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Adapting, manualizing and evaluating an evidence based CBT Group of intervention for youth with depressive symptoms for delivery in school-based settings


Background. This evaluation study examines the development and implementation of cognitive-behavioral group intervention for middle school and high school youth experiencing depressive symptoms. Evidence-based practice is emerging as a key approach to building quality and accountability in school based settings. Providing evidence-based mental health services in school settings is one way to ensure that a large number of students who are experiencing emotional and behavioral problems are getting effective services. Receiving mental health interventions in the schools may be perceived by students as less stigmatizing then receiving services with traditional mental health providers. Catron and Weiss (1994) reported that 98% of children and adolescents referred to school-based mental health workers received services while only 17% of similar students who were referred to traditional clinic-based mental health services received treatment. However, a majority of interventions delivered to children and adolescents to address emotional and behavioral issues in a school setting are not empirically based (Zins, Weissberg, Wang, & Walberg, 2004).

Purpose. The question that this study addresses is: Does a modified CBT group intervention delivered during the school day decrease youth depressive symptoms and improve school engagement and peer relationships?
Students at three school-based health and wellness (SBHC) clinics participated in the evaluation. The three SBHC settings serve a relatively high concentrations of students from families who receive Medicaid or are uninsured - approximately 50%. Each cognitive behavioral group intervention was delivered during the school day.
Youth were referred by school and health care center staff. The 9 session group intervention was adapted from an evidence-based intervention delivered in mental health clinic settings and manualized for delivery in school based settings. To ensure fidelity to the model, the social workers received training in CBT and were supervised by a CBT expert throughout the implementation of the group. Each CBT group session had specific objectives, skills to be learned and assessment measures to reinforce the skill learning.
Depressive symptoms, school engagement and peer relationships were assessed at the start and end of the group intervention using standardized measures. In addition, parents of youth at the middle schools who participated in the groups also completed standardized instruments to gain their perspective on the youth's functioning with peers, at school and with family at intake. A total of 60 youth participated in the depression groups. A majority of the youth are white (33% are black). The group intervention was delivered during the school day for an hour once a week at three different school based health clinic sites.

Key findings. Using standardized instruments to measure change over time for the students who participated in the depression group, we found that: 1.) the youth in the CBT group intervention demonstrated improvement in their level of depressive symptoms over time and 2) youth also reported improved school engagement and peer relationships. There were no significant differences based on gender or race on any of the standardized measures.
The youth at the time of entry into the group had CDI (Mean=30.64, SD=11.02) or BDI II (Mean=19.5, SD=9.08) scores indicating moderate levels of depression. Based on parent report, the middle school youth participating in the group had moderate functioning difficulties in school, friend and family relationships (Columbia Impairment Scale Scores Mean=20.70, SD=9.08).
The depression scores on the BDI and the CDI reflected a significant positive change for youth with overall levels of depression decreasing from the first group session to the final group session. At the six week follow-up, positive changes remained but the difference was no longer significant.
Qualitative comments from students indicated that they found the group sessions to be helpful to them and would recommend the group to other students. Most students (90%) could identify someone that they could talk with when feeling down. In addition, students reported that they had at least one adult who they felt comfortable talking to when they are having difficulties. Students reported that the thoughts/action/feelings triangle and the upward/downward spiral techniques were the most helpful to their learning and coping strategies.
Teachers at the middle schools reported improved engagement of students in class activities. Teachers also reflected post-group participation, that the students completed homework assignments more and earned better grades. Teachers who had a student in the CBT groups indicated that they would refer more students to the group since the outcomes were positive in their classes.

Recommendations. This evaluation study supports further development and evaluation of school based cognitive-behavioral group interventions for working with youth experiencing depressive symptoms or other emotional/behavioral disorders. The next step would be to test the effects of this intervention over time and to replicate this evaluation with youth in different school based settings.

Key references
Catron, T. & Weiss, B. (1994). The Vanderbilt school-based counseling program: An interagency, primary-care model of mental health services. Journal of Emotional and Behavioral Disorders, 2(4), 247-253.
Clarke, G.N., Lewinsohn, P.M., & Hops H. (2001). Instructor's manual for Adolescents Coping with Depression course. Retrieved from Kaiser Permanente Center for Health Research website: www.kpchr.org/public/acwd/acwd.html.
Zins, J.E., Weissberg, R.P., Wang, M.C., & Walberg, H.J. (Eds). (2004). Building academic success on social and emotional learning: What does the research say?. New York: Teachers College Press.

Contacts: Mary C. Ruffolo, University of Michigan, School of Social Work, 1080 South University, Ann Arbor, MI 48109-1106, Tel. 734-763-2345, mruffolo@umich.edu.

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