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Cognitive-Behavioral Interventions for Depression: Review and Implications for School Personell [sic]

John W. Maag University of Nebraska-Lincoln, [email protected]

Susan M. Swearer Napolitano University of Nebraska-Lincoln, [email protected]

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Maag, John W. and Swearer Napolitano, Susan M., "Cognitive-Behavioral Interventions for Depression: Review and Implications for School Personell [sic]" (2005). Educational Psychology Papers and Publications. 150. https://digitalcommons.unl.edu/edpsychpapers/150

This Article is brought to you for free and open access by the Educational Psychology, Department of at DigitalCommons@University of Nebraska - Lincoln. It has been accepted for inclusion in Educational Psychology Papers and Publications by an authorized administrator of DigitalCommons@University of Nebraska - Lincoln. Maag & Swearer in Behavioral Disorders (2005) 30(3). Copyright 2005, Council for Children with Behavioral Disorders. Used by permission. Cognitive-Behavioral Interventions for Depression: Review and Implications for SchoolPersonel1

John W. Maag & Susan M. Swearer University of Nebraska-Lincoln

ABS7RACT: Depression is one ofthe most commonly diagnosed psychiatric disorders among schoo/~ age youths. As such, school personnel should play an important role in the identificatioh/assessmeFd, and treatment of depression and related problems in school. School-basedtreatment ofdepressi6h is especially relevant for students with emotional and behavioral disorders (EB0) and learhing cjjsabihties (LD) because they may be at a higher risk than their nondisabledpeersofdisplaying depressive symptomatology. Cognitive-behavioral interventions (CBls) have shown promise as an evidence-based treatment for childhood and adolescent depressive disorders. This article focuses on how CBI techniques can be used by school personnel under theproper clinicalsupervisionfor reducing students' depressive symptomatology. First, common CBI techniques are described. Second, empirical studies using eBI to treat children and adolescents who are depressed are 'reviewed. Finally, implications for using these techniques in a collaborative effort among schoolpsycholQgiscs; counselors, and special educators in an ethical and valid manner are presented.

• Depression is a mood (affective) disorder Reid (1994) found that 10% of stude?ts\A,lil:h that affects approximately 2% of children and disabilities experienced sifSnificant depressiv; adolescents in the general population (Kashani symptomatology. How.;~er, 31). This prev~ITRET should be considered by school personnel in estimate is the same that exists in the g;nyri=l! the identification, assessment, and treatment of population of young people. In their IT).;~a~ depression (Reynolds & Stark, 1987). Students analytic review Maag and Reid (in pre~.?) with elTlOtional and behavioral disorders (EBO) concluded that, although students with LOhave and learning disabilities (LD) may be particularly statistically greater depressive symptomatology at risk for developing depression. For example, than their nondisabled peers, the magnitude Maag and Behrens (1989a) found that about was most likely not great enough to place them 21 % of EBD and LD students experienced in the clinical range for a depressive disorder. significant depressive symptomatology. . Regardless of the exact prevalence of However, an important distinction should be depreSSive disorders among students with rnade between depressive symptomatology EBD and LO-which would prove difficult and the clinical disorder: to accurately determine in the absence of using clinical interviews-the potential As a symptom, depression refers to sad affect and as such is a common experience increased risk for students with EBD and Ll? to of everyday life. As a syndrome or disorder, experience depression has direct implica.tions depression refers to a group of symptoms that for educators. First, school personnel should go together. Sadness may be part of a larger play an important role in identifying (but not set of problems that include the loss of interest diagnosing) students who may be depressed. in activities, feelings of worthlessness, sleep Youths spend more time in school than ifl most disturbances, changes in appetite and others. structured environments outside the home, and (Kazdin, 1990, p. 121). have their most consistent and extensive contact These distinctions may explain part of with trained professionals in the school setting. the discrepancies and debate over the actual Furthermore, students' behaviors, interpersonal prevalence of depression among students relationships, and academic performance-all with EBO and LO. For example, Maag and important indicators of mood and the ability to

Behavioral Disorders, 30 (3), 259-276 May 2005 I 259 cope-are subject to ongoing scrutiny in the reinforcernent (e.g., I~eynolds & Coats, 1986; c1assroorn. Accol-dingly, school personnel may Stark: ,Reynolds., & Ka~low, 1987). Finally, be the first professionals to notice a burgeoning cognitive-behavioral Interventions have depressive dismder (Povvers, 1979; Stark, 1990). prob.Jbly received the most attention and offer Second, students \,vith EBD and LD who are the greatest nonphi'lrmaceUlical promise for depressed may be best served with counseling treating childhood and adolescent depression as a related service (Maag & Katsiyannis, 1996; (Clarizio, 1985). Results of recent research Yell, 1998). There are a variety of school-based point to the combination of rnedication (i.e., intervention strategies to treat depression in fluoxetine) and cognitive-behavioral therapy youths (e.g., Clarke, DeBar, & Lewinsohn, as the "gold standard" for treating adolescent 2003; Reynolds & Stark, 1987; 5tal'k, Kendall, depl'ession (Treatment for Adolescents VVith et aI., 1996). Third, many of the intervention Depression Study ITADS] Team, 2004), techniques used to treat depression, such as Thel'efore, cogn i tive-behaviora I interventions social skills training, self-management training, (CBI) are regarded as a major component for and various cogn itive-behaviora I approaches, successfully treating depressive disorders. have all been used by special educators to CBls focus on t\o\IO general areas: cognitions address a variety of problematic behaviors and behavior. First, they target a young person's (Maag, 1993). private speech about hirnselflherself, the Over 15 years ago, Reynoldsand Stark (1987) environment, and his/her future. Interventions began describing school-based intervention that are primarily cognitive in nature include, strategies to treat depression in children and but are not limited to, self-instruction tl'aining, adolescents and identified difficulties in problem-solving training, attribution retl-aining, implementing them. First, treating depression and the cognitive restructuring approaches should not be approached in a cavalier fashion. such as Beck's (1976) cognitive therapy and Depression is a serious mental disorder that rnay Ellis's (1962) rational-ernotive therapy (RET) have life-threatening consequences. Second, (Braswell & Kendall, 1988; Maag, 1988). clinically trained individuals, such as school Second, virtually all effective CSI techniques psychologists, counselors, and social workers, with young people include behavioral should work collaboratively with teachers components such as modeling, role playing, to provide consultation in the development and positive reinforcement (BrasweU & and implementation of interventions. Third, Kendall, 1988). Irnportantly, some researchers prevention may be the best approach for treati ng have documented a vital temporal sequence depression in schools. However, preventative in cognitive and behavioral interventions for approaches wou Id I-equ ire that teachers receive depressive disorders (Stark, Swearel', et aI., tra·irl'lng in cognitive and behavioral techniques 1996). In many cases, the impfen,entation used for treating depression-something that of behavioral interventions should precede only some special educators typically receive. cognitive interventions (l

