Depression i n Adolescence:
Implications for School Counsellors
Kenneth G. Rice
Michigan State University
Nancy Leffert
Search Institute, Minneapolis Minnesota
Abstract
This paper briefly reviews literature o n adolescent depression relevant to school counselling activities and practices. A m o d e l o f adolescent mental health is presented that serves to underscore the multi-dimensional nature o f the development of depression and suggests a variety o f strategies to address adolescent depression. We limit discussion to activities involving assessment and referral, counselling, and prevention. Case examples are used to illustrate the application o f conceptual issues to actual practice.
R é s u m é
Cet article donne u n a p e r ç u de la bibliographie de la d é p r e s s i o n parmi les adolescents, en ce qui concerne les activités et les pratiques des conseillers d'orientation. L'auteur p r é s e n t e u n m o d è l e de la santé mentale parmi les adolescents; ce m o d è l e souligne la nature m u l t i d i m e n -sionnelle de la manifestation de la d é p r e s s i o n et propose plusieurs stratégies pour aborder la d é p r e s s i o n parmi les adolescents. Cette é t u d e se limite aux activités ayant trait à l'évaluation et à l'envoi, au counseling et à la p r é v e n t i o n . O n d é m o n t r e par des exemples de cas l'application des questions conceptuelles à la pratique actuelle.
T h e purpose o f this paper is to examine selected literature o n adolescent depression i n a m a n n e r that is relevant a n d applicable to the work o f school counsellors. T h e goal is to address three major topics: a) the relevance o f adolescent depression for the work o f school counsellors; b) a m o d e l for understanding the development o f depression a n d for conceptualizing interventions; a n d c) activities that school counselors can undertake to assess, prevent, a n d intervene i n adolescent depression. T h e topics are presented each i n turn, a n d woven into the discussion are case examples a n d examples o f programs that demonstrate the applica-tion o f conceptual issues a n d processes to practice.
A D O L E S C E N T D E P R E S S I O N
Schools are the sole institutions with a significant a n d sustained access to c h i l d r e n a n d adolescents (Weissberg & A l l e n , 1986). Because o f the compulsory education laws, schools occupy thousands o f hours o f time d u r i n g one's c h i l d h o o d a n d adolescence. Most adolescents spend one-half o f their average waking hours i n school. Furthermore, schools are located i n geographically consolidated settings, which enable t h e m to target larger populations o f c h i l d r e n a n d adolescents. In sum, schools
Adolescent Depression: Implications for School Counsellors 19
have ready access to a large p o p u l a t i o n o f y o u n g people and are ideally positioned to initiate a n d maintain activities a n d service to enhance the psychological development a n d well-being of youth. In particular, school counselling professionals c o u l d play a critical role i n assessment, inter-vention, a n d prevention o f adolescent depression.
Adolescent depression is a serious mental health p r o b l e m . A l t h o u g h depression i n adolescents has been conceptualized and measured i n a variety of ways, it is conservative to conclude that approximately 5-7% o f adolescents i n the general p o p u l a t i o n experience significant depression a n d that from 10-40% o f adolescents report some depressed or unhappy m o o d (see Petersen, Compas, B r o o k s - B u n n , Stemmler, Ey, & Grant, 1993, for a recent review). Rates o f depression increase significantly throughout the adolescent p e r i o d . G e n d e r differences i n the rates o f depression typically emerge b e g i n n i n g at a r o u n d age 13 or 14, with girls twice as likely to become depressed as boys (Nolen-Hoeksema & Girgus, 1994). Because o f the incidence rates o f depression a m o n g adolescents and because most adolescents attend school, it is quite likely that school counsellors will encounter depressed adolescents at some time.
Depression is a major mental health p r o b l e m because the features o f depressed m o o d may be c o m p o u n d e d by the conditions that often co-exist with depression. O t h e r than depressed or irritable m o o d , typical diagnostic features o f depression a m o n g adolescents i n c l u d e increased emotional sensitivity, a noticeable lack o f interest or ability to delight i n otherwise pleasurable experiences or activities, decreased energy level and increased fatigue, low self-worth or excessive feelings o f guilt, recur-rent thoughts about death or dying (e.g., suicidal ideation with or with-out a specific p l a n ) , withdrawal from friends, sleep a n d / o r appetite disturbances (e.g., restless sleep, weight gain/loss or failure to make expected weight gains), change i n school performance a n d / o r change i n attitude toward school, a n d r e d u c e d ability to think clearly or make decisions ( A m e r i c a n Psychiatric Association, 1994; Weinberg, R u t m a n , Sullivan, Penick, & Dietz, 1973). T h e intensity, duration, distress, and impact o n social a n d academic f u n c t i o n i n g set clinically-significant de-pression apart from n o r m a l fluctuations o f m o o d which are observed a m o n g many adolescents. T h e following example illustrates these points.
To most observers, Andrea had everything going for her. She had always been popular with her friends and with her teachers. She was an ideal student, always turning in assignments on time and with impeccable attention to detail. She was very active and seemed capable of doing many things well. No one was quite sure when things began to slip for Andrea, or why. Over a period of approximately four weeks, her teachers noticed a decline in her work and she often seemed inatten-tive in class. She became overly sensiinatten-tive to benign comments and extremely sensitive to critical feedback about her schoolwork, at one point bursting into tears during a brief meeting with a teacher after class. She began dropping activities she once enjoyed and excelled in, and she seemed less interested in talking with her friends. A teacher consulted the school counsellor and a conference was
sched-uled with her parents. Both parents reported noticeable changes in Andrea at home, such as sleeping much more than usual, spending a great deal of time in her bedroom (much more time than in previous weeks), refusal to attend family outings, missing meals, and a general "gloomy" mood about her.
Depression often covaries with one o f more other mental health problems. Substance abuse a n d eating disorders often are c o m o r b i d with depression (APA, 1994; Attie, B r o o k s - G u n n , & Petersen, 1990). C o n d u c t disorder, a disruptive behavioural p r o b l e m , is also often observed with depression a m o n g adolescent populations (Zoccolillo, 1992), at rates o f approximately 10-35% (Kovacs, Paulauskas, Gatsonis, & Richards, 1988). R o h d e , L e w i n s o h n , a n d Seeley (1991) reported that 42% o f the de-pressed adolescents i n a large, c o m m u n i t y sample had a c o m o r b i d dis-order, with boys m o r e likely to have co-existing disruptive behavioral problems a n d girls m o r e likely to have co-existing eating disorders. Anxiety is also observed to covary with depression at rates from 21-70%, d e p e n d i n g u p o n the p o p u l a t i o n surveyed (Kovacs, 1990; R o h d e et al., 1991).
