Cari McCarty, Ph.D.Cari McCarty, Ph.D.Research Associate Research Associate Professor, PediatricsProfessor, PediatricsDirector of Research, Director of Research, Adolescent MedicineAdolescent Medicine
School-Based Interventions for Childhoodand Adolescent Depression
Prevalence of DepressionPrevalence of Depression
Lifetime prevalence of mood disorders is Lifetime prevalence of mood disorders is 20.8% 20.8% (National Comorbidity Survey Replication)(National Comorbidity Survey Replication)
Hazard rates highest in mid to late Hazard rates highest in mid to late adolescence adolescence (Burke et al., 1990)(Burke et al., 1990)
MDD affects an estimated 6 million children MDD affects an estimated 6 million children and adolescents and adolescents (NIMH, 2002)(NIMH, 2002)
Burden of depressionBurden of depression
Depression now considered a “chronic Depression now considered a “chronic disease”disease”
Even subclinical levels of depressive Even subclinical levels of depressive symptoms interfere substantially with symptoms interfere substantially with adjustmentadjustment
Leading cause of disability worldwideLeading cause of disability worldwide Risk for suicide, other psychiatric disorders, Risk for suicide, other psychiatric disorders,
substance usesubstance use
Media Attention to Suicide
Recent high profile media cases have drawn increased attention to youth suicide (and bullying)
Research Pathway
Developmentand Context
Role of family, peers, school
Youth Depression
Understanding Youth Depression
Parental Depression
Parental Social Support
McCarty et al., 2005; Weisz, Southam-Gerow & McCarty, 2001; McCarty et al., 2007; McCarty et al., 2006; McCarty et al., 2009
Thinking Styles
Stressful events
Low caregiver support School Failure
*girls!
Youth Depression
Research Pathway
Developmentand Context
InterventionEfforts
Role of family, peers, school
Benefit of cognitive-behavioral skills
Youth Depression
Examining Treatment Effects
Family risk factors important (parental depression, family climate, parental cognitive style)
But, families have mostly NOT been incorporated into clinical treatment research with depressed adolescents (32% of studies)
Sander & McCarty (2005). Youth depression in the family context: Familial risk factors and models of treatment. Clinical Child and Family Psychology Review, 8, 203-217.
1998
Psychotherapy for Youth Depression: Evidence of Treatment Effects
Reinecke, Ryan & DuBois
6 CBT Trials
ES = 1.02
1999 2002
Lewinsohn & Clarke
12 Trials
ES = 1.27
Michael & Crowley
14 Trials
ES = .72
Weisz, McCarty & Valeri
35 Trials
ES = .34
Weisz, McCarty, Valeri, 2006. Psych. Bull. 132:132-149
more modest
Component Analysis of EBTs
Goal-settingSelf-monitoringAttention to relationshipsCognitive restructuringProblem-solvingBehavioral activation Child psychoeducationCommunication training
Youth with Suicidal Ideation in Primary Care
Have high levels of functional impairment (84% “definitely impaired”)
Higher levels of comorbidity (externalizing, substance use)
Only 26% received any mental health care in the previous year, including 13% outpatient mental health, 7% antidepressants, and 12% outside counseling/treatment
McCarty et al. (in press). Adolescents with suicidal ideation: Health care use and functioning. Academic Pediatrics.
Intervention Model: Positive Thoughts Intervention Model: Positive Thoughts & Actions& Actions
Individualvulnerabilities
Depression
Interpersonal
Behavioral
Cognitive
CHILDInterpersonal Skills
BehavioralActivation
Cog. RestructuringEmotion Regulation
Problem-Solving
Parentsand
FamilySchool Relationships
Salient Contextual Factors
PARENT Emotion RegulationEmpathy for TeenCommunication
Family
Why intervene in schools?
