Childhood Depression

CHILDHOOD DEPRESSION: GUIDELINES FOR PARENTS AND TEACHERS

DEFINITION: The essential feature is a change in mood or feeling where a child becomes sad, blue, gloomy, and irritable. There are many other symptoms or changes of behavior present in depression including (1) a marked loss of interest or pleasure in most activities; (2) increase or decrease in appetite with a weight gain or loss; (3) sleeping too much or too little; (4) restlessness or slow movements; (5) loss of energy and feeling tired; (6) feeling worthless or inappropriately guilty; (7) difficulty concentrating and thinking; and (8) often thinking about death or suicide (Diagnostic and Statistical Manual, DSMIII-R, 1987).

DURATION AND SEVERITY - While many children experience the above problems, the key in depression is that at least five of the above symptoms are observed changes in behavior and present almost every day for at least two weeks. The severity ranges from mild to severe according to the number of problems and their duration (DSMIII-R).

INCIDENCE - It is estimated that 3% to 10% of children experience severe to mild depression (McKnew, Catryn, & Yahres, 1983). Only since the 1960s has depression been recognized by professionals as a childhood disorder.

GENERAL INTERVENTIONS

The treatment and management of childhood depression involves many considerations and interventions. Depression especially requires treating the "whole child" and beginning with the "least restrictive alternative."

ASSESSMENT - Parents should first seek a thorough testing, which for depression often involves consulting many child professionals including the family's doctor, in addition to psychologists, psychiatrists, and school personnel. Testing should not only indicate the degree of depression but also all areas of development such as physical status and intelligence in addition to past history or the determinants concerning the development and maintenance of depression. Physical causes for depression symptoms especially need to be ruled out.

PRESCRIPTIVE INTERVENTIONS - The selection of the many intervention procedures applied to depression should depend on the child's individual needs. The counseling and management approaches for depression include behavioral, social skills, cognitive, familial, and multimodal interventions (see enclosed specific interventions).

FAMILY THERAPY -This approach is often applied to depression where the family is treated as a unit. For depression, counseling is directed at reducing maladaptive interactions between the depressed child and other family members which maintain depression symptoms in addition to scape- goating and family expectations.

SPECIAL EDUCATION - Depressed youths may be eligible for placement in "severe behavioral handicapped" programs at school. This is helpful when school failure due to depression is encountered.

MEDICAL TREATMENT - Medications and even hospitalization are often used by medical doctors to treat depression. However, these should be provided when other less restrictive treatments are found to be ineffective - such as counseling - or if life-threatening behavior is encountered.

SPECIFIC SUGGESTIONS ENCOURAGEMENT - Depressed children may have the "mistaken goal" that they can find their place with others by "display of inadequacy." Encourage them at those very times when they appear sad or hopeless to let them know that you aren't giving up on them; thus, you do not let them achieve their "mistaken goal."

CONFRONTATION - At times, telling the child he/she is wrong and eliciting anger helps break depression. Encouragement should be used following confrontations.

RULE OUT DRUGS AND ALCOHOL - Depressed youths may have a higher risk for substance abuse, and symptoms may be due to substance abuse rather than depression. Refer to the family physician and agencies specializing in chemical abuse if this is suspected.

TEACH SELF-MONITORING - Have the child record activities in a notebook and rate how he/she felt during each activity, using a 10-point scale (0 is the worst and 10 is the best you ever felt). Help the child correct misinterpretations which may have caused negative feelings.

PROMOTE INVOLVEMENT - Schedule activities during the depressed child's day at home and school to reduce passivity and increase interaction with peers and adults.

PROVIDE OPPORTUNITIES FOR REPEATED SUCCESS - Activities that are within the child's capabilities and are likely to result in success or pleasure should be arranged as part of the child's schedule.

PROVIDE SOCIAL SKILL TRAINING - A depressed child's social withdrawal often results from an inability to elicit and secure positive reinforcement from others as well as an inadequate repertoire of social behavior. Teach the child positive social interaction skills.

TEACH PROBLEM-SOLVING SKILLS - Depressed children often lack social competence to solve interpersonal problems. Exploring alternatives and examining potential consequences are strategies that facilitate problem resolution (see guidelines handout, Problem-Solving Techniques for Discipline and Guidance.)

