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Effectively Treating Pathological Self-Criticism in Depressed & Dysthymic Clients
Effectively Treating Pathological Self-Criticism in Depressed and Dysthymic Clients

Section 24
Family Interventions with Depressed Youth

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Family Interventions
Numerous studies have documented the importance of family attitudinal and interaction patterns for depressed youth (for reviews, see McCauley & Myers, 1992; Stark, Ostrander, Kurowski, Swearer, & Bowen, 1995), lending support to the inclusion of families in the treatment process. First, among youth with depression, greater family stress has been found to be associated with a longer initial episode and lower social competence at 3-year follow up (McCauley et al., 1993). Second, depressed children whose homes were characterized by high levels of parental criticism or emotional overinvolvement demonstrated significantly lower recovery rates at the end of the first year after hospitalization than did children whose parents scored low on these variables (Asarnow, Goldstein, Tompson, & Guthrie, 1993). Third, during depressive episodes, children demonstrate more negative and guilt-inducing behavior in laboratory-based family interactional tasks when compared to nondepressed psychiatric and control participants (Hamilton, Asarnow, & Tompson, 1999), underscoring the high level of stress experienced by families of depressed children. Fourth, maternal and child depressive episodes may be temporally linked such that symptoms in one member of the dyad potentiate symptoms in the other (Hammen et al., 1991). Fifth, although studies of depressed adults indicate strong family histories of depression in first degree relatives, familial loading appears to be even more substantial in children (Puig-Antich et al., 1989) and adolescents with major depression (Kutcher & Marton, 1991). Thus, children with depression are likely to be living with parents who also experience depression. Consequently, as Kazdin and Weisz (1998) pointed out, "Child and adolescent therapy is often de facto 'family context' therapy."

The data on families and depression are predominantly correlational, and thus the role of family factors in the etiology of depression remains unclear. However, a number of authors have noted that these findings support an interactional model (Asarnow et al., 1994; Coyne, Downey, & Boergers, 1994; Hammen et al., 1991; Keitner & Miller, 1990, 1994) in which parental depression and criticism, dysfunctional family interactional patterns, and family stress contribute to ongoing child depression, which in turn fuels family stress and dysfunction. Thus, regardless of their role in depression etiology, family factors may impact depressive symptoms, and the depressed individual impacts the family system. Family treatment strategies also have potential for decreasing the risk of depressive episodes across multiple family members (e.g., mother, children, father). Furthermore, depression in youth often presents with additional comorbid conditions, particularly anxiety and disruptive behavior disorders (Birmaher et al., 1996), and family-based treatments that improve family functioning and increase coping skills are capable of addressing a range of problems that these children are likely to present in treatment.

Although family and marital interventions have demonstrated efficacy in the treatment of adults with both depression (Jacobson et al., 1991; O'Leary & Beach, 1990) and, to a more limited extent, bipolar affective disorder (Haas et al., 1988; Miklowitz & Goldstein, 1997), examination of family-based treatments for depression in youth is extremely limited, and existing trials provide contradictory evidence as to their value. Research completed to date has examined both brief family education interventions as wall as more extended family interventions.

Brief Family Education Interventions

There is emerging support for the value of brief psychoeducational family programs. Brent, Poling, McKain, and Baugher (1993) examined the impact of family education on depression in youth. They reported that following a 2-hr psychoeducation session, participants showed greater knowledge about depression as wall as fewer dysfunctional beliefs about depression and the treatment of depression. Participants almost uniformly rated the program as worthwhile (97%) and felt that they had learned a lot (98%). In addition, in perhaps the largest adolescent depression treatment study completed to date, Brent et al. (1997) added a brief family psychoeducation component across all treatment conditions as a means of minimizing dropout and promoting a family atmosphere that would support treatment gains.

