Unhappiness and passing feelings of sadness are common, normal experiences for children and adolescents. However, when this depressed mood persists for several weeks, deepens, and starts interfering with school and everyday life, it becomes an illness. Depression is the illness that makes children and adolescents significantly impair as it has argued in some studies and it signifies recurrence and continuity into adulthood (Hammen, & Brennan, 2001).
Among the many intervention and treatment efforts dealing with this illness; cognitive behavioural therapy (CBT) is the most studied non-pharmacological intervention for the treatment of depression in youth, with over 80% of published psychotherapy trials testing the effects of CBT protocols ( Zalsman, Brent, & Weersing, 2006) . Child Adolesc Psychiatr Clin N Am.
In this paper, I will try to answer the question of “How can parents have a crucial role in outcome of CBT for treating youth’s depression?” In order to do that this paper will be divided in three sections. In the first section, I will examine the theoretical approach of Cognitive Behavioural Therapy, using of mostly Aaron T.Beck. This theory presents an analysis of the dysfunctional thinking, behaviour, and emotional responses. This theory involves helping clients develop skills for modifying beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviours. In the second section I will represent the psychosocial parent and family factors associated with youth depression, ranging from parental pathology to parental cognitive style to family emotional climate. In the third section of this paper I will try to answer the above question by providing empirical evidence followed by concluding with the summary of the whole paper and suggesting directions for further research.
CBT is based on Beck’s cognitive model of depression and its treatment. According to this theory, depression is viewed as function of maladaptive thoughts, including fast automatic thoughts that occur so quickly as to get away from notice. These thoughts are supported by systematic cognitive or perceptual biases that distort information, and by underlying negative beliefs. Beck characterized depressed youth by particular themes which included low self- esteem, self-blame, overwhelming responsibilities, and desire to escape (Beck, A.T.,1963). He argues that characteristic processes involved in the distortion of reality included irrational conclusion, selective abstraction, overgeneralization, exaggeration, and inexact labelling. Beck then concluded that depression results from the client’s negative or inaccurate interpretation of this or her experiences. Beck’s cognitive therapy approach seeks to alleviate emotional distress and other symptoms of depression by focusing on the client’s misinterpretations, self-defeating behaviours, and dysfunctional attitudes, and by helping clients to observe the relationship between their negative thoughts and negative feelings (Zarb, 1992).
Based on his theory, the depressed patient tends to view him/herself, him/her experiences, and his/her future in a negativistic way. He or she views his/her environment as a burden, sees him/herself as inadequate, undesirable, unlovable, and responsible for his/her negative experiences. He or she also expects no improvement in the future. The cognitive therapist has to form a collaborative alliance with the patient and focuses on identifying and modifying these negative thoughts, distortions, and beliefs (Reinecke, Dattilio, & Freeman, 2003) . Cognitive theory places secondary emphasis on emotions, behaviours, and the reality of the environment, and instead put primarily emphasis on the individual’s perceptions and resultant cognitions (Coyne, & Gotlib, 1983). The thinking patterns directly influence the emotional reaction and behaviours in a chain of connected experiences. According to Beck’s theory, depressed persons maintain a negative schema of themselves, and looking for information from that distorted point view within their surroundings and interactions (Beck, 1995). Ranieri and Chartier (1984) suggesting in their research that Beck’s perspective could also be applies to adolescent depression. (Karoly, & Steffen, 1988). To date, many studies have been done in terms of parent risk factors and family environment in children and youth depression. As has mentioned by Ho, the family is the basic resource of identity and support (Ho, 1996), and provides the roots and determinants of an individual’s orientations and life goals (Lee, Stewart, & Chan, 2006). Parents make great sacrifices for their children’s advancement (Chao, 1996) , however on the other hand family members are expected to provide assistance and fulfill parents’ expectations in return and respect the authority of the family (Ho, 1996). Based on this close relationship, as Ho identified, harmonious interpersonal relationships are highly valued and emotional connection with parents, especially with mothers is important for the sake of children (Ho, 1981). Other scholars also emphasized on the role of family relationships, particularly mothers, in youth’s mood. Some empirical study have shown that adolescent depression is inversely associated with the level of support provided in the family ( Duggal et al. , 2001; Stein et al. 2000) and also positively related to higher level of perceived family conflict (Low & Stocker, 2005). In another study also researchers found that mother-adolescent relationships were significantly worse in families with depressed adolescents than those where adolescents were not depressed (Sheeber, Davis, Leve, Hops, & Tildesley, 2007). In another study that has been examined in Chinese community, researchers found