Running head: PSYCHOLOGICAL TREATMENT FOR DEPRESSED STUDENTS
Psychological Treatment for Depressed Students
Amy A. Zieman
Monmouth University
Psychological Treatment for Depressed Students
Depression in school-age children may be one of the most overlooked and
undertreated psychological disorders of childhood, presenting a serious mental
health problem. Depression in children has become an important issue in
research due to its many emotional forms, and its relationship to
self-destructive behaviors. Depressive disorders are of particular importance
to school psychologists, who are often placed in the best position to identify,
refer, and treat depressed children. Procedures need to be developed to
identify depression in students to avoid allowing those children struggling
with depression to go undetected. Depression is one of the most treatable forms
of disorders, with an 80-90% chance of improvement if individuals receive
treatment (Dubuque, 1998). On the other hand, if untreated, serious cases of
depression in childhood can be severe, long, and interfere with all aspects of
development, relationships, school progress, and family life (Janzen, &
Saklofske, 1991).
The existence of depression in school-age children was nearly unrecognized
until the 1990’s. In the past, depression was thought of as a problem that only
adults struggled with, and if children did experience it, they experienced
depression entirely different than adults did. Psychologists of the
psychoanalytic orientation felt that children were unable to become depressed
because their superegos were inadequately developed (Fuller, 1992). More
recently, Clarizio and Payette (1990) found that depressed school-age children
and depressed adults share the same basic symptoms. In fact, only a few minor
differences between childhood and adult depression have been found, including
the assumption that with childhood depression, irritable mood may serve as a
substitute for the depressed mood criterion (Waterman & Ryan, 1993).
Depression in students has become difficult to treat due to a lack of referrals
for treatment, “parental denial, and insufficient symptom identification
training” (Ramsey, 1994). In addition, recognizing and diagnosing childhood
depression is not a simple task. According to Janzen and Saklofske (1991),
depression can develop either suddenly, or over a long period of time, “it may
be a brief or long term episode, and may be associated with other disorders
such as anxiety”. The presence of a couple of symptoms of depression is not
enough to provide a diagnosis. A group of symptoms that co-occur, and
accumulate over time should be considered more serious. Depression is
classified by severity, duration, and type according to the DSM-IV-TR,
published by the American Psychological Association (2000).
According to Callahan and Panichelli-Mindel (1996), many School Psychologists
are not required to diagnose affective disorders in students, but do need to
assess and develop interventions for them. The DSM IV appears to provide much
help to School Psychologists to determine the symptoms that indicate a
particular disorder, and to relay that information to professionals outside of
the school. According to Callahan and Panichelli-Mindel (1996), it may be
difficult to provide a diagnosis when childrens’ symptoms do not easily fit any
categories. Also, a child that does not clearly fit into a diagnostic category
may go without treatment when treatment is needed (Callahan & Panichelli-Mindel,
1996). The child’s diagnosis appears to be the most important aspect in
planning the appropriate treatment or intervention. Thus, misdiagnosing a child
could be harmful.
According to Fuller (1992), childhood depression may account for a variety of
behaviors, for example, “conduct disorders, hyperactivity, enuresis, learning
disability, and somatic complaints”. Fuller (1992) also reports that depression
in children may coexist with “irritability, low self-esteem, and inability to
concentrate”. Also, children may “internalize depression maladaptively”,
perhaps expressing it through conduct disorders, hyperactivity, or attention
deficit disorders (Fuller, 1992).
In a study conducted by Dubuque (1998), specific guidelines are provided to
help school staff generate awareness and support for depressed students.
Dubuque (1998) reports that school staff need to learn to identify signs of
depression in children because parents and significant others tend to attribute
symptoms of depression as “sensitive and shy”, or at the other extreme, they
may be mistakenly categorized as attention deficit disorder.
