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School-Based Interventions for Childhood

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1 School-Based Interventions for Childhood
and Adolescent Depression Cari McCarty, Ph.D. Research Associate Professor, Pediatrics Director of Research, Adolescent Medicine

2 Prevalence of Depression
Lifetime prevalence of mood disorders is 20.8% (National Comorbidity Survey Replication) Hazard rates highest in mid to late adolescence (Burke et al., 1990) MDD affects an estimated 6 million children and adolescents (NIMH, 2002) Quite common (1/5) Dep. is most severe of all mental disorders in terms of impact on functioning Hazard rate=probability that individual will develop disorder during that time interval, sugg adol as time

3 The statistics on this page, derived from the National Comorbidity Survey – Adolescent Supplement (NCS-A), represent 13 to 17 year olds experiencing major depressive disorder, dysthymic disorder, and/or bipolar disorder.

4 Burden of depression Depression now considered a “chronic disease”
Even subclinical levels of depressive symptoms interfere substantially with adjustment Leading cause of disability worldwide Risk for suicide, other psychiatric disorders, substance use Early onset depression increases the risk of subsequent depressive episodes later in adolescence and adulthood Associated with many negative outcomes, including substance abuse, academic problems, physical health problems, relationship difficulties, and a 30-fold increased risk of completed suicide

5 Media Attention to Suicide
Recent high profile media cases have drawn increased attention to youth suicide (and bullying) “Bullycide” is a new term that is being used to refer to a suicide that is caused from the effects of bullying. New websites, such as bully suicides.com and bullycide.org have been created to draw increased attention to this problem. On the left we have Jared High who committed suicide at age 13 after repeatedly being threatened/beat up by a peer. On the right is Phoebe Prince, who took her life on January 14, 2010 in South Hadley, Massachusetts. She was walking home from school when peers drove by in a car, hurling insults and an energy drink in her direction. She kept walking to her house, straight to her closet & hanged herself. As a human being and a parent and a researcher, this is completely horrifying. A lot of attention has been appropriately paid to reducing bullying. My focus has been to find ways to provide youth with stress and coping resources. I believe that teaching youth social emotional skills is just as critical as teaching them academic skills to success.

6 The chart below shows a map of the United States with each state’s average suicide rate between the years 2000 and 2006 indicated by color. Lighter colors indicate states with lower rates of suicide. You will notice that the entire West coast (except California) and western mountain region has relatively higher rates.

7 Research Pathway Development and Context Role of family, peers, school
So, we have clear evidence that many youth are struggling with stress and depression. My research career began by examining the contextual factors that contribute to youth development and mental health, including risk and protective factors in the family, peer networks, and school environment, with a particular focus on depression. Youth Depression

8 Understanding Youth Depression
Parental Depression Parental Social Support Youth Depression Thinking Styles My focus has been moreso on Modifiable factors, rather than intrinsic factors (genetic), because of my interest in intervention. We know that depression is a multifaceted problem, and that causes are heterogeneous and complex. In the past decade, the research I have been conducting has examined some of the pathways that are associated with depression. I have examined mediators that explain the link between parental depression and youth depression, and have found that parental social support is particularly important. I have written a number of papers examining the cognitive features –thinking style—to differentiate those that are specific to depression and those that are evident for youth with other mental health difficulties. I have examined how stressful life events and caregiver support each relate to depression. And finally, last year I published a paper finding that school failure experiences in high school, such as being suspended, expelled, or not graduating, were related to later depression among girls, but not boys. SO this is not a complete model, but it does start to show some of the important pathways and factors to consider. Here are the references for this work. Stressful events Low caregiver support *girls! School Failure McCarty et al., 2005; Weisz, Southam-Gerow & McCarty, 2001; McCarty et al., 2007; McCarty et al., 2006; McCarty et al., 2009

9 Research Pathway Intervention Efforts Development and Context
Role of family, peers, school Benefit of cognitive-behavioral skills A second branch of my work examines what we know about treatment efforts to intervene for depression. I will show you some aspects of this work next. Youth Depression

10 Examining Treatment Effects
Family risk factors important (parental depression, family climate, parental cognitive style) But, families have mostly NOT been incorporated into clinical treatment research with depressed adolescents (32% of studies) Sander & McCarty (2005). Youth depression in the family context: Familial risk factors and models of treatment. Clinical Child and Family Psychology Review, 8, I published a review paper examining what we know about family risk factors for youth depression and how families have been included in treatment studies thus far. The literature has consistently shown evidence for a number of family risk factors that are involved in depression, including parental depression, the family climate, and even parental cognitive style. But families have mostly NOT been incorporated into clinical treatment research studies with depressed adolescents. Only 32% of the studies included parents. (why? Adult models).

