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The most thoroughly tested form of psychotherapy for children is cognitive behavioral treatment. On the cognitive side, it takes aim at errors in thinking, especially self-defeating automatic thoughts that rule from the fringes of awareness. These thoughts are associated with sadness and withdrawal that make all of life's problems seem impossible to solve. The psychotherapist tries to make these unacknowledged thoughts explicit, and goes on to help the patient examine schemas, which are defined as pervasive fundamental systems of belief and ways of interpreting experience. The schema underlying depression, the so-called cognitive triad, is sometimes stated as, "I am worthless, the world is hostile, and there is no hope for the future." A depressed child or adolescent is shown evidence against these beliefs and helped to substitute new ways of thinking for pessimistic and self-critical attitudes. For this purpose, the patient may be asked to keep a daily record of thoughts and feelings.
On the behavioral side, children are encouraged to make a record of their activities and learn which ones give them pleasure or a sense of accomplishment. In therapy sessions and homework assignments, they rehearse new ways of behaving while learning assertiveness, practicing social skills, and developing strategies for solving problems.
Psychotherapists who work with depressed children may also be able to help their parents by improving family communication and problem-solving. Parents can be educated about depression, learning how to respond to the child's behavior and avoid situations that cause unnecessary conflict. In interpersonal therapy for adolescents, the last session is often a family meeting in which the therapist tries to help everyone distinguish between problems arising from depression and the usual tensions between teenagers and their parents. When a child has bipolar disorder, rehearsing what to do in case of a relapse may be useful. Families can also be taught how to avoid hostile and otherwise intensely emotional comments that raise the risk of relapse. Finally, treatment for a depressed parent is also treatment for a child who is depressed or at risk of depression.
Suicide is rare before age 12 but almost as common in late adolescence as it is in adults -- even though adolescent suicide is often concealed or not acknowledged, and may be disguised in the form of reckless driving and drug overdoses. Signs to explore are an apparent lack of interest in the future ("It's no use"; "Nothing matters"), constant thoughts about death and dying, and, of course, fantasies about suicide or a suicide plan. Suicidal thoughts and suicide attempts, even if not highly lethal, should always be taken seriously, because people who attempt suicide are at increased risk for completed suicide. It is safe to ask the adolescent direct questions, perhaps beginning "Have you ever felt so low that life seemed to be not worth living?" Teenagers who are not suicidal will say so. Some who have suicidal thoughts will not confess them, but others feel relieved to be able to talk about it. The therapist may offer solutions to the problem for which suicide was thought to be the answer, just to see whether the adolescent acknowledges that there are alternatives. Therapists may also convene a family meeting to make sure that the family has explicit plans for responding to suicidal impulses.
Hospitalization is sometimes necessary when the danger of suicide is immediate. Parents should ask why it is being recommended, what the alternatives are, whether the admitting physician is a certified child or adolescent psychiatrist, what the treatment program at the hospital is, and how long the child will be in the hospital. Legally, minors can be committed without their consent on the authority of a parent, but in practice psychiatrists will almost always consult their young patients first.
There are few controlled studies of psychotherapy for depressed children and adolescents, and most of them involve cognitive behavioral treatments. In a 1998 review, five of seven controlled trials found cognitive behavioral therapy to be more effective than no treatment (that is, being placed on a waiting list). The average rate of improvement was about the same as the rate found in medication trials. A 1998 meta-analysis (combined analysis) including six controlled studies of cognitive behavioral therapy for adolescents indicated that depressive symptoms were reduced for as long as two years. The most common control was a waiting list or relaxation rather than another form of psychotherapy or medication. Little is known about the effectiveness of other forms of psychotherapy.
Despite the uncertainty about causes, mental health professionals are beginning to work with schools in an attempt to prevent childhood depression. In one recent study, the families of 8- to-14-year-old children who had a parent with a mood disorder were divided into two groups. One group was given only educational lectures attended by many families. In the second group, therapists met four to eight times with individual families, including separate sessions for parents and children as well as joint meetings with the whole family, to discuss how the parent's depression affected the children. Family communication improved in both groups, but the response was better in families given individual attention.
In another study, researchers tested a school-based program for 10- to 13-year-olds who had symptoms of depression and conflicts with their parents. They were divided into four groups and assigned to cognitive training, social problem solving, a combination of both, or a control group with no special treatment. Children in all three treatment groups had fewer symptoms of depression than the controls immediately after treatment and six months later.
We still understand much less about mood disorders in children than we do about these disorders in adults. Long-term studies of prevention and treatment are needed, including more information about the adult outcome for children with depressive symptoms and how behavior disorders and attention deficit disorder are related to childhood depression. Far too little is known about either the risks or the therapeutic effects of antidepressants and mood stabilizers in children. We don't know whether the drugs are being overused or underused. Eventually, genetic and other research may reveal different kinds of childhood depression that respond to individualized forms of drug treatment and psychotherapy.
Reflection Exercise #7
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