O n e i m p l i c a t i o n o f the various features o f depression a n d co-occurrence o f depression with many other psychological problems is that depressed m o o d may not always be the presenting p r o b l e m a m o n g adolescents. Indeed, school counsellors may be m o r e likely to hear reports o f academic difficulties, concentration problems, somatic c o m -plaints (e.g., headaches, stomachaches), nervousness, peer problems, and substance abuse rather than reports o f depressed m o o d . Certainly not all students with concentration problems have depression. However, it is i n the best interests o f the student a n d the school i f the possibility o f depression is at least considered. T h e most obvious reason for b e i n g c o n c e r n e d about depression is the increased risk o f suicide w h e n an adolescent is depressed. T h e rate o f suicide a m o n g adolescents a n d young adults with a m o o d disorder is 25 times greater than the rate o f suicide a m o n g the general p o p u l a t i o n ( B l u m e n t h a l & Hirschfeld, 1984). Currently, suicide is the t h i r d l e a d i n g cause of death i n the 15-19-year age g r o u p ( G a r l a n d & Zigler, 1993) and schools are frequent sites o f debrief-i n g programs after a c o m m u n debrief-i t y experdebrief-iences an adolescent sudebrief-icdebrief-ide. School counsellors may be called u p o n to coordinate such programs i n order to prevent negative m o d e l i n g (i.e., additional suicides) as well as to help survivors process their grief reactions (Clarizio, 1994).
A M O D E L F O R U N D E R S T A N D I N G T H E D E V E L O P M E N T O F D E P R E S S I O N T h e r e are many theoretical models regarding the development o f depression i n adolescents. (Interested readers s h o u l d refer to the recent t h o r o u g h reviews and edited volumes by Clarizio, 1994; N o l e n -H o e k s e m a & Girgus, 1994, a n d Reynolds & J o h n s t o n , 1994.) T h e m o d e l o f mental health trajectories developed by Petersen a n d colleagues
Adolescent Depression: Implications for School Counsellors 21
(Petersen & Ebata, 1987; Petersen, Kennedy, & Sullivan, 1991; Rice, H e r m a n , & Petersen, 1993) is well-suited for understanding adolescent depression, intervention, a n d prevention. T h i s m o d e l is based i n part o n contributions from areas o f life-span development (Bakes & Reese, 1984), developmental psychopathology (e.g., Garmezy & Rutter, 1983), stress a n d adjustment (e.g., Kessler, Price, & W o r t m a n n , 1985), and c o p i n g (e.g., Compas, 1987).
T h e m o d e l describes how the n u m b e r a n d t i m i n g o f changes i n early adolescence affect mental health. Moderators o f these effects include parental a n d peer support as well as the c o p i n g skills o f the adolescent. It suggests that the m a n n e r i n w h i c h adolescents adjust to situational and developmental challenges or stressful life events and hassles (e.g., a bad grade, relationship break-up, parental divorce) is d e t e r m i n e d by the internal a n d external resources available to adolescents.
Challenges d u r i n g adolescence can involve normative life events, n o n -normative events, a n d hassles. Normative life events are experienced by most adolescents a n d o c c u r for many adolescents at approximately the same p o i n t i n the life course. Examples i n c l u d e school entry, school transitions, a n d puberty. Some o f these events are fixed by societal policies (e.g., age o f school entry or school structure) ; some are based o n i n d i v i d u a l or family decisions (e.g., m o v i n g ) , often within the framework o f societal norms; a n d others are developmentally based (e.g., puberty). These events confront individuals with new demands a n d expectations emanating f r o m self, family, peers, or society. F o r example, the physical changes resulting from puberty may produce body image changes i n the individuals (e.g., Petersen, Leffert, G r a h a m , D i n g , & Overbey, 1994), or increases i n expectations f r o m family members a n d others i n the society as a result o f the physical appearance o f maturity.
O t h e r challenges involve events that are non-normative, such as the experience o f parental death or divorce. Non-normative life events are less c o m m o n l y e x p e r i e n c e d than normative events or o c c u r at less pre-dictable points i n the life course. Physical or sexual abuse, for example, are particularly disturbing examples o f non-normative events. Girls are at greater risk for e x p e r i e n c i n g sexual abuse than boys. T h e risk for girls to be victims o f sexual abuse increases between the ages o f 10-15, with girls ages 14-15 at the highest level o f risk ( N o l e n - H o e k s e m a & Girgus, 1994). F u r t h e r m o r e , history o f sexual abuse p r i o r to age 18 places victims, b o t h male a n d female, at increased risk for depression a n d suicide (Beitchman, Zucker, H o o d , & Decosta, 1991; Stein, G o l d i n g , Siegel, B u r n a m , & Sorenson, 1988).
Major normative and non-normative life events affect adjustment i n part by increasing the n u m b e r o f m u c h more frequently o c c u r r i n g stressors c o m m o n l y referred to as hassles (Kessler et al., 1985). F o r example, parental divorce not o n l y changes the adolescent's
relation-ships with each parent a n d perhaps siblings, it may alter the school attended, peer relationships, opportunities to participate i n extracur-ricular activities, family e c o n o m i c stability, a n d the regularity o f daily life. In a d d i t i o n to the type of challenges (normative a n d non-normative) a n d hassles, the sheer n u m b e r o f changes experienced d u r i n g adolescence, the t i m i n g o f those changes, a n d the synchronicity with which they occur, have an impact o n mental health outcomes.
During the summer, the divorce of Jim's parents became final. Shortly thereafter, he and his mother moved to an apartment on the other side of the large city they lived near. As a result of the move, Jim had to change schools. He also was making the transition from grade 6 to grade 7 at about the same time. For a time, it seemed like he could not do anything right, he felt sad and angry about his parent's divorce, he wondered what he had done to contribute to their unhappiness, and he had difficulty making new friends and tended to keep to himself. It seemed like something went wrong almost daily for Jim (late for the bus, misplaced his homework, forgot to study for a test, etc.).
