CHAPTER 56 Depression

7/27/2019 CHAPTER 56 Depression

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Chapter 56HelpingStudentswith Deprtssion

DebbieW.NewsomePreview

Depressionn youthhasbeen he ocusof incrcased oncernduring thepast keedecades.Wlereas t used o be considereri disorderof adulthood,currentresearchersnd mentalheatth rofessionalsreaware hat many childrenandadolesccnts lso dcal with depression, disorder hat can be serious,complex,and,most mportant, reatedMerrell, 2001). ndeed, eelingdepresseds one ofthemostcommon nrotionalesponsesxperienceduringadolescenceYarcheski& Mahon,2000).Youngadolescents,n parlicular, resusceptibleo depressiondue o thc ntense iological, ocia.l,ndpsychologicalhangeshatoccur romlatechildhood o early adulthood.Professionalchmlcounselorsrc n a unique osition o initiateactivities ndservicesdesignedo helpprevcnt, dcntify, and coordinate he treaimentofdepressionn youth Rice& kffetl, \991).In t!.is hapter,actsabout epressionare presented,ncluding nformation egarding ypcsof depression,ignsandsymptoms f tbedisorder,actors nfluencing ls onset,and associatedisks.Suggestionsor intcrventionshatarebasedotroulcomestudiesand research redescribed,ncludinga list of resoDrccso helpprofcssionalchoolcounselorswith prcventiveand emedialactivities.

I'm normal, sort ol I talc honorsand AdvanccPlaccmentcourses. wasin the marchingband, playedvorsitysoccerfor twoyears-lut I havea diltinctqualiry hatsepcratesme mm themasses-l amsadmostof the ime. don't snlkaround or consrantlyplot woysto end my life; instead, withdraw Jrorn regularactivitiesa lot and spenda good deal of time thinking obout my l ife and mypurposehere.Somewhere own the line, amidstall the action and contintousresponsibility, I lost track of myself. I felt trapped in all my relationships andvirnally Lndno time o myself.Idisconunued ommunicationwith ybestfriends,and my goal everyweekwas o surtive to theweekend, here could relat ondput everything nhold. viewed ryselfas capable, utolsoasdlways allible. ByNovemberof my unior year, was a wreck Still, refused o ocknowlerigemyfeelingsas depression. didnl think t could happeno me.l7-ycar-cldighschool udent bowas realedordepression

Depresston efinedAccording o theNationalnstirute f Nlentallc;lth (NIMH, 2A$;2002), depressions acr;nrl it ionhot anaffecthoughts,celings,ehrviors, nd verall eallh.t can mpact leeping

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ilndappetite,rcwayonc ecls .rboutnesclf,md the nanrttrn whichoDc hinksubouthings.In addition o affecting sludent's urentqualityof life, dcpressivcymploms nddisordersthatbeginduringchildhoodor adolescencercdict ecurringor ongoing epressionn adulthood.Untess hedisorder s treated, arly onsetofthe disordercanpredictmore scvereandnegativcsymptomsater n life.Depressions an internalizingdisorder, s arc anxiety disordcrs, ocial withdrawal,andsomaticproblems Menell, 2001). namalizing disordcrsarecharaclcrized y overcontrol, whichimplies that ndividualsmayovenegulale r rnappropriately ontrol heir emotions. n lhecaseof interna.lizing isorders, he problemsare maintainedwithin the ndividual, in contrast oexternalizing disordcrs,such as OppositionalDefiant Disordcr and Attcntion-DcficiUHyperactivityDisorder AD/HD), which arcchancterized y actingout (McrreU).The definingcharacteristic f the nternalizingproblcmof depressions mooddjsturbancc. eprcssed outhexperience ifliculty regulating egativeemotions ffectivelyoncc heyareexperienccdStarhSander,Yancy,Bronik, & Hokc,20OO).Whcreasmuchof the research n depressionefcrs o cliuicaldepressiv isorders, thermanifesut.ionsf depression,hile not severe nougho merita clinicaldiagnosis,ancausedistressn youngpeople ndcall for lhe atlenlion f school ounselors.elcrsen, ompas, ndBrooks-Gunn 192) describcdhree ypcsof deprcssion:epressed md, deprcssivc yndromc,andclinicaldepression.cpressed ood s characterizedynegativc motions, spcially adnessand anxiety.Otheremotionsassociated ith depressed ood ncludeguilt, disgust,anger,andfear.Studentsmayexperience epresscdmood or ashortor extended erio'd ftime. Depressedmood soneof tlrekey symproms fclinical deprcssion;owever, chiJd anexpericnce epressedmood rvithout being clinically depressed, pproximatelyonc-thirdof adolescents xperienccdepressed ood(Petersent al.) and maybencfit rom preventiou r intcrvention ctivitiesinitiatedby th: profcssionalchool ounselor.Depressive yndrome efers to a collectionof commonsymptomsassociatedwithdepression.he ndividual s in distress fsome orm,but doesnotnecessarilyraveadiagnosablcproblem Menell,2C0l).Symptoms an nclude rxiety, adness,oneliness,earfulness,uilt,self-consciousness,nd worry. The prsonmay fcel unlovedand unlovableor a need o beperfect.Depressiveyndrome, hich s usually dentified hmugh heuseof questionnaires,affectsapproxiylyxlgt\j5%o f adolescentsPeiersent al., 1992).Croupcounselingmay beespecially elpful or studentstrugglingwith depressiveyndrome.For depression o he considercda clinical disorder,a collectionof syrnptomsmust bcevidenced hatmectspecificdiagnostic ritcriaaccordingo standardizedlassilication ystems,such as the Diognosticand StatisticalManual of Menial Disorders DSM-fi/-TR,AmericanPsychiatric ssrxiation, UD). Diagnosiss birsed n lhc inlcnsity nd durationof a setofsymptoms hatareserious nough o intcrfcrcwith one's cvel of functioning. xamples ftlepressiveisordersncludeMajorDepressiveisordcr ndDysthymic isorder see ablesand 3). AdjustmenlDisordcrwith depressed ood or mixedanxietyanddepressed ood)also

is markedby depressive ymptoms, s areBipolarDisorders,CyclothymicDisorder,andNloodDisorderdue to medicalcond.ition r sDbstanccbuse seeTablc4). ln rhis chapreqspecificrecommendationsor belpingstudenr with bipolar, yclothymic, r substancebuse-relaleddisorders ill not be addressed;nslead, be ocus s.on helping tudents ho strugglewirhdepressiveymptoms, ajorDepressive isorder,Dysthymicisorder,rAdjusrmentDisordetwith depressed ood.it is ikely tlratprofessionalchoolcounselors ill encounterludens ealingwithdepressedmood,depressive yndrorne,nd depressiveisorders. ' Iherefore,t is important o beknowledgeable f the diagnosric riteria or depression nd othermood disorders o thatappropriatenterventions nd/or eferralscanbe made Kaffenberger Seligman,2003).