In addition, our group (Asarnow & Scott, 1999) tested a combined cognitive-behavioral and family education intervention with fourth through sixth graders with depressive symptoms. The family education session followed nine sessions of group CBT during which children produced a video as a means of helping them to practice and consolidate the skills introduced in each CBT session. The family education session was designed to promote generalization of skills to key environmental contexts (home, school, community). A major part of the session was a brief parent-only segment where the emphasis was on (a) the importance of helping the children to generalize the skills to real-world contexts and problems, (b) the fact that children would be more likely to use the skills if they felt good about what they had accomplished in the group, and (c) the value of the family session as a means of helping parents to help their children to feel positively about the CBT skills and to use the CBT skills in real-world settings. After this introduction, parents and children were brought together for a multiple family meeting during which the children's video illustrating the treatment model was presented, and children were given awards for their accomplishments during the CBT. Parents and their children then engaged in a series of structured games designed to teach the parents the skills emphasized in the group CBT and promote generalization to critical life settings. The session ended with each child presenting his or her parents with an award for their participation in the family session. Results indicated that the intervention was associated with greater reductions in depressive symptoms as compared to a wait list control group. In addition, children and parents almost uniformly rated the intervention as enjoyable. When asked about the family component, all of the parents rated this intervention as useful. However, only 40% of the parents felt that more extended family sessions would be helpful, underscoring the potential utility of including some family education as well as the potential difficulties with lengthy family interventions.

Extended Family Interventions

Results of extant studies on the efficacy of extended family interventions are not encouraging. As shown in Table 1, Brent et al. (1997) compared systemic-behavioral family therapy, individual CBT, and individual nondirective supportive therapy for adolescents with major depression. The family treatment utilized a combination of reframing and communication and problem-solving skills training to alter family interaction patterns. Results indicated that systemic-behavioral family therapy was significantly less effective than CBT and was comparable in efficacy to nondirective supportive therapy in this study. However, it is important to note that all groups in this study received the brief family psychoeducation intervention described earlier.

Second, Lewinsohn and colleagues (Clarke et al., 1999; Lewinsohn et al., 1990) compared adolescent-only group CBT, adolescent group CBT plus parallel parental group CBT, and a wait list control condition. The addition of the parental component offered no clear advantage over group CBT alone. However, it is important to note that the Lewinsohn et al. group CBT does focus on family interactions by teaching communication, negotiation, and conflict resolution skills for use with parents and peers, and including homework assignments practicing these skills with parents.

Third, the depression-specific treatment employed in the Wood et al. (1996) study, which encouraged parents to help in the CBT, was significantly superior to relaxation training in reducing depression. However, the design of the study does not permit evaluation of the specific impact of family involvement per se.

Fourth, Fristad and colleagues (Fristad, Gavazzi, & Soldano, 1998) described a six-session multifamily psychoeducational group for childhood mood disorders. Psychoeducational groups sessions begin and end with both the parents and adolescent or child; however, much of the material is then presented in "breakout sessions" in which parallel parent and child or adolescent groups are conducted. Topics of discussion in each of the groups include education about mood disorders, medication and medication side effects, interpersonal factors, communication skills, and stress reduction. During the child and adolescent groups, participants are able to meet others who cope with similar difficulties, increase their knowledge of symptoms and symptom management, build their social skills, and discuss common developmental issues (e.g., adolescents may focus on issues of substance use which are commonly confronted). Although the impact of this treatment on clinical symptoms has yet to be evaluated, preliminary data indicate that families are satisfied with the intervention, and parents report positive changes in their interactions with their child or adolescent following the intervention.

