EDUCATING SECONDARY TEACHERS ON DEPRESSION IN STUDENTS THROUGH TEACHER DEVELOPMENT TRAININGS by Kate Packer A project submitted in partial fulfillment of the requirements for the degree of MASTER OF EDUCATION IN CURRICULUM AND INSTRUCTION WEBER STATE UNIVERSITY Ogden, Utah November 13, 2018 Approved DEPRESSION IN SECONDARY STUDENTS 2 Acknowledgements I would like to thank Dr. Penée Stewart who helped me through this project, step by step and taught me that it is not procrastination, it is working better under pressure. To Dr. Saunders who has helped me through the whole process of the master’s program. To Dr. Theresa Kay for being willing to be a part of this project. For my amazing in-laws who have been there to help watch my children and support me through this long journey. To my mother who has been there with constant support and love. For my father who has spent countless hours reading and reviewing my papers, who taught me the love for education, and who never lost faith in my abilities to succeed in whatever I put my mind to. To my sweet kids, Kambree, Rylee, and Bowen who are the light of my life. Finally, thanks to my amazing husband and partner in life, Brysen. He has been my biggest supporter and has helped me achieve all my goals. He has been patient, loving, and encouraging. I honestly could not have done this without his love and support. I would never have been able to complete this project without the remarkable people in my life cheering me on! DEPRESSION IN SECONDARY STUDENTS 3 Table of Contents NATURE OF THE PROBLEM...........................................................................................7 Literature Review.....................................................................................................8 Signs and Symptoms of Depression ............................................................8 Risk Factors that Increase Depression .......................................................10 Individuals with Disabilities Education Act ..............................................11 Deficiencies in Professional Development ................................................12 Teachers Have an Important Role to Play .................................................14 Need for Quality Professional Development .............................................17 Summary ................................................................................................................19 PURPOSE ..........................................................................................................................21 METHODS ........................................................................................................................22 Reviewers/Participants ...........................................................................................22 Instrumentation ......................................................................................................22 Procedure ...............................................................................................................24 RESULTS AND DISCUSSION ........................................................................................25 Needs Assessment Questionnaires .........................................................................25 Initial Development of Curriculum ........................................................................31 Final Development of Curriculum .........................................................................35 Limitations and Recommendations........................................................................37 Future Implications ................................................................................................39 REFERENCES ..................................................................................................................40 DEPRESSION IN SECONDARY STUDENTS 4 APPENDICES ...................................................................................................................45 Appendix A: Needs Assessment and Evaluation Questionnaires ..........................46 Appendix B: Approval Letters ...............................................................................51 Appendix C: Email Correspondence with Teachers and School Counselor ..........54 Appendix D: Teacher Development Training Finalized Curriculum ....................56 DEPRESSION IN SECONDARY STUDENTS 5 List of Figures Figure 1. Teacher Comments to the Needs Assessment Questionnaire ..........................27 Figure 2. Counselor’s Comments to the Needs Assessment Questionnaire ....................31 Figure 3. Teacher’s Comments to the Evaluation Questionnaire .................................... 35 DEPRESSION IN SECONDARY STUDENTS 6 Abstract The rate of depression is increasing among adolescents. This increase is associated with various challenges in social, family, and academic domains and is likely to impact the classroom. Many adolescents are being untreated due to symptoms not being identified and appropriately referred for mental health treatment. Teachers are in a position in which they can observe signs and symptoms of depression in their students. Unfortunately, teachers have limited training to understand symptoms they may be observing among their students in the classroom. Teachers need professional development training to increase knowledge of signs and symptoms observed in students, build confidence in identifying these symptoms, and to know how to refer the student to the appropriate professionals for increased assessment. This curriculum project was created to provide increased education to teachers regarding depression in adolescents and when and how to alert the appropriate school personnel for possible concerns. DEPRESSION IN SECONDARY STUDENTS 7 NATURE OF THE PROBLEM The National Institute of Mental Health (NIMH, 2014) reported that 11% of all adolescents in the United States will be diagnosed with major depressive disorder by the age of 18. The rate of depression appears to be increasing among adolescents and is associated with various challenges in social, family, and academic domains and is likely to impact the classroom (Holler, Kavanaugh & Cook, 2013). In teacher preparation, prospective teachers learn about disabilities (Utah Department of Administrative Services, 2015), but depression, which is not identified in the Individuals with Disabilities Education Act, is not included in the curriculum (American Psychological Association, 2016). Whether an adolescent has been diagnosed by clinicians or by self-report, the symptoms that are observed in the classroom may be the same (Torikka et al., 2014). Teachers are in a position where they are “well placed to observe some of the hallmarks of depression” (Moor et al., 2007, p. 82). Few training opportunities are available for teachers to assist in identifying possible symptoms of depression in their students and gaining knowledge of the referral process for further resources and treatment. Therefore, teachers are ill-prepared in identifying and referring adolescents with depression, leading to increased risk for untreated depression impacting students both academically and socially. It is reported that “recognition is also impaired by the lack of knowledge of professionals” (Moor et al., 2000, p. 221) in identifying different symptoms of depression among adolescents that may be “dismissed as teenage moodiness, ill temper, or laziness” (Moor et al., 2007, p. 82). Teachers are not responsible for diagnosing depression in adolescents, but they may play a vital role in properly identifying and referring at risk students for preventative measures. Therefore, DEPRESSION IN SECONDARY STUDENTS 8 materials and curriculum should be created to help educate teachers about identifying students who are most at risk for mental health issues. Literature Review This literature review will first define depression and discuss signs and symptoms that students who are at high risk may display in the classroom and identify potential risk factors that increase the likelihood of depression. Next, it will review current government laws, the deficiency of professional development training about adolescent depression, and the important role teachers can play in identifying symptoms of depression. Finally, it will discuss the need for increased professional development trainings to include identifying depression and the ability to alert the appropriate school personnel for possible concerns, including a short review of professional development components that maximize adult learning opportunities. Signs and Symptoms of Depression The rate of depression continues to increase among adolescents and can create challenges in various aspects of an adolescent's life. Major depressive disorder (MDD) is defined by the Mayo Clinic (2015) as being "a mood disorder that causes a persistent feeling of sadness and loss of interest" (paragraph 1). To be diagnosed with MDD, adolescents need to be evaluated to meet criteria for depression. Many adolescents have self-diagnosed symptoms but have not been directly assessed by a clinician. Carnevale (2010) reported that MDD is an under diagnosed problem of adolescence. Consequences of undiagnosed and untreated depression can have detrimental effects. The Diagnostic and Statistical Manual of Mental Disorder (DSM-V) lists the following symptoms that are accompanied with depression: “depressed mood most of the DEPRESSION IN SECONDARY STUDENTS 9 day, nearly every day, having markedly diminished interest or pleasure in all, or almost all activities with significant weight loss, insomnia, feelings of worthlessness, and a diminished ability to think or concentrate” as well as recurring thoughts of death (American Psychiatric Association, 2013, p. 160). In comparison, Holler, et al. (2013) reported “adolescent depression causes vegetative and affective symptoms, concerns about the future, interpersonal difficulties, and thought processing problems” (p. 1316). Other behaviors exhibited by adolescents with depressive disorders include impulsiveness with decision-making and deficits in “attentional switching” (Wilkerson & Goodyer, 2006, p.1286). Students with minor to major depression displayed reduced memory and lower ability to pay attention. Other characteristics of depression include decreased self-esteem manifested by self-deprecating comments, mild irritability with defiant behaviors and difficulties interacting, pessimistic comments and suicidal thoughts, peer rejection with increased isolation and withdrawal, boredom and noncompliance, impulsive and risky behaviors with increased theft, sexual activity, alcohol or drug use, and truancy (Crundwell & Killu, 2010; Holler et al., 2013). Students with depression often perform poorly both behaviorally and academically in school (Froese-Germain & Riel, 2012). It has been found in recent studies that students with these challenges made little progress in reading or math over the course of a school year. Students were more likely to be suspended for longer periods of time. Depression is likely to affect students’ emotional well-being and ability to learn and increases chances of dropping out of school (Froese-Germain & Riel, 2012; Minahan, 2012). DEPRESSION IN SECONDARY STUDENTS 10 Risk Factors that Increase Depression Multiple factors have caused depression to increase among