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.