260/ May 2005 Behavioral Disorders, 30 (3), 259-276 CBI Techniques for Depression Several factorswi II enhancetheeffectiveness of students using self-talk (Braswell & Kendal! CBI approaches underscore the cornplex 1988; Harris, 1982; Kendall, 1977). First: relaliollS arTlong cognitive factors (cognitive self-instructions should initially be limited to content, products, structures), affect, overt three words, a short phrase, or perhaps a brief behaviors, and the environrnent as contributing sentence at most. Second, the target student to various rnental illnesses (Braswell & Kendall, should generate the exact wording of the self­ 19(8). These fLictors CLin be traced back to statement. Third, a student is more likely to Lurid's C1961) and Vygotsky's (1962) develop­ use self-instructions when they are targeted rnental theories of the functional relation to increase or decrease the specific behavior, between languLige and behavior. Several rather than vague statements such as "I need years after the work of Luria and Vygotsky, to concentrate." Fourth, a student shou Id be Neisser (1967) wrote the text, Cognitive reinforced for using self-instructions, thereby Psychology, which represented the first increasing the likelihood that he/she will use extensive treatnlent of cognitive processes such them again. as mernory, attributions, pt'oblern solving, and self-referent speech. Research on these topics Attribution Retraining led to the development of a variety of cognitive therapies. In this section, four of the most Attribution retraining IS based on the common CBI techniques will be described. premise that a child's explanations for why They are all designed to change the maladaptive he/she is perforiTling well or poorly have~., style of processing information that is common implications for his/her behavioral persistence: among students with depression (Reynolds & expectancies for future performance, and Stark, 1987; StLirk, Sander, Yancy, Bronik, & emotional reactions to success and failure Hoke, 2000). (Braswell & Kendall, 1988). Young people who are depressed attribute negative events Self-Instruction Training to interna I, stable, and global attributions and attribute positive events to external, unstable, Self-instruction training was developed by and specific attributions (Hughes, 1988). These Meichenbaum and GoodlTlan (1971) for use young people are taught to attribute failure to with impulsive students and has been adapted more external, unstable, and specific factors for youth with depressive disorders (Stark et aI., and make attributions for success to more 2000). The goal is to teach young people posi­ internal, stable, and global factors (Reynolds & tive self-talk as a means of helping them gain Stark, 1987; Stark et aI., 2000). The goal is to self-control over certain aspects of depression, reduce levels of learned helplessness common such as countering negative self-statements with among some children who are depressed positive ones (LC\