adolescents. Au, Lau, and Lee (2009) discussed how psychosocial influences from family and peers have a direct correlation with depression and suicidal ideation and attempts. Low parental and peer support create feelings of hopelessness and lower self-worth in adolescents. Social support from family and peers is a vital coping resource, and individuals without this support can create self-damaging conditions and suicidal behavior during stressful life events (Au et al., 2009; Harter, Marold, & Whitesell, 1992; Nelson, 1987; Rich & Bonner, 1987). Other increased risk factors for depression among youth are “low family income and socio-economic status, as well as exposure to poverty in the early stages of life” (Torikka et al., 2014, p. 2). A child or youth from a family living in poverty is three times higher to have mental health problems than a child from a family not living in poverty (Trudgen & Lawn, 2011). Depression can be directly linked to an increase in suicidal ideation or behavior in adolescents. Depression has been reported to be a predictor in suicidal ideation as well as “an important mediator” (Au et al., 2009, p. 852) between stressors and suicidal ideation. Suicide is the third largest cause of death for adolescents worldwide. In the western domain of the world, the prevalence of suicide and depression increases for youth between the ages of 10 to 14 years old (Au et al., 2009, p. 851-852). Ang and Huan (2006) determined correlations among academic stress, depression, and suicidal ideation. They examined 1,108 adolescents between the ages of 12-18 years old and how depression “mediated the relationship between academic stress and suicidal ideation” (p. 133). Adolescents often view themselves in terms of their academic DEPRESSION IN SECONDARY STUDENTS 11 performance with pressure to excel. Academic failure is associated with depression among adolescents. Also, depressive mood can cause academic problems and achievement. Adolescents who experience difficulties in school often receive negative feedback regarding their academic performance, which can lead to more depressed feelings (Ang & Huan, 2006). A similar comparison was made by Holler et al. (2014) who also reported that MDD in childhood and adolescence may be associated with "impairments across global domains of functioning, including impairments in developmental, social, and academic domains"(p. 1316). Adolescents who potentially have MDD, may exhibit the signs and symptoms that have been previously discussed. However, other risk factors may increase the adolescents’ risk of having MDD such as a complex interplay of psychological, social, and biological factors (Froese-Germain & Riel, 2012). Individuals with Disabilities Education Act The Individuals with Disabilities Education Act (IDEA) is a federal law that was originally passed in 1975 “to ensure that children with disabilities have the opportunity to receive a free appropriate public education to meet their unique needs and prepare them for further education, employment, and independent living” (American Psychological Association, 2016). IDEA recognizes that students who are "seriously emotionally disturbed" as children or adolescents who can qualify for disability services in the classroom (Kauffman, Lloyd, Baker, & Riedel, 1995). However, children with serious emotional disturbance remain very much under identified in our nation’s schools (Forness & Knitzer, 1992). The National Comorbidity Survey Adolescent Supplement that was conducted from 2001-2004 found that almost half of the 13-18 years old who DEPRESSION IN SECONDARY STUDENTS 12 were studied met criteria for a mental disorder (Cottle & Green, 2014). Two-thirds of those adolescents with a mental health disorder have never received mental-health treatment. Forness and Knitzer (1992) reported the importance of better defining “serious emotional disturbance” in the IDEA act in an effort to better diagnose and establish more specific guidelines. They also reviewed the definition of emotional/behavioral disorder as: First, the “the level of difference of the child’s behavioral/emotional responses” and second, “that significant impairment exists in at least one area of education performance” (p. 12). This definition “ensures that other differential diagnoses or alternative reasons for the child’s difficulty are considered” (p. 12). Deficiencies in Professional Development Professional development does educate perspective teachers about disabilities (Utah Department of Administrative Services, 2015), but depression, which is not identified in the Individuals with Disabilities Education Act, is not included in the curriculum, causing students who are at risk for depression to not be identified and causing further complications such as behavioral or suicidal behaviors (IDEA, 2004). Teachers have little preparation in identifying at risk students and how to refer them to the appropriate school personnel (Froese-Germain & Riel, 2012; Trudgen & Lawn, 2011). Recognition of depression in students is impaired due to the lack of knowledge of professionals (Moor et al., 2000). Depression in adolescents is complex and can often be an avoided topic due to the discomfort it may bring. The social stigma that is associated with mental illness contributes to this “neglect of mental health and well-being” (Froese-Germain & Riel, 2012, p. 1). DEPRESSION IN SECONDARY STUDENTS 13 The Canadian Teachers’ Federation working in collaboration with the Mental Health Commission of Canada conducted a study in February 2012 in which they sent out a national online survey to teachers (Froese-Germain & Riel, 2012). Over 3,900 teachers responded to the survey. The purpose of the survey was to “gain a better understanding of the teachers’ perspective on issues related to student mental health and well-being, including teacher’ perceptions of factors that act as potential barriers to the provision of mental health services for students in their schools” (p. 10). The teachers were asked about their level of preparedness to address the mental health issues they are facing. The study concluded that 87 % of teachers agreed there was a lack of adequate training in dealing with students who have mental illness, which is a potential barrier to providing mental health services for students in their school. It was reported that 85% of teachers agreed that there is a lack of funding for school-based mental health services. Also, 75% agreed that there is a lack of coordinated services between the school and community. Just over half (54%) of teachers surveyed agreed that addressing mental illness in the classroom is not considered a role or priority in the school. Over two thirds of the teachers reported they had not received any professional development training to acquire the knowledge and skills to address student mental illness (Froese-Germain & Riel, 2012). In 2013, President Barack Obama asked teachers to “help identify and seek help for children who are suffering from mental health disorders, it is time to bring mental illness out of the shadows” (Adams, 2013, p. 1). He continued to add, “we’ve got to do a better job recognizing mental health issues in our children and making it easier for Americans of all ages to seek help” (p. 2). Schools need to increase the awareness of DEPRESSION IN SECONDARY STUDENTS 14 teachers. They are a part of the team working with the student and have a vital role to play in identifying mental health issues (Adams, 2013). In a qualitative research study conducted in Sao Paulo, Brazil in 2010, it was determined that there was “little information available on mental health for teachers, showing that strategies need to be developed to promote mental health in school” (Bressan, Brietzke, Estanislau, Lefevre, & Soares, 2014, p. 2). Due to lack of training, teachers do not know how to deal with mental health problems in their classrooms. Teachers are not properly prepared and are often overwhelmed by their students who struggle with depression or other mental health problems. Teachers also report not knowing the procedure in utilizing the school counselors’ services or proper channels of referral for mental health treatment (Cottle & Green, 2014; Minahan, 2012). Teachers do not need to become experts in diagnosis or treatment of mental health. They are not required to assume the role of a therapist or counselor. Teachers, however, need to receive training in mental health in learning to recognize the signs of potential danger (Cottle & Green, 2014). Teachers Have an Important Role to Play Teachers’ core responsibility is teaching and learning. There are educational guidelines established and demands of achieving outcomes that are implemented by government bodies (Trudgen & Lawn, 2011). Trudgen and Lawn (2011) stated “The educational literature that informs teachers’ roles promotes the importance of the student-teacher relationship and the need for teachers to understand and cater for students’ individual, differentiated learning” (p. 128). Teachers are often strained in their multiple DEPRESSION IN SECONDARY STUDENTS 15 responsibilities and workload making it difficult to provide appropriate differential teaching to students to meet their needs (Trudgen & Lawn, 2011; Minahan, 2012). In comparison, many students are struggling to “navigate the developmental task of surviving adolescence in a changing world” (Trudgen & Lawn, 2011, p. 128). Due to these changes, many students are struggling with anxiety and depression which may prevent them from learning appropriately and decrease their school attendance (Froese-Germain & Riel, 2012). In the US, only 30% of all children with mental health problems receive needed services. Only 70%-80% of those who gain services access these services through their schools showing the critical role schools play in promoting and protecting the mental health of all students (Rowling, Whitman, & Biewener, 2009). “Schools and teachers play a pivotal role in the life of their students with learning expected to include social and emotional wellbeing outcomes” (Murray-Harvey & Slee, 2010, p. 280). Teachers often know their students better than other adults, except for the parents. They are well placed to observe students as they relate to their peers and identify the students most at risk of mental health issues (Moor et al, 2007). “Teachers are not expected to diagnose students; however, they are in the position to identify symptoms and maladaptive behaviors, and alert school wellbeing coordinators/school counselors about possible concerns” (Trudgen & Lawn, 2011, p. 128). Research indicated that early identification and treatment of mental health conditions in adolescents can lead to improvement and recovery (Patel, Fisher, Hetrick, & McGorry, 2007; Trudgen & Lawn, 2011). In Australia, Trudgen and Lawn (2011) sought to identify if teachers recognized and reported concerns about depression in their students. This study investigated the DEPRESSION IN SECONDARY STUDENTS 16 threshold when teachers suspected depression in their students and then acted on their concerns. The study aimed to pinpoint the following: the direct and indirect behaviors of students who teachers suspect have depression; the threshold when a teacher who suspects a student has depression acts on this concern by referring or consulting with the school counselor; and why some teachers