Depression

Cognitive Behaviour Therapy with Children and Young People

Chrissie Verduyn, Julia Rogers, Alison Wood

• Publisher: Routledge
• Year: 2009
• eBook ISBN: 9781134148158
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In recent years there has been an increase in research into childhood depression, and it is now recognised that depression can severely impair young people in many aspects of their life, school, peer and social relationships, and frequently persists into adulthood.

Depression: Cognitive Behaviour Therapy with Children and Young People provides an accessible guide to recognising and treating depression in young people. Based on a successful manual developed for research trials, this book presents an overview of a cognitive behavioural model for working with this age group, as well as practical ideas about how to start therapy. Topics covered include:

• engaging young people
• setting goals for therapy
• cognitive behaviour assessment and formulation
• solutions for problems practitioners may face
• encouraging parents and agencies to support therapy.

Depression includes case examples and practical tips to prepare the practitioner for working with young people. Information is presented in a readable and practical style making this book ideal for professionals working in child and adolescent mental health services, as well as those in training. It will also be a useful guide for people working in community services for young people.

Online resources:

The appendices of this book contain worksheets that can be downloaded free of charge to purchasers of the print version. Please visit the website to find out more about this facility

1
Depression in adolescence

Until the 1970s it was generally believed that depressive disorders as seen in adults were rare in childhood. Depressive symptoms were considered a normal part of adolescence. Mood swings, low mood and irritability were seen as the consequences of developmental changes involved in the onset of puberty and adjusting to increasing independence and role changes. Studies in the 1970s and 1980s (Puig-Antich, 1982; Pearce, 1978; Weinberg et al., 1973) showed that depressive disorders occurred before adulthood. It is now recognised that depression can severely impair a young person in many important aspects of their life, school, peer and social relationships, and also will frequently persist into adulthood. In recent years there has been a significant increase in research activity in the area of depression in children and young people but still there are gaps in knowledge compared with the work on adults. The focus of research has moved away from the nature of depression in young people to recognition of the need for better identification of symptoms, referral on to appropriate services and delivering effective treatments.

In clinical use, the term depression is used to describe a cluster of symptoms involving significant changes in mood, in thinking and in activity. These symptoms persist and result in changes in personal and social functioning over a period of at least 2 weeks. Depressed mood may be accompanied by tearfulness and includes sadness and/or irritability with a loss of enjoyment of everyday activities. Children appear unhappy and may report feeling hopeless, helpless and miserable. Cognitive changes can include changes in ability to concentrate and attend to school work. Feelings of worthlessness, self-blame and a general lack of confidence are often present. In severe depression the young person may feel guilty and personally responsible for any past problems. This can be associated with suicidal ideas.

There may be changes in sleeping, eating, energy levels and motivation. Sleep problems may occur in a number of different ways but will involve a change from the young person’s normal pattern. There may be increased sleeping, early morning wakening or insomnia. Appetite may increase, with comfort eating, or decrease. Weight loss or failure to gain weight may be noted.

Ella, age 14, lives with her mother and two older brothers. She has some good friends whom she has known since they started nursery together. She enjoys listening to music, chatting online, shopping, going to the cinema or hanging around in the local park with friends at the weekend. Things at home are fine. Her mother works full time in an office. She feels low from time to time and does not go out much. Ella and her brothers see their father every week. He lives about 2 miles away. He and their mother separated 4 years ago and he has a new partner and baby. The first thing anyone noticed was that Ella had become bad-tempered. She would get annoyed if her friends were late or had forgotten to do something. She had been in fights with another group of girls in school and the school contacted her mother. She was getting into trouble in class and was not doing her school work and homework. She didn’t want to go to school in the mornings and her friends stopped waiting for her at the bus stop. At home her mother had to get on to her about doing anything to help. When she was in she disappeared to her room and avoided being around at mealtimes. Ella could not talk to anyone about feeling that everything she did was bad or wrong or pointless and that no one liked or had ever cared about her. She found it hard to think straight at all.

A couple of months after the depression started Ella had an argument with a friend at school and walked out. The school phoned her mother and she and Ella had a major row. Ella felt completely hopeless and could see no future. She felt that she was just a problem making everyone’s life more difficult. She took an overdose of her mother’s tablets. An hour later she felt sick, panicked and went round to a friend’s house and told her what she had done. At the hospital she had to stay overnight for treatment. On the following day she saw one of the Child and Adolescent Mental Health Service (CAMHS) team, who also met her mother and talked to her head of year, with her mother’s agreement. The CAMHS worker helped her understand that she was depressed.

The presentation of a depressive disorder depends on the developmental stage of the young person. The ability to communicate about experiences can vary widely between young people. Cognitive development influences the symptom profile. For example, feelings of guilt, existential thinking, nihilism and morbid introspection are usually only described by older, more mature adolescents. Younger adolescents may show more dependent behaviour with parents than usual.

