Richard W. Auger is an associate professor with the Department of Counseling & Student Personnel, Minnesota State University, Mankato.

E-mail: richard.auger@mnsu.edu

School-Based Interventions for Students with Depressive Disorders

Substantial numbers of children and adolescents suffer from depressive disorders, and these disorders bring with them an array of negative consequences. School counselors can assist students with depressive disorders by implementing individual and group interventions and consulting with teachers and other school staff to implement interventions in the classroom and the larger school environment. This article presents a set of guidelines and strategies to guide school counselors in their intervention efforts with depressed students. pidemiological studies indicate that hundreds of thousands of children and adolescents in this country suffer from a depressive disorder (Garrison et al., 1997; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; Shaffer et al., 1996). For example, one major national epidemiological study of more than 13,000 adolescents found that 9.2% of the participants reported experiencing a moderate to severe level of depressive symptoms (Rushton, Forcier, & Schectman, 2002). As many as 20% of youth have reported having experienced symptoms of a depressive disorder at some point in their lives (Lewinsohn et al., 1993). In addition, over recent decades the risk of developing a depressive disorder appears to be increasing, and those experiencing depressive disorders appear to be manifesting symptoms at an earlier age (Birmaher et al., 1996). Students who are experiencing a depressive disorder are at increased risk for many negative consequences, including social withdrawal and a lack of ability to experience pleasure (Stark, 1990), probability of recurrent depressive episodes (Lewinsohn, Rohde, Klein, & Seeley, 1999), development of a comorbid bipolar disorder (Geller, Fox, & Clark, 1994; Kovacs, 1996) or anxiety disorder (Kovacs, Gatsonis, Paulauskas, & Richards, 1989), substance abuse (Birmaher et al., 1996), difficulties in school (Evans, Van Velsor, & Schumacher, 2002), and both suicidal ideation (de Man & Leduc, 1995; Kovacs, Goldston, & Gatsonis, 1993) and completed suicide (Rao, Weissman, Martin, & Hammond, 1993). Furthermore, there is evidence that depression among youth often is untreated (Keller, Lavoie, Beardslee, Wunder, & Ryan, 1991; Wu et al., 1999), an issue that seems particularly problematic among African American youth and uninsured youth (Olfson, Gameroff, Marcus, & Waslick, 2003). Clearly there is a critical need for effective interventions for students with depressive disorders. Schools and school counselors can play a critical role in providing interventions for students with depressive disorders. There are several reasons why it is appropriate for schools and school counselors to provide interventions for students with depressive disorders. One reason is that depression negatively affects school performance (Kaltiala-Heino, Rimpelae, & Rantanen, 1998). In addition, students with depression, regardless of the type of out-of-school treatment they may be receiving, spend a significant portion of their lives in school and manifest symptoms of their depressive disorders in the school setting. Furthermore, there is empirical support for the effectiveness of school-based interventions for students with depressive disorders. Indeed, several studies have supported the positive impact of school-based group interventions for depression (Hains, 1994; Jaycox, Reivich, Gillham, & Seligman, 1994; Kahn, Kehle, Jenson, & Clark, 1990; Reynolds & Coats, 1986). Finally, the combination of increased numbers of students in need of mental health services and fewer inexpensive out-ofschool resources for childrens mental health needs means school counselors are often the only mental health service providers available to students (Lockhart & Keys, 1998). Although there is evidence that comprehensive intervention programs are effective in reducing the negative symptoms of students with depression, there is a need for additional intervention strategies that can be implemented by schools and school counselors. Not all schools have the resources to implement the types of major intervention programs that have been described in the professional literature. In addition, even if a school is able to implement a major depression intervention program, the

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participating students still spend the vast majority of the time they are at school in classrooms. Consequently, interventions that can be implemented by teachers can have considerable value. What many school counselors need is a set of brief intervention strategies that can be incorporated into their individual and group work with students with depressive disorders, as well as intervention strategies that can be provided to teachers and the larger school community for assisting students with depression. The purpose of this article is to translate existing research regarding interventions for depression into a set of guidelines for school-based interventions. For each guideline, I will propose a set of intervention strategies applicable to individual counseling sessions, group counseling sessions, or consultations with teachers. The intent is to provide school counselors with practical strategies that can be used to improve the lives of students with depressive disorders.

