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Depressive Disorders in Children and Adolescents: Identification and Treatment. Elizabeth McCauley, PHD, ABPP Professor University of Washington/Seattle Children ’ s Hospital. Agenda. What is Depression? Scope of the Problem Diagnostic Dilemmas

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Depressive disorders in children and adolescents identification and treatment

Depressive Disorders in Children and Adolescents: Identification and Treatment

Elizabeth McCauley, PHD, ABPP


University of Washington/Seattle Children’s Hospital

Agenda Identification and Treatment

  • What is Depression?

  • Scope of the Problem

  • Diagnostic Dilemmas

  • Causal Model: predisposing, precipitating, perpetuating

  • Adolescence as a Risk Factor

  • Assessment

  • Treatment

What is depression
What is Depression?? Identification and Treatment

  • Major Depressive Disorder

    • Depressed Mood/Irritability and/or anhedonia

    • Presence of subset of other symptoms: sleep or appetite disturbance, morbid ideation/suicidality, decreased energy, difficulties concentrating/making decisions, hopelessness/down on self

    • Symptoms which occur together, persist for at least two weeks and are associated with a significant loss of ability to function

  • Other depressive dxs: Dysthymia, Adjustment Disorder with Depressed Mood

  • Mounting body of evidence suggest that depression differs from normal experience in degree, rather than in type (Coyne, 1994; Ruscio & Ruscio,2000, 2002).

    • Major depression appears to be a quantitative variation of normal functioning

    • Use of continuous versus categorical assessment approaches

What is depression1
What is Depression?? Identification and Treatment

When is depression depression….?

  • Persistent vs. transient symptoms—79% persistence in recent study of 8th graders assessed via self-report in a school setting at 4 week intervals

  • Youth with subclinical symptoms at increased risk for subsequent depression, adverse outcomes

  • Experiencing a first episode of depression increases the likelihood of recurrence and continuation into adult life

  • Importance of assessing functional impairment

Depression scope of the problem
Depression: Scope of the Problem Identification and Treatment

  • Children: 1 year prevalence rate of 2%

  • Adolescents: 1 year prevalence rate of 4% to 8%

  • National Cormorbidity Survey: 6.1%, 15-24 years

  • Lifetime prevalence (up to age 18) 15%-20%

  • 65% of adolescents report some depressive symptoms

  • 5% to 10% of youth with subsyndromal symptoms have considerable psychosocial impairment, high family loading for depression, and an increased risk for suicide and developing MDD (Fergusson et al., 2005)

Scope of the problem
Scope of the Problem Identification and Treatment

  • Mean length of episodes: 7 to 9 months

  • 6% to 10% become protracted

  • Recurrence: 30 -50%

  • Approximately 20% develop bipolar disorder

  • Associated with significant:

    • comorbidity

    • functional impairment

    • risk for suicide

    • substance use

Diagnostic dilemmas comorbidity
Diagnostic Dilemmas: Comorbidity Identification and Treatment

  • Depression

    • 40% to 90% have co-morbid dx; 50% 2+

      -- Dysthymia and anxiety – 30% to 80%

      -- Disruptive Disorders – 10% to 80%

      -- Substance Abuse – 20% to 30%

    • Community-based study--43% of depressed youth had at least one other concurrent diagnosis, most commonly anxiety (18%). (Rhode, et al., 1994)

  • MDD presents after anxiety and disruptive dx: substance abuse 2nd to depression

  • Odds Ratios--Anx 8.2; Conduct and ODD 6.6; ADHD 5.5 times more common in depressed youth

Causal model
Causal Model? Identification and Treatment

Stress Diathesis Model

  • Diathesis—vulnerability

    • Biological—genetic, temperament

    • STRESS GENE ??

    • Environment—loss, abuse, neglect, demoralization

    • Cognitive Style—negative cognitive style, see cup ½ empty, attribute failure to internal characteristics, success to chance, hopelessness

Increasing prevalence of depression in adolescence
Increasing Prevalence of Depression in Adolescence

Depressive Disorders:

  • Adults: 15-20% rates; 2:1 female to male

  • Age 11: Incidence low; males > females

  • Age 13: Incidence rising; males = females

  • Age 15, 18, 21: Incidence rising; males < females

Adolescent development
Adolescent Development Adolescence

Development of overall rates of clinical depression (1-year point prevalence combining new cases and recurrences by age and gender)

(Hankin, et al., 1998)

Neurobehavioral development in adolescents
Neurobehavioral Development in Adolescents Adolescence

Early Adolescence

Puberty stimulates changes in brain systems regulating arousal and appetite that influence intensity of emotion and motivation

Middle Adolescence

adolescent emotional and behavioral problems 2nd to poor regulation skills--particularly when gap between pubertal arousal and consolidation of cognitive skills is extended

