This programme is a treatment manual intended for mental health professionals. It presupposes clinical training, experience of working with children and adolescents, and a supervision framework. It replaces neither your clinical judgement nor your ethical responsibility. The diagnostic criteria are reformulated in our own words, never reproduced: refer to the original manuals for the letter of the text.
1. The programme at a glance
Indication. A major depressive episode in a child from around eight years old and in adolescents up to eighteen, mild to severe, with or without concurrent medication.
Reference model. Cognitive behavioural therapy for depression adapted to children and adolescents, in the tradition of the protocols evaluated by the large paediatric trials, together with behavioural activation. The protocol follows the order the data support: safety first, behaviour next, cognition when age allows.
Format. Sixteen sessions of 50 minutes, weekly until session 12, then fortnightly. Four of them belong to the parents — sessions 4 and 11, and two joint slots in 1 and 16. Two booster sessions, at one month and at three months.
Target mechanism. Not to lift mood directly, but five changes: to make things safe, to restart activities that produce pleasure and contact, to learn to name and rate emotions, to make interpretations available for examination where development allows, and to change what those around the young person do with sadness and irritability.
| Session |
Focus |
Session output |
| 1 |
Assess in three voices, set the frame |
Frame and confidentiality explained, record installed |
| 2 |
Suicide risk and safety |
Written safety plan, means secured |
| 3 |
The formulation, explained to the young person |
Diagram drawn in their own words |
| 4 |
Parent session: understanding and changing |
Three instructions held at home |
| 5 |
Activation: observing |
One week of moments recorded |
| 6 |
Activation: scheduling |
Three activities planned |
| 7 |
The obstacles: refusal and fatigue |
Analysis of one refusal |
| 8 |
Emotions: naming them, rating them |
Thermometer installed |
| 9 |
Spotting thoughts |
Three-column record or comic strips |
| 10 |
Putting thoughts to the test |
One thought examined with evidence |
| 11 |
Parent session: criticism and conflict |
One rule of communication changed |
| 12 |
Relationships and the return to school |
One contact resumed, one written arrangement |
| 13 |
Problem solving |
One problem worked in six steps |
| 14 |
Sleep, the body, screens |
Bedtime and rising time fixed |
| 15 |
Self-criticism and shame |
Written answer to the critical voice |
| 16 |
Review, relapse, joint session |
Written plan in the young person's hand |
What the young person and the parents take away. Seven printable worksheets, listed in section 38 and downloadable from this page: my moments, my days, my thermometer, my thoughts, my safety plan, the parents' corner, my plan for what comes next.
What sets this programme apart from the adult manual. Three things. Irritability is treated as a presentation of depression and not as a behavioural problem. Assessment is done in three voices, and disagreement between them is data rather than a problem. And parents are agents of the treatment: what they do with their child's sadness and anger maintains the episode or undoes it.
2. Before you begin
Who this programme is for
This text is written for psychologists, child psychiatrists, psychotherapists and doctors trained in cognitive behavioural therapy with children and adolescents. It assumes you can conduct an interview with a minor and with a family, that you can assess suicide risk in a young person and act on it, and that you know the legal framework governing the care of a minor in your country.
It is written neither for young people nor for parents. It contains procedures, thresholds and criteria for non-response, and it raises matters — suicide, medication, reporting, prognosis — that must be put differently when speaking to the person concerned or to their family.
The question that comes first: what is this?
Four decisions are taken before the first procedure, and they are not taken in one session.
Is this a major depressive episode? A sullen adolescent for three weeks after a break-up is not one. Section 5 gives the elements, section 7 gives what must be ruled out.
Is this the irritability of a depression, or of something else? This is the most specific question in this manual. A child who has been permanently irritable for years does not present the same picture as a child who became irritable four months ago. See section 7.
Has there been a hypomanic or manic period? The question arises here as in adults, with one added difficulty: what looks like excitement in a child is rarely hypomania, and family history counts for more. Specialist opinion before any antidepressant is started where there is doubt.
What is the suicide risk, now? Session 2 is entirely devoted to it, and section 10 tells you how to conduct it.
What this programme does not treat
It does not treat disruptive mood dysregulation disorder. Chronic irritability installed since early childhood belongs to a different course of care. The distinction is developed in section 7; it is delicate and it governs everything else.
It does not treat bipolar depression. Behavioural work has its place there, in a different framework and with a child psychiatrist.
It does not, on its own, treat a severe depression with psychotic features, food refusal, or high suicide risk. These are situations where child psychiatric opinion comes first, and sometimes admission.
It does not treat an ongoing situation of abuse. A child living in a dangerous environment does not first need therapy: they need protecting. Section 7 says so, and section 11 says what you do with what you learn.
