Implementation of Adolescent

Depression Prevention Program in

Howard County High Schools
Laurel Pulford
Heather Freed, LCSW
Erikas Lighthouse
Konstantin Cigularov, Ph. D
Old Dominion University.

Mrs. Mary Jane Sasser

River Hill High School
May 30, 2016

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Imagine a world where a vicious disease runs rampant. The disease changes a
victim from the inside. The parasite alters a victims entire personality and sense of self
until they have convinced themselves that this is the only way they can liveno longer
happy, productive, or successful. Now return to this world where 1 out of every 8
students suffers from this imaginary disease. On earth, the disease is known as
depression.
Suicide is the third leading cause of death in adolescents ages 15 to 24 (Ruble et
al. 1025). With these shocking numbers in mind, 90-98% of all suicide is a result of
mental illness, the most common is depression (Shaffer et al. 340). Depression is a
mental disability that leaves the victim unable to perform normal activities because of
his/her extreme sadness or apathy. The World Health Organization found that Major
Depressive Disorder (MDD) is the number one cause of all disability among Americans
age 15 to 44 (Desrochers and Houck 11). According to the National Adolescent Health
Information Center, over 25% of adolescents in America are affected by at least mild
depressive symptoms; this accounts for around 18.8 million adolescents (Improving 1).
Only 25% of people with mental health symptoms believe that people are caring
and sympathetic to persons with mental illness (Center for Disease Control 19). This
affects how victims of depression perceive the world around them; this perception could
influence their help-seeking methods (if they choose to engage in any at all) and/or their
approaches to certain situations. Furthermore, there is a great amount of stigma that
surrounds the disease in which individuals identify it as a sign of weakness rather than a
physical illness. This stigma works to keep students, school staff, and family members
from openly discussing the disorder (Desrochers and Houck 12). Because of this lack of
discussion about depression, students in need of clinical help may not be diagnosed. In
fact, according to the Substance Abuse and Mental Health Services Administration, only
approximately two out of every five adolescents who suffer from depression receive
treatment (Improving 4).
With symptoms of nearly three-fourths of all lifetime diagnosable mental health
disorders beginning by age 24, it is critical to identify mental health disorders as early in
life as possible (Improving 1). Because depressive symptoms are so prevalent in
adolescents, a school-based universal program presented by a teacher and a
mental health professional should be implemented targeting juniors and seniors
in high school.
An adolescent depression prevention and early intervention programs target
audience is a major element of the program that makes it unique. The audiences history
and relationship with the topic can significantly determine the impact that the information

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of the program will have on the audience. With this in mind, three distinct types provided
by prevention programs have emerged to target different audiences of varied
backgrounds; they are known as universal, selective, and indicated programs.
Universal prevention programs are typically those that target a majority of a
population and are most popular in a school environmentusually as curricula. Universal
programs typically focus on developing a students cognitive and behavioral skills, such
as cognitive restructuring, anxiety management, relaxation, problem-solving skills,
emotion-focused coping, anticipating consequences, and assertiveness; furthermore,
the programs specifically focus on depression literacy, stigma reduction, and helpseeking behaviors (Horowitz and Garber 401; Freed 3).
Selective prevention programs are those that target students that have been
determined to be at an increased risk of having or developing depressive symptoms due
to family factors such as divorce, parental depression, parental death, or parental
alcoholism, environmental factors such as poverty, or personal characteristics such as a
negative cognitive style (Horowitz and Garber 401). These programs are usually
implemented in smaller groups of people than universal programs and focus on a similar
form of cognitive-behavioral techniques as universal programs.
Indicated intervention programs are geared towards those students who have
been identified as having subclinical or clinical signs and symptoms of depression,
including those having suicidal ideation and who have made attempts at suicide
(Robinson et al. 164). This means that there is an additional step of depression
screening to the recruitment process for finding participants which leads to more timeand cost-consumption. However, this ensures that those receiving the intervention are at
the greatest risk. These programs are implemented similar to the format of selective
programs (i.e. small-group) and a majority has taught cognitive techniques, such as
developing a more flexible thinking style and making more realistic, less pessimistic
attributions. Such programs also commonly teach problem-solving skills, goal setting,
perspective taking information gathering, and decision making (Horowitz and Garber
402).
All three types of programs have shown both positive and negative results. There
are many variables that determine the effectiveness of the program. However, a
universal

program

for

prevention

of

adolescent

depression

should

be

implemented into schools because of its proven effectiveness and ability to

impact the largest number of students based on its target audience.
There is significant evidence that universal prevention programs have had
positive or even better effect sizes on students than the two other program types. An

