Depression in Children and Adolescents: Guidelines for School Practice by John E
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Depression in Children and Adolescents: Guidelines for School Practice By John E. Desrochers & Gail Houck TABLE OF CONTENTS Front Matter Acknowledgments 1 Dedication 3 About the Authors 5 About This Book 7 SECTION 1: The School as a Setting for Preventing Depression 1. Depression in Childhood and Adolescence: A Quiet Crisis 11 2. School Mental Health Professionals as Front-Line Service Providers 23 SECTION 2: Strategies for Prevention and Intervention 3. School-Wide Interventions for Preventing Depression 35 4. Evidence-Based Interventions for Students at Risk for Depression 45 5. Intensive Interventions for Students With Depression 61 6. Depression Can Be Prevented: Effectiveness of Prevention Programs 77 SECTION 3: Protective and Risk Factors for Depression 7. Protective Factors 91 8. Vulnerabilities and Risk Factors 101 SECTION 4: Recognizing, Screening, and Assessing Students With Depression 9. Recognizing Students With Depression: Screening for Prevention 119 10. Assessment of Depression in Children and Adolescents 135 SECTION 5: Systems, Collaboration, and Administrative Structures 11. It Takes a Village: Collaborative and Integrated Service Delivery 155 12. Depression Within a Response-to-Intervention Framework 175 SECTION 6: Special Topics 13. Suicide Prevention and Intervention 185 14. Bullying: Peer Victimization and Depression 203 15. Pharmacotherapy for Depression 223 16. Advocating for Comprehensive and Coordinated School Mental Health Services 231 (By Kelly Vaillancourt, PhD, NCSP, Katherine C. Cowan, & Anastasia Kalamaros Skalski, PhD) Depression in ChildhoodCHAPTER 1 and Adolescence: A Quiet Crisis Depression among children and adolescents student–teacher interactions followed by fur- represents a quiet crisis for those students and ther student disengagement from school and their families, for schools, and for society as increased depressive symptoms. In a similar a whole. By the time they turn 18 years, ap- way, students exhibiting depression frequent- proximately 11% of children and adolescents ly also have difficulty maintaining social con- will have experienced some form of diagnos- nections with peers. They sometimes exhibit able depressive disorder (National Institute of irritability, indifference, or behavior problems Mental Health [NIMH], 2012). If one considers that alienate their classmates, contributing to subclinical levels of depression, the percent- feelings of disconnection and depression. Tar- age is even higher (Avenevoli, Knight, Kessler, diness and absence from school can reinforce & Meridangas, 2008). Studies have found that this downward cycle with teachers and peers. 10% to 30% of adolescents either show sig- nificant subclinical depressive symptoms or would meet clinical cutoffs if self-reports were In adulthood, these students often expe- considered, suggesting that “if 20% is consid- rience low educational and occupational ered a ‘middle ground’ approximation, the accomplishment (with correspondingly low data would indicate that, in a classroom of 30 income), early marriage and parenthood, and adolescent students, approximately six would marital dissatisfaction. Negative outcomes are have serious depressive symptoms or disor- more pronounced for those with more severe ders” (Huberty, 2012, p. 151). These students depression (Avenevoli et al., 2008). The World exhibit significant depressive symptoms and Health Organization (WHO) reports that functional impairment and are at increased major depressive disorder is the leading cause risk for the later development of clinical levels of disability among Americans age 15 to 44 of depression (Rudolf, 2009). years (WHO, 2011, as cited in NIMH, 2012). THE COST TO STUDENTS, Depression that is left untreated in childhood ADULTS, AND SOCIETY and adolescence results in significant suffering to these individuals as adults. It also makes Students with depression frequently exhibit later treatment more lengthy and costly and difficulties in academic performance and social places greater demands on family, healthcare, interactions. Their motivation, initiative, and welfare, educational, business, and justice sys- persistence can suffer, and teachers sometimes tems down the road, causing significant and misperceive them as lazy or not caring about preventable costs to society (NIMH, 2004). their work. This can result in fewer positive 11 Depression in Childhood and Adolescence: A Quiet Crisis The most tragic cost associated with depres- sion is suicide. Suicide is the third leading CHALLENGES TO DISCUSSING DEPRESSION IN SCHOOLS cause of death among children and adoles- QQ cents ages 10 to 24 years of age (NIMH, 2010). Depression is mostly internal to the student and hard to