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Signsand SYmPtoms f DePrtssionIdentifying dcpressionn young peoPlcmay becballengingbecause ymptomsare oftenmasked. ltbough tbcdiagnostic ritcria andkeydefining eatures f majordepressive isorderarc hesame or youthsas or adults, t may bc difficult for them to identify or describe heirfeclings NIMH, 2000). nstead, cprcssed tudentsmay^PPeN rritable,act oul, or withdrawfromfamily and iiends.AJso,anxietysymPtoms ndsomaticcomplaintsarc morecommon ndcprxscd childrenand adolcsccntshan in adults SurgeonGeneral,2ffi2). A list of commonsignsand symptosrsof dcprcssion videnced n youngPeoPles presentedn Table I (NIMH,2000;Rice & bfrert, 1997)'

Tbble . Slgrrs nd symptomsof depressionn childrenand adolescenls.. Feelingsad,empty,or hopeless. Increased motionalsensitiviry. Lackofinterestor abiliry o engagen pleasurablectivities. Decrcascd nergy evel. Physical omPlaints eadaches,tomachaches,iredness). Freguent bsencesrom school or poor performance). Outbunts shouting, omplaining,rying). Borcdom. Substancebuse. Fearofdcath. Suicirie deation. Slcclrppetite dishuba.oces. Reducedbility o thinkclearly ndmakedecisions. Increasedrritabi[ry. angcr,or restlessness. Farlurc o makecxpcctedweightgains. Reckless ehavior. Dfficulty with relationships

Thediagnostic riteriaor MajorDcpressivepisode ndDysthymicDisordcr reoullinedin Tables and3. However, snotedearlier, ludents ayexhibitsignsof depression ithoutmeeting he full diagnostic riteria.Thesestudents, s well as studentswho areclinicallydeprcssed,re ikely to benefit rom early ntcrventionby professional choolcounselors.Depressionn children ndadolescentsften s accompaniedy otherproblems,some fwhicharcclinicallydiagnosable.xamples fdisordershat requenily o-occurwithdepressionin youthareAnxietyDisorders, onductDisorder, atingDisorders, trsonalityDisorders,ndSubstancebuseDisordersPetersent al., 1992;Rice&Leffert.l99D. Particularly ighratesof comorbidityexistbctween epression nd anxiery isorders, ith reporied o-occurenceratesanging rom 30 to 70 percentKovacs,1990). lso,depression ay accompany edicalconditionsuchasdiabetesr other llnesses. iven hehigh ateofco-occunence,rofessionalschool ounselors ill want obesensitivco thepossibilityhat hedeprcssedtudentmayalsobestruggling ilh oneor moreotherconditions ndplan nterr'entionsccordingly.


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Table2. DSM-ry-TR Criieria for Il1ajor DepressiveEpisode ApA, 2fiD, p 356).A. Five (or mo;e) of t-he ollowing symptoms have been prcsentdurilg the same2-weekperiod and represenra changefrom previous functioning; at leasrone of the symptornsis eilher (l) depressedmood or (2) loss ofinterest or pleasurc.

Nole: Do not includcsymptoms ha t arectearlyduc ro a gcneralmcdicatcondition,ormood-incongruent clusionsor hallucinations.depressedmood most ofthe day,nearly every day,as indicated by eithersubjective reporr (e.g., feels sad or eepry) or observationmade by others (e.g.,appcan tearful). Notc: In children and adolcsccnrs, an bo irritablo mood.markedly diminisbed interest or pleasure n all, or almosl all, activities most ofthe day, nearly every day (as indicated by either subjective accounrorobservation made by others)3) significant weight osswhen no t dietingor weighrgain (e.g.,a changeof morethan 5o/oofbody weight in a month), or decrease r increase n appritencarryevery day.Note: In children,consider ailure ro makeexpcctedweightgains.4) insomnia or hypersomnia nearly cvery day5) psychomotoragitationor retardationnearlyeveryday (obxrvable by others,not merely subjective eelingsofrestlessness r beingsloweddown)6) fat.igueor loss ofenergy nearly every day7) feelingsofworthlessness r excessive r inappropriate uilt (which may bdelusional) nearly every day (not merely self-reproachor guilt about beingsick)

8) diminished abiliry ro rhink or concentrare,r indecisiveness,earl/ everyday(eitber bv subjective account or a-s bservedby orhen;9) recurrenr hougbtsofdeath (notjust fearofdying), recurrenr uicidal dearionwithour a specificplan, or a suicide anernpt r a specificpran or committingsuicideThe symptolns do noi rneetcriteria fcr a Mixed Episcrle.The symptomscauseclinica.lly ignificantdjshess r impairment n social,occupational, or otber important areasoffi:nctionirg.The symptomsarenot due ! rhe directphysiorogicar ffectsofa substancee.g.,a drugof abuse,a medicarion)or a generalmedical condition e.g.,hyporhyroid.ism).The symptomsare not beneraccounted or by Bereavement,.e., afler therossofaloved one, the symptoms penist for longer than 2 monlhs or are characterizedbvmarked unctional impairment,morbid preoccupation it h worth.lessness,uiciialideation,psychoticsymptoms,or psychomotor etardation.