that the quality of family relationships has significant associations with negative mood symptoms (Lee, Stewart, & Chan, 2006). However, theorists suggest that family relationships play a greater role in collective versus individualistic cultures, there have been few studies that indicate family relationships in adolescence is as important in the West as in Chinese cultures (Chen et. al. 2006). Researchers have also found that when parents have warm, responsive relationship with their daughters and sons, children demonstrate fewer aggressive and delinquent behaviours and lower levels of social withdrawal, depressed mood and psychological distress ( Pettit, Bates, & Dodge, 1997). Parental conflict is also another issue that may increase the chance of depression in youth. They often feel trapped in a situation of ongoing exposure to parental conflict. As Zarb argued in her study, in the situation of parental conflict, children begin to manifest symptoms of depression such as self-blame, anger, and hopelessness while they have little or no control over the situation ( Zarb, 1992). The result of an empirical research on depression in youngsters also shows that the amount of depressed youngsters among the family with marital and family dysfunction is significant. In a sample of 43 depressed youngsters, only a minority of the mothers 7(16%) were currently married to the biological father of the child, while 11(26%) divorced and not dating, 6 (14%) divorced and casually dating, 11 (26%) engaged and/or living with a boyfriend and 7 (16%) married to the child’s stepfather (Hammen, Rudolph, Weisz, Rao, & Burge, 1999). They also identified that marital difficulties may be significant obstacles to successful treatment of the child depression (Hammen, Rudolph, Weisz, Rao, & Burge, 1999).
Recent investigations that have been reviewed by Griest and Forehand (1981) have shown significant relationships between youth depression and following four types of family variables: parent’s perceptions of their child’s behaviour, parent’s perceptions of their marital status, parent’s perceptions of their personal adjustment, and parent’s perceptions of their extra familial interactions (Griest, & Forehand, 1982). Family represents the context in which the child develops essential cognitive and interpersonal skills. As it has argued by Kendall, family interaction patterns also could produce and maintain maladaptive schemas, beliefs, information-processing errors, and maladaptive interpersonal behaviours (Kendall, 2000). In another study also the critical role of family relations and interactions in the development and maintenance of child and adolescent depression has been indicated (Diamond, Serrano, Dickey, & Sonis, 1996).
During the developmental challenges, parents play a fundamental role. They may facilitate or inhibit this growth by recognizing and accepting differences or by disputing differences and emphasizing their own values of though, word, and deed. As it has identified in empirical research in some families which differences were seen as natural and part of the process of understanding one another, the developmental processes were enhanced and facilitated. However, in contrast, development was inhibited in families where differences were not permitted and a premium was set on conformity to one point of view (Worden, 1991). Moreover, researchers have shown indirect links from parental personality to youth behaviour problem through parenting behaviours (Brook, Whiteman& Zheng.2002), however they also may directly influence youth behaviour through means such as modeling or genetic factors (Prinzie, 2005). As Kendall argues, a child may have a genetic tendency toward depression that stems from having a depressed parent( Kendall, 2000) In some other studies indicated that children of depressed mothers have a higher risk of depression and anxiety disorder (Halligan et al., 2007; Hammen & Brennan, 2003). In fact we can say that depressed mothers’ interactions with their children, and the children’s observations of their mothers, dysfunctional interpersonal skills and cognitions may be transmitted that contribute to youngsters’ vulnerability to depression. Having a depressed mother, is one of the best empirically supported predictors of depression in youth that have been examined in many studies ( Hammen, & Brennan, 2001). Kendall also suggests that depressed parent would be a chronic stressor since they tend to perceive more misbehaviour in their children than actually exists. Moreover those parents have difficulty engaging their children in the types of interactions necessary for teaching affect regulation skills (Kendall, 2000). One study that has been done by Brennan and his colleges assessed 816 youth and found that maternal depression interacted with parental psychological control, maternal warmth, and involvement to buffer youth from depression (Brennan, LeBrocque, & Hammen, 2003). This means that youth with depressed mothers were more likely to be resilient to depression if mothers exhibited low psychological control, high warmth, and low over involvement. In addition to those factors, some other indicators that might increase the risk of youth depression have also been investigated such as: parent’s maladaptive cognitive styles like negative attributions or negative view of the self, world, and future, family emotional climate, negative family interactions, parenting practices, such as harsh parental discipline, maternal education, poverty, and also insecure attachment (Sander, & McCarty, 2006). The effect of perfectionist parental style, parent’s high expectancies and beliefs on youth mental health also seem to be an important area for future inquiry.
