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The role of British Columbia elementary school counsellors in assisting depressed students Farquhar, Jacqueline Lee 1995

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THE R O L E OF BRITISH COLUMBIA ELEMENTARY SCHOOL COUNSELLORS IN ASSISTING DEPRESSED STUDENTS by J A C Q U E L I N E L E E F A R Q U H A R A THESIS SUBMITTED I N P A R T I A L F U L F I L M E N T OF T H E REQUIREMENTS FOR T H E D E G R E E OF M A S T E R OF ARTS in T H E F A C U L T Y OF G R A D U A T E STUDIES (Department of Counselling Psychology) We accept this thesis as conforming to the required standard T H E UNIVERSITY OF BRITISH C O L U M B I A ° September 1995 Jacqueline Lee Farquhar, 1995 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) A B S T R A C T This study examined British Columbia elementary school counsellors' perceptions in relation to assisting depressed students, including: (a) their knowledge about depression; (b) their ideal role; (c) their current role; (d) their current practices; (e) barriers to assisting depressed students; and (f) factors which would help them to better assist these students. A questionnaire specifically designed for this study was mailed to 333 elementary school counsellors, and 248 (74.5%) were completed and returned. The percentages of counsellors who perceived various functions as part of their current and ideal roles were calculated, as were the percentages who engaged in various counsellor activities, and indicated factors which would help them to better assist depressed students. Sample means and standard deviations were calculated for the extent to which various factors were barriers to assisting depressed students. Results indicated most counsellors perceived identification, referral, and prevention of student depression to be part of their ideal and current roles, and have used these functions to assist depressed students. However, respondents were divided on treating depressed students, and only slightly more than one-third had assessed students even though two-thirds perceived it as part of their ideal role. Most counsellors have been referred depressed students by teachers, and have referred students to mental health and medical professionals. Approximately one-half perceived art and play therapy to be a more effective method of treating depression. ii Counsellors lacked basic information on childhood depression, and more learned about it through their own initiative, rather than professional development activities. Too high a student-to-counsellor ratio and lack of time were most consistently rated as the highest barriers to assisting depressed students. Other major barriers included: priority being given to acting out students; lack of knowledge about depression, assessment techniques, and treatment strategies; and lack of community resources. Lack of a clear role policy was not perceived to be a major barrier to assisting depressed students. The most frequent recommendations for helping counsellors to assist depressed students were more information about effective treatment strategies and a lower student-to-counsellor ratio. iii T A B L E O F C O N T E N T S Page A B S T R A C T i i T A B L E OF CONTENTS iv LIST OF TABLES v i A C K N O W L E D G E M E N T S v i i C H A P T E R 1: INTRODUCTION 1 Background to the Problem 1 Purpose of this Study 3 Definitions 3 Major Depressive Disorder 4 Dysthymic Disorder 5 Research Questions 6 Assumptions 7 Significance of the Study 7 C H A P T E R 2: REVIEW OF T H E L I T E R A T U R E 9 Childhood Depression 9 Role of the Elementary School Counsellor 14 Identification of Depressed Students 15 Assessment of Students for Depression 17 Treatment of Depressed Students 19 Referral of Depressed Students 24 Prevention of Student Depression 26 C H A P T E R 3: M E T H O D O L O G Y 32 Rationale 32 Sample 33 Design 34 Data Collection 37 Data Analysis 38 C H A P T E R 4: RESULTS 41 Questionnaire Returns 41 Respondents' Background Information 41 Research Questions . 45 Summary of Results of Research Questions 64 iv T A B L E O F CONTENTS, CONTINUED: Page CHAPTER 5: DISCUSSION 68 Discussion and Interpretation of the Results 68 Limitations of the Study ; 84 Recommendations 87 REFERENCES 9 2 APPENDIX A 99 APPENDIX B 103 APPENDIX C H5 v L I S T O F T A B L E S Page Table 1. Demographic Characteristics of Elementary School Counsellors 42 Table 2. Education of Elementary School Counsellors 42 Table 3. Work Experience of Elementary School Counsellors 43 Table 4. Characteristics of Work Assignment 43 Table 5. Counsellors' Knowledge of Childhood Depression 45 Table 6. Counsellors' Perception of Ideal Role in Assisting Depressed Students . . . 46 Table 7. Counsellors' Perception of Current Role in Assisting Depressed Students . 48 Table 8. Counsellors' Current Activities in Assisting Depressed Students 49 Table 9. Number of Depressed Students Identified 49 Table 10. Change in Estimate of Number of Depressed Students after Considering the DSM-IV Criteria 50 Table 11. Mean Differences in Identification of Depressed Students 51 Table 12. Referral Source of Depressed Students 51 Table 13. Assessment Techniques Used by Counsellors 52 Table 14. Counsellors' Perception of Whether Some Treatment Strategies were More Effective 52 Table 15. Treatment Strategies Counsellors Identified as More Effective 53 Table 16. Agencies and Professionals to Whom Counsellors Have Referred Depressed Students 54 Table 17. Prevention Activities Used by Counsellors 55 Table 18. Means and Standard Deviations of Counsellors' Perceived Barriers to Identifying Depressed Students 55 Table 19. Means and Standard Deviations of Counsellors' Perceived Barriers to Assessing Depressed Students 56 Table 20. Means and Standard Deviations of Counsellors' Perceived Barriers to Treating Depressed Students . . . 56 Table 21. Means and Standard Deviations of Counsellors' Perceived Barriers to Referring Depressed Students 57 Table 22. Means and Standard Deviations of Counsellors' Perceived Barriers to Preventing Student Depression 57 Table 23. Mean Differences Between Barriers Perceived by Counsellors Assessing and not Assessing Students 59 Table 24. Factors Counsellors Perceived Would Aid Them in Assisting Depressed Students 61 Table 25. Options Counsellors Included in the Five Factors Which Would Be Most Helpful in Assisting Depressed Students 62 vi A C K N O W L E D G E M E N T S I wish to thank Dr. John Allan for his guidance throughout my program. His enthusiasm and support for both this study and my clinical work made my time in this program an extremely enjoyable experience. His insights and many valuable suggestions continually challenged me to extend both my knowledge and skills, and will continue to influence my work for many years to come. I would also like to thank Dr. Frank Echols for the many hours of work he put into this study. His numerous contributions during Education 508 and throughout the duration of this study made exploration into new ground both exciting and manageable. For his review of my study and valuable contributions, I would also like to thank Dr. Bill Borgen. Finally, I would like to thank the Faculty of Education, University of British Columbia for providing a Graduate Research Grant which helped to fund the costs associated with this study. vii C H A P T E R 1 I N T R O D U C T I O N 1 Background to the Problem Depression in elementary school children is a serious problem, which continues to be underidentified, misdiagnosed, and undertreated (de Mesquita and Gilliam, 1994; Keller, Lavori, Beardslee, Wunder, & Ryan, 1991; Reynolds, 1990). Before its 1980 classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, American Psychiatric Association, 1980), there were many misconceptions about its nature, and even a denial of its existence (Poznanski, 1983; Reynolds, 1986). However, many studies have since verified that depression in children does indeed exist. Research suggests from 1.8% to 8.2% of elementary school children are depressed at any given time, and most of these children will continue to be depressed anywhere from six months to four years later (Anderson, Williams, McGee, & Silva, 1987; Kashani, Mcgee, Clarkson, Anderson, Walton, Williams, Silva, Robins, Cytryn, & McKnew, 1983; Kovacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein 1984; Kovacs, Akiskal, Gatsonis, & Parrone, 1994; McCracken, 1987; Nolen-Hoecksema, Seligman, & Girgus, 1992; Polaino-Lorente & Domenech, 1993; Ryan, Puig-Antich, Ambrosini, Rabinovichic, Robinson, Nelson, Iyengar, & Twomey, 1987). Furthermore, between 40% and 70% of these children will also experience at least one other episode of depression before reaching adulthood (Kovacs et al., 1984; Kovacs et al., 1994; Nolen-Hoecksema et al., 1992). Childhood depression can effect all aspects of a child's development including psychological, social, emotional, and academic functioning (Feshbach & Feshbach, 1987; Nolen-Hoeksema et al., 1992; Nousiainen, Frame, & Forehand, 1992; Reynolds, 1990). Childhood depression has also been associated with suicide ideation and attempts (Harrington, Bredenkamp, Groothues, Rutter, Fudge, & Pickles, 1994; Kovacs, Goldston, & Gatsonis, 1994; Marciano & Kazdin, 1994). Nevertheless, despite the significant prevalence rate, and the problems associated with childhood depression, little is known about how elementary school counsellors are currently assisting these students. Werthamer-Larsson (1994) suggests schools can fulfil a critical role in providing mental health services to students, which presumably includes depressed students. She makes a number of recommendations about the type of research needed in order to facilitate the improvement of these services. One of her recommendations is for researchers to establish what services are currently being used to help students experiencing mental health problems. Another recommendation is for researchers to determine which barriers prevent the utilization of these services. Another factor that may effect how elementary school counsellors assist depressed students, not mentioned by Werthamer-Larsson, is how elementary school counsellors perceive their role in relation to assisting these students. There are a number of possible interventions that counsellors could provide including identifying depressed students, assessing students for depression, providing treatment for depression, referring depressed students to Other community resources, and engaging in activities aimed at preventing student depression. 3 Purpose of this Study This study examined how elementary school counsellors perceived their role in assisting depressed students, what practices they used to assist depressed students, and what factors influenced the implementation of these practices. More specifically, this study identified British Columbia elementary school counsellors' perceptions of: (a) their ideal role in assisting depressed students; (b) their current role in assisting depressed students; (c) their knowledge about childhood depression; (d) activities they used to identify, assess, treat, refer, and prevent student depression; (e) barriers which hindered their ability to identify, assess, treat, refer, and prevent student depression; and (f) factors which would help them to better assist depressed students. Definitions Part of the problem when discussing childhood depression is defining what one means when using this term. Kendall, Cantwell, and Kazdin (1989) point out that people often describe a person who is experiencing a sad or unhappy feeling as being depressed. However, a depressed person can also be someone who has a 'depressive disorder', which is a condition characterized by a specific set of symptoms occurring together over a minimal period of time. The two depressive disorders most commonly examined by research on childhood depression are Major Depressive Disorder and Dysthymic Disorder, both of which are described in the various editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, American Psychiatric Association, 1980; 3rd. edition, revised, DSM-III-R, American Psychiatric Association, 1987; 4th. edition, DSM-IV, American Psychological Association, 1994). As the various editions of this manual provide the only operationalized definitions for childhood depression, they 4 continue to be the most frequently used diagnostic system (Anderson et al., 1987). Therefore, this study used the following definitions taken from the most recent edition, DSM-IV. Major Depressive Disorder A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. (2) marked diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. (4) insomnia or hyposomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (8) diminished ability to think, concentrate, or indecisiveness nearly every day (either by subjective account or as observed by others) (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide (APA, 1994, p.327). B. The symptoms cause significant impairment in social or other important areas of functioning, and are not due to physiological effects of substances (e.g. drugs), a general medical condition or bereavement. 5 Dysthymic Disorder A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year. B. Presence, while depressed, of two (or more) of the following: (1) poor appetite or overeating (2) insomnia or hypersomnia (3) low energy or fatigue (4) low self-esteem (5) poor concentration or difficulty making decisions (6) feelings of hopelessness C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time. D. The symptoms are not due to the effects of a substance, a medical condition, and cause significant impairment in functioning. During the episode there has been no occurrence of Major Depressive Disorder, or a chronic Psychotic Disorder, such as Schizophrenia (APA, 1994, p. 349). In addition, this study used the following terminology: Depressed Student. A student exhibiting symptoms associated with either Major Depressive Disorder or Dysthymic Disorder. Elementary School Counsellor. A person employed by a British Columbia (B.C.) school district, and designated as an elementary school counsellor by that district. Counsellor Function. The types of services counsellors could provide to depressed students including identification, assessment, treatment, referral, and prevention. Identification. Considering depression as a cause for a student's symptoms or behaviours. Assessment. Using a standardized instrument, DSM-IV criteria, or a projective technique to determine whether a student is depressed. Treatment. Providing intervention to students who have been identified as being depressed. Prevention. Involvement in activities specifically aimed at preventing students from becoming depressed. Research Questions 1. Are elementary school counsellors knowledgeable about childhood depression? 2. Are elementary school counsellors exposed to information about childhood depression during their professional development activities? 3. Which counsellor functions do elementary school counsellors perceive to be part of their ideal role in assisting depressed students? 4. Which counsellor functions do elementary school counsellors perceive to be part of their current role in assisting depressed students? 5. Which counsellor functions do elementary school counsellors currently use to assist depressed students? 6. How are the counsellor functions being implemented when elementary school counsellors assist depressed students? 7. What barriers hinder the ability of elementary school counsellors to assist depressed students? 