May 2005 /261 Behavioral Disorders, 30 (3),259-276 statements should be accornpanied with A variety of interpersonal problem­ specific behavioral efforts. For exarnple, solving training prograrns exist for elementary Shmt and Ryan (1984) found that attribution and secondary students (Mufson, Moreau, retraining was ineffective when students made Weissman, & Klerrnan, 1991; Shure & Spivack, effort-oriented statements prior to reading a 1974; Siegel & Spivack, 1973). Cesten et aL passage, rather than after' having had difficulty n 987) described severa I factors that may guide with the passage. In addition, attr'ibution the selection of problem-solving curricula retraining will be rnost effective for students depending on the age of a student. First, the who are not using skills they already possess­ ability to generate multiple solutions, regardless it would not be an appropriate technique of quality, is most effective for preschool for students who have specific skill deficits and primary-grade students. It is especially (Fincham, 1983; Schunk, 1983). important to help students who are depressed generate a variety of solutions because their Problem-Solving Training depressogenic thinking often results in them not being able to generate multiple solutions Or Some type of problem-solving training is biases in thinking of how solutions will fail (Stark incorporated into almost every CBt technique et aI., 2000). Second, the quality of solutions (Braswell & Kendall, 1988). Jt represents a (i.e., assertiveness and effectiveness), rather variety of skills that can be used to resolve than quantity of solutions, is most important conflicts that require either initiation of action for middle school students. Finally, secondary or reaction to the responses of others (Cesten, students appear to require less training in Weissberg, Amish, & Smith, 1987). Problem­ solution generation or consequential thinking solving skilfs may help students who are than in the means-ends thinking that is required depressed develop alternative solutions to to overcome obstacles and to implement problems that may be otherwise thought of as successfully the chosen solutions. insurmountable. For example, an adolescent boy may be feeling depressed because his Cognitive Restructuring girlfriend broke up with him. Problem-solving training may help him generate ways to feel Cognitive restructuring is a global term used better. It is also a way to change a depressed to describe techniques that focus on identifying youngster's locus of control orientation from and altering young people's irrational beliefs external to internal (Nezu, 1986). and negative self-statements. Its roots can be D'Zurilla (1988) described a problem­ traced to Ellis' (1962) Rationa I-Emotive Therapy solving model for young people under the (RET) and Beck's (1967) cognitive therapy for direction of a practitioner: depression. Both therapies basically teach young people to dispute irrational thoughts 1. Problem Orientation. A set of facilitative through the use of logical analysis and abstract cognitions are provided to help recognize thinking (Hughes, 1988). problems and know how to deal with them in appropriate ways. Rational-Emotive Therapy (RET) 2. Problem Definition and Formulation. Pertinent information is assembled to clarify RET was perhaps the first cognitively the nature of the problem, set a realistic oriented therapy to be used with children-a problem-solving goal, and reappraise the fact not commonly known, perhaps because significance of the problem. RET remained relatively independent of other 3. Ceneration of Alternative Solutions. As cognitive-behavioral therapies for some years many solution alternatives as possible are (Clarizio, 1985). Ellis (1962) based RET on generated to increase the chance that the the premise that most everyday emotional best solution will be considered. problems and behaviors stem from irrational 4. Decision Making. The available solution self-statements we tell ourselves when events alternatives are evaluated and the best in our lives do not turn out as we would like one(s) are selected to use. (e.g., awfulizing, dernandingness, damnation, 5. Solution Implementation and Verification. always and never thinking). Ellis' therapeutic The solution outcome is assessed and the approach is to teach young people to counteract effectiveness of the chosen sol ution in the irrational beliefs with more positive and realistic real-life situation is verified. statements. The emotive aspects of RET focus

262 / May 2005 Behavioral Disorders, 30 (3), 259-276 on children changing their irrational beliefs Review of CBI Research for Young by exaggerating them in ways that show their ridiculousness or phoniness, such as through People Who Are Depressed the use of humor. The behavioral component of The extant literature on CBt with children RET is reflected by encouraging a young person and adolescents who are depressed is often to act in ways that contradict irrational ideas. punctuated by more reviews than actual According to a RET rnodel, depression has treatment outcome studies. Despite this fact, crucial cognitive Clnd philosophic elements, there are two reasons for providing yet another which include absolutistic, dogmatic shoulds, review here. First, because the purpose of this oughts, and nlusts, that are absent from article is to present CBI techniques for young peoples' appropriate feelings of sadness (Ellis, people who are depressed, it is important for 1987). Cornbating these factors may help readers to be familiar with the research upon improve the self-image of young people who which the theoretical foundation is based. are depressed (Aust, 1984; DiGiuseppe & Second, this review lays the groundwork for Bernard, 1983). It is important for practitioners subsequent recommendations for school-based to take into consideration young people's use of CBI for children and adolescents who linguistic and cognitive development, both in are depressed. their ability to acknowledge the existence of a The follOWing parameters were used to problem and to internalize a philosophy of life obtain articles for this review. First, a search of that is more rational and realistic than the ones the Psych!NFO database was conducted using they commonly engage in when experiencing the descriptors child/adolescent depression, depression (Clarizo, 1985). cognitive-behavioraI interventrons/therapy/ modification. This database was searched for Cognitive Therapy for Depression articles beginning in 1980 and continuing to October, 2004. The year 1980 was selected Although cognitive therapy for depression because that was when published reports was developed independently by Beck (1976), of nonsomatic treatment of childhood and it has n,uch in common with Ellis' RET. Like adolescent depression began appearing in Ellis, Beck and his colleagues described the literature. Second, an ancestor search was several dysfunctional thinking styles (e.g., conducted of all articles that met inclusion overgeneralization, magnification and criteria. Third, references were exan)ined minimization, personalization, dichotomous from review articles obtained from 1980 thinking). The first step in Beck's approach is to October 2004 that reported on CBI and to have a young person identify dysfunctional childhood/adolescent depression. Three thoughts and maladaptive assumptions that articles specifically contained reviews of CBI may be contributing to feelings of depression. (Marcotte, 1997; Reinecke, Ryan, & DuBois, A child may be instructed to recall or imagine 1998; Southam-Gerow, Henin, Chu, Marrs, situations that elicited such emotions and & Kendall, 1997) whereas six focused more to focus on the thoughts experienced in generally on psychological treatments for those situations. Next, Beck recommended which CBI was included {Birmaher, Ryan, the use of several techniques to counteract Williamson, Brent, & Kaufman, 1996; Curry, the debilitating thought or dysfunctional 2001; Finn, 2000; Harrington, Whittaker, & assumption contributing to depression. One Shoebridge, 1998; Lewinsohn & Clarke, 19~9; popular technique is called "reality checking" Sherrill & Kovacs, 2002). Fourth, only studies or "hypothesis testing." After the young person investigating the efficacy of CBI as an approach has identified the debilitating belief or thought for treating, rather than preventing, depression and has learned to distinguish it as a hypothesis were included. A total of 22 studies were rather than as a reality, he/she is then in a obtained and are summarized in Table 1. position to test it experimentally (Martin & Pear, 2003). For example, if a girl believes that eBI Components everyone who smiles is teasing her, then she might be helped to devise a system for reading CSt has been defined as techniques for context and judging peers' facial expressions promoting emotional and behavioral change and body language so that she can determine by teaching children to change thou~hts and objectively if the thoughts behind her problem cognitive processing in an overt, active, and are indeed accurate.