Internal a n d external resources may interact with the effects o f major life events o r developmental challenges. Internal resources refer to as-pects o f the i n d i v i d u a l ' s personality, such as attributional style, cop-ing skills, intelligence, a n d perceived locus o f c o n t r o l . F o r example, the attributional styles associated with depression are those i n w h i c h adolescents interpret negative experiences as b e i n g caused by s o m e t h i n g within (e.g., "I'm a b a d / s t u p i d / w o r t h l e s s person, that's why she broke-u p with me"), as b e i n g indicative o f characteristics that will be stable over time (e.g., "I'm a failure with the girls a n d I always will be, so why bother"), a n d as signs o f more generalized or global deficits (e.g, "I d o n ' t just fail with relationships but I mess-up everything I do, i n school, o n the team, at home") (Abramson, Seligman, & Teasdale, 1978; Kaslow, R e h m , & Siegel, 1984). Likewise, adolescents (typically girls) are at increased risk for depression when they use affect-focused c o p i n g strate-gies that intensify already existing dysphoric m o o d (e.g., r u m i n a t i n g over troubles) while avoiding direct or more approach- or problem-focused c o p i n g strategies (HermanStahl, Stemmler, & Petersen, 1995; N o l e n -H o e k s e m a & Girgus, 1994).
Perfectionism is an example o f an internal factor that may enhance o r buffer the deleterious consequences o f negative life circumstances. T w o factors emerge w h e n defining a n d measuring perfectionism: maladap-tive evaluamaladap-tive concerns a n d posimaladap-tive achievement striving (Blatt, 1995; Frost, M a r t e n , Lahart, & Rosenblate, 1990;; Hewitt & Flett, 1989). A n adolescent with adaptive perfectionism w o u l d strive to excel but w o u l d accept personal or e n v i r o n m e n t a l factors l i m i t i n g performance. M a l -adaptive perfectionism is an attitudinal style i n w h i c h the adolescent harbours unreasonably r i g i d expectations for self a n d perhaps others. Less-than-acceptable performance o n an exam, for example, w o u l d be a significant blow to the maladaptive perfectionist's self-esteem (even
Adolescent Depression: Implications for School Counsellors 2:î
though acceptable performance likely w o u l d not be enjoyed). In con-trast, the adaptive perfectionist m i g h t view p o o r performance as disap-p o i n t i n g but not as indicative o f low self-worth. A s exdisap-pected, dedisap-pression consistently has been associated with maladaptive perfectionism. In turn, maladaptive perfectionism has been l i n k e d to increased risk for suicide (Blatt, 1995) a n d m a y b e especially detrimental for adolescents (Delisle, 1986; Shaffer, 1988).
External resources refer to interpersonal sources o f support a n d gui-dance, such as a solid relationship with a teacher, counsellor, parent, or friend. Deficits i n external resources also place adolescents at risk for developing depression. F o r example, having a depressed parent is a significant risk factor for the adolescent depression. P o o r parenting practices have also been l i n k e d to c h i l d h o o d depression (Reinherz, Stewart-Berghauer, Pakiz, 8c Frost, 1989). P o o r quality o f attachment to parents a n d to peers has predicted adolescent depression as well (e.g., A r m s d e n 8c Greenber g, 1987; Kenny, M o i l a n e n , L o m a x , & Brabeck, 1993). In one study e x a m i n i n g b o t h internal a n d external resources, Bennett a n d Bates (1995) f o u n d that lower social support, more so than attributional style, was a significant predictor o f subsequent depression
(6 months later) i n a sample o f 11 to 13 year-olds.
In addition to resources a n d their interaction with developmental challenges, it is important to consider specific sub-populations o f y o u n g people who are at particular risk for developing depression. Because o f increased i n c i d e n c e o f depression a m o n g these groups, they also are at risk for increased rates o f suicide o r suicide attempts. F o r ex-ample many gay, lesbian, a n d bisexual youth are thought to be at risk for special problems. T h e y are at risk o f receiving negative reactions from family a n d friends i f they reveal their homsexuality; they often are rejected by their peers; they often are physically assaulted or abused; a n d many have problems i n school, abuse substances, run away from home, a n d are involved i n d e l i n q u e n c y (Center for P o p u l a t i o n O p t i o n s , 1992; K a t c h a d o u r i a n , 1990; Petersen, Leffert, & G r a h a m , 1995; Remafedi, 1987; Savin-Williams, 1994). As a result o f overt and subtle i n d i v i d u a l a n d societal reactions to sexual orientation, these youth often feel vulnerable, isolated, a n d depressed ( M a r t i n & H e t r i c k , 1988). Gay, lesbian, and bisexual youth are but one example o f special populations a n d school counsellors s h o u l d be alert a n d sensitive to the particular needs or risk factors o f various subgroups o f adolescents.
T h e final assumption o f the m o d e l is that the m a n n e r i n w h i c h an adolescent copes with challenges not only influences his or her adjust-ment at that time but also determines, i n part, the personal a n d social resources that will be available to the adolescent i n subsequent developmental periods. T h i s may e x p l a i n , i n part, why there is a greater l i k e l i -h o o d o f e x p e r i e n c i n g subsequent depressive episodes once a person -has
h a d a depressive episode (Lewinsohn et al., 1989). F o r example, adoles-cents who become depressed may alienate themselves and withdraw from peers or caring adults, thus r e m o v i n g themselves even further from the very resources that might be able to assist them i n managing their depression. A n o t h e r possibility is that adolescents come to believe cer-tain things about themselves (e.g., inadequacy, worthlessness) a n d then subsequently behave i n ways that confir m such conclusions, similar to a self-fulfilling prophecy.
T h i s conceptual m o d e l suggests several considerations for interven-tions. First, challenges need to be considered from a developmental a n d age-appropriate perspective; that is, the t i m i n g o f the intervention a n d the intervention components s h o u l d be developmentally informed. Sec-o n d , e n h a n c i n g Sec-or mSec-odifying internal resSec-ources (e.g., c Sec-o p i n g style) a n d external resources (e.g., social support) through intervention s h o u l d affect the impact that challenges have o n mental health. Further, internal resources c o u l d also affect external resources, and vice versa, such that altering one may benefit the other. T h e availability a n d utility o f re-sources to meet the challenges o f adolescence can have implications for present a n d future mental health (Petersen et al., 1991; Rice, et al., 1993). Therefore, interventions for adolescents s h o u l d attend to the normative (e.g., puberty, school transitions) and non-normative (e.g., parental divorce, death i n the family) challenges confronting youth, a n d the enhancement o f internal a n d external resources for meeting those challenges.
The counsellor at Jim's new school was aware of his circumstances and facilitated his participation in a "partner program" for students new to the school. He also met with Jim occasionally to talk about the divorce and Jim's reactions; their discussions helped Jim alleviate his guilt about the divorce. The counsellor had learned that Jim enjoyed swimming and encouraged him to consider joining the swim team at school, which he did after the counsellor introduced Jim to the swim coach. After about a month, Jim was making friends and his mood had signifi-cantly improved.
