School Based Interventions: How can unipolar depression and externalizing disorders in urban youth in America be prevented by school interventions?
by Lana Denysyk
Among school-aged children, rates of depression have increased over the past few years. Depression as defined by the DSM IV- TR includes symptoms of a depressed or irritable mood, loss of interest in activities, and problems with attention and social functioning (Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev; DSM-IV-TR; American Psychiatric Association, 2000). Of children diagnosed with depression, 20% require mental health interventions, 11% have significant functional impairments, and 5% suffer from extreme impairment (Lyon & Budd, 2010). More than 70% of children and adolescents with depression do not receive proper treatment or diagnosis (Bhatia & Bhatia, 2007). During adolescence depression can have a negative impact on growth and development and school performance. In extreme cases, depression can lead to suicide (Bhatia & Bhatia, 2007). It is important to intervene as early as possible in children with depressive symptoms because children have limited communicative abilities and may not be able to identify how they are feeling.
Aside from depression, the diagnoses of externalizing or disruptive disorders have also recently increased. Children with externalizing disorders have an increased risk of academic failure, juvenile delinquency, and social problems, which in turn places strains on mental-health and educational services (Jaffee et al., 2002). Externalizing disorders include conduct disorders (CD), oppositional defiant disorders (ODD), and attention-deficit hyperactivity disorder (ADHD), however, for the purposes of this paper, only ODD and CD will be investigated. Externalizing disorders are among the most common reasons to refer a child to receive mental health services (Lyon & Budd, 2010). For instance, ODD and CD are usually first diagnosed in infancy, childhood, or adolescence (DSM–IV–TR, 2000). ODD involves patterns of negativistic, hostile, and defiant behavior, while CD involves patterns of behavior that violate the basic rights of others or major age-appropriate societal norms or rules (DSM–IV–TR, 2000). Due to the prevalence of externalizing disorders in school- aged children, prevention and intervention programs should be funded so that children with oppositional defiant disorder do not grow to have conduct disorder and these children do not present harm to society from their increased risk for juvenile delinquency and social maladjustment (Hudziak, Copeland, Stanger & Wadsworth, 2004).
Due to the increase in prevalence of depression and externalizing disorders in school-aged children, schools are being recognized as critical intervention sites for mental health service delivery due to the amount of time children spend in these institutions (Powers, Bower, Webber, & Martinson, 2011). Most notably, schools have the unique potential to provide settings for targeting children's mental health, academic performance, and witness how mental health can affect academic performance (Reinke, Stormont, Herman, Puri, & Goel, 2011). How can unipolar depression and externalizing disorders in urban youth in America be prevented by school interventions will discuss the public health framework approach to mental illness prevention as the method schools districts should aim for in establishing prevention and intervention programs in their schools. A public health framework will be suggested and then this paper will discuss how school personnel and risk factors fit within the proposed framework. Current programs already in place at schools will be critiqued per their strengths and limitations, and future implications will be discussed.
Proposed Public Health Framework
Whereas previously schools approached mental health illness prevention using an individual focus, researchers are currently advocating a public health framework (Dowdy, Ritchey, and Kamphaus, 2010). The public health approach focuses on the population rather than the individual due to the belief that even one individual’s illness can threaten the health of the entire population and, therefore, change must occur at the level of the population rather than the individual for lasting change in the community, (Dowdy et al., 2010). Dowdy et al. (2010) propose a three-tiered approach, where the third tier involves universal services for everybody in the school, such as prevention taught in health classrooms. The second tier would provide selective or targeted service to those students who are deemed to be at risk, while the first tier would provide intensive interventions for students with the greatest need. The three-tiered approach seems to be financially feasible and not overly time consuming because it does not involve superfluous one- on- one psychiatric interview with every student. In addition, the students who do not seem to have as high a risk would still receive preventative information and resources to help them should they develop risk factors. This three-tiered proposal accounts for all who fall on a continuum of mental health without wasting resources or time spent by teachers and school psychologists.
Teachers and School Psychologists
Teachers play an important role in the public health framework because they are the front line in observing student behavior and noting unhealthy behaviors, such as acting out or becoming withdrawn and depressed. For example, in a study by Reinke et al. (2011) to determine teacher perspectives on mental health needs and service in school districts and their role in supporting mental health in their students, teachers indicated that the most concerning mental health issues in their respective schools were behavior problems, hyperactivity and inattention problems, students with significant family stressors, social skills deficits, and depression. Teachers overwhelmingly agreed that more needs to be done about students' mental health needs, but only 4% of teachers indicated that they felt they have the ability and knowledge required to meet the mental health needs of their students (Reinke et al., 2011). The teachers’ inability to help their students is disheartening considering the fact that teachers had undergone workshops and graduate courses to gain the knowledge and skills to meet mental health needs. While interventions for depression and externalizing disorders at public schools are reasonable in theory, there are many obstacles that refute a successful method. The obstacles to providing comprehensive mental health assessments and treatment in schools include a lack of mental health identification and support training for teachers, as well as a lack of resources such as finances and time involved (Powers et al., 2011).
