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Community Education Service in collaboration with Child and Adolescent Mental Health
Parenting Sad and Depressed Children and Youth
Funding generously provided by Encana Corporation and the Alberta Children’s Hospital Foundation
Parenting Sad and Depressed Children and Youth {
What brought you here today? Questions
Outline {
What is Depression?
{
Stressors for Children & Adolescents
{
Protective Factors Against Depression
{
Signs and Symptoms
{
Caregiver Interventions
{
Helping Your Child Through Depression
{
Helping Your Adolescent Through Depression
{
Suicide Risk
{
Resources
1
Parenting Sad and Depressed Children and Youth
What Is Depression?
Depression Depression is more than feeling down in the dumps once in a while. It’s a: {
{
Mood disorder involving sadness, despair, hopelessness, that lasts for weeks, months, or even longer. Clinical depression interferes with a person’s ability to participate in normal activities.
Sadness vs. Clinical Depression Sadness o
”feeling down”
o
associated with events that affect a person’s mood at the time (i.e., poor grades, break up with a boyfriend, etc)
o
does not usually last longer than several days
o
does not severely interfere with day-to-day activities (i.e., individual is still able to get up and go to school)
o
does not require therapy or medication to resolve
2
Sadness vs. Clinical Depression Clinical Depression o
results from an inability to solve the problem caused by the event
o
debilitating feelings of dejection, sadness, and despair
o
loss of interest in others, withdrawal, and preoccupation with self
o
lasts two weeks or longer
Sadness vs. Clinical Depression Clinical Depression (cont’d) o
interferes with the ability to perform day-to-day tasks
o
use of unhealthy coping mechanisms (i.e., guilt, self-blame, alcohol or drug use)
o
often requires therapy and/or medication to help overcome such feelings
What Causes Depression? {
{
{
{
There is no single cause for depression. Many factors play a role, including genetics, medical conditions, life events, and certain thinking patterns that affect a person’s reaction to events. An imbalance of neuro-transmitters in the brain that regulate mood may make a person prone to depression. Children are more likely to become depressed if they have a parent who has been depressed. Children under the age of 5, even infants, can be depressed.
3
What Causes Depression?
Adapted from: Bilsker, D., Gilbert, M., Worling, D., & Garland, J., Child & Youth Mental Health Branch, Ministry of Children & Family Development
Situation •Loss of relationship •Loneliness •Arguing & conflict •Poor school performance
Thoughts •Negative thinking habits •Unfair self-criticism
Emotions •Sadness •Despair •Emptiness •Anxiety
Actions •Withdrawal from others •Reduced activity •Poor self-care
Physical State •Poor sleep •Low energy •Changes in appetite •Nervous system changes
Parenting Sad & Depressed Children and Youth
Stressors for Children & Adolescents
Stress (Risk) Factors for Children and Adolescents
Common stressors (risks) are: 1. 2. 3. 4. 5. 6.
Death of a loved one Separation/divorce of parents Change in residence and/or school Bullying Break-up of a significant relationship Sexual identity concerns
4
Protective Factors Against Depression Common Protective Factors are: 1. 2. 3. 4. 5.
High self-esteem Good coping skills School achievement Involvement in extra-curricular activities Positive relationships with parents, peers, and adults outside the family context
Parenting Sad and Depressed Children and Youth
Signs and Symptoms
Physical Symptoms { { { { { { { {
Upset stomach Increase or decrease in appetite Weight gain or loss Headaches and other body aches or pains Change in sleep (a lot more or a lot less) Tiredness due to lack of sleep or insomnia Lack of energy Fidgety or restlessness
5
Behavioural Symptoms Behaviour o Poor personal hygiene o Lack of care in physical appearance o Enuresis (wetting oneself) o ’Dark’ themes in writing or choice of music o Self-medicating with alcohol or street drugs o Talking about death or suicide o Increase in risk-taking
Behavioural Symptoms (cont’d) Behaviour...Cont’d o Decline in grades at school o Defiant and oppositional o Cutting and other self-harming behaviours o Social isolation/withdrawal from family and friends o Lack of participation in activities once found pleasurable o Poor school attendance
Emotional Symptoms Typically there are themes of Anxiety, Anger, Irritability, as reflected in the following: { { { { { {
Flat affect (i.e., unexpressive/unemotional) Cries easily (tearfulness) Easily irritated or upset Long-lasting sadness Feeling guilty Feeling worthless and/or unlovable
6
Emotional Symptoms (cont’d) {
Feeling helpless
{
Feeling hopeless
{
Feeling angry; angry outbursts
{
Feeling anxious
{
Feeling irritable or restless
{
Exaggerated need for perfection
Cognitive Symptoms {
Inability to concentrate
{
Indecisiveness
{
Poor memory
{
Loss/change in personal belief system
{
Unable to see a future any better than present
Cognitive Symptoms (cont’d) {
Belief that self is worthless, useless, and/or unlovable
{
Belief that self is a burden to others (e.g. “they’d be better off if I wasn’t around”)
{
May have auditory/visual hallucinations
{
Suicidal Ideation
7
Parenting Sad and Depressed Children and Youth
Caregiver Interventions
Caregiver Interventions If you suspect a child/adolescent is depressed: 1. Respect and validate the child’s feelings o
Listen without judging (no response needed, just validate)
o
Try to put yourself in your child’s shoes
Caregiver Interventions 2. Maintain open communication o
Don’t be afraid to ask your child how s/he is feeling
o
Let your child know she or he can come and talk to you at any time
o
Be patient. Teens especially will let you in and then push you away
8
Caregiver Interventions Communication.... Cont’d o
Be available when your child comes to talk to you. Don’t try to multi-task at the same time
o
Ask children about their friends (i.e. being bullied)
o
Use a rating scale (1-10) to understand how child is feeling (children don’t have the language to express feelings)
Caregiver Interventions (cont’d) 3. Help the child to label and/or identify his/her feelings 4. If a possibility for self-harm exists, remove the following items, to the best of your ability: o o o o o
sharp objects any means of strangulation any means of suffocation medications (prescription and over-the-counter products) poisonous household products
Caregiver Interventions (cont’d) 5. Encourage parents to find out if there are additional supports within the school system. 6. Consider seeking professional help (therapy and/or medication) o
The combination of a medication with therapy has been found to be the best treatment for clinical depression.