Three additional family treatment models have been proposed and are currently being evaluated. First, an ongoing study being conducted by Diamond and colleagues at the Philadelphia Child Guidance Center provides preliminary evidence that family treatment may be effective with depressed adolescents. Diamond and Siqueland (1995,1998) described a family treatment modal for depressed adolescents that derives from attachment theory and focuses on building the bond between the adolescent and his or her parents so that the family can serve as a secure base from which the adolescent develops increasing autonomy. The therapeutic strategies include a nonblaming reframing of the goals of treatment from a focus on the adolescent's symptoms to a focus on the quality of parent-adolescent relationships, building alliances between the therapist and both the parent and adolescent, promoting attachment between the parents and the adolescent, and building competencies within the adolescent. Although evaluation of this treatment approach is currently in its beginning stages, early results suggest greater recovery from depression among the family-treated group compared to a wait list control group (Diamond, personal communication, February 2, 1999). Second, Schwartz and colleagues (Schwartz, Kaslow, Racusin, & Carton, 1998) described Interpersonal Family Therapy, a sophisticated model integrating theory and techniques from family systems perspectives, cognitive behavioral approaches, attachment theory, interpersonal therapy, and developmental psychopathology. Goals of the treatment include decreasing depressive symptomatology, changing maladaptive cognitive patterns, improving family affective communication, increasing adaptive behavior, and improving both interpersonal and family functioning. Although to our knowledge no empirical evaluation of this approach has yet been completed, this treatment attempts to focus on identifying and intervening in areas of particular need within each family, thus providing a tailored strategy. Finally, Tompson and Asarnow are currently testing a family focused intervention for depressed children (ages 8-14) based on both cognitive-behavioral and family systems models. This approach provides expanded family psychoeducation and skills building within a family context. Goals of the intervention include (a) educating family members about depression, focusing on its interpersonal nature; (b) teaching parents and children skills that will enable them to communicate and solve problems more effectively; (c) improving positive communication that may help family members to provide one another with more effective support; and (d) helping families to solve specific family problems.

Collectively, the data reviewed earlier highlight the potential advantages and disadvantages of adding a family component to the intervention. On the plus side, the data suggest that families see brief family educational interventions as helpful; there are no data indicating that these interventions are detrimental; and there are some data from the adult literature indicating that family interventions are associated with improved outcome or course in unipolar depression (Jacobson et al., 1991; O'Leary & Beach, 1990), bipolar disorders (Clarkin, Carpenter, Hull, Wilner, & Glick, 1998; Hass et al., 1988; Simoneau, Miklowitz, Richards, Saleem, & George, in press), and schizophrenia (for review, see Goldstein, 1995). Alternatively, to our knowledge, there are no data showing that family treatments are more effective than other forms of treatment for depressed youth. Insisting on family treatment models also appears to result in a sizable proportion of families refusing treatment. Nine of the 15 families (60%) refusing randomization in the Brent et al. (1997) study did so because they did not want family treatment, an observation that is consistent with results from our pilot study indicating that families preferred a brief as opposed to more extended family intervention.

It is important to note, however, that studies examining family interventions have emphasized adolescents rather than younger children who may be particularly likely to benefit from family-based treatment. Indeed, a recent study of family intervention for childhood anxiety disorders underscores the importance of carefully considering age group. Barrett, Dadds, and Rapee (1996) compared individual CBT, CBT plus family treatment, and wait list control group. At posttreatment, significantly more children in CBT (57%) achieved recovery from their anxiety disorder than those in the wait list group (26%), but the CBT plus family treatment group showed the highest rates of recovery (84%). The difference between the two active treatments was maintained at both 6-month and 12-month follow-ups. Most interesting, however, was the finding of a significant age effect, where younger children (age 7-10) showed better outcomes in CBT plus family treatment, whereas older children (ages 11-14) did equally wall in both active treatments. These findings highlight the importance of examining family-based treatments in preadolescents.

Prevention of Depression
The promise of CBT for treating depression has led to efforts to prevent depression from developing in children and adolescents. According to the model of depression depicted in Figure 1, the same skills that would reduce depression could be used to inoculate children against depression. Improved ability to challenge dysfunctional thinking and to develop functional behavior would be expected to decrease the likelihood that stress would lead to the downward spiral of depression.