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Table3. DSM-IV-TR Criteria for DysthymicDisorder APA,2000,pp 380-381).Depressedmood for mostof t} e day, or more days han not, as ndicaledcrthcr bysubjective ccountor obscrvationby others, or at lcast2 ycars.Nole: ln childrcn andadolescents, ood can be rritableand durationn)ustbe al least I year.Presence,while depressed,of two (or more) of the following:

l) poor appetitcor overealing2) insomna or nypcrsomnla3) low eDergyor fatiguc4) Iow self-esleem5) poor concentration r difliculty maUng decisions6) feelngs of hopelessness

During tlre2-yeat peiod (l year fo r childrenor adolescents) f tlre disturbance, hepersonhasneverbecn without the symptoms n criteriaA and B for more than 2 monthsal a time.No Major DepressiveEpisodehasbeenprerentduring the first 2 ysx1566 th.disturbancel year for children and adolescents);.e., he disturbance s nct betteraccountedor by chronic Major DepressiveDisordcr,or Major DepressiveDisorder, nPartialRem;ssion.Nole: Theremay have becn a pr:vious Major DepressiveEpisodeprovided berewas a full remission no signifrcantsignsor syrnptoms or 2 monJrs)beforcdevelopmentof the Dysthymic Disorder- n addition,"fter the intial 2 years Iyear in childreD or adolescents)of Dysthymic Disor4er, tlere rnay be superi,,rposedepisoden of Major Depressive Disorder, in which c.,:. w$th iirgnoses may be givenwhen the criteria are met for a Major Deprcssivr Episode.Therc hasnever beena Manic Episode,a Mixed Eprs,-


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Table;1.Other disorders that have deprcssedmood as a syrDptom,Typcof DisorderBipolarDisorder

Cyc.lothymicDisorder

AdjustmentDisorderwithDepressedMood

CharacteristicsRare n youngchildrenbut canappearn children andadolescents.nvolvesunusual hifis n mood,cncrgy,andfunctioning. May bcgin with manic, dcpressivc,or mixedmanicanddeprcssiveymptoms.When heonsel s bcforcorsoonaftcrpuberty,t rnaybc cbaracterizcd y a continuous,rapid-cycling, rritablc,mixedsymptom tateand may co-occuIwith Anention-Defi itflypemctiviry DisorderorConductDisorder NIMH, 2000).Onsct ypically s carly adulftood,but thedisordercanoccuratyoungerages.Charactcrized y chronic, lucruatinguooddisturbance .i6 manyperiodsof bypomanic ymptomsandmanyperiods f depressiveymptoms.During he nitial one-yearperiod ior childrenandadolescents),nysymptom-freeperiodsdo not last onger han wo months A?A, 2000).

An AdjustrnentDsordcr is apsychologicalesponseo anidentifiedstressorbat esultsn thedevelopmenl f emotionalor psychological ymptoms hat aredistressingo theindividual. hc symptoms ustdevelop ithin lueemonthsafter hestressor ccursandshould esolvewithin sir monthsafter le stressorr tsconseguencesave nded, nlcss hestrcssors chronic. heprcdominantharucteristicsfAdjustmentDisorderwith Depressed ood are earfulness,feelings fhopelcssness,nddepressedood APA,2000).

Prev'ulenceIt is difficult to estimateatesof depressionn childrenand adolesccntsith certainty(Mencll, 2001). A conservaiive stimateof 5-8Voof adolcscents trugglcwith eitherclinicaldepression r depressive yndtome NIMH, 2001 Rice& Leffert, 1997). ccording o arecentNIMH report (2001),approximately .5Vo f childrenandbelween3-5Vo f adolescentsexperiencelinicaldepressionach ear.Ten o ofiy percent fyouthreport epressedr unhappyrnood, ith the atesncreasingtuoughout dolcscenceRice& Leffert). heonset f depressivedisordersppearso be occurring arlier n life than n previous ecades.arlydiagnosis ndtrearmentanhelpoffset ifficultieshatareassociatedithuntreatedepressionhenchildrenreach dulthoodNIMH,2001).Prior to age hirteen, le ratesof depressionor boysandgirlsarcsimilar.Howcver;genderdifferencesmerge etwe n heages f thirteen nd ourleen, ithgirls wice s ilely to becomedepressedsboys Menill,200l .Onehypothcsisor hisdifl'erences hat irls end o cxpe iencemore hallengesndsiressorsn earlyadolescencelran oys. heyaremoreikcly ogo luoughpubertyduring he ransition romelementaryo secondarychool,and bepressureo bepopularandartractive an be greater, speciallyor earlymrturinggir ls (Petersent al . , 1992).Furthermore,arly naturing irlsmay eelpressureo engagen sexual ctivity eforc heyare

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I ' r r r l cssr r r l : r lch ' r r l' , r r r : r c l in r ; , \l r r t jh r t r , kemotionallyeady o do so,whichcancontributco depressed ood.Regardlessf the easonsfor tbe differences,he increasedate of depressionn girls may make t more ikely thatpmfessionalchoolcounselonwill work with girlsstrugglingwith depressiveymptoms.FoctorsAssocated w thDepres ionSevcralmodels of dcpression avc becn proposed,many of which have reciprocalcomponents. ecognizing hat nteractionamong causal actors s likely and thatrescarchontheetiologyofdepression s ongoing,curnt research n biological andpsychosocialactorsassociated ith dcprcssionn youth s presentcd ext.Biological actors. Much of the researchaboutbiological influenceson depression asbccnconducted ith adults ather hanyouth.Conscguently,t is imporlant o keep n mind,when eadinghis section,hatgeneralizationsboulbiological nfluences n depression aynotbe completely pplicablco youngpeople.Specific iological aciorsassociated ith thedevelopment fdcpression ncludeabnormalitiesn the trnctioningof neurotransnittcrs nd/ortheendocrine ystem. n manycases,ndividualsmayhavea genctic redispositiono suchabnormalitiesMerrtll, 200 ).Certainbrain chemicals, ncluding serotoninand norcpinephrine, ffectmood and havebeen inked with mood disordersMerrell,200l). When lhereare abnormalit iesn theneuroransmissionf these ndother hemicalsin otherwords, n thcsending nd eceiving fneurotransminen),ooddisordersandevelop. ntidepressanledicationsevelopcd ithinthepast wo decades,uchas luoxetineProzac),lurlcxamineLuvox), ertralineZolofl),andparoxetincPaxil)block the euptake fserotonin, hcrcby ncreasingts availability o braincells-Othcr medications,such asvenlafaxinc(Efferor) and nefazodoneSerzone) ffect thcn-ansrnissionfboth serotoninandnorcpinephrine nd can b;,:ngabout elieffrom depressivcsymptomsStarket al.,2000).Also associated ith deprcssions abnormal unctioning f thecndocrinc ystem,whichreleasesormones nto thebloodstream. ariousabnormalitiesn the unctioningof thepiruitarygland,hyroidgiand,adrcnal land, ndglands hat eleaseexhormoncs ave cen inkcdwith

