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Part 1 book “CBT for depression in children and adolescents” has contents: Introduction, overview and rationale, assessing clients and planning treatment , how to use this treatment manual, CBT and relapse prevention program overview/rationale, and establishing timeline and goals, behavioral coping skills and family expressed emotion.
ebook THE GUILFORD PRESS CBT for Depression in Children and Adolescents CBT for Depression in Children and Adolescents A Guide to Relapse Prevention Betsy D Kennard Jennifer L Hughes Aleksandra A Foxwell THE GUILFORD PRESS New York London Copyright © 2016 The Guilford Press A Division of Guilford Publications, Inc 370 Seventh Avenue, Suite 1200, New York, NY 10001 www.guilford.com All rights reserved Except as indicated, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher Printed in the United States of America This book is printed on acid-free paper Last digit is print number: 9 8 7 6 5 4 3 2 1 LIMITED DUPLICATION LICENSE These materials are intended for use only by qualified mental health professionals The publisher grants to individual purchasers of this book nonassignable permission to reproduce all materials for which permission is specifically granted in a footnote This license is limited to you, the individual purchaser, for personal use or use with individual clients This license does not grant the right to reproduce these materials for resale, redistribution, electronic display, or any other purposes (including but not limited to books, pamphlets, articles, video- or audiotapes, blogs, file-sharing sites, Internet or intranet sites, and handouts or slides for lectures, workshops, webinars, or therapy groups, whether or not a fee is charged) Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the authors, nor the editors and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information Readers are encouraged to confirm the information contained in this book with other sources Library of Congress Cataloging-in-Publication Data Names: Kennard, Betsy D., author | Hughes, Jennifer L., 1981– , author | Foxwell, Aleksandra A., author Title: CBT for depression in children and adolescents : a guide to relapse prevention / by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Description: New York: The Guilford Press, [2016] | Includes bibliographical references and index Identifiers: LCCN 2015041065 | ISBN 9781462525256 (paper : alk paper) Subjects: | MESH: Child | Cognitive Therapy—methods | Adolescent | Evidence-Based Medicine | Secondary Prevention—methods Classification: LCC RJ505.C63 | NLM WS 350.2 | DDC 618.92/891425—dc23 LC record available at http://lccn.loc.gov/2015041065 About the Authors Betsy D Kennard, PsyD, ABPP, a clinical psychologist, is Professor in Psychiatry and Director of Cognitive-Behavioral Therapy (CBT) in the Pediatric Psychiatry Research Program at the University of Texas Southwestern Medical Center at Dallas (UT Southwestern) and Children’s Health System of Texas She also serves as Program Director of the Doctoral Program in Clinical Psychology at UT Southwestern and Clinical Director of the Suicide Prevention and Resilience Program at Children’s Health Dr Kennard has been a site co-investigator on three multisite treatment studies of adolescent depression and suicide funded by the National Institute of Mental Health (NIMH) and has coauthored CBT treatment manuals for these studies She developed this CBT sequential treatment strategy to prevent relapse in youth with depression and is currently Principal Investigator on an NIMH-funded treatment development study to treat suicidal adolescents Jennifer L Hughes, PhD, is a clinical psychologist at Children’s Health and Assistant Professor in Psychiatry at UT Southwestern She has received funding from the American Foundation for Suicide Prevention to study an intervention designed to prevent future suicide attempts in youth, and she has served as a therapist, treatment developer, and co-investigator on several multisite studies of depressed and/or self-harming children and adolescents Broadly, Dr Hughes’s research explores the efficacy and effectiveness of psychosocial approaches to the prevention and treatment of depression and suicide in youth and the dissemination of evidence-based treatments to the community v vi About the Authors Aleksandra A Foxwell, PhD, is a clinical psychologist at the Student Wellness and Counseling Services and Assistant Professor in Psychiatry at UT Southwestern She has served as a therapist and a co-investigator on several studies of suicidal children and adolescents with major depressive disorder Dr Foxwell’s clinical interests focus on using evidence-based treatments for depression, anxiety, and other mood disorders in children, adolescents, and young adults She also trains and supervises students and interns in using CBT for the treatment of depression Acknowledgments First, we would