health practitioners is to send a detailed letter prior to the initial phone contact outlining the student issues and behaviors that are of concern (Geroski, Rodgers, & Breen, 1997). School counselors should obtain signed parental consent for this type of communication, and ensure that the parents are aware of the contents of the referral letter (Geroski et al.). Guideline 2: Construct a Relationship Depressed students need positive adult relationships, partly because the social difficulties that often accompany depression may leave them with few social connections (Field, Diego, & Sanders, 2001a; Vitaro, Pelletier, Gagnon, & Baron, 1995) and partly because supportive or challenging statements offered to the student by adults are more likely to be heard and embraced if offered in the context of a caring relationship. In fact, the development of a caring relationship between a counselor and a student can be viewed as a prerequisite to the students acceptance of cognitive or behavioral treatment techniques (Stark, 1990). A solid working relationship between the counselor and the client has consistently been linked to successful counseling outcomes (Horvath & Symonds, 1991; Shirk & Karver, 2003). Indeed, among factors common to all therapies (i.e., not uniquely associated with a specific therapy), the working alliance between the client and the therapist is the most frequently mentioned in the psychotherapy literature and is estimated to account for the greatest amount of variance in psychotherapy outcomes (Wampold, 2001). The working alliance has been conceptualized as consisting of three elements: (a) agreement regarding the goals of therapy; (b) agreement regarding the specific tasks assigned to the client by the therapist; and (c) the personal bond between the client and the therapist (Bordin, 1979). The working alliance also has been defined as the therapists empathetic involvement with the client (Bordin). Empirical data support the value of therapist empathy for clients with depression; a study of adults seeking therapy for mood disorders found that clients of therapists who were rated as being the warmest and most empathetic improved significantly more than clients of therapists with lower empathy ratings (Burns & Nolen-Hoeksema, 1992). As applied to counseling with students with depressive disorders, creating a strong working alliance means developing rapport, being viewed by the student as a caring, interested person, and coming to a mutual agreement on the goals and techniques of the counseling sessions. For example, if a school counselor believes that negative cognitions are contributing to a students depressive symptoms, before beginning to dispute the cognitions it would behoove the counselor to discuss the connection

As many as 20% of youth have reported having experienced symptoms of a depressive disorder at some point in their lives.

GUIDELINES AND STRATEGIES FOR SCHOOL-BASED DEPRESSION INTERVENTIONS

The professional literature regarding treatments for depressive disorders in children and adolescents, while often not directly applicable to school-based interventions, does provide some direction for the creation of guidelines for effective school-based interventions for depression. These guidelines follow, with linkages to the professional literature where possible. Embedded in these guidelines, where appropriate, are practical intervention strategies and examples that can assist school counselors in implementing the guidelines. Guideline 1: Collaborate with Parents, School Staff, Physicians, and Mental Health Practitioners As with most mental health disorders, depressive disorders are best treated with a comprehensive approach involving families, physicians, mental health practitioners, and schools (American Academy of Child and Adolescent Psychiatry, 1998; Evans et al., 2002; Hart, 1991). School counselors are wise not to presume that their services alone are sufficient to intervene effectively with students with depressive disorders. Although school counselors have much to offer students with depressive disorders, they should avoid giving parents the impression that school-based counseling services alone are sufficient to treat a child with a depressive disorder. Close collaboration with out-of-school mental health practitioners such as psychologists, social workers, and licensed professional counselors can lead to more effective and better coordinated services for students. An effective way to initiate collaboration with physicians or out-of-school mental

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Students with depression, regardless of the type of out-ofschool treatment they may be receiving, spend a significant portion of their lives in school and manifest symptoms of their depressive disorders in the school setting.

between negative thoughts and depression with the student, and make sure this makes sense to the student. Doing so will increase the likelihood that the student will genuinely participate in the intervention efforts. It is also helpful for teachers to do what they can to construct a relationship with students with depressive disorders. Although teachers, particularly at the high school level, cannot be expected to develop a close relationship with every one of their students, it is possible for teachers to take some actions to strengthen their relationships with depressed students. For example, teachers can make a point to address depressed students by name, and make some type of personal comment to the students during every class period. In addition, school counselors can facilitate teachers relationship with depressed students by educating teachers about some of the behaviors associated with depression. In particular, it is helpful for teachers to know that irritability is a common and predictable component of depression in youth (American Psychiatric Association [APA], 2000). School counselors can help teachers view irritability as a symptom of depression, rather than viewing it as a defiant and oppositional personality style. Just as parents of toddlers tend to feel more successful and view their children more positively if they know that oppositional behavior among toddlers is normal and healthy, teachers can feel much more positively about students with depression if they understand that irritability is a symptom that is simply a part of the disorder of depression. This will increase the likelihood that they can look past the irritability and work to forge a caring relationship with the student. Guideline 3: Expand Awareness of Feelings Students with depressive disorders may have only a cursory awareness of their emotional life and may be unaware of why they feel the way they do (Stark, Rouse, & Kurowski, 1994). For example, an angry, irritable adolescent may be unaware that sadness is what fuels his anger. Another angry student may be unaware that unacknowledged grief is at the core of her anger. A number of strategies can be used to expand students awareness of their feelings. For example, three simple techniques that can be used in either individual sessions or group sessions are Emotional Vocabulary, Emotional Pie, and Emotional Thermometer. In Emotional Vocabulary (Stark et al., 1994), a set of index cards is created, each with the name of an emotion. The cards are placed face-down in front of the students, who take turns picking a card. Upon picking a card, the students read the emotion, state what it feels like, and give an example of a time they experienced the emotion. The Emotional Pie tech-

