Clinical practice recommendations 1 Self-help

5.4.1.1 In the assessment of a child or young person with depression, healthcare

professionals should always ask the patient, and be prepared to give advice, about self-help materials or other methods used or considered potentially helpful by the patient or their parent(s) or carer(s). This may include educational leaflets, helplines, self-diagnosis tools, peer, social and family support groups, complementary therapies or religious and spiritual groups. (GPP)

5.4.1.2 Healthcare professionals should only recommend self-help materials or

strategies as part of a supported and planned package of care. (GPP)

5.4.1.3 A child or young person with depression should be offered advice on the

benefits of regular exercise and encouraged to consider following a structured and supervised exercise programme of typically up to three

sessions per week of moderate duration (45 minutes to 1 hour) for between 10 and 12 weeks. (C)

5.4.1.4 A child or young person with depression should be offered advice about

sleep hygiene and anxiety management. (C)

5.4.1.5 A child or young person with depression should be offered advice about

nutrition and the benefits of a balanced diet. (GPP)

5.4.2 Family support/parental education

5.4.2.1 When assessing a child or young person with depression, healthcare

professionals should routinely consider, and record in the patient’s notes, potential comorbidities, and the social, educational and family context for the patient and family members, including the quality of interpersonal relationships, both between the patient and other family members and with their friends and peers. (GPP)

5.4.2.2 In the assessment of a child or young person with depression, healthcare

professionals should always ask the patient and their parent(s) or carer(s) directly about the young person’s alcohol and drug use, any experience of being bullied or abused, self-harm and ideas about suicide. A young person should be offered the opportunity to discuss these issues initially in private. (GPP)

5.4.2.3 If a child or young person with depression presents acutely having self-

harmed, the immediate management should follow the NICE guideline ‘Self- harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care’ as this applies to children and young people, paying particular attention to the guidance on consent and capacity. Further management should then follow this

depression guideline. (GPP)

5.4.2.4 When a child or young person has been diagnosed with depression,

consideration should be given to the possibility of parental depression, parental substance misuse, or other mental health problems and associated problems of living, as these are often associated with depression in a child or young person and, if untreated, may have a negative impact on the success of treatment offered to the child or young person. (GPP)

5.4.2.5 In the assessment and treatment of depression in children and young people,

special attention should be paid to the issues of:

G confidentiality

G the young person’s consent (including Gillick competence)

G parental consent

G the use of the Mental Health Act in young people

G the use of the Children Act. (GPP)

5.4.3 Social/environmental interventions

5.4.3.1 When bullying is considered to be a factor in a child or young person’s

depression, CAMHS, primary care and educational professionals should work collaboratively to prevent bullying and to develop effective antibullying strategies. (C)

6.1 Introduction

The psychological treatment of depression in children and young people is dissimilar from that provided for depressed adults. Although, as with physical treatments for depression, there has been some extrapolation from approaches used for adults (for example cognitive behavioural therapy [CBT] and psychodynamic therapy), in routine practice these formal individual therapies are not the most common psychological approaches. Whereas adults with depression are often treated for the disorder specifically, children with depression are often not thought of as ‘having’ depression but as affected by a set of emotional, behavioural, learning, relationship and family problems which need to be considered together, and may still need to be addressed together, even if depression in the child is a primary concern.

Thus, psychological therapies for depression in children and young people may

not be thought about as distinct from working with children, adolescents and families with a wide range of psychosocial difficulties. This is probably especially true with pre-adolescent children, but for adolescents as well depression is very likely to be seen as a sign of a more complicated situation, or result of earlier stresses within a system (the family or school for example).

Nevertheless, as adolescents move towards adult independence (or fail to do so), it is more likely that therapies designed for adults will be thought to be appropriate and extended to these young people. It may be for this reason, as well as because depression in children and young people is most prevalent in adolescence, that the studies reviewed here have generally been conducted with young people of secondary school age, and our conclusions should not be assumed to apply to younger children, without further investigation.

Children rarely initiate mental health assessment and treatment although adolescents may seek help for emotional difficulties in a wide variety of ways (see Chapter 5). While many clinically depressed adults recognise that they are depressed (or at least that they are ill) and seek treatment, both would be rare in children and adolescents. At a mild level, children are highly unlikely to be referred, unless it affects their behaviour in some obvious way (e.g. self-harm, withdrawn or aggressive behaviour at school, or failing academic performance). Depression in children and young people commonly presents as recurrent and unexplained physical symptoms, which may be difficult to recognise as depression, even for the healthcare professionals consulted (e.g. a GP, school nurse, paediatrician). Even when they recognise the underlying problem, parents, child,

teachers and others involved may well find it difficult to accept the need for psychological or psychiatric treatment, not uncommonly because of feelings of anxiety, anger and shame, or indeed because of stigma and lack of knowledge about mental health problems generally.

6 Psychological treatment of