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effect size is a number solved for by finding the difference between mean test scores of
a pre-test and a post-test for a program and then divided by the standard deviation;
positive effect sizes indicate improvement for the intervention group (Jan-Llopis 385).
As shown in Figure 1 and Figure 2, universal programs have a wide range of effect sizes
from -0.21 to 1.37. However, the program that had an effect size of -0.21 (meaning the
students knew even less about depression at the posttest than they did at the pretest)
saw immense growth immediately following the program to a 0.38 effect size at a followup test months afterward. Because the universal programs saw effect sizes such as
0.15, 0.66, 0.96, and 1.37 it can be said that the programs are likely to produce some
form of positive progress. Although 0.15 does not seem as impressive as 1.37, the
number means that those students still knew more about depression after the program
than they had going into the class. If one was to look past the generalized numbers and
see those numbers as individual students, they would also see the positive effectiveness
of a universal program.
The universal program, through its unique, broad-based target audience
structure, impacts the greatest number of students and increases the chances of making
a positive impact on a students life when compared to selected or indicated programs.
Some argue that a selected or indicated program is more effective because it gives the
vital information straight to the targeted high risk students with depression. However, the
screening tests required to find such students may leave some out. Through human and
technological error (i.e., misreading of data, misuse of machinery, etc.), such students
would be deprived of critical information from these types of programs that they need to
move through their lives. This information would be invaluable to them because it would
teach them techniques of how to react in certain situations, coping skills, help-seeking
strategies, and it would show them that depression is not something to be ashamed of. A
universal program would bypass this chance of error by including all students to give
them necessary and general information that they will need moving forward in life.
Programs such as the 9th grade health curriculum are created to provide information
freshmen will need moving through their high school career. However, what will the
student do in their college career if they do not remember the information they were
taught four years prior?
People often hold the mistaken belief that mental health is not the responsibility
of the schools and that, instead, it is the responsibility of the family to find services
outside of the school system (Desrochers and Houck 13). Furthermore, schools are
expected to play an important role in promoting the development of children and
adolescents by preparing them for their future roles in society To achieve the

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development of the childs personality, talents and mental and physical abilities to their
fullest potential, the teaching of social and emotional skills can be considered a core task
of school systems, in addition to cognitive-academic skills (Skald et al. 892). Especially
in Howard County schools, there is an enormous amount of focus on advanced
placement and superior academics. Students are being developed mentally for the rigor
of college classes but are not prepared for the rigor of college life on a students
emotions. A depression prevention and early intervention program should be
presented to juniors and seniors in high school because there is a great need
within the age group, students have forgotten the material from their freshman
year, and older students have a greater capacity to understand what is being
taught to them.
Although targeting students in 9th grade is beneficial because the students are
about to turn 15 and statistically are at an increased risk of developing depression,
juniors and seniors are still in the midst of the dramatic development of depression as
shown in Figure 3. These older students should not be ignored because they deserve to
have information about how they are feeling and what to do about it. Throughout high
school, juniors and seniors go through intense amounts of emotional strain and angst.
With the stress of striving for superior grades and SAT scores in their junior year and
writing incredible college essays and applications in their senior year, upperclassmen
undergo enormous amounts of anxiety. This is only the academic pressure put on
students from their school, parents, peers, and selves; students also go through
individual emotional journeys whether instigated through social stress or some other
aspect of their lives. Both academic and personal stresses put on the student in their
junior and senior year necessitate coping behaviors that most students find on their own.
When these students work alone to make their lives seem less stressful, they may turn
to negative behaviors such as drugs, alcohol, and lack of sleep. These behaviors can be
battled through the re-teaching of positive coping skills.
According to a Harris Poll conducted of college students in their second term,
60% wish that they had been more emotionally prepared for college and 87% said that
more emphasis was put on academic success and preparedness than on emotional
preparedness for college (The First-Year 16 & 13). There is a lack of emotional
education for students entering college to the extent that many students do not practice
skills that a universal program teaches such as help-seeking behaviors, anxiety
management, and coping skills. More than 1 in 10 of the students in the survey said that
they did not turn to anyone for help (The First-Year 5). Also, nearly 2 in 3 college
students handled stress negatively, such as staying up late and using drugs and alcohol