SEAL (Social, emotional, and academic learning) perspective
Broad reach of target population More likely to reach underserved youth Mental health service accessibility is poor in
many communities Potentially less stigma
TARGET AREASTARGET AREAS
Learning Learning GradesGrades Study Skills—Organization & Time ManagementStudy Skills—Organization & Time Management HomeworkHomework
RelationshipsRelationships FamilyFamily FriendsFriends School & CommunitySchool & Community
Healthy Mind and BodyHealthy Mind and Body Stress & MoodsStress & Moods SleepSleep NutritionNutrition ExerciseExercise
Goals of the Parent ComponentGoals of the Parent Component
Engaging parents in the intervention Engaging parents in the intervention processprocess
Providing parents a common language Providing parents a common language and understanding of the core skills and understanding of the core skills
Fostering a better parent-child relationship Fostering a better parent-child relationship
Raising parent awareness of students’ Raising parent awareness of students’ goals and progress goals and progress
Pilot Testing of InterventionPilot Testing of Intervention
2005-2007 School Years 2005-2007 School Years
– Eckstein, Hamilton, McClure, Whitman Middle Eckstein, Hamilton, McClure, Whitman Middle SchoolsSchools
Screened 684 youth for depression; 67 Screened 684 youth for depression; 67 included in intervention studyincluded in intervention study
Gains in skills (coping, cognition, Gains in skills (coping, cognition, communication)communication)
Middle School Matters StudyMiddle School Matters Study
Randomized to the previously developed Randomized to the previously developed program (Positive Thoughts & Actions) or brief program (Positive Thoughts & Actions) or brief intervention (MAPS)intervention (MAPS)
Screened for Depressive
Symptoms using MFQ
N=1190
Eligible based on inclusion &
exclusion criteria
N=242
Enrolled in Prevention Trial
N=123
Positive Thoughts & ActionsPositive Thoughts & Actions
11 groups, led by 6 different leaders in 4 11 groups, led by 6 different leaders in 4 different schoolsdifferent schools
Alderwood Middle School: Alderwood Middle School: After-School ModelAfter-School Model
MAPS MAPS
1-2 hour individual interview, computer-assisted, 1-2 hour individual interview, computer-assisted, elements of assessment, empathy, motivational elements of assessment, empathy, motivational interviewing, social support, and brief problem-interviewing, social support, and brief problem-solving solving
Middle School Matters - Intervention
REACHING YOUR GOALS
GOALSDeciding what we want to and who we want to be
STEPSBreaking goals into smaller steps takes us closer to our goals
To be effective, steps and goals need to be:
Realistic
ControllableWithin reachNot too easy
Specific
ClearMeasurableHas a timeline
Desirable
Something valuedA healthy choiceHelpful to all involved
PLANNING FOR TRIGGERS AND ROADBLOCKS
Hit your roadblocks and triggers head on! How? Make a plan that includes both thoughts and actions:
TRIGGERS Set us off course from the path to our goals
ROADBLOCKS
Get in the way of reaching our goals
First identify the thoughts and roadblocks that keep you from being successful. Then make a plan for what you can tell yourself and what you can do to stay on course.
THOUGHTS— What we tell ourselves to stay on track
ACTIONS— What we do to stay on track
MEETINGS WITH PARENTS
Meeting 1Getting to Know Each OtherHome visit with parent and student Meeting 2Understanding Your Child’s Emotional DevelopmentGroup parent meeting Meeting 3Communicating with Your 7th Grader Group parent meeting Meeting 4Staying Successful Home visit with parent and student
Ongoing Research Questions
Who is most at risk of developing depression?
What are the effects of skills-based group intervention vs. individual support?
Are effects specific to depression?
What components of the prevention are most important?
For whom does it work?
Summary Points
There are many common components of effective treatments for youth depression
Interventions in non-specialty settings (schools & primary care) may help provide access & reduce stigma
Benefits and barriers to in-school vs. after-school models must be weighed
Acknowledgements
Postdocs FundingHeather Violette, Ph.D. National Institute of Mental HealthBrian Wymbs, Ph.D.
Interventionists Research AssociatesRick Cruz Leticia HollemanMarissa Corona Mary Casey-GoldsteinAlyson Barry Elizabeth McCauleyJessie Waimau-AriotaUrsala SchwennSonja KottkeMarjorie NewmanCezanne HardyLisa Gloria-WallaceBecky Parrish
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