nique (Stark et al.) simply consists of having students draw a large circle on a piece of paper, then divide the resulting pie into segments based on how often they have experienced particular feelings in the past day or week. School counselors working with younger students can ask them to divide their pie based on how much they had experienced the basic emotions of happy, sad, mad, and afraid. Older students can be provided with a more extensive list of feelings, or be allowed to select their own feeling words. The Emotional Thermometer (Merrell, 2001) is another simple technique in which the school counselor draws a large thermometer on a board or a large piece of paper, then asks the students to rate the emotional intensity of various situations they have experienced. The intent of this technique is to teach children that the strength of emotions varies depending on the situation. In addition to formal techniques, school counselors also can expand students awareness of feelings by modeling appropriate disclosure of feelings and focusing on the emotional component of students conversations. Questions such as I hear your anger coming through loud and clear, but is there also some sadness thats a part of it? and Do you think there is a connection between the lack of energy youve been feeling and the death of your grandma? can be helpful in increasing students understanding of their emotional lives. Guideline 4: Emphasize the Connection Among Events, Thoughts, and Feelings Attribution theory (Weiner, 1985) suggests that people differ in the degree to which they believe they have personal control over the positive and negative events in their lives. There is some evidence that depressed individuals tend to attribute their negative life experiences to internal, stable factors (Abramson, Metalsky, & Alloy, 1989)that, in essence, they believe they are the cause of their own misery, and that they will always be miserable. One of the ways students with depressive disorders can begin to change this mindset and feel as if they are more in control of their moods is by learning that there is a connection between what they think and what they feel, and realizing that changing the way they think about a situation can affect how they feel about the situation. This learning can be initiated by providing examples of cases in which two people are exposed to the same situation but feel very differently because of the different way they think about the situation. For example, one student gets a D on an exam and feels terrible because he believes the grade is further confirmation that he is dumb. Another student gets a D on the same exam but feels great because she knows she did not study and views the grade as confirmation that she is smart and can

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get good grades if she applies herself. The connection among situations, thoughts, and feelings can be further explored by having depressed students keep a diary in which they record the situations they are in, how they felt in each situation, and what was going through their minds at the time. The school counselor and student can mutually review the diary and examine and work to change any negative thoughts that are evident. If some episodes of negative moods are due to unchangeable negative situations (e.g., a student living in a violent home), a discussion about coping strategies can ensue. Guideline 5: Challenge Pessimistic and Constricted Thinking A substantial body of research points to a link between negative cognitions and depressive symptoms (Garber, Weiss, & Shanley, 1993; Gladstone & Kaslow, 1995; Ostrander, Weinfurt, & Nay, 1998). From Aaron Becks notion that depressed individuals tend to have a negative view of themselves, the world, and the future (Beck, Rush, Shaw, & Emery, 1979) to the assertion of Martin Seligman and his colleagues (Burns & Seligman, 1991) that depressed persons tend to have a negative explanatory style (i.e., view their failures as being due to personal failings on their part, while refusing to take credit for their successes), a number of theorists and researchers have pointed to the crucial role cognitions play in depression. Research suggests that sad and unpopular children tend to base their selfesteem on select areas of competence, thereby undervaluing other possible areas of strength (Martin, Cole, Clausen, Logan, & Wilson Strosher, 2003). Finding a way to challenge the pessimistic and constricted thinking of students with depression, therefore, seems to be a promising avenue for intervention, particularly because preliminary results support the effectiveness of programs designed to encourage a more positive explanatory style in children with depressed mood (Gillham, Reivich, Jaycox, & Seligman, 1995). Individual and group counseling applications. There are a number of concrete strategies and activities that school counselors can use in individual or group settings to challenge the pessimistic thinking of students with depressive disorders. One approach is to assist students in identifying pessimistic or distorted thinking by having them evaluate their thoughts using a list of possible thinking errors (Merrell, 2001). Items on this list include blackand-white thinking, using binocular vision (i.e., seeing problems as being bigger than they really are or seeing personal strengths as being smaller than they really are), and accepting criticism but not compliments. A related technique is to simply ask students