Although it would be ideal to train every teacher to identify and support students with mental illnesses, most of the workload would rest on the shoulders of school psychologists and social workers. School psychologists and social workers provide another outlet within the school system to help students with mental illnesses. School counselors have been identified as the ideal members of the school to provide support for students because they can focus on student needs and interests and are aware of the developmental stages through which these students are progressing. In fact, Hains, Jandrisevits, Theiler, and Anders (2001) suggest that school psychologists and social workers address student problems and concerns through counseling relationships both individually and with small-groups as a method of preventative care. However, once at-risk students are identified, it is unclear as to what the treatment should be and who should be responsible. School counselors do not have the training required to conduct long- term therapy with their students, and many school districts do not believe that it is their role to do so (Hains et al., 2001). On the other hand, Stice, Shaw, Bohon, Marti, and Rohde (2009) found that shorter prevention programs produce significantly larger outcome effects than longer programs Although prevention programs are more effective when delivered by professional interventionists, teachers may also be trained in prevention skills to aid in personal, career, and academic growth by organizing and overseeing large-group, developmental skill-building activities (Baranowski, Cullen, Nicklas, Thompson, & Baranowski, 2002). Unfortunately, there are usually only a handful of school psychologists and social workers in large public schools. Currently, these mental health workers are bogged down with daily time-consuming tasks, such as tracking students’ attendance, that do not directly impact the mental health of their students (Powers et al., 2011). Although it is important to identify which student attend class, psychologists and social workers should take on more meaningful work within their school districts, such as teaching healthy coping skills or conducting therapy sessions for students in need.
In order for prevention programs to be effective, risk factors need to be universally agreed upon by researchers and clinicians in order to identify risk factors that may help predict mental illnesses. Otherwise, prevention and intervention programs cannot be fully valid because researchers will not know whether or not certain risk factors do in fact lead to exacerbation of mental illnesses. However, it should be noted that development is very complex, and children who have similar identifiable risk factors may not develop a similar disorder (Greenberg, Domitrovich, & Bumbarger, 2001). The intricacies of how a disorder develops further complicate the design of effective prevention programs.
In terms of risk factors for psychopathology in adolescents, Tully, Iacono, and McGue (2008) found that being the child of a depressed mother, but not a child of a depressed father, increases the likelihood of being diagnosed with a mental illness. Risk factors for oppositional defiant disorder and conduct disorder include low socioeconomic status, child abuse, being male, and parental mental illnesses such as mood or substance abuse disorders (Alan, 2011). Risk factors for depression in children and adolescents include poor parenting or family discord, poor school performance, being female, stressful life events, elevated depressive symptoms, a pessimistic explanatory style, parental mood disorders, and chronic illness (Bhatia & Bhatia, 2007; Jaffee et al., 2002; Stice, Shaw et al., 2009).
It may be useful to survey young children before they enter school for aggressive behavior, as aggressive behavior can be witnessed as early as two years of age and is fairly consistent in males (Shaw, Gilliom, Ingoldsby, & Nagin, 2003). However, other researchers disagree, arguing that screening should not be done for only certain disorders such as depression, oppositional defiant disorder and conduct disorder because many students with other disorders may be missed (Dowdy et al., 2010). Dowdy et al. (2011) assert that surveys should be given out to students and screen only for broad measures of maladjustment that have the potential to lead to disorders. By measuring for all maladjustments, schools can more readily identify all students who seem to be at risk for any mental illness, not just depression or externalizing disorders.
While it would be beneficial to survey all students within the school for risk factors, not all students will require intensive intervention. There are stronger effects in outcomes when the preventions and interventions are given to high-risk students rather than everybody in the school because students who do not have risk factors will not be motivated to work in the program (Stice et al., 2009). Students had the best outcomes in treatment when treatment was limited to those who were deemed at risk for depression, eating pathology, anxiety, and behavior problems (Stice et al., 2009). Outcomes in depression prevention programs were considered successful if they could reduce negative cognitions, promote problem-solving skills and social skills, and encourage the participant to engage in pleasant activities (Stice et al., 2009). Researchers found that cognitive, parent or family, and interpersonal interventions are potential mediators of prevention outcomes for depression (Collins, & Dozois, 2008). It has been shown that programs that involve teaching students cognitive-behavioral approaches to problems are successful in preventing depressive symptoms.