Late Adolescence

With age and experience comes maturation of frontal lobes which facilitates regulatory competence

Case presentations
Case Presentations Adolescence

  • 14 year old male, first semester of high school, bout of the flu—never back to school on a regular basis,

  • Stressors: Significant growth spurt in 7-8th grade, move from family home, start of high school, loss of cat, family discord

  • Presentation: Inability to attend school, irritability, appearance of depressed mood, loss of interest in activities, social withdrawal, marked sleep disturbance, dec concentration

Case presentations1
Case Presentations Adolescence

  • 10 yr old girl with history of marked irritability and tendency to see “cup half empty”

  • 13 year old Chinese Am girl, sudden drop in grades with acute onset depressive sx

  • 17 yr old female, senior in high school, high achieving, family conflict, struggling to emancipate

  • 16 yr old boy, junior in high school, active in scouts, threatens peer at school, parental illness

Importance of assessment
Importance of Assessment Adolescence

  • Assessment before making treatment plan

  • Assessment of changes in key symptoms/ behaviors during tx

  • Assessment of how things are going from family/youth’s persepctive

Assessment tools
Assessment Tools Adolescence

Why Use:

  • Raise adolescent’s awareness of issue as a possible concern

  • Let adolescent know these issues can be brought up

  • Allow opening for educational intervention

  • Demonstrate concern

Depression screening scales
Depression Screening Scales Adolescence

  • Patient Health Questionnaire for Adolescents (PHQ-A)

    • 5 minutes to complete, easy to score algorithms based on DSM-IV criteria for Major Depressive Disorder and Dysthymia

    • Algorithms for mental health comorbidities that might be seen in primary care (Generalized Anxiety Disorder, Panic Disorder, Substance Abuse or Dependence, Alcohol Abuse or Dependence, Nicotine Dependence, and Eating Disorders).

  • Children’s Depression Rating Scale (27)

    • Measures distress; clinical cut-off 20

Depression screening scales1
Depression Screening Scales Adolescence

  • Beck Depression Inventory for Primary Care (BDI-PC)

    • is a 9-item self-report measure of depressive symptoms, The primary care version has been shown to have high internal consistency, good concurrent validity in adolescent samples

  • Moods and Feelings Questionnaire (30)

    • Brief format—13; 11/8 clinical cut-off

  • Achenbach Youth Self-Report Form (103+)

    • Assesses social function, mood, anxiety, and behavioral problems

Moods and feelings angold et al 1995
Moods and Feelings (Angold et al., Adolescence1995)

  • I felt miserable or unhappy

  • I didn't enjoy anything at all

  • I felt so tired I just sat around and did nothing

  • I was very restless

  • I felt I was no good anymore

  • I cried a lot

  • I found it hard to think properly or concentrate

  • I hated myself

  • I felt I was a bad person

  • I felt lonely

  • I thought nobody really loved me

  • I thought I would never be as good as other kids

  • I did everything wrong

    0-2 scale. clinical cutoff 11

Patient health questionnaire phq 9
Patient Health Questionnaire (PHQ-9) Adolescence

  • Little interest or pleasure in doing things

  • Feeling down, depressed, or hopeless

  • Trouble falling/staying asleep, sleeping too much

  • Feeling tired or having little energy

  • Poor appetite or overeating

  • Feeling bad about yourself – or that you are a failure or have let yourself or your family down

  • Trouble concentrating on things, such as reading the newspaper, watching TV

  • Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual

  • Thoughts that you would be better off dead or of hurting yourself in some way

    0-3 scale. Not at all to Nearly Every Day; 10-14 Moderate Dep

Assessment depression
Assessment: Depression Adolescence

  • Sorting out parent/youth conceptualization of the problem

  • Parent/youth’s sense of what treatment will be useful

  • Differential trajectories—hopelessness depression, age of onset, ADHD or other co-morbidities

  • Acute family problems--parental mental health concerns, abuse/neglect, derogation, reinforcement for illness behavior, cultural/generational conflicts, unresolved grief

  • School Issues--learning disability, attendance problems, harassment, isolation

  • Peer/partner issues--pregnancy, sexual pressure, break-ups, sexual orientation issues, loss of friends

Assessment and case conceptualization
Assessment and Case Conceptualization Adolescence

  • Assessment before making treatment plan

  • Assessment of changes in key symptoms/ behaviors during tx

  • Ongoing assessment of issues to refine your case conceptualization

Case conceptualization tx choice

Anxiety Disorders Adolescence

Kendall’s Coping Cat; March’s OCD Tx

Social Effective Tx-Beidel

Exposure/Transfer of Control-Silverman


CBT—Clarke, Lewinsohn

Interpersonal Psychotherapy--Mufson

Behavioral Activation


Family, social skills, attentional skills training


Parent-child Interaction Therapy—Chamberlain

The Incredible Years—Webster Stratton

Parent/Child Treatment for Aggression—Barkley, Kazdin

Case conceptualization Tx Choice

Depression treatment issues
Depression: Treatment Issues Adolescence

Background and Rationale

  • Current tx response rates only 60-70% and high relapse within one year

  • Limitations of pharmacological options

    • Up to 40% are “non-responders”

