decreased behaviour symptoms
q Improved family interaction
q Improved access to care
q Proactive approach
NEVERTHELESS..
Access to trained clinicians
Cost / Time
- Can it be implemented in the school setting?
Parents/ Kids have to be on board
Follow up (Homework)

The cognitive model of depression.

Continue

Lesson of the Day:

Reviewing triggers, hurtful feelings and actions
Teaching the child to identify hurtful thoughts
Making connections among hurtful thoughts,
feelings, and actions
- Identify helpful actions
Breathing Exercise:
Child can choose (i.e. belly, bubble, balloon
breathing)
Session with Parents
New Take-Home Project

-
-
-

Cognitive Behavioural
Therapy(CBT)
CBT-the most widely investigated
psychotherapy for depression
You can change how you feel by
changing how you think
CBT Draws on 4 core sets of
strategies:
Facilitative
Behavioral Activation
Automatic Thoughts
Core Beliefs

Aaron T. Beck

Require ability to reect

on, monitor, and evaluate
own thinking process in
midst of heightened
emotional arousalmay
not have skills on board

Cognitive Behavioural
Therapy(CBT)
Cognitive behavior therapy (CBT) is a type of
psychotherapeutic treatment that helps patients
understand the thoughts and feelings that influence
behaviors.
Cognitive Component
-cognitive distortion
Behavioural Component

Bailey V APT 2001;7:224-232

2001 by The Royal College of Psychiatrists

2015-07-07

Moving on to TreatmentWhat Works Best?

Principles of CBT: Philosophy

Principles of CBT: Technology

p
p
p
p

p
p
p
p
p
p

Collaborative Model
Structured Sessions
Blend Didactic, Directive, & Socratic Questioning
Ongoing Assessment (inc. regular feedback)
Effect Change in Thought, Affect, & Behavior
Relapse Prevention

p
p
p

Agenda Setting
Mood Monitoring
Behavioral Activation; Structuring Activities
The ABCs of CBT: Linking Affect, Behavior, & Cognition
Thought Records & Changing Beliefs
Cognitive-Behavioral Case Conceptualization
Becoming Your Own Therapist

Thought diary.

Implication of CBT
Using CBT with children and depression
- Positives/ Negatives
- What does theory and research say?
- Success rate?
Access to Intervention
- Can it we implemented into the school setting?
Cost/ Time
Parents involvement
Personal insight
- Recognize that there is a problem and accept help
Bailey V APT 2001;7:224-232

2001 by The Royal College of Psychiatrists

Intervention Comparison

Both CBT and PEP produced substantial and statistically
significant reduction in depressive symptomology
PEP included more parent involvement and long term
change
PEP help children develop strategies, while CBT involve
cognitive restucturing and significantly higher academic
self-concept
Age levels
Ability levels
Preventative
Approach
Quality

Conclusion

Important to consider the following when determining

which type of therapy to use
Age of the child or teen
Comorbidity (Most children with MDD have a comorbid
psychiatric diagnosis:
*40 90% have a second psychiatric disorder
*20 50% have two or more comorbid disorders
Access and time
Parents involvement
Quality of the therapy
(trained professionals)
Cognitive Development
Ethnicity and belief system

2015-07-07

References
Abeta, J. R. Z., & Hankin, B.L. (2006). Cognitive vulnerability to depression in children and adolescents: A
developmental psychopathology perspective. In J. R.Z. Abels & B. L. Hankin (Eds.), Handbook of
depression in children and adolescents (pp.35-78). New York: Guildford.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Arlington, VA: American Psychiatric Publishing.
Asarnow, J. R., Scott, C.V., & Mintz, J. (2002). A combined cognitive behavioral family education
intervention for depression in children: A treatment development study. Cognitive Therapy and
Research, 26 (2), 221-229.
Grave, J., & Blissett, J. (2004). Is cognitive behavior therapy developmentally appropriate for young
children? : A critical review of the evidence. Clinical Psychology Review, 24 (4), 399-420.
Gutkin, Terry B. & Reynolds, Cecil R. (2009). The Handbook of School Psychology, Fourth Edition, Hoboken, NJ:
Jonn Wiley and Sons.
Hagermoser Sanetti, Lisa M., Gritter, Katie L., & Dobey, Lisa M (2011). Treatment Integrity of Intervention With
Children in the School Psychology Literature from 1995-2008. School Psychology Review. 40 (1). 72-84
Strohle, A., Hofler, M., Pfisher, H., Muller, A., Hoyer, J., Wittchen, H., et al .. (2007). Physical activity an
prevalence and incidence of mental disorders in adolescents and young adults. Psychological
Medication, 37, 1657 -1666.