7 8. What factors would help elementary school counsellors to better assist depressed students? Assumptions This study assumes that: (a) elementary school counsellors are aware that children can be depressed; (b) there are depressed students within the B . C . elementary school system; (c) identification, assessment, treatment, referral, and prevention of student problems are part of the role of elementary school counsellors; (d) elementary school counselling programs should offer assistance to depressed students; and (e) research on depressed children is applicable to elementary school students. Significance of the Study This study is significant for a number of reasons: 1. It examines the role of elementary school counsellors in assisting depressed students, an area not previously researched. 2. It describes what elementary school counsellors perceive their role to be in assisting depressed students, and the practices they use to assist these students. 2. It identifies barriers which hinder the ability of elementary school counsellors to assist depressed students, and the factors which would facilitate their ability to assist these students. 3 . The data suggests a number of modifications to the role of elementary school counsellors which would help them to more effectively assist depressed students. 4. The data can be analyzed in terms of current literature findings, leading to additional recommendations for the modification of the role of elementary school counsellors in assisting depressed students. 8 5. The results of this study indicate areas that need to be addressed in the training of elementary school counsellors, and the professional development of practising elementary school counsellors. 9 CHAPTER 2 REVIEW O F T H E L I T E R A T U R E As discussed in the introduction, there are a significant number of depressed students within the elementary school system who could be helped by elementary school counsellors through the implementation of the various counsellor functions. This chapter reviews the literature on childhood depression, the role of elementary school counsellors, and research findings relevant to the potential counsellor functions. The first section discusses research on the etiology of childhood depression. The second section examines research on the role of elementary school counsellors. This is followed by a more in depth review of literature relevant to the five counsellor functions which elementary school counsellors may be using to assist depressed students: identification, assessment, treatment, referral, and prevention of student depression. Childhood Depression Prevalence. According to Reynolds (1990), childhood depression "may be one of the most overlooked and undertreated psychosocial disorders of childhood" (p. 159). Over the last twenty years, research studies have suggested that anywhere up to 20% of children are depressed at any given time (de Mesquita & Gilliam, 1994; Hart, 1991). Unfortunately, numerous methodological problems limit the validity and reliability of the results for many of these studies, including: the failure to operationalize the term depression, use of a small sample size, use of clinical subjects rather than sampling from the general population, use of both children and adolescents as subjects, use of unreliable 10 and inconsistent methods of measurement, and reliance on only a single measuring device or informant. Nevertheless, three studies have addressed these issues. The first study used a cohort of children born at a New Zealand hospital during a one year period (Kashani et. al, 1983). When the children were 9 years of age, the authors located 955 of the 1139 children and assessed them for depression using behaviour reports from parents and teachers. After this initial screening, children identified as possibly being depressed were interviewed by a clinician using the Schedule for Affective Disorders and Schizophrenia-Child Version (Puig-Antich & Chambers, 1978), an instrument with established validity and internal reliability. According to the results, 1.8% of the subjects had major depression and 2.5% of the subjects had minor depression, with no significant sex differences for either result. However, limitations to the validity of the results include the failure to interview all children, and the significant attrition rate. Also, the failure to use consistent criteria for diagnosing major and minor depression threatens construct validity. A second study examined a cohort of children born at the same hospital one year earlier (Anderson et al., 1987). In this case, the children were tested at 11 years of age, and the researchers were able to locate and assess 792 of the 925 children. Results indicated 1.8% of the subjects had a major depressive disorder. Two factors give the results of this study greater validity than the previous one. First, psychiatrists who were blind to the results of the teacher and parent questionnaires interviewed all children before a diagnosis was made. Second, DSM-III criteria for the major depressive disorders were consistently applied to all subjects. 11 This study also had several weaknesses. The sample underrepresented low socio-economic status, single mother, and Polynesian ethnic groups, limiting generalizability. Attrition of subjects, and the researchers' use of the Diagnostic Interview Schedule for Children-Child Version (Costello, Edelbrock, Kalas, Kessler, & Klaric, 1982), an instrument with low retest reliability, also threatened the validity of the results. Finally, both this and the previous study assessed only children who were a single age (9 in the first, and 11 in the second). Whether these results can be generalized to all elementary school children is uncertain. . A final study assessed 6432 8-11 year old children from four urban and two rural areas of Spain (Polaino-Lorente & Domenech, 1993). Thirty six classes of students were randomly selected from the public and private schools in these areas, and 99.4% of the subjects participated in the study, enhancing the validity and generalizability of the results. The experimenters used teachers, parents, peers, and the children themselves as informants. They also used the Children's Depression Inventory (Kovacs, 1981) for initial screening, and the Children's Depression Rating Scale-Revised (Poznanski, Freeman, & Mokros, 1985) for clinical evaluation, two instruments with high validity and internal reliability. DSM-III-R criteria were used to make the final diagnosis. Results indicated 1.8% of children had Major Depressive Disorder, and 6.4% of children had Dysthymic Disorder, with no significant sex differences for either disorder. However, these results may only be generalized to 8-11 year-old children in Spain. In addition, the translation of instruments from English to Spanish may have affected the scores obtained, threatening the validity of the results. Finally, only children with 12 significant scores for depression on the Children's Depression Inventory were interviewed by a clinician, also threatening validity. Another factor which may limit the validity of the results in both this and the previous study is the lack of consensus on whether DSM-III-R criteria are appropriate for diagnosing childhood depression (Anderson et al., 1987; Fleming & Offord, 1993). However, i f further research confirms the validity of this diagnostic system, and the prevalence rates found in these studies, then there are a substantial number of children with depressive disorders within the elementary school system. Effects on functioning. Depression can effect "multiple areas of personal functioning, including behavioral, emotional, somatic, and cognitive domains." (Reynolds, 1990, p. 158). When Kovacs et al. (1994) studied 55 children with Dysthymic Disorder, they found 24% of the children had been suspended from school, and 36% had failed a school grade. Researchers have also linked childhood depression and depressive symptoms with impaired psychosocial functioning, a tendency to rate oneself as less socially competent, poor social skills, difficulties in conflict-negotiation, peer rejection, a more negative self-explanatory style, low self-esteem, the development of a more negative self-perception, and poor academic performance (APA, 1994; Feshbach & Feshbach, 1987; Kashani et al., 1983; Nolen-Hoeksema et al., 1992; Nousiainen et al., 1992; Puig-Antich, Lukens, Davies, Goetz, Brennan-Quatbrock, & Todak, 1985; Rudolph, K . D . , Hammen, C. & Burge, D . , 1994; and Stark, 1990). Nolen-Hoeksema et al. (1992) point out that because depressed children often experience academic and social deficits, they may become convinced that they have low academic ability and are 13 unlikeable. The above findings suggest that if depressed students do not receive early intervention, there are likely to experience many longterm consequences. Suicide ideation and attempts. A final issue that effects depressed children is the risk of suicide. A study by Kovacs et al. (1994) followed three groups of 8 to 13 year old psychiatric outpatients for an average of six years. The three groups included 113 depressed, 18 adjustment disorder with depressed mood, and 48 not depressed control subjects. The results indicated that 14% of the depressed children had attempted suicide before beginning the study; whereas, only 5 % of the adjustment disorder with depressed mood and none of the controls had attempted suicide. Furthermore, by completion of the study, 32% of the depressed subjects had attempted suicide, while only 11 % of the adjustment disorder with depressed mood and 8% of the controls had attempted suicide. These results indicate depressed children may be at a much higher risk for attempting suicide than other psychiatric outpatients. However, as this study did not sample from the general population, generalizability of these results is limited. An additional finding from this study was that of the 87 suicide attempts, 83.9% occurred during an episode of a depressive disorder or during an episode of another psychiatric disorder with "depressive" components. Only one of the 87 attempts occurred during a time when a subject was completely free from any psychiatric disorder. This suggests minimizing the length of time that children are depressed may reduce the rate of suicide attempts. Another study by Marciano and Kazdin (1994) examined levels of depression in 39 suicidal ideators, 42 suicidal attempters, and 42 nonsuicidal patient controls between the ages of 6 to 13 years. Their results showed suicidal children reported significantly 14 greater levels of depression than the nonsuicidal controls. In addition, the subjects' scores on the Children's Depression Inventory provided the best prediction for both suicidal ideation and attempts. A final study by Harrington et al. (1994) also supports the link between childhood depression and suicide attempts. In this study, 80 adults who had been diagnosed with depression in childhood or adolescence were compared to nondepressed psychiatric controls. The group with a history of depression had a significantly higher rate of suicide attempts during their adulthood. However, the authors do note that occurrence of depression in adulthood was an even stronger predictor of suicide attempts, than childhood or adolescent depression. Role of the Elementary School Counsellor In order for elementary school counsellors to effectively assist depressed students, they must perceive assisting these students as part of their role. Although a brief prepared by the British Columbia School Counsellors' Association (B .C .S .C .A . , 1990) on the role of counsellors encourages elementary school counsellors to have an up to date understanding of and expertise in dealing with depression, it does not specify which counsellor functions counsellors should use to assist depressed students. This lack of direction is unfortunate because as Schrader (1989) points out, i f school counsellors do not determine their role and provide reasons for what they do, "someone else will be certain to step in and tell them what they should be doing." (p. 230). Schrader suggests this can be avoided by counsellors actively telling other staff members what role they will fulfil, and what to expect of them. At present there is no role policy on how B . C . elementary school counsellors should assist depressed students. 15 If elementary school counsellors are to effectively assist depressed students, they also need to be aware of research findings related to the various counsellor functions they may want to implement. For example, if they wish to identify depressed students, they need to be aware of the symptoms associated with Major Depressive Disorder and Dysthymic Disorder. If they want to effectively assess depressed students, they need to be know how to use the different assessment techniques. If they want to treat depressed students, they need training and knowledge in how to select and implement effective treatment strategies, as well as knowledge of the issues related to treatment of depression. If they wish to refer depressed students, they need to be familiar with the resources in their community, and aware of which of these resources would be most appropriate for particular students. Finally, if they wish to prevent depression, they need to be knowledgeable about issues related to developing effective prevention programs, and information on the groups of students most at risk for developing depression. Each of these counsellor functions will now be discussed. Identification of Depressed Students Given the possible consequences of untreated childhood depression, it is important to identify these students as early as possible. Unfortunately, very few depressed children refer themselves, and some parents of depressed children have a tendency to deny or reject the idea that their children may be depressed (Reynolds, 1990). According to Reynolds, "a school-based procedure for identification of depressed youngsters may be viewed as an important component in the provision of services to children." (p. 165). As a result, he has developed a school wide screening program which can be used to identify 16 depressed students (Reynolds, 1986). However, implementation of this type of program may not be possible in many school districts, because of ethical reasons. Nonetheless, a "student's behaviour, interpersonal relationships, and academic performance - all important indicators of mood and the ability to cope - are subject to ongoing scrutiny in the school setting" (Maag, Rutherford Jr., & Parks, 1988, p.74), and can be used to assist counsellors in identifying student depression. According to Maag et. al's survey of 30 American secondary school counsellors, 79% of the subjects felt confident in their ability to identify depressed students. Although it is difficult to generalize these results to B . C . elementary school counsellors, it does suggest that trained school personnel may be comfortable with considering identification of depressed students as part of their role. Yet, "the counsellor's task of identifying depressed students is a difficult one because depressive symptomology is complex, highly variant for individuals, and pervasive in its effect upon individual functioning." (Hart, 1991, p.278). Nevertheless, i f counsellors become familiar with the symptoms of childhood depression, it is likely their ability to effectively identify depressed students wil l be greatly enhanced. Hence, part of this study determined the extent to which elementary school counsellors were familiar with the DSM-IV criteria for Major Depressive Disorder and Dysthymic Disorder. Another factor which may influence elementary school counsellors' ability to identify depressed students is teacher referral. It has been suggested identification of depressed students is largely dependent upon teachers noticing problems, as teachers are in a position to consistently observe and