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Depression in theClassroom: Considerationsand Strategies

Alison L. Calear, PhD

KEYWORDS

• Depression • School • Student • Teacher • Strategies• Prevention

Depression, or unipolar depression, is characterized in both adolescents and adultsby a depressed mood, a loss of pleasure and interest in everyday activities,diminished concentration and energy levels, disrupted sleep and eating patterns,feelings of worthlessness, and suicidal thoughts.1 For a clinical diagnosis to be made,this cluster of symptoms must be present for at least 2 weeks. Dysthymia is a milderand more chronic form of depression, which must be present for at least 1 year inchildren and adolescents, and includes appetite, sleep, and energy changes as wellas low self-esteem, difficulty making decisions, and hopelessness.1

In children and adolescents, depressed mood may be exhibited primarily asirritability rather than sadness. According to Lewinsohn, Rohde, and Seeley,2 the

ost frequently reported symptom of depression among adolescents is depressedood, followed by thinking, sleep, and weight difficulties. There are relatively fewifferences in the presentation of adolescent and adult major depression, althoughdolescents tend to report feelings of worthlessness and guilt more than adults.2

EPIDEMIOLOGY

Major depression often begins in adolescence, with a marked increase in prevalencebetween 15 and 18 years.3 The risk of developing a depressive episode increases

ith age during adolescence, with the reported rates of depression comparable to theifetime prevalence rates observed in the adult population.2,3 The one year prevalencerate of major depression among the child and adolescent population is 1% to 8%,with up to 28% of young people experiencing an episode of major depression by theage of 19 years.2,4–6 However, these figures may be an underestimation of the trueextent of emotional difficulties in the community, with many children and adolescentsexhibiting elevated, but subclinical, levels of depressive symptoms.7

The author has nothing to disclose.Centre for Mental Health Research, The Australian National University, Building 63, EgglestonRoad, Acton, ACT 0200, AustraliaE-mail address: Alison.Calear@anu.edu.au

Child Adolesc Psychiatric Clin N Am 21 (2012) 135–144doi:10.1016/j.chc.2011.08.014 childpsych.theclinics.com

1056-4993/12/$ – see front matter © 2012 Elsevier Inc. All rights reserved.

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136 Calear

MORBIDITY

Depression is among the major causes of morbidity among children and adolescents,with the disorder often taking a chronic, recurrent, and episodic course.8 Some of theegative outcomes associated with depression include family and social dysfunction,hysical ill health, poor academic performance, low self-esteem, increased psycho-athology, and suicide.2,8 Depression can be comorbid with a number or other

psychiatric conditions, including anxiety, attention deficit hyperactivity disorder,conduct disorder, and substance use disorders.9,10

SCHOOL-BASED PREVENTION AND EARLY INTERVENTION FOR DEPRESSION

Most prevention efforts with children and adolescents occur in the school environ-ment. The school system has been identified as an ideal setting for the implementa-tion of prevention and early intervention programs for depression, due to itsunparalleled contact with youth.11 The school environment provides the opportunityo target all individuals—those with depression that has not been identified, those atisk because of stressors or internal vulnerabilities, those with subthreshold symp-oms, and those who are asymptomatic but who may develop symptoms in the future.

With the incidence of unidentified and untreated depression so high, the inclusionf these programs in schools could help to alleviate the symptoms of affectedtudents, and provide them with a means to seek further assistance and support.chool-based prevention and early intervention programs could also be beneficial to

hose children and adolescents who are not symptomatic. These programs couldurther strengthen the resilience and coping skills possessed by these students, asell as make them more aware, and tolerant, of mental health problems in theommunity.12

EVIDENCE-BASED PREVENTION PROGRAMS

Three types of prevention programs—universal, indicated, and selective—have beendelivered in schools to prevent depressive symptoms.13 Universal prevention pro-grams are delivered to all students in a given population regardless of symptom leveland are often designed to enhance general mental health or build resiliency. Selectiveprevention programs target children and adolescents who are at risk of developingdepression by virtue of particular risk factors such as parental divorce or depression,whereas indicated programs target young people with early or mild symptoms ofdepression.13