T h e importance o f the school counsellor is evident here. H e facilitated the availability o f external resources by involving J i m in the "partner p r o g r a m " a n d by i n t r o d u c i n g h i m to the swimming coach. B o t h o f these external resources c o u l d have been accessed by J i m without the h e l p o f the school counselor. However, depressive affect can get i n the way o f one's ability to act o n one's own behalf because o f the interference o f feelings o f worthlessness and powerlessness, not to m e n t i o n the lack o f energy a n d other associated somatic symptoms o f depression. A n advo-cate i n the form o f a school counselor can go a l o n g way toward h e l p i n g a student get "back to n o r m a l .
T h e school counsellor i n t i e above case example also met with J i m to discuss his feelings about his p irents' divorce, allowing h i m an important outlet for w o r k i n g t h r o u g h ti e event. It is easy to see, even i n this brief
Adolescent Depression: Implications for School Counsellors 25
example, that talking with a c o n c e r n e d and caring adult c o m b i n e d with help i n enlisting other external resources may have circumvented a full-blown depressive episode.
A S S E S S M E N T , P R E V E N T I O N , A N D I N T E R V E N T I O N : T H E R O L E O F T H E S C H O O L C O U N S E L L O R
Adolescents d o not .necessarily display the same symptomatic picture o f depression as that o f adults and, therefore, may go u n r e c o g n i z e d a n d not be referred for treatment. Even i f properly identified, the n u m b e r o f adolescents who c o u l d benefit from c o u n s e l l i n g or other interven-tion exceeds the capacities o f most community professionals a n d para-professionals. In general, it is estimated that 12-15% o f youth u n d e r the age o f 18 experience e m o t i o n a l and behavioural problems serious e n o u g h to justify treatment, yet 70-90% o f these c h i l d r e n who require intervention d o not receive services ( A M A , 1990; Weissberg, C a p l a n , & Sivo, 1989). T h e reactive nature o f tertiary interventions a n d the likeli-h o o d tlikeli-hat many adolescents i n n e e d o f treatment may not be recognized by the mental health care system warrant the development o f proactive, primary interventions a n d prevention programs (Albee, 1985).
Assessment and Referral
A n awareness a n d understanding o f depression i n adolescence can serve several useful functions. First, knowledge about depression (e.g., signs, symptoms, co-occurring conditions) a n d sensitivity to a conceptual m o d e l about the development o f depression (e.g., normative a n d n o n -normative challenges, internal a n d external resources) arms the school counsellor with an array o f e m o t i o n a l , behavioural, a n d cognitive factors to explore a n d evaluate. S u c h an evaluation can occur t h r o u g h a variety of methods. T h e counsellor may individually interview a student identi-fied by a teacher as withdrawn a n d / o r irritable, or whose f u n c t i o n i n g has changed. T h e counselor may also tap the teacher's considerable exposure to the student a n d knowledge o f other factors possibly contrib-u t i n g to the stcontrib-udent's difficcontrib-ulties. Parent i n p contrib-u t may also be solicited for additional c o n f i r m i n g or d i s c o n t i n u i n g information about the student. Generally, a comprehensive approach to assessment (multiple methods of information gathering from m u l t i p l e sources) is the best strategy
(Clarizio, 1994).
Assessment results i n f o r m subsequent decisions regarding additional assessment and intervention. T h e obvious crisis nature o f some situations (e.g., suicidal ideation with clear p l a n and means) dictates an entire set of subsequent decisions a n d activities. S c h o o l counsellors s h o u l d be comfortably familiar with their institution's policies a n d procedures regarding crisis management, a n d work to develop such procedures i f none exist. A frequently encountered experience as a result o f an
assess-ment process described above is less, not necessarily more, certainty about the intensity, severity, d u r a t i o n , a n d impact o f depression. A n assessment may n e e d to be more t h o r o u g h or formal, a n d perhaps c o u l d involve the services o f a school psychologist or other professional trained to administer a n d interpret psychological assessments. B o t h assessment a n d intervention options may be m o r e or less l i m i t e d , given resources a n d capabilities within the school. Some schools may have on-site facili-ties i n w h i c h students can receive assessment services a n d i n d i v i d u a l counselling, although as M y r i c k (1993) noted, "individual c o u n s e l i n g is a luxury i n the schools." (P. 182) O t h e r schools may refer students to off-site locations for extensive assessment a n d counselling services. T h u s , the school counsellor plays a crucial role i n the initial assessment, coordina-tion o f referrals, a n d also may become involved i n an eventual treatment or follow-up p l a n . In addition, the school is sometimes ideally suited to e x p l a i n the necessity o f such referrals to the student a n d to parents, serving perhaps as a liaison between the referral agency a n d the family.
Counselling
Approaches to work directly with adolescents i n c l u d e i n d i v i d u a l a n d family c o u n s e l i n g a n d psychotherapy, g r o u p counselling, a n d preven-tion. A s m i g h t be expected, there exists a rather large literature o n interventions for adolescents. (Interested readers may refer to Reynolds a n d J o h n s t o n , 1994, for a m o r e t h o r o u g h e x p l o r a t i o n o f that literature.) Individual a n d g r o u p c o u n s e l l i n g a n d prevention efforts can draw u p o n the conceptual m o d e l described above for possible intervention strategies, content ideas, a n d expected results. F o r example, short-term i n d i v i d u a l c o u n s e l l i n g usually begins by developing a w o r k i n g alliance with the adolescent (developing a n external resource). T h e counselor can then i m p l e m e n t strategies to enhance the student's internal as well as other external resources. C o p i n g or problem-solving strategies c o u l d be e x p l o r e d a n d i m p r o v e d . Students can learn how to match appropriate c o p i n g strategies to the type o f p r o b l e m situations they encounter. F o r example, active problem-solving i n which an adolescent sets a goal, brainstorms possible solutions, anticipates consequences, a n d imple-ments a p l a n o f action, generally works for events or circumstances that are u n d e r an adolescent's c o n t r o l . Emotion-focussed strategies (e.g., relaxation) may be used when circumstances are not u n d e r the adoles-cent's c o n t r o l but are nevertheless upsetting. Cognitive interventions c o u l d be i m p l e m e n t e d to challenge a n d revise inaccurate perceptions o f self a n d others. Social skills (e.g., assertiveness training) c o u l d be ad-dressed a n d practiced i n order to increase the quantity a n d quality o f relationships with peers a n d family members.