appear to be able to identify depressed students. It also discussed the impact that years of teaching, professional development attended, and existing knowledge of depression may have on the teachers’ decisions to report their concerns and how to identify the perceived barriers to teachers reporting their concerns to appropriate school personnel. The teachers who participated in this study had face-to-face interviews asking questions about their knowledge of depression. It was found through this research that most teachers had no specific training in how to recognize and respond to depression in their students. Many teachers have struggled to distinguish the difference between “normal behaviors” of adolescence and those that “mimic depression in students.” The study raised concerns about “the knowledge and training required of all teachers, whose direct role in schools involved student wellbeing and student management” (Trudgen & Lawn, 2011, p. 137). This study also showed the importance of teachers’ role in their students’ mental well-being. "As a teacher, you have an important role to play. You have day-to-day contact with many young people. You are therefore able to observe students’ behavior and act when you suspect a student may be at risk of self-harm" (Suicide Prevention Resource Center, 2012, paragraph 1). DEPRESSION IN SECONDARY STUDENTS 17 Need for Quality Professional Development Teachers in most states are required to have a specific amount of professional development hours each year (Trudgen & Lawn, 2011). The Center for Public Education stated, “Professional development can no longer just be about exposing teachers to a concept in a one-time workshop or giving teachers basic knowledge about a teaching methodology. Instead, professional development in an era of accountability requires a fundamental change in a teacher’s practice that leads to increases in student learning in the classroom” (Gulamhussein, 2013, paragraph 2). Educating teachers through quality professional development needs to be presented in continuous ways with resources that are readily available. Teachers’ extra professional development trainings focused on depression may impact their ability to recognize anxiety and depression in their students (Froese-Germain & Riel, 2012; Trudgen & Lawn, 2011). Gulamhussein (2013) found that one-time, short workshops often do not change a teachers’ practice and have little effect on student achievement. While having a curriculum developed to educate teachers in a workshop-based setting can be helpful, this alone will not allow a teacher to have the appropriate knowledge necessary to continually assess their students and identify at risk students for depression (Trudgen & Lawn, 2011). Other methods of professional development can be implemented to better train teachers. Professional development needs to occur over time and be ongoing. Having coaches and mentors who have experience in the mental health field can be beneficial in providing the necessary support (Gulamhussein, 2013, Trudgen & Lawn, 2011). Teachers often feel they are part of the solution in helping students with mental health, but many DEPRESSION IN SECONDARY STUDENTS 18 have expressed a need for more assistance in the schools by “mental health professionals whose area of expertise would complement that of teachers” (Trudgen & Lawn, 2011, p. 19). According to Kutcher, Szumilas, & Venn (2009), schools are places to address student mental health issues for multiple reasons. These authors report the school environment is a place to start addressing mental health. Schools offer a simple and cost-effective way of reaching youth. Schools can implement mental health promotion strategies by improving mental health literacy through curriculum development, enhancing the knowledge about mental health and changing attitudes and decreasing stigma associated with mental illness. School personnel are in situations in which they can identify young people at risk for having a mental disorder. They can educate their staff to understand and recognize signs and symptoms of depression in their students (Kutcher et al., 2009). Adams (2013) identified that teachers are on the “front lines in identifying children who need mental health care” (paragraph 7). Many organizations such as National Education Association and the American Federation of Teachers, have come together to pledge to educate teachers, administrators, staff, students, and families about mental health issues. President Obama also proposed a budget in 2014 to allocate $205 million for mental health programs, including training teachers to recognize signs of mental illness (Adams, 2013). A vast majority of teachers are indicating the importance of receiving additional professional development in identifying and understanding symptoms of mental health concerns in their students (Trudgen & Lawn, 2011). Training teachers in mental health DEPRESSION IN SECONDARY STUDENTS 19 skills is essential to improve both access to care and the quality of care for students with depression and other mental health issues (Bressan et al., 2014). The structure of any professional development is critical to maximize the learning potential for adult learners. North Star’s Living the Learning Model: An Effective Approach for Leading Adult Professional Development (2018) is a modality used in developing curriculum that would meet the needs of adult learners in various ways. This model discusses how to design “airtight activities that lead participants to the right conclusion with minimal re-directing by the facilitator” (North Star Consultants, 2018). North Star reviews how to incorporate these airtight activities into a curriculum by using video clips that bring emotion and connection to the topic, use of large and small groups for sharing and reviewing information, and a case study to help the teachers learn to solve a problem and create hands on learning. It reviewed the importance of framing the information and allowing the participants to do the cognitive work and reflect on what was discussed, and then helping the teachers apply the information learned into real life practice (North Star Consultants, 2018). Application of this model could enhance teacher development training and provide optimal learning for all learning styles. Summary Understanding depression and the role it plays in adolescents’ lives is an ongoing process. As the world continues to change and depression increases rapidly among adolescents, teachers understanding the signs and symptoms of depression and risk factors in students can prevent students from self-harm and academic and social failure (Froese-Germain & Riel, 2012; Minahan, 2012). DEPRESSION IN SECONDARY STUDENTS 20 While the stigma of mental health is slowly dissipating due to increased education in society, the research shows there is still a deficiency in the schools to adequately train teachers to be prepared to work with students who have depression. Teachers play a vital role in identifying at risk students and appropriately referring them to the right school personnel. This gap in professional development needs to be addressed to meet the growing mental health needs of students. Research to identify the need and deficiencies in mental health professional development is widely found through journal articles and through the media. However, research related to the effects of proper education on student’s mental well-being is lacking, due to the scarcity in curriculum development and other resources to continually educate teachers (Froese-Germain & Riel, 2012; Trudgen & Lawn, 2011). DEPRESSION IN SECONDARY STUDENTS 21 PURPOSE Due to the rise of depression in adolescent students, schools are recognizing a need to educate teachers about depression in students through teacher professional development. Currently, a deficiency exists in the education teachers receive to understand and work with their students who may be struggling with a mental health disorder. To better reach at-risk students, it is vital to provide teachers with training to identify the needs of these students and provide the appropriate interventions to address their concerns. The research has emphasized a need for more ongoing professional development trainings to educate teachers on the mental health issues students are facing. This research has emerged due to the increasing rates of depression and mental health issues in adolescents. Missing from the research are the statistics of teachers’ experiences and perceptions of mental health once they have been appropriately trained through teacher development programs. The purpose of this curriculum project was to develop necessary information to educate teachers about signs and symptoms of depression and to understand the threshold of reporting to the appropriate school personnel. The objectives of this project were (a) identify mental health information; (b) create a presentation to be implemented at a teacher development training for secondary education teachers; (c) develop ongoing curriculum and resources for teachers to access through their school for constant reference; and (d) create a referral process and procedures in schools to help teachers identify steps to take in referring an at risk student. DEPRESSION IN SECONDARY STUDENTS 22 METHOD The goal of this curriculum project was to create a teacher professional development program and provide teachers with resources to help them understand and identify students who are high risk for depression. A compilation of various resources was created to give teachers more attainable information on adolescent depression and direction of referral for students who present high risk characteristics. Reviewers/Participants To ensure the curriculum meets the needs of the teachers, it was determined to have teachers and a school counselor give their perspectives as to what they know and what they need to know before developing the curriculum for the presentation. Therefore, two teachers and one school counselor from an inner-city school district in northern Utah participated in the needs assessment and evaluation questionnaires. The participants in the project were from the same high school who were referred by the district’s executive director. The teachers are both special education teachers. One teacher has her master’s degree in education and has been working as a special education teacher for over 5 years. The second teacher did not identify her years of experience or education. The school counselor has over ten years of experience as a school counselor in a high school setting. He also holds a master’s degree in school counseling. Instrumentation To provide optimal learning for educators, two high school teachers and a school counselor were asked for their input and knowledge of working with adolescents with depression. This was done by using two different instruments for this project. First, a needs assessment questionnaire (see Appendix A) was given to the school counselor DEPRESSION IN SECONDARY STUDENTS 23 and teachers to complete prior to the development of the curriculum for the teacher training. The needs assessment questions were based upon the research material summarized in the literature review which identified the areas of concern that needed to be addressed to make the training as effective as possible. Insights from the professional