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(The First-Year 14). Students do not remember or understand the coping skills that
they were taught in their freshman year of high school; consequently, they turn to the
negative coping skills they developed in high school. Students in college feel that their
school focused much more on academic success than on emotional preparedness;
schools let their students down by sending them to college unprepared for the
challenging emotional experience.
Although a universal program has been implemented in Howard County schools
as a part of the curriculum in health class for ninth graders, depression for students does
not cease after their freshman year. The class is a typical universal program that
enhances student literacy of depression and help-seeking behaviors. However these
students continue absorbing and reacting to information from more than 25 classes by
the time they graduate. Seniors in high school, even juniors, will have forgotten most of
the material they learned their freshman year. Some may question, If the juniors and
seniors had forgotten what they learned their freshman year in health class, what would
stop them from forgetting information in a new prevention program? The answer would
be that newly formed memories are vulnerable to interference and to being forgotten; the
students would most likely forget the information they would receive about adolescent
depression. Therefore, actions must be taken in order to construct an adequate
foundation for those memories to form such as a relearning session and a memory test
to secure those memories in each students brain (Eysenck and Keane 255-256). The
program would be focused towards young adults preparing for college so they could
receive the necessary emotional aid for the difficult years ahead of them.
Finally, having gone through 16 and 17 years of their lives, juniors and
seniors in high school have a greater capacity to understand what they are being taught.
In a meta-analytic review of 32 prevention programs, the authors hypothesized that
prevention programs would produce larger effects for older adolescents relative to
young adolescents and children at both posttest and follow-up based on the results of a
preexisting study by Horowitz and Garber. The researchers found that their hypothesis
was proven from their analysis, commenting that theoretically, this effect emerged
because the risk for depression increases during adolescence. However, it is possible
that older adolescents respond more favorably because they are better able to
understand the concepts taught in the prevention programs, due to improved abstract
reasoning (Stice et al. 499). By abstract reasoning, Stice means that older students
have a better ability to understand and reason with a variety of situations than their
younger, less experienced counterparts. No matter the true reason, a greater capacity to
understand or improved abstract reasoning, older adolescents respond more favorably

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to prevention programs than younger adolescents. Older students are the best fit for
receiving an adolescent prevention program because of their great need for it and
maturity.
The presenter of a prevention program can be a key factor in determining the
programs effectiveness. The delivery of the programs information can be crucial in how
students receive it and are affected and influenced by it. Furthermore, the relationship
between student and instructor play a role in impacting the students. A mental health
professional (MHP) and a teacher should be the program instructors based proven
effectiveness of both; the contemporary expertise that the MHP would have on the
topic at hand, and the personal connection between students and the teacher.
In Figure 2, the programs with the indisputably best effect sizes were those
where a graduate student accompanies a professional in the field. The table also shows
evidence that a teacher-run program may have significant results. Both show
consistencies in their effect size numbers. An interesting perspective on the program
leadership topic is that a mundane program that is incorrectly delivered by a
disinterested and unprepared program leader is likely to produce poorer results than one
that is innovative, based on up-to-date knowledge and delivered in an enthusiastic and
engaging manner (Neil and Christensen 212). This means that a MHP would be able to
introduce new, up-to-date knowledge to the program in order to enhance its
effectiveness. Figure 1 reveals excellent positive numbers from both a mental health
professional (HP) and lay personnel (i.e. graduate students) instruction. A MHP would be
able to induce the best results and be able to impact the most children because they
have been trained specifically in what they would be teaching the students. The MHP
would be able to bring expertise that would be presented to the students so that they
would comprehend the cognitive-behavioral skills they are being taught.
MHPs would be able to answer questions and provide information required to
increase the audiences depression literacy; in doing so, he/she would be able to build a
bridge to treatment by debunking myths and reducing stigma about getting help.
Granted, a teacher is also a professional in his/her classroom and may have extensive,
yet possibly outdated, knowledge of the topic. The professionalism of the MHP instructor
would have a greater effect on the teens because they would trust the information they
are being given. Students would be more likely to approach an MHP outside of class
when one has been in their classrooms already.
A teacher would assist the programs impactfulness by giving the students a
friendly, educated face that they feel that they can talk to. Students would naturally trust
someone whom they have gotten to know for a while over someone new. Therefore, a