G r o u p c o u n s e l l i n g strategies can be similar to those used i n i n d i v i d u a l counselling, although the opportunity for development a n d
enhance-Adolescent Depression: Implications for School Counsellors 27
ment o f external resources may be greater i n a g r o u p context than i n an i n d i v i d u a l context. In addition, the confrontation o f attributional errors may be m o r e potent i n g r o u p c o u n s e l l i n g than i n i n d i v i d u a l counselling, when the challenges o c c u r i n numbers from peers rather than from the counsellor.
Prevention
Problems associated with the identification o f adolescents with de-pression a n d with m a t c h i n g existing resources to treatment (Albee, 1985) argue for the i m p l e m e n t a t i o n o f primary a n d secondary preven-tion activities (Kazdin, 1993). C u r r e n t approaches to adolescent mental health p r o m o t i o n focus o n either primary or secondary prevention efforts. Primary prevention programs are those programs that are targeted to reduce the i n c i d e n c e o f dysfunctional mental health by b l o c k i n g problems before they begin. Secondary prevention is a i m e d at r e d u c i n g t h « severity o f expression i n those individuals who have already shown signs o f problems (Kazdin, 1993).
Primary Prevention. Primary or "population-wide" preventive
interven-tions target the entire p o p u l a t i o n o f adolescents because all adolescents are likely to experience at least some risk factors for depression. T h e general idea b e h i n d primary prevention is to prevent depression before it starts. H e l p i n g an entire p o p u l a t i o n o f adolescents to develop internal and external resources s h o u l d help to either prevent the later develop-ment o f depression or lessen its intensity when those adolescents are confronted with normative a n d non-normative challenges. Moreover, e n h a n c i n g resources t h r o u g h primary prevention may place adolescents o n a different mental health trajectory, one that emphasizes health a n d the b u i l d i n g o f new skills o n past successes. Thus, b o t h overall risk as well as incidence o f depression can be reduced.
A n example o f a primary prevention a n d mental health p r o m o t i o n p r o g r a m is the P e n n State Adolescent Study (PSAS) developed a n d evaluated by Petersen a n d her colleagues (Petersen, Leffert, G r a h a m , A l w i n , & D i n g , i n press; Rice & Meyer, 1994; Rice et al., 1993). Students were recruited from two successive, randomly-selected cohorts o f sixth graders from two Northeast communities (JV= 335). A p p r o x i m a t e l y half of the students were r a n d o m l y assigned to intervention a n d control groups. A l l subjects underwent extensive assessments o f c o p i n g , chal-lenge, relationships, a n d mental health, c o n d u c t e d at m u l t i p l e points i n time throughout the study i n o r d e r to assess the short-term a n d long-term effects o f the prevention program.
T h e intervention p r o g r a m o c c u r r e d over eight weeks i n 16 sessions, using a psycho-educational, school-based approach to teaching emo-tional, cognitive, a n d behavioural responses to adolescent stressors a n d challenges. Special emphasis was placed o n adaptive ways o f c o p i n g with
n o r m a l levels o f distressed affect that are typical reactions to develop-mental transitions a n d challenges. T h e p r o g r a m attempted to intervene by bolstering internal a n d external resources o r buffers to challenge. E a c h session focused o n a particular social skill, c o p i n g m e t h o d , or challenge a n d began with an activity designed to stimulate the small group (8-12 students) a n d to have members interact with one another u n d e r pleasurable circumstances. T o p i c s were presented i n an interac-tive fashion, with comments from the g r o u p consistently encouraged. T h e m a i n focus o f each session was typically an activity (or series o f activities) designed to demonstrate the session's topic t h r o u g h exper-iential activities (e.g., small group problem-solving, cooperative and competitive games). Activities permitted the practicing o f specific problem-solving methods (e.g., role playing) and applying those strate-gies to specific developmental challenges confronted i n early adoles-cence (e.g., peer pressure, m a k i n g and k e e p i n g friends, and problems i n the family). E a c h session closed with an interactive review/discussion o f the major points from the session and were l i n k e d to subsequent sessions (see Petersen et al., i n press, for more specific p r o g r a m i n f o r m a t i o n ) . T h e p r o g r a m appeared to improve c o p i n g skills but the effects were not apparent one year later. Lasting effects probably are not surprising given all o f the changes that o c c u r d u r i n g early adolescence and the relative brevity o f the intervention p r o g r a m . Such results suggest the n e e d for "booster sessions," longer "doses" o f initial interventions, or perhaps m o r e systematic infusion o f prevention program materials, as i n school-based a n d / o r community-based programs, throughout adoles-cence. T h e most effective interventions with adolescent behaviour have f o u n d that it is important to engage booster sessions as well as to change the environment, (e.g., Leventhal & Keeshan, 1993; Perry & Kelder, 1992).
Secondary Prevention. Activities or interventions that target a specific
audience who have been exposed to k n o w n risk factors are considered secondary prevention. Examples i n c l u d e a p r o g r a m that targets adoles-cents for intervention who have at least one parent with a depres-sive disorder (Beardslee, H o k e , Wheelock, Rothberg, van de Velde, & Swatling, 1992), programs that help y o u n g people adjust to the divorce of their parents (Garvin, Leber, & Kalter, 1991 ; G r y c h & F i n c h a m , 1992), and programs that attempt to prevent dysphoric m o o d from b e c o m i n g severe depression (Clarke, Hawkins, Murphy, Sheeber, L e w i n s o h n , & Seeley, 1995). O u t r e a c h to selected groups represents another set o f secondary prevention activities, such as psycho-educational presenta-tions o n stress management, test anxiety, a n d racism, or informational lecture a n d discussion that increase awareness o f services a n d referral procedures.
Adolescent Depression: Implications for School Counsellors 29
In one study o f a secondary prevention effort, C l a r k e et al. (1995) targeted 150 "demoralized" adolescents who reported elevated de-pressed m o o d , d i d not meet criteria for a diagnosis o f a major depressive disorder, but were considered at-risk for future depressive episodes. Adolescents were assigned to either a five-week (15 session) prevention course o n "coping with stress" or they were assigned to a no-treatment, usual care c o n d i t i o n . T h e p r o g r a m , a m o d i f i e d version o f the "Adoles-cent C o p i n g with Depression Course," was an after-schoool cognitive group intervention that was designed to enhance adolescent c o p i n g skills, especially skills that w o u l d challenge their depressive m o o d and cognitions a n d replace them with more adaptive thoughts (Clarke, L e w i n s o h n , & H o p s , 1990). Sessions were 45 minutes l o n g , three times a week, over five weeks.
