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 significant 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 depression 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: a his- Developmental Perspective tory of difficulty with adaptation at one stage makes it more likely that Recent information about the developmental the child will have difficulty with a nature of many mental health problems (Na- later stage, with the effect cascading through multiple developmental tional Research Council and Institute of Medi- levels. In fact, a child’s level of resil- cine, 2009) is refocusing the attention of school ience is now seen not exclusively as mental health professionals on the necessity a trait inherent to the child, but as a for early identification, prevention, and early developmental effect of the inter- intervention. Important concepts from this play of risk and protective factors in that child’s life history (Edwall, understanding of the development of mental 2012). disorders include the following: ESSENTIALS

QQ QQ The most effective programming Family–school–community collaboration is a critical component of inter- for addressing mental health re- vention for students with depressed quires an equal emphasis on men- behavior. tal health problems and on mental QQ health strengths (Miles, Espiritu, RTI frameworks that exist in schools should be used as frameworks for Horen, Sebian, & Waetzig, 2010). assessment and intervention with This move away from a disease- depression and other mental health oriented perspective may be es- problems. pecially relevant for children and adolescents. The implications of this view of mental health QQ While there may be some risk factors specific to depression, there are problems are profound for the prevention also more general risk factors that and treatment of depression and other men- contribute to a variety of mental tal health problems. For school mental health problems, including depression professionals, it means that they have both a (National Research Council & Insti- tute of Medicine, 2009). great responsibility (because depression and other mental health problems should be ad- QQ A child’s ability to successfully dressed during the school-age years) and a negotiate developmental stages depends on his or her prior history great opportunity (because they have access of success or failure. Moreover, the to students for a long stretch of time) to pre- effects of these successes or failures vent and treat depressive symptoms during a is cumulative, resulting in a cascad- critical period of child development. Some of ing effect whereby a preponderance the most important implications of this point of successful earlier experiences results in success with later expe- of view include the following: riences which, in turn, results in subsequent cascades of successful adaptation to each developmental 14 Depression in Childhood and Adolescence: A Quiet Crisis Depressive Symptoms Occur on ESSENTIALS a Continuum QQ Schools that offer programs to promote social and emotional health typically have Rather than being an all-or-nothing phenome- academic outcomes approximately 11 percentile points higher than schools that non, depression refers to a continuum of emo- do not tions and behaviors that vary in frequency,

QQ Depression is preventable. duration, and intensity. Temporary behaviors and emotions typically associated with depression (e.g., feelings of sadness) come and QQ School mental health professionals are go in most people’s lives. As these states in- ideally situated to deliver a coordinated, integrated set of mental health crease in duration, they can be considered as interventions from a developmental symptoms of a disorder. As the number of such perspective, offering a continuum of symptoms increase, they may be considered services from mental health promo- as constituting a syndrome existing below the tion through interventions for mental health problems—starting at the pre- level of formal diagnosis (e.g., a major depres- school level and extending through sive episode as defined by the Diagnostic and high school. Statistical Manual of Mental Disorders (DSM-IV- QQ It is not sufficient to simply look for TR; American Psychiatric Association, 2000). symptoms of depression and other mental health problems; we have to Finally, the existence of a syndrome of suffi- pay attention to risk and protective fac- cient intensity and duration may result in a tors and develop programs for preven- diagnosis of a disorder (e.g., major depressive tion. Depression (and many other mental disorders) exists on a continuum of disorder). severity from subclinical behaviors and symptoms to a diagnosable disorder. It Given the developmental nature of depres- is important to treat subclinical levels sion and the cascading effect of early -symp not only because they cause functional impairment in themselves, but also be- toms of depression on later development of cause, left untreated, they lead to more depressive disorders, prevention of depres- serious problems later. sive disorders should focus on interventions QQ Consider the cascading effect (in ei- that prevent the emergence of symptoms and ther a positive or negative direction) of successful or unsuccessful adapta- the development of syndromes such as major tion in childhood and adolescence for depressive episodes. The logic is irrefutable: subsequent mental health. It is criti- preventing major depressive episodes would cal to begin mental health services as early as possible and to take a longer- prevent major depressive disorders (Muñoz, term, more developmental view than Beardslee, & Leykin, 2012). we are generally accustomed to doing. The outcomes of what we do in second grade may not necessarily show up in end-of-year data, but may very well manifest in twelfth grade or even early adulthood.