experience of the researcher were also used to develop the questionnaire. The needs assessment included questions on the most effective delivery tactics for teacher development training as perceived by the school counselor. The needs assessment for the teachers slightly varied from the questionnaire given to the school counselor. The teacher’s questionnaire was given to assess the level of comfort and understanding teachers have regarding depression in adolescents. The questions also addressed understanding of referral processes, prior teacher development trainings on similar subjects, understanding their role as teachers in providing information, and identifying any areas that they would like more training and information. Another question addressed the best educational training approach that would be the most beneficial in educating teachers. The needs assessment was designed to quickly gather information and identify areas that need to be addressed in the curriculum. Second, an evaluation questionnaire was created for the school counselor and teachers to use to evaluate the newly developed curriculum (see Appendix A). The questions in the evaluation questionnaire were open ended and allowed the teachers and counselor provide feedback on the strengths of the curriculum and make additional suggestions for improvement. DEPRESSION IN SECONDARY STUDENTS 24 Procedure A training curriculum was developed to educate secondary teachers on depression in adolescent students. The first step in this curriculum project was to recruit secondary teachers and counselors to participate in identifying the needs to be met by the curriculum and then evaluation the resultant curriculum. The needs assessment questionnaire (Appendix A) was given to the two teachers and school counselor to identify what curriculum and information is currently available and what concerns need to be addressed at the schools for the teachers. The second step was completed by creating a teacher development training that reviewed signs and symptoms of depression, risk factors, communication techniques, the referral process, and the need for continuous education for preventative measures. The curriculum was created utilizing the feedback from the needs assessment questionnaires. Once the professional development training was created, the curriculum was reviewed by the same school counselor and teachers that initially completed the needs assessment questionnaire. The counselor and teachers were given a questionnaire (see Appendix A) to evaluate the effectiveness and overall quality of the teacher development training. They were also asked to suggest any additional information or improvements they felt were still needed. DEPRESSION IN SECONDARY STUDENTS 25 RESULTS AND DISCUSSION I am a Licensed Clinical Social Worker and have been working with depressed adolescents in crisis situations for over five years. I graduated with my master’s in social work and currently work as a crisis worker in the emergency room. My background knowledge and experience framed this curriculum project. I provide a unique perspective, with the increase in the number of adolescents who come to the emergency room to receive treatment for suicide ideation and depression. Over the last five years, the number of evaluations of adolescents I perform have exponentially increased to alarming rates. In working with these adolescents and their parents, it has been found that there is a discrepancy in the identification of their symptoms. Often, it is not until they are in a crisis when they reach out for help. Unfortunately, previously their depressive symptoms have been unidentified. In my review with patients, questions as to intervention opportunities and personnel assistance for depression were explored and rarely do patients acknowledge any assistance at the school level. There also appears to be a lack of understanding among school personnel on their role in helping these adolescents be identified and be referred for appropriate mental health treatment. As a professional, training in mental health has opened the opportunity to understand the needs in the community and to implement this knowledge in a curriculum for educators. Needs Assessment Questionnaire The initial needs assessment questionnaire was compiled of questions based off the literature and the experience I have working with depressed adolescents. The questions in the needs assessment questionnaire identified the teacher’s base knowledge of symptoms that adolescents may exhibit. Since Moor et al. (2007) discussed that DEPRESSION IN SECONDARY STUDENTS 26 teachers are in a position where they are “well placed” to observe symptoms of depression, understanding the teacher’s knowledge of symptoms was a pertinent question needed before creating the curriculum (p. 82). See Figure 1 for a list of the questions from the needs assessment questionnaire and the teachers’ responses to each question. DEPRESSION IN SECONDARY STUDENTS 27 Questionnaire Question Teacher A Teacher B 1. What knowledge do you have about depression in adolescents? Often seclude themselves and have poor self-esteem. They want help, but don’t know where to go. They often mask it with over-excitement Very little 2. What are some of the behaviors you have seen in students in your classroom that may have depression? Secluding themselves, poor self-esteem Lots of sleeping, withdrawal 3. Where do you find information on referral process to get your student assessed appropriately for depression? The school counselors No clue. Go to the counselor? 4. What educational training approach is most beneficial in educating teachers for professional development? A lecture with visuals and open for discussion Face to face, required training 5. Where would be a beneficial place for continued information on depression to be found for continual reference? On the district intranet Email thread, website 6. What education and training have you received in working with students with depression or other mental health concerns? Professional development from social workers and counselors Professional development lesson in faculty meeting at the beginning of last year 7. What knowledge do you feel you need to better work with students who have mental health concerns? How to give help AFTER they’ve been identified Not sure, just anything! So I can help them better 8. What training would be beneficial for teachers to have access to on how to work with at risk students? A district intranet page or a flowchart of how to identify and hook students with which services Any training would help! 9. What is your comfort level in identifying students with depression? Somewhat comfortable Medium 10. What is your role as a teacher in the process of helping students with mental health concerns? Making sure they have access to services. Check in with them/compliment their growth when possible Addressing concerns with counselors? 11. Any additional questions or concerns that need to be addressed? We are seeing high amounts of students struggling with mental health conditions, so any training or info would help Figure 1. Responses to the open-ended questions in the needs assessment questionnaire from the two teachers. DEPRESSION IN SECONDARY STUDENTS 28 The teachers were asked to discuss their understanding of the referral process once an adolescent has exhibited symptoms of depression. It was important for me to identify if a process was currently in place in their school explaining how to refer a student for continued mental health support. It was identified that both teachers did not have any knowledge of the specific guidelines their school had in place for proper referral. Each school district may have their own procedures in referring students for continued mental health treatment, but due to how the literature states that teachers are “ill-prepared in identifying and referring adolescents with depression” (Moor et al., 2000, p. 221), it is important to address each teacher’s understanding of the process. In creating the curriculum, I knew that the approach in the training needed to reach all level of learners and have long lasting benefits for continued practice, not to be quickly learned and quickly forgotten. This question was addressed through the feedback from educators who have attended trainings. They helped identify that when creating professional development curriculum, it is important to address the type of learning that is most effective to meet the needs of various individuals. The needs assessment questionnaire helped me identify that there is a need to educate teachers on identifying symptoms of depression in students, properly documenting the concerns, and then referring this information to the appropriate school personnel such as a school counselor. Throughout the literature reviewed, there was a blatant lack of professional development trainings for teachers to acquire the knowledge and skills to address student mental illness (Froese-Germain & Riel, 2012). The teachers reported they did not know their specific role in working with students with depression. Due to lack of training, teachers do not know how to deal with DEPRESSION IN SECONDARY STUDENTS 29 mental health problems in the classroom and are not properly prepared and instead are overwhelmed when working with students with mental health problem (Cottle & Green, 2014). Often teachers do not understand their role in helping students with depression and need to be reminded that they are not required to assume the role of a therapist or counselor and do not need to become experts in diagnosis or treatment (Cottle & Green, 2014). They do need to understand the procedure in utilizing the school counselors’ services and the proper channels of referral for mental health treatment (Minahan, 2012). This is critical because research indicates that early identification and treatment of mental health conditions in adolescents can lead to improvement and recovery (Patel et al., 2007; Trudgden & Lawn, 2011). The school counselor’s feedback provided increased information for the direction in creating the curriculum (see Figure 2). The school counselor reported that most trainings on depression among adolescents is geared towards school counselors and not teachers. This validated the purpose of creating this curriculum because of the apparent lack of training opportunities available for teachers in identifying depressed students. He discussed that as a school counselor his role is limited in working with depressed students, but he works with the students and their parents to appropriately refer for further treatment. This presented insight into the limited mental health treatment available in the school setting and the importance of referring for mental health care in the community. DEPRESSION IN SECONDARY STUDENTS 30 Questionnaire Question Counselor 1. What knowledge do you have about depression in adolescents? I have knowledge based on my experience over the years and with my work with our Foster Children. I know it affects adolescents and children differently than adults and can be confusing. 2. What are some of the behaviors you have seen in students in your classroom that may have depression? Acting out and in many cases, they are angry. One might think they would always be quiet, reclusive and anti-social. That has not always been my experience. 