They show that mood swings in depressed children alternate with days of a pervasive down mood. These moods involve sadness, loneliness, unhappiness, hypersensitivity, overreactivity, and negative attitudes. All of this is combined with irritability caused by sadness, self-deprecation ("I am worthless, stupid, and ugly"), feelings of being persecuted by others, an aggressive orientation toward authority, argumentativeness, and suicidal thoughts. Present as well is the trend of self-isolation or withdrawal from friends and a loss of social interest. Depressed children predict that activities at school will be boring, and thus tend to watch peers rather than participate (Friedberg & McClure, 2002). This decreased involvement in pleasure perpetuates their isolation. When related to school performance, this means lowered desire to complete schoolwork, turning in incomplete work, trouble concentrating, resistance to participation, and changed peer-groups.
While there are biological explanations for childhood depression that emphasize genetic factors and neurochemical determinants, this paper wants to focus on the cognitive viewpoint for grasping MDD. This viewpoint recognizes environmental factors as playing a large role in the production of depression. Erk (2004) summarizes the study of how family and peer environment impacts MDD formation in childhood. His book can be consulted for showing research into the significance of the environment in stimulating MDD. However, the cognitive approach focuses its attention primarily on negative patterns of cognition in the child. While it does not downplay environmental causes -- for example, bereavement, family divorce, abusive parental dynamics, school bullying, and other stressful life events that can trigger depression -- it attends more to the way the child can adapt to its social circumstances (the causes) by modifying its thought patterns.
The beginning of cognitive understandings and treatments of depressive disorder can be traced to Beck's revolutionary view, which Maag, Swearer, and Toland (2009) summarize: "According to Beck, depression results from the activation of three major cognitive patterns: (1) interpreting experiences in a negative way, (2) viewing oneself in a negative way, and (3) viewing the future in a negative way" (p. 237). Thus, children that fall into these cognitive patterns are prone to low moods, avoidance, social paralysis, dependency, and suicidal thoughts.
Cognitive explanations for MDD emphasize distorted thinking, inadequate problem-solving, low self-esteem, poor social skills, and negative attributions. In their view, children see themselves, others, and life in a negative and unrealistic way. This creates a damaged view of the self and leads to depression. Gladstone and Kaslow (1995) see evidence that maladaptive attributional patterns are associated with childhood depression. The child has a negative cognitive style, so that he or she generalizes negative events and makes predictions of negative outcomes regardless of contrasting evidence (Friedberg & McClure, 2002). Positive events are discounted, forgotten, or minimized, while negative events are remembered as evidence of personal inadequacy. In other words, the child blames negative events on the self and generalizes this negative into future. For example, if a child receives a low score on a test, it is taken to mean that he or she is stupid, which turns into a self-fulfilling prophecy. If a high grade comes, it is seen as chance or that the exam was easy. This negative attributional style becomes their way of interpreting and coping with events. It leads to hopelessness, a sense of powerlessness, and low self-esteem, which are predictors of long-term depression (Vostanis, Feehan, and Grattan, 1998 cited in Erk, 2004). Further, affirmation of other children may be viewed as a personal rejection, a cause of shame, and a perceived failure.
Treatment and Interventions
The treatment approach this essay wants to explore is child cognitive therapy, including cognitive behavioral therapy or CBT. The cognitive approach sees negative feelings and behavioral patterns rooted in systemic negative thought patterns. Therefore, it focuses on modifying those distorting thought patterns (Curry & Reineke, 2003). The main assumption of cognitive approaches to therapeutic intervention is that if the thoughts can be adjusted in a positive direction, then the emotional and behavioral problems might resolve themselves. Cognitive approaches are structured, focused, and often based around building skills. CBT is a particularly helpful and successful form of therapy for children with mood disorders. All cognitive approaches use some behavioral techniques and agree with the benefits of psychoeducation about depression. They all emphasize the child's need to monitor mood, to identify and modify maladaptive cognitions, and to learn problem solving, social, and affect regulation skills (Curry and Reineke, 2003).