Dubuque (1998) suggests that school staff should be “alert” to the symptoms or
signs of depression in children, for example: “persistent sadness or
hopelessness, inability to enjoy previously favorite activities, increased
irritability, frequent complaints of physical illness, such as headaches and
stomachaches, which do not get better with treatment, frequent absences from
school or poor performance in school, persistent boredom, continuing low energy
or motivation, poor concentration, a major change in eating or sleeping
patterns, poor self-esteem, a tendency to spend most of their time alone,
suicidal thoughts or actions, abuse of alcohol or other drugs, or difficulty
dealing with everyday activities and responsibilities”. Information on
childhood depression should be passed on to community members, children, and
families with children (Dubuque 1998). Training programs can be implemented for
school staff about childhood depression (Dubuque, 1998).
Adults often need to be reminded to take the time to really listen to students
by engaging in “active listening” techniques. Adults working with children will
be more likely to recognize problems if they engage in active listening skills,
including: maintaining eye contact with the child, maintaining appropriate body
language, leaning toward the child, nodding, sitting closely, and refraining
from giving immediate comments, or solutions which will allow the child to talk
through the problem, and possibly generate solutions on their own solutions,
and paraphrasing what the child has conveyed (Dubuque, 1998). School staff can
educate children to develop or expand a “feeling vocabulary”, to enable them to
accurately communicate their feelings to others (Dubuque, 1998). Children who
appear angry and irritable tend to respond well to an environment that is
consistent, with clearly defined limits (Dubuque, 1998). Dubuque (1998)
suggests that such an environment can be created by sticking to rules, routines
and reinforcements to create a secure atmosphere for children who frequently
act out. Physical outlets for stress and anxiety, like jumping rope or running
in place can be provided during the school day as a release (Dubuque, 1998).
Dubuque (1998) also recommends that adults allow the child to know that they
are sensitive to the child’s feelings and to look for positive changes in the
child’s behavior. Positive changes in the child’s behavior can include overt
changes such as a lower frequency of isolative behaviors, an increase in
activities with peers, or more positive self-statements.
To assist in identification of children in need of intervention, a variety of
instruments to assess depression in children are available, including: “The
Children’s Depression Inventory (CDI), The Children’s Depression Scale (CDS),
The Reynolds Adolescent Depression Scale (RADS), The Reynolds Child Depression
Scale, and The SAD Persons Scale” (Ramsey, 1994). Reynolds (1990) reports that
although School Psychologists do not usually use clinical interviews but they
appear to be one of the most effective means of assessment of depression.
Clinical interviews allow an exploration of symptoms, information regarding
whether possible symptoms are related to depression, or other factors
(Reynolds, 1990).
According to Dixon, (1987), there are four types of depression: normal,
chronic, crisis, and clinical. the four types are distinguished by degree,
intensity, duration, cause, hopefulness, response to treatment and level of
functioning (Dixon, 1997). Normal depression is defined as mild periods of
depression, linked to certain events that affect a student’s mood periodically
(Ramsey, 1994). Chronic depression involves frequent “bouts” of depression,
often without an identifiable cause (Ramsey, 1994). Depression in a crisis
state usually reflects a lack of problem-solving skills, and can be accompanied
by feelings of “sadness, and dispair” (Ramsey, 1994). Clinical depression
involves a predisposition in personality paired with a crisis state (Ramsey,
1994). Clinical depression in considered as having most severe prognosis due to
the fact that after a long period of therapy, a clinically depressed student
may or may not return to their normal level of functioning (Ramsey, 1994).
In addition to a clear diagnosis, it is important to consider a child’s
cognitive and emotional level when deciding a treatment approach (Sung &
Kirchner, 2000). The same study showed that treatment that is innapropriate for
a child’s level of cognitive functioning can foster negative outcomes.
According to Sung and Kirchner (2000), psychotherapy can be an effective method
of intervention for children with mild to moderate depression, and can be
combined with medication for children that experience more severe depression.