9
Caregiver Interventions Medication { {
{
{
Therapy is the first choice of treatment Research has shown that Cognitive Behavioural Therapy (CBT) and medication is most effective SSRI’s are the first choice of medication for children and adolescents Medications are normally prescribed in gradual doses in order to reach most effective dose. Mantra is “go low, go slow.”
Caregiver Interventions SSRI’s Prozac® (fluoxetine) Luvox® (fluvoxamine) Zoloft® (sertraline) Celexa® (citalopram) Paxil® (paroxetine)
NDRI Wellbutrin® (bupropion)
SNRI Effexor® (venlafaxine)
Parenting Sad and Depressed Children and Youth
Helping Your Child Through Depression *Drawn from: Filial Therapy: Strengthening Parent-Child Relationships Through Play, VanFleet (1994)
*These activities are not meant to be a replacement for treatment where this is needed. If expert assistance or treatment is needed, the services of a competent professional should be sought
10
How Does A Parent Help? o Parents are the most significant adults in children’s lives and are likely to have the greatest impact on their health, including their emotional health o When parents learn more ways of interacting with and helping their children, the results are likely to be more positive, profound, and longer lasting. Play is a primary, natural, and healthy way of interacting.
Why Play? {
{
Play is a child’s language. It is how children communicate and is crucial to their healthy development Through play, children: express their feelings master new skills integrate new experiences develop social judgment fine-tune their problem-solving and coping abilities
Playing With Our Children {
{ {
{ {
Enables children to recognize and express their feelings fully and constructively Gives children the opportunity to be heard Helps children develop effective problem-solving, social judgement, and coping skills Increases children’s self-confidence and self-esteem Children come to know, accept, and respect themselves
11
Playing...(cont’d) { {
{ {
Helps to increases trust and confidence Helps to reduce or eliminate negative behaviours, and increase self-control and self-direction Helps children develop appropriate behaviours Promotes a healthy family environment which, in turn, fosters healthy and balanced child development in all areas: social, emotional, intellectual, behavioural, physical, and spiritual
Child-Centred Play {
{
{
{
The child is in charge of the play, with the parent engaging only when the child requests it The child selects the toys to play with and the manner of play, parents demonstrate empathic listening and acceptance of child’s actions/feelings Empathic listening to show acceptance of the child’s actions and feelings Few rules (other than safety-related) to create an open atmosphere in which the child feels comfortable expressing his or her true feelings
Child-Centred Play (cont’d) {
{
Limits are enforced in a defined, effective manner so that the child understands the boundaries and learns to take responsibility for his or her actions Sessions are of relatively short duration using toys set aside for this sole purpose only, and are not to be interrupted by others except in case of emergency.
12
What To Do Child-Centered Imaginary Play {
Preparing:
•
Determine when, how often, and where sessions will occur, and Assemble a box of “session-only” toys
•
Meet with your child and set the rules/limits and consequences for negative behaviour, remembering that limits are only for the child’s safety, the safety of others, or the protection of valuable toys or property, and that, when parents routinely threaten their children with consequences which they fail to carry out, they may erode that child’s trust
•
Arrange child care for siblings, if necessary.
What To Do Child-Centered Imaginary Play {
Setting the Stage:
•
Make sure others are aware of the session and to not interrupt unless it is an emergency
•
Unplug/turn off the phones, T.V., computers, Blackberries, etc. and let the doorbell ring!
•
Set up the play area with a rug or blanket to define the floor space and set out all of the toys in full view
•
Invite the child into the play space and quickly review the rules, boundaries, and consequences
What To Do Child-Centered Imaginary Play {
Play(!): Let your child choose the toys and method of play while you: • •
demonstrate empathic listening provide undivided attention use your own words to name the feelings expressed
Example:
Child: “Look at my drawing - isn’t it great?” Parent: “You’re really proud of your drawing!”
maintain agreed-upon limits and apply consequences as necessary.
13
What To Do (cont’d) Empathic Listening o
Provide undivided attention
o
Use your own words to rephrase aloud the main feelings the child expresses
Example:
Child: “Look at my drawing, isn’t it great? Parent: “You’re really proud of your drawing”
What To Do (cont’d) Limit Setting o
Provides children with boundaries which are essential to their sense of security
o
When determining limits, it is important to consider whether the limit is necessary for the child’s safety, the safety of others, or the protection of valuable toys or property
o
When parents routinely threaten their children with consequences which they fail to carry out, they may be eroding the trust children place in them.
