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Adolescent depression is a serious public health problem. Affecting approximately 15% of teenagers in the USA before the age of 18 (Merikangas et al., 2010), major depressive disorder (MDD) in the adolescent population is associated with significant and potentially lifelong impairment in interpersonal relationships, academic achievement, and physical and behavioral health (including increased risk of substance abuse, suicide, and chronic disorder) (Birmaher et al., 1996). Given the high rates of youth depression and the impairment associated with this disorder, methods to address depressive disorders in children and adolescents have tremendous implications for population health and well-being.
Treatments for youth depression do hold promise. Recent research suggests that antidepressant medications, cognitive-behavioral therapeutic approaches, and interpersonal psychotherapy are associated with reductions in symptoms among depressed youth (Cheung et al., 2007). However, even in controlled research settings, only 50–60% of adolescents experience depression remission with treatment (Asarnow et al., 2002; TADS Team, 2004). Moreover, treating depression can be expensive, and many of the social and academic consequences of youth depression may persist even after the primary symptoms of disorder remit (Domino et al., 2008; Lewinsohn et al., 2003). Therefore, programs that intervene before the onset of child and adolescent depression are desirable.
A recent report by the US Institute of Medicine (2009) emphasized the importance of employing programs to prevent mental illness in youth, so that the personal and economic costs of mental illness to individuals, families, and society can be avoided. The evidence base for preventing depression in adolescents indicates that prevention programs can reduce the incidence of both depressive symptoms (Horowitz and Garber, 2006) and depressive episodes (Cuijpers et al., 2008).
The goal of most depression-prevention programs is to build resilience. Different children can be exposed to the same environmental stressor, and some of these children will develop depression while others will not. Children who do not develop depression have both internal (i.e., coping skills) and external (i.e., social supports) resources that enable them to be resilient in the face of adversity (Beardslee and Podorfesky, 1988). Depression-prevention programs are designed to help children develop coping skills and social supports so they can have resilient responses.
To date, youth depression-prevention programs have targeted universal, selected, and indicated samples. Although it may seem that providing prevention programs to all adolescents (i.e., universal samples) would produce maximum benefit for population health, the research suggests otherwise. According to the Institute of Medicine (2009), prevention programs that are provided just to youth with identified risk factors, or with subsyndromal symptoms of depression, are more effective than universal prevention programs. This may be because universal programs provide intervention to a number of individuals who are already doing well and therefore experience little benefit from participation. It is far more effective, and efficient, to identify those at the highest risk and provide them with targeted intervention.
As is discussed in Chapter 12, children of depressed parents are at a fourfold increased risk of developing depression themselves, making parental depression one of the most potent risk factors for the disorder. Parents with depression often experience disruptions in parenting, characterized by withdrawn and intrusive parenting behaviors. Such behaviors create a stressful environment for youth, and have been demonstrated to significantly mediate the relation between parental depressive symptoms and offspring psychopathology (Jaser et al., 2008). Research indicates that family factors maintain depression in children (Brent et al., 1997), and that intrusive and withdrawn parenting behaviors can continue in parents even after their depression has remitted (Seifer et al., 2001). Recently, several depression-prevention programs have been developed to address specifically the risk factor of parental depression, utilizing a family-based approach. In such prevention programs for children of depressed parents, children can be taught skills of resilience, and parents can learn how to adjust parenting behaviors to support their child’s development and resilience, even while they themselves are struggling with depression.
This chapter will describe three preventive interventions for children of depressed parents, all of which are either family-based or incorporate some form of parental involvement. This chapter also will describe family-based depression-prevention programs for children of parents experiencing other forms of adversity (i.e., bereavement and divorce). These descriptions are followed by a summary of clinical implications.
Family Talk
The Family Talk intervention is a 6–8-session, family-based program designed to increase depressed parents’ focus on their children, to increase children’s understanding of parental depression, and ultimately to reduce depressive symptoms in children of depressed parents. This is a strengths-based approach that encourages families to discuss the effects of parental depression on all family members.
In the first few sessions of Family Talk, psychoeducational materials are provided to the parents; the goal of this material is to teach parents about the causes of depression, the risk of depression to youth, how to build resilience in their children, and how to be good parents in the face of depression. It is emphasized that depressed parents can still be good parents, that their children are not destined to become depressed, and that resilience in their children can be increased by working together as a family. In subsequent sessions, the parents, and then each child individually, meet with the clinician to discuss their experiences and concerns related to parental depression. The parents work with the clinician to plan a family meeting, and then the clinician supports the parents in facilitating a family meeting with their children to talk about the parent’s depression, and to problem-solve about ways to increase the child’s supportive relationships and activities outside the home (both of which are associated with resilience in children of depressed parents) (Beardslee and Podorefksy, 1988). During this family meeting, parents correct misconceptions about depression and emphasize that children are not to blame, listen to the concerns of the children, and problem-solve regarding ways to improve family relationships and increase social activities for the children.
