School-based safety interventions

Identifying children and teens at risk for depression or violence.

Since the 1990s, schools have implemented a number of different programs aimed at preventing suicide and violence in children and teens. The stakes are high. Homicide is the second leading cause of death, and suicide the third leading cause of death, in Americans ages 10 to 24.

These tragic deaths attest to underlying problems that occur far more frequently: depression, substance abuse, and aggression. Two large-scale studies, for example, have estimated that more than 20% of young people will develop major depression by age 18. In a survey of a large, nationally representative sample of students, 22% of 12th graders said that they had used an illegal drug, and 44% reported drinking alcohol, in the previous month.

Other studies have reported that 13% of high school students said they had been in a physical fight on school property at least once in the previous year, 7% of students ages 12 to 18 said they had been bullied in the previous six months, and 8% of high school students said they had been threatened or injured by a weapon in school.

Left unaddressed, these issues create a volatile mix. The combination of depression and drugs or alcohol is especially dangerous: one analysis found that two-thirds of adolescents who attempted suicide had both a psychiatric disorder and a history of substance abuse.

In the past few years, new information has emerged about how effective school-based programs are at preventing depression and violence, and what challenges remain.

Detecting depression

Although depression can occur at any age, it affects adolescents and teens more often than younger children. A marked increase in depressive symptoms starts appearing around age 13, but the peak ages for onset are between 16 and 24. Yet depression can be difficult to diagnose in young people, mainly because symptoms seldom involve mood alone, and usually appear in conjunction with symptoms of a co-occurring disorder.

An analysis of symptoms experienced by 423 patients ages 12 to 17 enrolled in the Treatment for Adolescents with Depression Study, for example, concluded that only 20% of them suffered mainly from depressive symptoms. More often, these adolescents and teens developed a mix of mood and behavioral problems that did not, at first glance, suggest depression: symptoms such as agitation, anxiety, attention difficulties, distraction, or defiant and oppositional behaviors.

Symptoms of depression also tend to vary according to age and sex. In adolescents (ages 10 to 14), depression is likely to manifest as anxiety, refusal to go to school, or physical problems such as headaches or stomachaches. In older teens (ages 14 to 18), mood and thinking are more likely to be affected. They may show a loss of interest or pleasure in normal activities or negative thinking. In boys, depression may cause anger, acting out, risk-taking behaviors, or obsession with school work. In girls, it tends to cause tearfulness, apathy, social isolation, or weight gain or loss.

A variety of school-based depression screening programs exist. Signs of Suicide (SOS), for example, uses a video, a brief questionnaire, and classroom discussion to educate students about depression and suicide and help identify those at risk. TeenScreen uses a short screening questionnaire to identify students with symptoms suggesting depression, who then undergo a one-on-one interview with a mental health professional. Parents are notified if their children are deemed at risk, and offered a referral for mental health services.

School-based screenings used on their own, however, are controversial. The U.S. Preventive Services Task Force, for example, concluded in 2002 that the evidence was not sufficient to recommend for or against routine screening of children and adolescents for depression. The agency is currently conducting a review of the latest evidence.

Prevention and treatment

To move beyond one-time screenings, many schools have implemented various types of ongoing depression-prevention efforts. Although specific approaches vary, these programs generally educate staff and students about depression and suicide, provide advice and practice in challenging negative thinking, and seek to build resilience and problem-solving skills. Some are universal prevention efforts, offered to all students, while others are targeted to students most at risk.

Several reviews have concluded that interventions to fend off depression may be modestly effective, at least in the short term. In studies conducted six months to three years after such interventions, however, it's not clear that they have any lasting effect. As one reviewer put it, a depression-prevention program is not like an inoculation that confers immunity; instead, the most effective programs are those that incorporate some type of booster sessions and ongoing follow-up.

In an effort to provide school officials with the information and training to offer effective programs, clinicians in the psychiatry department of Children's Hospital Boston have developed a depression-prevention effort that grew out of a broader adolescent wellness program developed in conjunction with colleagues at McLean Hospital. The Swensrud Depression Prevention Initiative (named for the family foundation that funds it) provides training and an ongoing curriculum so that participants can incorporate what they've learned about depression into a system for monitoring and intervention. Workshops typically involve a range of people — teachers, school administrators, nurses, community leaders, parents, and students — in order to create a safety infrastructure that will remain in place after the training ends.

The program is currently being offered only in Massachusetts, but it may be launched nationally in the future, in conjunction with a documentary featuring teens with depression talking about their experiences. In the meantime, materials are available online (see "Resources").

A common question asked by school officials and parents is how to distinguish normal teenage mood swings and rebellions from actual symptoms of depression. Dr. Nadja N. Reilly, director of the Swensrud Depression Prevention Initiative (and a member of the editorial board of the Harvard Mental Health Letter), recommends evaluating three key areas.

Severity. Symptoms of teen depression encompass changes in mood (anger, sadness, irritability), behaviors (sleeping or eating more or less than usual, taking drugs or alcohol, acting out), feelings (loneliness, insecurity, apathy), thoughts (hopelessness, worthlessness), and perceptual disturbances (pain, hallucinations). The more pronounced these symptoms, the more likely that the problem is depression and not a passing mood.