interact with children over long periods of time (Maag et al. , 1988; Werthamer-Larsson, 1994, p. 121). However, as teachers may 17 understandably be more interested in getting help for disruptive students, it is possible that they are underreferring depressed children (Kashani et al., 1983). Also, teachers who are not specifically trained in how to recognize depression may find it difficult to do so (Reynolds, 1986). Other factors which may effect the identification of depressed students are the belief that children do not become seriously depressed, or will outgrow their moodiness, and the fact that depressed children often do not act out or display their symptoms in a very noticeable manner (Laurent, Stark, & Landau, 1993; Stark, 1990). Therefore, if school counsellors are to increase the identification rate of depressed students, they may need to promote staff awareness about the symptoms and risk factors associated with depression, as well as the possible consequences of not receiving early intervention (Downing, 1988; Levy & Land, 1994). Assessment of Students for Depression The second function counsellors may be using to assist depressed students is assessment for depression. According to Reynolds (1992), "the diagnosis of depression involves the evaluation and comparison of an individual's symptoms and their duration with specified criteria for one or more disorders." (p. 157). There are a number of techniques that counsellors can use to assess students for depression. These include comparing students' affect and behaviour to the DSM-IV criteria for depression, using one of the numerous standardized tests, and using projective techniques. There are a number of problems which make it difficult to assess students for depression using the DSM-IV criteria (APA, 1994). First, many of the symptoms used to diagnose depressive disorders are also criteria for other childhood disorders, such as 18 substance abuse, uncomplicated bereavement, post-traumatic stress disorder, and adjustment disorder (de Mesquita & Gilliam, 1994). Second, major depressive disorders often occur in conjunction with other disorders, especially anxiety disorder, conduct disorder, and attention deficit disorder (Kovacs et al., 1984; Laurent et al . , 1993). Both these may result in childhood depression being overlooked or misdiagnosed (de Mesquita & Gilliam, 1994). A problem with using standardized instruments to assess students for the presence of depression is deciding which instruments to use. Although it is best to use both multiple informants, and multiple methods of assessment (Kendall et al . , 1989), deciding how to proceed can be an arduous undertaking. At present, there are a minimum of eight different self-report questionnaires, three ratings by others questionnaires, and eight clinical interview measures. These instruments have varying degrees of validity and reliability (Reynolds, 1992), and use "different perspectives and sources of information (eg. parent, child, teacher, peer), as well as different assessment methods." (Reynolds, 1990, p. 162). Although indicators of possible depression have been associated with many of the projective techniques, such as the House-Tree-Person Test (Buck, 1992), projective techniques can not be used reliably to determine whether a student is actually depressed. In fact, a study by Gittleman (1980) evaluating the effectiveness of projective techniques in identifying psychiatric disorders in children indicated that projective techniques are not sensitive enough to determine the presence of depression or other psychiatric disorders. Even though it is uncertain whether elementary school counsellors currently assess depressed students, Clarizio's and Payette's (1990) study of 66 American school 19 psychologists provides some insight. Their results showed that 64 % of the psychologists questioned used their own knowledge, either alone or in conjunction with other criteria, to assess for the presence of depression, while only 51% used DSM-III-R criteria to diagnose student depression. Unfortunately, the authors failed to specify what they meant by the term "other criteria", and how analysis of their data led to these results. However, this study does suggest that little effort is being made to implement a consistent procedure for assessing depressed students. Whether these results are relevant to British Columbia counsellors remain to be determined. Hence, this study examined whether counsellors assessed students for depression, and what methods they were using. Treatment of Depressed Students The third function which elementary school counsellors may be using to assist depressed students is treatment. This is an area in which counsellors may be able to provide an important service, as the results of four studies indicate the majority of depressed children do not receive any form of intervention. These studies which examined the prevalence rates of depression in children and adolescents, also determined the percentage of depressed subjects for whom treatment had previously been sought. The results indicated that only from 18.4% to 47.1% of subjects had received any form of intervention for their depression (Fleming, Offord & Boyle, 1989; Kasahani et al., 1983; Keller et al., 1991; McCracken, Shekim, Kashani, et al., 1989). Based upon these results, Keller et al. (1991) concluded that it may be necessary to better educate the public on the validity of depression as a diagnoses, and the importance of depressed children receiving treatment, if we are to ensure that more depressed children receive appropriate intervention. Therefore, if counsellors perceive treating depressed children as 20 part of their role, they may need to educate parents, staff, and the public on the importance of treating childhood depression, before they can get the support needed to effectively provide these services. When deciding how to treat depressed students, there are a number of issues that need to be considered. First, determining what treatment strategies may be appropriate is dependent on assessment of depressive symptomology; and psychosocial, educational, and family functioning (Harrington, 1993), as well as the developmental status of the student (Klass & Gallagher, 1993). Second, "the treatment of depressed children... is not an activity which should be entered into without training and knowledge of affective disorders, psychological models of depression, and associated treatment modalities." (Reynolds, 1990, p. 166). Third, because there is much variation in how depression is manifested, treatment should be tailored to the individual needs of the student (Harrington, 1992). In other words, i f counsellors wish to treat depressed students, they should only do so once a thorough assessment has been completed. Three longitudinal prospective studies on clinically referred depressed children indicate that Major Depressive Disorder can last anywhere from six to twenty-four months; whereas, the mean length of Dysthymic Disorder is four years (Kovacs et al.,1984; Kovacs et al, 1994; Ryan et al., 1987). Another factor relevant to treating depressed children is that 40% -70% of depressed children will have at least one other episode of a depressive disorder before reaching adulthood (Kovacs et al., 1984; Kovacs et al. , 1994). The length of episodes of depression, and the high risk of recurrence means that depressed children should have repeated assessments for depression throughout their school careers (Harrington, 1992). As a result, comprehensive and longterm assessment and treatment 21 strategies may be required for depressed students. Yet, it is uncertain whether counsellors who treat depressed student ensure follow-up assessments are done. Finally, as families of depressed children often have substantial problems, effective treatment may require the involvement of other family members (Harrington, Fudge, Rutter, Pickles, & H i l l , 1990). However, a study done by Samis, Allan, and Echols (1993) indicates this type of service is not perceived to be part of the elementary school counsellor's role. Only 44% of the 249 British Columbia elementary school counsellors participating in their study perceived providing family counselling to be appropriate to the role of elementary school counsellors, and only 7% perceived providing family therapy to be an appropriate part of their role. There are a number of approaches that may be used to treat depressed children. These include art and play therapy, cognitive-behavioral techniques, group counselling, individual psychotherapy, family intervention, and pharmacological intervention. Unfortunately, very little research exists on treatment of childhood depression. Consequently, there are no definitive guidelines on how to best treat depressed children (Klass & Gallagher, 1993). However, Klass and Gallagher do suggest that social skills training may be a key component to treating many depressed children, and that psychotherapeutic methods which alter a child's inner world may be helpful with older children. One method which has been evaluated is the use of a modified form of interpersonal psychotherapy. Mufson, Moreau, Weissman, Wickramaratne, Martin, and Samilov (1994) have developed a 12 week program aimed at reducing depressive symptoms, and helping subjects to address interpersonal problems associated with the 22 onset of depression. They tested this intervention on fourteen depressed adolescents, and by the end of treatment 90% of the subjects were no longer depressed. However, the small sample size and lack of a control group limit the validity of these results. In addition, it is uncertain whether similar results would be obtained with depressed children. A number of studies have also examined the effectiveness of cognitive-behavioral interventions with groups of students. Stark, Reynolds, and Kaslow (1987) used two 12 session small group interventions with 29 moderately depressed children. One group focused on self-control treatment components, and the other focused on behavioral problem-solving. Both groups showed significant improvements in depressive symptomology when compared to a wait-list control group. Kahn, Kehle, Jenson, and Clark (1990) compared the effectiveness of cognitive-behavioral, relaxation training, and self-modelling intervention, with a wait-list control group. The researchers assigned 68 moderately depressed middle school (grades 6,7,and 8) students to one of the four groups. Students in all three treatment groups experienced significant decreases in depressive symptomology. However, two factors limit the results of both these studies. It is unclear whether the subjects actually had a depressive disorder, and no longterm follow-up was done to see if the subjects in either study continued to maintain the decrease in depressive symptomology. Lewinsohn, Clarke, Hops and Andrews (1990) have also tested two cognitive-behavioral interventions on 59 depressed adolescents. In this study, subjects were randomly assigned to a group using a modified form of the Coping With Depression Course; a group in which the adolescents completed the Coping With Depression course, 23 while the parents attended another group in which they learned about the course and coping skills to assist them in addressing family problems; or a wait-list control group. Both treatment groups showed a significant reduction in depression scores. However, it is uncertain whether these results can be generalized to children, who may not have the cognitive development needed for this program. Although there is no research examining the effectiveness of family intervention with depressed children, Diamond and Siqueland (1995) have developed a family treatment model for depressed adolescents. This model does not focus on the adolescent's depression, but instead focuses on facilitating normative family attachments through modifying maladaptive functioning in family relationships and relationships with others within the family's social system. Both individual and family sessions are used to address a wide variety of factors which may be influencing the family's interpersonal relationships. The authors are currently evaluating the effectiveness of this model with depressed adolescents, but have not modified it to be used with depressed children. Although many elementary school counsellors use play and art therapy with children, there are no published studies comparing the effectiveness of these methods with group, family, psychodynamic or cognitive-behavioral interventions. There are also no studies which have examined the effectiveness of these two methods with depressed children. As noted by Weisz, Weiss, Han, Granger, and Morton (1995) in their analysis of treatment outcome studies for children and adolescents, researchers need "to expand the base of evidence on the effects of the nonbehavioral interventions that are widely used in clinical practice but rarely evaluated for their efficacy in controlled studies." (p.461). 24 As it was not clear whether counsellors currently treat depressed students, and if so how, this study examined both these issues. Referral of Depressed Students It has been suggested that school counsellors should cautiously consider the appropriateness of referring students who appear to be depressed, in order to prevent the "launching of a career mental health patient" (Downing, 1988, p.233). Nevertheless, as the failure to provide adequate intervention for depressed children can result in serious lifelong consequences, the ethics of not intervening in a manner which best serves depressed students may be unethical. Therefore, unless counsellors are adequately trained in the use of various assessment and treatment methods, it may be better if depressed students are referred to a mental health or medical professional for evaluation and initial treatment. This position is supported by Clarizio's and Payette's (1990) survey of school psychologists, in which 77% of respondents included intervention by outside community agencies or clinicians as one of their treatment recommendations. The B.C.S.C.A. (1990) brief on the role of B.C. school counsellors also suggests counsellors should be coordinating with community resources, and referring students for assessment and treatment as part of their role. Counsellor referrals may be crucial in guaranteeing that depressed students receive intervention from appropriate community resources. Several studies are relevant to this issue. First, Morse and Russel (1988) asked 267 Pacific Northwest counsellors how much time they spent on various counsellor functions. The results showed that counsellors perceived they were spending more time consulting with other adults, than 25 working with students. A second study by Hoskins and Tilroe Stringer (1989) surveyed 12 Victoria elementary school counsellors about their practices. According to the results, about 10% of counsellor time was spent on community and referral activities. However, as the authors of both these studies failed to verify if counsellors' reported activities were reflective of their actual practices, both the validity and reliability of these results are threatened. A third study, in which counsellors actually logged their activities provided different results. Five half-time elementary school counsellors from two Manitoba school divisions recorded their activities for three periods of three weeks randomly selected during the 1988-89 school year (Madak & Gieni, 1991). According to the results, 47.6% of the counsellors' time was spent counselling students; whereas, only 23.5% of the time was spent in consultation, of which 3% was with clinicians. Obvious limitations on external reliability are the lack of purposeful sampling, and the use of only