What To Do (cont’d) Limit Setting (cont’d) o o o
Helps children learn that they are responsible for what happens to them During play sessions, limits should be kept to a minimum. Limits need to be stated and enforced as consistently as possible
Examples of Common Limits: o No throwing anything at windows or mirrors o Crayons should not be used on the walls, furniture, or blackboards
14
What To Do (cont’d) Examples (cont’d) o
Sharp objects should not be poked, thrown, or kicked
o
Play guns should not be pointed or shot at people when they are loaded
o
Valuable items should not be destroyed and there should not be a mass destruction of toys
o
Personal limits should be set to a minimum (i.e., no jumping on Mommy’s back, etc)
What To Do (cont’d) Challenges to limits o
When a limit is about to be broken, state the limit
o
Tone of voice should be pleasant, but firm and forceful
o
Use the child’s name, reflect the child’s desire to engage in the prohibited behaviour, then state the limit again
What To Do (cont’d) Challenges ... (cont’d) o
Help the child re-direct his or her play
Example: “Johnny, you would like to colour on the wall. Remember, I said I’d let you know if there’s something you may not do? One of the things you may not do here is colour on the wall. You can colour on the paper or in the colouring book.”
15
What To Do (cont’d) Challenges ... (cont’d) o
Giving a Warning:
Restate the limit and then tell the child what will happen if the child breaks it again (i.e., leave the play session); then redirect the play
Example: “Jane, remember that I told you that you may not colour on the walls? If you colour on the walls again, I will end the play time for today. You may colour on the paper or in the colouring book”.
What To Do (cont’d) Challenges... (cont’d) o
Enforcing the Consequence:
Restate the limit and then carry out the consequence given in the warning A pleasant but firm tone of voice is used
Example: “Johnny, remember I told you if you colour on the walls we would leave the play time? Since you chose to colour on the wall, we must leave. Right now.”
Parenting Sad and Depressed Children and Youth
Helping Your Adolescent Through Depression * Adapted from: Bilsker, D., Gilbert, M., Worling, D., & Garland, J., Child & Youth Mental Health Branch, Ministry of Children & Family Development
*These activities are not meant to be a replacement for treatment where this is needed. If expert assistance or treatment is needed, the services of a competent professional should be sought
16
Helping Your Adolescent... Three skills to help your adolescent: 1. 2. 3.
Realistic Thinking Problem-Solving Goal Setting
Helping Your Adolescent... 1. Realistic Thinking o
Spot depressive thoughts
o
Help your teen to notice how depressive thoughts affect his or her moods
o
Challenge depressive thoughts and replace them with realistic ones (Help child understand what is good enough – perfectionism is not realistic)
o
Learn about the triggers
Helping Your Adolescent... Realistic Thinking (cont’d) Identify depressive thoughts, which fall into one or more of the following categories:
All or nothing
Overgeneralizing
Labelling
Exaggerating
Mind-reading
Filtering
Hopelessness (“It doesn’t matter what I do”) Perfectionism
17
Helping Your Adolescent... Realistic Thinking (cont’d) o
Help your teen to notice how depressive thoughts affect his or her mood
Write down any depressive thoughts that go along with your negative moods (seeing your thoughts on paper makes it easier to look at them clearly) Remind the teen that these are just thoughts, NOT a reality Don’t allow the teen to criticize him or herself for having these thoughts. They are normal, but they do not have to determine one’s feelings and behaviour!
Helping Your Adolescent... Realistic Thinking (cont’d) o
Example: Situation
Depressive Thoughts A friend doesn’t call Everyone hates you. me.
Realistic Thoughts Maybe she was just busy and will call later.
Helping Your Adolescent... Realistic Thinking (cont’d) o
Challenge depressive thoughts - replace them with realistic ones. Use a chart to record situations and depressive thoughts, then replace the depressive thoughts with ones that are realistic Situation
Depressive Thoughts
Realistic Thoughts
18
Helping Your Adolescent... Realistic Thinking (cont’d) o
Learn about the triggers
o
Certain situations can trigger depressive thoughts. Start noticing what went on just prior to feeling depressed. Start writing these situations and experiences down so that they can be used to practice realistic thinking in the future.
Helping Your Adolescent... 2. Problem Solving A person who is already depressed will have difficulties solving problems. She or he might: See the problem as more difficult than it truly is. Have trouble finding solutions for the problem Get stuck in one way of dealing with the problem even though it isn’t working Find it hard to put a plan into action.
o o o
o
Helping Your Adolescent... Problem Solving (cont’d) Steps to take: o
Identify the problem and potential actions to take to help solve the problem
The Problem: On a scale of 1-10, this is a ___
- identify the problem by paying attention to how your mood changes through the week - focus on only one problem at a time
People who can support me:
Friends, siblings, parents, other concerned adults?
What I want to happen:
-what would you like the end result to be?
3 or more things I could do (my potential solutions):
- consider things that you could do with/without the help of someone else - it’s okay if you tried something and it didn’t work. Reward yourself!
19
Helping Your Adolescent... Problem Solving (cont’d) Steps…Cont’d: o
Compare the good and bad points of the different solutions
o
Pick the best solution from your list and do it. Be assertive and strike a balance between what you want and what others want, stating your own view and listening to the views of others.
o
Evaluate your results. If the problem is solved, celebrate! If not, revisit the list of solutions, add more if you can, pick another to try, and do it. Evaluate the result. Keep going till the problem is solved and then celebrate your success!
Helping Your Adolescent... 3. Goal Setting When people become depressed, they find it hard to set goals or do them. They may: o
Lack problem solving skills – struggle for solution & deal with the problem in one way, even if it is not working
o
Lack realistic thinking
o
Lack motivation
o
Not feel they have the energy to carry out the goal
o
Set goals that are too big – perfection not realistic
Helping Your Adolescent... Goal Setting (cont’d) Steps: a.
Choose a goal – SMART
(Specific, Measurable, Agreeable, Realistic, Timeline) b.