3. Is there currently a referral process in place for teachers to get students assessed appropriately for depression? Teachers refer to counselors or parents. Counselors will refer to parents and then help parents find avenues in which they can navigate and get the help they need. We currently have an onsite therapist from WHS that has a caseload of students referred to them by an intake group here at our school. 4. As a counselor, what is your role in working with students who are struggling with depression? We do very little once the referral has been made. We can touch base with the student often to see how they are doing with special permission from parents. 5. What education and training have you received in working with students with depression or other mental health concerns? We get special instructions through our PD through the district and through specific conferences geared towards these concerns. 6. What educational training is most beneficial in educating teachers for professional development? Not sure how to answer this. 7. Where would be a beneficial place for teachers continued reference information on depression to be found? Through the district or administration of each school. It would need to be information that is helpful and to make sure all educators are taking the same steps and protocol. 8. What knowledge do you feel you need to better work with students who have mental health concerns? Base on the parameters I have been given I believe I have the ability to help and be of service. Because of time constraints and our training, DEPRESSION IN SECONDARY STUDENTS 31 we must always refer and follow up. 9. Is there currently any training for teachers and staff to identify these concerns? Yes, as mentioned earlier, but mostly for counselors. 10. What training would be beneficial for teachers to have access to on how to work with at risk students? I am unfamiliar with data driven programs that would be best for teachers. 11. What is your comfort level in identifying students with depression? High 12. Any additional concerns or comments? Figure 2. Responses to the open-ended questions in the needs assessment questionnaire from the counselor. The needs assessment questionnaire identified a need for increased education and training for teachers. Both the school counselor and teachers were able to identify their strengths in recognizing students with depression and areas they would like more knowledge about. The teachers each discussed lack of understanding of the referral process for the student to get increased assistance. The school counselor was able to identify that students are referred to him by teachers and then he helps facilitate the process with the students’ parents to obtain increased mental health treatment. Both the teachers and school counselor’s insight will aid in the process of creating a teacher development curriculum geared towards adolescent depression. Initial Development of Curriculum Throughout the research it was reported that teachers struggled to distinguish the difference between “normal behaviors” of adolescence and those that “mimic depression in students” (Tudgen & Lawn, 2011, p. 137). Educating teachers on the signs and symptoms of depression was the first portion of the curriculum. In the needs assessment, the teachers identified a few symptoms they were aware that adolescents may have. DEPRESSION IN SECONDARY STUDENTS 32 While their comments was accurate and withdrawal, increased sleeping, seclusion, and poor self-esteem are correct symptoms, these are just a few of the multiple symptoms that can be exhibited by depressed students. The curriculum training was divided into three sections based on the North Star’s Living the Learning Model which was discussed in the Literature Review. This model provided suggestions and guidelines to create effective teacher development training, but the curriculum was created based on my professional experience. There is a scarcity of time to have professional development and the time allotted needs to have optimal impact. The training is designed to be given by the school counselor or social worker and is around 60 minutes in length. Because each district has their own formal procedure process, the presenter needs to share their school district’s formal process of referral during the training. The first section of the training is designed to grab the audience’s attention with a movie clip of a depressed teenager in hopes to create an emotional response among the teachers. This would lead into the PowerPoint presentation I created to provide direct and quick information. The PowerPoint discussed the signs and symptoms of adolescent depression, risk factors, and statistics. A video clip would then be shown solidifying the signs and symptoms of depression that were reviewed in the PowerPoint. The second section of the training is a large group discussion about the information taught through the PowerPoint and video clip. Specific questions would be asked to the teachers to promote comprehension of the information taught. These questions are as follows: DEPRESSION IN SECONDARY STUDENTS 33 • What are some specific symptoms of depression that were described in this video that you have seen in your students? • What are some symptoms you have noticed in your students that you did not realize were possible signs of depression? The purpose of the large group is to discuss signs and symptoms of depression. The large group discussion would introduce the use of the behavioral log (see Appendix D) that I created for teachers to use as a guide in identifying symptoms of depression in specific students. This is an informal way for teachers to keep data that could be shared with the school counselor. The behavioral log was specifically created to make the information taught be practically applied in their classrooms. The behavioral log has two columns, one identifying specific behaviors observed and the other for dates and times the behavior was exhibited. Detailed instruction on the upper section of the log will guide the teachers in how to complete it. Step by step instruction by the presenter would then be introduced on how to appropriately fill out the behavioral log, reiterating this does not take the place of formal district reporting requirements but is an informal support for making identification of depressed behaviors in students easier. It should be emphasized to the teachers that this log was not to diagnose the students, but to guide observation and provide a log to record concerning behaviors and possible patterns of behaviors (Trudgen & Lawn, 2011). The third section of the training is a small group discussion where the teachers will review a case study and practice using the behavioral log. The case study was created based on actual symptoms of depression I have observed among adolescents I work with (see Appendix D). Using the case study, the teachers would then work in their small DEPRESSION IN SECONDARY STUDENTS 34 group to complete the behavioral log. Practicing filling out the behavioral log will increase their understanding of how it can be used. A small group discussion would be facilitated by the group’s spokesperson asking the following questions: • Think about a student you have had who has shown signs of depression. • What signs of depression did you recognize? • How could you have applied the knowledge learned today to fill out the behavioral log and refer the student? After completing the work in the small groups, a large group discussion would connect what was learned in their small groups and provide necessary reflection of information learned. This would be done by having an individual from each group discuss what they reviewed in their group and how they completed the behavioral log. The end of the training would show another video clip, with hopes of bringing emotion to the audience to solidify the importance of the curriculum as well as increasing the overall understanding, empathy, and desire to be part of the solution for students in crisis. The goal of this curriculum focused on educating teachers on how to identify the signs and symptoms of depression in their students, their specific role, the importance of referring to the school counselor, and learning how to use the behavioral log for their continued reference in the classroom. The curriculum was also meant to be completed in an hour to not overwhelm the teachers with information. The information taught was simple and direct to optimize learning. DEPRESSION IN SECONDARY STUDENTS 35 Final Development of Curriculum After the curriculum presentation was created, the curriculum, behavioral log, and PowerPoint presentation were sent to the teachers who participated in the need’s assessment questionnaire. The evaluation questionnaire had fewer questions and was focused on assessing if the teachers gained the needed knowledge through the curriculum and if any information still needed to be added (see Figure 3). Questionnaire Question Teacher A Teacher B 1. What information did you find beneficial in the curriculum that was developed? Signs and symptoms of depression in teens. The signs and symptoms of teen depression. 2. Did the information in the curriculum help you better understand your role with students who struggle with depression? If so, how? I feel like more info could’ve been shared about teacher’s roles. I could use more information on roles of teachers. 3. Is there any information that has been missed in the curriculum that needs to be addressed? If so, what? More information about teacher’s role and referral processes. More info about the referral process and roles of teachers. 4. Would you feel prepared to identify and appropriately refer students for increased assessment after this training? If so, how? Yes, on identifying, no on referrals. I feel prepared to identify but not to refer. 