Depression in Children and Youth: Information for Families

1
Depression in Children and Youth Information
for Families

• Compiled by
• Dr. Michael Cheng,
• Child and Family Psychiatrist,
• Ottawa, Ontario, Canada
• This presentation is available from
  http//www.drcheng.ca

2
What is Clinical Depression?

• A medical condition where a person has
• Body (physical) symptoms
• E.g. problems with energy, sleep, appetite,
  concentration)
• Mind (emotional, psychological) symptoms
• Mood problems (e.g. sad, irritable, or bored
  mood)
• Depressive thinking (e.g. low self-esteem,
  magnifying negatives, difficulty seeing
  positives, loss of hope)
• Social symptoms
• Troubles functioning with school, work, or
  relationships
• Social withdrawal, or avoiding people
• Symptoms lasting at least 2-weeks

3
Other terms

• Other terms used for depression may include
• Major depression
• Major Depressive Disorder (the official DSM-IV
  term)
• Euphemisms in common language include Burnout,
  Stress, Mental breakdown, Blues

4
Good and Bad News

• First, the bad...
• You have depression, which is a serious condition
• It will require hard work in order to get better
• It may be a very stressful time for you, your
  family and friends as we try to overcome the
  depression that has crept into your life

5
Good and Bad News

• Now, the good news...
• Its not your fault
• You didnt cause your depression
• Depression is treatable, through various ways
• You will get better
• Bad news is that although it isnt your fault
  for depression, you arent completely off the
  hook you still have the responsibility to deal
  with the depression
• The good news is that you are not alone, and we
  will help you through it...

6
How Common Is Clinical Depression?

• At any one time (prevalence)
• 1-3 children have depression (M gt F, incidence
  1)
• 3-9 teenagers have depression (F gt M, incidence
  3)
• Over whole lifetime, 20-25 people will meet
  criteria for depression

7
What causes depression?

• Before we can talk about what causes depression,
  it is important to first talk about what every
  normal person needs...

8
Everyone needs a healthy body, mind, spirit

• People have the following needs
• Biological/ Physical healthy Body, Brain
  (Neurotransmitters)
• Mind (Psychological health, e.g. good
  self-esteem, good emotional state)
• Psychological needs, include need for
• Sense of control
• Sense of connections (with people)
• Spiritual need for hope and meaning

9
Everyone needs a healthy body, mind, spirit
Body

• Body (Physical, Biological Self)
• Mind (Psychological, Emotional Self)
• Spirit (Spiritual Self)
• Note Overlap, e.g. psychological interventions
  can cause biological changes, and vice versa

Mind
Spirit
10
What causes Depression?

• Any stresses can contribute to depression
• Body (Biological/ Physical) e.g. medical
  illness, drug use, physical vulnerability (e.g.
  strong genetic or family history of depression)
• Mind (Psychological) needs
• Sense of control any events that lead to a
  feeling of failure, e.g. failing a major exam or
  test, not getting a job promotion
• Sense of connections (with people) any events
  that cause problems in relationships, e.g.
  conflict with others, loneliness, stresses such
  as death, breakups
• Spirit any events that lead to loss of hope or
  meaning

11
Biological / Physical Strategies

• Staying physically healthy
• Sleep
• Diet / Nutrition
• Omega 3 with gt 1000 mg EPA daily
• ? Vitamin B12 1000 mcg daily
• Exercise
• Aerobic exercise
• Organized sports
• Martial arts
• Yoga (interestingly, many meditative
  mindfulness techniques being incorporated into
  various therapies)
• Individual sports

12
Biological Approach to Depression

• Traditional Medications
• may be indicated, but generally ONLY if various
  non-medication interventions were tried first and
  were unsuccessful
• recent controversy about safety
• Alternative medications
• St. Johns Wort for mild depression
  (controversial)
• Omega 3 fatty acids (evidence still lacking)

13
Biological Approach to Depression

• Medications
• safe as long as properly prescribed
• prescription glasses analogy
• Medications are like glasses
• If you use someones glasses without a proper
  prescription, they probably wont work, BUT that
  does not mean that ALL glasses are bad
• If it doesnt work, then it simply means
  different ones may need to be tried until the
  right pair is found