Carry out the goal
c.
Evaluate the goal
d.
Celebrate
20
Helping Your Adolescent... Goal Setting (cont’d)
a. Choose a goal for the next week, and make the goal: •
Specific: unclear goals are less likely to be carried out and result in feelings of failure
•
Measurable: develop a goal that is easy for you to track your progress and success
•
Agreeable: develop a goal that works for you and those around you (e.g., your family, your counsellor)
•
Realistic: goals that are too big often result in feeling discouraged. Should be easy enough to carry out even if you feel depressed over the next week
•
Scheduled: the more exact in stating your goal, the more likely to carry it out
Helping Your Adolescent... Goal Setting (cont’d) b.
Carry out the goal, using the problem solving steps noted earlier
c.
Evaluate your progress/success •
•
Recognize what has been accomplished. Parents, often need to help with this, as it is frequently difficult for your depressed teen to acknowledge her or his successes. Give credit for trying to accomplish the goal too and review or revise the plan as needed.
Helping Your Adolescent... Goal Setting (cont’d) d. Celebrate •
Provide nurturing/emotional rewards, like time with you (the parent), instead of monetary rewards
21
Helping yourself: Practicing Self-care Strategies: {
Express your feelings!
{
Periodically get away from it all
{
Child benefits most when adult is happy and comfortable
{
Take care of yourself
{
Nurture adult relationships
{
Join a parent support group
Parenting Sad and Depressed Children and Youth
Suicide Risk
Suicide Risk Indicators {
Withdrawal from friends
{
Talk about suicide, death, or going away
{
{ {
High risk behaviours (ie. Restricting eating, asking about medication, drug use, putting themselves at risk) Giving away valued possessions Sudden signs of happiness after prolonged sadness, or any other sudden, visible change in mood
22
Suicide Risk Indicators... { {
Ending of relationships Making final arrangements (e.g. writing a will, drafting a suicide note)
{
Prior suicide attempt
{
Writing/talk about suicide
{
Idolize & romanticize people who have committed suicide
What To Do { {
Suicide must always be taken seriously. Ask if the child/youth is thinking about suicide. Listen openly and without judging. Believe what he/she says and take all threats seriously.
{
Never leave a suicidal child/youth alone.
{
Never keep someone’s suicidal feelings a secret. Share the responsibility by getting others involved.
{
Reassure the child/youth that help is available and that you are going to assist in getting it for him/her.
What To Do (cont’d) {
{
Remove, Monitor and/or supervise the means for self-injury Act immediately Accompany the child or youth to the Emergency Department of the closest hospital, to her/his family doctor, or to a mental health professional.
23
Resources • Access Mental Health
403- 943-1500
• Calgary Outlink: Centre for Gender and Sexual Diversity
403-234-8973
• Crisis and Suicide Help Line
403-266-1605
• Kids Help Phone
1-800-668-6868
• Teen Help Line
403-264-TEEN
• Mental Health Help Line
1-877-303-2642
• Wood’s Community Resource Team
403-299-9699
• Distress Centre
403-266-1605
Bibliography* Bilsker, G., Worling, & Garland (n.d). Dealing with Depression: Antidepressant Skills for Teens. A free download from http://www.mcf.gov.bc.ca/mental_health/teen.html. Teens Health (1995-2008). Retrieved from http://www.kidshealth.org/teen VanFleet, R. (1994). Filial Therapy: Strengthening Parent-Child Relationships Through Play. Sarasota, Florida: Professional Resource Press * These books can be obtained from your local library and/or by contacting the Family and Community Resource Centre library (403-955-7745)
Bibliography* Landreth, G.L., (1991). Play therapy: The art of the relationship. Accelerated Development Inc. Bristol, PA p. 378 Booklet: Parents and Teachers as Allies, Recognizing Early-onset Mental Illness in Children and Adolescents, Second Edition, 2003. NAMI, the Nation’s voice on Mental Illness. See www.nami.org.
* These books can be obtained from your local library and/or by contacting the Family and Community Resource Centre library (403-955-7745)
24
Online Sites {
National institutes of Mental Health www.nimh.nih.gov
{
PsychDirect, Dept., of Psychiatry and Behavioural Neuroscience, McMaster University, Hamilton, ON www.Psychdirect.com
{
Kids have stress too. The Psychology Foundation of Canada www.kidshavestresstoo.org
{
American Academy of Child and Adolescent Psychiatry www.aacap.org The Centre for Children with Special Needs. Children’s Hospital and Regional Medical Centre. Seattle, Washington. www.cshcn.org, click on resources, and click A-Z list, then look for the anxiety and depression link
{
Acknowledgements We would like to acknowledge the contributions of the many clinicians who participated in our Focus Groups and thus contributed to refreshing the content of this presentation. As well, we would like to thank the following clinicians who have gone the ‘extra mile’ and made significant editorial and/or content contributions to this presentation: Lindsay Hope-Ross, M.Sc., R. Psych., Clinical Supervisor, Healthy Minds/Healthy Children Rekha Jabbal, B.SP, Pharmacy Clinical Practice Leader, Child and Adolescent Mental Health Blaine Munro, Family Counsellor, MSW, RSW, Collaborative Mental Health Care (CMHC) Billie Orr, R. Psych., Adolescent Day Treatment Program Susan Ponting, M.Ed., R. Psych., Mental Health Education Specialist, Community Education Service
Community Education Service To register for notification or an upcoming education session go to: www.fcrc.sacyhn.ca For general CES enquiries Email: [email protected] Call: 403-955-7420
Funding generously provided by Encana Corporation and the Alberta Children’s Hospital Foundation
25
Parenting Sad and Depressed Children and Youth
Funding generously provided by Encana Corporation and the Alberta Children’s Hospital Foundation
Parenting Sad and Depressed Children and Youth {
What brought you here today? Questions
Outline {
What is Depression?