like to thank the children and families who participated in the treatment studies of relapse prevention cognitive-behavioral therapy (RP-CBT) This work would not have been possible without their time, energy, effort, and input Our work with them inspired many of the examples, as well as the fine-tuning of skills included in this book In addition, we are grateful to the National Institute of Mental Health (NIMH), who provided the funding for the clinical trials that led to the development of this treatment approach (NIMH R34 MH072737, principal investigator: B Kennard; NIMH R01 MH39188, principal investigators: G Emslie and B Kennard) We would like to acknowledge the original RP-CBT Development Team—Betsy D Kennard, PsyD, Sunita Stewart, PhD, Jennifer L Hughes, PhD, Puja Patel, PhD, Avery Hoenig, PhD, and Jessica Jones, MA—who were instrumental in developing the initial intervention Additionally, we would like to thank Graham J Emslie, MD, who was the co-principal investigator for the NIMH R01 randomized controlled trial to test RP-CBT Given his experience in testing and developing continuation-phase treatments for youth depression, his input was invaluable in developing our approach to the clinical care of these children and their families We are also grateful to the many therapists, co-investigators, study coordinators, and graduate students who contributed to the success of this work: Taryn Mayes, MS, Jeanne Nightingale-Teresi, RN, MS, Carroll Hughes, PhD, RongRong Tao, MD, Kristi Baker, PhD, Mikah Smith, MA, LPC, Charlotte Haley, PhD, Kate Kennard, BA, Jessica King, BA, Alyssa Parker, PhD, Ashley Melson, MSW, Krystle Joyner, MS, Kristin Wolfe, MRC, Jarrette Moore, MA, Hayley Fournier, PhD, vii viii Acknowledgments Heather Lindburg, MS, Jeanne Rintelmann, BA, Lauren Smith, BA, Annie Walley, LCSW, Shauna Barnes, BA, and Tabatha Hines, PhD Thank you to Kevin Stark, PhD, and his graduate students, Kim Poling, MSW, John Curry, PhD, and Greg Clarke, PhD, for their careful review of the manual and helpful suggestions In addition, we are grateful to those who served as consultants on the clinical trials of this manual, including David A Brent, MD, A John Rush, MD, Greg Clarke, PhD, Michael Frisch, PhD, Robin Jarrett, PhD, and Kevin Stark, PhD We would also like to acknowledge the influence of several important works that have shaped the development of RP-CBT These individuals and their work have affected the care of depressed children and have had a major impact on our field Treating depressed youth: Therapist manual for “ACTION.” (2007b) K D Stark, S Schnoebelen, J Simpson, J Hargrave, J Molnar, and R Glen Cognitive behavior therapy manual for TADS (2000) J Curry, K Wells, D. Brent, G Clarke, P Rohde, A M Albano, M Reinecke, N Benazon, and J March, with contributions by G Ginsburg, A Simons, B D Kennard, R. LaGrone, M Sweeney, N Feeny, and J Kolker Cognitive behavior therapy manual for TORDIA (2000) D Brent, M. Bridge, and C Bonner Cognitive therapy treatment manual for depressed and suicidal youth (1997) D Brent and K Poling Continuation therapy for major depressive disorder (2001) R B Jarrett Cognitive behavior therapy for suicide prevention (CBT-SP) teen manual, version (2006) D A Brent, G Brown, J F Curry, T Goldstein, J L Hughes, B D Kennard, K Poling, M Scholossberg, B Stanley, K C Wells, and the TASA CBT Team The SAFETY Program: Ecological cognitive-behavioral intervention for adolescent suicide attempters (2015) J R Asarnow, M Berk, J L Hughes, and N L Anderson Stress and your mood: Teen and young adult workbook (1999) J Asarnow, L Jaycox, G Clarke, P Lewinsohn, H Hops, and P Rohde Stress and your mood: A manual for individuals (2010) J Asarnow, L. Jaycox, G Clarke, P Lewinsohn, H Hops, P Rohde, and M Rea For additional work related to RP-CBT, readers are referred to Kennard, Emslie, et al (2008a); Kennard, Stewart, et al (2008b); and Kennard et al (2014) Session 2 67 Summary and Homework/Practice Summarize the family session • Assess the family’s understanding of expressed emotion • Elicit feedback about the session “How is this relevant to your family’s situation?” “How can I, as the therapist, be helpful?” • Have the family summarize the session Collaborate to develop a family homework assignment Homework ideas include: • The negotiation of an “escape plan.” Have the family agree that when emotions get high, they will use the listening and communication strategies discussed in the session Have the family report back on how these strategies worked for them • Have the family plan an activity to in the upcoming week This activity should have a low risk of conflict Contract with the family to this activity and report back on how it went Did It Stick? (Review Questions from the Session) What are behavioral coping skills—which types work for you? Why should we monitor mood? Why is it important in relapse prevention? Case Example: Session In the second session, Lily brings in her