The origins of the depressive disorder and the particular way it presents itself will vary according to the circumstances of the individual but research has highlighted the following main areas of difficulty.

Main features of depression in adolescents

Mood changes:

• sadness, misery
• irritability.

Negative styles of thinking:

• low self-esteem
• feelings of helplessness and hopelessness
• suicidal thinking.

Difficulties with social relationships:

• social withdrawal
• social skills problems
• social problem-solving difficulties.

Physical symptoms of depression:

• sleep disturbance
• appetite disturbance
• inactivity
• loss of interest, apathy.

The effects of depression are wide ranging, and involve changes in the young person’s behaviour, feelings and thoughts. Commonly a vicious circle is created, in which symptoms of depression enhance themselves. For example, inactivity leads to disturbed sleep and to increased time for worrying, both of which increase the symptom of low mood, which in turn leads to further inactivity. Lack of sleep and poor concentration can lead to problems with schoolwork and an increasing sense of failure. As for Ella, irritability and sensitivity can lead to arguments and difficulties in relationships which escalate and prove to the young person that they are hopeless, worthless and that no one cares about them.

Diagnosis of depression

It is now generally accepted that depressive disorders occur in children and adolescents and that these can be diagnosed according to adult criteria (Harrington and Wood, 1995). The two international diagnostic systems, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) and International Classification of Diseases (ICD-10; World Health Organization, 1993) both categorise depression as mild, moderate and severe. ICD-10 puts the emphasis on symptoms whereas DSM-IV considers symptoms and functional impairment.

Both ICD-10 and DSM-IV require that symptoms be present for at least 2 weeks. ICD-10 describes depressive episodes as mild (F32.0); moderate (F32.1) and severe (F32.2 and F32.3). For each, at least two of the most typical symptoms (depressed mood, loss of interest and enjoyment, increased fatiguability) are required with the presence of at least three additional symptoms for moderate, and at least four, all of severe intensity, to be present for severe depression. Additional symptoms that must be present nearly every day are weight or appetite loss, sleep disturbance, observed restlessness or being slowed down, feelings of worthlessness, impaired concentration and morbid thinking or suicidal ideation. ICD-10 also includes a category for psychotic symptoms (F32.3).

DSM-IV requires the presence of five or more symptoms that result in significant distress or impairment in social, occupational or other important areas of functioning. In younger children psychosomatic symptoms such as abdominal pain or headaches may be prominent as well as separation anxiety, school refusal or failure to progress academically. In older children irritability, anxiety, motor agitation and social withdrawal feature more.

It appears that depressive disorder for children is different from that for adolescents. Children are more likely to have depression with another disorder (Alpert et al., 1999) and the diagnosis is commonly associated with major family dysfunction (Harrington et al., 1997).

It is now recognised that young people presenting with symptoms of depression that do not meet the threshold for diagnosis are vulnerable to developing full-blown depressive disorders. These young people with ‘subthreshold’ depression are more likely to become depressed than the general population (Costello et al., 1999). Depression is often encountered in young people following traumatic events such as assault or rape, where there are chronic family problems, where there is drug or alcohol misuse, aggressive behaviour or chronic school attendance problems.

Severity of depression is rated according to the number of symptoms present and degree of impairment in everyday life. Symptoms vary with age. Depressive symptoms commonly exacerbate life problems in a vicious cycle.

Multiple problems (co-morbidity)

In specialist mental health services depression is rarely seen in isolation. Concurrent symptoms of behaviour problems or anxiety will be present in almost all cases and between 50% and 80% of depressed young people will also meet criteria for another disorder. About 25% will have conduct or oppositional defiant disorder and a similar figure for anxiety disorder (Goodyer and Cooper, 1993; Angold and Costello, 1995). Other problems may have been present for several years. It may appear that the challenges presented by coping with difficulties in childhood become manifest as low self-esteem as the young person enters adolescence and is more acutely aware of their problems. The presence of multiple problems challenges successful intervention.

Depression can also be associated with physical illness such as diabetes, asthma or rheumatoid arthritis.

Some depressed young people use alcohol or drugs in an attempt to feel better. The after effects may compound difficulties for instance drugs such as cocaine may cause an irritable, depressed state (Barker, 2004).

Co-morbidity with other emotional and conduct disorders is common.