{
Stressors for Children & Adolescents
{
Protective Factors Against Depression
{
Signs and Symptoms
{
Caregiver Interventions
{
Helping Your Child Through Depression
{
Helping Your Adolescent Through Depression
{
Suicide Risk
{
Resources
1
Parenting Sad and Depressed Children and Youth
What Is Depression?
Depression Depression is more than feeling down in the dumps once in a while. It’s a: {
{
Mood disorder involving sadness, despair, hopelessness, that lasts for weeks, months, or even longer. Clinical depression interferes with a person’s ability to participate in normal activities.
Sadness vs. Clinical Depression Sadness o
”feeling down”
o
associated with events that affect a person’s mood at the time (i.e., poor grades, break up with a boyfriend, etc)
o
does not usually last longer than several days
o
does not severely interfere with day-to-day activities (i.e., individual is still able to get up and go to school)
o
does not require therapy or medication to resolve
2
Sadness vs. Clinical Depression Clinical Depression o
results from an inability to solve the problem caused by the event
o
debilitating feelings of dejection, sadness, and despair
o
loss of interest in others, withdrawal, and preoccupation with self
o
lasts two weeks or longer
Sadness vs. Clinical Depression Clinical Depression (cont’d) o
interferes with the ability to perform day-to-day tasks
o
use of unhealthy coping mechanisms (i.e., guilt, self-blame, alcohol or drug use)
o
often requires therapy and/or medication to help overcome such feelings
What Causes Depression? {
{
{
{
There is no single cause for depression. Many factors play a role, including genetics, medical conditions, life events, and certain thinking patterns that affect a person’s reaction to events. An imbalance of neuro-transmitters in the brain that regulate mood may make a person prone to depression. Children are more likely to become depressed if they have a parent who has been depressed. Children under the age of 5, even infants, can be depressed.
3
What Causes Depression?
Adapted from: Bilsker, D., Gilbert, M., Worling, D., & Garland, J., Child & Youth Mental Health Branch, Ministry of Children & Family Development
Situation •Loss of relationship •Loneliness •Arguing & conflict •Poor school performance
Thoughts •Negative thinking habits •Unfair self-criticism
Emotions •Sadness •Despair •Emptiness •Anxiety
Actions •Withdrawal from others •Reduced activity •Poor self-care
Physical State •Poor sleep •Low energy •Changes in appetite •Nervous system changes
Parenting Sad & Depressed Children and Youth
Stressors for Children & Adolescents
Stress (Risk) Factors for Children and Adolescents
Common stressors (risks) are: 1. 2. 3. 4. 5. 6.
Death of a loved one Separation/divorce of parents Change in residence and/or school Bullying Break-up of a significant relationship Sexual identity concerns
4
Protective Factors Against Depression Common Protective Factors are: 1. 2. 3. 4. 5.
High self-esteem Good coping skills School achievement Involvement in extra-curricular activities Positive relationships with parents, peers, and adults outside the family context
Parenting Sad and Depressed Children and Youth
Signs and Symptoms
Physical Symptoms { { { { { { { {
Upset stomach Increase or decrease in appetite Weight gain or loss Headaches and other body aches or pains Change in sleep (a lot more or a lot less) Tiredness due to lack of sleep or insomnia Lack of energy Fidgety or restlessness
5
Behavioural Symptoms Behaviour o Poor personal hygiene o Lack of care in physical appearance o Enuresis (wetting oneself) o ’Dark’ themes in writing or choice of music o Self-medicating with alcohol or street drugs o Talking about death or suicide o Increase in risk-taking
Behavioural Symptoms (cont’d) Behaviour...Cont’d o Decline in grades at school o Defiant and oppositional o Cutting and other self-harming behaviours o Social isolation/withdrawal from family and friends o Lack of participation in activities once found pleasurable o Poor school attendance
Emotional Symptoms Typically there are themes of Anxiety, Anger, Irritability, as reflected in the following: { { { { { {
Flat affect (i.e., unexpressive/unemotional) Cries easily (tearfulness) Easily irritated or upset Long-lasting sadness Feeling guilty Feeling worthless and/or unlovable
6
Emotional Symptoms (cont’d) {
Feeling helpless
{
Feeling hopeless
{
Feeling angry; angry outbursts
{
Feeling anxious
{
Feeling irritable or restless
{
Exaggerated need for perfection
Cognitive Symptoms {
Inability to concentrate
{
Indecisiveness
{
Poor memory
{
Loss/change in personal belief system
{
Unable to see a future any better than present
Cognitive Symptoms (cont’d) {
Belief that self is worthless, useless, and/or unlovable
{
Belief that self is a burden to others (e.g. “they’d be better off if I wasn’t around”)
{
May have auditory/visual hallucinations
{
Suicidal Ideation
7
Parenting Sad and Depressed Children and Youth
Caregiver Interventions
Caregiver Interventions If you suspect a child/adolescent is depressed: 1. Respect and validate the child’s feelings o
Listen without judging (no response needed, just validate)
o
Try to put yourself in your child’s shoes
Caregiver Interventions 2. Maintain open communication o
Don’t be afraid to ask your child how s/he is feeling
o
Let your child know she or he can come and talk to you at any time
o
Be patient. Teens especially will let you in and then push you away
8
Caregiver Interventions Communication.... Cont’d o
Be available when your child comes to talk to you. Don’t try to multi-task at the same time
o
Ask children about their friends (i.e. being bullied)
o
Use a rating scale (1-10) to understand how child is feeling (children don’t have the language to express feelings)
Caregiver Interventions (cont’d) 3. Help the child to label and/or identify his/her feelings 4. If a possibility for self-harm exists, remove the following items, to the best of your ability: o o o o o
sharp objects any means of strangulation any means of suffocation medications (prescription and over-the-counter products) poisonous household products
Caregiver Interventions (cont’d) 5. Encourage parents to find out if there are additional supports within the school system. 6. Consider seeking professional help (therapy and/or medication) o
The combination of a medication with therapy has been found to be the best treatment for clinical depression.
