Gena P. Phillips M.A., LPC, LCAS Natalie Spencer M.Ed.

, LPC

Ice Breaker Lets Get to know each other!

Outline
What is Depression Symptoms and Signs of Depression Risk Factor for Suicide Prevention Efforts and Effectiveness Family Dynamics

Schooling
Cultural Implications Questions?

Case Study #1
Montrel is a 2nd grader. His teacher has come to you

with some concerns. She tells you that Montrels behavior has changed in the past few weeks. She said Montrel is usually outgoing and productive in the classroom. She says that recently he complains of stomach aches everyday when they have free time. Instead of interacting with his peers, he sits at his desk and gazes out the window. She also said that when she asks him what is wrong, he always says I dont know but I dont feel right. She needs your guidance with this student. What do you tell her? What do you think might be going on with Montrel?

Case study #2
Jamel is in 8th grade. You are walking down the hall at

school and she frantically runs into you. She is crying and she snaps at you by saying get out of my way. You ask her whats going on and she says leave me alone, you wouldnt understand in a very angry tone. She walks away and you follow her into the bathroom. At that time, you hear her in the stall on her cell phone saying I dont know what to do, I just wish I would die. When she comes out of the bathroom, she is still crying. What do you do? What would you say to Jamel? What do you think is going on?

What is Depression? Clinical Criteria (Major Depressive Episode)

Five (or more) of the following symptoms have been

present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is (1) depressed mood or (2) loss of interest or pleasure.

Clinical Criteria (cont)

Adults
(1) Depressed mood most of

Children
Mood can be depressed or

the day, nearly every day, as indicated by subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)

irritable. Children with immature cognitive-linguistic development may not be able to describe inner mood states and therefore may present with vague physical complaints, sad facial expression, or poor eye contact. Irritable mood may appear as acting out; reckless behavior; or hostile, angry interactions. Adult-like mood disturbance may occur in older adolescents.

Clinical Criteria (cont)

Adults
(2) Markedly diminished

Children
Loss of interest can be in peer

interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation made by others)

play or school activities.

Clinical Criteria (cont)

Adults
(3) Significant weight loss

Children
Children may fail to make

when not dieting, or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day

expected weight gain rather than losing weight.

Clinical Criteria (cont)

Adults
(4) Insomnia or hypersomnia

Children
Similar to adults

nearly every day

Clinical Criteria (cont)

Adults
(5) Psychomotor agitation or

Children
Concomitant with mood

retardation nearly every day (observable by others, not merely subjective feeling of restlessness or being slowed down)

change, hyperactive behavior may be observed.

Clinical Criteria (cont)

Adults
(6) Fatigue or loss of energy

Children
Disengagement from peer

nearly every day

play, school refusal, or frequent school absences may be symptoms of fatigue

Clinical Criteria (cont)

Adults
(7) Feeling of worthlessness

Children
Child may present with self-

or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

depreciation (e.g., I'm stupid, I'm a retard). Delusional guilt usually is not present.

Clinical Criteria (cont)

Adults
(8) Diminished ability to

Children
Problems with attention and

think or concentrate, or indecisiveness, nearly every day (by subjective account or as observed by others)

concentration may be apparent as behavioral difficulties or poor performance in school.

Clinical Criteria (cont)

Adults
(9) Recurrent thoughts of

Children
There may be additional

death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

nonverbal cues for potentially suicidal behavior, such as giving away a favorite collection of music or stamps.

Risk Factors for Suicide

Roughly 9 out of 10 adolescents who die by suicide give

clues to others before their suicide attempt

Recognizing risk factors early can prevent suicide and

get teens the help they need

Impact of some risk factors can be reduced greatly by

interventions

Risk Factors for Suicide

Previous suicide attempt or gesture Feelings of hopelessness or isolation Substance abuse Family history of

Psychopathology (depressive disorders/

mood disorders) Parental psychopathology

suicidal behavior Life stressors such as interpersonal losses (relationship, social, legal, etc.) Disciplinary problems Access to firearms Physical/verbal/sexual abuse

Risk Factors (cont)

Conduct disorders or Contagion or imitation

disruptive behaviors Sexual orientation (homosexual, bisexual, and trans-gendered youth) Juvenile delinquency School and/or work problems Aggressive-impulsive behaviors

(exposure to media accounts of suicidal behavior and exposure to suicidal behavior in friends or acquaintances) Chronic physical illness Living alone and/or runaways

Protective Factors
Family cohesion (family with

mutual involvement, shared interests, and emotional support) Good coping skills Academic achievement Perceived connectedness to the school Good relationships with other school youth Lack of access to means for suicidal behavior Help-seeking behavior/advice seeking

Impulse control Problem solving/conflict

resolution abilities Social integration/opportunities to participate Sense of worth/confidence Stable environment Access to and care for mental/physical/substance disorders Responsibilities for others/pets Religiosity (a controversial topic currently)

Early Warning Signs

Withdrawal from friends Loss of interest in

and family Preoccupation with death Marked personality change and serious mood changes Difficulty concentrating Difficulties in school (decline in quality of work) Change in eating and sleeping habits

pleasurable activities Frequent complaints about physical symptoms, often related to emotions, such as stomach aches, fatigue, headaches, etc. Persistent boredom Loss of interest in things one cares about

