Modifications in Timing Presentation and Implementation of Interventions

For complex childhood or adolescent depression, modifications of CBT often are needed. These are reflected in the case formulation, which may be modified as treatment progresses (Rogers, Reinecke, & Curry, 2005), as illustrated in three examples.

Consider first the "cognitively immature" adolescent. Cognitive immaturity may be reflected in a lack of self-reflection or insight; poor verbal abstraction skills; an inability to identify and label emotions, and to appreciate relationships between one's thoughts and feelings; or delays in the development of hypotheticodeductive reasoning and problem-solving skills. This may be a function of age, delayed intellectual functioning, or a learning disability. As a general rule, CBT proceeds more slowly for cognitively immature teens than for other teens, and places a relatively greater emphasis on behavioral interventions.

Quite often emphasis during early sessions is placed on developing affect recognition and labeling skills, and on assisting the patient to appreciate how life events, thoughts, and emotions influence one another. Techniques such as attending to physiological changes and somatic experiences associated with anger, tension, and happiness, may prove helpful in this regard. Once these fundamental skills are developed, Mood Monitoring, Behavioral Activation, and Rational Disputation modules are introduced. As behavioral strategies are introduced, more immature teens may benefit from active modeling by the therapist or by interactive games within sessions. These serve to illustrate connections between activity level and mood, and can be helpful in maintaining a positive therapeutic rapport.

When cognitive techniques are introduced, it is helpful for therapists to take a more directive stance. Many young adolescents find rational disputation and cognitive restructuring difficult. Techniques that adults and older adolescents find useful, such as the three-column technique, are simply unhelpful. Under such circumstances therapists may want to present teens with a brief list of alternative "adaptive" thoughts that may lead to more positive affect, and ask them to choose the ones they feel are most sensible. They then practice repeating these "adaptive self-statements," much like a mantra, when they become anxious or depressed.

A second type of modification is needed for young people who experience labile affect. Clinically depressed youth often manifest difficulties in regulating negative moods. Affect regulation skills that develop over the course of childhood and adolescence have been implicated in the development of psychopathology among youth (Bradley, 2000). Several cognitive-behavioral theories of depression emphasize the role of early experience in the acquisition of these capacities, and focus on teens' development of these skills over the course of treatment (Spence & Reinecke, 2003). For emotionally volatile or explosive youth, training in cognitive and behavioral strategies for regulating affect need to be introduced early in course oftreat-ment, shortly after mood monitoring. Otherwise, treatment may be disrupted by behavioral outbursts, self-cutting, or suicidal gestures that occur with little apparent provocation. Both Brent's CT and the TADS CBT protocol used a method developed by Rotheram (1987). After the adolescent becomes familiar with monitoring moods with an "emotions thermometer," he/she is asked to designate a point on the subjective thermometer where emotions reach a "boiling point"—the point at which he/she perceives a loss of control. Then the teen is asked to go back down the thermometer to identify a "choice point," where he/she is still able to control the reactions. The teen then works with the therapist to identify and practice coping strategies (e.g., relaxation, distraction, taking a walk, talking with a parent, adaptive self-statements, shooting baskets) that can be implemented at the "choice point." These are rehearsed in session, and potential triggers for losing control are identified. Strategies for coping with rapid shifts in emotion are reviewed with the parents, who support their child's attempts to use them at home.

A third type of complex depression occurs with adolescents who lack necessary support systems. Such teens may have parents who are impaired by a psychiatric or substance use disorder, or who suffer from severe socioeconomic disadvantage. For these teens, it can be quite difficult to participate in psychotherapy on a regular basis, and their parents may be unable to assist them with practicing cognitive-behavioral skills at home. They may come from chaotic homes and communities, and frequently miss sessions or "disappear" from treatment for weeks at a time. The therapist, therefore, will want to order treatment so that the most important elements are covered first. It is inadvisable in such cases to use a skills-sampling approach, because of the adolescents' inconsistent attendance. A small number of key skills should be introduced, with an emphasis on instilling a sense of hope and personal control. At the same time, sessions with parents may focus on understanding and rectifying their beliefs, attitudes, expectations, and attributions that may reduce their motivation for participating in treatment. They may believe, for example, "We've tried everything. Therapy won't work," "They're just seeking attention with their suicide talk. We should just ignore it," "This is just blaming the parents, telling us it's our fault," or "It's just a phase, she'll grow out ofit." Beliefs such as these, as well as the perception that the therapist does not fully appreciate their perspective about their child's difficulties, can undermine parents' support for the treatment.

The therapist uses psychoeducation, Socratic questioning, and empathic listening to address these beliefs and to give parents a sense that their children's difficulties are both understandable and resolvable. CT endeavors to give parents, as much as their children, a feeling of being understood and supported, and a sense of hopefulness. At the same time, the therapist attempts to resolve practical issues (e.g., work schedules, cab fare) that may interfere with attendance.

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