Across a one-year follow-up p e r i o d , Clarke et al. (1995) f o u n d fewer cases o f m o o d disorders a m o n g adolescents who h a d experienced the course when c o m p a r e d with adolescents who had not. T h e incidence o f depression a m o n g adolescents i n the intervention g r o u p was one-half that o f those y o u n g people not e n r o l l e d i n the intervention. T h e authors expect, however, that the effects o f the intervention will "fade over time;" they also suggest b r i e f "booster" sessions to renew the cognitive tech-niques presented i n the intervention (Clarke, et al., 1995).
Consultation
Consultation is an i n d i r e c t form o f service delivery i n that it generally refers to a voluntary, collaborative relationship between two professional or a professional a n d an interested person (e.g., parent). Consultation i n the schools occurs most often between the school counsellor a n d the teacher o r parent with the goal o f the collaboration to improve the functioning o f a t h i r d person (e.g., child) or organization (Conoley & Conoley, 1992; Dustin & Ehly, 1992). Consultation might occur when a teacher suspects that a student is e x p e r i e n c i n g a depressed affect a n d the teacher contacts the school counsellor to discuss the situation. T h e school counsellor w o u l d then work toward e n h a n c i n g the teacher's abil-ity to assess depression, provide intervention, a n d / o r make a referral. (Brown, Pryzwansky, 8c Schulte, 1995, a n d C o n o l e y 8c Conoley, 1992, provide more complete descriptions o f consultation models than can be accommodated i n the present article. Interested readers might also refer to the special issue o n consultation a n d school c o u n s e l l i n g i n Elementary S c h o o l G u i d a n c e a n d C o u n s e l i n g , V o l . 26, 1992.)
Consultants often begin by assessing the factor (s) experienced by the c o n s u l t é e that keep h i m or her f r o m intervening appropriately. Typically, those factors i n c l u d e lack o f knowledge, lack o f skill, lack o f objectivity, or lack o f confidence. F o r example, a teacher may be unaware o f gender differences i n c o p i n g a n d depression, risk factors for adolescent
de-pression, developmental transitions, normative and non-normative life events, o r the roles o f internal a n d external resources i n the development of depression. A school counsellor/consultant c o u l d provide the teacher with greater understanding o f depression i n adolescence.
In some approaches to consultation, a thorough behavioural assess-ment o f the p r o b l e m situation is r e c o m m e n d e d (e.g., base rates, anteced-ents, consequences). Consultant interventions then take the form o f clearly defined steps, i m p l e m e n t e d by the c o n s u l t é e a n d a i m e d at client behavioural change. F o r example, members o f the school or family system may have observed an adolescent e x p e r i e n c i n g low self-worth a n d withdrawing from social situations. T h e school counsellor c o u l d sur-mise that, through-negative reinforcement (avoiding aversive situa-tions), the adolescent is increasingly likely to miss opportunities for potentially pleasurable experiences. Teachers or parents c o u l d be i n -structed to provide the adolescent with positive consequences (e.g., m i n i m a l encouragers or verbal praise) for even m i n i m a l attempts at social interaction.
H a n s e n , H i m e s , and M e i e r (1990) identified several issues that affect school-based consultation efforts. School counsellors may encounter teachers or parents who are reluctant to engage in consultation. Reasons for such reluctance might i n c l u d e lack o f administrative support for consultation, scheduling, transportation limits, reluctance to express vulnerabilities a n d seek assistance, concern about m u l t i p l e roles o f the school counsellor, or simple lack o f awareness that the school counsellor is w i l l i n g and able to provide consultation. Flexibility i n scheduling (e.g., before a n d after school, or evening availability), brief consultation ses-sions, in-service presentations o n consultation services and procedures, presentations to parent groups i n the school or community, a n d other actionoriented strategies can enhance the school c o u n s e l l o r / c o n -sultant's credibility a n d impact.
The Role of the School Counsellor
T h e r e are often many demands for time and expertise placed o n school counsellors. D e p e n d i n g u p o n the school setting, counsellors may be called u p o n to conduct i n d i v i d u a l c o u n s e l l i n g and group counselling, crisis intervention, training, teaching, p r o g r a m development, course scheduling, a n d a variety o f c o o r d i n a t i o n activities. T i m e a n d efficiency become highly valued a m o n g many school counsellors.
Adolescent depression is likely best treated through a thoughtful set o f efforts, perhaps initiated a n d / o r coordinated by a school counsellor. A l t h o u g h i n d i v i d u a l c o u n s e l l i n g can h e l p adolescents who are de-pressed, it also is clear that i n d i v i d u a l c o u n s e l l i n g p r o v i d e d by the school counsellor to every adolescent suspected o f b e i n g depressed will not be i n the best interests o f any m e m b e r o f the school community. O t h e r
effi-Adolescent Depression: Implications for School Counsellors 31
cient a n d beneficial uses o f a school counsellor's time may involve a c o m b i n a t i o n o f primary prevention, secondary prevention, a n d consulta-tion services (Conoley & Conoley, 1992; K u r p i u s & Rozecki, 1992) such that larger groups o f adolescents are served a n d the responsibility for h e l p i n g depressed adolescents is shared across the school. S u c h activities c o u l d i n c l u d e in-service presentations to school personnel regarding the identification o f depression a n d interventions that h e l p improve depres-sion (e.g., h e l p increase internal a n d external resources), c u r r i c u l u m revision a n d infusion o f depression-relevant content i n appropriate classes, a n d small g r o u p c o u n s e l l i n g for students sharing some risk factors.
C O N C L U D I N G R E M A R K S
Adolescent depression varies i n intensity, duration, a n d severity. Schools and school counsellors i n particular s h o u l d be c o n c e r n e d about adoles-cent depression because (a) depression can significandy interfere with the l e a r n i n g process, (b) depression is often associated with other emo-tional a n d behavioural problems (e.g., anxiety, conduct disorder, eating disorders, substance abuse), a n d (c) depression is l i n k e d to youth suicide.
We have presented a m o d e l that places depression i n the developmen-tal context o f adolescence. Most adolescents manage the challenges o f adolescence without significant problems, but others are at-risk for the development o f depression based o n the presence o f one or m o r e factors frequently associated with it. Some adolescents become depressed as a result o f e x p e r i e n c i n g stressful events i n the face o f lacking the skills necessary to h e l p them cope with those events.