Duration. Any notable deterioration in behavior or mood that lasts two weeks or longer, without a break, may indicate depression.

Domains. Problems noticed in several areas of a teen's functioning — at home, in school, and in interactions with friends — may indicate depression rather than a bad mood related to a particular situation.

Resources

Adolescent Wellness, Inc.Children's Hospital Boston and McLean Hospital

Provides information about two curricula: one to promote overall mental health, and the other for preventing depression.

www.adolescentwellness.org

Center for Men and Young MenMcLean Hospital

Offers comprehensive services for male adults and adolescents to cope with stress and emotional challenges.

www.mclean.harvard.edu/patient/adult/cfmym.php

School Psychiatry ProgramMassachusetts General Hospital

Provides online links to a variety of screening tools and advice about a range of psychiatric problems.

www.massgeneral.org/schoolpsychiatry

Signs of Suicide (SOS)Screening for Mental Health, Inc.

Offers a class discussion program about depression and suicide for middle and high school students.

www.mentalhealthscreening.org

TeenScreen ProgramColumbia University

Offers a two-part screening program for depression and a referral for further evaluation when necessary.

www.teenscreen.org

Violence prevention programs

In an effort to reduce violence and aggression in schools, about 90% of schools now offer programs that teach anger management, discourage bullying, or teach mediation and social skills. Instruction about dating violence and sexual assault is offered in 52% of middle schools and about 80% of high schools. Two analyses published in 2007 concluded that such school-based interventions are effective at reducing aggression and violence.

The larger of the two looked at 249 studies of intervention programs and concluded that both universal and targeted approaches were effective. Both types of programs rely on cognitive interventions, although the targeted programs (designed for children and teens with conduct disorders) may also incorporate behavioral interventions, social skills instruction, and counseling. The researchers estimate these programs may result in 25% to 33% reductions in the number of students involved in aggressive or disruptive behavior, such as school fights, use of offensive words, or bullying.

Regardless of design, all of the violence prevention programs examined were about equally effective as long as they were given on a regular basis. So the real task for school officials is to find a program they can reliably implement.

The worst kind of violence — a school shooting or other type of attack that leads to injuries and death — is fortunately rare. Even so, since the 1999 shootings at Columbine High School in Colorado, schools have been seeking advice about how to prevent such attacks. A report by researchers at McLean Hospital, the U.S. Secret Service, and the U.S. Department of Education provides new information.

The report is a follow-up to an earlier study, the Safe School Initiative, which found that — prior to the 37 school attacks analyzed — many attackers had felt bullied, 61% had a history of feeling depressed or desperate, and 78% had attempted suicide or had suicidal thoughts. In 30 of the incidents (four out of five), at least one other person knew in advance that some type of attack was planned, while in 22 incidents (three out of five), more than one person knew ahead of time. Yet in most cases, these bystanders — usually friends, schoolmates, or siblings — did not alert authorities.

Dr. William S. Pollack, director of the Center for Men and Young Men at McLean Hospital and lead author on the new study, said the interviews with bystanders revealed that a key determinant of whether someone came forward with information was whether he or she felt an emotional connection to an adult at the school — a teacher, administrator, or school safety officer. School staff and teachers can promote such connections through seemingly small acts that help build relationships — such as greeting students regularly, addressing them by name, and talking to them about life outside of school.

The study also encourages schools to develop policies and provide specific methods for reporting threats, including anonymously; to specify who at the school is responsible for investigating the threat; and to ensure that the informant will be treated with respect and the information provided will be closely guarded.

It all comes down to thinking about making connections, Dr. Pollack says. He suggests that schools weave the type of safety net — among students, school faculty, administrators, and staff — that will help to prevent a violent attack. Those same connections, forged as part of ongoing violence and depression-prevention efforts, can prevent other types of less dramatic, but pervasive, suffering as well.

Hahn R, et al. "Effectiveness of Universal School-Based Programs to Prevent Violent and Aggressive Behavior: A Systematic Review," American Journal of Preventive Medicine (Aug. 2007): Vol. 33, Suppl. No. 2, pp. S114–29.

Herman KC, et al. "Empirically Derived Subtypes of Adolescent Depression: Latent Profile Analysis of Co-Occurring Symptoms in the Treatment for Adolescents with Depression Study (TADS)," Journal of Consulting and Clinical Psychology (Oct. 2007): Vol. 75, No. 5, pp. 716–28.

Pollack WS, et al. Prior Knowledge of Potential School-Based Violence (Washington, D.C.: U.S. Secret Service and U.S. Department of Education, May 2008).

Sutton JM. "Prevention of Depression in Youth: A Qualitative Review and Future Suggestions," Clinical Psychology Review (June 2007): Vol. 27, No. 5, pp. 552–71.

Wilson SJ, et al. "School-Based Interventions for Aggressive and Disruptive Behavior: Update of a Meta-Analysis," American Journal of Preventive Medicine (Aug. 2007): Vol. 33, Suppl. No. 2, pp. S130–43.

For more references and PDFs of some of the resources mentioned, please see www.health.harvard.edu/mentalextra.