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Sarah Kennedy
Treatment Plan Paper
Psychopathology: Spring 2016

Major Depressive Disorder, or MDD, affects 11.4% of adolescents aged 12 to 17 (Major

Depression Among Adolescents, 2015). MDD in children and adolescents is so important to
discuss, as roughly 60% of adolescents with depression have recurrences of the disorder
throughout adulthood. Even more frightening, adults with MDD that were also adolescents with
MDD have a higher rate of suicide than adults who did not have depression in adolescence
(Clark, Jansen & Cloy, 2012). Understanding, treating, and preventing MDD in children and
adolescents is an important role of persons in the school as well as community, or clinical/mental
health counselors.
MDD is marked by 5 or more of the following symptoms being present during the same
2-week period: 1) depressed mood most of the day, nearly every day; 2) markedly diminished
interest or pleasure in all, or almost all, activities; 3) significant weight loss when not dieting or
weight gain, or a decrease in appetite; 4) insomnia or hypersomnia nearly every day; 5)
psychomotor agitation or retardation nearly every day; 5) fatigue or loss of energy nearly every
day; 7) feelings of worthlessness or excessive or inappropriate guilt nearly every day; 8)
diminished ability to think or concentrate, or indecisiveness; 9) recurrent thoughts of death,
recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide (American Psychiatric Association, 2013). To get a diagnosis of MDD, one
of the symptoms must be either depressed mood most of the day or markedly diminished interest
or pleasure in activities. These symptoms must cause clinically significant distress or impairment

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in social, occupational, or other important areas of functioning; the episode must not be due to a
substance or other medical condition; the episode cannot be better explained by another disorder;
and there cannot have ever been a manic or hypomanic episode (American Psychiatric
Association, 2013).
In children and adolescents, the symptoms of MDD may present a bit differently than
they present in adults with the same disorder. On an even more complex level, these symptoms
can also present differently at school versus at home. Across all situations, the child or
adolescents mood could appear to be more persistently irritable, rather than persistently sad as it
is in adults with the same disorder (American Psychiatric Association, 2013). The child or
adolescent could also appear tearful more often than they had previouslythis could be in
combination with the irritable mood, or it could present with a sad mood (Massachusetts General
Hospital, 2001). It is important to note the young persons changes in mood and symptoms
across all of their environments.
At home, parents may be able to observe many symptoms that differ from adult major
depressive symptoms. Children with depression may have specific sleep disturbances, including
having a hard time falling asleep, taking more naps, or wanting to go to bed right after they get
home from school (Massachusetts General Hospital, 2001). It is important to note that this
symptom alone does not indicate that the child or adolescent has depressionespecially because
at certain ages or periods in development, children require more sleep. A child or adolescent with
MDD may also experiment with alcohol or drugs (Massachusetts General Hospital, 2001). This
is more common in adolescents, and may be due to a lack of knowledge about the effects of
drugs and alcohol. While a teen may be using substances as a way of coping with their

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symptoms, in reality, substance abuse can make their symptoms worse. Parents should take
seriously any of these symptoms that are happening in the home.
Teachers, school counselors, and other adults that see children in the school environment
can also take note of specific symptoms that could be signs of MDD. Any student with a
remarkable change in academic performance, whether its new difficulty concentrating,
forgetfulness, or inability to use plan, organize, or use abstract thinking should be closely
monitored for other depressive symptoms (Massachusetts General Hospital, 2001). While a
negative difference in academic performance alone does not necessarily indicate MDD, it could
be indicative of a loss of pleasure in activities that the student used to find pleasurable. Students
with MDD may also withdraw from their peers and appear more socially isolatedthese
students could also have an increase in fighting, arguments, or may become more sensitive to
real or perceived criticism (Massachusetts General Hospital, 2001). Any significant change in the
way a student is acting in school is grounds for concern-especially if the change is unprecedented
or severe.
Major Depressive Disorder can affect any person at any time in their lives; however,
there are certain risk factors that make some children and adolescents more likely to develop
MDD. Physical risk factors, such as low birth weight, medical illness, and obesity put a child at
risk for developing depression (Clark, Jansen & Cloy, 2012). Additionally, the average age of
onset for depression is between 14 and 18, meaning high school students are far more likely to be
diagnosed with MDD than children younger than high school (Lewinsohn, Rohde & Seely,
1998). The later age of developing depression could be due, in part, to hormonal changes that
happen during puberty (Clark, Jansen & Cloy, 2012). Before age 14, there is no significant
difference between male and female diagnoses of the disorder. However, once in high school,

