In clinical practice, children are seldom seen without a parent, and depression often arises within the context of family or social difficulties (see Chapter 2). Clinicians therefore have the task of engaging with both the child and family members. It is important to have strategies to ensure the child is included in all stages of the assessment process and involved in the management plan. Communication with the child depends on the child’s developmental level and his or her verbal and cognitive ability. The language and approach must be appropriate to the child’s age (e.g., toys or drawings in younger children). Time available varies from setting to setting, so techniques need to be tailored to the child and the situation. Here are some tips that often facilitate engagement:

Adolescence is a time when young people move from dependence on parents to independent functioning. This stage is accompanied by a greater affinity for peers and an increase in novelty seeking and risk taking. Cognitively, adolescents move to increased abstract thought, although brain development, and accompanying judgment, is not complete until the mid-20s. Adolescents and those around them have to adjust to rapid developmental changes with negotiations over levels of independence that typically continue throughout adolescence.

To support the need for independence and to establish a working relationship, it is important to spend time alone with the adolescent. This allows for a more accurate monitoring of mood and of risk behaviors that may be associated with mood disorders, such as substance abuse, suicidal thoughts and behaviors, and sexual activities. Parents should also be given time alone with the therapist and be kept informed of progress.

There are strategies that can be used to engage depressed adolescents and their families. Adolescents report that they appreciate it if clinicians take an interest in them, rather than just in their problems. The HEADDS interview (mnemonic for Home, Education/employment/eating, Activities, Diet, Drugs/cigarettes/alcohol, Sexuality/suicidality/depression/safety)2,3 (see Appendix 5.1) provides a good framework for assessing the psychosocial situation of adolescents and supports the
development of rapport. Motivational interviewing4 offers another useful set of techniques to engage adolescents and their parents and to enhance willingness to consider changing maladaptive behaviors (Table 5.1). In this approach the aim is to build on the adolescent’s own reasons (e.g., plans, desires) for making a change. Strategies include the use of open-ended questions and responses that affirm adolescents’ thoughts and feelings by reflecting their ideas back to them. For example, “If I am following you correctly, it sounds like you are feeling pretty overwhelmed by school right now.” Summary statements can also be used, such as “Just to review what we talked about today, it sounds like you are feeling pretty stressed out but are willing to try getting to bed earlier over the next couple of weeks to see if that is helpful.”

As with other physical and mental health problems, a depressive disorder may impede the development of independence and sap self-confidence. Having a “mental illness” has a potentially negative influence on the adolescent’s sense of identity. A number of challenges are raised for parents as well. They may become more protective and may have a sense of guilt and responsibility; alternatively, parents can become rejecting, critical, and punitive, particularly if depression manifests itself with irritability, noncompliance, and rejection of family values. These responses may impact on the relationship with the therapist. Labeling the problem as “depression” or “depressive illness” allows the adolescent and the family to distinguish between the person and the problem. Externalizing the difficulty has the advantage that adolescents, parents, and therapist can join forces and work together to find strategies to deal with the difficulties.

Providing adolescents with information about the causes and treatment of depression allows them to participate in decisions about management. Knowing that depressive disorder is common and strategies are available to deal with it is helpful. Adolescents may find it easier to talk about stress management or motivational problems than depression as an illness. Fact sheets and websites can be used to supplement information given by clinicians. (see Resources for Patients, Families, and Teachers at the end of the chapter.)

Giving adolescents details about interventions, choice about the preferred treatment, and discussing with them and their families how family members might be involved promotes a sense of efficacy. The process of “shared decision making” improves outcome in the management of depression.5 This should then be followed by including adolescents in active monitoring of their progress (e.g., through the use of rating scales) and discussing with them options at all stages of therapy. Here are some tips to facilitate engagement with adolescents (see also Chapter 3):

The risk of suicide must be monitored in all young persons who are treated for depression, particularly in those who are on antidepressant medications (see Chapter 14). Because of the evidence that media coverage of suicide acts can increase the risk of completed suicide, there has been concern that raising the issue of suicidal ideation and behavior in a clinical context may increase risk. In fact, clear evidence indicates that asking about suicidal ideation and behavior in this context does not increase risk.6

Managing risk while maintaining a good relationship with the young person can be challenging, and it is best done collaboratively with the youth. Asking about the context of the risk, and asking the young person what precipitated the thoughts or actions is helpful. It is also worth asking about times when the young person had thought about self-harm or suicide but had not acted on it. Finding out the strategies they have used themselves can be applied to support the youth’s sense of their own strengths, and to prompt discussion about other methods that could be used to reduce self-destructive behavior. It may be helpful to develop an action plan that the young people can use if they feel their risk has increased. This could include things the youth could do and supportive people the young person could approach. Involving families in managing risk is discussed later.

Young people use mobile phones and the Internet extensively to communicate with each other, and there is increasing interest in their clinical applications. Clinicians can take advantage of text messaging or e-mail to remind about appointments, give prompts about tasks set in therapy sessions, and get quick progress reports from the young person, among others. Using technology for these purposes is in its infancy but is bound to have a multitude of applications and to become more important.

Involvement of parents in situations where the youth is a ward of the state or is in foster care is a complex issue. The extent and type of involvement by the parents should be decided depending on the individual situation, keeping in mind that the welfare of the young person is paramount, and the child’s views should be taken into consideration in any decisions. The first priority is to ensure the young person is not at risk of harm, particularly if there is a history of abuse. If contact with one or both parents is very distressing for the child, or if contact puts the young person at risk, then involvement of the parents may be limited. These decisions should not rest on the shoulders of the therapist alone but involve liaison with child protection services, the wider family group where possible, and at times the juvenile justice system. In some countries such as New Zealand, provision is made for “family group conferences,” which afford a forum for family members and professionals from the health, child protection, education, and justice systems to work together and find solutions. It is helpful to have a specific person to provide support for the child and argue the case for them, either formally—through a “counsel for the child”—or informally.

It is hard for parents to ask for help. It is even more difficult when they have not recognized that there is a problem and the issue is raised by a teacher, health professional, or where an adolescent has sought help of their own accord. As a rule of thumb, with children it is important to engage the parents while making the child feel included. With adolescents it is important to engage the adolescent while making the family members feel included. Greeting all family members specifically, setting up clear expectations at the beginning of a consultation, providing separate time for children
and their parents, and checking with parents about their own well-being (being careful not to imply that parents are the target of treatment) are all strategies that can be used to make family members feel valued and supported. Adherence to a management plan is unlikely unless all involved think the plan is a good one. It is therefore important to reach agreement with the young person and their parents about the best way forward. Where there is disagreement, it is critical to try and resolve this. Even in cases when adolescents are seen on their own, it is advisable to see one or both parents from time to time (if at all possible with the knowledge and permission of the patient), it is advisable to see one or both parents from time to time. This can take just a few minutes at the beginning or end of the consultation, with or without the adolescent present. The aim is to keep parents informed, facilitate communication, clarify issues, and to validate adolescents’ reports—not always realistic or truthful.

Although parents report that receiving information about depression is helpful, adding a formal parent psychoeducation package to existing treatment has not yet resulted in improved outcomes.10,11,12 This may be related to high dropout rates because of the demands of the packages and to the practical difficulties of attending a regular program while running a home, getting to work, and dealing with a depressed child. However, ensuring that parents are informed about depression, treatment options, and involving them in decisions about management is part of good and ethical practice.13