mooddisturbancesn youth and adults Merrell, 20Ol; NIMtl, 2001). n particular,hormonalchanges uringpubertymay be associated ith depressive ymptoms Starkct aI.,2000).Genetics layan mportantole n aperson's ulnerabiliryo dcpressionndothermenlaldisorders.t is theorizedhatmultiple ene ariants.atherhanasingle ene, cl n conjunctionwith cnyironmcnlal factorsand developmcnlalevcnts, hus making a personmore likely toexperience epressive ymptoms NIMH, 2001).Cognitiveand behavioral octors. Cognitive theory describesa strong ink bctwcen anindividual'scognitions,emotions, nd behaviors. ccording o cognitive heory,people'sinlerpretationsf events, atherhan heeventshemselves,riggeremotional psets ndmooddisturbancese.g.,Beck, 976).Such nterpretationsffeclone's iewof self, hcworld,and -hefuture. naccuraie nterprctations,r faulty informationprocessrng,an ead o depressivesymptomsn youthandadulS Asarnow, aycox,& Tompson, 000;Beck, 976;Kcndall,2000).Examples ffaulty informationprocessingncludcnegative ttributions-andognitivcdistortions.Childrenwith negativeattributional tylesmay believe hat theyarehe!plesso influenceeventsn their ives.Theymayalso elievehat heyare esponsibleor any ailures ndproblemsthalarc cxpericnccd, ul not for successful,ositiveevents Mcnell, 2001).For cxample,astudent ay believe hatshe s responsibleor herparents' ivorceand hus ontinually lameherselfor thebreak-upof theirmarriage. r whensomething ositivehappens,ike winning anaward or achievement, lre tudent nributes he event o luck.Cognitivedysfirnctionsefer o negative,naccurate iases hatcan e-sultn unhealthymisperceptionsf events. o llustrate,n a studycomparing epres.sedouth o nondepressed

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youth, hsdeprcssedtudcr)tsicwed hernselvesls csscapablehan heir classrnales,vendroughheir eachersid not(Kendall,Stark,&Adan\ 1990).Cognitive heorists ave dentifiedseveralypes f cognitive ysfunctions,ncluding xaggeratingrenegaLive, inimizing heposirive, vergeneralizing,atastrophizing,ndpersonalizing.ognitivcdistortions lsoareevidenced henyoungpeopleengagen all or nothing hinkingor selcctivcabstraction, uchaswhen akingadetailout of contextandusing t tro egatcan entireexperience. ucbdistorlionscan esultn negative utomatic houghs,which henaffeclemotions ndmoodstrtes.TeachingsrudeDts ays o conect faully informationprocossings one way to effectivelyhclp youngpeoplewho aredepressedKendall,2000).Brhavilr-s ss^.i:i3dr"iih :::g:tive ::;nitions and cclings an bothcontributeo andmaintain epressiveymptomsn children nd adolcscenls.n particular, ithdrawing rompeers nd amily mernbcrs an exacerbaleeelings f depressionnd oncliness uough heresultingackof social e nforcementMenell,20OI .Rclatedosocialwjtldrawal s the endencyof depressedndividualso quit engagingn activitieshat orrnerlywereplcasurable,uchasathletics r hobbics, hcrebycreatinga cycle hat makes t difficu!t o alleviate epressivesymptoms. obreak hecycle,professionalchool ounselorsanhelpchildren dentify activitiestheyconsider leasurablend makecommitrnentso participaten *roseactivities etweensessionsStark& Kendall,1996).Challenges nd stressors. outh who experience urneroustressorsnaybe more ikelyto experiencc epressionhan hoscwho do not. ndred,onemodelof adolescentepressiondevetopedy Petersent al . (1992)andPetenon t al. (1993) roposedhat he number ndtimingof changesndchallengesn earlyadolesccnccffcctmental ealth,with neglt ivcconseguenceseing moderated y parental ndpersupportandcopingskills. Cha.llengesanbe categorizedsnormativeife cvcnts expectedhalges, uch sschool ntryandpubcry),non-nonnaliveventse.9., ivorce, busc, ovingaway), nddailyhasslesc.g., onflictwithfriends, xcessivehoolwork). n a srudy fadolescenb etwecnie ages f 12-14, resswasfound o havca strong ausal ffectoo deprcssionswell asa negalive ffecton self-esteem(Yarcheski Mahon,2000). hc mannern whichstresssexperiencedaries reatly rom oncstudent o another.Recognizing he potenlialdetrimental ffeclsofstress,profcssional choolcounselorsanconduct lxsroom guidancecssons ndgroup essionso leach ludcnts aysto manage tress frect.ivelyseechapter 2,"HelpingSludents anageStress,"or specificexamples).Family and peer i:..l1uences. numbcr of family-related actors are associaledwithdepres.sion,ncluding xtcnsivc onfl icl, oor ommunicationaiterns,ow farnily ohcsion,and the cmotional navailability f parentsMerrcll,2001;Pctersent al., 1992).Havingaparcntwith a mooddisorderncreascs young crson'siskof experiencingepression,ue npan lo heredily ntl n part o the amily ntcractionshatoccur fthe parent's onditions notbeing realed uccessfully.n community ettings,-amily ounselings often recommendedwhena mcmber f the amily is iepresscd; owevcr,hisoption Day ot be availablen theschoolsetting.f not,professionalchool ounselorsanbe nstrumentaln helping amiliesbecomeawareof opporfunitiesor fanily counselingn tlrecommunity.Poor rclationshipswith peen, not havinga ciose nend.andbeingconsidered npopularor "diffcrent" alsocan ead o depressiveymptomsn srudentsPerersent al., I 992).Certainpopulations,ncludinggay, esbian,andbisex.ualoulI, maycxperiencc greater egeeofpeerrejectionand solation, hus ncreasingheirvulncrabilily o depressionRice& Leffert,1997).A critical ole of theprofessionalchool ounselors to servc sanadvocateor a.ll tudents.Tolerancendacceptancean be demonstratednd aughln multiplcways, ncluding arentand eachcrraining rograms,lass uidanceessons,nd mall roup essions.ee able fora listof risk factorsor depressionNliUH,2@0).