5. Would you easily be able to access the information for continual reference and find any additional information needed? There needs to be like a handout or something for non-presenters to refer to, rather than just the presenter sheet and presentation. Yes, but would like a packet to be able to refer to. 6. Any additional comments or questions? Figure 3. Responses to the open-ended questions in the evaluation questionnaire from the two teachers who assessed the curriculum. The lack of knowledge of professionals impairs the ability to recognize symptoms of depression (Moor et al., 2000). Educating on the signs and symptoms of depression was thoroughly addressed in the curriculum and would be presented in various ways to ensure the teachers understand the information. DEPRESSION IN SECONDARY STUDENTS 36 The role for teachers was discussed in the original curriculum but more definitive information was added to help clarify teacher’s specific role. The curriculum emphasized that teachers are not to diagnose students or become experts but are in a position where they can help identify the symptoms and refer to the appropriate professionals for continued treatment (Cottle & Green, 2014). An additional statement was added to the curriculum to discuss that teachers are well placed to observe students as they relate to their peers and identify the students who are most at risk of mental health issues (Moor et al, 2007). The wording was changed to be more direct in teacher’s exact role of helping students with depression. When reviewing the curriculum, there was no direct statement on the process of referring students to the appropriate school personnel. This was created by adding a step by step process of what to do when a teacher first recognizes symptoms of depression in a student. It was also discussed that each school has their own protocols and it is important to understand the steps the school has implemented. The referral process included keeping a behavioral log on the student exhibiting symptoms and observing them over time. This behavioral log is not a school procedure and a standardized practice but a tool for the teachers to aid in their support of at-risk students The teachers stated a handout with information taught would be beneficial. I created an additional handout for teachers to have access to for future reference on the referral process and signs of depression in Adolescents (see Appendix D). I then addressed in the curriculum for the presenter to discuss available resources in their district. This would vary based on the community and would need to be individually addressed. DEPRESSION IN SECONDARY STUDENTS 37 I also sent the school counselor the same material as the teachers with a set of questions similar to the teachers. In reviewing the school counselor’s responses, there appeared to be some confusion about the purpose of the curriculum. He identified a concern with how the information would be presented. He asked if it would be discussed in a health class, assembly setting, or in small groups with students. The counselor stated he felt comfortable talking about depression in his office with students and parents but did not feel comfortable addressing this without parent’s permission and input in a larger group setting. The counselor also stated that parents may be concerned that the school is diagnosing their students with depression The school counselor’s concerns are accurate, but since this curriculum is designed specifically for educating teachers, it was not valid in the completion of this project. The school counselor stated he would be willing and excited to present this information to educate teachers on depression in adolescents. I highly question the validity of the counselor’s comments related to the curriculum since he obviously misunderstood that this training was created for teachers, not students. Limitations and Recommendations Several obstacles occurred while creating this curriculum. The first obstacle was finding willing teachers and school counselors to participate in the assessments. Initially, the plan was to have two teachers participate from a high school level and two teachers participate from a junior high level for varied perspectives from the different age groups. Due to the lack of teachers willing to participate, the information for needs and concerns was limited. DEPRESSION IN SECONDARY STUDENTS 38 Finding school counselors from both age groups was also difficult. Insight from more than one school counselor was desired, but schools do not have many counselors, and their caseloads are high, thus rendering them unable to participate. The school counselor also confused the professional development training with training geared towards educating students. This mistake did limit his feedback and hindered the validity of his responses about what would be beneficial as a school counselor when helping teachers work with students with mental health concerns. The period during which this curriculum was created and when the assessment was given was over a long span of time, making for reduced consistency in the formation of the curriculum. This problem could be avoided in future projects if the time frame is decreased. It would aid in teachers and school counselors being more willing and able to participate in a shortened time frame. Also, because the time frame between the initial questionnaires and the final review of the curriculum presentation was long, the school counselor did not remember the first needs assessment questionnaire and therefore was unsure what this training was for. An in-person interview with the two teachers and school counselor could have made the information from the need’s assessment and evaluation questionnaires more substantial and applicable. Confusion of the curriculum could have been easily discussed and addressed allowing for more insight and information to be put in the curriculum. A lot of the curriculum is based off my professional experience as a social worker which was able to fill in the gaps the teachers and school counselor were not able to discuss. Initially one purpose of this curriculum project was to include a referral process and procedures in schools to help teachers identify steps to take in referring an at-risk DEPRESSION IN SECONDARY STUDENTS 39 student. Throughout the process, it was discovered that each school has its own protocols in place and specific procedures would vary between schools. Therefore, it was determined to create a general referral process for teachers and explain that the behavioral log is only a tool for the teachers to aid in their support of at-risk students, not a standardized practice. It is not feasible to cover every district’s procedures, but I felt there was a need to have something to assist teachers in the process of getting information on students to the counselors. It is recommended that further research be developed on identifying signs and symptoms of depression for elementary teachers. This information could be presented to elementary, junior high, and high school teachers with only a few variations in the curriculum. As the literature and research recognized, early identifications and treatment of mental health conditions in adolescents can lead to improvement and recovery (Patel, Fisher, Hetrick, & McGorry, 2007; Trudgen & Lawn, 2011). Teachers who understand the signs and symptoms of depression and risk factors in students can prevent students from social and academic failure and self-harm (Froese-Germain & Riel, 2012; Minahan, 2012). Future Implications Currently, no specific plan to implement this training in any secondary schools has been made. The curriculum created may need updates in the future, but most of the information will continue to remain relevant over time. This curriculum was created with the intent to bring greater mental health awareness to teachers of adolescents and to minimize the stigma depression creates. DEPRESSION IN SECONDARY STUDENTS 40 References Adams, J. (2013). President Obama calls on teachers to help identify mental health disorders in students. EdSource. Retrieved from http://edsource.org/2013/president-obama-calls-on-teachers-to-help-identify-mental-health-disorders-seek-help-for-students/32959 American Psychiatric Association. (2013). 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DEPRESSION IN SECONDARY STUDENTS 45 APPENDICES Appendix A: Needs Assessment and Evaluation Questionnaires Appendix B: Approval Letters Appendix C: Email Correspondence with Teachers and School Counselor Appendix D: Teacher Development Training Finalized Curriculum DEPRESSION IN SECONDARY STUDENTS 46 Appendix A Needs Assessment and Evaluation Questionnaires DEPRESSION IN SECONDARY STUDENTS 47 Needs Assessment Questionnaire on Depression in Adolescents (For Teachers) 1. What knowledge do you have about depression in adolescents? 2. What are some of the behaviors you have seen in students in your classroom that may have depression? 3. Where do you find information on referral process to get your student assessed appropriately for depression? 4. What educational training approach is most beneficial in educating teachers for professional development? 5. Where would be a beneficial place for continued information on depression to be found for continual reference? 6. What education and training have you received in working with students with depression or other mental health concerns? 7. What knowledge do you feel you need to better work with students who have mental health concerns? 8. What training would be beneficial for teachers to have access to on how to work with at risk students? 9. What is your comfort level in identifying students with depression? 10. What is your role as a teacher in the process of helping students with mental health concerns? 11. Any additional questions or concerns that need to be addressed? DEPRESSION IN SECONDARY STUDENTS 48 Needs Assessment Questionnaire on Depression in Adolescents (For Counselors) 1. What knowledge do you have about depression in students? 2. What are some of the behaviors you have seen in students in the school that may have depression? 3. Is there currently a referral process in place for teachers to get students assessed appropriately for depression? 4. As a counselor, what is your role in working with students who are struggling with depression? 5. What education and training have you received in working with students with depression or other mental health concerns? 6. What educational training is most beneficial in educating teachers for professional development? 7. Where would be a beneficial place for teachers continued reference information on depression to be found? 8. What knowledge do you feel you need to better work with students who have mental health concerns? 9. Is there currently any training for teachers and staff to identify these concerns? 10. What training would be beneficial for teachers to have access to on how to work with at risk students? 11. What is your comfort level in identifying students with depression? 12. Any additional concerns or comments? DEPRESSION IN SECONDARY STUDENTS 49 Evaluation Questionnaire (For Teachers) 1. What information did you find beneficial in the curriculum that was developed? 2. Did the information in the curriculum help you better understand your role with students who struggle with depression? If so, how? 3. Is there any information that has been missed in the curriculum that needs to be addressed? If so, what? 4. Would you feel prepared to identify and appropriately refer students for increased assessment after this training? If so, how? 5. Would you easily be able to access the information for continual reference and find any additional information needed? 6. Any additional comments or questions? DEPRESSION IN SECONDARY STUDENTS 50 Evaluation Questionnaire (For Counselors) 7. What information did you find beneficial in the curriculum that was developed? 8. Did the information in the curriculum help you better understand your role with students who struggle with depression? If so, how? 9. Is there any information that has been missed in the curriculum that needs to be addressed? If so, what? 10. Do you feel the information given will be beneficial in helping teachers work with students with mental health concerns? If so, how? 11. Would you easily be able to access the information for continual reference and find any additional information needed? 