Late Warning Signs

Actually talking about suicide or

a plan Exhibiting impulsivity such as violent actions, rebellious behavior, or running away Complaining of being a bad person or feeling rotten inside Making statements about hopelessness, helplessness, or worthlessness. Giving verbal hints with statements such as: I wont be a problem for you much longer, Nothing matters, Its no use, and I wont see you again

Refusing help, feeling beyond

help Not tolerating praise or rewards Becoming suddenly cheerful after a period of depression-this may mean that the student has already made the decision to escape all problems by ending his/her life Giving away favorite possessions Making a last will and testament Saying other things like: Im going to kill myself, I wish I were dead, or I shouldnt have been born.

6 Generic Questions to Assess Lethality

- (Wubbolding, 1996)

Are you thinking about killing yourself? Have you attempted suicide in the past? Do you have a plan? Do you have the means available to you?

Will you make a no-suicide agreement to stay alive?

Is there anyone close to you who could prevent you

from killing yourself and to whom you could speak if you feel suicidal?

Prevention Efforts and Effectiveness

Many studies focus on the treatment of depression in

both children and adults, however few focus on its prevention In a recent study the Journal of American Medical Association (JAMA, 2009) examined the effectiveness of prevention interventions in adolescents with depressed parents Study concluded that Cognitive Behavioral Therapy (CBT)- is effective in reducing the risk of depressive symptoms in adolescents with depressed parents

Prevention Efforts and Effectiveness

Study consisted of 316 adolescents aged 13-17 who had

at least one parent or caregiver with a current or past diagnosis of depressive disorder The participants also had a history of current or past depressive symptoms. Participants randomly assigned to groups to receive either sessions of group CBT or their current treatment. Participants participated in 8 weekly CBT sessions followed by 6 monthly session ( learn coping and cognitive restructuring and problem solving skills)

Prevention Efforts and Effectiveness

Study measured the rate of occurrence of depressive

episodes that lasted 2 weeks. At conclusion of study and follow up period incidence of depressive episodes in the intervention group as 21.4% versus 32.7% in the control group. Intervention group reported improvement in depression symptoms more often then control group.

Prevention Efforts and Effectiveness

Family Based therapies have produced

positive results with children of depressed parents Help children recognize symptoms Promote resilience

Prevention Efforts and Effectiveness

Wake County School Prevention Effort: Signs of

Suicide Video and SOS information was presented to 9th graders in Health/PE class Students filled out a form if they ever considered suicide or felt depressed, sad, or unhappy Counselors would review forms and met with students before the end of school

Family Dynamics
Family conflict can trigger or worsen depression

symptoms Parents should open lines of communication to encourage children/teens to talk Families often place attention and energy on depressed child and neglect own health and other family members Important to keep whole family strong and healthy

Family Dynamics

Resistant Parents- Pro-active vs. Re-active The Mentally Ill Parent Making Recommendations- Parents can resist help Shame and Fear Emotionally and Physically Attached-

What do you do?

Family Dynamics
Families should maintain balance by: Reaching out for help- Support groups, friends, etc Be open with family- Dont cover up situation. Invite

other children and teens to ask questions Avoid the blame game- Not the time to point fingers, but offer support.

Schooling
Depression in children and teens can have negative

effects on schooling. In schools (rather than home or community) students problems with academics, peers or other issues are more likely to be evident. At schools, students have the greatest access to multiple helpers, such as teachers, counselors, nurses, and classmates who have the potential to intervene.

Schooling
Depressed teens often skip school Decline in academics- Important for teachers to

receive training to know reasons why school performance drops Students who feel connected to schools ( believe teachers care about them, feel part of the school) are less likely to engage in suicidal behaviors.

Cultural Implications
Cultural differences can be reflected in differences in

preferred styles of coping with day-to day problems. Evidence indicates there is a persistent disparity in the health status of racial and ethnic minority populations as compared to the overall health status of the US population

Cultural Implications
People in the lowest socio- economic positions are 2-3

times more likely than those in the highest positions to experience mental disorders Racism and discrimination are highly stressful and can adversely affect health and mental health.

Cultural Implications
In 2003 11% of African American male students in

grade 9-12 seriously considered suicide In 2002 the suicide rate among African American females was the lowest of all racial/gender groups- 1.6 per 100,000 Among males ages 15-24 American Indians and Alaskan Native have the highest suicide death rate of 27.9 per 1000, 000 population
US Department of Health and Human Services

Cultural Implications
Multiple studies suggest that children and adolescents

of Hispanic origin experience more mental health problems than their non- Hispanic counterparts Asian Americans do not access mental health treatments as much as other racial /ethnic groups. This is perhaps due to a strong stigma related to mental illness. Emotional problems are viewed as shameful and distressing .

Cultural Implications
Gay and lesbian teens suffer from

depression as well. Gay and lesbian teens may experience depression if they are rejected by family or society for being gay or are victims of harassment.

 Thank you for your time! Questions/Comments