Clarke, Hawkins, Murphy, and Sheeber (1993) developed a primary prevention program targeting normal adolescents in school and was unable to detect significant benefits over a 12-week follow-up period. However, three studies that attempted to prevent depression among children with elevated depressive symptoms showed more success. Clarke et al. (1995) found that, among adolescents with depressive symptoms but without Major Depressive Disorder or Dysthymic Disorder, group treatment based on CBT was associated with lower depressive symptom scores, lower rates of onset of major depression or dysthymia over 12 months of follow-up, and improved psychosocial functioning, compared to a no intervention comparison group. Jaycox, Reivich, Gillham, and Seligman (1994) selected children at risk for depression by virtue of subthreshold depressive symptoms or a high degree of family conflict at home and randomized schools to CBT or waitlist control conditions. Immediately after treatment, the 69 treated children showed lower levels of depressive symptoms and better classroom behavior compared to 73 children in the no-treatment condition (Jaycox et al., 1994).

Moreover, the treated children continued to report fewer depressive symptoms at a 2-year follow-up assessment, with the number of treated children who reported symptoms of depression in the moderate to severe range reduced by one half (Gillham, Reivich, Jaycox & Seligman, 1995). King and Kirschenbaum (1990) conducted a program of social skills training and consultation with parents and teachers and found that treated children fared better than those who received consultation only.

Another approach to preventive interventions has been tested by Beardslee et al. (1992), who identified youth at high risk for depression based on having a parent with a serious mood disorder. Beardslee et al. (1992) tested a family-based preventive psycho-educational intervention. This 6- to 10-session intervention involved individual sessions with both the parents and the child aimed at helping parents to convey to their children an understanding of the parent's mood disorder, informing the parents about factors that increase resiliency in children, and assisting the child in identifying questions and concerns for the parents to address. One or two family meetings were then held to enable the patents and child to address these issues together. The children in these families were between the ages of 8 and 14 years. Compared to participants in a lecture-only control group, parents in the family intervention group reported greater satisfaction and more behavior and attitude changes, including increased family communication about the mood disorder, improved understanding of the child's experience, and more.

Although the research reviewed earlier supports the value of psychosocial interventions for depression in youth, several caveats merit note and underscore the critical need for additional research on the treatment of depression in youth.

  1. The psychosocial treatments tested to date with clinically depressed youth have shown relatively limited efficacy. When clinically depressed samples have been employed, roughly 40% to 50% of the sample has failed to show significant recovery or remission as defined in each study. This rate is consistent with the relatively low recovery rate observed in extant pharmacologic trials, where about 40% to 50% of the sample have continued to show significant symptoms at the end of treatment (Ambrosini, Bianchi, Rabinovitch, & Elia, 1993; Emslie et al., 1997). Thus, although the tested treatments have shown promise, a substantial proportion of youth fail to respond. These data underscore the need to develop more effective treatment strategies.
  1. The most marked improvements have generally been found on measures of depression. Improvements in functioning outcomes have been more difficult to demonstrate and may require more extended treatment or alternative approaches. Although requiring replication, recent demonstrations of improvement in social functioning following IPT (Mufson et al., 1999; Rosello & Bernal, 1999) are likely to lead to advances in this area. Future research should include assessments of multiple domains of outcome including social functioning outcomes as well as domains that are presumed to be causally related to treatment outcomes (e.g., dysfunctional cognitive and attributional patterns).
  1. Most studies with clinically depressed samples have emphasized acute treatment during depressive episodes. Despite the relatively high risk of relapse found in child and adolescent depression, there is very limited data on continuation treatment. Clarke et al. (1999) found that booster CBT sessions every 4 months were associated with accelerated recovery among youth who were still depressed after acute treatment, but did not have a significant effect on recurrence rates. Kroll, Harrington, Jayson, Fraser, and Gowers (1996) found that continuation CBT following roughly 10 weeks of acute treatment was associated with lower relapse rates (.20) as compared to a historical control group (.50). Vostanis et al. (1996) and Wood et al. (1996) found that the rate of depressive relapse was around 40% in the first 6 to 12 months after withdrawal of acute treatment. Emslie et al. (1998) found similar rates of relapse and recurrence in a 1-year naturalistic follow up of a cohort participating in a medication trial. These data underscore both the promise of continuation treatments as wall as the critical need to develop optimal strategies beyond acute phase treatment.
  1. Although extant research on psychosocial treatments for depressed youth have emphasized CBT, other approaches have also shown promise. For example, IPT has been shown to be efficacious in adult depression, and recent data support the feasibility, acceptability, and efficacy of IPT for adolescent depression (Mufson et al., 1999; Rosello & Bernal, 1999). Additional research is needed to identify alternative treatment approaches or to improve on current treatments.
  1. Most of the studies of youth with clinical depressive disorders (major depression or dysthymic disorders) have emphasized adolescents. Of the completed treatment studies with youth meeting criteria for depressive disorders, only the Wood et al. (1996) and Vostanis et al. (1996) studies included children below the age of 14 years. This is not surprising given the increased rate of depressive disorders with adolescence. However, additional work is needed to clarify optimal treatment strategies for younger children suffering from depressive disorders.
  1. Despite the promise of cognitive-behavioral interventions for depressed youth, the literature suggests weaker effects for youth treated in real-world settings (Weisz et al., 1995). This underscores the need for research focusing on how to bridge the gap between research demonstrations of efficacy and real-world clinical practice settings.