As we have argued in second section of this paper, parents have long been viewed as primary agents of socialization for their children. The youth depression literatures have also emphasized the primacy of parents for child socialization processes and effective child regulation of negative emotions (Silverman, Kurtines, Jaccard, & Pina, 2009). This emphasis on parents is apparent as well in youth depression treatments in order to enhance the outcome of youth depression treatment (Silverman, Kurtines, Jaccard, & Pina, 2009). Braswell and Kendall also suggest that since the role of the parents in youth depression has been recognized, the inclusion of these individuals in the intervention process must be considered (Braswell, L. & Kendall, P.C. (2001). Due to the importance of parent’s role in the process of youth depression, concepts from traditional cognitive behavioural approaches have been incorporated into cognitive behavioural family therapy by some theorists (Sander, & McCarty, 2006). in which family schemas would mainly be focused instead of the focus on individual schemas. Moreover, in this approach parents are actively involved in their youth treatment. However, the result of some studies have found that youth depression was reduced whether parents are either minimally involved (CBT) or actively involved ( CBTF) in their youth’s treatment (Silverman, Kurtines, Jaccard, & Pina, 2009). As it has cited in many other studies adding certain forms of CB skill training for parents can enhance the effectiveness of other types of treatment for youth depression (Braswell, L. & Kendall, P.C. (2001). CBT is an approach that can help youth overcome their depression by involving their parents cognitively. As Kendall suggests, CB therapist must be aware of parent’s beliefs about the cause of their child’s depression in order to fully endorse and enthusiastically participate in a treatment plan (Braswell, L. & Kendall, P.C. (2001). CBT can help parents to create a reasonable set of expectations for the adolescents’ home and also school behaviour and to clarify how unmet expectations can be corrected. It will also help parents and youth to discover new ways of having fun together and experience more close relationship. As Kendall suggest, therapist should work with parents to guide them away from endorsing global and internal attributions for the young person’s behaviour and instead to move them toward explanations that are relatively more local, and external. Since modeling is an effective way of achieving or eliminating of behaviour, CB therapists will work with parents in order to help them become more conscious models of the skills they would like to see developed in their youth (Braswell, L. & Kendall, P.C. (2001). Moreover, while all human are more likely to model behaviour displayed by individuals who are liked and admired, it seems that would be effective if therapist involves parents as a model into the therapy in order to pass their family’s values and beliefs to their youth. Study shows that parents of depressed youth who received problem-solving training, would be more successful to explore more pleasurable events for their youth’s life (Braswell, L. & Kendall, P.C. (2001). In another study that has been done by Kazdin and Crowley, reported that the combination of problem-solving training and parent management training was the most successful way of helping youth who are suffering from depression (Braswell, L. & Kendall, P.C. (2001). Janet also in her book indicates several family interventions consistent with a CB approach which included: Behaviour-Analysis Skill Training, cognitive Restructuring in Parent Sessions, Communication-Skills Training, Conflict- Negotiation Skills Training, contingency Contracting, Discipline-Effectiveness Training, Expectations –Establishment Training, Independence Training, Problem-Solving Training, and Relationship-Enhancement Training (Zarb, M.Z., 1992).
In conclusion, many studies indicated that there are several parent and family risk factors associated with youth depression, including parental cognitions, parenting behaviours of and emotional availability, parental pathology, individual coping with the family environment, and family relationships and conflict. The most important factor related with youth depression as suggested by many studies is parental depression that clearly linked to youth depression. However other factors such as maternal warmth and emotional availability have also profound implication in youth depression. Clinicians and researchers have found that family interventions that are consistent with a cognitive- behavioural orientation would be successful in treating youth depression. However, evidence has not positively indicated that parental involvement in the CBT approach is necessary for successful treatment of youth depression, but more studies addressing the inclusion of parents in treatment and specific predictors of success will allow for a better understanding of how it is best to incorporate the family in treating depressed youth. As a result of this paper, I should say that since the result of most of the studies either have been reviewed in this paper or not, are based on cultural-majority populations. In order to recommend treatment practices with more confidence, both regarding risk and outcome of parent’s involvement in treating youth’s depression, studies need to include and report finding as they related to specific minority and cultural groups.
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