one data source. However, the logging of counsellor activities, the length of the data collection periods, and the use of low inference descriptors does give the results some internal reliability. Unfortunately, none of these studies show whether counsellors are referring students to resources outside of the school specifically for treatment of depression. Welch and McCarroll (1993) have suggested that in the future, the role of the school counsellor may move increasingly towards that of being a consultant who provides a link between within school needs, and resources within the community. They see the counsellor of the future as a "community resource specialist", rather than someone concerned with only school based issues. If these predictions do occur, then it is possible that elementary school counsellors may increasingly refer students elsewhere for 26 treatment of various problems. Resources to which counsellors can refer depressed students include: family physicians, psychiatrists, private therapists, school psychologists, mental health agencies, school based team, and psychiatric hospital units (Maag et al., 1988). Whether counsellors are referring depressed students to other resources is uncertain. Consequently, this study determined if elementary school counsellors referred depressed students, and if so, to whom they were referring these students. Prevention of Student Depression The final counsellor function which may be used to assist depressed students is prevention of depression. According to Weissberg, Caplan, & Harwood (1991), "the educational system offers the most efficient and systematic means to promote the psychological .... health of school-age children" (p.837). This is because school staff come in regular contact with students, and are likely to notice any changes in students' affect or functioning. In addition, providing comprehensive prevention services in the school setting is one of the best ways of ensuring all children receive this type of intervention. Also, as McClellan and Trupin (1989) point out, children may be more likely to participate in prevention programs if they are integrated into existing school programs. However, prevention of depression is not easy as there is no identifiable single cause for depression. Researchers believe that genetic, physiological, social, psychological, and environmental factors can all play a role in the development of depression (O'Brien, 1991). Therefore it is difficult to ascertain which type of prevention programs would be most effective in preventing student depression. Nonetheless, O'Brien identifies three types of prevention activities that school personnel can use to help improve children's mental health. Primary prevention activities 27 are those aimed at averting the appearance of a psychiatric disorder. Secondary prevention activities are used to diagnose and treat a psychiatric disorder early in its development. While, tertiary prevention activities are those which limit the disability caused by a psychiatric disorder, and promote maximum functioning in the person who has a disorder. Primary prevention of childhood depression is important because activities which prevent the initial development of depression may also protect students from later episodes. Yet, it is difficult to study this form of intervention as it is unclear what criteria should be used to measure the results of intervention, and considerable longterm follow up is needed in order to substantiate results (O'Brien, 1991). One study by Clarke, Hawkins, Murphy and Scheeber (1993) examined whether a three-session educational intervention program, or a five-session behavioral skills training intervention program would help prevent depression in secondary school students. According to the results, neither program had any longterm effect on levels of depression. Therefore, the authors concluded that longer prevention programs may be needed in order to show significant changes in levels of depression. Clarke and Hawkins (1995) have since tested a 15 session cognitive program on 150 adolescents at-risk for depression, as indicated by their elevated level of depressive symptomology. Subjects in both the treatment and control groups were tested using various instruments for depression 6 and 12 months after completion of the program. Those who had been in the treatment group had a significantly lower rate of depression than those in the control group at both intervals. However, this program has not been tested with children, and it is unknown whether it would be developmentally appropriate for this age range. 28 Another program developed by Rice and Meyer (1994), uses a psycho-educational approach to assist adolescents in developing internal and external resources to stressors and challenge. Students are taught adaptive emotional, cognitive, and behavioral responses to various challenges which confront youth. The goal of this program is to provide a short term intervention available to all students, which may aid in preventing the development of depression in response to these challenges. Unfortunately, the short and longterm effectiveness of this program in preventing depression have yet to be evaluated, as no studies have been published testing the effectiveness of this program. Finally, Petersen, Compas, Brookes-Gunn, Stemmler, Ey, and Grant (1993) have suggested a primary prevention program for depression may need to address three different aspects of student functioning in order for the program to be effective. These are dysfunctional cognitive patterns, skills for coping with stress, and strategies to deal with interpersonal relationships and problems. Providing secondary prevention services for depressed students is also essential, because early identification and treatment may minimize the time that students are depressed, and prevent further episodes from occurring (Kovacs et al., 1994). Furthermore, as depressed children tend to have a pessimistic explanatory style, early intervention may help these students to become more optimistic and effectual in their thinking (Nolen-Hoeksema et al. 1992). Finally, early intervention may also prevent many of the academic, social, and psychological consequences associated with childhood depression. Some of the issues related to secondary prevention have already been discussed in the sections on identification and treatment of depressed students. Other factors which 29 can increase the chances of depressed students receiving early intervention include: establishing links with community resources that provide assessment and treatment; educating parents about childhood depression, and providing them with information about available community resources; and providing follow-up in order to make sure referred students actually receive intervention (Levy & Land, 1994). Another way of ensuring depressed students receive early intervention is to identify students most at risk for developing depression. These students can then be monitored for symptoms of depression on an ongoing basis (Petersen et al., 1993). This approach is supported by the B .C.S .C . A . (1990) brief which states that elementary school counsellors should recognize "the characteristics of students at risk or in crisis, and [offer] preventative and intervention services" (p. 8). The highest risk factor for a child developing depression is having a parent who has had a depressive episode, or some other type of psychopathology (Downey & Walker, 1992; Hammen, 1991). Other risk factors include: parental death, parental abuse, pessimistic explanatory style, divorced parents, single parent, low level of social support, low socioeconomic status, and unemployed parents (Downey & Walker, 1992; Kaslow, Deering, & Racusin, 1994; Nolen-Hoeksema et al., 1992; Stone, 1993). At present, tertiary prevention activities often make up the majority of services provided for students experiencing mental health problems (Werthamer-Larsson, 1994). There are many activities which elementary school counsellors can use to assist depressed students, and these have already been discussed in the section on treatment of student depression. 30 It is not clear whether elementary school counsellors perceive themselves or mental health and medical professionals to be the primary providers of treatment. Nonetheless, regardless of whomever is designated the primary caregiver, "there is much that can be done within school settings to moderate, remediate, and even effectively rehabilitate depressive symptoms." (Hart, 1991, p.277). Possible interventions for depressed students include: providing support for depressed students through the use of individual counselling and group counselling, helping students to address social deficit skills, providing students with problem solving strategies, working with the students' teachers, communicating with the students' parents, and acting as a liaison with any professionals from outside of the school system (Clarizio & Payette, 1990; Downing, 1988; Hart, 1991). Finally, a number of research studies seem to suggest elementary school counsellors do not have enough time to implement prevention programs. First, a survey of the actual and ideal roles of B.C. elementary school counsellors indicated that although counsellors wanted to spend more time doing preventative counselling, most of their time was spent on remedial counselling (Allan & Ross, 1979). Another survey of the Heads of Special Services in non-urban B.C. school districts suggested that these personnel also thought that counsellors should spend more of their time on prevention activities (Allan & Boland, 1981). Although generalizability of these findings to the specific issue of student depression fifteen years later is questionable, these results do suggest a shortage of time for prevention activities is an area needing further examination. Whether elementary school counsellors engage in activities aimed at preventing depression is not known. Therefore, this study determined if elementary school counsellors provided services aimed at preventing depression, and the types of activities they used to implement this function. 32 CHAPTER 3 METHODOLOGY A s mentioned earlier, the purpose of this study was to identify how elementary school counsellors perceived their role in assisting depressed students, what activities they used to assist these students, and what factors effected the implementation of each of the counsellor functions. This was done by designing a questionnaire to survey a sample of B . C . elementary school counsellors. This chapter w i l l describe the procedures used including the rationale for research method, sample selection, questionnaire design, data collection, and data analysis. Rat ionale Very little was known about what elementary school counsellors perceive their role to be i n assisting depressed students, what practices they use to assist these students, and what factors effect their ability to assist depressed students. According to the recommendations in Werthamer-Larsson's (1994) article on investigating school-based mental health services, some of the first steps in exploring these issues include establishing what types of services are currently in place, and identifying the barriers which may prevent the utilization of these services. In addition to Werthamer-Larsson's recommendations, the author of this study also believed that an examination of counsellor role perceptions was also a critical component of the initial research into this area. Given all these factors, this study was designed to identify the current state of counsellor role perceptions, practices, and factors effecting these practices in assisting depressed students. 33 Requests to the heads of student services in the 75 B . C . school districts resulted in a list of 333 elementary school counsellor names and addresses. The primary goal of this study was to determine counsellor perceptions and practices. A questionnaire was chosen as the most effective tool to obtain information from a group this size. Limitations on resources and time also made this the most efficient method for acquiring the information. Sample The target population was all B . C . elementary school counsellors. A graduate research grant from the Faculty of Education, University of British Columbia, made it possible to survey this population. However, at the time of this study, there was no up to date list of B . C . elementary school counsellors. Samis (1991) encountered a similar situation when she surveyed B . C . elementary school counsellors about the use of family therapy. Therefore, her methods to acquire a list of the accessible population were used. A letter requesting the names and addresses of all elementary school counsellors working in the district during the 1994/95 school year was sent to the supervisors of elementary school counsellors in each of the 75 B . C . school districts. In order to increase the response rate, two follow-up letters were sent at one month intervals (see Appendix A) . A total of 62 districts (82.7%) responded resulting in a list of 333 elementary school counsellors. Of the thirteen districts which did not respond, eight had less than two thousand elementary school students, and five had between two and eleven thousand elementary school students (Ministry of Education, 1995). It is likely that some of the smaller districts may have had no elementary school counsellors; however, some of the larger districts more than likely did. These thirteen districts were spread throughout 34 the province, except there were no nonresponders in the Lower Mainland a predominantly urban region. Questionnaires were mailed to all the elementary school counsellors whose names and addresses were compiled from these lists, and the sample consisted of those counsellors who completed and returned the questionnaire. Design Questionnaire development. Four sources were used to generate preliminary questions. First, a review of the literature on childhood depression and the role of elementary school counsellors identified a number of areas which could be explored. These included counsellors' role perceptions in relation to identification, assessment, treatment, referral, and prevention; the methods they use to implement these counsellor functions; and counsellors' knowledge about childhood depression. A second source was Samis's (1991) research on the use of family counselling by B . C . elementary school counsellors. This provided ideas for questions about counsellor demographics, counsellors' work environments, barriers which could hinder counsellors' ability to perform the various counsellor functions, and factors which may aid counsellors in assisting depressed students. A third source, Dillman's (1978) Mai l and Telephone Surveys: The Total Design Method, provided information on designing specific questions in a clear, unambiguous, and readable manner, as well as how to maximize the questionnaire return rate. A final source of information was preliminary interviews conducted between May and August 1994 with 7 Lower Mainland elementary school counsellors (Vancouver, Surrey, Langley, and Maple Ridge). The interviews were semistructured, using a preliminary questionnaire consisting of both closed and open-ended questions. The closed 3 5 questions gathered information on counsellors' demographics, work environment, and role perceptions. The open-ended questions elicited information on practices used to assist depressed students, barriers to implementing these practices, and factors which would aid counsellors in better assisting depressed students. Counsellors were also asked to comment on the clarity and appropriateness of both the open-ended and closed questions. From the initial interviews, a tentative questionnaire was designed, which was then submitted to the thesis committee for further revision. Through the initial interviews and discussions with the thesis committee, it became apparent that a specific definition of childhood depression would need to be provided, as people's perceptions of what constituted "depression" varied greatly. As most recent literature on childhood depression has used the American Psychiatric Association's criteria for Major Depressive Disorder and Dysthymic Disorder, the criteria for these disorders found in DSM-IV were used. Consequently, a summary of the criteria for both these disorders was included in the beginning of the revised questionnaire (see Appendix B). A copy of the revised questionnaire and accompanying cover letter was then piloted on five Lower Mainland elementary school counsellors (Vancouver, Surrey, Langley, and Maple Ridge) in the presence of the investigator. This gave participants an opportunity to ask questions and provide immediate feedback about the questionnaire. The pilot subjects found the questions to be clear and comprehensive in determining their knowledge, perceptions, and practices in regards to assisting depressed students. Counsellor comments were reviewed, and minor changes were made to the questionnaire. A final version was then completed and mailed (see Appendix B). 