Whats the evidence? or Is there another way to look at it? when they describe their distorted thoughts (Stark et al., 1994). Another approach is to discuss with students events they have recently experienced in which they felt depressed, probing for underlying pessimistic thoughts. Once these thoughts are identified, the school counselor and students can jointly develop more realistic and productive replacement thoughts. With adolescents, this process can be aided by having them keep the type of thought diary described previously, where they record significant events in their day, along with their associated thoughts and feelings. A final strategy school counselors can use to combat the pessimistic thinking of students with depression is working with the students to develop positive statements that they can say to themselves in situations that typically elicit depressive feelings. The key is to develop statements that are not generic but are individualized and that feel realistic to the student. As an example, a student faced with a difficult math test might use the statement I have never failed a math test before, and even if I do I am still an A student in my other subjects, rather than the generic I am smart. Classroom applications. In my experience, the way in which teachers challenge the negative thinking of depressed students is largely dependent on the personality of the teacher, the personality of the depressed student, and the relationship they have. In some cases the teacher can simply reflect back to the student a pessimistic statement and ask the student to consider whether it is really true: I heard you say that youre sure you will fail this test. Do you think thats really true? Is there another way to think about it that might be more helpful to you? In other cases the teacher could make a more challenging statement: I heard you say that youll fail this test for sure. Youve gotten at least a C on every exam so far this semester, so its just not realistic to expect that youll do so much worse on this one. In both cases, though, the teacher has listened for evidence of pessimistic thinking on the part of the student and has challenged that thinking in some way. Guideline 6: Create a Network of Support In addition to the larger network of parents, physicians, and mental health professionals, school-based supportive networks also can be helpful for students with depressive disorders. Social isolation, low levels of social support, and social difficulties are common correlates of depression (Schraedley, Gotlib, & Hayward, 1999; Vitaro et al., 1995), which suggests that the establishment of positive social relationships is an important part of an intervention program for a depressed student. Fostering supportive relationships between depressed students and teachers,
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A solid working relationship between the counselor and the client has consistently been linked to successful counseling outcomes.

coaches, police liaison officers, school nurses, and other involved adults can provide depressed students with the sense that they are not alone in their struggles, and that they have a team of adults in their corner. Peers also can be members of this supportive network. Group counseling applications. If properly used, counseling groups can serve as ready-made networks of support. The group itself can serve as a supportive environment in which students can receive affirming messages from multiple persons (Brigman & Earley, 1991). Some students, in fact, may find it easier to talk with peers in a counseling group than with an adult in school (Greenberg, 2003). To maximize the amount of support available in groups, group leaders can use several strategies. One is to construct groups, when possible, around a shared issue, such as a grief group or a group for students who have experienced a separation or divorce. Students who share a similar issue or life circumstance may be more likely to understand and support each other (Greenberg). Leaders can encourage support within the group by modeling supportive responses following members disclosures. It is also helpful for leaders to listen carefully for any supportive statements offered by group members, and explicitly thank members for giving such statements. Group leaders also can conduct activities that encourage support among members. One example is a compliment book activity. For this activity, the group leader gives each member precut sheets of 4-ft-by-4-ft paper, as well as a single 4-ft-by-4-ft sheet of heavy paper. The members are told that the papers will be used to make a compliment booklet, and they are are asked to place their name and any decorations they wish on the heavy sheet for use as a cover. The covers then are collected, and randomly selected. When a name is read, all members write a compliment to that student on one of the sheets of paper. The sheets are collected and stapled to the cover, completing the compliment booklet. Group leaders who are concerned that some of the members may include uncomplimentary comments may wish to quickly scan the comments as they are being collected and discard those that are not positive. Staff consultation applications. School counselors can enhance the network of support for students with depressive disorders via informal consultation with a variety of staff members. Teachers, teaching assistants, coaches, administrators, support staff, and other staff members can be enlisted to provide support. Staff members need not be informed about the presence of the depressive disorder, just that the student is having a tough time and could use some extra support. For example, the network of support for one depressed seventh-grade boy was

enhanced by asking the schools police liaison officer to make a special effort to talk to the boy in the halls and during lunch. This was easy to do, and it provided the boy with a greater sense that there were supportive adults in the building who cared about him. Guideline 7: Maximize Opportunities for Success A behavioral explanation for depression is that individuals with depression are not able to obtain sufficient positive reinforcement from the environment (Lewinsohn, 1974). This suggests that a useful intervention for depressed students is to increase the amount of positive reinforcement they receive. One way to do this is to increase the amount of success they are experiencing in school. How this can be accomplished depends largely on the creativity and ingenuity of the strategies that can be generated by classroom teachers, with the assistance of the school counselor. Possible strategies range from providing extra after-school tutoring to changing desk placement so the student with depression is seated closer to the teacher. Research findings do provide some hints as to how to maximize students success. First, research suggests that depression has specific effects on memory. Children with high levels of depression have been found to struggle with tasks requiring immediate recall of learned material (Lauer et al., 1994). Paradoxically, depressed children also tend to overestimate their memory skills, which can lead them to neglect using learning and memory strategies that might facilitate recall (Lauer et al.). The good news is that depressed children tend to perform as well as nondepressed children on memory and learning tasks when they have the opportunity to learn the material over repeated trials (Lauer et al.). This research implies that teachers can improve the learning performance of children with depression by providing repetitive reviews of important material and encouraging the students to use learning strategies rather than relying on raw memorization. For example, in a class session on the Great Lakes, students could be taught the mnemonic HOMES to remember the Great Lakes, rather than being asked to simply memorize them. Second, research consistently suggests that students with depression tend to have negative academic self-concepts (Masi et al., 2001; McGee, Anderson, Williams, & Silva, 1986). This in turn suggests that it would be helpful for classroom teachers to give students the message that success in class comes from putting in the effort to learn skills, rather than from just being smart. If students with depression perceive that only smart students are capable of being successful in a class, they may become discouraged and give up, because due to

