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Eitan Novick

Understanding Diverse Learners


Depression in School-Age Children: How Schools Can Help
Schools, because of their centrality in a school age childs life, are uniquely
situated to identify and positively address depression in students. Furthermore,
depression is a condition that often impacts student achievement, both
academically and socially. As an academic and whole child issue, schools have a
responsibility to address it in order to ensure all students are receiving the help they
need to succeed. Otherwise they are failing them not just from a mental health
perspective, but from an academic one.
Depression: What is it?
In discussing depression in school age children, we must first understand
what depression is and what it looks like in general. In terms of its clinical usage,
the diagnosis of depression means more than just sadness. Anne M. Bauer (1987),
siting the American Psychological Associations (APA) 1979 Manual for Mental
Disorders, states that the primary symptom for depression is a dysphoric mood,
or a loss of interest or pleasure in almost all daily activities (p.81). Rather than
provide a definition of depression, most researchers provide characteristics of what
it looks like. Bauer goes on to explain that for a clinical diagnosis of depression,
someone would need to exhibit at least four of the following prominent symptoms
for at least a two week period: changes in appetite or weight, sleep disturbance,
psychomotor agitation, loss of energy, feelings of worthlessness or excessive guilt,
difficulty concentrating, and thoughts of death or suicide (p.81). MaryLou Ramsey

(1994) describes the symptoms of depression similarly, stating that depression is a


mood disturbance continuum characterized by feelings of sadness, inferiority,
inadequacy, hopelessness, dejection, guilt or shame (p.256). Abrams, Theberge,
and Karan (2005) add to the list, a decreased ability to experience pleasure;
irritability and anger;headaches and stomachaches;exhaustion (p.284). It is
also worth noting that on their website, the APA lists depression as the most
common mental illness.
Ramsey (1994) encourages us to view depression along a continuum with
four major types of depression: normal, chronic, crisis, and clinical. As someone
moves along this continuum, the degree, intensity, and duration would increase. A
normal depression would be what she calls a down period, a short, temporary
period of depressed feelings, which would not be a psychopathological experience.
With chronic depression bouts of depression can be caused by a variety of
different reasons or no perceivable reasons at all. A crisis state of depression
would be brought about by an inability to solve an issue or crisis, which leads to
debilitating feelings of dejection, sadness, and despair. And clinical depression
is usually brought on by the same event as a crisis, the difference being that in
this state, a personality predisposition is exacerbated (p.256-257). This continuum
is going to be significant because it forces us to not ignore those who may be
suffering from depression like symptoms, even if they would not be diagnosed as
depressed. Abrams, et al. (2005) make a similar point, highlighting a depressive
spectrum that spans from not diagnosable to major depressive disorder. They
argue that while a student may not display indicators of depression sufficient for a
clinical diagnosis theyre condition is still serious enough to prevent them from
functioning at their optimal level academically and socially (p.285).
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Until very recently there was no concept of depression occurring in children.


As Ramsey (1994) explains, depression in children and adolescents was viewed as
nonexistent or very different from that of adults. Now, however, scientific
consensus recognizes that although developmentally-oriented features need to be
explored, depression in school-age children manifests the same basic symptoms as
depression in adults (p. 256). In fact, according to Bauer (1987), the number of
school-age children showing some signs of depression (not necessarily diagnosable
clinically) is a very significant 20%, which means that in a classroom of thirty
students, a teacher may anticipate that one or two students will exhibit symptoms
of depression (p.81). Using Ramseys terminology, that means that a teacher, over
the course of his or her career, can expect to have a few students who would fall
somewhere on the depression continuum.
Childhood depression is usually identified by interviewing the parents and the
child and by using behavior rating scales or other rating instruments, which are
questionnaires that can be administered to the student, his or her parents, and
peers. There are several challenges to identifying depression in school-age
children. First, there can be a wide range of how depression can look in students.
Because school-age children are progressing through developmental stages, the
specific behaviors exhibited by depressed students may vary based on their stage
and can be somewhat different from that of adults. Bauer (1987) quotes a study
performed by Kovacs and Paulaniskus, which demonstrates an example of this
notion. They found that while less mature students showed greater disruptions in
experiencing pleasure and were more self-deprecating, more mature students
exhibited disobedience, oppositional behavior, and complaints of aches and pains
(p.81-82).
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Another challenge is that it is common for depressed people to react


