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October 2010 | Volume 68 | Number 2
Interventions That Work
R. Marc A. Crundwell and Kim Killu
When teachers recognize a student's depression and intervene with flexible supports, that student can feel—and learn—better.
Fourteen-year-old Rita has been on an alarming downward swing throughout her first semester at Brentwood High—a larger school than she's ever attended. She has lost interest in most daily activities, cries often, and has a difficult time concentrating. Although Rita always earned good grades before, her grades have steadily dropped. She has made no friends and tends to spend her extra time at school with a few select teachers. Other students describe Rita as irritable and resistant to their attempts at friendship or conversation. She whines often, is extremely shy, and does not embrace interests common to teenage girls.
The few people Rita interacts closely with at school have noted danger signs. Rita has told Mrs. Shannon, her history teacher, that her parents are fighting. She admits she feels isolated and severely anxious about navigating the demands of high school. Rita feels that she has no one at home to turn to; both of her parents work, and she feels lonely at home even with her siblings around; she has even shared with Mrs. Shannon that she thinks of death as a way out of loneliness.
Rita's story illustrates the essential features of clinical depression in children and adolescents: a persistent sad or irritable mood, loss of energy, decreased interest in daily activities or previously enjoyed activities, persistent feelings of worthlessness or guilt, withdrawal, and, possibly, recurrent thoughts of suicide. Children and adolescents with depression may also show appetite changes resulting in weight gain or loss, disturbed sleep patterns, increased defiance or oppositional behavior, and impaired concentration.
Although depression is classified as an adult disorder—and depression in very young children is rare—middle to late adolescence is the most common age when symptoms first appear or a first major depressive episode happens (Burke, Burke, Regier, & Rae, 1990). Lewinsohn, Hops, Roberts, Seeley, and Andrews (1993) randomly sampled adolescents within a U.S. community and discovered that the average age of onset of major depression was 14. Sadly, the earlier the onset of depression in children and adolescents, the more protracted and severe the course of the disorder usually is (Kovacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein, 1984).
As Figure 1 (p. 48) illustrates, research and clinical experience show that depression manifests itself differently in children than in adolescents in terms of what teachers see in the classroom (Kashani, Rosenberg, & Reid, 1989).
Characteristics of Depression in Children
What It Looks Like in School
Complaints of feeling sick, school absence, lack of participation, sleepiness
Isolation from peers, problems with social skills, defiance
Difficulty concentrating on tasks/activities
Poor work completion
Short-term memory impairments
Forgetting to complete assignments, difficulty concentrating
Difficulties with planning, organizing, and executing tasks
Refusing to complete work, missing deadlines
Facial expressions or body language indicating depression or sadness
Easily hurt feelings, crying, anger
Poor performance and follow-through on tasks
Poor work submission, variable academic performance
Separation anxiety from parents or caregiver
Crying, somatic complaints, frequent absences, school refusal
Characteristics of Depression in Adolescents
Decreased self-esteem and feelings of self-worth
Defiance with authority figures, difficulties interacting with peers, argumentativeness
Negative perceptions of student's past and present
Pessimistic comments, suicidal thoughts
Isolation, frequent change in friends
Lack of interest and involvement in previously enjoyed activities
Isolation and withdrawal
Impulsive and risky behavior
Theft, sexual activity, alcohol or drug use, truancy
Acting out of character, sleeping in class
When depression is recognized early and when professionals provide treatment, young people can experience improved mood and function better in school and life. Thus, the stakes are high. School personnel play a pivotal role in identifying depression—and intervening. Teachers, administrators, and other school staff must also be knowledgeable about depression because the disorder can seriously impair academic and interpersonal behavior at school (Hammen & Rudolph, 2003).
Depression is significantly correlated with poor academic grades, and students with higher ratings of depression are less likely to graduate from high school (Forehand, Brody, Long, & Fauber, 1988). Cognitive issues may include low tolerance for frustration and negative patterns of thinking. Depressed students often give up more quickly on tasks they perceive as daunting, refuse to attempt academic work they find too difficult, and quickly doubt their ability to independently complete academic tasks or solve problems. Memory, speech, physical and motor activity, and the ability to plan may also be affected. Many depressed children and adolescents are lethargic, speak laboriously, and have difficulty completely expressing thoughts and ideas.