12. Any additional comments or questions? DEPRESSION IN SECONDARY STUDENTS 51 Appendix B Approval Letters DEPRESSION IN SECONDARY STUDENTS 52 DEPRESSION IN SECONDARY STUDENTS 53 DEPRESSION IN SECONDARY STUDENTS 54 Appendix C Email Correspondence with Teachers and School Counselor DEPRESSION IN SECONDARY STUDENTS 55 To Whom it May Concern, My name is Kate Packer and I am currently finishing up my Master of Education degree at Weber State University. I was given your contact information by Stephanie Christensen who reported you may be interested in participating in my master’s project. For this project I am creating teacher development curriculum to provide teachers with resources to help them understand and identify students who are high risk for depression. A compilation of various resources will be created to give teachers more attainable information on adolescent depression and direction of referral for students who present high risk characteristics. Your participation would include filling out a needs assessment questionnaire to help me better identify what to focus this project on. You will then fill out an evaluation questionnaire once the curriculum will be developed. Your participation should not take more than an hour for each questionnaire and all of your answers will be confidential. I am looking for one school counselor from a middle school and one counselor from a high school. I am also looking for one middle school teacher and one high school teacher. If you have a teacher who may be interested, please send me their contact information so I can get the questionnaire sent to them. If you would be interested in participating in this project or if you have any further questions, please contact me at katepacker8@gmail.com or call me at 801-791-4126. I will send out the first questionnaire to fill out as soon as I know who is interested in helping with this project. My goal is to get the questionnaires back from each person by the end of June. Thank you for your time, Kate Packer DEPRESSION IN SECONDARY STUDENTS 56 Appendix D Teacher Development Training Finalized Curriculum DEPRESSION IN SECONDARY STUDENTS 57 Teacher Development Training CONTENT Educating Teachers on Depression in Students PRESENTOR A school counselor or social worker OBJECTIVE • Teachers will be able to better identify signs and symptoms of depression in students • Teachers will become more sensitive to how an adolescent is feeling and behaving • Teachers will be able to keep record of concerning behaviors and know the process in conveying this information to the correct school personnel OVERVIEW • 1-hour interactive development training • Implementation of small and large group activities and discussions • Movie clips about depression and suicide in adolescents • Case studies for problem solving • Reflection of information taught • Assessment of training TRAINING Movie Clip Time Allowance: 3 min • Video: “I’m Fine-Teen Depression PSA” • YouTube • https://www.youtube.com/watch?v=8g_kA2soWOo Introduction into Topic Time Allowance: 3 min • Today we are going to discuss teenage depression and how to recognize the signs and symptoms students may be demonstrating. Depression in youth is at a critical point and needs to be more frequently assessed and acknowledged. • Have each participant have the Power Point printed out with space for them to write notes during the presentation. • I want you to take away from this training the ability to feel more comfortable in recognizing possible symptoms of depression in your students. I want you to be able to document these symptoms that are identified on a behavioral log that has been created and know how to convey this information to the school counselor/social worker. DEPRESSION IN SECONDARY STUDENTS 58 • Your job as a teacher is not to diagnose a student. Your part it to help in the diagnosis process by identifying behaviors in students and then referring them for further evaluation. Teachers are often in a position where they can see behaviors in students that parents and other professionals often miss. Your role in this process is vital and important to prevent depression from going untreated and the potential of self-harm and suicide to be decreased. • Anxiety is often related to depression and may have similar symptoms. We will not be addressing this as a main concern today, but it will be discussed in a subsequent presentation. PowerPoint Presentation Time Allowance: 10 minutes • What does depression look like in adolescents? • Slide 3,4, & 5: Background Information • Slide 3: Basic statistics • The National Institute of Mental Health (NIMH) reports that 11% of all adolescents in the United States will be diagnosed with Major Depressive Disorder by the age of 18 (National Institute of Mental Health, 2014 ) • Major Depressive Disorder is defined by the Mayo Clinic as being “a mood disorder that causes a persistent feeling of sadness and loss of interest” (Mayo Clinic, 2014). • Slide 4: Basic statistics cont. • Carnevale (2010) reports, “major depression is a significant yet under diagnosed problem of adolescence. The consequences of undiagnosed and untreated depression in this vulnerable population can have detrimental effects” (P. 51). • In 2016, an estimated 2.2 million adolescents aged 12 to 17 in the United States had at least one major depressive episode with severe impairment. This number represented 9.0% of the U.S. population aged 12 to 17 (National Institute of Mental Health, 2016 ) • Approximately 60% of adolescents with major depressive episode did not receive treatment. (National Institute of Mental Health, 2016 ) • Slide 5: Chart • Slide 6 & 7: Risk Factors Causing Depression • Slide 6: Risk Factors • Psychosocial (i.e. parental support, religious background, socioeconomic status) influences from family and peers have a direct correlation with depression DEPRESSION IN SECONDARY STUDENTS 59 • Depression significantly increases during the transition from childhood to adolescents • “Low family income and socio-economic status, as well as exposure to poverty in the early stages of life” (Torikka, Kaltiala-Heino, Rimpela, Marttunen, Luukkaala & Rimpela , 2014). • Slide 7: Risk Factors Cont. • “Dynamic and complex interplay between biological, genetic, and psychosocial factors that lead to depression ("Teaching students with," 2001). • Academic stressors • Abuse and Trauma • Slide 8: Research Findings on Signs and Symptoms of Depression in Adolescents • Slide 8: Signs and Symptoms • Diagnostic and Statistical Manual of Mental Disorder V (DSM) (2014) it discusses the following symptoms that are accompanied with depression: “depressed mood most of the day, nearly every day”, having “markedly diminished interest or pleasure in all, or almost all, activities”, with “significant weight loss, insomnia, fatigue, feelings of worthlessness, and a diminished ability to think or concentrate”, as well as recurring thoughts of death (DSM V, p. 160) • Slide 9: Signs and Symptoms Cont. • Decreased self-esteem manifested by self-deprecating comments, mild irritability with defiant behaviors and difficulties interacting, pessimistic comments and suicidal thoughts, peer rejection with increased isolation and withdrawal, boredom and noncompliance, impulsive and risky behaviors with increased theft, sexual activity, alcohol or drug use, and truancy (Crundwell & Killu, 2010). • Obviously as teachers you may not know how a student is acting at home or out of the classroom, but a lot of their behavioral changes may be seen in the classroom. Movie Clip Time Allowance: 3 minutes • Focus question. Ask the teachers to pay attention to specific symptoms that are being discussed. Have them think about specific situations they may have seen with students exhibiting these behaviors. • Video: Recognizing Teen Depression • https://www.huronregional.org/HealthLibrary/HIE%20Multimedia/60/000 648.htm DEPRESSION IN SECONDARY STUDENTS 60 • Discuss with teachers that they may not notice a lot of symptoms in the classroom but the following ones may be easier to identify: • Weight loss, fatigue, inability to concentrate, change in behavior, truancy, decline in school work and performance, cuts or other forms of wounds that are self-harm, irritability, withdrawn, isolative, comments verbally or through homework of not wanting to live, impulsive behaviors, possible substance abuse, and negative comments about self. Large Group Discussion Time Allowance: 10 minutes • Slide 11:Questions • Ask the following questions: • What are some specific symptoms of depression that were described in this video that you have seen in your students? • What are some symptoms you have noticed in your students that you did not realize were possible signs of depression? • Slide 12: Behavioral Log • Discuss the behavior log and how to use it. Small Group Discussion and Case Study Review Time Allowance: 10-15 minutes • Slide 13: Guidelines for small group discussion • Review how to fill out the behavioral log. • The behavioral log is not to diagnose students, but to observe concerning behaviors and see if there are patterns of concerning behaviors. • The information provided will help the school counselor/social worker better know how to help the student. • The behavioral log has a list of symptoms that may be easily observed in a classroom setting. If a symptom is observed, write the date next to the symptom. • Keep track of varying symptoms that occur and then discuss the information with a school counselor/social worker. The observation time may be anywhere from a few days to a few weeks depending on the severity. • If there is concern for a student’s safety, immediately contact the school counselor or administrator. Write any additional concerns or comments at the bottom of the log. Also, make sure to put the student’s name and what subject/class period they are in. • Group teachers in small groups of 4-5 (making up around 5-6 groups depending on number of teachers attending. DEPRESSION IN SECONDARY STUDENTS 61 • Set up rules for the groups (To make the discussion go quickly have specific guidelines of who does what) • Spokesperson (nearest birthday)-leads the discussion and presents • Timekeeper (most recent past birthday)-keeps track of time and keeping on task • Scribe (lives the farthest from the school)-writes down information on referral sheet • Reader (lives the closest to the school)- reads the case study • Give each group the same case study to review. • Have each group member individually fill out the behavioral log • After each person has filled out the behavioral log, have a group discussion about observations they agreed upon. Have the scribe write these observations on a poster board. • Allow 10 minutes to read and write what was identified • To personalize this discussion, have the group spokesperson also ask the following questions for a quick discussion • Think about a student you have had who has shown signs of depression. • What signs of depression did you recognize? • How could you have applied the knowledge learned today to fill out the behavioral log and refer the student? Large Group Discussion in Reviewing what was Discussed Time Allowance: 5-10 minutes • Have the spokesperson in each group discuss the behavioral log and what they identified and wrote on the poster board. • To keep within timeframe, groups 2-5 can add anything they may have identified different from the first group’s observation. • Presenter will give them prompts of specific things to discuss Conclusion Time Allowance: 5 minutes • Reflect on discussion of identifying signs and symptoms of depression by having everyone write down what they have learned and plan on utilizing in their classroom • Discuss available resources in the district • Hope squad, district protocols (Presenter tip: find in your district the exact protocol