9
Caregiver Interventions Medication { {
{
{
Therapy is the first choice of treatment Research has shown that Cognitive Behavioural Therapy (CBT) and medication is most effective SSRI’s are the first choice of medication for children and adolescents Medications are normally prescribed in gradual doses in order to reach most effective dose. Mantra is “go low, go slow.”
Caregiver Interventions SSRI’s Prozac® (fluoxetine) Luvox® (fluvoxamine) Zoloft® (sertraline) Celexa® (citalopram) Paxil® (paroxetine)
NDRI Wellbutrin® (bupropion)
SNRI Effexor® (venlafaxine)
Parenting Sad and Depressed Children and Youth
Helping Your Child Through Depression *Drawn from: Filial Therapy: Strengthening Parent-Child Relationships Through Play, VanFleet (1994)
*These activities are not meant to be a replacement for treatment where this is needed. If expert assistance or treatment is needed, the services of a competent professional should be sought
10
How Does A Parent Help? o Parents are the most significant adults in children’s lives and are likely to have the greatest impact on their health, including their emotional health o When parents learn more ways of interacting with and helping their children, the results are likely to be more positive, profound, and longer lasting. Play is a primary, natural, and healthy way of interacting.
Why Play? {
{
Play is a child’s language. It is how children communicate and is crucial to their healthy development Through play, children: express their feelings master new skills integrate new experiences develop social judgment fine-tune their problem-solving and coping abilities
Playing With Our Children {
{ {
{ {
Enables children to recognize and express their feelings fully and constructively Gives children the opportunity to be heard Helps children develop effective problem-solving, social judgement, and coping skills Increases children’s self-confidence and self-esteem Children come to know, accept, and respect themselves
11
Playing...(cont’d) { {
{ {
Helps to increases trust and confidence Helps to reduce or eliminate negative behaviours, and increase self-control and self-direction Helps children develop appropriate behaviours Promotes a healthy family environment which, in turn, fosters healthy and balanced child development in all areas: social, emotional, intellectual, behavioural, physical, and spiritual
Child-Centred Play {
{
{
{
The child is in charge of the play, with the parent engaging only when the child requests it The child selects the toys to play with and the manner of play, parents demonstrate empathic listening and acceptance of child’s actions/feelings Empathic listening to show acceptance of the child’s actions and feelings Few rules (other than safety-related) to create an open atmosphere in which the child feels comfortable expressing his or her true feelings
Child-Centred Play (cont’d) {
{
Limits are enforced in a defined, effective manner so that the child understands the boundaries and learns to take responsibility for his or her actions Sessions are of relatively short duration using toys set aside for this sole purpose only, and are not to be interrupted by others except in case of emergency.
12
What To Do Child-Centered Imaginary Play {
Preparing:
•
Determine when, how often, and where sessions will occur, and Assemble a box of “session-only” toys
•
Meet with your child and set the rules/limits and consequences for negative behaviour, remembering that limits are only for the child’s safety, the safety of others, or the protection of valuable toys or property, and that, when parents routinely threaten their children with consequences which they fail to carry out, they may erode that child’s trust
•
Arrange child care for siblings, if necessary.
What To Do Child-Centered Imaginary Play {
Setting the Stage:
•
Make sure others are aware of the session and to not interrupt unless it is an emergency
•
Unplug/turn off the phones, T.V., computers, Blackberries, etc. and let the doorbell ring!
•
Set up the play area with a rug or blanket to define the floor space and set out all of the toys in full view
•
Invite the child into the play space and quickly review the rules, boundaries, and consequences
What To Do Child-Centered Imaginary Play {
Play(!): Let your child choose the toys and method of play while you: • •
demonstrate empathic listening provide undivided attention use your own words to name the feelings expressed
Example:
Child: “Look at my drawing - isn’t it great?” Parent: “You’re really proud of your drawing!”
maintain agreed-upon limits and apply consequences as necessary.
13
What To Do (cont’d) Empathic Listening o
Provide undivided attention
o
Use your own words to rephrase aloud the main feelings the child expresses
Example:
Child: “Look at my drawing, isn’t it great? Parent: “You’re really proud of your drawing”
What To Do (cont’d) Limit Setting o
Provides children with boundaries which are essential to their sense of security
o
When determining limits, it is important to consider whether the limit is necessary for the child’s safety, the safety of others, or the protection of valuable toys or property
o
When parents routinely threaten their children with consequences which they fail to carry out, they may be eroding the trust children place in them.