36 Questionnaire and research questions. This subsection clarifies the relationship between the research questions and questionnaire items. "Part II" of the questionnaire asked counsellors whether they had previously been provided with the DSM-IV criteria for the two depressive disorders, and whether childhood depression had been a topic in any of the professional activities they may have participated in. These questions were designed to answer research questions 1 and 2: 1. Are elementary school counsellors knowledgeable about childhood depression? 2. Are elementary school counsellors exposed to information about childhood depression during their professional development activities? Questions 12 and 13 in "Part III" of the questionnaire asked counsellors to identify which counsellor functions they perceived as being part of their ideal and current roles is assisting depressed students. These addressed research questions 3 and 4, which asked: 3. Which counsellor functions do elementary school counsellors perceive as being part of their ideal role in assisting depressed students? 4. Which counsellor functions do elementary school counsellors perceive as being part of their current role in assisting depressed students? Questions 14, 19, 22, 25, and 28 in "Part III" of the questionnaire asked counsellors whether they had participated in identifying, assessing, treating, referring, or preventing student depression. These questions were designed to answer the research question: 5. Which counsellor functions do elementary school counsellors currently use to assist depressed students? 37 Questionnaire questions 15-17, 20, 23, 26, and 29 in "Part III" asked for more specific information about the implementation of each of the five counsellor functions. These questions asked counsellors which specific activities they had used when implementing the various counsellor functions. These questions were designed to answer the research question: 6. How are the counsellor functions being implemented when elementary school counsellors assist depressed students? Questionnaire questions 18, 21, 24, 27, and 30 in "Part III" asked counsellors to use a rating scale from 1 (not a barrier) to 4 (large barrier) to rate the extent to which various factors hindered their ability to perform the five counsellor functions. These questions were designed to answer the research question: 7. What barriers hinder the ability of elementary school counsellors to assist depressed students? Finally, questionnaire questions 31 and 32 in "Part III" identified factors which could aid counsellors in assisting depressed students, and then asked counsellors to identify which five would be most helpful. These questions were designed to answer the research question: 8. What factors would help elementary school counsellors to better assist depressed students? Data Collection Once the final version of the questionnaire was completed, a package was sent to the 333 counsellors on the compiled list in February 1995. The package included a questionnaire, a covering letter, a blank envelope, and a stamped and addressed return 38 envelope. Participants were first asked to anonymously complete the questionnaire. They were then instructed to place the completed questionnaire into the blank envelope. Finally, participants were told to place the blank envelope into the numbered and stamped envelope. When the package was received by the investigator, the two envelopes were separated. This allowed the investigator to track respondents, while at the same time maintaining the participants' anonymity. Once a decrease in responses was noted, a follow-up letter was sent to remind nonrespondents about completing the questionnaire (see Appendix C). When an additional decrease in responses occurred, a second questionnaire package was sent. This package was identical to the first, except a new cover letter was included (see Appendix C). By July 14, 1995, 248 (74.5%) counsellors had completed and returned the questionnaire. Data Analysis The Statistical Package for the Social Sciences (SPSS-X) was used to analyze the data. For the questions in which participants responded 'yes', 'no', or 'not sure', "Part I" questions 1, 2, 5, 7, and 8; "Part II" questions 9-11; "Part III" questions 12-14, 16, 17, 19, 20, 22, 25, 26, 28, and 29 (Appendix B), the number and percentage of respondents to each category were calculated. For the questions in which participants gave a numerical answer "Part I" questions 3, 4, and 6; and "Part III" question 15, categories were created based upon the range of responses, and then the number and percentage of respondents answering in each category were calculated. For question 23 in "Part III", in which respondents were asked to identify treatment strategies they thought were more effective, categories were created 39 based on participants' responses. The number and percentage responding to each category were then calculated. For questions 17, 21, 24, 27, and 30 in "Part III", respondents were asked to identify the extent to which various factors were barriers to performing the five potential counsellor functions. Each of the four categories were assigned a score: not a barrier = 1, small barrier = 2, moderate barrier = 3, and large barrier = 4. The respondents' scores for each factor were recorded, and sample means and standard deviations for each factor-function pair were calculated. Questions 31 and 32 "Part III" asked counsellors to identify which potential ways of addressing barriers would help them to better assist depressed students. The number and percentage of respondents answering to the affirmative for each potential way were calculated. Question 33 in "Part III" asked counsellors i f they had any additional information. Also, questions 17, 18, 21, 24, 26, 27, 30, and 31 "Part III" provided 'other' spaces in which counsellors could write additional information relevant to the specific questions. The comments from both these areas, along with other comments written in the questionnaire, were recorded. For comments made by more than one counsellor, the number of counsellors making the same comments were recorded. The initial results of the survey led to two additional calculations, both involving comparison of the means between groups, in order to determine i f a significant difference between the means existed. The first set of calculations compared the means between the number of depressed students identified by counsellors familiar with the criteria for the depressive disorders, and those not familiar with the criteria. The second set of 40 calculations compared the means of barriers to assessing depressed students. Both groups included counsellors whose ideal role included assessment, with one group having assessed students for depression, while the other had not. The difference in the means for both sets of calculations were then used to calculate "t" values, so that a level of significance could be determinedy C H A P T E R 4 41 R E S U L T S This chapter contains three sections. The first section discusses the return rate of the questionnaire. The next section presents data about the respondents including demographic background, level of education, work experience, and working conditions. The final section presents the results of the remainder of the questionnaire in terms of the specific research questions they were meant to answer, including a summary of counsellor comments relevant to each specific question. Questionnaire Returns Questionnaires were mailed out to the 333 B .C . elementary school counsellors whose names and addresses had been provided through the requests sent to each B .C . school district. The return rate of completed questionnaires was 248 (74.5%). One questionnaire was completed by a classroom teacher, and another by a person who had not worked as a school counsellor. Neither of these questionnaires were used for this study. This left 246 (73.9%) respondents from whom data was collected. Respondents' Background Information Information on respondent characteristics, such as demographics, education, work experience, and working conditions of the respondents is shown in Tables 1 to 4. A brief summary of the results focusing on the most important highlights wil l now be presented. Demographic characteristics. According to the results, female counsellors (61.8%) outnumber males (38.2%), and the majority of counsellors are between the ages of 40 and 59 (85.0%). 42 Table 1. Demographic Characteristics of Elementary School Counsellors Characteristic n % of respondents Gender Female 152 61.8 Male 94 38.2 Age 20-29 3 1.2 30-39 29 11.8 40-49 139 56.1 50-59 71 28.9 60-64 5 2.0 Table 2. Education of Elementary School Counsellors Characteristic n % of respondents Degree B.Ed. 109 44.3 B.A. 85 34.6 B.Sc. 5 2.0 B.S.W. 4 1.6 B.A. and B.S.W. 2 0.8 B.A. and other Bachelor 2 0.8 Other Bachelor 15 6.1 Diploma in Guidance Studies 15 6.1 Other Diploma 6 2.4 M.Ed. 141 57.3 M.A. 63 25.6 M.S.W. 5 2.0 M.Sc. 4 1.6 Other Master's Degree 4 1.6 Ed.D. 5 2.0 Ph.D. 2 0.8 Highest Level of Degree Bachelor 24 9.8 Diploma 9 3.7 Master's Degree 205 84.0 Doctorate 6 2.4 Table 3. Work Experience of Elementary School Counsellors 43 Characteristic n % of respondents Less than 2 years 38 15.6 2 to 5 years 73 30.0 6 to 10 years 77 31.7 11 to 15 years 24 9.9 16 to 19 years 13 5.3 20 or more years 18 7.4 Table 4. Characteristics of Work Assignment Characteristic n % of respondents Region of British Columbia Greater Vancouver 128 52.5 Vancouver Island 34 14.0 Fraser Valley 20 8.2 Okanagan 19 7.8 North/South Coast 14 5.7 Kootenays 11 4.5 Northern Interior 10 4.1 Peace River 5 2.0 Mainline-Cariboo 3 1.2 Percent time employed 35% or less 12 4.9 40% to 55% 30 12.2 60% to 75% 26 10.6 80% to 95% 38 15.4 100% 140 56.9 Number of assigned schools One 46 18.9 Two 62 25.4 Three 77 31.6 Four 30 12.3 Five 9 3.7 Six 9 3.7 Seven or more 11 4.5 Number of students per counsellor Less than 400 22 9.1 400-799 70 28.8 800-1199 88 36.2 1200-1599 50 20.6 1600 or more 13 5.3 44 Education. Many of the counsellors reported only their graduate level degrees, so the results for the undergraduate degrees are likely underrepresentative. However, of those reporting, it is clear that a B.Ed. (44.3%), and a B . A . (34.6%) were the most common undergraduate degrees held by counsellors. A vast majority of the counsellors also had a graduate level degree (86.4%), with the most common being an M . E d . (57.3%), or M . A . (25.6%). Work Experience. Almost half of the respondents had been employed as elementary school counsellors for five years or less (45.6%), while just over one-half had been employed 6 years or more (54.3%). Work Assignment. The majority of B . C . elementary school counsellors worked in the Lower Mainland (52.5%), which consists of urban and suburban communities, including the provinces four largest districts, each with over 100,000 people (Vancouver, Surrey, Burnaby, and Richmond). About one-third of the counsellors (39.8%) worked in mixed urban, suburban, and rural regions of the province. This includes Vancouver Island, the Fraser Valley, the Okanagan, the North/South Coast, and the Northern Interior. These regions include communities ranging from under a 100 people to cities with over 60,000. The remainder of the counsellors (7.7%) worked in regions where the communities range from less than 15,000 people to under 100 (Kootenays, Peace River, and Mainline-Caribou. More than one-half of the counsellors (56.9%) worked full-time. Just over half of B . C . elementary school counsellors (55.8%) worked in 3 or more schools, and were responsible for 800 or more students (62.1%). 45 Research Questions Research question 1. "Are elementary school counsellors knowledgeable about childhood depression?". Table 5 presents the number and percentage of counsellors who were knowledgeable about the two types of childhood depression referred to in the questionnaire. Just over half (55.1%) indicated they had encountered the criteria for Major Depressive Disorder before doing this survey, while less than a third (30.1%) had encountered the criteria for Dysthymic Disorder, or were familiar with the criteria for both disorders (30.1%). Table 5 . Counsellors' Knowledge of Childhood Depression Characteristic Yes No Not sure n % n % n % Provided with criteria for: Major Depressive Disorder (MDD) 135 55.1 98 40.0 12 4.9 Dysthymic Disorder (DD) 74 30.1 151 61.4 21 8.5 Both M D D and D D 74 30.1 Participated in activities childhood depression has been a topic in: Discussions with colleagues 211 85.8 32 13.0 3 1.2 Journals read 159 66.0 65 27.0 17 7.1 Books read 155 64.3 76 31.5 10 4.1 Other written materials read 140 58.8 68 28.6 30 12.6 Workshops attended 132 54.1 103 42.2 9 3.7 Courses taken 110 45.8 116 48.3 14 5.8 Conferences attended 103 42.2 126 51.6 15 6.1 Watched video/television 86 36.4 129 54.7 21 8.9 Research question 2. "Are elementary school counsellors exposed to information about childhood depression during their professional development activities?". The results for this question are also found in Table 5. The most common activity in which 46 childhood depression was a topic was discussion with colleagues (85.8%). About two-thirds of the counsellors read about childhood depression in journals (66.0%), books (64.3%), and other written materials (58.8%). Only one-half learned about childhood depression through workshops (54.1%), courses (45.8%), and conferences (42.2%). Thus, more counsellors acquire information about childhood depression from self initiated activities, such as discussions with colleagues and reading, than activities put on by other professionals, such as courses, workshops, and conferences. Four counsellors also wrote the information they had been given was on depression in general, and not specifically childhood depression. Research question 3. "Which counsellor functions do elementary school counsellors perceive to be part of their ideal role in assisting depressed students?". The data found in Table 6 reports the number and percentage of counsellors who answered for each category. Over 92.2% of counsellors perceived referring depressed students, identifying depressed students, and engaging in activities aimed at preventing student depression as part of their ideal role. Table 6. Counsellors' Perception of Ideal Role in Assisting Depressed Students Intervention Yes No n % n % Referring depressed students to other professionals or agencies Identifying depressed students Engaging in activities aimed at preventing student depression 241 99.2 232 94.7 226 92.2 156 64.5 142 59.4 19 7.8 86 35.5 97 40.6 2 13 0.8 5.3 Assessing students for depression Treating depressed students 47 However, counsellors were divided on the other two functions, with only 64.5% perceiving assessment as being part of their ideal role, and 59.4% perceiving treatment as part of their ideal role. Counsellor comments indicated that a number of counsellors did not perceive themselves as being qualified to assess or treat depressed students. These included: assessment should only be part of the ideal role i f counsellors receive input from medical or mental health professionals (n = 6), assessment should only be part of the ideal role i f the counsellor is adequately trained (n = 6), and treatment should be part of the ideal role only i f it is done in consultation with medical or mental health professionals (n = 7). No comments to this effect were written for identifying, referring, or preventing students depression. Research question 4. "Which counsellor functions do elementary school counsellors perceive to be part of their current role in assisting depressed students?". Table 7 reports the number and percentage who answered for each category. As in the ideal role, the majority of counsellors perceived referring depressed students (95.9%), and identifying depressed students (85.7%) as part of their current role. However, fewer counsellors perceived preventing student depression (71.0%) as part of their current role, which suggests some counsellors may have thought they ideally should be preventing student depression even though it is not perceived to be part of their current role. Just over one-half the counsellors (55.0%) perceived treating depressed students as part of their current role. Comments also reflected this uncertainty, with 12 counsellors writing they perceived treatment as part of their current role only i f done in consultation with a medical or mental health professional, and 2 writing they would only treat i f there was no other available community resources. 