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Table 5. Risk factors or depnssion.' Family historyof mooddisordcn. Genderadolcscentirls wiceas ikelyasboys o develop epression). Strcss. lrss of parentor lovcd onc. Brcak-upof a romantic elationship. AD/IID, conductCsorder,or leamingdisorder. Cigarcncsmoking. Chronic llness(e.g.,drabctes). Abuscor neglect. Other rauma, ncluding naturaldisasters

Consequencesf DepressionA widc rangeof intrapersonal nd nterpersonalroblems an arisewhendepression oesundiagnosednduntrcatcdn youngpcople.Adiminished ense fself-worth, ack ofconfidence,andageneralendencyoviewoneselfnegativelyfiengohand-in-handithdepressionMerrell,2001).For somesrudents,he depressionndensuingatigue anresult n diff iculr iesnconcentration, otivation, ndacademic erformance.s slated arlier,mpaired elationshipswith pecn and amily membersanboth ead oandbcaconsequencefdepression.ntcrpenonaldifficultiesassociated ith acute tagcs f deprcssion avebeen ound o continueafter ecovery.sometimesenistingbto adulthoodMufson,Moreau,Weissman, Klerman,1993). n addition,youth with.unbeateddeprcssion te al an incrcasedisk for physical llness,substance busc,recurrcntepisodcsof deprcssion, nd suicidalbchavior(ND4H, 2000; 2001). Consequenrly,therc s a sbong need o identify dcpressivc ymptomsearly andmake it possible or youthsirugglingwith depressiono get the hclp theyneed.Suicide risk The most severep:cblem associatcd ith Jepressions the risk of suicide.Although mostpoplc wbo arc depressed o not commit suicide,deprcssed outh, espcciallythosedcaling with what heyperceivcasa crisis,areat agreater isk for suicidalbehaviors- hestrongest isk facton for attempted uicide n youngpeopleare depression, ubstance buse,and aggrcssiveor disruptivebchaviors (NIMH, 2A02a).The suicide rate among youth hasincreascd ramaticallyduring hepast hrccdccadcs,with suicide eportedas the third leadingcause f deathamong 5- to24-year-oldsNIMH, 20@b).Morc girls attemptsuicide hanboys;horvever, oys arc'four timesas ikely to actuallyhll themselves nd tendto usemorc lethaimeansSurgeonGeneral,2O02).ln 997,21pcrcent fhigh schoolstudents alionwide eportedthat they had scriouslyconsi.dered ttempting uicidewithin the pasryear,and 8 percenthadactuallyattemptcd uicidc Center or DiseaseConrol, 2002).Suicide attempts reoftenpreceded y signals,wamings;or actual hreats.Someof thesigns o watch or includeverbalmessagesc.g., I wish I weredead," "Ihere's only onewayout,"or l' l won't be aroundmuch onge/'),apreoccupationith death, hangesn sleeping ndeatingpatterns, ecline n schoolperformancc, r giving awaypossessions. uicidalbehaviorsand hrear rcpresent cry for help andmustbc akenscriously. ofessional schoolcounselorstypically avebcen ainedn suicide ssessment,ndmost chools ave olicies ndproce,juresrelated o crisis ntervention.Vhenaprofessional choolCounseloras eason o beiieve lat astudents contcmplatinguicide,hecounselor ill want o assesshenarure nd ntensity f thestudent'shoughtsand ollow up with aresponschatwill keep hestudentsafe.Menell (2001)listssix basicsteps hatcanbe ollowed n respondingopotentially uicjdal outh [Nore:Besure hescstepsareconsistent ith your schoolsystempolicy before mplemenring hem]:


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I ' roJcssionel churl ( i lurrs.:lrn-q:1 IIrurdhrrl

l. Thinkingabout suicide. f therc is plausiblc reason o believc that a srudent sconsideringsuicide,ask the studentabout t directly. Kecping the wordingdevelopmentally ppropriatc,hc counselor anask, Havcyou bcen hinking abouthurtingyourself?"or "Havc you bceo hinkingabut wanting o bc dead?"2. Suicideplon.lf tberc s any ndication of suicidal dcation, hc ncxt step s l,odcterminewhether hc studenthas madc an actualplan.Ask qucstionssuchas "Have youthought bouthowyou mightdo it?'or "How wouldyou do it?'Gcncrally,morcspccific, thoughl-outplans ndicatc a grcaacrisk of an attcmpt, although withimpulsiveyouth, this s not neccssarilyhccase.3. Method, f the studcnthasa plan,determincwhathas becnalrcadyput in placctocarry out the plan.W}at mcthodsarebcingconsidered nd how availablcarc thcy?Determine hc exact ocationof any ethalmeans c.9., ireanns,drugs).4. Inlended laceor setting.Whcrc dws thc shrdentnte[d ro commit$c suicidc act?Hashc or shewrittena note,and f so, whatdocs t say?5. Innediote protecrive ction.U lhcrc s rcasonobclicvc h"t thestudents seriouslyconsidering uicide,mmediate rotcctivcactionshouldbe alcn. lfthcrc is a risk ofimminentdanger,notify parcDts nd whocvcrclsenccds o bc notified,dcpcndingon tie circumstances,choolpolicy,and ocal aws.Do not leavca suicidalstudcntalonc,evenbriefly.6. Suicideconrractandfollow-upplanning.lfthereisnoevidenceofimmincntdangcrbut Ore rofessional chool ounselorsstillconcernedbout hepossibi.liryfsuicidc,help the srudenlcompletea writtcDcontractn which hc or shepromiscs o (a) notengagen any self-dcstn tivcbehavior, nd@)call anappropriatc cnon or agcncyif he or she s considering elf-barm.Makc surcthc studcnthas namesand phonenumbers of peoplc to contact-Plan for ongoing counseling,bc mindful ofconfidentialityssues,onsul!with others, ndmcetwith hc studcDt'saren$ f thcsiruafon warrantsdoing so.(p. 30)Inlerven!ionsProfessional chool counselors aveopportunitieso intervcneal multiple cvels o helpchildren and adolescents eal with depressive ymptoms.nterventioncan takc thc form ofprevention, hich s designcd o reduce nciciencesf dcpressioncforcproblcms egin,ordirect counseling ervices or at-riskproupsand ndividuals. nterventionsat all levcls nccd tobe developmcntallynformed,wilh an overarching oal of enhancing r modi$lng srudenls'internaland external esourceshal arearncnablco chaDgcRicc& lrffert, 197).A numberof factors, ncludingschoolpolicy andsizc,maydictatc hCnahre andrypeof.interventionsn which the professional choolcounselors involved.hofessionalschoolcounselors re esponsibleor a wide angeof seniceiandwork with a argenumber f srudents,teachers ndparents.f too much imc s spentwith only a few srudents,hc argerproportionofthe student odymay be shortchangedRipley,Erford,Dahir,& Eschbach, 003).Rc.cognizjngthe chal!enge f balancingmultipleresponsibiliries,rofessionalchoolcounselors lay crucialroles n assessing,oordinating eferrals, nd,whennecded,roviCing Lect reatrnent r follow-up servicesor depressedtudentsRice& Leffert, 1997). hcy alsoarekey leadersn planningand mplementing reventionprograms or srudents, arents, nd eachers.A ss ssmet and EvuluutiotrAccuratcly ssessingepressionn childrenandadolescenlsan be a challengingask.Often, hesymptoms aDnolbe observed irectly andLherefore aygounreccgnized. y beingaware f thesigns, ymptoms, nd o-occurringond:tionsssociatedithchitdandadclescent