What To Do (cont’d) Limit Setting (cont’d) o o o
Helps children learn that they are responsible for what happens to them During play sessions, limits should be kept to a minimum. Limits need to be stated and enforced as consistently as possible
Examples of Common Limits: o No throwing anything at windows or mirrors o Crayons should not be used on the walls, furniture, or blackboards
14
What To Do (cont’d) Examples (cont’d) o
Sharp objects should not be poked, thrown, or kicked
o
Play guns should not be pointed or shot at people when they are loaded
o
Valuable items should not be destroyed and there should not be a mass destruction of toys
o
Personal limits should be set to a minimum (i.e., no jumping on Mommy’s back, etc)
What To Do (cont’d) Challenges to limits o
When a limit is about to be broken, state the limit
o
Tone of voice should be pleasant, but firm and forceful
o
Use the child’s name, reflect the child’s desire to engage in the prohibited behaviour, then state the limit again
What To Do (cont’d) Challenges ... (cont’d) o
Help the child re-direct his or her play
Example: “Johnny, you would like to colour on the wall. Remember, I said I’d let you know if there’s something you may not do? One of the things you may not do here is colour on the wall. You can colour on the paper or in the colouring book.”
15
What To Do (cont’d) Challenges ... (cont’d) o
Giving a Warning:
Restate the limit and then tell the child what will happen if the child breaks it again (i.e., leave the play session); then redirect the play
Example: “Jane, remember that I told you that you may not colour on the walls? If you colour on the walls again, I will end the play time for today. You may colour on the paper or in the colouring book”.
What To Do (cont’d) Challenges... (cont’d) o
Enforcing the Consequence:
Restate the limit and then carry out the consequence given in the warning A pleasant but firm tone of voice is used
Example: “Johnny, remember I told you if you colour on the walls we would leave the play time? Since you chose to colour on the wall, we must leave. Right now.”
Parenting Sad and Depressed Children and Youth
Helping Your Adolescent Through Depression * Adapted from: Bilsker, D., Gilbert, M., Worling, D., & Garland, J., Child & Youth Mental Health Branch, Ministry of Children & Family Development
*These activities are not meant to be a replacement for treatment where this is needed. If expert assistance or treatment is needed, the services of a competent professional should be sought
16
Helping Your Adolescent... Three skills to help your adolescent: 1. 2. 3.
Realistic Thinking Problem-Solving Goal Setting
Helping Your Adolescent... 1. Realistic Thinking o
Spot depressive thoughts
o
Help your teen to notice how depressive thoughts affect his or her moods
o
Challenge depressive thoughts and replace them with realistic ones (Help child understand what is good enough – perfectionism is not realistic)
o
Learn about the triggers
Helping Your Adolescent... Realistic Thinking (cont’d) Identify depressive thoughts, which fall into one or more of the following categories:
All or nothing
Overgeneralizing
Labelling
Exaggerating
Mind-reading
Filtering
Hopelessness (“It doesn’t matter what I do”) Perfectionism
17
Helping Your Adolescent... Realistic Thinking (cont’d) o
Help your teen to notice how depressive thoughts affect his or her mood
Write down any depressive thoughts that go along with your negative moods (seeing your thoughts on paper makes it easier to look at them clearly) Remind the teen that these are just thoughts, NOT a reality Don’t allow the teen to criticize him or herself for having these thoughts. They are normal, but they do not have to determine one’s feelings and behaviour!
Helping Your Adolescent... Realistic Thinking (cont’d) o
Example: Situation
Depressive Thoughts A friend doesn’t call Everyone hates you. me.
Realistic Thoughts Maybe she was just busy and will call later.
Helping Your Adolescent... Realistic Thinking (cont’d) o
Challenge depressive thoughts - replace them with realistic ones. Use a chart to record situations and depressive thoughts, then replace the depressive thoughts with ones that are realistic Situation
Depressive Thoughts
Realistic Thoughts
18
Helping Your Adolescent... Realistic Thinking (cont’d) o
Learn about the triggers
o
Certain situations can trigger depressive thoughts. Start noticing what went on just prior to feeling depressed. Start writing these situations and experiences down so that they can be used to practice realistic thinking in the future.
Helping Your Adolescent... 2. Problem Solving A person who is already depressed will have difficulties solving problems. She or he might: See the problem as more difficult than it truly is. Have trouble finding solutions for the problem Get stuck in one way of dealing with the problem even though it isn’t working Find it hard to put a plan into action.
o o o
o
Helping Your Adolescent... Problem Solving (cont’d) Steps to take: o
Identify the problem and potential actions to take to help solve the problem
The Problem: On a scale of 1-10, this is a ___
- identify the problem by paying attention to how your mood changes through the week - focus on only one problem at a time
People who can support me:
Friends, siblings, parents, other concerned adults?
What I want to happen:
-what would you like the end result to be?
3 or more things I could do (my potential solutions):
- consider things that you could do with/without the help of someone else - it’s okay if you tried something and it didn’t work. Reward yourself!
19
Helping Your Adolescent... Problem Solving (cont’d) Steps…Cont’d: o
Compare the good and bad points of the different solutions
o
Pick the best solution from your list and do it. Be assertive and strike a balance between what you want and what others want, stating your own view and listening to the views of others.
o
Evaluate your results. If the problem is solved, celebrate! If not, revisit the list of solutions, add more if you can, pick another to try, and do it. Evaluate the result. Keep going till the problem is solved and then celebrate your success!
Helping Your Adolescent... 3. Goal Setting When people become depressed, they find it hard to set goals or do them. They may: o
Lack problem solving skills – struggle for solution & deal with the problem in one way, even if it is not working
o
Lack realistic thinking
o
Lack motivation
o
Not feel they have the energy to carry out the goal
o
Set goals that are too big – perfection not realistic
Helping Your Adolescent... Goal Setting (cont’d) Steps: a.
Choose a goal – SMART
(Specific, Measurable, Agreeable, Realistic, Timeline) b.
Carry out the goal
c.