Sung and Kirchner (2000) suggest that the majority of available research on
children ten years old and older deals with cognitive behavior therapy, to help
patients alter negative cognitions about themselves and the world. Cognitive
behavior therapy with depressed children has been shown to be productive over
both long and short-term treatment because of a high degree of cognitive
distortions that contribute to depression in children (Sung & Kirchner,
2000). A meta-analysis of various studies revealed that cognitive behavioral
therapy was shown to be more effective with depressed children than
“nondirective supportive therapy, and systematic family therapy” (Sung &
Kirchner, 2000).
Shure (1995) suggests that cognitive behavioral therapy teaches children how to
think for themselves rather than think for the children. Shure (1995)
recommends a cognitive approach to treatment named “Interpersonal Cognitive
Problem Solving”, that is appropriate for children of various ages and IQ
levels. Shure (1995) suggests that lesson based games can be applied as early
as preschool. The games are designed to help children get in touch with their
feelings, as well as the feelings of others (Shure, 1995). According to Shure,
ICPS can help children learn to generate or apply more than one solution for a
problem, learn to create dialogues to express their feelings, and increase
coping skills (Shure, 1995). Family intervention also appears to be beneficial
in order to address parental self-blame. Education of the child as well as the
family enhances both understanding, and compliance with treatment (Sung &
Kirchner, 2000).
Reynolds (1990) suggests that no one should ever engage in the treatment of a
depressed child without proper training and knowledge of affective disorders,
models, and treatment for several reasons. The treatment of a distressed child
with a combination of symptoms, and potential suicidal ideation is a very
serious task. Reynolds (1990) suggests that if treatment fails, the child could
be faced with increased feelings of helplessness, or despair.
Another approach to treating children with depression is a very basic
symptom-focused approach reported by Ramsey (1994). According to Ramsey (1994),
it is important to begin treatment by developing an empathetic understanding of
the child’s attempts to reduce negative feelings of unworthiness by demanding
praise and support from others. It appears that if this need exists within the
student, they will be more willing to partake in treatment. Ramsey (1994),
notes that the first step to effective treatment is to establish good rapport
with the child rather than begin with psychological support. A good
relationship with the student appears to provide enough support in the
beginning of treatment.
The second step involves exploration of the student’s feelings, physical
health, daily activities, relationships with others, and assumptions about
treatment (Ramsey, 1994). Once a good relationship has been established, Ramsey
(1994) suggests that interventions should be “symptom specific”, and recommends
several interventions based on particular symptoms.
A student’s poor self concept is sometimes formed when children feel that they
do not measure up favorably to other siblings or parental expectations (Ramsey,
1994). To help children develop more positive self concepts, children can
benefit from being engaged in group activities or tasks at home or school that
are consistent with their skills and provide a chance to feel successful
(Ramsey, 1994). Parents can also benefit from instruction, role-play, and
parenting groups to help learn to understand, and communicate with children who
struggle with low self-esteem (Ramsey, 1994). In order to gain a sense of how
the child feels and thinks, Ramsey (1994) recommends engaging the child in play
therapy, drawings, incomplete sentences, or fantasy games. By asking a child
with a poor self-concept how they would like to be, a counselor can gain an
idea of what is troubling the child about their status. Counselors can help the
student establish a goal, identify alternative behaviors, and rehearse the new
behaviors (Ramsey, 1994). Cognitive restructuring exercises can also be applied
to help children increase positive thinking and rational coping skills (Ramsey,
1994). For example, messages like “I am not good at math” could be changed to
“I can try to be good at math”.
Withdrawn children often require projective techniques such as pet therapy,
art, music or diaries in order to properly engage them in therapy (Ramsey,
1994). Active listening skills on behalf of the therapist is also beneficial
when treating a withdrawn child. Ramsey (1994) also recommends involving
withdrawn children in group activities with other children that they admire.