observe. In 2009, this country lost 4,636 young people QQ ages 5 to 24 years to suicide; 1,934 of those Knowledge about depression is lacking. who died were between the ages of 5 and 19 QQ Stigma and denial about mental health years (CDC, 2012). problems exists in society. QQ People may hold the mistaken belief that mental health is not the responsibility of the schools. ESSENTIALS QQ School personnel may be concerned that QQ In a classroom of 30 students, approximately addressing depression would overwhelm 6 might have serious symptoms of resources. depression. QQ Depression is associated with impaired school performance; negative interpersonal, vocational, and mental health outcomes in adulthood; and death through suicide. THE NATURE OF DEPRESSIVE SYMPTOMS A QUIET CRISIS The nature of depressive symptoms does not make it easy to observe or talk about. The Notwithstanding the huge, long-lasting cost symptoms, like those of other internalizing to students, families, and society, the preven- disorders, are internal to the student; that tion and treatment of depression is discussed is, the key symptoms of depression are usu- very little in schools. The reasons for this in- ally internal thoughts and feelings not eas- clude (a) the nature of depression and other ily observable by others. Many depressive internalizing disorders, (b) lack of knowledge symptoms that are observable behaviors (e.g., among educators about student depression, restlessness, agitation, irritability, classroom (c) the stigma associated with depression, and misbehavior) are often misinterpreted by (d) limited resources. Given the long-standing adults as a lack of motivation or as discipline consequences, it is imperative that we begin problems. As a result, the true problems of the discussion. students suffering from depression are often not recognized or treated appropriately. 12 Depression in Childhood and Adolescence: A Quiet Crisis LACK OF KNOWLEDGE LIMITED RESOURCES ABOUT DEPRESSION The problem of limited resources, including Most educators are not taught to identify signs inadequate numbers of school mental health of depression. Most people, including educa- professionals, often exerts subtle pressure to tors, are also not aware that depression has a avoid looking too closely into these problems. significant effect on academic performance, The unspoken fear is that if school personnel that it can be prevented, and that school staff were to become involved in addressing de- can effectively implement programs that pre- pression and anxiety to the same extent that vent and reduce depressive symptoms. More- they now address mental health issues such as over, very little attention is paid to this issue aggression, conduct problems, and other ex- in educators’ professional development. This ternalizing disorders, they would not be able lack of knowledge makes it less likely that to handle the additional work. teachers and other school personnel would realize that the topic of depression was even within their professional purview, making it WHO ARE SCHOOL MENTAL very unlikely that they would feel comfortable HEALTH PROFESSIONALS? or empowered to talk about issues of identifi- QQ School counselors cation and intervention in their classrooms or QQ School nurses schools. QQ School psychologists QQ School social workers STIGMA AND DENIAL Despite continuing gains in this area, there is still a stigma associated with mental illness in MAJOR THEMES OF THIS BOOK general and depression in particular among a Several major themes are addressed through- significant portion of society. This stigma op- out this book. One central theme is that de- erates to keep students, school personnel, and pression is an under-recognized problem family members from talking openly about among children and adolescents that causes these issues, regardless of whether it concerns them and their families significant suffering, an individual student’s suffering or school- and results in immense cost to schools and so- wide programs to address mental health. De- ciety at large. Another is that, to be most ef- nial can also sometimes be at work with de- fective, services for students with depression pression, much as it is with a variety of mental need to be comprehensive in scope, integrated health problems. In addition, people often with other programs in the school and com- hold the mistaken belief that mental health is munity, and delivered in a coordinated man- not the responsibility of the schools and that, ner. Other themes central to this book are in- instead, it is the responsibility of the family to troduced in this section and are elaborated in find services outside of the school system. subsequent chapters. 13 Depression in Childhood and Adolescence: A Quiet Crisis Depression is Best Understood From a stage. The reverse is also true: