Sophie doesn’t remember the last time she had a good night’s sleep or got through a day without crying at some point. Going swimming, riding her bike and loading songs onto her iPod used to be favorite activities, but nothing really seems to be worth getting off the couch for anymore. Phone calls from friends go unanswered, and she hasn’t attended a party in over three months. Most days Sophie just feels like it would be very nice if she never had to get out of bed again.
Sophie is 11 years old.
Dr. Kevin Stark
Although an estimated 12 percent of women suffer from clinical depression and most of them report having had depression as children, no large-scale treatment studies of depressed preteen girls had been conducted until four years ago when Dr. Kevin Stark, a College of Education professor at The University of Texas at Austin, launched a large-scale five-year treatment outcome study. Stark’s goal is to identify the most effective treatment for clinically depressed girls in the 9-13 age range and uncover the best means of preventing future episodes of depression.
“We want to find a safe, sound way to treat girls with depression before they reach that very critical, high-risk period around age 13, 14 or 15,” says Stark, who is in the Department of Educational Psychology. “Before 13 or so, the incidence of depression in boys and girls is about the same—around 2 to 4 percent—but when girls hit 13 or 14, the incidence for females doubles. It doesn’t change for boys.”
According to Stark, depression is episodic, and preteen girls who suffer from it are very likely to experience it again in their teens and have recurring bouts in adulthood. Identifying and treating it—or executing a “preemptive strike”—before the especially vulnerable teen years is crucial.
With a $1.7 million grant from the National Institute of Mental Health, Stark and six therapists are working with 140 girls in fourth through seventh grades at six schools in Georgetown and Pflugerville, Texas.
For the study, the girls with symptoms of depression are divided into three groups, including a group in which the girls receive cognitive behavioral therapy (CBT), a group in which the girls and their parents receive cognitive behavioral therapy and parent training skills, and a “minimal contact” control group.
Dr. Jennifer Hargrave
Cognitive behavioral therapy emphasizes the crucial role of thinking and perceptions in how a person feels and acts—if a person’s thoughts, rather than outside factors like people, the environment or events, cause feelings and behaviors, then a person can change the way he thinks in order to feel better and act differently. If you’re experiencing negative feelings and engaging in unwanted behaviors, CBT asserts that you must discover the thought patterns that are causing the unwanted feelings and actions and learn how to replace this thinking with thoughts that lead to more desirable outcomes.
To find study participants, consent forms are sent home with female students, and if parents agree to have their child screened for depression, a doctoral student from the Department of Educational Psychology’s school psychology program assesses the child.
Signs of depression that the therapists look for include changes in appetite, sleep disturbances, fatigue, irritability, difficulty concentrating, feelings of worthlessness and even thoughts of self-injury. According to Stark, in addition to suffering from these symptoms, around 65 percent of girls with depression are found to have at least one other psychological disorder, such as anxiety, as well.
“Attempting to screen all of the girls in the grades we’re examining is one of the many unique features of our project,” says Stark. “Previous research on childhood depression, for example, has not been anywhere near this large in scope. It’s much more typical of researchers to issue a call for volunteers.
“This project runs through both the fall and spring semesters, and this fall we had around 111 girls screen high for depression. Our therapists did quick interviews with the girls to make sure that they weren’t simply reporting having a difficult couple of days and that they had experienced symptoms of depression over an extended period of time. The therapists recommended 75 of those girls for the study, and we ended up with 55 consent forms from guardians who agreed to let their child participate in an extensive diagnostic interview.”
Girls who receive CBT complete 20 group sessions and two individual therapy sessions. This exceeds the number of sessions that children who are seeing a therapist normally end up attending, according to Stark. Parents participating in the study attend eight group sessions and two family meetings.
“One key to therapy for depressed individuals is to activate the person physically and emotionally,” says Dr. Jennifer Hargrave, a postdoctoral student in the school psychology program and the research project coordinator. “You want to get the person up and engaged and doing fun things and activities that lead to mastery. The therapist shows these girls how to cognitively shift to a more positive mindset.
“If during therapy a girl exhibits a positive skill or mentions a positive experience, you really maximize and stress that good thing and help her learn how to use it in the future to feel better. We show the girls how to pay attention to what their bodies, brains and behavior are telling them and that they have control over their moods.”
Fashioned around the easy-to-recall acronym “ACTION,” the girls’ therapy materials accentuate the positive by instructing them to: “Always find something to do to feel better. Catch the positive. Think about it as a problem to be solved. Inspect the situation. Open yourself to the positive. And Never get stuck in the negative muck.”
The materials the girls receive are developmentally appropriate, which is another unique feature of the study, and have lively, upbeat illustrations of girls successfully detecting and defeating negativity, or “the Muck Monster.” In therapy, the girls are taught to be “emotion detectives” and to look for clues in their brain, body and behavior that indicate the onset of depression. They keep a “take action” list of at least three specific activities that they find enjoyable and are encouraged to do as many of those things each day as possible. Fun activities and successful coping strategies are written down in their “Catch the Positive Diary.”
“We use the acronym ACTION to help the girls remember how to recognize mood changes as they’re occurring and the symptoms of depression,” says Stark. “We want those changes in mood to serve as a signal. If a problem is out of their control, we teach them emotion-focused coping strategies.
“If it’s a problem they can control, we teach them how to use problem-solving skills and to notice what strategies work and which do not. We try to help them think in a realistic and positive way—to identify negative thoughts, figure out if the thought is even realistic or accurate and then actively argue back with the negative thought.”
According to Hargrave, the fact that the groups are girl-only and conducted by female therapists helps the girls relax and build trust. One student will offer support and words of encouragement to another at a level that a 10- or 11-year-old understands, and “the sessions create a safe, positive environment where the students can be silly, playful girls their age and start noticing what makes them truly happy and what they find to be fun.”
Often the girls are each other’s best therapists and role models.
“I remember one instance in which a little girl reported that she was very down about not being asked to dance at parties and stated that she felt so ugly,” says Hargrave, “and another little girl in the group just looked at her in amazement and said, ‘Wait a minute—at the last dance there was this huge group of boys standing around you, and yes you did dance.’ If one girl says she’s a rotten singer, and that’s totally untrue, another girl will jump in and tell her how fantastic she is.”
Because many of the girls with depression have become experts, over time, at hiding their symptoms in order to please parents, teachers and other adults, the therapy sessions may be the first opportunity they have had to discuss their distress.
Since the five-year study is only in its fourth year, Stark does not have final research results to report, but the prognosis is very promising. According to Stark, the majority of girls who receive cognitive behavioral therapy become symptom-free over the course of treatment.
“Our study is unique in so many ways,” says Stark. “It’s school-based, the participants all are girls, we’re dealing with the 9-13 age range, it includes the largest number of Hispanics of any study and we’re offering therapy sessions twice a week. The intervention is unique in that a case is individualized and conceptualized for each girl, and our materials are developmentally appropriate.
“We teach the girls in a way that fits their experiences and age, with lots of visuals and teaching methods appropriate for several learning styles. The therapy sessions also are tailored specifically to girls, which is unique. We conducted focus groups before we developed the treatment and asked girls what they did to make themselves feel better, then used that feedback to fashion the treatment. We also offer ‘booster’ meetings and follow the girls, after therapy, for up to four years, and that’s not been done in any other similar study.”
To the principals, teachers, parents, coaches and transformed girls, the specifics and science behind the study may seem relatively unimportant and best left to professors. Teachers simply see students that are smiling for the first time since school began and, as one parent phrased it, “I’ve finally got my daughter back.”