A large clinical trial compared Family Talk with a control lecture condition, which provided parents with the same psychoeducational material over two meetings but did not include efforts to connect the material to the family’s illness experiences. Children’s understanding of depression changed significantly in both groups, with greater change in the Family Talk condition. Follow-up data at 2.5 (Beardslee et al., 2003) and 4.5 years (Beardslee et al., 2007) after the intervention indicated long-standing benefits of the Family Talk program, with the amount of change in parent’s child-related behaviors and attitudes, and children’s understanding of parental illness increasing over time. Furthermore, children who participated in the intervention reported decreased depressive symptomatology over time. In examining the mechanism of these improvements, Beardslee (2002) found that families that did make changes often talked repeatedly about depression, and also conducted family meetings to strategize about other topics. They also found that understanding of depression changed as children matured, and that families might need to have new meetings as the illness progressed or as the child developed.
The Family Talk intervention has been adapted for many populations. Adaptations for use in the USA include those for urban minority families (Podorefsky et al., 2001), for Latino families (D’Angelo et al., 2009), and for the Head Start/Early Head Start programs (Beardslee et al., 2010). Portions of the Family Talk intervention have also been incorporated into programs for military families (Saltzman et al., 2011) and children with inflammatory bowel disease (Szigethy et al., 2006). Iterations of Family Talk have been implemented in Australia, Colombia, Costa Rica, Finland, Iceland, the Netherlands, Norway, Rwanda, and Sweden.
Prevention of Depression program
The Prevention of Depression (POD) program is a cognitive-behavioral group intervention, adapted from the Coping with Stress course developed by Clarke and colleagues (2001). POD is a manualized, cognitive-behavioral, and psychoeducational group program for symptomatic (i.e., current subsyndromal depressive symptoms or history of depression) adolescents of parents treated for depression. The intervention consists of eight weekly, 90-minute adolescent group sessions and six monthly, 90-minute continuation sessions that teach cognitive restructuring, communication skills, and skills for interpersonal problem-solving. The way children cope with the stress of parental depression can predict their psychological symptoms (Jaser et al., 2008). Providing a cognitive-behavioral intervention to offspring of depressed parents can provide them with the skills to adaptively respond to the stress of parental depression. In addition to adolescent group sessions, the POD intervention includes two concurrent parent sessions that focus on a review of the material presented in the teenager sessions.
POD was evaluated in a four-site, randomized control trial. Garber and colleagues (2009) reported that incidence of depressive episodes was significantly lower in adolescents who received the POD program than in those receiving care as usual. Current baseline parental depression moderated intervention effects, such that children of parents with current depression did not respond significantly better to the POD program than to usual care (Garber et al., 2009). More recently, the efficacy of the POD intervention has been found to persist across a 33-month follow-up interval (Beardslee et al., 2013). These findings indicate that, while the program may be helpful to at-risk children, it may be necessary for parents to be treated for depression before children can benefit.
Although data regarding the efficacy of the POD parent component have not yet been published, anecdotal evidence suggests that many parents found these sessions to be quite helpful and useful in supporting their children’s participation in the intervention. It is noteworthy that, in an earlier, one-site study of a group cognitive-behavioral program for adolescents at risk of depression, parental participation in psychoeducational sessions did not significantly enhance adolescents’ intervention response (Lewinsohn et al, 1990). Analyses are currently underway to explore any additive effects of participation in the POD parent sessions.
A family group cognitive-behavioral intervention
Citing the research on both Family Talk and POD, Compas and colleagues (2009) created a family-based group cognitive-behavioral intervention to prevent depression in children of depressed parents. The intervention consists of eight weekly and four monthly booster sessions for groups of four families each. For the first three sessions, parents and children are provided with psychoeducation and an overview of coping skills together. The remaining five sessions divide the children and the adults for the majority of the session time, with the exception of brief homework descriptions provided to them together at the beginning and end of each session. As in POD, children in this intervention are provided with cognitive-behavioral coping skills to ADAPT, an acronym for the core skills of Acceptance, Distraction, Activities, and Positive Thinking. As in Family Talk, parents are taught skills to encourage their child’s development and resilience (by praising, spending positive time with children, encouraging the child’s use of coping skills, and providing structure and consistent punishment and reward for child behaviors). Both parents and children are assigned homework to reinforce skills. Booster sessions help participants to implement changes at home and continue using their skills.
This intervention was tested in a two-site, randomized control trial comparing the family group cognitive-behavioral intervention to a self-study program for children and parents on psychoeducation and coping (Compas et al., 2009). One year after entry into the study, children in the family group cognitive-behavioral intervention reported significantly fewer internalizing problems than children did in the self-study condition. Fewer children in the family group condition (8.9%) experienced depressive episodes than in the self-study condition (20.8%) at a level that approached significance (p = .07). Parents in the family group intervention also experienced fewer depressive symptoms than parents in the self-study condition.
Related posts:
Thinking about children of parents with mental illnesses as a form of intergenerational dialog and practice
Mothers with eating disorders and their children
Helping children understand their parent’s mental illness
E-learning professional development resources for families where a parent has a mental illness
Preventing unnecessary loss of child custody
Parental psychiatric disorder: translating The Family Model into practice change
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