Conclusion and Discussion
The past 20 years have witnessed major advances in knowledge regarding depression in youth. Advances have been achieved in knowledge regarding phenomenology, correlates, etiology, and psychosocial factors. Major advances have also been achieved in knowledge regarding the treatment of depression in children and adolescents. Although additional research in this area is needed, clinicians can now turn to treatment strategies with demonstrated efficacy, and guidelines for clinical practice have been developed and disseminated. To date, psychosocial treatment research has emphasized cognitive-behavioral approaches and acute phase treatment.

Based on extant research and current guidelines, if Alice were seen today, treatment planning would begin with a thorough evaluation to confirm a diagnosis of depression and determine whether there are complicating comorbidities or psychosocial problems that need to be addressed in the treatment plan. For example, a comorbid diagnosis of substance abuse would suggest the need to treat the substance abuse prior to initiating depression treatment, and identification of depression in Alice's mother would indicate a need to address the mother's treatment needs. Second, based on our limited ability to predict which youth will benefit from which forms of treatment, offering Alice and her family a choice regarding treatment options would appear to represent a logical strategy and one that is likely to promote treatment adherence. Treatment options with support from the efficacy literature include CBT and meditation (selective serotonin reuptake inhibitor). In addition, two initial studies support the promise of IPT for depressed adolescents (Mufson et al., 1999; Rosello & Bernal, 1999), with reported effect sizes for IPT exceeding those for CBT among adolescents with depression. Limited data further indicate that families are likely to view brief family psychoeducation as helpful (Asarnow & Scott, 1999; Brent et al. 1997). Following acute treatment, should Alice continue to show symptoms, there is some support for the value of continuation CBT (Clarke et al., 1999). However, empirical data to support decisions regarding continuation treatment for youth are presently lacking.

Additional research is needed to evaluate other treatment approaches, combined treatments, algorithms for making sequential treatment decisions, interventions for preventing relapse, strategies for promoting recovery among nonresponders to acute treatment, and to further clarify active treatment components and the processes through which therapeutic change occurs. There is also a critical need for research aimed at developing strategies for ensuring that efficacious treatments are available in real-world clinical practice settings where children like Alice seek treatment. As the field progresses, results of treatment research will further inform our models for the development and progression of depressive disorders in youth, as this body of research continues to inform our treatment strategies.

- Asarnow, Joan Rosenbaum, Jaycox, Lisa H., Tompson, Martha C.; Depression in Youth: Psychosocial Interventions; Journal of Clinical Child Psychology; Feb 2001; Vol. 30; Issue 1.

Personal Reflection Exercise #10
The preceding section contained information regarding interventions with depressed youth.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 24
Based on the data, what was suggested regarding the usefulness of family educational interventions? Record the letter of the correct answer the CEU Test.

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