Empirical Basis

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Only a few empirical studies for childhood depression exist before 1990, in part due to the lack of recognition for depression as a clinical disorder in children before that time. These landmark studies incorporated treatment components that remain a cornerstone of treatment for childhood depression. Butler, Miezitis, Friedman, and Cole (1980) treated fifth and sixth graders with depressive symptoms in either role-play, cognitive restructuring, attention placebo, or control groups that met weekly for 10 weeks. The cognitive restructuring condition but not the attention placebo group was associated with significant improvement from pre- to posttreatment; however, no comparisons between treatment conditions were conducted. Stark, Reynolds, and Kaslow (1987) randomly assigned a sample of 29 elementary school children who scored 13 or higher on the Children's Depression Inventory (CDI) to either self-control, behavioral problem solving, or a wait-list control group. The self-control condition emphasized attribution training, self-monitoring, self-evaluating, and self-reward. The behavioral condition emphasized pleasant activity scheduling, self-monitoring, sensitivity training, problem solving, and social skills. After 12 treatment sessions spanning 5 weeks, results showed significant reductions in depressive symptoms for participants in both treatment groups. In 1990, Liddle and Spence (as cited in Curry, 2001) compared a primarily behavioral social competence training group with an attention group and a no-treatment group and found no differences among the three conditions; however, the sample consisted of only 31 children in grades 3 to 6. Also in 1990, Kahn, Kehle, Jenson, and Clark (as cited in Curry, 2001) compared CBT to relaxation, self-modeling, and a wait-list for 68 middle school students twice a week for 6 to 8 weeks. All treatment conditions led to significantly more symptom reduction than the wait-list but no differences were found between the results for the treatment conditions.

Trends in recent studies include the incorporation of control enhancement, family, and prevention interventions. For example, Weisz and colleagues demonstrated a relationship between perceived control and childhood depression (Weisz, Thurber, Sweeney, Proffitt, & LaGagnoux, 1997). They implemented an effective 8-session primary and secondary control enhancement program (PASCET) with 500 elementary school children from grades 3 to 6 identified with depressive symptomatology. Their program involved training children to apply primary control (enhancing reward by making objective conditions conform to the child's wishes) to modifiable conditions and applying secondary control (enhancing reward by adjusting one's beliefs or understanding in response to objective conditions) to conditions that could not be altered.

Asarnow, Scott, and Mintz (2002) designed an efficacious beyond that combined CBT and family education intervention to address data suggesting that family factors can predict outcomes and treatment response in depressed children. They selected 23 fourth-through sixth-grade-children to participate in the "Stress Busters" afterschool program twice a week for 5 weeks. "Stress Busters" included family education to enhance generalization of CBT technique to the real world and promote family support; the creation of a video viewed by parents that exhibited the children practicing newly learned CBT skills; and utilized generic as well as depression-focused CBT techniques. Sessions included activities such as games, homework, and role-playing designed to assist children in building problemsolving skills, goal-setting skills, social skills, relaxation techniques, as well as learning to effectively respond to positive or negative emotional spirals.

The Penn Resiliency Program (PRP) (Freres, Gillham, Reivich, & Shatte, 2002) aimed at preventing depression in children before it occurred. Children (aged 10-13) at risk for future depression learned CBT techniques and coping skills so that they could more effectively handle negative life events and increase their global sense of mastery and competence. Results indicate that depressive symptoms have been significantly reduced in many trials using this program regardless of the differing cultural and socioeconomic backgrounds of the participants (Freres et al., 2002).

Recent studies have also shown the longitudinal effectiveness of CBT. For example, in a study that included 54 children and adolescents aged 5 to 17 with depression or significant depressive symptoms, Vostanis, Feehan, and Grattan (1998) showed a significant difference between a CBT group and a nonfocused treatment group in remission of depressive symptoms over a 2-year follow-up. Such findings show the promise of CBT to remit symptoms over a brief time and to help curtail them over the long term.

A number of treatment studies with depressed adolescents exist and have informed treatment approaches with children (e.g., Lewinsohn's Coping with Depression Course). However, it is unknown whether the treatment effects seen with adolescents generalize to children. Currently, the Treatment for Adolescents with Depression Study (TADS) Team (2003) at Duke University Medical Center has begun to look at the effectiveness of brief CBT interventions for depression in adolescents in combination with and versus mood-stabilizing medication. The TADS study will help clinicians better understand the best treatment combination for adolescents with depression and as a result may impact the way childhood depression is treated.

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