Behavioral Disorders, 30 (3),259-276 May 2005 /263 TABLE 1 Effective Cognitive-Behavioral Interventions for Depressive Disorders in Children and Adolescents

, . i I i I i Dependent Setting Design Study CBI Components Participants Measures Results

Self-monitoring, ShOl't term identifying and testing improvcment in irrational cognitions, DSRS, CDRS, DSI~S ilnd CDRS Asarno\V &: 10-year-old Psychiatric Case role pl

Collaborative emp i,·icism; monitoring and 37 adolescents, K-SADS, Improvement on Brent et al. Psychiatric Group modification of age 13-18 BOI, DSM-1l1 all measures; no (1997) hospit

StatisticaIII' Recognize irrational significant ilutOllliltic thoughts, 56 fifth and improvement ill adopt logical thinking, SES, OJ!, Butler et aI., sixth graders Public Group COl and NSLCSC, enhance listening MMSAQ, (1980) (35 males, 21 school design but role-play skills, recognize NSLCSC females) condition was relation between more effective; no thoughts and feel ings follow-up

Improvements Relaxation tra ining, in SOl and increasing ple

Significantly Identify and challenge 150 fewer cases of Clarke et al. irrationa I bel iefs, High CES-D, adolescents, Group depression; results (1995) role playing, group school des·lgn HDRS, GAF mean age 15.3 maintaincd at 12- discussions month follow-up

Mood monitoring, Positive resuhs improving social skills, on all measures; 96 adolescents BO!, HORS, Clarke et al. activity scheduling, Outpatient Group 100°1<, recovery (70.8°/0 K-SADS-E, (1999) communication clinic design at 12 months, females) GAF, CBCL training, conflict 35.7% recovery at resolution training 24 months Multistep, structured, manualized therapy focLlsed on how 1mprovements DiSalvo & 16-year- actions impact ilnd Outpatient Case in MMP1-A and McCullough old female MMPI-A, CDI shape environmental clinic COl scores; no (2002) adolescent study circumstances with follow-up problem-salvi ng conlponent

Manllalized approach Improvements vvilh cognitive priming, in COl and Eight children, sel f-Illonitoring, Friedberg e1 al_ mean age 8.8 RCMAS; some self-instruction, Outpatient Case (2003) (seven males, COl, RCMAS regression but not ra/iona I an

264/ May 2005 Behavioral Disorders, 30 (3), 259-276 TABLE 1 (continued) Effective Cognitive-Behavioral Interventions for Depressive Disorders in Children and Adolescents . .. Study CBI Components Participants Setting Design Dependent Measures Results Muhislep, structured, manu.llized lherapy Improvements focus(c'cJ on friendliness Open Ten in BOI and GUlinoI' & skills, self-monitoring, Outpatient clinical HRSD scores; adolescents, BDI, HRSO Lawrence (2002) p!t;,lsant event clinic trial age 13-1 B improvements scheduling, cognitive format maintained at 3- restructuring, problem month follow-up solving

39% experienced Test pessimistic decreases in beliefs, improve 1301, CGAS, depression; Gaynor et al. 87 adolescents, Outpdtient Group problem solvi ng, dffect K-SAOS treatment gains (2003) age 13-18 clinic design regulation and social maintained on skiIls BDI at 3-month follow-up

Participants with I

Constructive thinking, Positive changes self-monitoring, in all dependent self-reinforcement, 69 adolescents, measures; Kahn ct al. pleasant events age 10-14 Middle Group RADS, BID, improvements (1990) scheduling, role (33 males, 36 school design COl maintained at playing, problem females) 1- and 6-monlh solving, social skills follow-up training

Collaborative Reductions empiricism, K-SADS-P/E, in cognitive '103 socialization to GDI, BHS, distortions and Kolko ct al. adolescents, Outpatient Group cognitive model, CNCEQ, anxiety; some (2000) mean age 15.6 clinic design self-monitor automatic CBQ, ACQ, improvements (75'Yo females) thoughts, problem FAD, LW-MAT maintained at 24- solve, affect regulation month follow-up Less than 0.2% Centra1 elements of relapse compared 29 adolescents, Beck's (1967) cognitive to 0.5% for Kroll et al. mean age 13.7 Psychiatric Group therapy, social K-SAOS, MFQ control group; (1996) (12 males, 17 hospital design problem solving, fewer relapses remales) activity scheduling at 6-month follow-up

Increasing pleasant Improvements activities, relaxation, 59 adolescents, in all measures; Lewinsohn et aI. controlling depressive Outpatient Group K-SAOS-E, mean age 16.9 gains maintained (1990) thoughts, improving clinic design BOI, CE5-0 (61% females) at 2-year follow- social interaction, up conflict resolution Problem solving, Decline in Beck's (1967) cognitive 31 children, Catholic depression Liddle & Spence therapy, instructions, age 7-11 (21 Group COl, CDRS, primary scores; decl·eases (1990) discussion, modeling, males, 10 design MESSY, LSSP schools maintained at 2- role pl

Behavioral Disorders, -.n n \ ') r.:;q_/ 7(, May 2005/265 TABLE 1 (continued) Effective Cognitive-Behavioral Interventions for Depressive Disorders in Children and Adolescents

. i I I i - Dependent Setting Design Study CSt Components Participants Measures Results