    • 58-61% report bias against meds (Gray, 2003)

      • “Medicine might…change my personality, control my thoughts, not let me be myself”

      • Beliefs about efficacy and stigma

    • Concerns regarding potential increased risk of suicide in youth using antidepressant medication

Medications issues
Medications Issues Adolescence

  • 3 to 8 fold increase in the use of antidepressants in children and adolescents from approx 1990-2000 (Zito, et al., 2002; Rushton, et al. 2001)

  • Efficacy:

    • Fluoxetine (Prozac) – efficacious

    • Up to 40% are “non-responders”

  • Resistance/Adherence: Adolescent Attitudes (Gray, 2003)

    • 69% stopped taking meds by end of 4 weeks

    • 58-61% report bias against meds

    • “Medicine might…change my personality, control my thoughts, not let me be myself”

    • Issues around belief in efficacy of meds and stigma about MI

Duration of antidepressant use
Duration of Antidepressant Use Adolescence

Richardson, DiGiuseppe, Christakis, McCauley, Katon, 2004.

Psychotherapy for Depression: Adolescence Evidence of Treatment Effects

Weisz, McCarty & Valeri

35 Trials

Inc. TADS N=439

IPT- 2 trials

ES = .34

(0.40 ULS)*

Reinecke, Ryan & DuBois

6 CBT Trials

ES = 1.02


Lewinsohn & Clarke

12 Trials

ES = 1.27

Michael & Crowley

14 Trials

ES = .72





Weisz, McCarty, Valeri, 2006. Psych. Bull. 132:132-149

* Unweighted least squares

2007 Adolescence

Adjusted mean Children's Depression Rating Scale-Revised (CDRS-R) total scores

The TADS Team, Arch Gen Psychiatry 2007;64:1132-1143.

Moving on with treatment
Moving on with Treatment Adolescence

CBT-the most widely investigated psychotherapy for depression

“You can change how you feel by changing how you think”

  • CBT Draws on 4 core sets of strategies:

  • Facilitative

  • Behavioral Activation

  • Automatic Thoughts

  • Core Beliefs

Aaron T. Beck

Require ability to reflect on, monitor, and evaluate own thinking process in midst of heightened emotional arousal—may not have skills on board

Moving on to Treatment—What Works Best? Adolescence

Principles of CBT: Philosophy

  • Collaborative Model

  • Structured Sessions

  • Blend Didactic, Directive, & Socratic Questioning

  • Ongoing Assessment (inc. regular feedback)

  • Effect Change in Thought, Affect, & Behavior

  • Relapse Prevention

Principles of CBT: Technology Adolescence

  • Agenda Setting

  • Mood Monitoring

  • Behavioral Activation; Structuring Activities

  • The ABC’s of CBT: Linking Affect, Behavior, & Cognition

  • Thought Records & Changing Beliefs

  • Cognitive-Behavioral Case Conceptualization

  • Becoming Your Own Therapist

Getting Started: Adolescence

Assessment, Feedback, & Treatment Plan


15-year-old girl (Kelly) presenting with depressed affect, loss of interest, sleep and concentration problems, and low self-esteem. Chief complaints are sadness, social isolation, and slipping grades. Maternal history of depression and substance use, absent father, limited family/social support. Endorses suicidal ideation; no plan.

Provide feedback and psychoeducation re: depression and appropriate treatment, discuss role of pharmacotherapy and psychotherapy, establish treatment plan including course of CBT.

Initial Sessions: Adolescence

  • Agenda Setting (organize session & model effective strategy)

  • Mood Monitoring (highlight highs and lows)

  • Activity Scheduling (behavioral activation to improve mood, increase social exposure)

  • Continue building rapport (validate, praise, model optimism)

  • Ongoing case conceptualization

Middle Sessions: Adolescence

  • The ABC’s of CBT: Linking Affect, Behavior, & Cognition

    • What was the situation?

    • What were you thinking?

    • How were you feeling?

    • What did you do?

  • Thought Records

  • Middle Sessions: Adolescence

    • The ABC’s of CBT: Linking Affect, Behavior, & Cognition

      • What was the situation?

      • What were you thinking?

      • How were you feeling?

      • What did you do?