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deprcssion,rofessionalchool ounselorsan help dentifysrudents ho may be in needofservjces.hepurpose fassessmenls o nform ealmenl, ]hichmay nvolvedirect ounselingservicest theschool r clsewhere.'Ilpically, multiplc sources f informationareuscd oguidedecision-making nd reatrnentplanning. t helps to gethcr nformation rom thechild, parents, nd teachers. elf-reportinstruments,trucrurcd r scmi-strucrurcdntcrvicws,andbehavior alingscales resomcof theme$ods hatcan bc used n assessmenl.rofcssional choolcounselorswho havebecn rainedin appraisalproccduresmay choosc o usc asscssmentnstrumenlsdesigned or dcpressionscreeDing,uchas hc ChildrenbDepresslonnventory CDI), the BeckDepression nventory(BDI), andthcCentcrfor Epideniologic Studies epressionCES-D)Scole secNIMH, 2000).lf a professional choolcounselor asnot been ained to usea particular nsfument, he or shcshouldgetsupervision o cnsure lal the nstrumenls adrninistered nd nterprctedpropcrly. fthescrerning valuationndicateshestudent asdcprcssivc ymptoms ndpossiblya dcpressivcdisorder, heprofessional choolcounselorwill want to provide eferral nformationto parcntsso thata more comprehensiveiagnostic valuation an bc conducted.n such cases, hcpmfcssional choolcounselor anscrvcas a liaisonbctweenhc refenal agencyand he amily(fuce & l,z-tren,1997\.Di rect Counseing Servic sIndividualcounseling. or somestudents, hort-termndividual counseling r groupcounseling n the schoolmay bc warranted.Research asdemonstratedhecfficacy ofcertaintypcs of counseling,especially ognitive-behavioralherapy CBT), in alleviatingdeprcssivespnptomsiryoungpeopleNIMH,2001).Thegoalof CBT s to helpchildrenandadolescentsdevelopcognitive strucmres hat will positivcly inlluence heir futurc experiencesKcndall,20O0). he cognitive component f CBT hclps ndividuals dentify and changeneBativc,pcssimistichinking,biascs, ndanributions.he bchavforalomponenl, lso mponant o theprocess,ocuseson incrcasing ositivcbehaviorpanerns nd mproving socialskills (Asarnowet al.,2001).

Anotherq'pc of counscling,nterpersonalherapy or adolescentsIPLA), was adaptedfrom IPT for adults.Although it basnot bcen researched s extensivelyas CBT with youngpcople, tudies aveshown t to beeffectiven treating eprcssionn adults e.g.,Mufion et al.,1993). he wo primarygoalsof IPf are o reduccdcpressivcymptoms nd o improvcdishrbedpcnonal elationshipshatmaycontributeo depression.othCBT artd PT weredevclcpcdotreatdepression ut differ in theory andpractice.Both approacbescguire training to bc usedeffectively ith students.In conductingndividual ounseling ith students hohavedepressiveymptoms,uceard lrffert (1997) recommended cognitive-behavioral pproach hat fccuseson developingintemalandexlernal esourceshatareamenableo change. he irst step s to build a workingalliance ith thesrudent,herebyosteringhedevelopmentf anextemal esource. ext,otherstraiegiesanbe mplementeduchas heonesdescribedelow:

Coping or problcm-solving srategics could bc crplorcd and mprovcd. Studcnts cil learn howto match appropriatc coping sltategies to tic typc ofprobicm situations r.lrcyencounter. Forer.amplc, aclivc problem-solving in which art adolcsccnt sets a Boal, brainstorms po.ssiblcsolutions, alticipates conscquences,atd irnplements a plan of action, generally works for evenrsor circumslances tlat arc under al adolcsccnt'sconrrol. Emotion-focused sirategies (e.g.,rcluation) may bc used whcn circurnstances arc not under tlc adolescent's control but uenevcrtheless psening.Cognitivc intenenrions could be mplemented o challengean d reviseinrccurate pctccplions of sclf an d othcrs. Social ski l ls (e.g.,assenivencss raining) could bc

525


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I ' r , , l . . , r i , , r l l, J r , ' , ' l" r r r r " r r r r ' l l . ' r r r i l r ' ' l

addresscddd practiced in order to incrcase le quantity and qualiry ofrelationships with pcrsild fmily membrs. (p. 26)

hofessional schoolcounselors ho wotk individually with depressedtudentswill wantrocollaboratewith family memhrs and eachers o hat heycansupporthc work that s bcingdone with tlrechild. By consultingwith parents nd teachers, rofessional choolcounselorscan help significantothers n the sludent's nvionment learn how lo encouragc hc student'suscof newskills (Starket al., 2000).Referral.Attimes,professionalchool ounselors ill workwith students hoseproblensaresevercand chronic.When his rrcrus. lheanorqpriatesgponsemay bc to make eferrals omentalhealthprofessionalsn thecommunity.n particular,f the equircdnterventions annotbe implemcntedn the school, f medications apossibiliry,or if thesrudenlappearso bc indangerof harminganyone,making a referralmay be thc prefcrrcdcourscof action. n suchcases, he profcssional choolcounselorwill wanl to mcct with thc parentsof the student odiscussconcemsand detcrmine heirwilLingnesso pusuc outsidcbclp. f thcy arc willing toconsideroulsidchelp,a encrwrinenby theprofessional choolcounscloro the eferralscurcccan facilitate reatrnent ndcollaboration Mcnell, 2001).