BIBLIOTHERAPY - Bibliotherapy involves the use of books to promote adjustment of children. Books, articles, or stories carefully selected that deal with the subjects of death, divorce, and so forth may be used to reduce unrealistic perceptions in addition to promote positive coping skills.

USE MUTUAL STORY TELLING - This is an excellent technique to provide insight and instill hope for the depressed child. After the child tells a story, the teacher or parent offers a slightly altered version containing a resolution of some problem or a special message. Once both stories are concluded, a lesson is offered for the stories.

EXPLORE ENVIRONMENTAL MODIFICATIONS - Change in schools, special education resources, and reorganization of custody/visitation rights are examples of adjustments which may help.

PARABLES, METAPHORS AND FABLES - These are alternative thinking devices which may help convey a message or help the depressed child clarify his/her feelings.

TEACH POSITIVE SELF-TALK - The use of positive covert speech and coping statements mitigates the depressed child's diminished feelings of self-esteem and reduces associated anxiety.

USE MODELING - Find appropriate model(s) for the depressed child. Rearrange the seating to promote involvement with peer(s).

BREAK TASKS INTO SMALLER UNITS - Careful assignments which provide frequent successful experiences increase self-esteem and are particularly useful for dealing with the depressed child's lack of interest and energy, especially for school-related tasks.

AGENDA SETTING - Involve the child in the scheduling of pleasurable activities or daily routines to increase feelings of control and mastery as well as increase the likelihood of success.

ARRANGE FOR THE DEPRESSED CHILD TO HELP OTHERS - Often doing something special for others helps the helper feel better about himself-herself and is incompatible with negative rumination or preoccupations.

CORRECT THINKING ERRORS - The depressed child often distorts reality by thinking errors such as overgeneralizations ("I am always going to be a loser.") and dichotomous thinking ("I failed the test so I must be stupid.") Call attention to these when observed and provide alternative, positive thinking (e.g., "Kites rise highest against the wind." - Winston Churchill).

USE HUMOR - Humor is often effective to point out fallacies or thinking errors of depressed children (e.g., "Even postage stamps become useless when they get stuck on themselves").

POSITIVE SELF-RATINGS - Ask the child to write down positive attributes about himself/herself. Use this list as targets about the child to be pointed out for encouragement and reinforcement when observed at home or school.

CATCH THE CHILD BEING HAPPY - Praise and approve positive behavior such as self-confidence or humor and try to ignore depressed behavior as much as possible.

USE DIARIES, DRAWINGS, PUPPETS, STORY-TELLING, AND FANTASY GAMES - These techniques promote communication and understanding of the child's feelings and thoughts.

SUICIDE TREATMENTS - Suicide thoughts and behavior frequently occur with depression, and this life-threatening condition should be identified and treated if present.

THE CLASSROOM TEACHER MAY ALSO BE OF ASSISTANCE BY:

1. Encouraging the student to attempt even partial assignments or par-ticipate even on a minimal basis in class.

2. Providing opportunities for repeated success. Encourage activities which are within the pupil's capabilities and are likely to result in success or pleasure upon completion.

3. Stressing short-term goals and objectives. Offer rewards for activities completed that require sustained effort and concentration.

4. Specific classroom reinforcement schedules may be developed to provide sustained praise and encouragement at selected times throughout the day.

5. Making sure expectations do not exceed the child's capabilities.

6. When possible, decrease the amount of perceived stress.

7. Being aware that feelings of worthlessness, diminished ability to concentrate, suicidal thoughts, loss of interest in usual activities, and changes in eating and sleeping patterns commonly accompany depression. Do not expect the child to initiate social activities. Gently guide and suggest activities that may not be too strenuous or overwhelming.

8. Being realistic in regard to what the child will be able to accomplish in the traditional classroom. Depression requires professional treatment. Both counseling and medication use need time to alleviate the depressive symptoms.

9. Severe depression may be related to suicidal behavior in certain cases. Precautionary measures should be taken as the depression begins to subside and the student gains more energy.

References

Clarizio, H. (1985). Cognitive-behavioral treatment of childhood depression. Psychology in the Schools, 22, 308-322.

McKnew, D.H., Catryn, L., & Yahres, H. (1983). Why isn't Johnny crying? New York: Norton. Venzke, R.C., Farnum, M. K., & Kremer, B.J. (1987).

Childhood depression. American Mental Health Counselors Association Journal, 1, 28-36.