Emphasized ["aining 30 adolescents, Irnprovements of scM-control RADS, BDI, mCiln age on all measures; Reynolds 8- skills including High Group BID, RSES, 1565 (11 gilins maintained Coats (19116) self-monilori ng, school design ASCS-HS, males, 19 at 5-week self-evaluation, and STI\I females) follow-up sel (-rei nforcement

Increasing pleasilnt ,Jctivitics, relaxation, 115 controlling depressive adolescents, K-SADS-E, Improvements on Rhode et al. Outpatient Group thoughts, improving mean ilge BDI, HDRS, all mcasures; no (1994) clinic deSign social interilction, 16.3 (69.9% GN follow-up conflict resolution females) training

Significant Identify how thoughts, COl, 71 adolescents, reduction in COl Rossello & daily activities, and Outpatient Group PHCSCS, meanage14.7 scores; gains Bernal (1999) interilctions with clinic design SASCA, (54%, females) maintained at 3- others influence mood FEICS, CBCL month follow-up

Significant Self-monitoring, self- COl, CDS, improvements evaluation, attributing Stilrk et al. 29 children, Elemcntilry Group CDRS-R, on all measures; cause of good and (1987) age 9-12 school design CBCL CSEI, results maintained bad outcomes, self- RCMAS at 8-week consequating follow-up

Recognition and Significant labeling of emotions, improvement K-SADS, Vostilnis et al. enhancement of Outpatient Group on all measures; 57 children SAle MFQ, (1996) social skills, changing clinic design gains milintained RCMAS negative cognitive at 9-month attribu!ions follow-up

(~ombat negative Sign i fican! thinking styles based 33 children reductions in on Beck's (1967) and MFQ, Wood et al. Outpatient Group depression; results cognitive therapy, ildolescents, RCMAS, WJS, (1996) clinic design maintained at social problem mean age 14.2 ABS 3- and 6-month solving, activity (69% females) follow-up scheduling

ABS = Antisocial Behavior SCilie DSM-1I1 MOD = Diagnostic and MMSAQ = Moyal-Miezitis Stimulus ACQ = Adaptation in the Area of Statistic Manual of Mental Disorders Appraisal Questionnaire Change Questionnaire (3 I'd) Major Depressive Disorder NSLOCSC '" Nowicki-Strickland Locus ASCA-HS = Academic Self-Concept DSRS = Depression Self-Rating Scale of Control Scale for Children Scale High School Version FAD", Family Assessment Device PHCSCS = Piers-Harris Children's GDI = Beck Depression Inventory FEICS = Family Emotional Involvement Self-Concept Scale BHS", Beck Hopelessness SCilie and C"iticism Scale RADS = Reynolds Adolescent BID = Bellevue Index of Depression GAl' = DSM-HI Globa! Assessment Depression Scale CBCL = Child Behavior Checklist of Functioning SCilie RCMAS = Revised Children's Manifest CBQ = Conflict Behavior Questionnaire HDRS = Hamilton Depression Anxiety SC31e COl = Children's Depression Inventory Rating Scale RSES = Rosenberg Self-Esteem Scale CDRS = Children's Depression K-SADS = Schedule for Affective SAICA = Social Adjustment JnventolY Rating Scale Disorders and Schizophrenia for Children and Adolescents CDRS-R = Children's Depression for School-Age Children SASCA = Social Adjustment Scale RJting Scale-Revised K-SADS-E = Schedule for Affective for Children and Adolescents CDS = Child Depression Scale Disorders and Schizophrenia for School­ SES '" 15-item reduced version CES-D = Center for Epidemiological Age Children-Epidemiologic version o( the Piers-Harl'is Children's Studies - Depression Scale LSSP = List of Social Situation Problems Self-Concept Scale CGAS", Children's Global LW-MAT", Locke-Wallace Marita!­ STAI = State-Trait Anxiety Inventory AssessmC:f1t SCJle Adjustment Test WJS = Warr and Jackson CNCEQ = Children's Negative MESSY = Matson Evaluation for Social Self-Esteem Scale Cognitive Errors Questionnaire Skills for Youngsters CSEI = Coopersmith Self- MFQ '" Mood and Feelings Esteem Inventory Questionnaire