Group counseling.Group counselingprovides anothermodc by which srudentswithdepressiveymptomsanbehelped. everal ulcome tudies ave emonslrated}e eflicacy fimplementing omprehensiventervcntion rograms hat emphasize ognitive behavioralrechniquesseeKaslow& Thompson, 998,or a reviewof outcomc fudies f intcrventionswir-h eprcssedhildren ndadolescents).'fhcnlcnentionprogramsmplementedn thcse fudiesfollowed a treatment-manualormat, therebyproviding a replicablescopcand seguence finterventions. hrec of the programs hat bavebeenusedsuccessfully ith youngpeoplearc:(l) theAdolescentCopingwith Depression ourseCWD-A;Clarke, winsohn & Hops, 990),rhe Taking ACTION Program (ACTION; Stark & Kendall, 1996), and InterpersonalPs,rchotherapyor Adolescents ith Depres.cionIFrf-A;Mufsonetal., 1993).Sourcesor theseprograms,ncluding briefdescriptionf each, re isted n Table .Three of the interventionprogmrrddcscribed n Table 6 range rom a minimum of 12sessionso as many as 30 sessions; oDscqucntly,n some schools t will not be fcasiblc toimplement hemas designed. enell (2001)suggestedevising modifiedcomprehensivegroup program, ncorporating ey elemens hat heprograms ave n common,which nclude:

(a)dcveloping therapeuticelationsbipascd n rustand espect;(b) educationegarding epression;(c) activity scbedulingmonitoring,ncreasing articipationn pleasant vents);(d) emotional ducationidentiiying ld labelingernotions,dentifying ituationsnwhich cmotionsare ikely to occur, ecognizinghe ink betweenhoughtsandfeelings);(e)cognitive hange trategieschallengingegative r nationalhuughts, racticingappropriatettributions,ncreasinghe ocuson positivehoughtsndevents);(f) problem-solving, egotiation,md conflictresolutio:r;(g) relaxation raining;(h) social skills andcommunication kills; and(i) goalsetting nd elapse revention.p.76)

526


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t . r r ) t c \ \ t { \ t } . r r ) L , r r r r t ( i U [ \ c , l r n r ] . \ I i r , l , J b r ) { , I

Tbble 6. Resources nd intervention programs or helping students with depression.fitle Description PublishingInformation

Helping StudentsCvercome DeprYssionand Amiety: A PracticalGuidc Qllerrell,200l)

Provides comprehcnsivcinformation aboutchild andadolescentdcprcssionand otherintemalizing disorders.Offerspractical guidelines or assessmentand intervcntion. Describesover40 psychoeducationalandpsychosocialnterventionechniqueslhol can be adapted or youth atdifferenl developmentalevels.hovidcs rcproducible workshcetsfor use ryith students.

TheGuilfordhess72 SpringStreetNewYork,NY100t2800-3657006www.guilford.com

Ta*ingACTIONProgran(Stark& Kendall, 996)A comprehensive nterventionprogram designed or youthbetween t}e agesof 9 and | 3,althoughactivities anbe adaptedfor younger or older students.Provides guidclines for 30 groupcounseling scssions ltat focus onaffective education,problem-solving skills,socialskills,copingskjlls, and cognilivc nlcrventions.

Workbook ublishing298 lanfair cadArdmore, A 19001610-896-9797

Adolescent Coping withDepression Course(Clarkeet al., 1990)A comprehcnsivecognitive-behavioral intervcntion programdesigned or small group work withadolescents ges il-18 (althoughit may bc adaotedor youngersludents).Providesirections or I 6two-hour psychocducationalcssiorActivities archighly sructurcd.Length of sessionsmay beproblematicn a schoolsetting.

CastaliaPublishing Co.P.O.Box 1587Eugene,OR 9744054 t -343 -M 3 l

lnterpersonal Therapyfor Adolcscents withDepression (Mufsonet al., 1993)

hovides an overview ofinterpersonal ierapy anddepression, n n-depthdescriprionof applications of IPT fordcprcsscd dolcsccnts,nd adiscussionf spccialssuc.srclated o workingwith youth.May bemoreappropriateormarure,nsighduladolescents.Due o ts clinical ocus,t maybc essapplicablen a schoolsetting.

Cuil ford Publ icarions72 SpringStreetNew York,NY l0Ol2800-365-7006www.gui l ford.com

527


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I ' r o l i ' s s io n a l Sc h r r r l ( u u r l . e t t t t , \ l l r u r r l l u t l

When onducting roups or students hoaredepressedr who areat risk for deprcssion,professionalchool counselorswill wanl o adaptactivitiesso that they arc developmenrailyappropriatendso hatstudenls' eallife conccrnsre ntcgnled nto lc format Stark& Kcndall,1996).ncluding omeworkassignmenlsetwecn essions,nvolvingparent5, ndadding oostersessionshatoccuraner he Program asbeen ompletcd reways o incrcasc hcefficacyof theexperience. ttcntion shouldbe givcnto age ange,gender omposition,and goup size,withfour to tenstudenlsn agroupbeingdcal Menell,2001).whercas ndividual and/orgroupcounselingmay be beneficial and needed or somesfudents, way oreachevenmorestudentss tluoughschool-basedrevention rograms,whicharediscusscdext.School-basedPrevention P rograttsStudent'oriented rograms.Professionalchoolcounselors an be instrumenralncoordinatingnd eadingifc skillsuaining rogramsopromoteosilivcmenral ealri nyoungpeople.Because ll youtl| arc exposedo sourccsof stfessand many youth are at risk forexpcricncing eprcssiveymploms fsomc ypc, t is importantor profcssional chool ounselorsto enhancerudents'abiliryorespond daptivclyndcopcwell Petersent al.,1992). hegoalof preventionrogramss to helpanentire opulationf stude !sdevelopntemulandextemalresourcesohelppreventhe onset fdcprcssionr to iesscnts ntensity houldt occur Rice& l*ffert, I D7). Prevention rograms anbe designed sclassroom uidance,which s gearedlowardstudents,r as tainingprograms, hicharegearedoward arents rd/orschool enonnel-Topics or srudent-orientedrevention an ncludcmanyof theelementshat weredescribe inthesectionon groupcounseling:emotional wiuencss,ecognizinghe inl between houghtsand eelings, opingskiJIs, roblem-solvinBkills, nterpcrsonalkills, conJliclresolution, ndrelaxation raining.Ar exar::plc f a srudent-orienledrevention rogram-rbc Pe;rnStateAdolescent rudy- 'wasdevelopedy Petcrsent al.(1992) adPetersont d. (1993)o promotemental ealth ndincieaseoping killsamong ixth-graderudents.his l6-sessionsychoeducationalrogram