Rita's case illustrates three other issues with regard to recognizing depression. First, the essential features of depression are as recognizable in youth as they are in adults, and the same diagnostic criteria are used for both age groups (Mitchell, McCauley, Burke, & Moss, 1988). Second, irritability is more common in depressed youth than in depressed adults. Third, teachers often overlook children with depression because symptoms like a sad mood or fatigue are more internal and subjective than the kinds of disruptive behavior shown by kids with more externalizing disorders, such as attention deficit disorder. Depressed young people often don't ask for help at school because of negative thinking patterns: No one cares about my feelings, nothing can be done to help me, and so on (Cash, 2003). Younger students often lack the necessary language skills and self-awareness to report—or recognize—their own depressed state.
Because depression can have broad negative effects on students' academic work and comfort in school, schools need to provide a variety of accommodations and instructional strategies to increase these students' success. Figure 2 (p. 50) shows strategies that can benefit children and adolescents battling depression.
The best approach is often individualized. Here we describe an approach school personnel might use to help Rita.
As Rita's teacher Mrs. Shannon became worried about her, she shared her concerns with Rita's parents. They were relieved that the school had contacted them and were encouraged by the school's willingness to collaborate with them to address Rita's downward spiral and make decisions about ways to help her. With their cooperation, Mrs. Shannon and the school's guidance counselor brought together a team to provide interventions for Rita. This team brought in the school psychologist, who first strongly recommended that Rita's family physician evaluate her to determine whether further referral to a child psychiatrist was appropriate.
The school's intervention team, the school psychologist, and Rita's parents together developed an individualized plan of accommodations and instructional strategies to help Rita cope. After determining some appropriate interventions, the team met with Rita to discuss these possibilities and get her feedback; they knew this would increase the chance she would buy in. All the players involved agreed to meet monthly to review Rita's response to the interventions, ensure that their actions were helping her, and make any modifications needed.
Rita and a teacher from the resource room in her school, Ms. Hunt, began meeting weekly to help Rita develop specific goals for how she could manage better academically, socially, and in terms of behavior. Ms. Hunt was chosen because, as a resource teacher, she had flexibility to meet with Rita and could coordinate services with all of Rita's teachers. They met each Monday morning to review any work that Rita completed over the weekend and to set goals, targeting four areas in which depression typically affects students most strongly: work completion, work submission, social interactions, and physical activity.
The team considered it important that Rita take an active role in setting and achieving goals. This would help her learn self-management skills, which would later serve her in managing her depressive symptoms, accomplishing difficult tasks, and achieving personal goals (Cooper, Heron, & Heward, 2007). On Fridays, Rita again met with Ms. Hunt to review the week's progress toward her goals and discuss any assignments for the weekend. She also informally checked in with Ms. Hunt before lunch and at the end of most days.
Ms. Hunt became a nonthreatening liaison between Rita and her other teachers. Rita's teachers met weekly with this resource teacher to communicate clear guidelines and expectations for Rita's coursework. Thus, Ms. Hunt could help Rita coordinate her work across subjects and follow through on a self-management checklist of in-class assignments. Getting kids to use such self-monitoring tools has been found to improve on-task behavior in the classroom (Wood, Murdock, Cronin, Dawson, & Kirby, 1998); homework completion (Trammel, Schloss, & Alper, 1994); and academic performance (Wolfe, Heron, & Goddard, 2000).
As a result of their fluctuating moods, depressed students often have difficulties organizing work and persisting. Proactive strategies like monitoring progress and providing frequent feedback on whether students are meeting teachers' expectations are essential.
Rita's classroom teachers monitored her mood and energy level closely, periodically giving her a short break when her energy appeared to flag or her frustration peaked. They developed a system for Rita to initiate a break on her own. She moved to a quiet area of the classroom or left class to sit in the school counselor's office for 10 minutes; after this break, Rita returned to the task at hand.
The school considered the impact of side effects from Rita's antidepressant medications. Rita was allowed to keep water or juice on her desk to combat "dry mouth." She was seated close to the door in each class and given permission to leave the room quietly as needed to use the restroom.
Instructors also broke Rita's schoolwork into discrete tasks and helped her develop and manage a time line for when to complete each task based on her mood and energy levels. This enabled Rita's teachers to shorten or modify work. Teaching students with depression to recognize their typical mood and energy fluctuations throughout the day and take a break before returning to the task at hand increases their self-management.