15 Depression in Childhood and Adolescence: A Quiet Crisis

QQ Formal and informal screening for “The logic is irrefutable: depression and suicide. preventing major depressive QQ Psychological and functional be- episodes would prevent major havioral assessment. depressive disorders.” QQ Group and individual counseling. QQ Behavioral and cognitive-behavioral approaches to managing depression.

School Mental Health Professionals QQ Referral and case management in- Are Front-Line Service Providers volving community providers such as therapists and medical personnel. In the United States, most mental health services provided to children are provided in school, primarily by school-employed mental Moreover, a great deal of research has shown health professionals. These professionals in- that school mental health professionals have clude school counselors, school nurses, school the capability to effectively design, imple- psychologists, and school social workers. ment, and monitor a number of programs that Each has a unique contribution to make to the prevent and treat depression and other men- mental health team and all are critical provid- tal health problems (see, for example, Durlak, ers of mental health services to children and Weissberg, Dymnicki, Taylor, & Schellinger, adolescents with depression. 2011).

Collaboration Is Critical to Effectively ESSENTIALS Addressing Depression

QQ Most mental health services for children are provided by school counselors, school While schools and school mental health pro- nurses, school psychologists, and school fessionals have a critical role in interventions social workers. for depression, school personnel cannot do it QQ School mental health professionals have the alone; authentic family–school–community training to prevent and treat depression. collaboration is a key component of any effective intervention program for students with depression. Schools and school mental health School mental health professionals provide a professionals are at the nexus of these systems comprehensive range of mental health servic- and are in an excellent position to coordinate es including the following: an integrated continuum of services for students. QQ Education about depression for students, parents, school personnel, and members of the community.

16 Depression in Childhood and Adolescence: A Quiet Crisis

services should be delivered in a comprehen- ESSENTIALS sive and coordinated way across three tiers of intervention: QQ Family–school–community collaboration is a critical component of intervention for students with depressed behavior. QQ Tier 1—Universal Interventions:

QQ RTI frameworks that exist in schools Universal interventions are pro- should be used as frameworks for assess- vided to everyone in a given ment and intervention with depression population (e.g., all students in the and other mental health problems. school, all parents, or all teachers) without regard to whether or not members of that population are at Response to Intervention Can Be an risk. Examples are social–emotional Effective Framework for Delivering learning programs for students, Mental Health Services staff education about depression, or teaching all parents about the signs Delivery of services for students with depres- of depression and suicide. sion is best provided through a multi-tiered problem-solving model. In schools, this model QQ Tier 2—Targeted Interventions: is often represented by the framework known Targeted interventions are provided as response to intervention (RTI). RTI is an to individuals or groups of people educational reform that has been adopted by at risk of developing depression. the majority of states in a relatively very short Examples are groups for children of divorce, social skills groups, and time. programs for parents of students at risk for depression. RTI “is a practice of providing high-quality instruction and interventions matched to stu- QQ Tier 3—Intensive Interventions: dent need, monitoring progress frequently to Intensive interventions are provided make decisions about changes in instruction to students who have symptoms of depression or who are at very or goals, and applying child response data to high risk of developing depression. important educational decisions” (National Examples of intensive programs Association of State Directors of Special Edu- include a variety of individual and cation, 2006). Certain procedures have made group counseling programs for stu- RTI a powerful force for reform in the deliv- dents with symptoms of depression. ery of academic services: multi-tiered problem solving model of service delivery, em- Integrating mental health assessment and in- phasis on prevention, use of evidence-based tervention with the academic side of the RTI interventions, and assessment practices such framework offers the opportunity to improve as screening and progress monitoring. These services to students, reduce the marginaliza- procedures are the same ones that should be tion of mental health services in schools, and used as a framework for assessment and in- allow school mental health professionals to tervention of students with depression. Of more fully utilize all the skills in their clinical particular importance is the idea that these repertoires. 17 Depression in Childhood and Adolescence: A Quiet Crisis Improving Student Mental Health Advocacy Is Part of Our Job Improves Academic Outcomes Most ethical codes for the helping professions require that professionals advocate for pro- The primary mission of schools is education, grams and services needed to promote the and the argument is sometimes made that welfare of their clients. School mental health schools should invest only in strictly academic interventions and programs and not be dis- professionals often address their advocacy tracted from that mission by providing student efforts to the need for targeted and intensive mental health programs. At this point in time, services for students at risk of depression and however, it is clear that students who partici- other mental health problems. This continues pate in programs designed to promote social to be an important focus given that services and emotional health perform significantly for students with depression are often margin- better on academic outcomes than students alized, overextended, or even nonexistent. who do not have access to these programs. Indeed, schools that offer such programs typically have academic outcomes approximately “Advocacy is part of our 11 percentile points higher than schools that do not (Durlak et al., 2011). Providing com- jobs; it is often the first step prehensive social, emotional, and behavioral toward intervention for support systems for students not only suc- students with depression.” cessfully prevents mental illness but also significantly improves academic outcomes.