differently to different situations. A study by Meyer and Hokanson (1985) found that
depressed individuals would react in various ways depending on the nature of the
person with whom he or she was interacting. When stressed by someone intimate,
depressed people were likely to show sadness. But when similarly stressed by
strangers, they would respond by withdrawing. This could make it complicated to
identify depression in school-age children, because there are so many different
types of relationships between peers and teachers and administrators in any given
day, and we may not always be aware of the nature of all their relationships.
Ramsey (1994) similarly points to a few other issues, stating that the identification
and subsequent treatment remain a major problem because of the lack of referrals,
parental denial, and insufficient symptom identification training (p.256). Maag and
Swearer (2005) also highlight the dearth of studies conducted on children, and even
fewer conducted in a school setting.
Just as depression is complex and intricate in how it manifests in students
suffering from it, so too the causes and triggers of depression in students are not
always clear. Epstein and Cullinan (1986) determined that there is no conclusive
knowledge as to the sources of childhood depression. Similarly, Ramsey (1994)
states that there are many explanations for the origin of depression. Some
potential sources she sites are: genetic predisposition, overidentification with
parents who are depressed, loss of social reinforcement, loss of role status, or loss
of meaningful existence (p.257-258). She continues that these potential roots can
be grouped into two main categories: loss or threatened loss of a love object,
status role, or other psychosocially determined support, and failure to meet
internalized standards, values, or goals (p.258).
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Weller, Weller, and Fristad (1984) suggest four models of how depression
might be triggered in children. The first is the behavioral reinforcement model,
which suggests that inadequate or insufficient positive reinforcement leads to a
sense of powerlessness in the student. The learned helplessness model states
that depressed students create a perception of hopelessness because they see their
behavior as independent of reinforcement. The model of cognitive distortion
claims that depression comes from negative conceptualizations of the self, world,
and/or future. And finally, the life stress model states that depression is formed
when there are changes in the life of the child that necessitate adaptation. Ramsey
(1994) adds that depression can be brought about by embarrassment; social
setbacks; frustration; conflicts with authority, friends or loved ones; personal
failures; serious illness or death (p.258).
There is also a potential medical component to depression, based on the
chemicals in the brain. Arkowitz and Lilienfeld explain that a deficiency of certain
neurotransmitters (chemical messengers) at synapses, or tiny gaps, between
neurons interferes with the transmission of nerve impulses, causing or contributing
to depression. They point out that in modern day, the chemical serotonin

has

garnered the most interest, but there are actually many other chemicals that may
be playing a role. The effectiveness of antidepressants, which in most cases
increase the levels of serotonin, is often used as evidence for this notion of a
chemical imbalance being the root cause of depression. Akowitz and Lilienfeld,
however, argue that brain chemicals are just one component of depression and that
we need to integrate everything we know about depression in order to treat it. This
may explain why many psychiatric professionals and researchers, such as Maag and