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girls are twice as likely as boys to have MDD (Lewinsohn et. al, 1998). Other risk factors include
a family history of depression, parental conflict, poor peer relationships, deficits in coping
skills, and negative thinking (Clark, Jansen & Cloy, 2012, 442). While there are many children
that have multiple risk factors and never have a depressive period, children with multiple risk
factors should be cared for in and out of the school environment to ensure or teach healthy
coping mechanisms.
While it is vital that parents, teachers, and school counselors keep an eye on students who
may be showing signs of depression, there are also multiple remarkable treatments and
prevention strategies people close to the students can use with them. There are three different
levels of treatment or prevention: Primary, secondary, and tertiary. Primary preventive
interventions are used to prevent new cases of MDD; Secondary preventive interventions focus
on quickly detecting and treating cases of MDD; and Tertiary preventive interventions have the
task of reducing negative outcomes of an existing disorder (Gillham, Shatt & Freres, 2000).
Each of these levels are important to discuss and have very different methods of treatment.
Primary prevention techniques in the school require knowing and identifying risk factors
for depression. After risk factors are assessed, there are many options for primary prevention.
Group therapy sessions have proven effective, where groups of students that are at risk of
developing depression get together in a process group to discuss their depressive symptoms.
Psychoeducational groups are also vital so students can learn to cope with their depressive
symptoms before they become significantly escalated, and psychoeducation within the group
setting teaches students how to identify these symptoms in themselves (Gillham, Shatt &
Freres, 2000). In fact, psychoeducation is the single most important piece of primary prevention.
In middle and high school, psychoeducation can simply be provided in health class. This way,

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high-risk students arent singled out, and low-risk students arent forgotten about. In the
elementary school setting, school counselors can utilize time during in-class guidance lessons to
provide psychoeducation about what MDD is and where its felt in the body. Again, this method
ensures that high-risk students are getting the information without being singled out, and lowrisk students are not slipping through the cracks.
While psychoeducation is key in the primary prevention of MDD, not many people know
how to teach these methods to children and adolescents. One effective method of teaching
students to note their own depression symptoms if to teach them to examine the 3 Bsbrain,
body, and behaviors. This means that students should be taught to be more aware of their
emotions (brain), inaccurate thoughts (body), and behaviors that stem from and maintain
depression (Patel, Stark, Metz & Banneyer, 2013). Patel et al. (2013) also discussed teaching
students how to use a mood meter so they can track changes in their own moods over time, and
so they can become more sensitive to changes in their 3Bs.
In the school, primary prevention is key. As many schools do not have the resources to
effectively treat MDD in students, it is important that students are aware of any resources that the
school can provide to them. Not surprisingly, schools that screen students for depression and
treat those who are diagnosed with MDD quickly and accordingly have had significant success in
prevention and reduction of MDD (Cuijpers, van Straten, Smits & Smit, 2006). One screening
method for students is the Beck Depression Inventory for Primary Care. Students who score high
on this scale are recommended for further testing to ensure proper treatment (Clark, Jansen &
Cloy, 2012). Early screening, education and awareness are key in preventing MDD in the school.
The secondary level of treatment involves a lot of collaboration between the school and
parents. Both must work together to quickly notice changes in a student that may be indicative of

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a major depressive episode. If these symptoms are quickly noticed, diagnosed, and treated, then
intervention can remain at the secondary level. Screening is an important part of this, and
something the school psychologist can do. Again, a helpful method for this is group therapy
sessions where multiple students who have a new diagnosis of MDD get together, speak about
their symptoms and problems, and receive psychoeducation about ways to cope with their
symptoms (Gillham, Shatt & Freres, 2000). In conjunction with the school interventions,
community therapy can be a helpful addition. In the community, CBT has proven exponentially
helpful.
An example of a proven effective secondary level of treatment is Cognitive
Restructuring. Cognitive Restructuring involves teaching students to become aware of their
negative thoughts. This is done by teaching these people that (a) thoughts affect feelings and
behavior, (b) there are multiple stimuli that can be attended to at any time, (c) thoughts are
constructed, (d) the construction process is not veridical so thoughts may not be true, (e)
thoughts can be changed, and (f) changing thoughts changes affect and behavior. (Patel et al.,
2013, 375). This is such an important method, because many children have no idea that
thoughts are not always true. Teaching them that, yes, thoughts can be untrue, and then teaching
them how to challenge those untrue thoughts is a proven way to help students at risk of
developing MDD.
Tertiary treatment is difficult for the school, as by the time a student needs the attention
of tertiary prevention, the needs of the student go beyond what the school can realistically
provide. However, teachers and parents taking note of the students symptoms and the school
counselor or school psychologist providing a referral to outpatient counseling center is an
intervention in itself. In the community, CBT has again proven largely effective for treating