Depression is Preventable ESSENTIALS

The hopeful conclusion emerging from the QQ Schools that offer programs to promote contemporary developmental understanding social and emotional health typically have academic outcomes approximately 11 of mental health and research demonstrating percentile points higher than schools that the effectiveness of readily available interven- do not tions is that depression is preventable. It has QQ Depression is preventable. been estimated that services provided over the course of a lifetime could prevent 22% to 38% of major depressive episodes (Muñoz et Meanwhile, other school professionals (e.g., al., 2012). Schools have a critical role in this teachers, administrators) typically focus their project because they have long-term access to advocacy efforts on services that enhance ac- students and adolescents at critical periods of ademic outcomes for the greatest number of their development, employ mental health pro- students. This continues to be an important fessionals capable of delivering appropriate effort given that so many students are under- interventions, and are positioned at the nexus of the family–school–community system. performing in this area. But research demonstrating the reciprocal relationship between

18 Depression in Childhood and Adolescence: A Quiet Crisis mental health and achievement, along with RESOURCES recent conclusions about the effectiveness of social, emotional, and behavioral programs This book will provide key information and in improving academic outcomes through- resources for assessing, preventing, and inter- out the school, creates the opportunity for all vening with depression. Professionals wish- school professionals to unite in advocating ing to become more expert on this topic will equally for improving mental health and aca- require further study. One of the three com- demic services in their schools. If improving prehensive textbooks on depression among academic services improves mental health children and adolescents listed below would outcomes and improving mental health out- provide an excellent starting point. comes improves academic outcomes, advo- QQ Handbook of Depression in Children cacy for these programs becomes a broader and Adolescents, edited by J. R. Z. agenda of advocacy for all students, not just Abela and B. L. Hankin (2008; New those with mental health problems or just York, NY: Guilford). Covering only those with academic problems. In fact, the children and adolescents, this edited textbook covers foundations, treat- two issues are so intertwined as to be indis- ment, and prevention of depression tinguishable. Advocacy is part of our jobs; it in a very authoritative manner. is often the first step toward intervention for QQ Anxiety and Depression in Children students with depression. and Adolescents: Assessment, Interven- tion, and Prevention, by T. J. Huberty ACTION PLAN (2012; New York, NY: Springer). Organized as a graduate-level text- QQ As a school counselor, school nurse, book, this resource comprehensive- school psychologist, or school so- ly covers foundations, assessment, cial worker, reflect on your role as prevention, intervention, and legal a member of a collaborative team of issues for anxiety and depression. mental health professionals. What is the scope of practice permitted un- QQ Helping Students Overcome Depres- der your certification or licensure? sion and Anxiety: A Practical Guide What competencies do you possess (2nd ed.), by K. W. Merrell (2008; as a mental health professional? New York, NY: Guilford Press). This How can you expand your role in highly readable book is written spe- preventing depression? cifically for use by school mental health professionals in their treatment of students with depressed behavior. It covers the basics of assessment but is strongest in its de- scriptions of school-based interventions for depression.

