The all-encompassing goal of therapy is to help patients reach the highest level of functioning of which they are capable, while alleviating mental pain or anguish.
Probably the most commonly used form of psychological therapy is dynamic psychotherapy, which is based on the premise that a person's emotional difficulties arise from unconscious conflicts, which lead to distorted views of oneself and others accompanied by painful feelings. This form of therapy strives to use insight into personal difficulties if the patient is intellectually and emotionally ready for it.
Another form of behavioral therapy is the so-called cognitive therapy, as developed by Aaron T. Beck and modified for use in children by Kovacs3 at the University of Pennsylvania. Their basic assumption is that emotional disturbances, including depression, are caused by distortion in thinking on a conscious level. The disturbed thinking of a depressed person, according to this theory, includes three major elements: 1) negative self-esteem; 2) negative view of the past and present; and 3) hopeless outlook for the future. Cognitive therapy attempts to correct this disturbed thinking by direct logical examination of the patient's views, thus helping him to gradually adopt a realistic view of himself, his environment, and his destiny.
GOALS AND TYPES OF THERAPY
Working With Families
All work with families contains a certain amount of insight therapy and a certain amount of guidance, and children and parents may benefit from both.
The choice of method will depend on the severity and length of the illness, the age of the child, and the intelligence, motivation, and insightfulness of the parents. The younger the child, the more responsive she or he will be to environmental changes alone. For example, a change in the amount of time that the mother or father is available to the child can be extremely helpful.
Pediatricians and mental health professionals sometimes see families who are unaware of the potential harm to the child of some of their child-rearing methods. The pediatrician may also suggest to the parents that they help the child cope more effectively with specific depressive issues that have arisen in the child's life. If there has been a recent death, the family will be advised to talk about it with the child openly and to answer frankly any questions he may have. Grief may be lightened by being brought out in the open. If the child is depressed about not having friends, the parents may be advised on how to go about teaching and helping the child to make more friends.
When the child is older, in grade school, or when depression is of long duration or great intensity, work with families should include the affected child and often other family members as well. In such cases, it often has to be supplemented by the pediatrician's or therapist's individual work with the depressed child and with the parents - particularly if, as so often happens, one or both parents are depressed. Whenever it can be used, a form of therapy that interprets what is going on, but does not direct the family in so many words what to do, is most effective in producing longterm benefits.
For instance, the pediatrician may try to get the family to understand the process of scapegoating4 in an effort to decrease depreciation and rejection of the child. In scapegoating, the child is blamed for virtually every untoward event that occurs. Naturally the child's self-esteem is negatively affected - and low self-esteem is a cardinal mark of depression. With some families, the therapist can help undo this process. He can get them to see that scapegoating makes a child feel worthless, inhibits his natural desire to accomplish things, and makes him wonder if life is worth living. When the child's family members come to realize this, through insight, they are more likely to abandon the scapegoating pattern than if they are simply given direct advice.
If a parent of a patient has a depressive illness, it is important to advise appropriate treatment for him or her in order to improve the parent's functioning and thus to furnish a non-depressed model for the child to identify with and follow.
Individual Therapy With the Child
In some cases of childhood depression, family and parental treatment may not suffice, and individual psychotherapy for the child may be indicated. The crucial goal is the development of a close empathie and trusting relationship with the therapist. Many distinguished therapists, such as Levy5 and Alien,6 have even gone so far as to say that such a relationship accounts for most successes achieved with children.
Second in importance is what Alexander7 called a "corrective emotional experience": the child experiencing a caring and more supportive response from his therapist than he had experienced previously in his life. The child is accepted in his totality without criticism and judgment. Since low self-esteem and hopelessness are the hallmarks of childhood depression, the therapist has to make special efforts to convey to the child that he values him as a person regardless of shortcomings and has firm hopes about the child's ability to overcome his difficulties.
A third important element is encouraging the child to ventilate all negative feelings and thoughts: fears, worries, sadness, hopelessness, conflicts with important people, anger, and distortions about himself and others. Although Anna Freud, among others, stressed that such ventilation is not sufficient, nevertheless it is important that the child feel free to get things off his or her chest with appropriate affect in a non-threatening and supportive situation.
As with adults and families, advice and counseling play important roles. They may include encouraging the child to attempt new relationships or repair old ones which went awry because of misconceptions grown out of depressed feelings. Pediatricians, therapists, and parents as well can encourage children to get into activities at which they are known to excel, eg, sports, music, drama, photography, dancing, or writing. Participation in such work and play is an important way of increasing the self-esteem and psychological strength of a depressed child.