S c h o o l counsellors can work individually, i n groups, a n d i n larger-scale programmatic efforts to h e l p adolescents prepare for difficult situations through the e n h a n c e m e n t o f internal and external resources. Indeed, given the compulsory nature o f education, the time that c h i l d r e n spend i n school, schools have access to a large n u m b e r of young people. Schools are u n i q u e l y positioned to have considerable opportunity to intervene i n , a n d to prevent, adolescent depression.
References
Abramson, L . Y , Seligman, M . E . P., & Teasdale, J . (1978). Learned helplessness i n humans: Critique a n d reformulation. Journal of Abnormal Psychology, 87, 49-74.
Albee, G . (1985). T h e argument for primary prevention. Journal of Primary Prevention, 5(4), 213-19.
A m e r i c a n M e d i c a l Association. (1990). America's adolescents: How healthy are they? Chicago, I L : A m e r i c a n M e d i c a l Association.
A m e r i c a n Psychiatric Association. ( 1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D C : Author.
Armsden, G . C , & Greenberg, M . T. (1987). T h e inventory o f parent and peer attachment: Individual differences and their relationship to psychological well-being i n adolescence. Journal of Youth and Adolescence, 16, 427-53.
Attie, I., Brooks-Gunn, J . , & Petersen, A . C. (1990). A developmental perspective o n eating disorders and eating problems. In M . Lewis & S. M i l l e r (Eds.), Handbook of developmental psychopathology (pp. 409-20). New York: P l e n u m Press.
Baltes, P., & Reese, H . (1984). Developmental psychology: An advanced textbook. Hillsdale, N J : E r l b a u m .
Beardslee, W. R., H o k e , L „ Wheelock, 1., Rothberg, P., van de Velde, P., & Swatling, S. (1992). Initial findings on preventive interventions for families with parental affective disorders. American Journal of Psychiatry, 149, 1335-40.
Beitchman,J., Zucker, K , H o o d , J . , & DeCosta, G . (1991). A review o f the short-term effects o f c h i l d sexual abuse. Child Abuse and Neglect, 15, 537-56.
Bennett, D . S., & Bates, J . E . (1995). Prospective models o f depressive symptoms i n early adolescence: Attributional style, stress, and support. Journal of Early Adolescence, 15, 299-315. Blatt, S . J . (1995). T h e destructiveness of perfectionism: Implications for the treatment o f
depression. American Psychologist, 50, 1003-20.
B l o o m , M . (1985). Debate o n primary prevention: A paradigmatic response. Journal of Primary Prevention, 5(4), 238-41.
Blumenthal, S., & Hirschfeld, R. (1984). Suiäde among adolescents and young adults. Washington, D C : National Institute o f Mental Health.
Center for Population Options. (1992). lesbian, gay and bisexual youth: At risk and underserved. Washington, D C : Author.
Clarke, G . N . , Hawkins, W., Murphy, M . , Sheeber, L . B., Lewinsohn, P. M . , & Seeley.J. R. (1995). Targeted prevention o f unipolar depressive disorder in an at-risk sample o f high school adolescents: A randomized trial of a group cognitive intervention. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 312-21.
Clarke, G . N . , Lewinsohn, P . M . , & Hops, H . (1990). Instructor's manual for the Adolescent Coping with Depression Course. Eugene, O r : Castalia Press.
Clarizio, H . F. (1994). Assessment and treatment of depression (2nd ed.). Brandon, V T : C l i n i c a l Psychology Publishing Company.
Compas, B . E . (1987). C o p i n g with stress d u r i n g adolescence. Clinical Psychology Review, 1, 275-302.
Conoley, J . C , & Conoley, C . W. (1992). School consultation: Practice and training (2nd ed.). Boston: A l l y n & Bacon.
Delisle, J . (1986). Death with honors: Suicide among gifted adolescents. Journal of Counseling and Development, 64, 558-60.
Dustin, D . , & Ehly, S. (1992). School consultation in the 1990s. Elementary School Guidance and Counseling, 26, 165-75.
Frost, R. O . , Marten, P., Lahart, C , & Rosenblate, R. ( 1990). T h e dimensions of perfectionism. Cognitive Therapy and Research, 14, 449-68.
Garland, A . F., & Zigler, E . (1993). Adolescent suicide prevention: Current research and social policy implications. American Psychologist, 48, 169-82.
Garmezy, N . , & Rutter, M . (Eds). (1983). Stress, coping, and development in children. New York: M c G r a w - H i l l .
Garvin, V , Leber, D., & Kalter, N . (1991). C h i l d r e n of divorce: Predictors of change following preventive intervention. American Journal of Orthopsychiatry, 61, 438-47.
Grych, J . H . , & F i n c h a m , F. D . (1992). Interventions for children o f divorce: Toward greater integration o f research and action. Psychological Bulletin, 111, 434-54.
Hansen, J . C , Hirnes, B . S., & Meier, S. (1990). Consultation: Concepts and practices. Englewood Cliffs, N J : Prentice-Hall.
Harder, C . ( 1990). The winner's seminar: A leadership experience for youth. Cedar Rapids, IA: Carole H a r d e r & Company.
Herman-Stahl, M . A . , Stemmler, M . , & Petersen, A . C . (1995). A p p r o a c h and avoidant coping: Implications for adolescent mental health. Journal of Youth and Adolescence, 24, 649-65.
Adolescent Depression: Implications for School Counsellors 33
Hewitt, P. L . , & Flett, G . L . (1989). T h e multidimensional perfectionism scale: Development and validation. Canadian Psychology, 30, 339.
Kaslow, N . J . , R e h m , L . P., & Siegel, A . W. (1984). Social-cognitive and cognitive correlates of depression i n children. Journal of Abnormal Psychology, 12, 605-20.
Katchadourian, H . ( 1990). Sexuality. In S. F. Feldman & G . R. Elliott (Eds.), At the threshold: The developing adolescent (pp. 330-51). Cambridge, Mass: Harvard University Press.
Kazdin, A . E . ( 1993). Adolescent mental health: Prevention and treatment programs. American Psychologist, 48(2), 127-41.
Kenny, M . E . , M o i l a n e n , D . L . , L o m a x , R., & Brabeck, M . M . (1993). Contributions o f parental attachments to view o f self and depressive symptoms among early adolescents. Journal of Early Adolescence, 13, 408-30.
Kessler, R., Price, R., & Wortmann, C. (1985). Social factors i n psychopathology: Stress, social support, and c o p i n g processes. Annual Review of Psychology, 36, 531-72.