Swearer (2005), argue for a combination of medicationand cognitive-behavioral


therapy.
The Role of Schools
Now that we have addressed what depression looks like in school-age
children, we need to investigate why schools need to be involved and what their
role should be. The foremost argument for schools being involved in identification
and treatment of depression is that it affects learning. A study by Korup (1985)
found that students who were depressed scored significantly lower when assessed
for effort. If students are unable to demonstrate effort, which will likely take a toll on
academic achievement. Ramsey (1994) explains that with depressed students,
every academic failure can lead to a poor self-concept, which can lead to feelings of
hopelessness and worthlessness, decreased effort, and therefore continued
academic failures. This can form a very dangerous cycle of failure and loss of effort
and motivation.
The other major argument for school involvement in depression is because
schools are best suited for the task. Maag and Swearer (2005) emphasis that
schools need to play a role in identifying (not diagnosing, that is the role of
psychiatric professionals) depression in students because they spend more time in
school than in most structured environmentsand have their most consistent and
extensive contract with trained professionals in the school setting. They state
further that the very things that are warning signs for depression, students
behavior, interpersonal relationships, and academic performance, are under
ongoing scrutiny in schools and classrooms (p.259-260). Abrams, et al. (2005)
site another important issue of students and families access to the care they would
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need, stating that the rising number of students and families in need of mental
health services, coupled with the decline in mental health programs, place school
counselors in the difficult position of sometimes being the only accessible mental
health service provider" (p.284). Bauer (1987) argues that teachers are in a great
position to assist in identification of at risk students and to make referrals to
guidance counselors, and Abrams, et al. (2005) claim that school counselors are in a
situation to understand the needs of both the student and the family, and may have
knowledge of and access to resources in the community.
Interventions and Treatment
Before delving into what can be done at the school level, it must be noted
that one of the most helpful treatments of depression is medication. According to a
study by Epstein and Cullinan (1986), approximately 75% of depressed individuals
taking medication show improvement. This is not a treatment that would be carried
out by the school, but if necessary, the school can play a role in assisting in setting
students and families up with appropriate psychiatric care. It is also important to
note, as Bauer (1987) points out, that these medications do present side effects
that can be physically dangerous and/or academically challenging, such as fatigue,
dry mouth, nausea, cardiovascular irregularities, and seizures (p. 83). Given that
teachers spend large periods of time observing and working closely with students,
they need to be aware of students being medicated and keep a lookout for these
side effects.
On a systematic, or school-wide, level there are a number of approaches to
addressing depressed students. One such systematic approach is the ecological
approach, which is presented by Abrams, et al. (2005). The concept behind this
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approach is that a student has many different factors and influences impacting his
or her life and an understanding and appreciation for those factors can help in
addressing depression. The model identifies four systems with which any child
interacts. The mesosystem, or microsystem, is the one closest to the child and
includes family, school, peers, and neighborhood. Next, the exosystem focuses on
factors that are outside a childs microsystem but can affect it, such as government
cutbacks in services. The macrosystem is further removed and includes things like
culture, society, global events, etc. And finally, the chronosystem accounts for the
time in history in which the child lives (this may seem irrelevant, but given that until
recently depression was not believed to exist in children, the time in which a child is
born can play a role in his or her mental wellbeing).
The argument behind this system is that schools, and particularly school
counselors have access to the student, as well as various aspects of their
microsystem. According to this approach, the counselor would lead the process by
convening a team made up of those in a students life. That team would form
hypotheses through an investigation of the students systems as to what might be
negatively affecting a childs depression and also what possible sources of strength
and healing exist within his or her world (p. 286). Interventions would then be
created and implemented based on these findings.
The team would begin with the individual student, looking for potential issues
stemming from him and possible interventions to address those issues, and would
then move outward through the different systems. For example, starting from the
child, if the team sees that the child is not receiving ample opportunity to be active
in school, they might create an intervention that allows for more exercise, as that
releases endorphins and is an effective way to combat depression. Other
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interventions at the level of the child might include a change in nutritional intake,
sleep patterns, and counseling. The microsystem level might uncover issues such
as divorce and interventions might include teaching a child coping mechanisms or
encouraging him to leave the house if things get heated. Similarly, if a depressed
student is struggling in school, an intervention might include finding areas of
competence and allowing him opportunities to invest time in those areas. The
energy and positive feelings he experiences in those times may spill over into the
rest of his day. As Abrams, et al. (2005) write, success breeds success. It may be
very effective to build success into the students day by ensuring that academic
goals are achievableand by involving the student in the discussion of goal setting
(p.289).
Another approach that is applicable at a school-wide level is that of CognitiveBehavioral Interventions (CBI), which focuses on cognitions and behaviors. With
regards to cognition, interventions target a students thoughts and private speech
about himself/herself, the environment, and his/her future (Maag and Swearer,
2005, p.260). CBI also includes a behavioral component, which includes modeling,
role playing, and positive reinforcement.
Maag and Swearer (2005) offer four CBI techniques for countering
depression. The first is self-instruction training, which is a means of teaching
children positive self-talk as a means of helping them gain self-control over certain
elements of depression, such as countering negative self-statements with positive
ones (p.261). The concept is to teach students to use certain positive phrases
while carrying out tasks that help instruct them as to how to be successful in the
task.