helpcdsfudents evelop posilive emotional, ognitive,andbehavioral csponseso strcssorsandchallenges-achscssion mpha"izedparticular crcialki!|, opingmethod, r challenge,andbeganwith an activiry hatdernonstratedlc. topic.Students erc givenoppomrnitiesopractice ewproblem-solvingkills or ssues uch speer ressure, aking riends, nd amilyconflict.Eachsession ndedwith a summary nddiscussionf majorpoints hatwere henlinked o uqxoming essions. valuationndicatedhat students'copingkills andproblem-solvingabilities mprovedaftcr participatingn theprogram, ut hee fectswercncrobsen,ablconeyear ater, eading o the suggestionffollowing up with boostcr essionshroughourheschool ear o enhanceheprogram'song-terrnffectiveness.Parenl nrl eacherraining rograms.n additionoplanning tudent,orienledreveniionprograms,rol'essionalchool ounselorsan niliatc raining rogramsbr teachersndparenrs-Teachersndparentsypicallyhavemore nteraction ith youth hananyot}eradults. rainingprogramshat facilitate he developmentf skills n communication,.coping, ndbehaviormanagcmentan bc instrumcnraln promoling colthy ntcroctionr,husnelpingprevenlhedevelopmcntf depressiveymptomsn young cople. lso,programs esignedo aise arenland eacher warenessbouldepressionanhelp mprove ccesso neededmenla.lealrb arefor childrenwhose epression ightotherwise o undetected.anyparenls n


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l ' r i , l f . , . , i r , i l r l 5 , i r , , , j J , , r , 1 . r . l i r ! , \ I l . r I L j / ; , , , , 1

Kirchner t.at . 2000) eveloped pirotprogram, epressionn theCrrtssroom,or K-12teachersoeducatearticipantsbout epressionnd uicidaliry mong hil


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l ) , , ) l ! \ s r { r r . , } i l r r r , l ( r r r r r r r rr r r ; , \ | l ; r r r t l l r , , , l

Clarke,G., Lewinsohn,P.,& Hops,H. (1990).Coping with adolescent epressioncourse;lzader's manualfor odolescent roups.EugenqOR: Casralia.Katfenberger, ' J., & Seligman,L- (2N3). Helping studentswirh mental and cmotionaldisorders.n B. T. Erford(Ed.),Transforminghe schoolcounseling rofession pp. 249-283)-Columbus, H:MerrilVhenlice-Hall.Kaslow, N. J., & Thompson,M. P. (1998).Applying rhe criteria for cmpirically supporredtrealmenls10sludiesof psychosocialntervcntions or child and adolescenldcpression.Jounal of Clinical ChildPsychology, 7, 146155.Kendall,P.C. (2000).Guiding heory or thcrapywitirchildrenandadolesccnls.n P.C. Kendall(Ed.),Child ondadolescentherapy:Copnitive-belnvioral rocadures Zd ed.,pp.3-27).New York: Guilford.Kendall,P.C., Snrk,K., & Adan, T. ( 9m). Cognitivcdeficitor cognitive istortion n childhccddepres on. Jou na of Abno ma Ch d Psycho ogy, I 8, 261 2t3.Kirchner, .8., Yodcr,M. C.,Kramcr,T. L., Undsey,M. S.,& Thrush,C. R. (2000).Devetopmenrof an educational rogram o incrcase choolpcrsonncl's warenessboutchild andadolescent epression. ducation, 2 , 235-246.Kovacs,M. ( 990). omorbidanxiery isordersn childhood-onsere ressions.n J.D. Maser

& C. R. Cloniger (Eds.),Comorbidity of mood and auiety disorders(pp. Z7Z-281).Washington,C: AmericalPsychiatric ress.Ivierrell,K. W. (2001). lelping studenrs vercome epression ndauiery: A practical Buide.New York:Cuilford.Mufson,L. , Moreau,D. , Weissman, . M. , & K lc rman,C. L . (1993) . n te rpersona lpsychotherapyfor depresseddolescents. cw York:Cuilford.National nstitute of Mental Health. (2000).Depressionn childrenand adolescenrs: factsheetor physicians.RetrievedMay 28, 2002, from hrrp://www.ninrh.nih.gov/publicar/depchildresfact.cfmNational nsdrute of MentalHealth. (2001).Depression esearch t theNarional lrctirute ofMental Ilealth. RetrievedMay 30, 20A2, rom hup://www.nimh.nih.gov/publicar./depresfact.cfmNarional nstituteof Mental Hcalrh. (2002a). zt's talk aboutdepression. etricve


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, l r s r i l n . r l S r : h , , , r l ' o u n s c l i r r r ' : I e r t l f ' r r r l .

Slark,K. D., Sander, . 8., Yoncy, r ! . G., Bronik, Nl. D., & Hoke, J. \ . (2000). Treatmenlofdeprcssion n chi ldhood and adolesccncc:Cogni l ivc-bchavioral proccdurcs for theindividual and family. In P. c. Kendall (Ed.), child and odolescent therapy: Cognirive-behaviorol procedures (?il ed.Xpp. 1'13-234).New York: Guilford.

Surgeon General. (2002). Depression and suicide in children and adolescents. RetrievedFebruary 28 , 2002, from http://www.surgeongeneralgovAlt:rarylmentalhealth/chapte13/sec5.hunl

Yarcheski,A. , & Mahon, N. E. (2000). A causal model of depression in early adolescents-WestcmJournal oJ NursingResearch,?2,879-894.

CHAPTER 56 Depression

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