Kurpius, D . J . , & Rozecki, T. (1992). Outreach, advocacy, and consultation: A framework for prevention and intervention. Elementary School Guidance & Counseling, 26, 176-89. Kovacs, M . (1990). C o m o r b i d anxiety disorders i n childhood-onset depressions. I n j . D . Maser
& C . R. C l o n i g e r (Eds.), Comorbidity of mood and anxiety disorders (pp. 272-81). Washington, D C : A m e r i c a n Psychiatric Press.
Kovacs, M . , Paulauskas, S., Gatsonis, C , & Richards, C. (1988). Depressive disorders in child-hood: 3. A longitudinal study o f comorbidity with and risk for conduct disorders. Journal of Affective Disorders, 15, 205-17.
Leventhal, H . , & Keeshan, P. (1993). P r o m o t i n g healthy alternatives to substance use. In S. G . Millstein, A . C . Petersen, & E. O . Nightingale (Eds.), Promoting the health of adolescents: New directions for the twenty-first century (pp. 260-84). New York: O x f o r d University Press. Martin, A . D., & Hetrick, E . S. (1988). T h e stigmatization o f the gay and lesbian adolescent.
Journal of Homosexuality, 15, 163-83.
Myrick, R. D . (1993). Developmental guidance and counseling: A practical approach (2nd ed.). Minneapolis, M N : Educational M e d i a C o r p o r a t i o n .
Nolen-Hoeksema, S., & Girgus.J. S. ( 1994). T h e emergence of gender differences i n depression d u r i n g adolescence. Psychological Bulletin, 115, 424-43.
Perry. C. L . , & Kelder, S. H . ( 1992). Models for effective prevention. Journal of Adolescent Health, 13, 355-63.
Petersen, A . C , Compas, B . E „ Brooks-Gunn, J . , Stemmler, M . , Ey, S„ & Grant, K . E. (1993). Depression i n adolescence. American Psychologist, 48, 155-68.
Petersen, A . C , & Ebata, A . T. (1987). Developmental transitions and adolescent problem behavior: Implications for prevention and intervention. In K . H u r r e l m a n n , F. X . Kaufmann, & F. Lösel (Eds.), Social intervention: Potential and constraints (pp. 167-84). New York: Walter de Gruyter.
Petersen, A . C , Kennedy, R. E . , & Sullivan, P. (1991). C o p i n g with adolescence. In M . E . G ö l t e n & S. Gore (Eds.), Adolescent stress: Causes and consequences (pp. 93-110). New York: A l d i n e De Gruyter.
Petersen, A . C . , Leffert, N . , & Graham, B. L . (1995). Adolescent development and the emer-gence o f sexuality. Suicide and Life Threatening Behaviors, 25, 4-17.
Petersen, A . G , Leffert, N , Graham, B . , Alwin, J . , & D i n g , S. (in press). P r o m o t i n g mental health du ring the transition into adolescence. I n j . Schulenberg.J. Maggs, & K . H u r r e l m a n n
(Eds.), Health risks and developmental transitions during adolescence. New York: Cambridge University Press.
Petersen, A . C . , Leffert, N . , Graham, B . , D i n g , S., & Overbey, T. (1994). Depression and body image disorders i n adolescence. Women's Health Issues, 4(2), 98-108.
Reinherz, H . 1., Stewart-Berghauer, G . , Pakiz, B . & Frost, A . K . (1989). T h e relationship o f early risk and current mediators to depressive symptoms i n adolescence. Journal of the American Academy for Child and Adolescent Psychiatry, 28, 942-47.
Remafedi, G (1987). Adolescent sexuality: Psychosocial and medical implications. Journal of Pediatrics, 79, 326-30.
Reynolds, W. M . , & Johnston, H . F. (Eds.) (1994). Handbook of depression in children and adolescents. New York: P l e n u m Press.
Rice, K . G . , H e r m a n , M . A . , & Petersen, A . C . (1993). Challenge i n adolescence: A conceptual model and psycho-educational intervention. Journal of Adolescence, 16, 235-51. Rice, K . G . , & Meyer, A . L . (1994). Preventing depression among young adolescents:
Prelimi-nary process results o f a psycho-educational intervention program. Journal of Counseling Csf Development, 73, 145-52.
Rohde, P., Lewinsohn, P. M . , & Seeley, J . R. (1991). Comorbidity o f unipolar depression: 2. Comorbidity with other mental disorders i n adolescents and adults. Journal of Abnormal Psychology, 100, 214-22.
Savin-Williams, R. C . (1994). Verbal and physical abuse as stressors i n the lives o f lesbian, gay male, and bisexual youths: Associations with school problems, r u n n i n g away, substance abuse, prostitution, and suicide. Journal of Consulting and Clinical Psychology, 62, 261-69. Shaffer, D . (1988). T h e epidemiology o f teen suicide: A n examination o f risk factor. Journal of
Clinical Psychiatry, 49, 3f>41.
Stein, J . A . , G o l d i n g . J . M . , Siegel, J . M . , B u m a m , M . A . , & Sorenson, S. B . (1988). Long-term psychological sequelae of c h i l d sexual abuse: T h e Los Angeles epidemiologic catchment area study. In G . E . Wyatt & G . J . Powell (Eds.), Lasting effects of child sexual abuse (pp. 135-54). Newbury Park, C A : Sage.
Weinberg, W., R u t m a n . J . , Sullivan, L . , Penick, E . , & Dietz, S. (1973). Depression i n c h i l d r e n referred to an educational diagnostic center: Diagnosis and treatment. Journal of Pediatrics, 83, 1065-72.
Weissberg, R. P., & A l l e n . J . P. ( 1986). P r o m o t i n g children's social skills and adaptive interperso-nal behavior. In B . A . Edlestein & L . Michelson (Eds.), Handbook of prevention (pp. 153-75). New York: P l e n u m Press.
Weissberg, R. P., C a p l a n , M . Z., & Sivo, P.J. ( 1989). A new conceptual framework for establishing school-based social competence p r o m o t i o n programs. In L . A . B o n d , & B . E. Compas (Eds.), Primary prevention and promotion in schools (pp. 255-96). Newbury Park, C A : Sage. Zoccolino, M . ( 1992). Co-occurrence of conduct disorder and its adult outcomes with
depres-sive a n d anxiety disorders: A review. Journal of the American Academy for Child and Adolescent Psychiatry, 31, 547-56.
Address correspondence to: Kenneth G . Rice, Department of Counseling, Educational Psychol-ogy and Special Education, 440 Erickson H a l l , Michigan State University, East Lansing, M I 48824-1034. Electronic mail may be sent via the Internet to k g r l @ p i l o t . m s u . e d u .