What this programme is not
It is not drug treatment, and it is not a substitute for it. The place of medication is stated in section 13, in full.
It is not parenting guidance. Parents have four sessions, but the object of treatment is the young person's depressive episode, not child-rearing.
It is not family therapy. What happens between the parents, between parents and child, within a sibling group, is taken into account and sometimes treated — but this manual does not replace an indication for family therapy when one exists.
How to use it
Read the whole manual before the first session, in particular sections 7, 10, 11 and 13: the differential, suicide risk, confidentiality, and medication. These are the four places where things go wrong, and the middle two can have immediate consequences.
Each session is described on the same frame: the aim, the run-through in steps, what you say, the common errors, and the criterion for moving on.
One warning particular to this age. The young person is almost never the one asking. They come because they are brought, they sit down saying everything is fine, and they wait for the hour to pass. That does not mean they are refusing care: it means the alliance has to be built with them and not only with their parents, and that the first session decides a great deal.
3. The clinical picture by age
What misleads
Depression in children does not look like depression in adults, and that is the first cause of diagnostic delay. Three traps recur.
Irritability is taken for a behavioural problem. A child who slams doors, answers back and loses their temper over homework is seen as rude. In an adult you would look for mood; in a child you look for a punishment.
Somatic complaints are taken for a medical problem. Stomach aches, headaches, tiredness, and a run of consultations lasting months before anyone asks how school is going.
Withdrawal is taken for shyness, or for adolescence. "He's in his room, it's his age" is true most of the time, and that is exactly what makes the cases where it is not go missing.
Before about ten
Mood shows itself more than it is spoken. The child does not declare their sadness: they act it, they somatise it, or they deny it.
What you observe. Irritability and disproportionate outbursts, loss of interest in play — a major sign and often overlooked —, repeated somatic complaints, school refusal, regression, clinginess, sleep disturbance, appetite change, falling results.
What you hear from the child. Short, concrete sentences: "I'm rubbish", "nobody likes me", "I'm bored all the time". And thoughts of death stated plainly, sometimes with a calm that unsettles.
What the parents report. That he has changed. This is often the most reliable datum: the change from the child they knew.
From ten to thirteen
The hinge period. The child begins to be able to name, but not yet to examine their thoughts in the abstract.
The picture moves closer to the adult one: spoken sadness, self-deprecation, guilt, loss of interest, tiredness. Irritability remains very present. School becomes the marker: falling marks, avoidance, conflict.
This is also the age when social comparison becomes painful, and when bullying produces full depressive pictures. To be looked for systematically.
In adolescence
The picture resembles the adult one more closely, with four differences that matter.
Irritability stays in the foreground in a large proportion of depressed adolescents, and it coexists with sadness rather than replacing it.
Hypersomnia and increased appetite are more frequent than in adults, whereas one expects the opposite.
Mood reactivity is more often preserved: the adolescent can laugh with friends in the evening and be flattened the next morning. This makes parents — and sometimes clinicians — doubt that the disorder is real.
Behaviour takes centre stage: substance use, risk-taking, self-harm, dropping out. These mask the episode more than they reveal it.
What maintains the episode
This is the useful part of the picture, because it is the part one treats.
Withdrawal. Fewer activities, fewer friends, more bedroom and more screen. The loop is the same as in adults, only faster: at this age, a few weeks are enough to lose a place in a group.
School avoidance. Every day missed makes the return harder, and the accumulated backlog becomes an objective reason not to go.
Rumination, present from adolescence onwards, on the same themes as in adults, with a stronger social component.
What those around the young person do. This is what this manual adds. Four parental reactions, all well meant, maintain the episode: criticism — "you're letting yourself go" —, over-protection that exempts the child from all effort, accommodation that organises the household around avoidance, and comparison with siblings.
Bullying, if it is ongoing. No protocol works on top of active bullying. It is asked about in the first session and treated first.
What depression is not
It is not adolescence. Adolescence produces mood swings, conflict, relative withdrawal. It does not produce lasting anhedonia, stable self-deprecation, or persistent thoughts of death.
It is not a lack of willpower, and it is not laziness. This is the most important sentence to say to the parents, and it will have to be repeated.
It is not always somebody's fault. Parents look for a cause and often nominate themselves. Some episodes have an obvious trigger, others do not.
Epidemiology, in four useful figures
Depression is rare before puberty — of the order of one to two per cent — and its frequency rises markedly in adolescence, approaching adult figures by the end of that period.
Before puberty, boys and girls are affected in comparable proportions. The gap appears in adolescence, with a female predominance that settles then and does not reverse.