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MDD in children and adolescents, and CBT in both group and individual settings (Gillham,
Shatt & Freres, 2000).
One specific community-based cognitive-behavioral therapy group to target MDD is the
Adolescent Coping With Depression Course. This 8-week course consists of 16 2-hour sessions.
The group is designed like a classroom, and the teachers promote controlling depressed moods
by teaching workbook materials such as brief readings, short quizzes, and homework
assignments (Lewinsohn et al., 1998). This group also targets parental interaction so students can
generalize their new skills into their home environment.
In the community, clinical/mental health counselors should also consider antidepressant
medications such as tricylic antidepressants and other medications such as Fluoxetine,
Citalopram, and Sertraline (Clark, Jansen & Cloy, 2012). However, it is important to note that in
many individuals, medicine alone is not an effective method of treatment, and should be used in
conjunction with psychotherapy. In fact, in must cases, psychotherapy, such as CBT, alone is
more effective than medicinal treatment alone (Antonuccio, Danton & DeNelsky, 1995).
As cognitive-behavioral therapy is something that has been mentioned multiple times in
treatment suggestions, it is important to discuss CBT as a whole and its effectiveness with
treating MDD in children and adolescents. CBT is usually a short-term therapy, meaning it has a
set number of sessions, usually between 6 and 20. It aims to teach clients specific skills, and
focuses on the ways in which a persons thoughts, emotions, and behaviors are connected
(Association for Behavioral and Cognitive Therapies, 2016). CBT is active, as skills are taught,
and directive, as homework is typically assigned (Antonuccio, Danton & DeNelsky, 1995).
One specific type of CBT is Pleasant Activity Therapy. Pleasant Activity Therapy works
off the idea that depression can be the result of a stressor that disrupts normal behavior patterns,

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causing a low rate of response-contingent positive reinforcement (Antonuccio, Danton &
DeNelsky, 1995, 575). When a person stops obtaining positive reinforcement for previously
reinforcing activities, a sort of pattern can develop where almost all positive reinforcement stops,
and the person spirals into depressive symptoms, such as the loss of interest in activities that
used to interest them. On the flip side of this, Pleasant Activity Therapy also suggests that there
could be some sort of social reinforcement for depressive symptoms as family members and
friends tend to rally around the depressed person to help them feel better (Antonuccio,
Danton & DeNelsky, 1995). Pleasant Activity Therapy works with the person with MDD to
increase the frequency and quality of their pleasant activities.
An increasingly popular and wildly effective method for adolescents with depression is
family therapy. The family structure is what shapes a child, and the child also shapes the family
structure. This is a bidirectional relationship that only becomes stronger when the child has a
psychiatric disorder, as sometimes both the family and the child feel as though the disorder is
what rules the whole system (Broderick & Weston, 2009). Family therapy can stand-alone or be
used in combination with other treatments, and can operate psychodynamically, structurally,
strategically, and cognitive-behaviorally (Broderick & Weston, 2009). This type of therapy
focuses on the relationships between family members, educates members on the specific needs of
the individual with a psychiatric disorder, and gives all parties coping skills (Broderick &
Weston, 2009). This is a powerful method of therapy that can effectively help the child with
depression feel more supported in their home environment.
Major Depressive Disorder is a serious psychiatric disorder that effects a large portion of
the adolescent population. There are many different methods and levels of treatment for this
serious disorder, including school-based groups and lessons, community-based cognitive-

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behavioral groups, individual cognitive-behavioral therapy, and family therapy. Medicine is
another method for treatment, but typically recommended in conjunction with a kind of therapy.
Psychoeducation and depression screenings are important pieces of prevention of major
depressive disorder.

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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: American Psychiatric Publishing.
Antonuccio, D.O., Danton, W.G., & Denelsky, G.Y. (1995). Psychotherapy versus medication
for depression: Challenging the conventional wisdom with data. Professional
Psychology: Research and Practice, 26(6), 574-585.
Association for Behavioral and Cognitive Therapies. (2016). About psychological treatment.
Association for Behavioral and Cognitive Therapies. Retrieved April 20, 2016, from
http://www.abct.org/Information/?m=mInformation&fa=_WhatIsCBTpublic
Broderick, P., & Weston, C. (2009. Family therapy with a depressed adolescent. Psychiatry
(Edgmont), 6(1), 32-37.
Clark, M.S., Jansen, K.L., & Cloy, J.A. (2012). Treatment of childhood and adolescent
depression. American Family Physician, 86(5), 442-448.
Cuijpers, P., van Straten, A., Smots, N., & Smit, F. (2006). Screening and early psychological
intervention for depression in schools: Systematic review and meta-analysis. European
Child & Adolescent Psychiatry 15(5).
Gillham, J.E., Shatt, A.J., & Freres, D.R. (2000). Preventing depression: A review of cognitivebehavioral and family interventions. Applied and Preventive Psychology, 9(2), 63-88.
Lewinsohn, P.M, Rohde, P., & Seeley, J. (1998). Major depressive disorder in older adolescents:
Prevalence, risk factors, and clinical implications. Clinical Psychology Review, 18(7),
765-794. Retrieved April 21, 2016.
Major Depression Among Adolescents. (2015). Retrieved April 20, 2016, from
http://www.nimh.nih.gov/health/statistics/prevalance/major-depression-amongadolescents.shtml

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Massachusetts General Hospital. Depression in children and teens. (2001). Retrieved April 21,
2016, from http://www2.massgeneral.org/schoolpsychiatry/info_depression.asp#looklike
Patel, P.G., Stark, K.D., Metz, K.L., & Banneyer, K.N. (2013). School-based interventions for
depression. Issues in Clinical Child Psychology Handbook of School Mental Health, 369383.