A number of manualized depression interventions with promising and/or well-established efficacy are available for therapist use. Many of these interventions have been applied or adapted to school settings. Table 5.2 provides a summary of select manuals that are designed to treat depression. One of the most widely studied interventions is the Coping with Depression for Adolescents (CWD-A; Clarke, Lewinsohn, & Hops, 1990), which is available for free download (see http://​www.​kpchr.​org/​research/​public/​acwd/​acwd.​html). Other manuals are available from the authors or from the publisher of the manual. While these treatments vary in length, duration, and format, they are all based upon CBT principles and contain similar therapy components.

Chorpita and Daleiden (2009) report that the most common therapy strategies, or “practice elements,” for treating childhood depressed mood include cognitive, psychoeducational–child, maintenance/relapse prevention, activity scheduling , problem solving, and self-monitoring. Rather than discussing each manual separately, we will focus on describing these commonly used CBT approaches for children. Brief descriptions of which elements are within the available manualized interventions are included in Table 5.2.

The first therapy element typically found in depression manuals is psycho-education for the child, which establishes the foundation for therapy. Typically, a cognitive behavioral model of depression is presented to teach a child about the relation between thoughts, feelings, and behaviors and how depression is maintained. Manuals may present this information in different ways. For instance, some manuals discuss the downward and upward spirals of depression (Asarnow & Scott, 1999; Clarke et al., 1990; Curry et al., 2005), whereas others do not. A typical goal of psychoeducation in CBT protocols is to help children understand that behaviors and thoughts influence emotions, and you can improve your mood by doing and thinking differently. PASCET (Weisz, Sandler, Durlak, & Anton, 2005) exemplifies this concept by using “ACT” (Primary Control) and “THINK” (Secondary Control) skills as ways children can change their mood. Children also learn about the structure of the intervention and the importance of therapeutic homework.

Activity scheduling or behavioral activation is another frequent practice element. The goal of this therapy strategy is to increase the amount and quality of pleasant activities the child engages in on a weekly and daily basis. Youth with depression, especially with anhedonia , tend to withdraw and do not engage in pleasurable activities or tend to select activities that are not reinforcing. Most manuals encourage children and adolescents to identify a number of activities they can engage in on a weekly basis, including more physical activities. Treatment manuals may also focus on demonstrating this skill in vivo in session as well as how to manage when children are “stuck” and “don’t feel like doing anything.”

Problem solving is another therapy strategy common to depression manuals. Children and adolescents who are depressed tend to feel helpless and hopeless and often have a difficult time handling problems. Problem solving teaches children an active, systematic approach to managing problems. Different protocols have various acronyms to help children remember the steps of problem solving, such as “5 P’s” (Stark, Struesand, Krumholz, & Patel, 2010), “STEPS” (Chorpita & Weisz, 2009; Weisz, Gray, Bearman, Southam-Gerow, & Stark, 2005), and “RIBEYE” (Curry et al., 2005). Each of these procedures help children to brainstorm various solutions, evaluate each solution by thinking of the pros and cons, choose a solution to try, and use self-reinforcement (e.g., praise, pat on the back).

Not surprisingly, a major component of the CBT model is identifying and changing negative thinking to improve one’s mood (Beck, 2011). A case conceptualization provides a guiding framework to tailor treatment to a child’s individual needs and creates an understanding of the client’s uniqueness, as well as their cognitive patterns. Case conceptualizations evolve over time and should be refined throughout treatment as a therapist gains a better understanding of the client. Each manual presents various methods for helping children and/or adolescents identify negative thoughts and change them into more positive thoughts. For instance, CWD-A (Clarke et al., 1990; Rohde, Lewinsohn, Clarke, Hops, & Seeley, 2005) uses a C-A-B method to help youth identify the Consequence (e.g., noticing when the youth is feeling down), Activating event (e.g., what situation triggered the low mood), and Belief (e.g., the thoughts that led from the activating event to the consequences). The therapist then helps the adolescent develop an alternative belief using Socratic questioning (e.g., What is another way to look at the situation? What would you tell your best friend?). Many manuals also incorporate techniques to manage cognitive rumination, such as “Changing the Channel” found in PASCET (Weisz, Gray et al., 2005).

Self-monitoring and maintenance relapse prevention are also common approaches. Typical CBT for depression incorporates self-monitoring throughout treatment. Practice or homework is assigned outside of the session and mood monitoring is used to determine the effects of various strategies. Given that depression is a recurrent disorder, maintenance and relapse prevention are included in many depression intervention protocols. In addition to preparation at the conclusion of therapy, many protocols incorporate “booster” sessions to help promote continued use of skills and monitor progress (Clarke et al., 1990; Curry et al., 2005; Stark et al., 2010).

Overall, these CBT programs for treating depression in youth involve a combination of behavioral and cognitive strategies. The principles for these strategies are common across treatment manuals; however, the presentation of the skills and the amount of time dedicated to each skill will vary for each protocol. Other variations to the manuals that therapists should consider include the format of the intervention (individual vs. group), duration and length of sessions, developmental appropriateness, incorporation of other practice elements (e.g., communication training, interpersonal skills), availability of the manual (e.g., free vs. cost), training required, and caregiver involvement.

While schools are recognized as an important setting to deliver mental health services (Atkins, Hoagwood, Kutash, & Seidman, 2010), there are a number of roadblocks that should be considered when implementing manualized depression programs in schools. Lack of support from school administrators and staff can be a fundamental barrier. Although there is a strong desire for practitioners to do therapy in schools, specifically CBT, administrators often do not want student achievement to be adversely impacted by their spending time out of the classroom to receive an intervention. Several strategies can be used to ease this concern and gain support from staff.

First, it can be helpful to provide education around the prevalence of depression and its negative impact on students’ academic performance, as well as about the therapy itself to resolve any misperceptions about depression or the need for therapy. As examples, the practitioner can educate staff about how a quietly depressed student may not necessarily appear to be in distress, especially in a classroom with 25 other adolescents, but that this “internalizing” of symptoms can mask the extent of a child’s impairment. Another important educational point is that the irritability associated with depression may often be misperceived as oppositional behavior. Sharing information with school staff in general about depression may help build awareness about how depressive symptoms can interfere at school. Therapists should also emphasize the goal of CBT is to help students learn to improve and manage their mood through acquiring “toolbox” of skills that they can use in and outside of the classroom. Once the teacher or administration is in support of allowing screenings, prevention, or interventions for depression in the school, the next barrier is related to logistics.