Cari McCarty, Ph.D. Research Associate Professor, Pediatrics

1. Cari McCarty, Ph.D. Research Associate Professor, Pediatrics Director of Research, Adolescent Medicine School-Based Interventions for Childhood and Adolescent Depression

2. Prevalence of Depression Lifetime prevalence of mood disorders is 20.8% (National Comorbidity Survey Replication) Hazard rates highest in mid to late adolescence (Burke et al., 1990) MDD affects an estimated 6 million children and adolescents (NIMH, 2002)

4. Burden of depression Depression now considered a “chronic disease” Even subclinical levels of depressive symptoms interfere substantially with adjustment Leading cause of disability worldwide Risk for suicide, other psychiatric disorders, substance use

5. Media Attention to Suicide • Recent high profile media cases have drawn increased attention to youth suicide (and bullying)

7. Research Pathway Development and Context Role of family, peers, school Youth Depression

8. Understanding Youth Depression Parental Depression Parental Social Support Youth Depression Thinking Styles Stressful events Low caregiver support *girls! School Failure McCarty et al., 2005; Weisz, Southam-Gerow & McCarty, 2001; McCarty et al., 2007; McCarty et al., 2006; McCarty et al., 2009

9. Research Pathway Intervention Efforts Development and Context Role of family, peers, school Benefit of cognitive-behavioral skills Youth Depression

10. 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.

11. Psychotherapy for Youth Depression: Evidence of Treatment Effects Reinecke, Ryan & DuBois 6 CBT Trials ES = 1.02 Lewinsohn & Clarke 12 Trials ES = 1.27 Michael & Crowley 14 Trials ES = .72 Weisz, McCarty & Valeri 35 Trials ES = .34 more modest 1998 1999 Weisz, McCarty, Valeri, 2006. Psych. Bull. 132:132-149 2002

12. Component Analysis of EBTs Goal-setting Self-monitoring Attention to relationships Cognitive restructuring Problem-solving Behavioral activation Child psychoeducation Communication training

13. 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.

14. Intervention Model: Positive Thoughts & Actions

15. 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

16. TARGET AREAS Learning Grades Study Skills—Organization & Time Management Homework Relationships Family Friends School & Community Healthy Mind and Body Stress & Moods Sleep Nutrition Exercise

17. Goals of the Parent Component Engaging parents in the intervention process Providing parents a common language and understanding of the core skills Fostering a better parent-child relationship Raising parent awareness of students’ goals and progress

18. Pilot Testing of Intervention • 2005-2007 School Years • Eckstein, Hamilton, McClure, Whitman Middle Schools • Screened 684 youth for depression; 67 included in intervention study • Gains in skills (coping, cognition, communication)

19. Middle School Matters Study Randomized to the previously developed program (Positive Thoughts & Actions) or brief intervention (MAPS)

20. Middle School Matters - Intervention Positive Thoughts & Actions 11 groups, led by 6 different leaders in 4 different schools Alderwood Middle School: After-School Model MAPS 1-2 hour individual interview, computer-assisted, elements of assessment, empathy, motivational interviewing, social support, and brief problem-solving

21. REACHING YOUR GOALS GOALS Deciding what we want to and who we want to be STEPS Breaking goals into smaller steps takes us closer to our goals To be effective, steps and goals need to be: Realistic Specific Desirable • Controllable • Within reach • Not too easy • Clear • Measurable • Has a timeline • Something valued • A healthy choice • Helpful to all involved

22. PLANNING FOR TRIGGERS AND ROADBLOCKS • TRIGGERS • Set us off course from the path to our goals • ROADBLOCKS • Get in the way of reaching our goals • Hit your roadblocks and triggers head on! How? Make a plan that includes both thoughts and actions: • THOUGHTS— What we tell ourselves to stay on track • ACTIONS— What we do to stay on track 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.

23. MEETINGS WITH PARENTS Meeting 1 Getting to Know Each Other Home visit with parent and student Meeting 2 Understanding Your Child’s Emotional Development Group parent meeting Meeting 3 Communicating with Your 7th Grader Group parent meeting Meeting 4 Staying Successful Home visit with parent and student

24. 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?

25. 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

26. Acknowledgements PostdocsFunding Heather Violette, Ph.D. National Institute of Mental Health Brian Wymbs, Ph.D. InterventionistsResearch Associates Rick Cruz Leticia Holleman Marissa Corona Mary Casey-Goldstein Alyson Barry Elizabeth McCauley Jessie Waimau-Ariota Ursala Schwenn Sonja Kottke Marjorie Newman Cezanne Hardy Lisa Gloria-Wallace Becky Parrish