48 Table 7. Counsellors' Perception of Current Role in Assisting Depressed Students Intervention Yes No n % n % Referring depressed students to other professionals or agencies 235 95.9 10 4.1 Identifying depressed students 210 85.7 35 14.3 Engaging in activities aimed at preventing student depression 174 71.0 71 29.0 Assessing students for depression 83 34.2 160 65.8 Treating depressed students 133 55.0 109 45.0 For assessment of depression, there was a significant change in the number of counsellors who perceived it as part of their current role. Only one-third (34.2%) perceived it as part of their current role even though two-thirds (64.5 %) perceived it as part of their ideal role. Four counsellors wrote district policy prevents them from doing assessment. In addition, counsellors wrote they consult with a medical or mental health professional when doing an assessment (n = 7), they need more training before they can assess students for depression (n = 10), and they forward students to other professionals for assessment (n = 7). Research question 5. "Which counsellor functions do elementary school counsellors currently use to assist depressed students?". The number and percentage who have used each function are reported in Table 8. The results show the number of counsellors who have used the various counsellor functions during the previous two years are consistent with the number who perceived each function as part of their current role. The majority of counsellors have referred (90.6%) and identified depressed students (85.7%). Over one-half have engaged in activities aimed at preventing student depression 49 Table 8. Counsellors' Current Activities in Assisting Depressed Students Intervention Yes No n % n Referring depressed students to other professionals or agencies Identifying depressed students Engaging in activities aimed at preventing student depression Assessing students for depression Treating depressed students 221 90.6 23 9.4 209 85.7 35 14.3 180 74.1 63 25.9 89 36.2 157 63.8 157 64.9 85 35.1 (74.1%), and treated depressed students (64.9%); whereas, less than half of the counsellors have assessed students for depression (36.2%). Research question 6. "How are the counsellor functions being implemented when elementary school counsellors assist depressed students?". Counsellors were asked about the activities they used for each of the five potential counsellor functions in order to determine how these functions were being implemented. Table 9 reports the number of depressed students identified by counsellors during the previous two years. About two-thirds of the counsellors (65.9%) identified 6 or Table 9. Number of Depressed Students Identified Characteristic n % of respondents Number of depressed students identified during the previous two years 1-3 66 32.7 4-6 67 33.2 7-9 13 6.4 10-12 31 15.3 13 or more 25 12.4 50 fewer students, with one-third (32.7%) identifying 3 or fewer students. As most counsellors are responsible for a minimum of 400 students (90.9%), and many are responsible for 800 or more (62.1%), this suggests that counsellors may be identifying less than 1% of their students as being depressed. The results from Table 10 also suggest that counsellors are underidentifying depressed students. Over one-half the counsellors (56.4%) indicated that after considering the DSM-IV criteria for the depressive disorders, they would increase their estimate of the number of students who may have been depressed. Four counsellors also wrote that after completing the questionnaire, they realized they had been missing some depressed students. Table 10. Change in Estimate of Number of Depressed Students after Considering the DSM-IV Criteria Change in estimate n % of respondents Much less than I identified 1 .5 Somewhat less than I identified 5 2.4 No change 84 40.8 Somewhat more than I identified 99 48.1 Much more than I identified 17 8.3 In order to explore the relationship between knowledge of the depressive disorders and rate of identification, the mean number of students identified by those counsellors familiar with the criteria for major depressive disorder and dysthymic disorder, and counsellors not familiar with these criteria were compared. The total number, mean, and "t" values are reported in Table 11. The results indicate those familiar with the criteria for major depressive disorder identified significantly more students (M=2.84), than those 51 Table 11. Mean Differences in Identification of Depressed Students Characteristic Cases Mean* t Familiar with criteria for Major Depressive Disorder Yes 117 2.84 No 73 2.18 2.59* Familiar with criteria for Dysthymic Disorder Yes 66 2.84 No 118 2.38 1.79 A Mean range = 1-5 where 1 denotes "1-3 students", 2 denotes "4-6 students", 3 denotes "7-9 students", 4 denotes "10-12 students", 5 denotes "13 or more students". *rj< .01. not familiar with the criteria (M=2.18,1=2.59, p<.01). However, there was no significant difference between those familiar with the criteria for dysthymic disorder (M=2.84), and those who were not (M=2.38, t=1.79, p=.08) Counsellors who have identified depressed students during the last two years were asked to indicate how these students came to their attention. The number and percentage who answered for each referral source are reported in Table 12. Of the 207 respondents, most had been referred depressed students by teachers (92.8%), students' parents (72.9%), school based team (69.3%), and self-referral (65.2%). Less than half had been Table 12. Referral Source of Depressed Students Referral source n % of respondents Teachers 192 92.8 Students' parents 151 72.9 School based team 142 69.3 Student self-referral 135 65.2 Principals 100 48.8 Other students 62 31.6 School Psychologist 41 19.9 52 referred depressed students by principals (48.8%), other students (31.6%), and school psychologists (19.9%). Counsellors who had assessed depressed students during the last two years, were asked to indicate which assessment methods they used. The results are reported in Table 13. Of the 90 respondents, over half used projective techniques (66.7%) such as the House-Tree-Person Test (Buck, 1947), and the DSM-III or DSM-IV criteria for the depressive disorders (60%). On the other hand, less than one-half (40%) had used a standardized instrument. Table 13. Assessment Techniques Used by Counsellors Technique % of respondents Projective techniques such as the House-tree-person 60 66.7 DSM-III or DSM-IV criteria 54 60.0 Standardized instrument for depression 36 40.0 Counsellors who had treated depressed students were asked if they found any techniques to be more effective. Of the 149 who responded, 121 (81.2%) answered yes (see Table 14). These counsellors were then asked to list which techniques they found to Table 14. Counsellors' Perception of Whether Some Treatment Strategies were More Effective Perception n % of respondents Yes No 121 28 81.2 18.8 be more effective. Their answers, and the number and percentage who indicated each method, are listed in Table 15. Only art and play therapy were found by the majority of respondents to be more effective (52.1%). Cognitive-behavioral therapy was the second most identified method (28.1%) as being more effective. Other techniques identified include: other projective therapies (17.2%), group counselling (16.5%), parent consultation (14.9%), teacher consultation (10.7%), monitoring the student (9.9%), family counselling (9.9%), and self esteem work (8.2%). In addition, 9 counsellors wrote the treatment strategy they used depended on the student and the level of depression the student exhibited. Table 15. Treatment Strategies Counsellors Identified as More Effective Technique n % of respondents Art/play therapy 63 52.1 Cognitive-behavioral 34 28.1 Other projective techniques 21 17.2 Group Counselling 20 16.5 Parent consultation 18 14.9 Teacher consultation 13 10.7 Monitoring the student 12 9.9 Family counselling 12 9.9 Self esteem work 10 8.2 Counsellors who indicated they had referred depressed students during the last two years were asked to identify who they were referring these students to. The percentage and number who referred to each agency or professional are provided in Table 16. Of the 221 counsellors who answered this question, most referred to a mental health agency (88.1%), medical doctor (74.1%) and psychiatrist (66.1%). Also, about one-half the 54 Table 16. Agencies and Professionals to Whom Counsellors Have Referred Depressed Students Agency or professional n % of respondents Mental health agency 192 88.1 Medical doctor 164 74.5 Psychiatrist 146 66.1 Private therapist 123 55.9 School based team 113 51.8 Hospital 66 30.1 School nurse 44 20.2 counsellors referred to private therapists (55.9%), and school based team (51.8%). Only a small minority referred to a hospital (30.1%) or school nurse (20.2%). Counsellors who indicated they had participated in activities aimed at preventing student depression during the last two years were asked to identify these activities. The number and percentage who indicated they had used each activity are listed in Table 17. Of the 183 counsellors who responded to this question, a large majority had developed students problem-solving skills (98.4%), and social skills (97.8%). However, 8 counsellors wrote when they did these activities they were not specifically aimed at preventing depression. A large majority had monitored physically and sexually abused students for depression (89.6%), and counselled students they perceived to be at risk for depression (88.4%). However, less than one-half had educated staff (46.1%) or students (31.7%) about childhood depression. Research question 7. "What barriers hinder the ability of elementary school counsellors to assist depressed students?". Tables 18 to 22 list, from highest to lowest, Table 17. Prevention Activities Used by Counsellors 55 Activity % of respondents Developing students' problem-solving strategies 180 98.4 Developing students' social skills 178 97.8 Monitoring physically and sexually abused students 163 89.6 Counselling for students at risk for depression 160 88.4 Monitoring students with a depressed parent 129 70.9 Monitoring students who have previously been depressed 123 67.2 Monitoring students from single parent families 96 52.7 Educating staff about childhood depression 83 46.1 Educating students about childhood depression 57 31.7 Table 18. Means and Standard Deviations of Counsellors' Perceived Barriers to Identifying Depressed Students Barrier n M A SD Too large a student/counsellor ratio 242 3.10 1.08 Priority is given to acting out students 241 3.10 0.90 Lack of time 240 2.9 61.08 Lack of knowledge about student depression 238 2.33 0.93 Lack of teacher referral 234 1.94 1.06 Being new to the school(s) 235 1.71 1.00 Role uncertainty 239 1.46 0.82 A Mean range = 1-4 where 1 denotes "not a barrier", 2 denotes small barrier", 3 denotes "moderate barrier", and 4 denotes "large barrier". 56 Table 19. Means and Standard Deviations of Counsellors' Perceived Barriers to Assessing Depressed Students Barrier n SD Too large a student/counsellor ratio 233 3.02 1.07 Lack of time 233 3.00 1.05 Lack of knowledge about assessment instrument/criteria 231 2.67 1.11 Role uncertainty 232 2.06 1.13 Parent reluctance 229 1.78 0.80 *Mean range = 1-4 where 1 denotes "not a barrier", 2 denotes "small barrier", 3 denotes "moderate barrier", and 4 denotes "large barrier". Table 20. Means and Standard Deviations of Counsellors' Perceived Barriers to Treating Depressed Students Barrier n M A SD Too large a student/counsellor ratio 235 3.10 1.24 Lack of time 237 3.09 0.99 Priority is give to acting out students 237 2.88 0.96 Lack of knowledge about effective treatment strategies 236 2.80 1.04 Lack of adequate facilities 235 2.33 1.08 Role uncertainty 233 2.08 1.09 Parent reluctance 232 1.80 0.80 Noncooperation of community professionals 234 1.49 0.78 Noncooperation of school system professionals 234 1.48 0.79 A Mean range = 1-4 where 1 denotes "not a barrier", 2 denotes "small barrier", 3 denotes "moderate barrier", and 4 denotes "large barrier". 