In a recent review by Calear and Christensen,14 42 randomized, controlled trialsertaining to 28 individual school-based depression prevention programs were

dentified. A large proportion of the programs identified in the review were deliveredy a mental health professional or graduate student, were 8 to 12 sessions long andere based on cognitive–behavioral therapy. Other common therapeutic techniques

ncluded psychoeducation and interpersonal therapy; program leaders includedlassroom teachers and nurses in some programs. Just over half of the identified trials

ncluded adolescents as the target audience and were universal in nature.Overall, 23 of the 42 (55%) trials identified in the review reported significant

eductions in participants’ symptoms of depression at postintervention or follow-up.ffect sizes for these trials ranged from 0.21 to 1.40.14 Indicated prevention programsere found to be the most effective type of school-based intervention, compared withniversal and selective school-based programs. Trials utilizing teacher program

eaders generally had smaller and fewer significant effects than trials led by mental

ealth professionals or graduate students. The review concluded that there is some

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137Depression in the Classroom

support for the implementation of depression prevention programs in schools andthat these programs should continue to be implemented in schools as a means ofpreventing the onset of depression in children and adolescents.14

It is apparent from the review that face-to-face depression prevention programs arenot always as effective when delivered by classroom teachers.14 The reason for thisfinding is not entirely clear, but it could be a reflection of program content,implementation, or training. Nevertheless, it is important to identify ways to improvethe delivery of depression prevention programs by classroom teachers, because thedelivery of these programs by mental health professionals and graduate students isnot sustainable in terms of economic costs or workforce availability. One possiblesolution to this problem may be the introduction of Internet-based depressionprevention programs into the classroom. These programs are currently growing innumber and offer a self-directed program that does not require extensive teachertraining or expertise to be delivered.15

Detailed below is an example of an evidence-based, online depression preventionprogram, as well as the 3 face-to-face depression prevention programs identified inthe review as having the most evidence supporting their effectiveness. Table 1presents an overview of these programs.

MoodGYM

The MoodGYM program (available at: www.moodgym.anu.edu.au) is a free, interac-tive, Internet-based intervention designed to prevent and decrease symptoms ofdepression in young people. Table 2 presents an overview of the MoodGYMprogram. When delivered in the school environment, the MoodGYM program ispresented by the classroom teacher during 1 class period a week for 5 weeks. Theprogram is based on cognitive–behavioral therapy, and contains information, ani-mated demonstrations, quizzes, and “homework” exercises. The overall aims of theMoodGYM program are to change dysfunctional thoughts, improve self-esteem andinterpersonal relationships, and to teach important life skills, such as relaxation andproblem solving.16 The MoodGYM program has been evaluated as a universalschool-based program with young people aged 13 to 17 years. Significant effects ofbetween 0.31 and 0.43 were reported in this study for male depression at postinter-vention and the 6-month follow-up.16

Penn Resiliency Program

The Penn Resiliency Program (PRP) is a 12-session group intervention designed foryoung people aged 10 to 14 years. The program aims to teach cognitive–behavioraland social problem-solving skills, including cognitive restructuring, assertiveness,and relaxation. The cognitive and problem-solving techniques are taught and appliedthrough group discussions and weekly homework assignments.17 PRP is among themost widely researched school-based depression prevention programs,18 with atleast 10 school-based randomized controlled trials having been conducted with PRPor a PRP-based program (eg, Aussie Optimism program) since 2001. PRP has beenevaluated as a universal, indicated, and selective program, with significant effectsreported in at least eight trials at postintervention and/or follow-up, with significanteffect sizes ranging from 0.27 to 1.05.14 PRP has been delivered by classroomeachers, graduate students, and mental health professionals.

Interpersonal Psychotherapy: Adolescent Skills Training

The Interpersonal Psychotherapy: Adolescent Skills Training program is based on

interpersonal therapy and aims to prevent depression by teaching social and

Table 1Overview of 3 evidence-based prevention programs for depression

ProgramAge Group(yrs) Intervention Type Content Program Leader

No. ofSessions

Effect Sizes(Cohen’s d)

PRP 10–14 Universal, indicated, andselective

CBT and problem solving Classroom teacher, MHP,graduate student

12 0.27–1.05

IPT-AST 11–16 Universal and indicated IPT and psychoeducation Graduate student 10 0.31–1.35

SIT 15–18 Universal CBT MHP, graduate student,research team

9–13 0.93–1.40

Abbreviations: CBT, cognitive–behavioral therapy; IPT-AST, Interpersonal Psychotherapy-Adolescent Skills Training; MHP, mental health professional; PRP, PennResiliency Program; SIT, Stress Inoculation Training.