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combination of both an extensively knowledgeable instructor and a knowledgeable and
trusted instructor would result in a positive response to the program from the students.
There are many factors that go into programs such as that which is presented
here; each plays a crucial role in how the program is received. A universal program
would be able to affect and impact the largest number of students and is proven to be
effective from past experiments. Additionally, the students instructor is a factor that can
determine a students first impressions of the program; therefore, both a mental health
professional and a health teacher should instruct the prevention program so that the
students are put into good hands but also hands that they trust.
Upperclassmen are going through some of the most difficult years of their lives in
high school. Whether it be through emotional, social, or academic strain, students are
pushed to find ways to deal with their situation. One out of every eight students in
Howard County public high schools and high schools all over America is going through
some kind personal of battle with depressive symptoms for various and unknown
reasons. The students under the greatest amount of stress are the upperclassmen with
incredible academic and social pressures that they feel every day. Unfortunately, most
college freshmen feel that they were so academically prepared for college in high school
that they never received the proper training to be emotionally successful in their
collegiate careers. Schools, especially Howard County schools, focus far too heavily on
the academic successes of their students that most students enter college particularly
unprepared mentally for the emotional stresses that college bears on the individual. The
best thing that the school system can do is to do as much as possible to see to it that
these students have ALL of the tools that they need in order to move forward with their
lives and not live in fear of the vicious disease that runs rampant. After all, isnt that
everyones goalschool systems, teachers, parents, and studentsto assure that the
students lead happy, productive, and successful lives?
Data was collected among Howard County graduates in order to better
understand the students emotional preparedness for college. A survey based on the
THE FIRST-YEAR, Harris Poll was sent out and 50 Howard County responses were
received and analyzed to prove or disprove the hypothesis that Howard County public
high school seniors are underprepared emotionally for the emotional difficulties of
college. Several startling trends in data were discovered. As seen in Figure 4 (which
students were asked to answer the question: Which of the following activities, if any, did
you typically do when you felt overwhelmed or stressed during your final year in high
school (or first term at college/university)? Please select all that apply.), there was a
significant increase in the amount of students who chose to drink alcohol when stressed

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which shows a negative trend. Furthermore, there was an increase in the amount of
students who slept when stressed which can be neither determined as positive nor
negative. 1 out of 10 Howard County students rated their high school experience as
Excellent but their first term in college as Poor or Fair. 12% felt depression, 56% felt
stressed, and 46% felt overwhelmed most or all of the time in their first term at college.
2% of Howard County students did not participate in any Extracurricular activities in their
senior year of highschool; but 14% did not participate in Extracurricular activities in their
first term in college. Extracurricular activities are highly recommended to incoming
freshmen in college because they are a great way to meet new people and get involved
in order to keep themselves busy. A 12% increase in students who did not participate in
Extracurricular activities shows the researcher that students are unprepared to seek new
friendships and to seek healthy ways of fitting in. 69% of Howard County graduates feel
that their time management skills need improvement. Based on these significant results,
Howard County students are in desperate need for at least an adolescent depression
prevention plan that includes promotion of coping skills and time management skills in
order to better prevent depression for college-bound seniors.

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Figure 4: Comparison between Coping Decisions between High School and College

Works Cited
1. Center for Disease Control & The Substance Abuse and Mental Health Services Administration
(2010). Attitudes toward mental illness. Morbidity & Mortality Weekly Report, 59(20), 619-625.
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401-15. Print.

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7. "Improving Early Identification & Treatment of Adolescent Depression: Considerations &
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