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their often negatively distorted academic self-concepts, they typically view themselves as being unintelligent. Teachers can help depressed students avoid this trap by giving an overt message that the purpose of the class is for students to learn new skills, and that with effort every member of the class can be successful. Rather than fostering a competitive classroom atmosphere, teachers could strive to emphasize a mastery learning approach. Guideline 8: Build Social Skills Because students with depression often have poor social relationships (Vitaro et al., 1995), improving their social competence by teaching them social skills makes good sense. This is particularly important because a lack of social competence and poor social relationships can create a situation in which students are not able to obtain positive social reinforcement, which is a condition that has been theorized to contribute to depression (Lewinsohn & Gotlib, 1995). Social skill building can be done in a number of ways. School counselors can role-play social situations with students, using either contrived scenarios or social situations that the students have actually experienced, and during or following the role-play they can model and discuss appropriate social skills. In addition, it is often helpful to provide students with a social vocabulary of individualized phrases that can be used to initiate conversations, maintain conversations, and deal with interpersonal conflict. School counselors also can present developmental guidance lessons in classrooms focusing on basic social skills such as building and maintaining friendships and resolving interpersonal conflict. Teachers can assist in the process of building the social skills of students with depressive disorders by paying special attention to their social behavior and sharing these observations with the school counselor. This can assist the school counselor in specifically targeting intervention efforts toward those skills areas that are most deficient. Guideline 9: Provide Concrete Evidence of Work Performance and Improving Skills Depressed students tend to view the world through the lens of negative expectations and low self-esteem (Masi et al., 2001; Stark, Ostrander, Kurowski, Swearer, & Bowen, 1995). Nonspecific positive comments (e.g., You have been doing very well in my class this semester) can be discounted or distorted, and the positive intent of the comment lost. A way to contest these distortions is to provide factual, objective, concrete evidence of success (e.g., I notice you have learned 25 new spelling words in the past 3 weeks) that is harder to discount. In addition to providing more specific and undisputable verbal feedback, teachers also may be help-

ful by keeping a visual record of depressed students increasing skills. One way to provide this type of visual feedback is by creating a simple bar graph, in which progress (e.g., number of books read, number of math skills mastered, number of projects completed) can be charted and represented with an increasing bar. At the secondary level it is generally best to do this individually, because depressed adolescents may be uncomfortable with public displays of their progress. One possible way to do this would be to use a graph kept in the teachers desk. Guideline 10: Increase Engagement in Pleasant Events Research suggests that depressed adolescents tend to engage in fewer pleasant events than those who are not depressed (Joiner, Lewinsohn, & Seeley, 2002). One easy way to translate this finding into a simple but effective intervention is to have students with depressive disorders list 10 events or activities they enjoy, then set a goal of engaging in at least one of those activities every day. These can range from listening to favorite music to going to a movie to having a hot-fudge sundae. In a group counseling setting, part of the beginning check-in process at the start of each group could be a review of the types of pleasant events in which each member has engaged. Students also should be encouraged to reward themselves for successful completion of such activities (Evans et al., 2002). Guideline 11: Increase Level of Physical Activity Research points to a clear link between increased physical exercise and improvements in depressive symptoms (Craft & Landers, 1998; Field, Diego, & Sanders, 2001b). School counselors can help students with depressive disorders develop a regular exercise program and encourage the students to stick with the program. Pairing students with an exercise partner can help both increase compliance with the exercise plan and build social relationships. A visual record of progress (e.g., number of miles walked) can provide extra reinforcement. School counselors may find it beneficial to collaborate with physical education teachers in figuring out appropriate and fun ways to add more physical activity into the lives of students with depressive disorders. Guideline 12: Provide Education About Depression Depression can be a mysterious, unpredictable, and frightening disorder. Learning more about typical signs, symptoms, causes, and treatments can help depressed students make sense of what they are experiencing and provide them with hope that they can overcome the depression. Helpful information can be found on the Internet (e.g., http://www.
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aacap.org/publications/factsFam/depressd.htm, http://helping.apa.org/changeyourmind/index. html) and in books such as Recovering from Depression: A Workbook for Teens (Copeland & Copans, 2002) and Depression Is the Pits, But Im Getting Better: A Guide for Adolescents (Garland, 1997). School counselors can provide helpful information about depression to students in individual counseling sessions or in group counseling sessions. Furthermore, it can be very helpful for school counselors to provide information about depression to all students via special programs or developmental guidance lessons (Evans et al., 2002). Teachers also can benefit from information about depression. Educating teachers about the risk factors contributing to depression, signs of depression, and developmental challenges impacting depression can better equip teachers to recognize early signs of depression and increase the likelihood they will appropriately refer to the school counselor students exhibiting signs of possible depression (Evans et al., 2002). Parents, as well, can benefit from information about depression and its signs and symptoms. Guideline 13: Be Flexible About Work Expectations Depression often impedes academic performance. There are multiple reasons for this, including the impact of depression on energy level and concentration (Christensen & Duncan, 1995; Livingston, Stark, Haak, & Jennings, 1996), the tendency of depression to lead to a perception that even small tasks require large expenditures of effort (APA, 2000), and the tendency of depression to lead to low academic self-esteem and beliefs that one is unable to be successful (Masi et al., 2001). There may be times when students with depression are simply unable to keep up with a normal workload. Providing these students with flexibility and understanding regarding work expectations can prevent them from entering a downward spiral of becoming farther and farther behind at school. School counselors can be instrumental in helping teachers see the need for flexibility and assisting teachers and students in negotiating an understanding that considers the depressed students diminished energy level and concentration while at the same time appreciates the teachers need to have the student learn the required material. A useful analogy to help teachers appreciate the need for flexibility is chemotherapy treatments for cancer. It is the rare teacher who would refuse to allow some flexibility in work expectations for a student with cancer who is undergoing chemotherapy. Yet severe depression, like chemotherapy, also can create somatic difficulties and diminished energy. If there is a clear link between the presence of a