14
Biological / Physical Strategies

• Medications
• Should usually be tried only after other options
  have been tried first
• If other options have been tried and not been
  successful, medications can often be very helpful

15
Medications

• SSRI (Serotonin specific reuptake inhibitors)
• Fluoxetine (Prozac)
• Citalopram (Celexa)
• Fluvoxamine (Luvox)
• Sertraline (Zoloft)
• Others
• Mirtazapine (Remeron)
• Bupropion (Wellbutrin, Zyban)

16
Are medications safe in youth?

• For up to date news, visit
• Food and Drug Administration (USA)
• www.fda.gov/cder/drug/advisory/mdd.htm
• www.fda.gov/cder/drug/antidepressants/default.htm
• Health Canada
• www.hc-sc.gc.ca

17
Are medications safe in youth?

• Good news
• Epidemiological studies show that youth suicide
  has declined in countries in which SSRIs are used
• Recent study in summer 2004 showing that for
  depression, youth did best with combination of
  Fluoxetine AND Cognitive Behavioral Therapy
  (March J TADS study, 2005)

18
Importance of Tailoring Treatment to the
Individual

• Treatments are like prescription glasses need to
  figure out which works with which person, at
  which time

19
General Support Strategies for Depression

• When supporting the other person
• Assertive, but firm Im worried about you. We
  need to talk. Is now a good time? Or should we
  talk later?
• Ask for permission, I care about you. How can I
  support you?
• Do you want me to just listen?
• Or do you want my advice?

20
Psychological / Coping Strategies

• Having positive coping strategies to deal with
  various stresses
• Usual stresses are
• Family
• Friends
• School
• Work
• Positive thoughts
• Positive behaviors

21
Problem-Solving

• Figure out what the problem is AND what the
  desired outcome/solution is
• Brainstorm different possible strategies to get
  to that outcome
• Try one out (for a reasonable amount of time)
• Reassess
• If it doesnt work, then try something else!

22
Interpersonal interventions

• Helping people regain their basic needs for
• Agency, autonomy, achievement or control over
  ones life (as opposed to having no control or
  power in ones life)
• Affiliation, or connection with others (as
  opposed to conflict or withdrawal from others)
• Sense of meaning, or hope (as opposed to having
  no meaning or hope)
• Activity (as opposed to passivity)

23
Interpersonal interventions

• Agency, Autonomy or Control
• Sense of control comes from being able to deal
  with stresses and master them
• Help the person identify what their stresses are,
  and help them problem-solve them
• E.g.
• If school work is a stress, then problem-solve
  with the youth how to deal with their school work

24
Interpersonal interventions

• Affiliation, or Connection with Others
• Help the person identify what their
  relationship/social stresses are, and help them
  problem-solve them

25
Interpersonal interventions Conflict Resolution

• Conflict when one person has one set of
  expectations, wishes, and when the other person
  has a different set

26
Interpersonal interventions Conflict Resolution

• Approach
• Figure out what each person wants
• Ensure what each person wants is healthy
• Figure out what they have in common
• With things that differ, negotiate and compromise

27
Interpersonal interventions Conflict Resolution

• Example classic conflict with parents over rules
  
• Approach
• Jason wants more freedom, e.g. being able to stay
  out later
• Parents want more responsibility, e.g. being able
  to get homework and chores done
• Possible solution
• Increased privileges tied to ability to get key
  chores done, with contract ON PAPER
• Result less fighting/arguing/nagging over
  chores, which leads to better relationship

28
Cognitive Interventions in Depression

• Depression is maintained by various cognitive
  distortions or depressive thinking patterns
• Cognitive interventions, as seen in Cognitive
  Behavioral Therapy (CBT) seek to change those
  distortions, thus resulting in improvement in mood

29
I dont want your help

• Having a good alliance makes it easier in helping
  another person, e.g. for concerned parents to
  help their youth
• An alliance is based on
• Agreement on Goals
• Agreement on Tasks
• Bond
• Empathy, Understanding
• Competence
• Consistency, Reliability
• Acting in other persons interests