Interpersonal psychotherapy for adolescents (IPT-A) is one cognitive-based form for psychosocial intervention for children with major depressive disorder (Brown et al., 2008). Its primary goal is to reduce depressive symptoms through enhancement of communication and interpersonal skills (Stark, Herren, and Fisher, 2009). It targets common problem areas (grief, role disputes, interpersonal deficits) and applies a cognitive behavioral approach. It uses communication analysis, questions, affect encouragement, conflict clarification, role playing, and event linking to try to enhance self-esteem and encourage change. IPT -- A assists the child in grasping and resolving interpersonal issues. The rate of successful recovery is good.
Another cognitive approach is the Modular Therapy Model for treatment. Its components are within-session flexibility, between-session flexibility, designation of core vs. non-core modules, individualized pace of treatment, individualized sequence, flexible involvement of parents and family, and adaptations to address comorbidity (Curry and Reineke, 2003). This approach integrates personal CBT with parent session. Therefore, there is more emphasis on improving relationships within the family environment.
In all cognitive treatments, clients are "taught to identify dysfunctional thoughts and maladaptive assumptions -- either through recall or imagined situations -- that may be contributing to feelings of depression" (Maag, Swearer, and Toland, 2009, p. 237). Once this happens, techniques are used to contradict the debilitating thought. One technique is "reality checking" or "hypothesis testing." Here the child distinguishes between true and not true, reality and hypothesis, and goes out with a sleuth mentality to test this experimentally. The example these authors give is a boy who thinks his smiling peers are all teasing him. The therapist will help him "devise a system for reading context and judging peers' facial expressions and body language so that he can determine objectively if the thoughts behind his problem are indeed accurate" (Maag, Swearer, and Toland, 2009, p. 237). This is typical of cognitive approaches with children since the ideas presented in therapy require active and concrete reinforcement. This reinforcement also comes through the behavioral components of rehearsal and modeling. The child is essentially taught and trained by the therapist to monitor herself, evaluate herself, and reinforce what she has learned in practical ways at school and home. This integration of behavioral techniques is based on the premise that cognitive restructuring alone is often ineffective with children if not behaviorally reinforced.
A third example of cognitive behavioral interventions for depressed children is Stark's ACTION treatment (Stark et al., 2007). This program for girls follows a workbook and is conducted in schools in small groups. This is important since it shows a school-based delivery of therapy in which teachers also receive intervention training. The focus is on developing self-control and coping skills. Through conversations, role plays, self-map building, homework, and self-monitoring diaries, the program helps girls acquire affective education (identifying feelings), goal setting, progress recognition, coping skills training, problem-solving training, cognitive restructuring, and building positive self-image. One way coping skills are developed, for instance, is to encourage the replacement of negative (maladaptive) thoughts with something fun and distracting (Stark, 2009, p. 279). All of the activities are to direct the child's attention from negative to positive information, thus restructuring maladaptive thoughts and beliefs and supporting them through more adaptive ones. Similar to the ACT and ADAPT intervention strategy (Stark, Herren, and Fisher, 2009), it teaches the child to gain control over mood through learned problem-solving for problems they can change, and to adapt to problems they cannot change. There is, in addition, a focus on externalizing negative thoughts, such as by talking back to or blaming the "muck monster" rather than the self, which creates emotional distance between the child and depressive thinking. The intervention strategy is designed to help the child see multiple perspectives and recognize self-blame and cognitive errors.
Finally, Mannasis (2008) has given a list of cognitive strategies to apply in child CBT therapy. These include teaching the child to recognize his or her own feelings, to make sharing feelings with helpful adults a treatment goal (since it reduces acting out from unacknowledged feelings), and to label emotional symptoms and externalize them concretely which encourages them to defend against 'thought bullies," "snowball thoughts" (catastrophic thinking), and "black cloud thoughts" (negative thinking). Since children often cannot provide adaptive thoughts for themselves, the therapist should, and then ask them to choose which is true for them. In addition, the therapist ought to repeat adaptive thoughts that are meaningful to the child and use them in different situations (repetition mantra) or give them cards with helpful coping strategies and reminders. Superheroes can be used…