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communication skills that are necessary to develop and maintain positive relation-ships.19 The program consists of 2 initial individual sessions and 8 weekly, 90-minutegroup sessions and is targeted at young people aged 11 to 16 years. The groupsessions are based on psychoeducation and general skill building surroundinginterpersonal role disputes, role transitions, and interpersonal deficits. Programstrategies are taught through didactics, games, role plays, and communicationanalysis.20 Interpersonal Psychotherapy: Adolescent Skills Training has been evalu-ated as both a universal and indicated classroom program delivered by graduatestudents. The results of these trials have been positive, with a significant effect sizeof 0.31 reported at postintervention for the universal trial19 and significant effect sizes

f between 0.96 and 1.35 reported at postintervention and 3- and 6-month follow-upsn the indicated trial.20

Stress Inoculation Training

The Stress Inoculation Training program is based on cognitive–behavioral therapyand provides both individual and group-based sessions for young people aged 15 to18 years. The program is delivered over 9 to 13 sessions and parallels a 3-phasestress inoculation model: A conceptualization phase, a skill acquisition phase, and askill application phase. Techniques taught in the Stress Inoculation Training programinclude cognitive restructuring, problem solving, and relaxation.21 Stress Inoculation

raining has been evaluated in 3 universal school-based trials, 2 of which foundignificant effects of between 0.93 and 1.40 at postintervention.21,22 In each of these

trials, the program was delivered by either a graduate student, mental healthprofessional, or a member of the research team.

PREVENTION PROGRAM DELIVERY CONSIDERATIONS

The following list of factors should be considered in the establishment of a prevention

Table 2Overview of the MoodGYM program

Module Description

Feelings Teaches users how to identify negative thinking patterns, biased perceptionsof situations, and negative views about the future. Users are taught theassociation between thoughts, feelings, and behavior.

Thoughts Teaches users how to identify dysfunctional thoughts and how to contestand change them. Personal areas of vulnerability are discussed, and thereis an introduction to the topic of self-esteem and some basic strategieswith which to increase self-esteem.

Unwarping Teaches users specific ways to change dysfunctional thoughts, with a focuson seeking evidence for warped thoughts and identifying alternatives forthem. Further strategies to build self-esteem are discussed, as well as theimportance of developing new skills and interests.

Destressing Teaches users to identify the situations or events that may precipitatenegative thinking and the ways in which these situations could be handledbetter. Stress and stressors and how they can be alleviated are discussed, aswell as the impact of parenting styles on negative thoughts. Relaxationtechniques are introduced and trialed in this module.

Relationships Teaches users about relationship breakups and how to cope with them. Asimple problem-solving strategy is introduced and demonstrated.

program in the school environment.

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140 Calear

Target Audience

It is important to identify early who the target audience will be—all students(universal), only those students with elevated symptoms of depression (indicated), oronly those students identified as being at-risk of developing depression (selective). Ifan indicated or selective program is to be implemented, then a reliable method ofidentifying eligible students needs to be determined.23

Program Scheduling

It is essential that (a) enough time is scheduled to complete each module or sectionwithin a given session and (b) enough sessions are scheduled to allow the program tobe completed in its entirety. It is also important to consider when the program will bedelivered to students. The program could be delivered in the classroom as part of theschool curriculum, or it could be offered as an after-school or lunch-time activity.When a program is delivered is likely to be influenced by the availability of space in thecurriculum, the preferences of participating students and their parents (ie, someparents may not want their child withdrawn from core subject areas to participate inthe program), and the availability of staff to facilitate the delivery of the program.23,24

Support and Protocols for Referral

It is likely that some students will require additional assistance or support during orafter the completion of a depression prevention program. It is important therefore tonotify the school counseling service of the program’s delivery.23 This will allow theschool counseling service to prepare for a possible increase in student referrals orvisits. Students should also be made aware of the support services available to themwithin the school and surrounding area.