completed Mood Monitor Log and sleep diary After setting the session agenda, Lily and the therapist review the practice assignments In reviewing the Mood Monitor Log, it became clear that Lily’s lower mood ratings were associated with conflict at home In addition, the sleep diary indicated problematic sleep habits, including napping during the day and using her cell phone in bed to use social media Lily reported continued improvement in mood, with less sadness, but also described continued irritability, in particular with her sister She rated her average mood as a “5” on a 1–10 scale, with 10 being the worst mood 68 Self-Beliefs: • When I feel sad, I notice Past Why does everything good happen to my sister? • It’s never going to get any better • No one likes me • This school sucks • Negative Automatic Thoughts: Still fight a lot with sister (irritability) Nothing is as fun as it used to be, and I still hang out alone a lot Take care of my dog No naps after school Be more social Get along better with sister My Goals Sing Future Things I well: Draw Present Napping every day Ways that I know I am still feeling down: FIGURE 6.1. Lily’s completed timeline during Session Take more naps Feel sadder Angrier to my sister and parents My drawings become dark Nothing is fun anymore; I want to stay in my room My grades go down, and it’s hard to concentrate I moved to a new school in 6th grade • My sister made Student Council, and I ran for office and did not win • I got into a fight with a friend on text, and the friend said she would no longer hang out with me Stressors: No naps Obstacles and Future Challenges: Social media Ride bike, walk dog, meet friends Art project Study in kitchen Coping Skills and Positive Self-Talk: Session 2 69 The therapist introduced the behavioral coping strategies as a way to reduce irritability and improve mood The therapist commented that this set of skills could be particularly helpful given Lily’s reported irritability and tied this idea to Lily’s agenda item of getting along better with her parents and sister Lily and the therapist noted that irritability had been listed as a residual symptom on her timeline (see Figure 6.1) The therapist and Lily reviewed the five categories of behavioral activation skills, and Lily was able to identify several activities to fit within each of these categories: • Distracting and fun: being on social media, watching TV series and movies • Relaxing and soothing: hot bath, reading a book • Expending energy: riding bike, taking dog for a walk • Social: texting a friend, going to mall with a friend • Mastery: art project The therapist and Lily planned how these activities could be used over the coming week to improve mood In addition, they planned how she could use these strategies in response to irritability or conflict at home They developed a specific homework/ practice plan for the following week Lily and the therapist ended the session by planning for the family session Lily stated that she thinks her parents still don’t understand her depression The therapist helped her identify ways that her parents could be more supportive They agreed to this in the family session FIGURE 6.2. Postcard reminder after Session 70 CBT for Depression in Children and Adolescents In the family session, the therapist collaboratively set the agenda, which included further psychoeducation about depression Lily introduced behavioral coping skills to her parents and how they are relevant to her treatment and continued prevention of relapse The therapist highlighted the connection between problem communication behaviors and negative emotion and the risk for relapse In the family session, the therapist worked with the parents and Lily to collaboratively determine ways to provide support to Lily They discussed parents’ expectations for Lily at home, which included wanting Lily to spend more time with the family, wanting her to stop taking so many naps, and requiring her to have planned study time daily at the kitchen table The therapist and Lily worked with the family to call a truce on questions about schoolwork and grades and planned a few specific family behavioral coping activities for the week, including a family bike ride, game night, and breakfast at Grandma’s on Sunday The therapist met with Lily’s parents briefly at each visit to obtain input about her progress and to answer questions about the skills handouts provided to the parents at each session A postcard reminder of the session content, which included a review of applying skills (see Figure 6.2), was sent before the next session 71 Self-Care Self-Acceptance Social Success Self-Goals What I did for fun Things that I was My short-term Sleep—What time Positive statements that I good at and long-term I went to bed goals Exercise—Time I say to myself spent in activity Food—Things I eat Spiritual Soothing Times I spent What I did to in reflection or relax doing something for others