57 Table 21. Means and Standard Deviations of Counsellors' Perceived Barriers to Referring Depressed Students Barrier n M A SD Wait lists for community resources 234 3.01 0.99 Lack of community resources 238 2.77 1.08 Too large a student/counsellor ratio 237 2.40 1.12 Lack of knowledge of criteria for childhood depression 235 1.95 1.00 Lack of knowledge about community resources 239 1.61 0.80 Lack of cooperation from community professionals/agencies 238 1.40 0.67 "Mean range = 1-4 where 1 denotes "not a barrier", 2 denotes "small barrier", 3 denotes "moderate barrier", and 4 denotes "large barrier". Table 22. Means and Standard Deviations of Counsellors' Perceived Barriers to Preventing Student Depression Barrier n M " SD Lack of time 234 3.28 0.93 Too large a student/counsellor ratio 237 3.16 0.93 Lack of knowledge about childhood depression 231 2.13 0.93 Lack of appropriate facilities 231 1.93 0.95 Role uncertainty 234 1.87 0.95 Working with other school system professionals 233 1.64 0.82 Parent refusal to have students participate 228 1.61 0.69 "Mean range = 1-4 where 1 denotes "not a barrier", 2 denotes "small barrier", 3 denotes "moderate barrier", and 4 denotes "large barrier". the sample means and standard deviations indicating the extent to which different factors were perceived as barriers to performing the various counsellor functions. "Too large a student-to-counsellor ratio" and "Lack of time" were most consistently perceived as being amongst the greatest barriers. Counsellors rated these 58 items as "Moderate barriers" to identification, assessment, treatment, and prevention of student depression (M=3.02-3.16, and M=3.00-3.28 respectively). On the other hand "Role uncertainty" was rated as "Not a barrier" to identification (M=1.46, SD = .82), and only as a "Small barrier" to assessing, treating, and preventing student depression (M= 1.87-2.08). In addition to "Too large a student-to-counsellor ratio" and "Lack of time", "Priority being given to acting out students" was also rated as a "Moderate Barrier" to identification of depressed students (M=3.10, SD = .90). Furthermore, five counsellors wrote misbehaving students take up most of their time, thus depressed students are often overlooked. Other perceived barriers to identification, all rated as "Small barriers", are "Lack of Knowledge about childhood depression", "Lack of teacher referral", and "Being new to the school" (M=L71-2.33). One barrier not asked about, but commented on by a number of counsellors, was what people believed about the construct childhood depression. Some counsellors wrote that identifying depressed students is not productive because it is a symptom not a disorder (n=5), while others wrote convincing school personnel that childhood depression exists is a major barrier (n=6). Along with "Too large a student-to-counsellor ratio" and "Lack of time", "Lack of knowledge about assessment instruments/criteria" was also rated as a "Moderate barrier" to assessment (M=2.67, SD = 1.11). A number of counsellors wrote that a lack of available assessment instruments prevents them from assessing depressed students (n=9). "Parent reluctance" to have the student assessed was only rated as a "Small barrier" (M=L78, SD = .80). 59 As approximately one-half of the counsellors who perceived assessment of students for depression as part of their ideal role had assessed students for depression, and the other one-half had not, the means of how the two groups perceived each barrier to assessment were compared. Table 23 reports the total "n", mean difference, and "t" values for each barrier. As can be seen from the results, there is a significant difference in how two of the barriers were perceived. "Lack of knowledge about assessment criteria and instruments", and "Role uncertainty" were both perceived to be greater barriers to assessment by those who had not assessed students for depression, than those who had (t=2.32, p_< .05 and 1=2.24, p_< .05 respectively). Table 23. Mean Differences Between Barriers Perceived by Counsellors Assessing and not Assessing Students Barrier n Mean Difference t Too large a student/counsellor ratio 151 0.01 0.03 Lack of time 150 0.04 0.08 Lack of knowledge about assessment instruments/criteria 148 1.04 2.32* Role uncertainty 149 0.74 2.24* Parent Reluctance 151 0.15 0.45 *p_<.05 Two barriers to treatment were rated as "Moderate" besides "Too large a student-to-counsellor ratio" and "Lack of time". These are "Priority being given to acting out students", and "Lack of knowledge about effective treatment strategies" (M=2.80-2.88). On the other hand, "Lack of adequate facilities" and "Parent reluctance" were both rated as "Small barriers" (M=1.80-2.33) to treating depressed students. 60 In the case of referral of depressed students, the highest rated barriers were "Wait lists for community resources", and "Lack of community resources" (M=2.77-3.01). "Too large a student-to-counsellor ratio" was only rated as a "Small barrier" (M=2.40, SD = 1.12), as were "Lack of knowledge about criteria for childhood depression", and "Lack of knowledge about community resources" (M=1.61-1.95). As mentioned earlier, "Too large a student-to-counsellor ratio" and "Lack of time" were both rated as "Moderate barriers" to prevention of student depression. Four factors were rated as "Small barriers" to preventing student depression. These are "Lack of knowledge about childhood depression", "Lack of appropriate facilities", "Working with other school system professionals", and "Parent refusal to have a student participate" ( M = L 61-2.13). Research question 8. "What factors would help elementary school counsellors to better assist depressed students?" To answer this question, counsellors were asked to indicate which of a list of possible factors would aid them to better assist depressed students. The number and percentage of those answering in the affirmative to each factor are presented in Table 24. Counsellors were also asked to identify which five of these factors would be most helpful. The number and percentage of respondents who included each factor in their top five are presented in Table 25. "Information on effective counselling techniques for depressed students" was the most frequently identified helpful factor (89.8%), and was also the factor most frequently rated in the top five (69.7%). This is puzzling as only one-half the counsellors rated treating depressed students as part of their current and ideal roles, even though "Lack of 61 Table 24. Factors Counsellors Perceived Would Aid Them in Assisting Depressed Students Factor n % of respondents Information on effective counselling techniques for depressed students 220 89.8 Information on childhood depression 204 83.3 Reduced student/counsellor ratio 201 82.0 Workshops/seminars on childhood depression 201 82.0 Greater staff awareness of childhood depression 201 82.0 More time for prevention activities 200 81.6 Shorter wait lists for community resources 195 79.6 Information on effective assessment techniques 184 75.1 Increase in community resources for depressed students 179 73.1 Training on assessing students for depression 177 72.2 Team approach between school and community personnel 173 70.6 Greater community awareness of childhood depression 167 68.2 Clear policy on counsellor role in assisting depressed students 142 58.0 More adequate working space 108 44.1 Information about available community resources 108 44.1 Less priority given to acting out students 92 37.7 knowledge about effective treatment strategies" was perceived to be one of the highest barriers to treatment. The second highest priority for counsellors was " A reduced student-to-counsellor ratio", which was identified as being helpful by the majority of counsellors (82.0%), and rated in the top five helpful factors by over one-half of the counsellors (56.7%). Counsellor comments related to this included the desperate need for more counsellors (n=3), the number of counsellors has been cut (n=2), and lack of time keeps counsellors from doing what they would like to do (n=2). This is also in line with counsellors 62 Table 25. Options Counsellors Included in the Five Factors Which Would Be Most Helpful in Assisting Depressed Students Factor n % of respondents Information on effective counselling techniques for depressed students 166 69.7 Reduced student/counsellor ratio 135 56.7 Workshops/seminars on childhood depression 99 41.6 Information on childhood depression 98 41.0 More time for prevention activities 93 39.1 Training on assessing students for depression 84 35.3 Shorter wait lists for community resources 76 31.9 Information on effective assessment techniques 76 31.9 Increase in community resources for depressed students 76 31.9 Team approach between school and community personnel 63 26.5 Greater staff awareness of childhood depression 61 25.6 Clear policy on counsellor role in assisting depressed students 34 14.3 More adequate working space 33 13.9 Greater community awareness of childhood depression 27 11.3 Less priority given to acting out students 26 10.9 Information about available community resources 25 10.5 consistently rating "Too large a student-to-counsellor ratio" as one of the highest barriers to implementing the various counsellor functions. The next group of factors most frequently identified as being helpful were "Information, workshops, and seminars on childhood depression", and "More time for prevention activities". These were identified by 81.6%-83.3% of the counsellors, and rated in the top five by 39.1%-41.6%. Given that "Lack of time" was the highest rated barrier to engaging in prevention activities, and "Lack of knowledge about childhood depression" was rated in the midrange as a barrier to identifying, referring, and 63 preventing student depression, these results are consistent. The next most commonly identified factors were "Training on assessing students for depression", "Shorter wait lists for community resources", "Information on effective assessment techniques" and an "Increase in community resources for depressed students". These were identified by about three-quarters of the counsellors, and rated in the top five by about one-third of the counsellors. As discussed earlier, lack of training and knowledge about assessment techniques, and shortage of, and wait lists for community resources were identified as being amongst the highest rated barriers to assisting depressed students. Therefore, it is expected that a large number of counsellors would find these factors helpful. "Greater staff awareness about childhood depression" was identified by a large proportion of counsellors (82.0%) as being helpful, but was only ranked in the top five by one quarter of the counsellors (26.5%), suggesting that while it would be helpful, greater staff awareness is not a priority. A "Clear policy on the role of elementary school counsellors in assisting depressed students" was identified as being helpful by just over one-half of the counsellors (58.0%), but was rated in the top five by a very small minority (14.3%). This, along with the low rating given to a "Lack of a clear role policy" as a barrier to the various functions suggests that for many counsellors, a clear role policy is not needed in order for them to assist depressed students. Other factors rated in the top five by a small minority of counsellors included "More adequate working space", "Greater community awareness of childhood depression", "Information about available community resources", and "Less priority being given to acting out students" (10.5%-13.9%). The first three are consistent with 64 their low ratings as barriers, but "Less priority being given to acting out students" was rated as one of the highest barriers to both identifying and treating depressed students. Finally, another area commented on by a number of counsellors, but not included in the questionnaire, is the role of the family in childhood depression. Counsellors wrote childhood depression is related to family problems (n=5), getting assistance for depressed children should be the responsibility of the family and not counsellors (n=3), and it is hard to assist depressed students when parents refuse services because of their own instability (n=3). Summary of Results of Research Questions The results of this study indicate the majority of B . C . elementary school counsellors were consistent in their perception of identifying, referring, and preventing student depression as part of both their current and ideal roles. Their practices also reflected these perceptions. However, counsellors were divided on whether assessing and treating student depression should be part of their ideal role, with a slight majority supporting both. The numbers who perceived treating depressed students as part of their current role, and actually engaged in treatment activities, also reflected this split. The number who perceived assessment as part of their current role, and those who actually engaged in assessment, represent only about one-third of the respondents, or about one-half of those who perceived it as part of their ideal role. Counsellors also seemed to be underidentifying depressed students, although the majority recognized this after considering the criteria for the depressive disorders. This is not surprising given that most counsellors had not previously been exposed to the criteria for the two depressive disorders. Results indicate the counsellors who were 65 familiar with the criteria for major depressive disorder identified significantly more depressed students than those who were not, while familiarity with the criteria for dysthymic disorder did not seem to be related to the number of students identified. Only about one-half of the counsellors had participated in workshops, conferences, and courses in which childhood depression was discussed. Instead, most counsellors appeared to be learning about childhood depression through discussions with colleagues and reading materials. As most counsellors identified workshops; seminars; and information on childhood depression, assessment techniques, and treatment strategies as factors which would help them to better assist depressed students, this suggests counsellors need more education about childhood depression. Lack of time and too large a student-to-counsellor ratio were consistently perceived to be the largest barriers to performing the various counsellor functions. A reduced student-to-counsellor ratio was also rated as the second highest factor which would help counsellors to better assist depressed students. This suggests that the current work load in which the majority of counsellors are assigned three or more schools, and 800 or more students, is greatly hampering the ability of counsellors to assist these students. Depressed students came to the counsellors' attention mostly through teachers, followed by parent referral, school based team, and student self-referral. Despite the high number of counsellors who had teachers referring depressed students to them, lack of teacher referral was still perceived to be a barrier to identifying depressed students. Counsellors also rated priority being given to acting out students as one of the highest barriers to identifying depressed students. 66 Those counsellors who did assess students for depression were mostly using projective techniques and the DSM-III-R or DSM-IV criteria. The lack of training and availability of assessment instruments, such as the Children's Depression Inventory and the Children's Depression Rating Scale-Revised, may account for the lower use of standardized tests, as both were identified as being barriers to assessment. In addition, counsellors who perceived assessment of students as part of their ideal role who were not currently assessing, rated two barriers higher than those who perceived it as part of their ideal role and were currently assessing. These two barriers were lack of knowledge about assessment instruments and the criteria for depression, and role uncertainty. A large majority of counsellors who treated students for depression perceived some methods to be more effective than others, with art/play therapy and cognitive-behavioral therapy being identified by the most number of counsellors. Lack of knowledge about effective treatment strategies, and priority being given to acting out students were both perceived to be amongst the highest barriers to treatment. Surprisingly, although only one-half the counsellors perceived treating depressed students as part of their current and ideal roles, more information on effective counselling techniques was the highest rated factor that would help them to better assist depressed students. Depressed students were predominantly being referred to mental health agencies or medical professionals. However, counsellors indicated there were not enough of these resources. In addition, they also indicated the resources which did exist had lengthy wait lists. Shorter wait lists and more community resources were both rated in the midrange of factors which would help counsellors to better assist depressed students. 