19 Depression in Childhood and Adolescence: A Quiet Crisis

For a more comprehensive textbook that cov- QQ ers depression from childhood to adulthood, Doll & Cummings: Why Popula- tion-Based Services Are Essential for the Handbook of Depression (2nd ed.) edited School Mental Health and How to by I. H. Gotlib and C. L. Hammen (2009) is an Make Them Happen in Your School. authoritative edited volume covering theory, QQ Baker: Assessing School Risk and assessment, prevention, and treatment of de- Protective Factors. pression. Although this book covers depres- QQ sion across the lifespan, there are several out- Christenson, Whitehouse, & Van- Getson: Partnering With Families to standing chapters devoted to children and Enhance Students’ Mental Health. adolescents. QQ Merrell, Gueldner, & Tran: Social and Emotional Learning: A School- The book edited by B. Doll and J. A. Cum- Wide Approach to Intervention for mings, Transforming School Mental Health Socialization, Friendship Problems, Services: Population-Based Approaches to and More. Promoting the Competency and Wellness of QQ Mazza & Reynolds: School-Wide Children (2008; Thousand Oaks, CA: Corwin Approaches to Prevention of and Press—a joint publication with the National Intervention for Depression and Su- Association of School Psychologists) is also icidal Behaviors. highly recommended, in particular for its dis- QQ Adelman & Taylor: School-Wide cussion of providing school-wide interven- Approaches to Addressing Barriers tions for students. Chapters in this book of to Learning. particular interest include the following:

20 Depression in Childhood and Adolescence: A Quiet Crisis

REFERENCES Miles, J., Espiritu, R., Horen, N., Sebian, J., & Waetzig, E. (2010). A public health approach to children’s mental health: A conceptual approach. Washington, DC: Abella, J. R. Z., & Hankin, B. L. (2008). Handbook of depres- Georgetown University Center for Child and Human sion in children and adolescents. New York, NY: Guil- Development. Retrieved from http://gucchdtacen- ford Press. ter.georgetown.edu/publications/PublicHealthAp- American Psychiatric Association. (2000). Diagnostic and proach.pdf statistical manual of mental disorders (4th ed., text rev.). Muñoz, R. R., Beardslee, W. R., & Leykin, Y. (2012). Major Washington, DC: Author. depression can be prevented. American Psychologist, Avenevoli, S., Knight, E., Kessler, R. C., & Meridangas, 67(4), 285–295. K. R. (2008). Epidemiology of depression in children National Association of State Directors of Special Educa- and adolescents. In J. R. Z. Abela & B. L. Hankin, tion. (2006). Response to intervention: Policy consider- Handbook of depression in children and adolescents. New ations and implementation. Alexandria, VA: Author. York, NY: Guilford Press. National Institute of Mental Health. (2004). Preventing Centers for Disease Control and Prevention. (2012). Un- child and adolescent mental disorders: Research roundta- derlying cause of death, 1999–2009 results. CDC Won- ble on economic burden and cost effectiveness. Retrieved der Online Database. Retrieved from http://wonder. from http://nimh.nih.gov/scientificmeetings/eco- cdc.gov nomicroundtable.cfm Doll, B., & Cummings, J. A. (2008). Transforming school Suicide in mental health services: Population-based approaches National Institute of Mental Health. (2010). the U.S.: Statistics and prevention. Retrieved from to promoting the competency and wellness of children. http://www.nimh.nih.gov/health/publications/ Thousand Oaks, CA: Corwin Press (a joint publica- suicide-in-the-us-statistics-and-prevention/index. tion with the National Association of School Psy- shtml#children chologists). National Institute of Mental Health. (2012). NIMH fact- Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Taylor, sheet 2012 on depression. Retrieved from http:// R. D., & Schellinger, K. B. (2011). The impact of www.cmhnetwork.org/resources/show?id=315 enhancing students’ social and emotional learning: A meta-analysis of school-based universal interven- National Research Council and Institute of Medicine Child Development, 82 tions. (1), 405–432. [NRC & IOM]. (2009). Preventing mental, emotional, and behavioral disorders among young people: Progress Edwall, G. E. (2012, Spring). Intervening during child- and possibilities. Washington, DC: National Acad- hood and adolescence to prevent mental, emotional, emies Press. Retrieved from http://www.nap.edu/ and behavioral disorders. The Register Report, 38, catalog.php?record_id=12480 8–15. Rudolf, K. D. (2009). Adolescent depression. In I. H. Got- Gotlib, I. H., & Hammen, C. L. (Eds.). (2009). Handbook of lib & C. L. Hammen, Handbook of depression, 2nd ed. depression, 2nd ed. New York, NY: Guilford Press. (pp. 444–466). New York, NY: Guilford Press. Huberty, T. J. (2012). Anxiety and depression in children and adolescents: Assessment, intervention, and prevention. New York, NY: Springer.

Merrell, K. W. (2008). Helping students overcome depression and anxiety: A practical guide (2nd ed.). New York, NY: Guilford Press.