11 Psychotherapy for Youth Depression: Evidence of Treatment Effects
Reinecke, Ryan & DuBois 6 CBT Trials ES = 1.02 Lewinsohn & Clarke 12 Trials ES = 1.27 Michael & Crowley 14 Trials ES = .72 Weisz, McCarty & Valeri 35 Trials ES = .34 more modest Here we see a graph that shows effect sizes (standard benchmark) to measure the outcome after depression treatment. An effect size is calibrated such that for 0 means no effect, negative values indicate a harmful effect. For positive values, .2 is considered a benchmark for small effects, .5 medium, an .8 large. We published the largest meta-analysis on youth depression effects to date in 2006, and when all studies were included, in fact the effect size was .34, somewhere between the benchmarks for small (.2) to medium (.5). 17 of these studies were school-based samples (about half). 1998 1999 Weisz, McCarty, Valeri, Psych. Bull. 132: 2002

12 Component Analysis of EBTs
Goal-setting Self-monitoring Attention to relationships Cognitive restructuring Problem-solving Behavioral activation Child psychoeducation Communication training

13 Youth with Suicidal Ideation in Primary Care
Have high levels of functional impairment (84% “definitely impaired”) Higher levels of comorbidity (externalizing, substance use) Only 26% received any mental health care in the previous year, including 13% outpatient mental health, 7% antidepressants, and 12% outside counseling/treatment McCarty et al. (in press). Adolescents with suicidal ideation: Health care use and functioning. Academic Pediatrics. There are many other good reasons for conducting depression intervention in schools, such as that kids at risk for and with depression are often NOT being detected in primary care settings. We conducted a study with adolescents from Group Health, aged 13-18, who are all insured. We compared youth with SI to those without SI, and covaried for depression.

14 Intervention Model: Positive Thoughts & Actions
This research suggested to me that we weren’t nearly doing enough to involve the context, and that we needed to develop better, more robust intervention strategies. I wrote a NIH K-award to develop and test a school-based prevention program for middle school youth. We have named this program: Positive Thoughts and Actions. First, we recognize that there are multiple individual vulnerabilities that may create propensity toward depression. -- Like other programs, we target those vulnerabilities that are modifiable. Youth are taught interpersonal skills, behavior activation, cognitive restructuring, emotion regulation, and problem solving in the first part of the intervention. These skills are expected to attenuate the risk for depression, relative to youth who do not learn these skills. This is the first level of intervention, and is based upon cognitive, behavioral, and interpersonal orientations. --PTA also specifically aims to create change for youth in their ability to influence salient problems within contexts. By applying the intervention skills to improve their communication with their parents, to resolve problems in school, and to improve their relationships, --we expect that youth who participate in the intervention are decreasing their risk for depression --PTA has a parent component in which parents are given an overview of emotion regulation, and are taught empathy skills and effective communication strategies.

15 Why intervene in schools?
SEAL (Social, emotional, and academic learning) perspective Broad reach of target population More likely to reach underserved youth Mental health service accessibility is poor in many communities Potentially less stigma Because I am interested in prevention, I see the schools as a valuable place to consider helping youth reach their full potential. The SEAL perspective stands for social emotional and academic learning. This framework for school-based prevention encourages efforts to promote students’ health, character and citizenship with intentional programming to improve academic performance and other school functioning. Students social emotional competence fosters better academic performance in a variety of ways. For example, students who become more self-aware and confident about their learning abilities try harder, and students who motivate themselves, set goals, manage their stress, and organize their approach to work perform better. There are many other good reasons for conducting depression intervention in schools, such as…

16 TARGET AREAS Learning Relationships Healthy Mind and Body Grades
Study Skills—Organization & Time Management Homework Relationships Family Friends School & Community Healthy Mind and Body Stress & Moods Sleep Nutrition Exercise The curriculum focus on three target areas Facilitating Learning (in and out of school) Enhancing Relationships (particularly close relationships) Increasing Healthy Emotional and Physical Behaviors (Mind & Body)

17 Goals of the Parent Component
Engaging parents in the intervention process Providing parents a common language and understanding of the core skills Fostering a better parent-child relationship Raising parent awareness of students’ goals and progress The parent component of our intervention is tailored to actively engage parents in the intervention process. Parents are given the same information that students learn in the group session to provide parents and teens with a common language and understanding of the core skills. We talk about how parents can be supportive of their child’s effort to achieve their goals. We discuss adolescent development and the importance of perspective taking and empathy, and the use of effective communication to foster better parent-child relationships. At the final session, students share their goals and progress with their parent.