depressive disorder and impaired school performance, school counselors can pursue either an evaluation for special education services or development of an accommodation plan under the auspices of Section 504 of the Rehabilitation Act of 1973 (i.e., a 504 plan). Depressed students deemed eligible for a 504 plan should be provided with a written plan that includes simple, concrete accommodations (see Smith, 2002, for an example). The guidelines presented in this article can be used to generate ideas for appropriate accommodations. Guideline 14: Set Realistic Expectations for Yourself Although school counselors and other school personnel can do much good for students with depressive disorders, it is not realistic for any individual to expect that he or she alone should or can effectively remediate the depression and turn a student with depression into a healthy, happy individual. To have this expectation is to tie ones professional (and sometimes personal) self-esteem to success in dealing with a mental health condition that often has deep roots and multiple causes. A more reasonable expectation is to provide students with depression with the best possible school environment and as much assistance as is possible given the constraints of the school setting.

SUMMARY
Substantial numbers of children and adolescents in this country are affected by depressive disorders, and with those disorders come a host of negative consequences. Simply put, depressive disorders among youth are prevalent and destructive. School counselors can play a critical role in improving the lives of these students by providing appropriate interventions in individual counseling sessions and group counseling sessions and by working with teachers and other staff members to provide helpful interventions in the classroom setting and in the school at large. The guidelines presented in this article can assist school counselors in developing these interventions. Much more research is needed regarding the link between all types of school-based mental health services and actual student outcomes (Hoagwood & Erwin, 1997), and the area of depression is no exception. More research is needed to further identify and validate school-based interventions for students with depressive disorders. School counselors can be helpful in this area by contributing their experiences of working with depressed students to the professional literature. In this way, better linkages can be made between the types of general intervention guidelines suggested by current research

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and practical, usable, specific interventions that can be employed in the schools. ! References
Abramson, L. Y., Metalsky, G. I., & Alloy, L. Y. (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Review, 96, 358372. American Academy of Child and Adolescent Psychiatry. (1998). Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 37(Suppl.), 63S83S. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Beck, A. T., Rush, J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., Kaufman, J., Dahl, R. E., et al. (1996). Childhood and adolescent depression: A review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 14271439. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252260. Brigman, G., & Earley, B. (1991). Groups counseling for school counselors: A practical guide. Portland, ME: J. Weston Walch. Burns, D. D., & Nolen-Hoeksema, S. (1992). Therapeutic empathy and recovery from depression in cognitive-behavioral therapy: A structural equation model. Journal of Consulting and Clinical Psychology, 60, 441449. Burns, M. O., & Seligman, M. E. P. (1991). Explanatory style, helplessness, and depression. In C. R. Snyder & D. R. Forsyth (Eds.), Handbook of social and clinical psychology: The health perspective (pp. 267284). Elmsford, NY: Pergamon Press. Christensen, L., & Duncan, K. (1995). Distinguishing depressed from nondepressed individuals using energy and psychosocial variables. Journal of Consulting & Clinical Psychology, 63, 495498. Copeland, M. E., & Copans, S. (2002). Recovering from depression: A workbook for teens (Rev. ed.). Baltimore: Paul H. Brookes. Craft, L. L., & Landers, D. M. (1998). The effect of exercise on clinical depression and depression resulting from mental illness: A meta-analysis. Journal of Sport & Exercise Psychology, 20, 339357. de Man, A. F., & Leduc, C. P. (1995). Suicidal ideation in high school students: Depression and other correlates. Journal of Clinical Psychology, 51, 173181. Evans, J. R., Van Velsor, P., & Schumacher, J. E. (2002). Addressing adolescent depression: A role for school counselors. Professional School Counseling, 5, 211219. Field, T., Diego, M., & Sanders, C. (2001a). Adolescent depression and risk factors. Adolescence, 36(143), 491498. Field, T., Diego, M., & Sanders, C. E. (2001b). Exercise is positively related to adolescents relationships and academics. Adolescence, 36(141), 105110. Garber, J., Weiss, B., & Shanley, N. (1993). Cognitions, depressive symptoms, and development in adolescents. Journal of Abnormal Psychology, 102, 4757. Garland, E. J. (1997). Depression is the pits, but Im getting better: A guide for adolescents. Washington, DC: Magination Press.

