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Preventing Teen Depression

A Program Based on Cognitive Behavioral Therapy Gives Adolescents Some Tools to Stave Off Depression

By Jane Gillham

14_depression.jpgDepression is one of the most prevalent psychological disorders and, as such, it is an important target for prevention efforts. Recent research has identified several risk factors for depression, including genetic vulnerabilities, family conflict, traumatic life experiences, pessimistic cognitive styles, and elevated depressive symptoms, which has paved the way for a wide range of prevention programs. Most of these are based on cognitive-behavioral treatments of depression that teach clients skills for coping with stress and for challenging negative beliefs.

Adolescence is a particularly important period for depression prevention efforts. Rates of depression increase dramatically during adolescence, beginning at about age 13. In fact, by high school, depression is one of the most common public health problems affecting approximately 5 to 10 percent of adolescents each year. Even more adolescents suffer from high but sub-clinical levels of symptoms, and these symptoms cause great distress and interfere with functioning. In addition, depression is often recurrent, with first episodes occurring most often during adolescence. Thus, prevention of depression during adolescence may help to prevent suffering across a person’s lifespan.

Early adolescents deal with a number of physical, cognitive, social, and environmental changes that often occur together and may increase their risk for emotional and behavioral problems. Most children go through puberty at this time. Social relationships become far more complex. Peer relationships become more important, and vulnerability to peer pressure increases. The transition from elementary to middle school is marked by increased academic demands and often by a decrease in the individualized attention students receive from their teachers. These changes may increase risk for a variety of difficulties, including eating disorders, conduct problems, substance abuse, and underachievement as well as depression.

During this same period, abstract reasoning and perspective-taking abilities increase. As compared with younger children, early adolescents are better able to reflect on their beliefs and to engage in hypothesis testing by examining evidence and considering alternatives. These meta-cognitive skills are at the heart of cognitive-behavioral therapy, currently one of the most widely researched and empirically supported treatments for depression.

Although effective treatments are available, it would be much better to prevent depression from occurring in the first place. Depression is associated with considerable suffering and increased risk for substance abuse, academic failure, and other serious problems. Depression is underdetected and undertreated. Research suggests that most adolescents who are suffering from depression do not receive appropriate care.

Much of our research team’s work focuses on developing prevention programs that target the early adolescent developmental period. We hope to give young teens the cognitive skills and mental resiliency they may need to resist the onset of depression just a few years later.

Our Penn Resiliency Program (PRP) is a group intervention designed to teach a variety of cognitive and behavioral skills that are relevant to the wide range of challenges and stressors that are common during the teen years. Using a group format and a structured curriculum, the PRP can be implemented in schools, after-school programs, clinics, and other community settings.

The PRP includes approximately 18 to 24 hours of content, usually delivered in twelve 90- to 120-minute lessons. The program is typically delivered to small groups—about eight- to 14- students—by teachers, counselors, and clinicians who have received training in the intervention.

In the PRP, students first learn about Albert Ellis’s ABC model, which states that beliefs and interpretations of events have powerful effects on our emotions and behaviors. In Ellis’s model, there is an Activating event or Adversity, which prompts an automatic Belief or interpretation of the situation; this in turn leads to an emotional and/or behavioral Consequence. The model states that the Belief mediates the relationship between the event and the resulting Consequence.

The sessions begin with a discussion of the Adversities of adolescence—students make lists of the problems they encounter—which prompts them to think about those problems that are a normal part of life. The next step is to establish the role of Beliefs through skits that introduce the concept of internal dialogue, or “self-talk.” The goal here is to help students understand that “self-talk” is a normal process and to encourage them to be aware of their underlying beliefs. The third step is to ensure that students are able to label and describe emotional experiences—one type of “C” in the ABC model. Initially, the conversation focuses on the most basic emotions—happiness, sadness, and anger—and then progresses to more complex emotions such as shame and guilt. Students explore emotional intensity, sharing experiences and describing how intense they were on a scale of one to 10.

The leader then teaches students about the causal influence of cognition. Through role plays and discussions, students learn how self-talk can produce emotions and behaviors. Students learn that different people often experience different emotions in response to the same activating event—and they are encouraged to consider the sources of these different reactions. Students learn about “self-fulfilling prophecies,” or how pessimistic beliefs (“I’m stupid”) can lead to behaviors (stop studying) that lead to new activating events or adversities (fail an exam) that seem to confirm the initial beliefs (“See. I knew I was stupid.”). Students learn to identify and challenge pessimistic beliefs by examining evidence and generating more realistic alternatives. Thus, the program encourages students to think accurately and flexibly about the problems they encounter.

In addition to these cognitive skills, the PRP teaches skills for solving problems, coping with uncontrollable stressors, and being comfortable with a full range of emotions. Students also learn assertiveness, negotiation, and relaxation techniques as well as skills for overcoming procrastination. (More: PRP)

The PRP has been evaluated in at least 19 controlled studies, making it one of the most extensively evaluated depression-prevention programs. These studies have included a total of approximately 2,500 children from a variety of socio-economic and cultural backgrounds. A recent meta-analytic review of PRP studies found that PRP significantly reduces and prevents symptoms of depression. In some studies, its effects have been large. For example, the first study of the PRP found the intervention halved the rates of moderate to severe symptoms two years after the program ended. The program is less effective when group leaders receive minimal training or do not cover the intervention content adequately.

Current work on the program focuses on expanding and strengthening the intervention and achieving effective dissemination. Studies are evaluating booster sessions for students and a parallel intervention for parents that teaches them to use the PRP skills in their own lives, so that they can model resilience for their children. Research on the effectiveness of the parent program is ongoing, but results from a pilot study indicated that combining PRP with parent training may more powerfully prevent symptoms of depression and anxiety

Although initially developed to prevent depression, the PRP is currently conceptualized as a program that teaches valuable life skills. These skills are relevant to a variety of academic, social, and family situations, and are helpful to most children. This view of PRP is supported by studies that evaluate effects on outcomes. For example, several studies have documented beneficial effects on anxiety, behavioral problems, cognitive styles, and hopelessness. Further evaluations of PRP’s effects on positive emotions and achievement that are currently underway may help enrich our understanding of the power of providing young people with cognitive coping skills that not only protect them from depression, but lead them to develop positive life skills that are not otherwise part of their expected education.

Jane Gillham’s research and clinical interests are at the intersection of clinical psychology, developmental psychology, and education. She developed the Penn Resiliency Program with Karen Reivich and Lisa Jaycox when they were graduate students working with Martin Seligman at the University of Pennsylvania. Since that time, she has collaborated extensively with Reivich and Seligman on several evaluations of the PRP, funded by grants from the National Institute of Mental Health. She is co-director of the Positive Psychology for Youth Project, a joint project between Wallingford-Swarthmore School District and research teams at Swarthmore and Penn, which is evaluating this curriculum with funding from the U.S. Department of Education She received a B.A. from Princeton University and a Ph.D. from Penn.

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