Although the goals of therapy are basically the same for children of all ages, the technique obviously has to be tailored to the child's chronological age and the degree of his/her cognitive or emotional readiness. In our experience, children as young as 5 or 6 years can talk and discuss their difficulties in a reasonable manner and require a minimum of nonverbal activities such as play or games. Clearly, younger children require play therapy which employs dolls and other play materials and games. Through these media, the child can express in his or her own way all the problems that older children verbalize more directly. The level of interpretation also has to be adjusted to the age of the child.
There are many cases, of course, where family conditions make traditional psychiatric intervention unfeasible. In such cases, the therapist will collaborate or work with community resources such as schools, juvenile courts, halfway houses, foster homes, and the police on behalf of his depressed patients. In the course of treatment of depressed children, we have often gone to schools for meetings with the teachers, arranged for halfway houses or foster homes, talked to the police, and testified in court.
DRUG OR PHARMACOLOGICAL THERAPY
In recent years, there has been a greatly increased use of drugs in the treatment of depression in adults. More recently, drugs have been used in affective disorders in children.
Tricyclic drugs, as well as the monoamine oxidase inhibitors in childhood depression, have been in wide use in Europe8 and are coming into vogue in this country. Unfortunately, most of the past drug studies suffered from methodological flaws, which makes their interpretation difficult. The most important deficiency has been, without any doubt, the lack of diagnostic rigor, which often led to lumping together of heterogeneous conditions into artificial subgroups on flimsy clinical grounds. The other flaw was a failure to define prospectively the criteria of improvement. The dosage and duration of treatment have often been arbitrarily defined. Considering the potential hazards of antidepressant drugs, especially to the cardiovascular system, caution is definitely indicated. The recent studies of Puig-Antich9 and of Weinberg10 of children with a major depressive disorder indicate their good response to imipramine. The doses ranged from 1.5 mg/kg to 4.5 mg/kg. The side effects include dry mouth, nausea, constipation, somnolence, tachycardia, and anorexia. The improvement was gradual and became significant after 3 to 4 weeks on maximum dose. These studies, while representing an important beginning, were not double-blind and thus are subject to bias.
In clinical practice, one would be justified in the judicious use of tricyclic antidepressants in children in whom a depressive illness has been reliably diagnosed and who failed to respond to psychotherapy and environmental manipulation. Careful monitoring of side effects and only gradual increments in dosage are definitely indicated. Blood pressure, pulse and EKG should be screened at regular intervals.
As to the monoamine oxidase (MAO) inhibitors, eg, Eutonyl, Eudron, Nardil, and Ramate, we are not aware of any systematic attempts to administer these drugs to children. However, with their increasing use in adults, one may expect them to be tried in children as well, particularly in those who are unresponsive to tricyclic drugs.
Much of the criticism of antidepressant drug studies applies to lithium studies in children as well (ie, open design, heterogeneous diagnostic grouping, no defined length of stay or follow-up).11 The psychiatric conditions in children, reported to be responsive to lithium include: hyperactivity, cyclic mood changes, aggressive behavior, and explosive outbursts. Our own lithium study12 indicates good response in bipolar disorders (ie, when the depressed child has had a manic episode or a first-degree relative has a history of mania). It rakes between 7 to 14 days before a significant therapeutic effect is apparent. In contrast to some European reports, which stress the frequent need for the use of adult doses in children (1500 to 1800 mg/ day), our own experience indicates that in most children (ages 6 to 12), 900 mg/day is the maximum dose needed to maintain a therapeutic plasma level of 0.5 mEq/L to 1,5 mEq/L. Although adult side effects include diarrhea, nausea, weakness, tremor, hypo- and hyper- thyroidism, blurred vision, drowsiness, polyuria and polydypsia, our findings confirm earlier reports about the relative rarity of side effects in children. Recently there have been some reports of permanent kidney damage in adults after prolonged lithium administration.13 The renal changes included interstitial nephritis and tubular necrosis. So far no such complications have been reported in children. However, prudence would dictate: 1) the contraindication of lithium in children with renal, cardiovascular, or thyroid disease; 2) periodic screening of thyroid (TSM, T2T3) amd renal; function (urine concentration test and creatinine clearance); and 3) caution in determining the length of lithium therapy in children. The need, safety, and dosage in children has yet to be determined.
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