Garrison, C. Z., Waller, J. L., Cuffe, S. P., McKeown, R. E., Addy, C. L., & Jackson, K. L. (1997). Incidence of major depressive disorder and dysthymia in young adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 458465. Geller, B., Fox, L. W., & Clark, K. A. (1994). Rate and predictors of prepubertal bipolarity during follow-up of 6- to 12-yearold depressed children. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 461468. Geroski, A. M., Rodgers, K. A., & Breen, D. T. (1997). Using the DSM-IV to enhance collaboration among school counselors, clinical counselors, and primary care physicians. Journal of Counseling & Development, 75, 231239. Gillham, J. E., Reivich, K. J., Jaycox, L. H., & Seligman, M. E. P. (1995). Prevention of depressive symptoms in schoolchildren: Two-year follow-up. Psychological Science, 6, 343351. Gladstone, T. R. G., & Kaslow, N. J. (1995). Depression and attributions in children and adolescents: A meta-analytic review. Journal of Abnormal Child Psychology, 23, 597606. Greenberg, K. R. (2003). Group counseling in K-12 schools: A handbook for school counselors. Boston: Allyn & Bacon. Hains, A. A. (1994). The effectiveness of a school-based, cognitive-behavioral stress management program with adolescents reporting high and low levels of emotional arousal. The School Counselor, 42, 114125. Hart, S. L. (1991). Childhood depression: Implications and options for school counselors. Elementary School Guidance & Counseling, 25, 277289. Hoagwood, K., & Erwin, H. D. (1997). Effectiveness of schoolbased mental health services for children: A 10-year research review. Journal of Child and Family Studies, 6, 435451. Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A metaanalysis. Journal of Counseling Psychology, 38, 139149. Jaycox, L. H., Reivich, K. J., Gillham, J., & Seligman, M. E. P. (1994). Prevention of depressive symptoms in school children. Behaviour Research & Therapy, 32, 801816. Joiner, T. E., Lewinsohn, P. M., & Seeley, J. R. (2002). The core of loneliness: Lack of pleasurable engagementmore so than painful disconnectionpredicts social impairment, depression onset, and recovery from depressive disorders among adolescents. Journal of Personality Assessment, 79, 472491. Kahn, J. S., Kehle, T. J., Jenson, W. R., & Clark, E. (1990). Comparison of cognitive-behavioral, relaxation, and selfmodeling interventions for depression among middleschool students. School Psychology Review, 19, 196211. Kaltiala-Heino, R., Rimpelae, M., & Rantanen, P. (1998). School performance and self-reported depressive symptoms in middle adolescents. Psychiatria Fennica, 29, 4049. Keller, M. B., Lavoie, P. W., Beardslee, W. R., Wunder, J., & Ryan, N. (1991). Depression in children and adolescents: New data on undertreatment and a literature review on the efficacy of available treatments. Journal of Affective Disorders, 21, 163171. Kovacs, M. (1996). Presentation and course of major depressive disorder during childhood and later years of the life span. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 705715. Kovacs, M., Gatsonis, C., Paulauskas, S. L., & Richards, C. (1989). Depressive disorders in childhood. IV. A longitudinal study of comorbidity with and risk for anxiety disorders. Archives of General Psychiatry, 46, 776782. Kovacs, M., Goldston, D., & Gatsonis, C. (1993). Suicidal behaviors and childhood-onset depressive disorders: A longitudinal investigation. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 820.
8:4 APRIL 2005 | ASCA