266/ May 2005 Behavioral Disorders, 30 (3),259-276 problern-orientcd way (Reinecke et .11., -1998). 1999; Vostanis, Feehan, Grattan, & Bickerton, Kendzdl and MacDonald (1993) described 1996; Wood et aI., 1996). However, the the goal of CBI as identifying distorted number and length of sessions varied greatly processing, helping children to modify their from eight sessions with length not specified distorted thinking and teaching them new (Jayson et .11.) to 40 sessions, also with no length coping processing styles. All 22 studies specified (DiSalvo & McCullough). Other described methods that fall under these studies presented very specific information. For I'ubrics, to varying degrees of specificity. In example, Gaynor et .11. (2003) conducted 16 addition, pmblem-solving techniques, another two-hour sessions over 8 weeks. form of CBI, were incorporated into nine in summary, the most prominent cognitive studies (Asarnow & Carlson, 1988; Clarke, intervention strategies for depression in young Hops, Lewinsohn, & Andrews, 1992; DiSalvo people were some form of Beck's (1967) & McCullough, 2002; Gaynor & Lawrence, cognitive therapy. in addition, problem-solving 2002; Kahn, Kehle, Jenson, & Clarke, 1990; training, self-control training, and activity Kolko, Brent, Baugher, Bridge, & Birmaher, scheduling were typically incorporated into 2000; Krol I, Harrington, Jayson, Fraser, & most of the therapies. Finally, number and Gawel's, 1996; Liddle & Spence, 1990; Wood, length of sessions varied greatly across studies. Harrington, & Moore, 1996). Behavioral components such as activity Participants and Settings scheduling, reinforcement, modeling, rehearsal, and role playing were used less All participants were diagnosed as having a frequently. Activity scheduling (i.e., increasing depressive disorder using DSM clinical criteria pleasant events) was the most common (the edition of the DSM would vary depending behavioral technique and was used in nine On when the study was conducted). Both semi­ studies (Asarnow & Carlson, 1988; Clarke et structured interviews such as the Schedule aI., 1992; Clarke, Rohde, Lewinsohn, Hops, & for Affective Disorders and Schizophrenia for Seeley, 1999; Gaynor & Lawrence, 2002; Kahn School-Age Children (K-SADS), and self-report et ai., 1990; Kroll et aI., 1996; Lewinsohn, rating scales such as the Beck Depression Clarke, Hops, & Andrews, 1990; Rhode, Inventory (BDI) were used to make the Le\vinsohn, & Seeley, 1994; \Nood et al., diagnosis. Participants were more likely to be 1996). Two studies incorporated reinforcement either females or male and female adolescents. (Asarnow & Carlson; Liddle & Spence, 1990) Females were either the sole focus or a and four studies included modeling and/or substantially larger percentage of participants role playing (Asarnow & Carlson; Clarke for nine studies (Asarnow & Carlson, 1988; et ai., 1995; Kahn et .11.; Liddle & Spence). Brent et aI., 1997; Clarke et aI., 1999; DiSalvo Conversely, self-control techniques-which & McCullough, 2002; Jayson et al., 1998; have been conceptualized both from cognitive Kolko et aI., 2000; Reynolds & Coats, 1986; and behavioral orientations-were used as Rhode et al., 1994; Wood et aI., 1996). Only often as problem-solving training. Specifically, five studies focused on children (Asarnow & eight studies employed self-monitoring, self­ Carlson; Butler, Miezitis, Friedman, & Cole, evaluation, and/or self-reinforcement (Asarnow 1980; Friedberg et ai., 2003; Liddle & Spence, & Carlson; Clarke et al., 1999; Friedberg et al., 1990; Stark et al., 1987). Two studies had 2003; Gaynor & Lawrence; Kahn et al.; Kolka both children and adolescents as participants et ai., 2000; Reynolds & Coats, 1986; Stark et (Kahn et aI., 1990; Wood et al., ). Regardless ai., 1987). Two other techniques, which could of age, the number or percentage of female also fall under both cognitive and behavioral versus male participants was not specified in strategies, were social skills training (Gaynor et five studies (Clarke et al., 1992; Clarke et ai., aI., 2003; Kahn et al.) and relaxation training 1995; Gaynor & Lawrence, 2002; Gaynor et (Lewinsohn et al., 1990). aI., 2003; Rhode et al.). Specific CBt treatment protocols and Most of the studies (73%) were con­ therapist training were described in over half ducted at psychiatric hospitals (11 = 4) or the studies (Clarke et aI., 1995; Clarke et al., mental health clinics on an oLJtpatient basis 1999; DiSalvo & McCullough, 2002; Friedberg (n = 12). Unfortunately, it does not appear et .11., 2003; Gaynor & Lawrence, 2002; Jayson, that the six studies conducted in school Wood, Kroll, Fraser, & Harrington, 1998; Kahn settings represented a recent trend. The first et aI., 1990; Kroll et .11., 1996; Lewinsohn et .11., study usi ngCBI to treatchildren and adolescents 1990; Rhode et aI., 1994; Rossello & Bernal, who were depressed was conducted in a