Current Programs in Place
A current technique further studied by Lyon and Budd (2010) is Parent-Child Interaction Therapy (PCIT). Parent-Child Interaction Therapy utilizes cognitive-behavioral therapy to help parents strengthen their relationship with, and set limits for, their disruptive children. Parents are taught skills to help increase their child’s prosocial behavior and decrease their disruptive behavior through child directed interaction where the child directs the parent in play, and parent directed interaction where parents utilize behavior management that they have learned (Lyon, & Budd, 2010). Lyon and Budd (2010) focus on moving beyond controlled research settings and into community mental health centers, where ethnic minorities typically receive their health care services. Although Parent –Child Interaction Therapy has been shown to work in controlled research settings, it has not yet been studied outside of the clinical setting. Even within a clinical setting, many parents dropped out of the treatment before it ended. It is of utmost importance to study the financial and cultural barriers preventing parents from fully participating in their children’s treatment because parent training has been found to be the best treatment for children with externalizing disorders (Lyon & Budd, 2010). While the attrition rate of this study was high, the researchers found that the parent-child dyads that completed treatment had clinically significant results in decreasing their externalizing behaviors.
Much like Parent-Child Interaction Therapy, The Penn Resiliency Program (PRP) is a program that attempts to intervene on groups of students in middle and elementary schools. The program attempts to mediate by teaching cognitive-behavioral problem solving skills, as well as social skills (Collins, & Dozois, 2008). Cognitive Behavioral Therapy (CBT) is a popular methodology in psychotherapy, and this prevention teaches students skills that they would learn after suffering from a mental disorder. Only six to ten students were in the fifteen-session course, and the results indicated that there was a reduction in depressive symptoms after the intervention and during the follow-up period (Collins & Dozois, 2008). A majority of interventions utilized the Penn framework with positive results for a reduction in depressive symptoms.
The Coping with Depression Course is another cognitive–behavioral intervention program that has shown significant post-treatment effects (Collins & Dozois, 2008). The depression course includes teaching coping skills such as cognitive evaluation, relaxation, and pleasant activity scheduling. Negative thoughts and self-esteem scores mediated participants’ depressive symptoms post-treatment which suggests that the cognitive interventions used accounted for the changes in depressive symptoms, while it remains unclear which aspect of treatment may have contributed to changes in self-esteem (Collins, & Dozois, 2008). It is suggested that stronger emphasis on cognition may make depression prevention more effective. While the Penn Resiliency Program and Parent-Child Interaction Therapy programs seem to have significant results in prevention and intervention, they are not currently used in schools or administered by school personnel. Part of the reason may be that including a parent component to interventions with students may increase the efficacy of prevention programs, and results may not be seen if only the students receive care (Collins, & Dozois, 2008).
Current research indicates that prevention and intervention programs have the potential to improve mental health outcomes in school-aged children. However, more research needs to be done to study the risk factors that are most predictive of future mental health problems in school-aged children so that more children can receive help. While all students may not benefit from prevention programs, the amount that will benefit makes these programs a success from the public health standpoint. Determining risk factors that have the highest predictive rate for future mental illness is of utmost importance for the advancement of prevention in schools. Without knowing what to look for, researchers, clinicians, and school personnel will not be able to effectively help.
Despite its success, the Penn Resiliency Program, Parent-Child Interaction Therapy and the Coping with Depression Course still have flaws that need to be addressed by adding new methods of intervention and treatment. Penn Resiliency Program also suffers in a real world setting, as do most interventions. As with Parent-Child Interaction Therapy, the Penn Resiliency Program relies heavily on parental involvement for its success. The Parent-Child Interaction Therapy study showed significant findings when participants stayed with the program, but it is necessary to find a way to entice parents and have a lower attrition rate for the general public who are not as motivated or dedicated to helping their children. However, stable parental involvement in a child’s treatment is taken for granted in a laboratory setting, as it does not translate well into the real world.
Further research should be done to determine exact risk factors of unipolar depression and externalizing disorders as well as the settings in which prevention and intervention programs take place. While many prevention and intervention programs show significant results within a laboratory setting, such perfect conditions of parental involvement, free treatment for research purposes, and cultural attitudes towards psychotherapy are not seen in typical urban America. Research should focus on how to make the programs work in the real world, after they have established that prevention and intervention programs produce significant results in the laboratory.
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