Master K is a 15-years-old male studying in class XI belonging to middle socioeconomic status and urban domicile presented with complaints of sadness of mood, anger outburst, decreased interaction, refusal to attend school, and decreased interest in studies. K was apparently well until 6 months back, when a girl of his class whom he liked mocked at his physical appearance in front of others. K could not respond to the comment at that time, but he reported thinking about the same even after two weeks. He reported feeling embarrassed while entering the class, or giving answer to the questions asked by the teacher. K did not discuss the incidence with anyone. Gradually, he stopped talking to anyone in his class and remained quiet. His parents reported that K would often seem sad and preferred to stay in his room. If his parents coaxed him to talk or study, he would react with anger and disobedience. K was angry at slightest of comment by parents for his decline of interest at academics. When he obtained results of a class test, he reported having severe headache and was relieved from the school. That day, K lied in his room and did not talk to anyone at home. He declared that he will not go to school. His parents were informed by his school counselor that since past few weeks, K was non-talkative in class, he was not attending sports or library period, his attention in class was declining, and he was often found eating his lunch alone. With these complaints, K was referred to a psychiatrist for identification and management of the problem. He was diagnosed as having moderate depression without somatic complaints using ICD 10 system of classification. He was given antidepressants and was sent to psychologist for further management.

Assessment is an essential and integral part of psychotherapy with adolescents as it provides clinical data and subsequently aids in planning and implementing appropriate intervention.

The cognitive behavior therapy assessment is a structured approach to identify issues to be addressed in therapy. Some relevant areas to be covered are in Table 11.2.

Assessment incorporates the application of inventories, rating scales, and self-report questionnaires to assess degree and severity of depression and other comorbid disorders.

Some assessment tools are given in Table 11.3.

Assessment of a depressed adolescent follows a developmental perspective incorporating the systematic, successive, and interdependent changes overtime in adolescent’s mood, thoughts, and behavior.

Parents, teachers, and peers are important sources of information apart from adolescent himself. Use of verbal interaction and careful analysis of verbal reports appear to be a strong alternative to the standard test procedures. These ensure greater participation of adolescents and produce more valid information.

Later on, in the therapy, some measures may be used. These include ABC chart (see Appendix Ia) and Dysfunctional Thought Record (see Illustrations 11.1 and 11.6) which will be discussed in the intervention part.

The assessment showed that K was having depression since past 6 months. K had teased his classmate for being over talkative. In turn, the girl had said that K looked like a monkey and that no girl would want to talk to him (situation). This happened in front of group of his friends who also laughed at him. His thoughts were, “They think I look like monkey. Nobody supported me. They all laughed at me” (thoughts). On most days, his mood was sad and he would avoid smiling or making eye contact with his classmates (avoidance behaviors). If his friends would ask him to play along, he would refuse. Gradually, his friends stopped asking him and this strengthened the idea that none of his friends really cared. Gradually, he started spending most of his time in thinking about what went wrong? (Ruminations). He could not pay attention in class as he would notice other classmates’ behavior toward himself. He realized that he had not understood anything in class and avoided asking his parents for help. He started feeling anxious at the thought of failing in his tests (worrying thoughts). On the day he obtained his test results, he had a thought that “They will laugh at me again. What all will they think about me?” (automatic thought). He had headache (somatic complaints) and he took leave that day.

K spends his day by sitting alone in his room. He rarely watches TV which he used to like earlier. If coaxed he reacts to his parents with anger. He refuses to go out and play. His grades are declining since past few months. He has completely stopped going to school since three weeks (socio-occupational functioning). His father constantly scolds him for disobedience and acting irresponsibly. His mother constantly keeps a check on him and attempts to talk to him about problems (reaction of parents).

There was nothing significant found in the birth and developmental history. There is absence of family history of any psychiatric illness.

A complete assessment permits the evolution of a comprehensive case formulation. The CBT formulation has been illustrated in Fig. 11.1 with examples of some thought content in depressed adolescent.

The therapeutic alliance has been found in a meta-analysis to be significantly associated with outcomes in child and adolescent therapy (Shirk et al. 2003). Working alliance is formed from the point of meeting with the adolescent and goes beyond termination. The essential characteristics of a therapist include accurate empathy, warmth, and genuineness (Brent et al. 1997). In CBT, the therapist serves as an active “coach,” with an emphasis on a collaborative process.

Therapist may focus on setting goals for the management. The adolescent and the parents may be asked about their expectations from therapy. The goals then may be modified so that goals are as follows:

Some common goals may be in Table 11.4.

The intervention is guided by the case formulation specific to the depressed adolescent. The formulation informed by assessment sessions including self-report inventories, comorbid diagnosis, experiences in family or school environment.

The following section will focus on reducing the core symptoms of depression. Refer to Table 11.4 for the goals and corresponding technique to be used across sessions.

Collaborative empiricism is an important premise of CBT; hence, it is relevant to inform the adolescent about the nature, components, and course of CBT. Information that needs to be emphasized is as follows:

In India, family system is strong influencing agency on the adolescent. Family can be a protective, predisposing, or maintaining factor in depression. It is important to involve and work with families of depressed adolescents:

While emphasizing the interrelationship between thoughts, feelings, and actions, instances may be elicited from the adolescent that reflect engaging in some activities lead to change in thoughts and mood. Small tasks including age-appropriate challenging and pleasant tasks tend to improve mood. The large, difficult, and uninteresting tasks lead to sadness, boredom, or thoughts of worthlessness. With this premise, behavioral actions aim to:

These functions can be attained by scheduling:

Parents and adolescent can collaborate to identify each of these activities by: