Treatment Of Depression Among Adolescents Adaptations of Standard Cognitive Therapy

Three CBT protocols have been developed for use with depressed adolescents. The first of these is based on the "standard model" of cognitive therapy (CT) for depression developed by Aaron Beck and his colleagues (Beck,

Rush, Shaw, & Emery, 1979). Based upon cognitive diathesis-stress paradigms, this model emphasizes the importance of changing automatic thoughts, maladaptive tacit beliefs or schemas, and other cognitive products or processes associated with depression as a means of bringing about behavioral and emotional change. Brent and Poling (1997) adapted Beck's CT protocol for use with adolescents. Based on the core principles of CT, their approach emphasized identifying and modifying negative automatic thoughts, dysfunctional attitudes, and maladaptive beliefs. Behavioral interventions, such as activity scheduling, are of value with more impaired depressed teens who are withdrawn or passive. These techniques are viewed, however, chiefly as methods for eliciting and testing the validity of negative cognitions. An emphasis is placed on identifying and rationally disputing teens' maladaptive thoughts that occur spontaneously during sessions.

CT for teens is delivered in an individual psychotherapy format, and parents are encouraged to participate in psychoeducational sessions. The length of acute treatment is 12-16 weeks, with sessions held on a weekly basis. As in adult CT, the adolescent's depression is assessed before each session with a self-report scale. Teens are also asked to generate goals for their treatment, and these are used as reference points over the course of treatment.

As in adult CT, emphasis is placed on maintaining a positive, supportive therapeutic rapport, characterized by collaborative empiricism. Adolescents are taught to adopt the role of a "personal scientist" as they work with the therapist to understand how negative thoughts and maladaptive beliefs or schemas are maintaining their depressed state. Teens are encouraged to participate actively in constructing an agenda for each session. In contrast to CT with depressed adults, the Brent and Poling (1997) model places relatively less emphasis on between-session homework assignments. Like its adult counterpart, however, the model utilizes frequent summaries of main session points. As therapy proceeds, adolescents assume a greater responsibility for directing the treatment process. They learn to set the agenda for the session, to explore key cognitions, and to summarize the session. Through this process the adolescent learns how to become his/her own therapist (Brent & Poling, 1997).

Although CT does not explicitly focus on developing social or behavioral competencies, it remains to some degree a skills-based treatment. To the extent that they are introduced, specific behavioral or cognitive skills or techniques are directed toward assisting the adolescent to identify and modify key cognitions. The same techniques used in adult CT are used to modify adolescents' cognitions, including Socratic questioning, role-playing, and the analysis of "pro" and "con" arguments supporting or challenging the utility of holding certain beliefs. Cognitive restructuring in CT focuses on developing more adaptive and flexible thoughts, attitudes, beliefs, and expectations. Therapists typically do not suggest specific alternative thoughts. Attention is paid to issues of adolescent autonomy and the impact that developmental tasks may have on the family and peer relationships. A relatively greater emphasis is placed on helping teens to learn problem-solving methods than is typical with adults. Social skills training may be included.

The most significant modification made in adapting Beck's CT for work with adolescents, however, centers on the role ofthe family. A major emphasis is placed on psychoeducation and on including parents in the treatment process. Brent and Poling (1997) recommended providing caregivers with information about the nature of depression and the process of CT. An objective of psychoeducation is to help parents to understand that depression is an illness, and to counter potentially maladaptive parental beliefs such as "My child is doing this on purpose," or that he/she could "snap out of it."

A second variant of CBT for depressed adolescents is Clarke and Lewinsohn's Coping with Depression (CWD) course (Lewinsohn, Clarke, Hops, & Andrews, 1990). This treatment is based on Lewinsohn's model of depression, which posits that depression is a function of inadequate positive reinforcement, especially social reinforcement. Depression is characterized by decreased behavioral activity, reduced social interaction, and negative thinking. Lewinsohn and Clarke view mood, cognition, and behavior as transactionally related aspects of human functioning that influence one another as the individual adapts to his/her environment. To alleviate depression, a person can make changes in cognition, behavior, or environment.