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Lauer, R. E., Giordani, B., Boivin, M. J., Halle, N., Glasgow, B., Alessi, N. E., et al. (1994). Effects of depression on memory performance and metamemory in children. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 679685. Lewinsohn, P. M. (1974). A behavioral approach to depression. In R. J. Friedman & M. M. Katz (Eds.), The psychology of depression: Contemporary theory and research (pp. 157185). New York: John Wiley & Sons. Lewinsohn, P. M., & Gotlib, I. H. (1995). Behavioral theory and treatment of depression. In E. E. Beckham & W. R. Leber (Eds.), Handbook of depression (2nd ed., pp. 352375). New York: Guilford Press. Lewinsohn, P. M., Hops, H., Roberts, R. E., Seeley, J. R., & Andrews, J. A. (1993). Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology, 102, 133144. Lewinsohn, P. M., Rohde, P., Klein, D. N., & Seeley, J. R. (1999). Natural course of adolescent major depressive disorder: I. Continuity into young adulthood. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 5663. Livingston, R. B., Stark, K. D., Haak, R. A., & Jennings, E. (1996). Neuropsychological profiles of children with depressive and anxiety disorders. Child Neuropsychology, 2, 4862. Lockhart, E. J., & Keys, S. G. (1998). The mental health counseling role of school counselors. Professional School Counseling, 1, 36. Martin, J. M., Cole, D. A., Clausen, A., Logan, J., & Wilson Strosher, H. L. (2003). Moderators of the relation between popularity and depressive symptoms in children: Processing strength and friendship value. Journal of Abnormal Child Psychology, 31, 471483. Masi, G., Tomaiuolo, F., Sbrana, B., Poli, P., Baracchini, G., Pruneti, C. A., et al. (2001). Depressive symptoms and academic self-image in adolescence. Psychopathology, 34, 5761. McGee, R., Anderson, J., Williams, S., & Silva, P. A. (1986). Cognitive correlates of depressive symptoms in 11-yearold children. Journal of Abnormal Child Psychology, 14, 517524. Merrell, K. W. (2001). Helping students overcome depression and anxiety: A practical guide. New York: Guilford. Olfson, M., Gameroff, M. J., Marcus, S. C., & Waslick, B. D. (2003). Outpatient treatment of child adolescent depression in the United States. Archives of General Psychiatry, 60, 12361242. Ostrander, R., Weinfurt, K. P., & Nay, W. R. (1998). The role of age, family support, and negative cognitions in the prediction of depressive symptoms. School Psychology Review, 27, 121137.

Rao, U., Weissman, M. M., Martin, J. A., & Hammond, R. W. (1993). Childhood depression and risk of suicide: A preliminary report of a longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 2127. Reynolds, W. M., & Coats, K. I. (1986). A comparison of cognitivebehavioral therapy and relaxation training for the treatment of depression in adolescents. Journal of Consulting and Clinical Psychology, 54, 653660. Rushton, J. L., Forcier, M., & Schectman, R. M. (2002). Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 199205. Schraedley, P. K., Gotlib, I. H., & Hayward, C. (1999). Gender differences in correlates of depressive symptoms in adolescents. Journal of Adolescent Health, 25, 98108. Shaffer, D., Fisher, P., Dulcan, M. K., Davies, M., Piacentini, J., Schwab-Stone, M. E., et al. (1996). The NIMH Diagnostic Interview Schedule for Children version 2.3 (DISC-2.3): Description, acceptability, prevalence rates, and performance in the MECA study. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 865877. Shirk, S. R., & Karver, M. (2003). Prediction of treatment outcomes from relationship variables in child and adolescent therapy: A meta-analytic review. Journal of Consulting and Clinical Psychology, 71, 452464. Smith, T. E. C. (2002). Section 504: What teachers need to know. Intervention in School and Clinic, 37, 259266. Stark, K. D. (1990). Childhood depression: School-based intervention. New York: Guilford. Stark, K. D., Ostrander, R., Kurowski, C. A., Swearer, S., & Bowen, B. (1995). Affective and mood disorders. In M. Herson & R. T. Ammerman (Eds.), Advanced abnormal child psychology (pp. 253282). Hillsdale, NJ: Lawrence Erlbaum. Stark, K. D., Rouse, L. W., & Kurowski, C. (1994). Psychological treatment approaches for depression in children. In W. M. Reynolds & H. R. Johnston (Eds.), Handbook of depression in children and adolescents (pp. 275307). New York: Plenum Press. Vitaro, F., Pelletier, D., Gagnon, C., & Baron, P. (1995). Correlates of depressive symptoms in early adolescence. Journal of Emotional and Behavioral Disorders, 3, 241251. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates. Weiner, B. (1985). An attributional theory of achievement motivation and emotion. Psychological Review, 92, 548573. Wu, P., Hoven, C. W., Bird, H. R., Moore, R. E., Cohen, P., Alegria, M., et al. (1999). Depressive and disruptive disorders and mental health service utilization in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 10811092.

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