An episode in adolescence strongly increases the risk of episodes in adulthood. This is the central argument for relapse prevention work, and it is said to the parents.
And a substantial proportion of episodes are neither recognised nor treated, particularly in boys, in whom irritability and behaviour are read as a conduct problem.
4. The model that guides this programme
Three loops instead of two
The adult manual describes two. Here there are three, and the third is what distinguishes this protocol.
The behavioural loop. An event, a loss, a failure, bullying reduce activity. Less activity means less pleasure, less success, fewer friends. Which further reduces desire and activity. In a young person this loop closes faster than in an adult: three weeks of absence are enough to lose a group.
The cognitive loop. Interpretation is distorted about self, others and the future. It is usable from around ten or eleven; before that, one works mainly on the first loop.
The interpersonal loop. Withdrawal and irritability provoke reactions — parental criticism, teachers' remarks, friends drifting away — which confirm to the young person that they are useless and unloved. This loop is not context: it is a mechanism, and it is treated.
What these three loops imply
We start by making things safe. Suicide risk is treated before anything else, in session 2. An activation protocol run on an adolescent who has a plan is a mistake.
We then start with behaviour. Because it acts faster, because it is feasible when one can no longer think, and because a nine-year-old will not do abstract cognitive work.
We act before feeling like it. As in adults, but it has to be said differently: "we are not going to wait until you feel like it, because feeling like it is exactly what is broken at the moment".
We work on those around the young person at the same time. Not afterwards. What parents do with sadness and anger maintains the episode or undoes it, and four sessions belong to them.
What the model explains to the young person
Why he is angry all the time. The most useful question to address early: many adolescents do not know they are depressed, they know they are irritable and they hold it against themselves.
Why he is permanently tired although he sleeps a lot. Because the fatigue of depression is not a sleep debt, and staying in bed adds to it.
Why nothing interests him any more, even what he used to love. Anhedonia, explained with his own examples.
Why he argues with his parents more than before. The interpersonal loop, seen from the inside. Saying that it is predictable comes as a relief.
What the model implies you should not do
Do not wait for desire to return.
Do not aim at sadness first. What moves first is the number of activities, contact with friends, and sleep.
Do not reassure. "It will sort itself out" is as inoperative here as with adults, and the adolescent hears in it that they have not been listened to.
Do not take sides in family conflicts. You are the young person's therapist, and you work with their parents. That is not the same as being their advocate.
5. The DSM-5-TR criteria, reformulated
The criteria below are a reformulation in our own words, for reference. They do not replace the manual: refer to the DSM-5-TR (American Psychiatric Association, 2022) for the letter of the text and the application notes.
A major depressive episode involves the same elements as in adults, with two adjustments explicitly provided for children and adolescents.
At least five manifestations present during the same two-week period, representing a change from previous functioning, among which must figure either a depressed mood or a loss of interest or pleasure.
First adjustment: mood may be irritable rather than sad in children and adolescents. This is not a concession, it is an equivalence. An adolescent who has been constantly irritable for two months meets this criterion.
Second adjustment: failure to make expected weight gain may replace weight loss. A child who stops gaining weight over several months is concerned, even if the scales do not fall.
The other manifestations are those of the adult: sleep, energy, observable agitation or retardation, worthlessness or excessive guilt, concentration or indecisiveness, recurrent thoughts of death or suicidal ideation.
Clinically significant distress or impairment of functioning — here, at school, at home or socially.
No attribution to a substance or a medical condition, and no history of mania or hypomania.
Persistent depressive disorder
The same logic as in adults with one difference of duration that counts in practice: one year is enough in children and adolescents, where two are required in adults. And mood there may be irritable.
Many young people meet both: a chronic background of a year or more, with a clear episode on top. This is frequent, it carries a poorer prognosis, and it changes what the programme can be expected to achieve.
The specifiers that change management
Severity, the presence of psychotic features — which require child psychiatric opinion —, of anxious, melancholic or atypical features, and the single or recurrent character.
Two matter particularly here. Anxious distress, very frequent at this age and associated with higher suicide risk. And atypical features — hypersomnia, increased appetite, preserved mood reactivity — more frequent in adolescents, and which cast doubt on the reality of the disorder when one is expecting an adult picture.
What these criteria do not say and what must be assessed
They say nothing about bullying, which produces complete depressive pictures and is treated first.
They say nothing about what those around the young person do, which is the third loop of the model.
They say nothing about school functioning in detail — absences, accumulated backlog, arrangements — which determines whether everything else is feasible.
And they do not measure chronic irritability, the distinction from an episode being the main diagnostic issue at this age.