18 Pilot Testing of Intervention
School Years Eckstein, Hamilton, McClure, Whitman Middle Schools Screened 684 youth for depression; 67 included in intervention study Gains in skills (coping, cognition, communication) Over the course of two school years, we screened 684 7th graders for elevated depressive symptoms at 4 Seattle middle schools. Students who scored above the cutoff (top 25%) on the Moods and Feelings Questionnaire and met our eligibility criteria were invited to participate. 67 student and their caregiver were randomized assigned, 36 to the intervention group, 31 to treatment as usual control. Outcomes suggested gains in adaptive coping, cognition, and communication. The prevention program was well-received by students and parents. Students in the intervention group reported high levels of satisfaction – 77% of students felt comfortable in the group; 84% liked it very much or pretty much Overall, the parent workshop components were rated to be “very helpful” (45%) or “somewhat helpful” (55%) by those who participated. Parent participation rates very high (94% received ¾ sessions).

19 Middle School Matters Study
Randomized to the previously developed program (Positive Thoughts & Actions) or brief intervention (MAPS) Screened = 1190, including 20 children of Spanish speaking parents, and 4 children of Vietnamese speaking parents Inclusion – MFQ score of 14 or above (roughly 25th percentile) Exclusion – Probable MDD, Suicidal ideation, self-contained classroom, already in treatment 31 students of the follow up had SI-2 with very mild SI were included. Screening questionnaire – includes items on anxiety, school bonding, perceived discrimination, height & weight, health behaviors, Physical activity, parent-child communication, parent-child conflict

20 Middle School Matters - Intervention
Positive Thoughts & Actions 11 groups, led by 6 different leaders in different schools Alderwood Middle School: After-School Model MAPS 1-2 hour individual interview, computer-assisted, elements of assessment, empathy, motivational interviewing, social support, and brief problem-solving

21 REACHING YOUR GOALS GOALS
Deciding what we want to and who we want to be   STEPS Breaking goals into smaller steps takes us closer to our goals To be effective, steps and goals need to be: Realistic Controllable Within reach Not too easy Specific Clear Measurable Has a timeline Desirable Something valued A healthy choice Helpful to all involved

22 PLANNING FOR TRIGGERS AND ROADBLOCKS
Set us off course from the path to our goals ROADBLOCKS Get in the way of reaching our goals Hit your roadblocks and triggers head on! How? Make a plan that includes both thoughts and actions: THOUGHTS— What we tell ourselves to stay on track ACTIONS— What we do to stay on track First identify the thoughts and roadblocks that keep you from being successful.   Then make a plan for what you can tell yourself and what you can do to stay on course.

23 MEETINGS WITH PARENTS Meeting 1 Getting to Know Each Other
Home visit with parent and student Meeting 2 Understanding Your Child’s Emotional Development Group parent meeting Meeting 3 Communicating with Your 7th Grader Meeting 4 Staying Successful

24 Ongoing Research Questions
Who is most at risk of developing depression? What are the effects of skills-based group intervention vs. individual support? Are effects specific to depression? What components of the prevention are most important? For whom does it work?

25 Summary Points There are many common components of effective treatments for youth depression Interventions in non-specialty settings (schools & primary care) may help provide access & reduce stigma Benefits and barriers to in-school vs. after-school models must be weighed Who can name some of the common components?

26 Acknowledgements Postdocs Funding
Heather Violette, Ph.D. National Institute of Mental Health Brian Wymbs, Ph.D. Interventionists Research Associates Rick Cruz Leticia Holleman Marissa Corona Mary Casey-Goldstein Alyson Barry Elizabeth McCauley Jessie Waimau-Ariota Ursala Schwenn Sonja Kottke Marjorie Newman Cezanne Hardy Lisa Gloria-Wallace Becky Parrish


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