The next technique is attribution retraining, which focuses on the fact that
depressed students often attribute failure to something internal and unchanging in
themselves, and success as something external and changing. This technique tries
to reverse that thinking. One way to do this is to have students make statements
that link failure to insufficient effort, i.e. something that is changeable and can be
affected by himself.
Another technique mentioned by Maag and Swearer is problem solving
training, which teaches students a variety of skills to use in order to resolve a
conflict or address an issue. The purpose of this technique is to help students who
are depressed develop alternative solutions to problems that may be otherwise
thought of as insurmountable and to change their locus of control orientation from
external to internal (p.262). This tactic shows students that they have control over
their situations, they can act and need not feel helpless.
Cognitive restructuring is a technique that focuses on identifying and
altering young peoples irrational beliefs and negative self-statements by training
them to dispute irrational thoughts through the use of logical analysis and abstract
thinking (p. 262). Maag and Swearer site two types of cognitive restructuring:
rational-emotive therapy (RET) and cognitive therapy. The premise of RET is that
most everyday problems come from irrational self-statements we tell ourselves
and we can counter that by teaching children to counteract irrational beliefs with
more positive and realistic statements (p.262). The primary way this is
accomplished is by having children exaggerate these irrational beliefs to show their
ridiculousness. In cognitive therapy, children are instructed to identify the negative
thoughts that may be leading to depression and to work on counteracting them.
One method for doing that is reality checking, in which the child forms a
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hypothesis based on the negative thought and tries to test it to determine if his
negative thought is accurate.
Aside from school-wide approaches, there may be things all adults in a
depressed childs life can do to create an environment for success. Teachers and
parents need to help children form positive self-concepts. Ramsey (1994) suggests
that adults capitalize on strengths and children should be encouraged to become
involved in group activities that utilize their skills and give them the opportunity to
feel accepted and succeed (p.260). In school and at home, we can give children
tasks that utilize their skills and strengths and set them up for success and positive
self-concepts. Ramsey suggests further that even the language we use can build
positive self-concepts and encourage positive thinking. For example, students who
are struggling with a task can be challenged to change their thinking from I cant
to I will try (p. 261). Furthermore, students suffering from depression need to be
given control over their tasks. One suggestion Ramsey offers it to ask a child to join
you in making a task list. Additionally, because depressed students often suffer from
anxiety, physical exercise, active relaxation procedures (such as yoga), or passive
relaxation techniques (such as imagery) help reduce and manage anxiety (p. 261).
Lastly, and maybe most importantly, depression often goes along with suicidal
feelings and thoughts. Ramsey stresses how important it is for students to be
provided with ample and always available opportunities to talk about troublesome
feelings and events without judgement. It is also crucial that a school have a crisis
intervention plan that details the process for handling emergencies immediately
(Abrams, 2005, 291).
The school is a central institution of a childs or adolescents life. Students
spend a large portion of their waking hours there, it is often the source of most of
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their social interactions, it is where they learn, play, and eat. Given this centrality
and the mission of a school to prepare their students for the world, identification
and treatment of student depression is a responsibility that schools cannot deny.
Schools cannot take the place of mental health professionals, but they have a
critical role to play in addressing this very important need and creating an
environment in which all their students can succeed.

References
Abrams, K., Theberge, S. K., & Karan, O. C. (2005). Children and adolescents
who are depressed: An ecological approach. Professional School Counseling, 8(3),
284-292.
APA Psychology Topics: Depression. (2000). Retrieved from
http://www.apa.org/topics/depress/.
Arkowitz, H., & Lilienfeld S. O. (2014, March 1). Is Depression Just Bad
Chemistry? Scientific American Mind, 25. Retrieved from
http://www.scientificamerican.com/article/is-depression-just-bad-chemistry.
Bauer, A. M. (1987). A teachers introduction to childhood depression. The
Clearing House, 61(2), 81-84.
Epstein, M.H., & Cullinan, D. (1986). Depression in children. Journal of School
Health, 56(1), 10-12.

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Koroup, U. L. (1985). Parent and teacher perceptions of depression in


children. Journal of School health, 55, 283-88.
Maag, J. W., & Swearer, S. M. (2005). Cognitive-behavioral interventions for
depression: Review and implications for school personell. Behavioral Disorders,
30(3), 259-276.
Meyer, B.E., & Hokanson, J.E.. (1985). Situational influences on social
behaviors of depression prone individuals. Journal of Clinical Psychology, 53(5), 64756.
Ramsey, M. (1994). Student depression: General treatment dynamics and
symptom specific interventions. The School Counselor, 41(4), 256-262.
Weller, E. B., Weller, R. A., &Fristad, M.A. (1984). Assessment and treatment
of childhood depression. Current perspectives on major depressive disorders in
children. San Francisco: Jossey-Bass.

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