Suicidality and self-harm

Suicide or suicidal behaviour is associated with depressive disorders in adolescents (Kerfoot et al., 1996). Andrews and Lewinsohn (1992) found that adolescents who had deliberately self-harmed were 3–18 times more likely to be depressed than a control group. Pfeffer et al. (1993) found that non-depressed self-harmers had less suicidal ideation and less risk of future problems than the depressed group. Weissman et al. (1999) found that 7% of adolescents who developed a depressive disorder are at risk of committing suicide in their young adult years. Boys were more at risk of suicidal behaviour especially if they have a conduct disorder and alcohol or substance misuse (Shaffer and Craft, 1999). It is important for clinicians to enquire routinely about suicidal thoughts and self-harm and assess risk (see Chapter 10 for management of self-harm).

There is a strong relationship between depression and self-harm.

How common is depression?

Adolescent depressive disorder is not uncommon. Fleming et al. (1989) reviewed early studies and found the level of prevalence ranged from 1% to 6%. More recent studies have confirmed this. In a national survey of children’s mental health (Meltzer et al., 2000), 4% of 5 to 15-year-olds had an emotional disorder (anxiety and depression). Most studies have found that depressive disorder is much more common in adolescents than preadolescents (Olsson and Van Knorring, 1999; Angold et al., 1998a). Meltzer and colleagues found that participants were 8.5 times more likely to have depression at age 11 to 15 compared to age 5 to 10.

Studies consistently show increased prevalence associated with social disadvantage including living with a lone parent, parental unemployment and parents scoring highly on questionnaires suggesting emotional disorder (Hill, 1995; Melzer et al., 2000; Corcoran and Franklin, 2002; Myers, 2000).

Evidence from several studies suggests that ethnicity does not have a significant impact on the risk of adolescent major depression after sociodemographic adjustments are made (Doi et al., 2001; Chen et al., 1998; Roberts et al., 1997).

Studies have estimated that as many as 75% of children and adolescents with a clinically identifiable mood disorder are untreated in the community (Andrews et al., 2002; Coyle et al., 2003).

Between 1% and 6% of children will suffer from depression with rates increasing during adolescence.

Causes and factors in the development of depression

A substantial majority of young people experience depression in the context of long standing family and social difficulties, some with a clear precipitating life event and others with a slow deterioration in coping socially and in the family. In adulthood similar multiple pathways to depression have been described (Kendler et al., 2002).

It is most likely that the aetiology of adolescent, as for adult, depressive disorder is multifactorial. Theoretical models of depression include biochemical, genetic, psycho-social, and socio-economic frameworks. Some are summarised below.

Biochemical theories, such as the monoamine hypothesis, describe how underactivity in brain amine systems causes depression. Carlson and Garber (1986) proposed that too little serotonergic activity resulted in agitated depression and too little noradrenergic activity results in lethargic depression. This is discussed further in relation to use of medication in treatment of depression .

Genetic studies have indicated that genetic predisposition plays a more significant role in bipolar disorder than in unipolar depression (Kendler et al., 1995).

Children who develop major depression are more likely to have a family history of the disorder, often a parent who suffered depression in adolescence. This is unlikely to be owing to genetic influences alone (Harrington et al., 1997). Environmental and familial factors play a significant role in the aetiology of adolescent depression. Harrington (1994, 1999) argued that family factors are more widespread than a genetic factor in the development of adolescent depression. Parental depression can impact directly on the child’s early environment as symptoms may cause impaired parenting skills, lack of warmth or hostility to the child (Goodman and Gotlib, 1999). Parental depression is associated with marital discord (Quinton and Rutter, 1985). Asarnow et al. (1988) found that young people who had inpatient treatment for depression had worse outcomes if discharged to families with high levels of expressed emotion than those with a less critical family.

Harrington (1999) discussed the importance of bi-directional influences. Children with problems are a stress to their parents. There may be depressed thinking about their competence as parents. Negative cycles of interactions can develop and exacerbate parental depression (Hammen, 1991).

The social environment outside the family may also be influential on the development of depression in adolescents. Acute life events, including problems with peers and bullying may contribute directly (Harrington, 1992). Maternal depression is associated with social deprivation (Fergusson et al., 1995). Parental unemployment, poor housing, poor support networks and poor standards of living are all associated with increased risk of psychological disorders (Mental Health Foundation, 1999).

Once a young person is depressed, environmental factors associated with development of the disorder such as family relationship problems or school failure may then escalate and impair chances of successful recovery.

Biochemical, genetic, psycho-social ...

Table of contents

• Title Page
• Copyright Page
• Cover Page
• 2 Cognitive behaviour therapy: an introduction and overview
• 3 Cognitive behavioural assessment and formulation
• 4 Starting therapy
• 5 Early stages of therapy
• 6 Cognitive techniques
• 7 General cognitive behavioural techniques
• 8 Ending therapy
• 9 Working with the wider system
• 10 Special issues: bullying, bereavement, trauma and suicidality
• 11 Common problems
• Materials and worksheets
• References