In contrast to CT, the CWD course places equal emphasis on learning new behaviors and on learning new, more adaptive ways of thinking. A wide range of skills is taught, including goal setting, mood monitoring, increasing pleasant activities, relaxation, social interaction skills, communication, and interpersonal problem solving. A group format is used. The method of delivery is more similar to that of a classroom than to that of an individual psychotherapy session, thus reducing stigma and taking advantage of the teens' sense of familiarity with the process. Homework assignments are emphasized, and group time is highly structured. Therefore, there are relatively few opportunities for tailoring the treatment to the needs ofparticular individuals. Treatment typically lasts 7-8 weeks, with sessions held twice per week. Parents may be seen in psychoeducational groups once per week, where they discuss the skills their teens are learning, as well as ways to help them implement these skills at home. More recent versions include conjoint parent-adolescent problem-solving sessions.

CWD maintains a clear focus on developing cognitive, social, and behavioral skills to rectify social and cognitive deficiencies associated with depression. Mood is monitored daily on a brief self-report form, and teens learn how activity levels and cognitions influence their mood. Much as Beck and colleagues (1979) encouraged each patient to become a "personal scientist," the CWD course endeavors to help adolescents appreciate how their actions and thoughts influence their mood, and to develop relapse prevention plans that build upon these observations.

More recently a third CBT approach for treating clinically depressed youth, the TADS protocol, has been developed. By the late 1990s a completed body of controlled outcome research supported the acute treatment efficacy of the CT and CWD approaches, as well as medication management with fluoxetine, for treating adolescent depression (Emslie et al., 1997b; Reinecke, Ryan, & DuBois, 1998). CBT and medication had never been compared, however, in a placebo-controlled trial with clinically depressed youth. With this in mind, the TADS was initiated to test the relative and combined effectiveness of CBT and fluoxetine in the acute and continuation treatment of adolescent major depression. TADS treatment was manualized for use across multiple sites by clinicians with varying levels and types of CBT training, and for adolescents typical of clinical samples (Curry & Wells, 2005).

The CBT protocol used in the TADS study represents an amalgam of the two models reviewed above. Borrowing from the Brent and Poling's (1997) CT protocol, TADS CBT utilizes an individual psychotherapy mode of delivery and includes parent and teen psychoeducation about depressive disorder. It emphasizes the importance of maintaining a collaborative therapeutic relationship and incorporating the full array of CT strategies and techniques developed by Beck, including agenda setting, summaries, assignment of homework, and rational disputation of dysfunctional attitudes and thoughts. Like Clarke and Lewinsohn's CWD approach, the TADS CBT protocol places equal emphasis on changing behaviors and cognitions, and requires that all teens receive training in a set of core cognitive and behavioral skills. Additional skills training is optional (Curry & Wells, 2005).

As Curry and Reinecke (2003) noted, TADS CBT uses an individualized, "modular" approach to treatment. After an adolescent has been exposed to the core skills, therapist and patient have a degree of latitude to select skills or modules that best meet the teenager's needs. Unlike the CWD course, the TADS CBT protocol can be tailored to address a teen's specific concerns. All treatment sessions, nonetheless, are relatively structured and follow a general format of agenda setting, homework review, skills train ing, working on the agenda items, formulation of a homework assignment for the upcoming week, and review. The use of modules permits the therapist to modify the treatment based on the specific needs of the teen, or of the parents, and the selection of treatment targets based on the case formulation.

Mandatory or "core" modules in TADS CBT include Psychoeduca-tion, Goal Setting, Mood Monitoring, Increasing Pleasant Activities, Problem Solving, and Cognitive Restructuring. At the conclusion of therapy, all adolescents participate in one or more sessions during which they summarize and synthesize the material discussed over the course of treatment, and develop strategies for coping with stressful events that might occur in the future. As in CT with depressed adults, active attempts are made to provide teens with skills for preventing relapse. Optional modules include training in Relaxation, Affect Regulation, Assertion, and Social Interaction Skills. All parents receive two sessions of psychoeducation about the nature of major depression and their child's treatment. Optional parent-adolescent sessions center on family communication, problem solving, adjusting parental expectations, and providing appropriate consequences.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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