30
How Families and Friends can Help a Depressed
Person

• Do
• Express your concern for the person
• E.g. Ive noticed that... Im worried about
  you...
• Express your support
• E.g. I know this may be a tough time, but I
  support you.
• Promote the persons autonomy by giving choices
  whenever possible rather than simply telling the
  other person what to do
• E.g. How do you want me to support you? Spend
  time with you? Listen to you? Give you my opinion
  on things?
• Promote the persons affiliations/connections
  with people by encouraging social connections,
  activities
• Go step by step in making change if a person is
  not yet able to accomplish a larger goal/task,
  then set a smaller goal/task

31
I dont want your help

• Dont
• Blame, or make the depressed person feel guilty
  it usually backfires by making the person feel
  worse
• Just lecture or tell the other person what to do
• Say I told you so

32
Helping Alliance Disagreement on Goals Not a
good situation
Task B
Point A
Point B (Your goal)
Task C
Point C (Other persons goal)
33
Helping Alliance Agreement on Goals, but Not Yet
Tasks Not a good situation
Your Task
Point A
Point B (Shared Goal with you and other person)
Other Persons Task
34
Helping Alliance Agreement on Goals and Tasks
The Ideal Situation
Agreement on Task
Point A
Point B (Shared Goal between you and other person)
35
Helping Someone with Depression Deal with
Situations

• When you notice someone upset about a situation
• Ask about what happened
• How did that affect your mood?
• Whats the worst part about what happened?
• What does it mean to you that this happened?
• How can I support you with this?
• What can we do to cope?
• What would you like to see different?

36
Helping Someone See the Positive

• If the depressed person expresses a positive
  thought
• Validate it and reinforce it, e.g. I really like
  what you said.
• If its a negative thought, consider
• Reframing in a more positive way, like the way we
  try to see the glass as being half full rather
  than half empty
• Reminding him/her of past strengths, or of past
  happier times
• Reminding him/her that you love and support
  him/her
• Reminding him/her that depression makes people
  have sad thoughts, and it will be better when the
  depression is gone

37
Solution-, Interpersonal, Behavior Approaches

• What do you want? (Ensure its a healthy goal)
• What can you do to get there?
• Evaluating behaviors
• So, last night, you wanted Jessica to like you
  more. Youre saying that you ignored her. Did
  that help things?
• What would be more helpful?

38
Environmental / Social Interventions

• Eating dinner together as a family
• Fun activities with the depressed person, either
  in one-on-one, or larger groups during these
  times, avoid talking about problems
• Regular talk-time with the depressed person
• Getting a pet, e.g. a dog
• Holistic/Alternative approaches include
• Feng Shu
• Way of arranging the environment believed by the
  Chinese to foster positive energy
• E.g. a depressed person may wish to dress all in
  black, or make their room all black let them
  express themselves, but insist on a balance of
  positive energy by still having some bright, more
  cheerful colors

39
Spiritual Interventions Finding Hope and Meaning

• Find out what gives that person hope and meaning
• Fill their life with those things (as long as
  they are healthy)
• Specific examples include
• Helping others, e.g. volunteer work at local
  veterinarians, old age home, hospital
• Working with animals
• (Constructive) Hobbies, e.g. music
• Organized religion, e.g. Church, Synagogue,
  Temple, Mosque

40
Suicide

• Thoughts of ending ones life may often occur,
  particularly if a person is feeling depressed, or
  under stress
• Two types
• Passive suicidal ideation person thinks about
  dying, but has no intent nor plan occasional
  passive suicidal ideation is common
• Active suicidal ideation person has intent and
  plan to die this requires a Crisis
  Intervention, which may range from contacting a
  Crisis Line, taking person to their doctor, or
  going to the local emergency room

41
Practical Tips on Preventing Suicide The Will
to Die

• Thoughts of harm are usually a means to solve a
  problem
• Types of problems usually involve
• Loss of Connection
• Loss of Control
• Loss of Hope / Meaning
• Help that person find other healthier ways to
  solve their problem, or reach their goals

42
Practical Tips on Preventing Suicide The Means
to Die

• Preventing the means to die
• Secure life threatening objects from the home
• Firearms
• Heavy rope
• Dangerous medications

43
Practical Tips on Preventing Suicide The Will
to Die

• Communication
• Open communication
• Listen
• Empathize
• Be non-judgemental
• Help with problem-solving, What is the problem
  that makes you think about suicide?
• Offer support, How can I support you?
• Point out strengths
• Be ready to ask for help from non-professionals
  and professionals

44
Practical Tips on Preventing Suicide The Will
to Life

• The fact that person is still is proof that
  despite the part that wants to die, there is
  clearly a larger part that wants to live
• Our goal is to magnify that part
• What makes you want to live?
• What keeps you living?
• What needs to change so life is more worth
  living for you?
• I love you how can I support you?