  • Thought Records

  • Using Thought Records in Ongoing Case Conceptualization

  • Middle Sessions: Adolescence

    • Cognitive Restructuring:

      • Validation

      • Downward Arrow

      • Evidence Testing

    Automatic Thoughts

    Underlying Beliefs

    Middle Sessions: Adolescence

    • Cognitive Restructuring:

      • Validation

      • Downward Arrow

      • Evidence Testing

    • Using Cognitive Restructuring in Case Conceptualization

    Final Sessions: Adolescence

    • Relapse Prevention:

      ‘Becoming Your Own Therapist’

    • Termination

    Core principles of interpersonal psychotherapy
    Core Principles of Interpersonal Psychotherapy Adolescence

    • Link between mood and life events

    • Focused, time limited treatment

    • “Here and Now” treatment

    • Medical Model

    • Active Therapist

    General ipt techniques
    General IPT techniques Adolescence

    • Supportive listening

    • Optimistic stance

    • Encouragement of affect

    • Eliciting details

    • Exploring options

    • Role playing

    • Communication analysis

    • Use of the therapeutic relationship

    Initial phase sessions 1 4
    Initial Phase (sessions 1-4) Adolescence

    • Conduct psychiatric interview, assess symptoms, diagnose, offer the sick role

    • Conduct Interpersonal Inventory

    • Select interpersonal problem area as patient’s treatment focus

    • Provide patient with an interpersonal case formulation

    Interpersonal inventory
    Interpersonal Inventory Adolescence

    • Ask about significant people in the adolescent’s life (family, friends, mentors)

    • Start with the basics

      • Frequency of interactions

      • What do they do together?

    • Expectations for the relationship

      • Were they fulfilled?

    • What changes does the adolescent want to make in the relationship

      • Has the adolescent tried to make changes already?

      • What worked or didn’t work?

    • How has depression affected the relationship?

    Life events associated with the depression
    Life Events Associated with the Depression Adolescence

    • Probe for:

      • Changes in family structure

      • Changes in school

      • Moves

      • Death, illness, accident, or trauma

      • Onset of sexuality and sexual relationships

      • Establish a time frame and sequence of events relating to the depression

    Common developmental issues for adolescents
    Common Developmental Issues for Adolescents Adolescence

    • Separation from parents

    • Exploration of authority in relation to parents

    • Development of dyadic interpersonal relationships with members of the opposite sex

    • Initial experience with death of a relative or friend

    • Peer pressure

    Interpersonal problem areas
    Interpersonal Problem Areas Adolescence

    • Grief

    • Interpersonal disputes

    • Role transitions

      • Single-parent family situations

    • Interpersonal deficits

    Strategies for treating interpersonal disputes
    Strategies for Treating Interpersonal Disputes Adolescence

    • Focus on the adolescent’s expectations for the relationship

      • Are they realistic?

      • How do they differ from expectations of others?

      • How has teen tried to resolve the dispute?

    • Explore communication patterns that may be complicating the resolution of dispute

    • Help the teen gain perspective on what has occurred in the relationship

    • Help the teen find strategies for coping with unreasonable expectations of the parent and the feelings of anger/sadness engendered

    Communication analysis
    Communication Analysis Adolescence

    • Goal is to teach the adolescent to communicate in a more effective manner through:

      • Clarity

      • Directness

    • 5 categories of ineffective communication

      • Ambiguous and/or nonverbal communication instead of open confrontation

      • Holding incorrect assumptions

      • Using unnecessarily indirect verbal communication

      • Using “the silent treatment” and closing off communication

      • Using hostile communication

    Communication analysis ii
    Communication Analysis (II) Adolescence

    • Help the adolescent to understand

      • The impact of his/her words on others

      • The feelings he conveys with verbal and nonverbal communication

      • The feelings that generated the verbal exchange

    • Teach alternative communication strategies

      • How to communicate feelings and opinions directly

      • Using empathy

      • Understanding the other person’s perspective --“putting yourself in other person’s shoes”

    Treatment strategies for role transitions
    Treatment Strategies for Role Transitions Adolescence

    • Mourn the loss of the old role and accept the new one or find an alternative role

    • Examine the positive and negative aspects of old role, what adolescent is afraid will be lost, and the teen’s perception of new role

    • Educate parents about the role transition

    • Develop social skills to help teen to successfully negotiate the transition

    • Help adolescent generate opportunities to increase social support

    Plug for treatment development
    Plug for Treatment Development Adolescence

    Behavioral Activation

    “You can change how you feel by changing what you do”

    Decrease in frequency or range of reinforcing stimuli or increase in frequency of punishment  depression

    Peter Lewinsohn

    • Focuses 3 core strategies:

    • Facilitative

    • Activation

    • Processes that inhibit activation:

      • Withdrawal

      • Avoidance

      • Ruminative thinking

    Allows adolescent to practice with “coach” planning, monitoring and evaluation skills needed to coordinate affect arousal and cognitive skills w/o direct challenge to beliefs

    Thanks! Adolescence