that is used when teachers see depression in their students and need to know how to refer them for further evaluation) • Give each teacher multiple pages of behavioral log • Have a table of resources in the back for teachers to take DEPRESSION IN SECONDARY STUDENTS 62 • Slide 15: Review the referral process • 1. Student starts exhibiting concerning behaviors • 2. Start a behavioral log for this student and observe behaviors for a period of time, anywhere between a few days to a few weeks. • 3. Write the date next to the symptom of depression the student is exhibiting. • 4. If the behaviors continue to occur or there are immediate concerns for student’s safety, take this behavioral log to the school counselor/social worker and discuss your concerns. • 5.The behavioral log can be for your own use or can be given to the school counselor/social worker when you discuss the concerning behaviors. • 6.Your role as a teacher is to observe possible depressive behaviors that are concerning and pass this information on to a school counselor/social worker for continued follow up. You do not diagnose. • Ask for any closing comments or questions • Finish with strong statement about the ability for teachers to save a student’s life by taking time to notice any symptoms in their students that are concerning. Teachers are well placed to observe students as they relate to their peers and identify the students most at risk of mental health issues. State we need to help our students understand that “We See You” in introducing the closing video. Discuss that the video was developed by teachers at Lone Peak High School to address the rise of suicides that occurred. Movie Clip Time Allowance: 5 minutes • Video: “We See You” • YouTube • https://www.youtube.com/watch?v=j3w_Zs1c6MU • Hand out evaluations of training MATERIALS: • Behavior Log • Case Studies • Printed PowerPoint with note space for teachers • Computer and projector for PowerPoint • Pens • Poster board • Permanent Markers • Handouts DEPRESSION IN SECONDARY STUDENTS 63 Behavioral Log Please complete one log per student. This log can help identify specific behavioral or emotional concerns that may be observed in the classroom setting. Below is a list of possible signs that may be observed in students. Write date/s next to symptoms observed and then discuss with the school counselor/social worker for further evaluation of student. Additional Comments: ________________________________________________________________________________________________________________________________________________ Depression Symptoms Dates Symptoms were Observed Weight loss Fatigue Sadness Tearful Inability to concentrate Change in behavior Truancy Decline in school work and performance Comments verbally or through homework of feeling hopeless, depressed, suicidal, etc. Cuts or other forms of self-harming wounds Irritability Withdrawn Isolative Impulsive behaviors Substance abuse Negative comments about self DEPRESSION IN SECONDARY STUDENTS 64 ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Student Name: _________________________________________________________________________________________________ Class Period/Subject: _________________________________________________________________________________________________ Teacher: ________________________________________________________________________ DEPRESSION IN SECONDARY STUDENTS 65 Case Study Katie is a 15-year-old female who is a Sophomore. She is a good student with mostly A’s and a few B’s. She behaves well in class and has not had previous behavioral concerns. She is shy but does converse with other classmates and participates in classroom discussion. She rarely misses school and is never tardy. Katie is well kempt. She submits her assignments on time. Her English teacher starts noticing some changes in Katie a couple months into the school year. He started keeping track of her behaviors on a behavioral log. On October 4 he has noticed that Katie has missed several days of school and has been tardy many times missing a total of 4 days, and tardy 3 times. Those dates of missing school are Sept 28, Oct1, Oct 2, and Oct 3. She was tardy on Sept 24, Sept 27, and Oct 5. Her homework is turned in sporadically and often not fully completed. She missed turning in her homework on Sept 25, 27, and Oct 2. On Oct 1, he noticed that on a homework assignment that she talked about feeling sad and tired all the time. He first noticed her withdrawing and isolating from the classroom discussion and her classmates on Oct 2 and again noticed those behaviors for the next 3 days. On Oct 3 he noticed that she had appeared to have been crying with red, swollen eyes and a tearful look. He noticed she appeared sad and tired. On Oct 5 he noticed that when he asked her a question in class, she was startled and did not appear to be concentrating on what was occurring in the classroom. He noted the comments she made through her homework in the additional comments section to have more specific detail. Over the last two weeks he has identified multiple concerning behaviors and on October 5 after seeing this drastic change in her behavior, took his behavioral log to the school counselor to discuss these concerns. DEPRESSION IN SECONDARY STUDENTS 66 T EACH E R DEVE LOPMENT T RAI NI NG DEPRESSION IN STUDENTS YOUTUBE “I’M FINE-TEEN DEPRESSION” • https://www.youtube.com/watch?v=8g_kA2soWOo DEPRESSION IN SECONDARY STUDENTS 67 BACKGROUND INFORMATION • The National Institute of Mental Health (NIMH) reports that 11% of all adolescents in the United States will be diagnosed with Major Depressive Disorder by the age of 18 (National Institute of Mental Health, 2014 ) • Major Depressive Disorder is defined by the Mayo Clinic as being “a mood disorder that causes a persistent feeling of sadness and loss of interest” (Mayo Clinic, 2014). BACKGROUND INFO CONT. • Carnevale (2010) reports, “major depression is a significant yet under diagnosed problem of adolescence. The consequences of undiagnosed and untreated depression in this vulnerable population can have detrimental effects” (P. 51). • In 2016, an estimated 2.2 million adolescents aged 12 to 17 in the United States had at least one major depressive episode with severe impairment. This number represented 9.0% of the U.S. population aged 12 to 17 (National Institute of Mental Health, 2016 ) • Approximately 60% of adolescents with major depressive episode did not receive treatment. (National Institute of Mental Health, 2016 ) DEPRESSION IN SECONDARY STUDENTS 68 PREVALENCE OF MAJOR DEPRESSIVE EPISODE AMONG ADOLESCENTS Major Depression. (2017, November). Retrieved from https://www.nimh.nih.gov/health/statistics/major-depression. shtml#part_155031 RISK FACTORS CAUSING DEPRESSION • Psychosocial influences (i.e. parental support, religious background, socioeconomic status) from family and peers have a direct correlation with depression • Depression significantly increases during the transition from childhood to adolescents • “Low family income and socio-economic status, as well as exposure to poverty in the early stages of life” (Torikka, Kaltiala-Heino, Rimpela, Marttunen, Luukkaala & Rimpela , 2014). DEPRESSION IN SECONDARY STUDENTS 69 RISK FACTORS CONT. • “Dynamic and complex interplay between biological, genetic, and psychosocial factors that lead to depression ("Teaching students with," 2001). • Academic stressors • Abuse and Trauma RESEARCH FINDINGS ON SIGNS AND SYMPTOMS OF DEPRESSION IN ADOLESCENTS • Diagnostic and Statistical Manual of Mental Disorder V (DSM) (2014) it discusses the following symptoms that are accompanied with depression. “depressed mood most of the day, nearly every day”, having “markedly diminished interest or pleasure in all, or almost all, activities”, with “significant weight loss, insomnia, fatigue, feelings of worthlessness, and a diminished ability to think or concentrate”, as well as recurring thoughts of death (DSM V, p. 160) DEPRESSION IN SECONDARY STUDENTS 70 SIGNS AND SYMPTOMS CONT. • Decreased self-esteem manifested by self-deprecating comments, mild irritability with defiant behaviors and difficulties interacting, pessimistic comments and suicidal thoughts, peer rejection with increased isolation and withdrawal, boredom and noncompliance, impulsive and risky behaviors with increased theft, sexual activity, alcohol or drug use, and truancy (Crundwell & Killu, 2010). “RECOGNIZING TEEN DEPRESSION” • https://www.huronregional.org/HealthLibrary/HIE%20Multimedi a/60/000 648.htm DEPRESSION IN SECONDARY STUDENTS 71 FOLLOW UP QUESTIONS • What are some specific symptoms of depression that were described in this video that you have seen in your students? • What are some symptoms you have noticed in your students that you did not realize were possible signs of depression? BEHAVIORAL LOG DEPRESSION IN SECONDARY STUDENTS 72 CASE STUDY Guidelines for Small Group Discussion Get in small groups of 4-5 Each person fills out their own behavioral log Group will discuss their observations, scribe will write it on a poster board • Spokesperson (nearest birthday)-leads the discussion and presents • Timekeeper (most recent past birthday)-keeps track of time and keeping on task • Scribe (lives the farthest from the school)-writes down information on poster board • Reader (lives the closest to the school)- reads the case study REFERRING STUDENTS TO SCHOOL COUNSELOR/SOCIAL WORKER • 1. Student starts exhibiting concerning behaviors • 2. Start a behavioral log for this student and observe behaviors for a period of time, anywhere between a few days to a few weeks. • 3. Write the date next to the symptom of depression the student is exhibiting. • 4. If the behaviors continue to occur or there are immediate concerns for student’s safety, take this behavioral log to the school counselor/social worker and discuss your concerns. • 5.The behavioral log can be for your own use or can be given to the school counselor/social worker when you discuss the concerning behaviors. • 6.Your role as a teacher is to observe possible depressive behaviors that are concerning and pass this information on to a school counselor/social worker for continued follow up. You do not diagnose. DEPRESSION IN SECONDARY STUDENTS 73 “WE SEE YOU” • https://www.youtube.com/watch?v=j3w_Zs1c6MU REFERENCES • Carnevale, T. (2010). An integrative review of adolescent depression screening instruments: applicability for use by school nurses. Journal of Child and Adolescent Psychiatric Nursing, 21, 51-57. • Crundwell, R. M. A., & Killu, K. (2010). Responding to a student's depression. Interventions that work, 68(2), 46-51. • Depression in Children and Adolescents (Fact Sheet). (n.d.). National Institute of Mental Health. • "Depression (Major depression disorder)." Mayo Clinic, 14 Feb 2014. • Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed., pp.160-167). (2013). Washington, D.C.: American Psychiatric Association. • Major Depression. (2017, November). Retrieved from https://www.nimh.nig.gov/health/statistics/major-depression.shtml#part_155031 • Torikka, A., Kaltiala-Heino, R., Rimpela, A., Marttunen, M., Luukkaala, T., & Rimpela , M. (2014). Self-reported depression is increasing among socio-economically disadvantaged adolescents-repeated cross-sectional surveys from Finland from 200 to 2011. BMC Public Health, 14(408), 1-19. doi: 0.1186/1471-2458-14-408 DEPRESSION IN SECONDARY STUDENTS 74