From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) Day Wellness Log Handout 6.1 72 10 From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) Feeling Happy How you know where your mood is? Feeling Distressed Actions and Thoughts Mood therMoMeter handout 6.2 handout 6.3 Feeling FaCeS From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) 73 74 THOUGHT THOUGHT From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) MOOD THOUGHT THOUGHT doWnWard Spiral handout 6.4 75 From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) Relapse Lapse Lapse Thought: Event: Slippery Slope Handout 6.5 76 From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) SelF-triangle handout 6.6 Handout 6.7 Behavioral Coping Skills Do something DiStrAcTiNg and FuN Do something relaxing and soothing Expend ENERGY Do something Do something that makes you feel successful: Mastery From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) 77 78 Mon Tues Wed Thurs Fri Sat Sun From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) Activity Activity Scheduling Handout 6.8 79 What lifts you UP? Sandbags What brings you DOWN? From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) Hot Air Lift Your Mood Handout 6.9 Handout 6.10 The Basics of Depression: Psychoeducation for Teens and Parents WHAT IS DEPRESSION? Depression is an illness that affects your moods, thinking patterns, behavior, and motivations Symptoms include: • Sad, anxious, or bored mood • Irritability and/or anger • Change in energy • Restlessness • Slowing down of body or speech • Loss of interest or pleasure • Change in sleeping patterns • Change in eating patterns • Change in socializing • Inability to concentrate or slowed thinking • Hopelessness • Guilt/worthlessness • Suicidal ideation and/or behavior MYTHS ABOUT DEPRESSION • Depression will go away on its own • Everyone feels this way • The person with depression can control it and should be able to “pull him- or herself up by the boot straps” and feel better on his or her own • Depression is a sign of weakness • If a person talks about suicide, this means the person will not go on to attempt suicide HELPING YOURSELF • Be hopeful—depression can be treated • Take medication as prescribed, even if beginning to feel better • Be direct in communicating • Be active in treatment • Keep a journal • Keep busy HELPING A LOVED ONE WITH DEPRESSION • Changing expectations • Take care of yourself; go on with your life • Be direct in communicating • Provide feedback about positive changes you noticed • Always take suicide talk seriously—let us know • Make school aware of how teachers and staff can be supportive • Remember the illness is causing the person’s changes—avoid taking angry comments personally • Look for gradual improvement TREATMENT OPTIONS • Cognitive-behavioral therapy • Family therapy • Medications Adapted from Poling and Brent (1997) and Kennard and Rush (1997) with permission from the authors From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) 80 Handout 6.11 Problem Communication Behaviors Problem Communication Habits Positive Alternatives • Accusing, blaming • Making “I” statements (“I feel when happens”) • Using sarcasm • Making communication direct, using a neutral voice • Put-downs, name calling, shaming • Accepting responsibility; making “I” statements • Interrupting • Listening quietly • Lecturing, preaching, moralizing • Identifying the problem; being brief • Criticizing • Identifying the positive; collaborating on solutions • Mind reading (telling others what they think and • Asking people what they think and feel feel) • Getting off topic • Catching onself and returning to the problem • Dwelling on the past • Sticking to the present and future (suggesting change to correct past problems) • Monopolizing the conversation • Taking turns making brief statements • Threatening • Suggesting alternative solutions • Clamming up; not responding • Reflecting; validating, expressing both negative and positive feelings • Using “the silent treatment” • Negotiating a later time to talk when everyone has “cooled off” Adapted from the Treatment for Adolescent Depression Study (TADS) From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes, and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies of this handout (see the box at the end of the table of contents) 81 ... Restructuring and Identifying Unhelpful Thoughts 82 Chapter Session 4: Problem Solving 10 1 Chapter Session 5: Identifying Skills for Maintaining Wellness and Building the Wellness Plan 11 1 Chapter 10 .. .ebook THE GUILFORD PRESS CBT for Depression in Children and Adolescents CBT for Depression in Children and Adolescents A Guide to Relapse Prevention Betsy D Kennard Jennifer L Hughes Aleksandra... www.guilford.com/kennard-forms for personal use or use with individual clients (see copyright page for details) CBT for Depression in Children and Adolescents Ch a p t e r Introduction Major Depression in Children and