Behavioral Disorders, 30 (3), 259-276 May 2005 /267 public school setting (Butler et aI., 1980); Results and follow-up hovvever, this vvas not the norm across the studies reviewed. The most recent study In every study, CBI had a positive imjJa '. I ct included in this review that \vas conducted on c1epresslon III t ,e reduction of SCores - J On in a school setting was still a decade old at measures at c epression and related constructs the time this article vvas published (Clarke and/or fewer cases of diagnosed depression and et aI., 1995). Half the studies reviewed were relapses. However, results are less conclusive conducted after 1995 in psychiatric hospitals in the 11 studies that cornpared CBI to other or outpatient n,ental health clinics. Therefore, treatments. Four studies found CBI superior it is difficult to generalize the efficacy of to either sys.temic beha~ior family ther'apy CBl for use in school settings from only six or nondll'ectlve supportive therapy, social studies-only three of which were published competence training, or relaxation training after the decade of the 1980s (Clarke et ai" (Brent et aI., 1997; Clark et al., 1999; Gaynor 1995; Kahn et al., 1990; Liddle & Spence, et al., 2003; Wood et aI., 1996). In eight 1990). Nevertheless, a I'eview of a larger group stue/ies, no differences were obtained between of studies of CBls for depression can inform CBl and CBI for adolescents and parents us as to important aspects of treatment for (Clarke et aI., 1999; Lewinsohn et aI., 1990; depression that could be relevant to school­ Rhode et aI., 1994) and other' treatments based efforts, including relaxation training, interpersonal psychotherapy, behavioral problem solving, Designs and Dependent Measures nonfocused intervention, and self-modeling (Kahn et al., 1990; Reynolds & Coats, 1986; The majority of studies reviewed employed Rossello & Bernal, 1999; Stark et aI., 1987; some type of traditional group design (81 %). Vostanis et aI., 1996). In an early study, role There were three case studies (Asarnow playing was superior to CBI (Butler et aI., & Carlson, 1988; DiSalvo & McCullough, 1980). 2002; Friedberg et aI" 2003) and one open An encouraging finding was that a majority clinical trial format (Gaynor & Lawrence, of the studies (77'%) conducted some type of 2002). There were no studies that employed follow-up. In all cases, treatment gains were single subject designs. This ornission may be maintained to some degree. The shortest follow­ expected because depression is primarily a up \·vas 2 months (Liddle & Spence, 1990) disorder of affect. That is not to say that single and the longest was 5 1/2 years (Asarnow & subject methodology could not be used to Carlson, 1988), Two studies collected follow­ determine changes in weight, sleep patterns, up at multiple times (Clarke et aI., 1992; Kahn and pleasant interactions with others. However, et aI., 1990). Follow-up occurred four times this approach was more often to be employed during the Clarke et al. study-at 1, 6, 12, and in traditional (i.e., skills deficit rnodel) social 24 ITlonths-but treatment gains were only skills training studies with young people who maintained up to 6 months. were depressed (e.g., Frame, et a!., 1982; Sch loss, et a I., 1 984). The CBI studies reviewed used a Implications for School Personnel combination of diagnostic interviews for Researchers have demonstrated that depressive disorders, self-report depression CBI is an evidenced-based approach for inventories, and ratings of depression treating depressive disorders in children and completed by others. A variety of related adolescents-at least in clinical settings. The constructs were also assessed before and after question remains as to whether CBI is a viable treatment, including, but not limited to, social adjustment, self-concept, locus of control, approach for school personner. Results were anxiety, hopelessness, and social adjustment. encouraging but somewhat dated. Of the six CBI studies conducted in school settings, three Only one study collected direct observations of overt behaviors (Kahn et a!., 1990); used currently employed school psychologists and school counselors as therapists (Clarke ~Ithough no treatment of this data is provided et al., 1995; Kahn et ar., 1990; Reynolds & III the results section. The lack of targeting overt behavior's was probably for the sa/TIe Coats, 1986), Graduate students at various reason llone of the studies ernployecl single levels of training (e.g., post graduate, doctoral, subject designs. graduate) in applied and clinical psychology

268/ May 200S Behavioral Disorders, 30 (3),259-276 served as thcrZlpists in the other three studies

Primary Roles of School Although many school psychologists serve Psychologists and Counselors primarily as assessment specialists, there are many schools and school districts that utilize School psychological and counseling school psychologists' expertise in counseling services have evolved to the point of and consultation. The school psychologist considerable compatibility (Murphy, DeEsch, can play a vital role in assessing students & Strein, 1998). Training accreditation who may experience a depressive disorder standards for both professions include skill and then vvorking with these students and development in the areas of assessn,enC their families to obtain appropriate services. consultation, and counseling and in facilitating These services may either be delivered Or the delivery of comprehensive services within supel'vised by the school psychologist or the a multidisciplinary tean, concept (Council school psychologist may refer the student for the Accreditation of Counsel ing and and his/her family for professional care in Related Educational Programs, 1994; National the community. Association of Schoo! Psychologists, 1994). In Nastasi, Varjas, Bernstein, & Pluymert addition, school psychologists and counselors (1997) described four levels of set'vices across alike obtain licenses in their respective areas which school psychologists can be involved that permit them to conduct psychotherapy either directly or indirectly in developing and receive third party reimbursement. They mental health programs in schools: also have unique training and expertise that 1. Prevention: helping a school choose a complement each other-especially when program for students to manage theit" it comes to addressing the needs of students feelings. "vho display depressive symptomatology. 2. I<"isk reduction: helping counselors target Specifically, school counselors have skills students whose parents suffer from in small group counseling, large group depressive disorders and work with these developmenta1 interventions, and vocationa1 students in a support group.

