Depressive Disorders in Youth

Identification/Assessment Strategies

Thorough assessment strategies are necessary for accurate diagnosis and treatment of depressive disorders, and facilitate the prescription of effective medications by physicians (Evan-Lacko, dosReis, Kastelic, Paula, & Steinwachs, 2010). Although recommendations from the field specify that psychopharmacotherapy should be used in conjunction with counseling, it is an important component to some treatment plans for youth with depressive disorders. The most effective assessment procedures for determining a youth’s emotional distress levels involve the collection of multiple data points from self- as well as other-report measures (Kendall & Comer, 2010). Therefore, in addition to using information collected from the youth through either self-report or observation, counselors should also incorporate information collected from the youth’s parents/caregivers, siblings, teachers, school staff, and other important people.

Children’s Depression Inventory
The Children’s Depression Inventory (CDI; Kovacs, 1992) is a 27-item self-report measure used to assess depression in children and adolescents from the previous two-week period. This measure can be used to evaluate five factors (i.e., negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem), and one item is included to assess for suicidal ideation. For younger children or those with reading difficulties, the CDI can be administered orally. Additionally, parent-report (17 items) and teacher-report (12 item) versions of the CDI are available. The CDI can be utilized for diagnostic assessment as well as evaluation of progress in counseling.

Beck Depression Inventory for Youth
The Beck Depression Inventory for Youth (BDI-Y; Beck, Beck, & Jolly, 2001) is a 20-item self-report measure used to identify symptoms of depression in children and adolescents. This measure includes items regarding feelings of sadness, guilt, negative thoughts (about self, life, or the future), and disturbances (e.g., sleep, appetite). Written at a second-grade reading level, the BDI-Y can be utilized for diagnostic assessment as well as evaluation of progress in counseling.

Resources:
American Academy of Child and Adolescent Psychiatry. (2007). Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 46(11), 1503-1526. doi:10.1097/chi.0b013e31814ae1c 

The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) provides supplemental assessment tools for depression: http://www.integration.samhsa.gov/clinical-practice/screening-tools#depression

Intervention/Treatment Strategies

Approaches rooted in cognitive behavioral treatment principles are believed to be the most effective in treating depressive disorders in youth. When working with youth who experience depressive symptoms, counselors should be vigilant about assessing and monitoring for suicide risk. What follows is an overview of the most evidence- based approaches and interventions used to treat youth depression.

Psychoeducation
Regardless of one’s treatment approach, when working with youth that have depression, psychoeducation becomes an important aspect of the counseling process (Smith, Jones & Simpson, 2010). Psychoeducation typically involves counselors engaging in conversations with youth and their families about the effects and patterns of depressive concerns. Ultimately, psychoeducation serves to help young people link the relationship between their emotional experiences, thinking, and behaviors. When working with young children, writing, drawing, and play are some techniques that can be used to illustrate the connection between emotions, thoughts, and behaviors (Stark, Streusand, Krumholz, & Patel, 2010).

Psychoeducation enhances a youth’s awareness of the effects depressive symptoms have on behaviors and is linked to more positive treatment outcomes (Smith et al., 2010). Counselors are encouraged to consider including pyschoeducation as part of a youth’s treatment plan, as increased understanding can also facilitate a sense of empowerment in young clients. Psychoeducation lays the groundwork for youth to participate in self-monitoring, self-initiating, and self-regulating skills that are essential to cognitive behavioral treatment approaches, and help young people to manage depressive symptoms.

Cognitive Behavioral Therapy
A cognitive behavioral therapy (CBT) approach to youth depression involves educating youth to recognize their reactions to depressive symptoms and utilize behavioral and cognitive coping strategies (Friedberg, McClure, & Garcia, 2009; Stark, Streusand, Prerna, & Patel, 2012). When youth are depressed they frequently ruminate and focus on negative thoughts about themselves, their world, or the future. Therefore, the goal of CBT is to assist youth in identifying, challenging, and modifying their thoughts, beliefs, and assumptions in order to generate more adaptive thought processes. The essential goal in CBT is to have youth shift their thinking to becoming aware of their positive attributes and skills (Kress & Paylo, 2015). CBT principles and interventions are important counseling interventions to apply with youth who have depression (Klein, Jacobs, & Reinecke, 2007).

Cognitive restructuring is one technique that may be used in counseling, and this technique involves young clients identifying and replacing distorted cognitions with more positive, adaptive beliefs. Counselors will need to assist youth in identifying cognitive distortions and help them elaborate on their interpretations and assumptions, in alignment with their developmental level. Next, counselors should have clients assess whether or not there is evidence to support the harmful or negative thoughts. With young clients, a visual representation (e.g., the use of pictures, visual or cyclical patterns, drawings, paintings, puppets, or clay) may be used to help identify and challenge distorted thoughts.

Behavioral Activation Therapy
Behavioral activation therapy (BAT; Chartier & Provencher, 2013) is used to modify young clients’ behaviors, which consequently reduces their depressive symptoms, feelings, and thoughts.  The basic premise of BAT is that if you stay busy and engaged in activities that are enjoyable, you will begin to feel better. When young people are behaviorally activated they are more likely to participate in enjoyable activities, which then contributes to an enhanced mood.

The implementation of BAT with youth involves activity scheduling to assist them in challenging the withdrawal, stagnation, and passivity that depression often invites (Chu, Colognori, Weissman, & Bannon, 2009). When using BAT, a counselor helps youth reflect on previous experiences, identify activities that were once enjoyable, and engage in those pleasurable activities. Youth who have depression often have a difficult time listing previously- enjoyable activities, and counselors will need to be active in facilitating this process. Family members and/or caregivers may also be helpful in identifying previously-enjoyed activities. In between sessions, youth are encouraged to self-monitor their involvement in the activities identified. In addition to documenting their activities, clients are also asked to write down their mood after participating in the activity. The aim of BAT is to emphasize for clients that involvement in pleasurable activities enhances their energy level and improves their general well-being.

Psychopharmacotherapy
When counseling youth, some professionals recommend the use of medication in combination with counseling (Sommer-Flanagan & Campbell, 2009). Especially with youth who have severe depression or persistent depression that is not responsive to counseling, medication referrals may be necessary (Kress & Paylo, 2015). In this case, medication compliance should be integrated into the young client’s treatment plan. Counselors should attempt to collaborate with medical professionals, the client, and the family to ensure medications are being taken as prescribed.

Research suggests that certain medications are effective in lessening depressive symptoms (Kendall & Comer, 2010). Counselors should be aware that antidepressant medication has been linked to an increased risk of suicidality in adolescents (Barbui, Eposito, & Cipriani, 2009). As such, counselors must regularly assess for suicide, especially with young people who have recently started to take medication or those who have had changes in their medication (Barbui et al., 2009).

Resources:
Articles on Behavior Activation Therapy http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223147/ http://www.personal.kent.edu/~dfresco/CBT_Readings/BM_Lejuez_BATD_Manual.pdf

Beck Institute for Cognitive Behavior Therapy 
http://www.beckinstitute.org/get-informed/tools-and-resources/professionals/

The American Association of Suicidology provides resources for families and clinicians about suicide risk factors http://www.suicidology.org/resources/recommended-videos

The Development of the Interpersonal and Social Rhythm Therapy (IPSRT) website was supported by the National Institute of Mental Health grant R34MH091319 https://www.ipsrt.org/

The National Center for Biotechnology Information: Provides information on Interpersonal Therapy http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1414693/

Youth Suicide Prevention Program http://www.yspp.org/downloads/resources/YSPP_depression_Final_low.pdf