Supplementing Standard CT

Supplements to standard CBT include an array of methods used in clinical child and adolescent psychology, as well as medications prescribed by child psychiatrists. Four commonly used psychosocial supplements include neo-behavioral techniques, school-based interventions, family-based interventions, and extended family or community interventions.

Neobehavioral techniques are derived from more recent models of treatment, including dialectical behavior therapy (DBT), and mindfulness-and acceptance-based models. DBT techniques, for example, are often help ful when working with adolescents who engage in self-damaging behavior, such as cutting. Self-soothing techniques that focus on emotion regulation and distress tolerance, such as guided imagery, distraction, and controlled breathing (Linehan, 1993), can be quite helpful in this regard. Acceptance-based interventions focus on recognizing and observing with detachment depressive, anxious, or suicidal thoughts and emotions (Teasdale, 2004). Patients are taught to disengage from maladaptive thoughts and to limit rumination. Unlike standard CT, which focuses on changing the content of thoughts, mindfulness-based approaches emphasize the value of "decenter-ing" from maladaptive thoughts (i.e., viewing them as objects, and not as central to one's sense of self) and of accepting them (rather than actively challenging their validity or endeavoring to escape or avoid them). This permits greater awareness that these are "just thoughts" (not reality) that can be tolerated and will pass.

Reciprocal relations exist between school performance and mood among children and adolescents. Depression can impair academic performance, and a significant percentage of depressed adolescents meet criteria for a comorbid learning disability. School-based interventions, including consultations with teachers, administrators, and school counselors, as well as classroom observations of the student, can be quite helpful in developing a comprehensive treatment program. CBT with children and adolescents attends to not only their intrapsychic experience but also the contexts in which they live, their school and home environments. Depression can have a debilitating effect on academic work, and on relationships with classmates. In many cases, explaining to parents and school personnel the nature of the teen's disorder, and of the consequent necessity for adjusted expectations during the recovery period, is of significant benefit. In this regard it is important to convey to school personnel and to parents the anticipated duration of a depressive episode, and the fact that even good response to treatment does not quickly translate into recovery of normal functioning.

Depressed teens are often seen by others as sullen, withdrawn, and apathetic, and their relationships with other family members are often tense and conflicted. Evidence indicates that family conflict is both a cause and a consequence of depression among youth (Kaslow, Deering, & Racusin, 1994). With this in mind, family-based interventions may be a useful supplement to individual or group CBT. Adolescents whose depression is rooted in negative thoughts about self in relation to family, for example, may benefit from family sessions in which a more secure and supportive parent-adolescent attachment is rekindled. Parents whose teenagers' depression is intertwined with oppositional behavior may benefit from parent training about clear communication, monitoring, and providing appropriate consequences. In some cases, the therapist needs to determine whether it is preferable to rely on the family for support in the therapeutic process or to facilitate adolescent independence from the family. The latter option may be considered when family-based interventions exacerbate the adolescent's depression.

Extended family or community interventions engage a broader network of support in assisting depressed teens. For adolescents who live with an extended family, the therapist wants to understand dimensions of affection, caring, control, and authority in the family, as well as the expectations, attributions, attitudes, and beliefs held by other family members. For depressed adolescents who are involved in the judicial or foster care system, community interventions may include meetings with probation officers, court counselors, foster parents, or case managers. In such cases it may be helpful to share the principles of CBT, including the importance of positive reinforcement, limit setting, and the development of realistic, positive beliefs and expectations. It is critical that the therapist engaging in family-, school-, or community-based interventions have a clear case conceptualization and a sense ofthe role that the wider family and social systems play in maintaining the adolescent's depression. The focus of treatment remains on alleviating the teen's depression, not on effecting broader systemic change. Put another way, the identified patient remains the adolescent and the identified problem remains the depression.

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