Behavioral Disorders, 30 (3), 259-276 May 2005 /269 3. Earfy intervention: helping preschool and tary level-has been to conduct individual elelTlentary teachers recognize the signs and group counseling (Hargens & Gysbel's, and syn,ptoflls of depressive disorders. 1984). More recently, school Counselors 4. Treatment: delivering dil'ect treatment have been assLlming an increased role as to students experiencing a depressive menta! health counselors (Lockhart & Keys, disorder. 1998). Nowhere is this role as important as in providing services for students who Universal preventative ITleasures may are depressed or experiencing depressive consist of the school psychologist implernenting syr-nptornatology. Evans, Van Velsol-, and Reynold's (1986) three-stage screen ing to identify Schumacher (2002) described the role of children and adolescents who were at risk for school counselors in using CBI as that of experiencing depression in school settings: (a) active collaboration with the student. School conducting large-group screening with self­ counselors ask questions, surnrrlarize, get report depression measures; (b) retesting, 3-6 feedback, and promote alternative responses. weeks later, students who, on the basis of the This active approach fits well into the culture large-group screening in Stage 1, meet cutoff of schools and helps avoid awkward silences score criteria for depression; and (c) conducting that make many students ill at ease (Evans & individual clinical interviews with students who Murphy, 1997; Platts & Williamson, 2000). manifest clinical levels of depression at both Evans et ai, (2002) also described three classic Stage 1 and Stage 2 evaluations. A selective levels of prevention using CBI that school preventative measure might include the school coullselors can undertake: primary, secondary, psychologist identifying students whose parents and tertiary. have a depressive disorder and then working Applying the 10M (1994) model, the with those students to educate them about the recommendations of Evans et a!. (2002) nature of depression and ways to cope vvith may be modified and elaborated on in the depressed rnood. The third and fourth steps following ways. Primary prevention would of early intervention and treatment includes be the responsibility of the school psycholo­ case identification and standard treatment for gist implementing Reynold's (1986) three­ known disorders. Educating teachers and school stage screening program described previously. personnel in the identification of depressive Evans et al. also recommend the use of symptomatology would be a vital component problem-solving and social skills training for referral. School psychologists can provide during this phase because the goal of these inservice training for teachers regarding the signs approaches is enhanCing coping mechanisms and symptoms of depression. Stark, Kendall, et and interpersonal abilities of students at al. (1996) developed a data-based treatment risk for developing depression. Problem­ program for depression in youth that can be solving techniques can help students delivered in the school setting, confront issues they face in normal growth Nastasi and colleagues' (1997) del ineation and development. Social skills training can of the school psychologist's role in effective promote positive socialization thereby giving mental health services in the schools does students greater access to reinforcement, not include 10M's (1994) maintenance which is important to prevent depression. component. However, school psychologists are However, these two techniques more typically well trained to aid in treatment maintenance have been associated with the rOM treatment by developing follow-up plans with depressed phase. Problem-solving training and social students and their parents. Additionally, school skills training have been used individually psychologists can help coordinate after-care to treat depression and also have been plans with community providers. School incorporated into some CBI approaches psychologists are often the link to community (Maag & Forness, 1991; Stark, Swearer, et mental health agencies and can help facil i­ ai., 1996). Evans et al. recommended that tate horne-school-community communication school counselors' role in maintenance would (Cowan & Swearer, 2004). be to maintain open communication with community mental health care providers in Roles of Schoof Counselors order to monitor campi iance with long-term goals and reduce the risk of relapse when One of the roles of school counselors after-care services are provided. for the past 20 years-at least at the elemen-

270/ May 2005 Behavioral Disorders, 30 (3L 259-276 Ancillary Role of Special Educators adaptive ones. There is some research to suggest that the cognitive functioning of chddren and Special educators are not trained, nor adolescents who are depressed is characterized do they hold licenses, to provide counseling more by negative self-evaluations than a lack of services to students with disZlbilities. That is active information processing (Kendall, Stark, 110t to say, however", that they cannot play & Adam, 1990). Therefore, special educators' an important ancillary role. There is some role may be to help a student follow through on evidence to suggest that students with EGO, LO, personal experiments designed by the school and mental retardation experience depressive psychologist or counselor to refute negative syrnptomatology CIt higher levels than their self-statements. nondisabled peers (e.g., Maag& Behrens, 1989b; Teachers have been using social problem­ Reynolds & Miller", 1985). In addition, special solving curricula fOt" many years. One of the educators have received training in some of the earliest programs was developed by Shure and techniques typically incorporated into CBI. Spivack (1974) for use with preschoolers. Since Self-monitoring has been used to then, other programs have been developed for l improve students academic achievement use with elementary and high school students, and decrease inappropriate social behaviors both for prevention and intervention (Cesten et such as aggression and noncompliance (Reid, al., 1987). Classroom teachers have successfully 1996; Webber, Scheuermann, McCall, & served as trainers in many problem-solving Coleman, 1993). In a review of research on training studies (Pellegrini & Urbain, 1985). self-monitoring, Reid concluded that it is an Most published curricula contain easy-to­ intervention repeatedly proved to be effective by follow scripted lessons. Therefore, it vvould not any objective standard and easily incorporated be unreasonable to envision special educators into existing classroom structures and activities. carrying out problelTl-solving training lessons Self-monitoring has been successfully used that were modified by the school psychologist by special educators to increase appropriate or counselor for specific use with students who verbalizations and decrease inappropriate are depressed. verbalizations in students with EGO (DiGangi & Maag, 1992). It would be a simple matter to deSign self-monitoring sheets for students who Conclusion are depressed to record the number and type of Depression is one of the most cornrnonly positive interactions they have with others and diagnosed psychiatric disorders among school­ daily accomplishments. age youths. As such, school personnel should Special education teachers have also play an important role in the identification, successfully used a variety of CBI strategies assessment, and treatment of depression and for improving students' decoding and reading related school problems. School-based treat­ comprehension skills, vocabulary, spelling, ment of depression is especially relevant for writing, and mathematics (e.g., Pressley et special educators who work with students with a[., 1990). However", there is an important EBD and LD because they may be at a higher distinction between CBI strategies used in risk than their nondisabled peers for developing teaching academics and in treating depression. depression. Three major areas \I\fel"e addressed SpeCifically, cognitive strategies for remediating in this article: (a) comrnon CBt approaches; (b) academics assume the problem is a cognitive review of CBI with school-aged youths; and (c) deficit. That is to saYI a student is lacking a implications for school personnel. specific strategy to perform a given task. For Four of the most cornman CB I approaches example, a student may be competent at addi ng, were described: (a) self-instruction U-aining; subtracting, and multiplying numbers and yet (b) attribution retraining: (c) problem-solving not understand how to divide. What is lacking training: and (d) cognitive restr~cturing (Bec.k:s is a strategy to combine those prerequisite cognitive therapy of depreSSion and Ellis s skills into competent performance. Conversely, RET). The first three approaches have been cognitive distortions exist when an individual used in schools by special educators to teach interprets information irrationally and in an academics and manage students' behavior erroneous fashion. In this case, CGI strategies problems. All four approaches have been used would focus on teaching the individual to by school psychologists and counselor's for identify her maladaptive thoughts, dispute treating depression. those thoughts, and r'eplace them with more

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