Young students that are experiencing agitated anxiety can gain relief by
talking to other children their age in group therapy who have similar feelings
(Ramsey, 1994). In order to determine the possible causes of the child’s
feelings, autobiographies, drawings, puppets and play therapy can be used
(Ramsey, 1994). Relaxation techniques, or imagery can be taught to help
students learn to manage anxious feelings (Ramsey, 1994). Ramsey (1994)
suggests that the more agitated students might respond well to token economies,
in order to reward positive behavior.
When treating students for depression, it is not uncommon to encounter students
that engage in self-destructive behaviors. Ramsey (1994) notes that when
treating this population, it is a good idea to have the student review everything
that has taken place in the child’s life within the past few days in order to
become aware of any threats, hints, or self-destructive intentions. If a child
suggests any intentions to harm himself or herself, it should be considered as
“a cry for help”, and not just attention seeking behavior (Ramsey, 1994). The
therapist should provide an environment that the child will view as
non-judgmental (Ramsey, 1994). Some incidents that contribute to suicidal
thoughts include: “losses of loved ones or pets, feelings of failure; and
extreme shame or grief” (Ramsey, 1994). Of course, therapists always need to
determine if the child has a plan, how well thought out it is, and if they have
the means to carry out the plan. Based on this information, a counselor or
therapist should be able to determine if the child is in need of referral to
crisis services. The parents need to be notified of any suicidal risk and
education regarding feelings of guilt, warning signs, and panic (Ramsey, 1994).
These children need special attention because often young children do not
understand that death is “irreversible” (Ramsey, 1994).
In a study by Fitts and Landau (1998), brief therapy is regarded as
inappropriate for children with depression. Fitts and Landau (1998) suggest
that these children are in need of “longer-term therapy” that provides
extensive emotional guidance and support to make a lasting improvement to
child’s quality of life. It is also suggested, based on research, that people
who are “extremely self-critical” require long-term therapy (Fitts &
Landeu, 1998). Fitts and Landeu (1998), clearly point out that despite these
circumstances, “managed care” manages costs by endorsing brief therapy
regardless of the circumstances. Thus, just because a school psychologist makes
a referral outside of the school system does not necessarily mean that a child
will receive the long-term therapy needed.
In light of the unique challenges involved in engaging young children in
therapy, Friedburg (1996) provides information regarding games and workbooks
that can be utilized for this purpose. Friedburg (1996) notes that cognitive
behavioral therapy can be modified in a creative way to interest young students
with age-specific learning materials. For example, cognitive orientated workbooks
can provide a connection between individual problems and cognitive techniques
(Friedburg, 1996). These games and workbooks are geared specifically towards
internalizing issues in children, such as depression and anxiety (Friedburg,
1996). An example of one of the games is the “Depression Management Game” which
requires children to seek out the irrational beliefs in various scenarios, and
replace the thoughts with more positive statements (Friedburg, 1996). Friedburg
reports that the workbooks benefit the school psychologist because they are
familiar to the students, they require active participation, and provide
direction for the therapy (Friedburg, 1996). In addition, the exercises can be
retained as a document, and pages can be taken home as a homework assignment
(Friedburg, 1996). Friedburg (1996) warns that the overuse of the workbooks can
negatively affect the therapeutic relationship.
In conclusion, there are many treatment options available to school
psychologists today. Cognitive behavior therapy appears to be the orientation
most frequently endorsed by research on treatment of depressed students.
Materials can be used in therapy to actively engage students who are reluctant
to comply with treatment. The materials available can present as a fun activity
to students, and help the therapist gather information, and establish rapport.
Stimulating activities are also suggested for use with symptom specific
interventions (Ramsey, 1994). It appears that the most troublesome aspect of
the treatment of childhood depression is the fact that many children remain
untreated, or misdiagnosed. Education and an increase in awareness of the signs
of childhood depression can help reduce the amount of children that are left
untreated. Coincidentally, National Childhood Depression Day is May 4th. This
event is symbolized by a green ribbon, and is an event created by the National
Mental Health Association to help spread awareness, and education regarding the
seriousness of childhood depression.
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