Evaluate the goal
d.
Celebrate
20
Helping Your Adolescent... Goal Setting (cont’d)
a. Choose a goal for the next week, and make the goal: •
Specific: unclear goals are less likely to be carried out and result in feelings of failure
•
Measurable: develop a goal that is easy for you to track your progress and success
•
Agreeable: develop a goal that works for you and those around you (e.g., your family, your counsellor)
•
Realistic: goals that are too big often result in feeling discouraged. Should be easy enough to carry out even if you feel depressed over the next week
•
Scheduled: the more exact in stating your goal, the more likely to carry it out
Helping Your Adolescent... Goal Setting (cont’d) b.
Carry out the goal, using the problem solving steps noted earlier
c.
Evaluate your progress/success •
•
Recognize what has been accomplished. Parents, often need to help with this, as it is frequently difficult for your depressed teen to acknowledge her or his successes. Give credit for trying to accomplish the goal too and review or revise the plan as needed.
Helping Your Adolescent... Goal Setting (cont’d) d. Celebrate •
Provide nurturing/emotional rewards, like time with you (the parent), instead of monetary rewards
21
Helping yourself: Practicing Self-care Strategies: {
Express your feelings!
{
Periodically get away from it all
{
Child benefits most when adult is happy and comfortable
{
Take care of yourself
{
Nurture adult relationships
{
Join a parent support group
Parenting Sad and Depressed Children and Youth
Suicide Risk
Suicide Risk Indicators {
Withdrawal from friends
{
Talk about suicide, death, or going away
{
{ {
High risk behaviours (ie. Restricting eating, asking about medication, drug use, putting themselves at risk) Giving away valued possessions Sudden signs of happiness after prolonged sadness, or any other sudden, visible change in mood
22
Suicide Risk Indicators... { {
Ending of relationships Making final arrangements (e.g. writing a will, drafting a suicide note)
{
Prior suicide attempt
{
Writing/talk about suicide
{
Idolize & romanticize people who have committed suicide
What To Do { {
Suicide must always be taken seriously. Ask if the child/youth is thinking about suicide. Listen openly and without judging. Believe what he/she says and take all threats seriously.
{
Never leave a suicidal child/youth alone.
{
Never keep someone’s suicidal feelings a secret. Share the responsibility by getting others involved.
{
Reassure the child/youth that help is available and that you are going to assist in getting it for him/her.
What To Do (cont’d) {
{
Remove, Monitor and/or supervise the means for self-injury Act immediately Accompany the child or youth to the Emergency Department of the closest hospital, to her/his family doctor, or to a mental health professional.
23
Resources • Access Mental Health
403- 943-1500
• Calgary Outlink: Centre for Gender and Sexual Diversity
403-234-8973
• Crisis and Suicide Help Line
403-266-1605
• Kids Help Phone
1-800-668-6868
• Teen Help Line
403-264-TEEN
• Mental Health Help Line
1-877-303-2642
• Wood’s Community Resource Team
403-299-9699
• Distress Centre
403-266-1605
Bibliography* Bilsker, G., Worling, & Garland (n.d). Dealing with Depression: Antidepressant Skills for Teens. A free download from http://www.mcf.gov.bc.ca/mental_health/teen.html. Teens Health (1995-2008). Retrieved from http://www.kidshealth.org/teen VanFleet, R. (1994). Filial Therapy: Strengthening Parent-Child Relationships Through Play. Sarasota, Florida: Professional Resource Press * These books can be obtained from your local library and/or by contacting the Family and Community Resource Centre library (403-955-7745)
Bibliography* Landreth, G.L., (1991). Play therapy: The art of the relationship. Accelerated Development Inc. Bristol, PA p. 378 Booklet: Parents and Teachers as Allies, Recognizing Early-onset Mental Illness in Children and Adolescents, Second Edition, 2003. NAMI, the Nation’s voice on Mental Illness. See www.nami.org.
* These books can be obtained from your local library and/or by contacting the Family and Community Resource Centre library (403-955-7745)
24
Online Sites {
National institutes of Mental Health www.nimh.nih.gov
{
PsychDirect, Dept., of Psychiatry and Behavioural Neuroscience, McMaster University, Hamilton, ON www.Psychdirect.com
{
Kids have stress too. The Psychology Foundation of Canada www.kidshavestresstoo.org
{
American Academy of Child and Adolescent Psychiatry www.aacap.org The Centre for Children with Special Needs. Children’s Hospital and Regional Medical Centre. Seattle, Washington. www.cshcn.org, click on resources, and click A-Z list, then look for the anxiety and depression link
{
Acknowledgements We would like to acknowledge the contributions of the many clinicians who participated in our Focus Groups and thus contributed to refreshing the content of this presentation. As well, we would like to thank the following clinicians who have gone the ‘extra mile’ and made significant editorial and/or content contributions to this presentation: Lindsay Hope-Ross, M.Sc., R. Psych., Clinical Supervisor, Healthy Minds/Healthy Children Rekha Jabbal, B.SP, Pharmacy Clinical Practice Leader, Child and Adolescent Mental Health Blaine Munro, Family Counsellor, MSW, RSW, Collaborative Mental Health Care (CMHC) Billie Orr, R. Psych., Adolescent Day Treatment Program Susan Ponting, M.Ed., R. Psych., Mental Health Education Specialist, Community Education Service
Community Education Service To register for notification or an upcoming education session go to: www.fcrc.sacyhn.ca For general CES enquiries Email: [email protected] Call: 403-955-7420
Funding generously provided by Encana Corporation and the Alberta Children’s Hospital Foundation
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