Whole School Support

It is essential that the program has the full support of the school executive. Thesupport of the school executive significantly contributes to a program’s success in theschool environment by ensuring that the required resources (both staffing andmaterial) and support are directed toward the program.23,24

TREATING DEPRESSION IN SCHOOLSDisorder Recognition

Recognizing the signs and symptoms of depression in a student can be difficult,because many of the symptoms are internal and may not be easily identified.Students may withdraw, and this behavior may be missed, or not perceived as beinga problem, owing to the nondisruptive nature of this behaviour.12,25 As a result, it ismportant that any changes in a student’s behavior or general demeanor be noted andlosely observed. Students with depression may not ask for help or assistance. Thisay be because of feelings of embarrassment and shame, a lack of self-awareness

r recognition of symptoms, or in younger students, not having the language skills toescribe their emotional state.26 It is important, therefore, that schools assist studentsith depression by destigmatizing depression and encouraging help-seeking behav-

or, educating staff, students, and parents on the signs and symptoms of depression,mplementing prevention and early intervention programs in the classroom thateduce the incidence of depression, and monitoring students at risk for depression,

articularly during stressful times (eg, during examinations).26

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IMPACTS ON SCHOOL PERFORMANCE

Children and adolescents exhibiting the symptoms of depression tend to haveimpaired concentration, memory, recall, problem solving, and physical motor skills, aswell as an irrational or pessimistic cognitive style.7,26 These factors can significantlympact their school performance through reduced motivation, task completion,ttendance, work performance, and social interactions. The disordered and negativehinking patterns associated with depression can also influence their perception andnterpretation of events, leading to negative views of their environment, self, anduture.27 Children and adolescents experiencing depression may also be less alert or

attentive in class, have a heightened sensitivity to criticism, and be more irritable andargumentative26 (Box 1). As a result, it is important that children and adolescents withdepression be supported fully in the school environment.

MODIFYING THE SCHOOL ENVIRONMENT FOR DEPRESSION

Depression is treatable and the difficulties associated with this disorder improve withappropriate care and intervention. However, while the young person is recovering anumber of modifications can be made to the school environment to assist studentsexperiencing depression. These changes can encourage school attendance andimprove academic achievement.

Classroom Modifications

Students with depression may have a seating preference within the classroom. Thismay be at the front of the class, where they are closer to the teacher for assistancein refocusing or remaining on task, or near the door, so that they can easily leave ifthey are feeling unwell or are unable to cope. Some students with depression mayrequire frequent breaks to sustain concentration. Seating preferences and breaks,where possible, should be accommodated within the classroom to improve studentcomfort and learning.

Scheduling Modifications

Depression can be associated with sleep disturbances. As a result, some studentsmay have difficulty waking in the morning or may experience excessive sleepiness atschool. This can be accommodated in the school environment by allowing the studentto arrive to school late, shortening the student’s school day, or scheduling more

Box 1Signs and symptoms of depression in schools

Withdrawn/reduced social behavior

Low mood

Poor school attendance

Impaired concentration and memory skills

Irrational or pessimistic thinking style

Loss of interest

Irritability

demanding academic subjects at times when the student is most alert. Scheduling

142 Calear

modifications should be revised frequently, with the priority being ongoing schoolattendance.

Testing Modifications

The test environment may need to be modified to cater for the memory difficultiesoften associated with depression. This may include multiple-choice formats, ratherthan open-ended responses, or the provision of more time to complete tests.Scheduling tests for when the student is most alert, or offering alternate testingarrangements (eg, oral examinations), may also be beneficial. All efforts should bemade to support the student in their demonstration of what they have learnt.

INSTRUCTIONAL TECHNIQUES FOR DEPRESSION

There are a number of techniques that can be used in the classroom to assiststudents with depression. These techniques and strategies are presented in Box 2and often cater for the student’s impairments in concentration, focus, energy,memory, and social functioning.26

SUMMARY

Depression is a prevalent and debilitating disorder that can severely affect a youngperson’s social, emotional, and academic functioning. Identifying depression early isessential to reducing the impact of this disorder. Depression is treatable. However,there are a number of classroom and school supports that can be put in place toassist a young person experiencing or recovering from depression. Preventing thedevelopment of depression through effective classroom programs should be encour-

Box 2Instructional techniques for depression

Develop clear expectations and guidelines.

Provide frequent feedback on progress.

Teach goal setting and monitoring.

Teach problem-solving skills.

Assist the student in developing, organizing and planning their day (eg, use of a diary).

Strategically increase opportunities for positive social interactions with peers (eg, group assign-ment, small group activity).

Develop a home-school communication system.

Modify classroom tasks, homework or assignments to accommodate mood and energy levels (eg,more time, shorter tasks).

Provide copies of class notes and study sheets before exams to help focus and guide the student’sstudy.

Break large projects into smaller and more manageable tasks and assist the student in planningtheir time.

Assign tasks one at a time.

Write out instructions on the board.

aged and supported within the school environment.

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