Students with depression often find studying for tests a struggle because their disorder hampers independent study and concentration. Rita was given access to recorded class lectures that she could review outside class to assist her with taking notes and organizing class material to focus on relevant information. Teachers coached Rita in learning and study strategies to increase her independence in the classroom, including making outlines, doing conceptual mapping, and using mnemonic devices (memory skills can be dulled by depression [Brigham & Brigham, 2001]). Depressed students benefit from teacher-developed study guides for tests that enable them to focus on the most important material.
Within the general education classroom, Rita's teachers integrated specific interventions into the classroom routine. Typically, after the class started doing individual work, the classroom teacher would review with Rita the assignment and expectations. Throughout class, the teacher would frequently check on Rita's progress and give feedback on her performance. At the end of class, she would review Rita's work and provide her with any necessary materials or help she needed to complete the task.
Students suffering from depression often experience social difficulties and problems maintaining friendships as a result of mood fluctuations and their tendency to perceive relationships and interactions negatively. To foster an accepting, social environment for Rita, her teachers included cooperative group activities in the classroom and carefully selected whom to place in Rita's groups to increase the likelihood she would enjoy some positive interactions. Group work also let her share cognitive responsibilities, alleviating the stress depressed learners often feel about engaging in and completing learning demands independently (Perkins, 1993). Rita's teachers monitored her peer interactions and contribution to the group to ensure that she was participating.
Because students with depression often stop attending group activities they previously found engaging and view interactions with others negatively, it's important to intervene and schedule activities for these youth. Rita's parents and school staff collaborated to enroll her in an after-school program that focused on teaching social skills, and they arranged for individual counseling with the school psychologist. They worked to ensure that Rita took part in physical activity for a short period every day.
Brentwood School developed a home–school communication and tracking system that facilitated better communication between the school and Rita's family. Such communication systems increase depressed learners' participation in school activities by drawing on their personal experiences, letting parents know about classroom events and deadlines, offering a venue for problem solving, and reporting on progress (Davern, 2004).
Ms. Hunt noted Rita's daily progress toward goals and provided feedback on her mood and interactions through a home–school communication notebook. This notebook also enabled the family to keep Brentwood up-to-date on events at home, Rita's treatment, and other helpful information.
Because Rita had mentioned suicide, it was imperative that school personnel monitor her suicidal thoughts or intentions. For many students, it's important to develop a "no-suicide contract"—an agreement between student and school in which a student promises that if he or she experiences suicidal impulses, the student will inform a health care professional, family member, or teacher rather than engage in self-injurious behavior. In Rita's case, Rita, her parents, and Ms. Hunt signed a contract that indicated the key people Rita should go to if she experienced such thoughts and the procedures and process that would be followed. If Rita told school personnel she was having suicidal thoughts, they would immediately contact Rita's parents, and her parents would take her to an emergency room for a psychiatric evaluation.
Rita's case study reflects an ideal approach in a school where high levels of collaboration exist. Although many schools have worked hard to become more collaborative in their approach to working with students like Rita, in many places teachers will not find this level of support and collaboration. Teachers who find themselves in a school with less support and collaboration may not be able to implement as complete an approach as that discussed here, but they could implement many of the strategies noted.
For example, any teacher could initiate Monday morning meetings with a student struggling with a mood disorder to discuss the coming week, develop goals, and talk over how the student might keep up social interactions. A classroom teacher could support a student like Rita by providing a list of daily in-class assignments, coaching the student in organizing and initiating these tasks, and setting up a schedule to monitor progress and provide frequent feedback. Any teacher who sees one of her students facing mood fluctuations like Rita's could make task-by-task accommodations or modifications to meet that learner halfway, supply the kind of study supports discussed, and flexibly provide intermittent breaks throughout the day.
Depression in children and adolescents has significant implications for students' academic, behavioral, social, and physical well-being. School personnel must educate themselves on the characteristics and effects of depression, so they can provide the most effective interventions. Educators are responsible for not only meeting the academic needs of depressed students, but also ensuring their safety and welfare.
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Author's note: All names are pseudonyms.
R. Marc A. Crundwell is a school psychologist with Greater Essex County District School Board, Windsor, Ontario, Canada; email@example.com.
Kim Killu is associate professor of special education, School of Education, University of Michigan–Dearborn;
Copyright © 2010 by ASCD
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