45
Sequence of Interventions

• Self-help
• Mental, e.g. reading, music
• Physical, e.g. sports, walking
• Social, e.g. talking to others, going out
• Turning to others
• Friends, Neighbours
• Family (immediate family, relatives)
• Church / Spirituality
• Peers at school, work colleagues

46
Sequence of Interventions

• Professionals
• School teachers, social workers
• Agencies
• Physician / pediatrician
• Private psychologists
• Private counselors, e.g. social workers
• Try non-medication interventions first
• If despite various other intervention(s),
  depression persists, consider medication,
  especially if strong family history of depression

47
School Accommodations for Depression include

• Flexibility for missed time for doctors
  appointments
• Exact accommodations may need to be
  individualized to the individual student
• Closer supervision, and emotional support or
  check-ins with staff (e.g. teachers, social
  workers, vice-principals...)
• Ensuring continued school attendance is
  important, although may consider reducing
  academic expectations in the interim, e.g. less
  courses, more time in resource room

48
Finding a psychologist

• Employee Assistance Program, or Student Health
  Services (at University/College)
• Ontario Psychological Association Referral
  Service, 1-800-268-0069, www.psych.on.ca
• Ottawa Academy of Psychology, [phone],
  www.ottawa-psychologists.org/find.htm

49
Service Agencies Providing Counselling, Support

• Youth Services Bureau (for teens aged 12-20),
  [phone], www.ysb.on.ca
• Family Service Centre, [phone],
  www.familyservicesottawa.org
• Catholic Family Service Centre, [phone],
  www.cfssfc-ottawa.org
• Jewish Family Service Centre, [phone]
• Ottawa Christian Counselling, [phone],
  www.christiancounsellingottawa.ca
• Immigrant Services Organization [phone],
  www.ociso.org

50
Service Agencies Providing Counselling, Support

• Centre for Psychological Services at U of Ottawa,
  [phone], www.socialsciences.uottawa.ca/psy/
  eng/centre.asp
• Centre Psychosociale pour enfants et familles,
  [phone], www.centrepsychosocial.ca

51
Service Agencies Providing Counselling, Support

• For trauma
• Centre for the Treatment of Sexual Abuse and
  Childhood Trauma. Tel [phone]. Web
  www.centrefortreatment.com
• Ottawa Rape Crisis Centre, PO Box 20206, Ottawa,
  K1N 9P4, [phone] Fax [phone]

52
Resources for youth with problems with violence
or behavior

• For youth under age 12
• Crossroads Childrens Treatment Centre,
  613-723-1623
• For youth above age 12
• Robert Smart Centre (during a crisis),
  613-722-4591
• Youth Services Bureau, 613-729-1000
• For parents ? Parents Supporting Parents
• Irrespective of age
• Liaison with Ottawa Police Services, either
  through School Resource Officers, Youth Division,
  Ottawa Police Youth Centre

53
Crisis resources include

• Distress and Telephone Aid Lines
• Distress Centre, 613-238-3311
• Kids Help Phone, 1-800-668-6868
• Parents Help Line, 1-888-603-9100
• During a crisis
• Ottawa Mobile Crisis Team (age 0-16),
  613-562-3004
• Robert Smart Centre Crisis Unit, 613-722-4591
• Poison Control Centre, 613-737-7600

54
Hospital Emergency Rooms

• Age 0-18
• CHEO
• Aged 16
• Ottawa Hospital (General or Civic Campus)
• Queensway Carleton Hospital
• Hôpital Montfort

55
Support Group

• Parents Lifeline of Eastern Ontario, CHEO-based,
  parent group providing support to parents whose
  youth are struggling with mood and behavior
  problems, www.pleo.on.ca

56
There is Hope Depression is treatable!
57
Acknowledgements

• Stock photo of sky from www.freestockphotos.com