67 Almost all the counsellors used developing students' problem-solving strategies and social skills as prevention activities, although some acknowledged that they were not using them specifically to prevent depression. A majority of counsellors also monitored students at-risk for depression, and provided counselling services to at-risk students. However, most counsellors were not educating staff or students about childhood depression. More time for prevention activities was rated as one of the highest factors that would help counsellors to better assist depressed students. Finally, although there seems to be a division about whether treatment and assessment of student depression should be part of the current and ideal roles, lack of a clear role policy was only rated as a small barrier to most counsellor functions, and a clear policy on the role of counsellors was one of the lowest rated factors which would help counsellors to better assist depressed students. This suggests that although there is some disagreement over counsellor role, the majority of individuals feel confident in their role perception. CHAPTER 5 68 DISCUSSION This chapter begins with a discussion of the results, including an interpretation in terms of the literature. The first section discusses the results of the survey, and is divided into seven subsections: demographics, education, work experience and setting; knowledge of childhood depression; role in assisting depressed students; identification; assessment; treatment; referral; prevention; and counsellor priorities. This section is then followed by a section on the limitations of the study. The chapter ends with a section on recommendations, which is divided into two subsections, recommendations relating to counsellors, and recommendations for future research. Discussion and Interpretation of the Results Demographics, education, work experience and setting. According to the results, female counsellors outnumbered males by a ratio of 2:1 (61.8% versus 38.2% respectively). The proportion of female elementary school counsellors has thus increased from the 55.8% found by Samis (1991). This may be more reflective of the greater number of female staff working in elementary schools. The average age of elementary school counsellors continues to be high, with the vast majority (87%) being 40 years or more. As Samis points out, this is partially due to many counsellors having a teaching career before becoming counsellors, and the B . C . graduate training programs for counsellors preferring "mature" students. However, since the early 1980s there has been a lower than normal turnover of professionals within the school system due to economic factors. Consequently, this has prevented many younger 69 people from entering the school system. As a result, older teachers may have retained their seniority as they obtained the appropriate training and moved into counselling positions, making it more difficult for younger people to obtain these positions. This may also explain why almost one-half the counsellors (45.6%) had 5 or fewer years of elementary school counselling experience, despite the majority of counsellors being 40 or more years of age. The percentage of counsellors who have obtained a graduate level degree has continued to rise, with 86.4% in the current study having a master's degree or higher. This is somewhat higher than the 81.8% identified by Samis in 1991, and substantially higher than the 69% identified by Allan and Ross in 1979. This is likely a result of the increasing number of school districts which require candidates to have completed a graduate training program before hiring them as elementary school counsellors. The majority of counsellors worked in the Lower Mainland (52.5%), although only 39% of the public elementary school students attend schools in this region (B.C. Ministry of Education, 1995). One possible explanation is that a higher proportion of counsellors from the Lower Mainland may have responded to the survey. However, of the 333 questionnaires sent out, 169 (50.8%) were sent to Lower Mainland counsellors. The return rate for this group was 75.8%, which is not significantly different from the overall return rate of 74.5%. The working conditions of B . C . elementary school counsellors appears not to have changed in the last four years despite recommendations for a decreased work load (Samis, 1991). She found that the majority worked full-time (65.1%), had three or more schools (61.3%), and were responsible for 750 or more students (73.9%). In the current study, 70 the majority also worked full-time (56.9%), worked in three or more schools (55.8%), and were responsible for 800 or more students (62.1%). Knowledge about childhood depression. Only a small majority of counsellors were familiar with the criteria for major depressive disorder (55.1%), and only one-third were familiar with the criteria for dysthymic disorder (30.1%). There are two possible reasons for this. One is this study used the American Psychiatric Association's criteria for depression found in DSM-IV. It may be that some elementary school counsellors have been using a different definition or set of criteria for the construct depression. If this is so, the B . C . Counsellors Association needs to adopt a single definition of depression, in order to facilitate consistent identification and the provision of appropriate services. A second plausible reason is counsellors may not have been provided with the criteria for the depressive disorders during their professional development. This appears to be the case given that more counsellors indicated they had learned about childhood depression from their own initiative, such as discussions with colleagues and reading, than from more formal learning environments, such as workshops, course work, and conferences. Although this survey did not ask counsellors to identify specifically what they learned about childhood depression from these various activities, their unfamiliarity with the criteria for the two depressive disorders, and assessment and treatment strategies for depressed students, suggests they are not being provided with enough information about childhood depression during their training. Counsellor role in assisting depressed students. Prior research suggests there are more counsellors who perceive functions involving consultation as part of their role, than 71 there are counsellors who perceive functions involving direct intervention as part of their role (Samis, 1991). Both discussion with others during the identification process, and discussions with agencies and other professionals during the referral process, can be considered as consultative activities. On the other hand, assessing, treating, and preventing student depression are all functions which provide direct intervention to students. The vast majority of B . C . elementary school counsellors perceived the two consultative functions, identification and referral, as part of their ideal (94.7%-99.2%) and current (85.7%-95.9%) roles. This perception is higher than Clarizio's and Payette's (1990) study, in which 77% of school psychologists indicated they would refer depressed students. Differences in training and role expectations may account for this result. These results are consistent with the B . C . S . C . A . (1990) brief on the role of counsellors which suggests referral for assessment and treatment of various student problems should be part of the elementary school counsellors' role. A large majority of counsellors also perceived prevention of student depression to be part of their ideal role (92.2%), but a somewhat smaller number perceived it to be part of their current role (71.0%). This may be because some counsellors believed they should be doing prevention activities, even though it was not expected by their district. Another possibility is some counsellors may ideally like to include prevention as part of their role, but do not perceive it as realistic given their current working conditions. As "Too high a student-to-counsellor ratio" and "Lack of time " were identified as the largest barriers to doing prevention activities, and "More time for prevention activities" was identified by a majority of counsellors (81.6%) as being a factor which would help 72 them to assist depressed students, this second hypothesis has some merit. Only about two-thirds of the counsellors indicated assessing students for depression was part of their ideal role (64.5%); thus, there is less of a consensus on this function. As counsellors perceived "Lack of knowledge of assessment techniques and criteria" as a "Small barrier" to assessment, it may be those who have not been trained in assessment also do not perceive it as part of their ideal role. This is supported by the fact that counsellors who perceived assessment as part of their ideal role and were not assessing students for depression found "Lack of knowledge about assessment instruments and criteria" to be a significantly greater barrier to assessment than those who were assessing students. Also, a number of counsellors indicated assessment should only be done in consultation with medical or mental health professionals. Therefore, how counsellors perceived their ideal role in regards to assessment may be related to whether counsellors perceived their training to be adequate enough to perform this function. Further research is needed in order to clarify this finding. About one-half the counsellors who perceived assessment as part of their ideal role also perceived it as part of their current role (53.2%), while the other one-half did not perceive it as part of their current role (46.8%). One possible reason for this is some counsellors may have believed they should be assessing depressed students, even though they were uncertain whether it was expected of them. As "Role uncertainty" was identified as being a significantly greater barrier by those who were not assessing students, it is likely that this factor may be contributing to this division, as in many districts school psychologists are responsible for administering assessment tests. If this is the case, B . C . elementary school counsellors need to clarify with their districts what their 7 3 role should be in regards to this function. Furthermore, i f counsellors are expected to assess students for depression, the results indicate they need knowledge about the various assessment instruments and criteria for childhood depression. This can be provided through workshops and other professional development activities. Counsellors were also split on whether they perceived treating depressed students as part of their role. A slight majority perceived it as part of their ideal role (59.4%), while just over one-half perceived it as part of their current role (55.0%). A number of factors may have contributed to this division. Comments indicated some counsellors did not think they should be treating depressed students unless doing so in consultation with a medical or mental health professional (n=12). This may have caused some counsellors to be hesitant about including it as part of their role. Counsellors may also have associated the term "treatment" with a more medical approach, rather than the counselling strategies commonly used by elementary school counsellors, and therefore not perceived this function to be part of their role. A lack of knowledge about effective treatment strategies, a lack of time, and too high a student-to-counsellor ratio may also have contributed to some counsellors not including treatment as part of their role, as these were rated as the largest barriers to treatment. It appears that counsellors are more unanimous on engaging in the consultative functions, and are more divided about whether they should be providing direct intervention through assessment, treatment, and prevention of student depression. As counsellors identified "Too high a student-to-counsellor ratio" and "Lack of time" as being the biggest barriers to each of the latter three functions, it is reasonable to hypothesize that the high work load of some counsellors may be contributing to this 74 apparent division in how counsellors perceive their role. In support of this conclusion is research suggesting that when counsellors are given an unmanageable student-to-counsellor ratio, they tend to rely more on consultation rather than providing direct services (Dinkmeyer & Dinkmeyer, 1978; Samis, 1991; Umansky & Holloway, 1984). Both identification and referral of depressed students often require much less time than the other three counsellor functions. Identification. The majority of counsellors have identified depressed students during the last two years, consistent with their perception of identification as being part of their current role (85.7%). However, although research indicates that between 1.8%-8.2% of children are depressed at any given time (Anderson et al., 1987; Kashani et al . , 1983; McCracken, 1987; Polaino-Lorente & Domenech, 1993), counsellors identified much less than this. Over one-half the counsellors had a case load of 800 or more students per counsellor (62.1%), yet two thirds (65.9%) indicated they had identified 6 or less students. Therefore, it seems that only a small proportion of depressed students were identified by the counsellors. One obvious explanation for this is counsellors lack adequate knowledge about childhood depression. Only a small number of counsellors indicated they were familiar with the criteria for both depressive disorders (30.1%), and more than one-half the counsellors (56.4%) indicated they would increase their estimate of the number of depressed students after reading the criteria. Thus, unlike Maag et al.'s (1988) study of American secondary school counsellors, it appears that B . C . elementary school counsellors may not be totally confident in their ability to identify depressed students. This observation is supported by counsellors rating "Lack of knowledge about childhood 75 depression" as a "Small barrier" to identification. If counsellors are to become more successful in identifying depressed students, they need to be provided with the criteria for the depressive disorders. Another possible reason for the underidentification of depressed students may be teacher referral. Although more counsellors had been referred depressed students by teachers than any other source (92.8%), counsellors identified "Priority being given to acting out students", and "Lack of teacher referral" as being "Moderate" and "Small" barriers to identification of depressed students. Consequently, teachers may be underrefering depressed students, and giving priority to acting out students as has been previously suggested (Kashani et al., 1983). This may become even more of a factor for counsellors who have a high student-to-counsellor ratio, and are thus limited in the number of students they can be referred. A final source of underreferral alluded to in the research is both depressed students, and the parents of these students, tend not to make referrals (Reynolds, 1990). As this study did not ask who made the referral for each student the counsellors identified, it is impossible to determine whether this was a factor. Finally, as nearly all counsellors perceived identifying depressed students as part of their role, increasing the identification rate may also increase the number of depressed students who receive intervention. With only 18.4% to 47.1% of depressed children receiving assistance (Fleming, Offord, & Boyle, 1989; Kashani. et al., 1983; Keller et al., 1991; McCracken et al. , 1989), increasing counsellor identification of depressed students could lead to a very significant improvement of this rate. However, to maximize identification, counsellors need to become familiar with the criteria for the depressive disorders. In addition, as suggested by Downing (1988), and Levy and Land (1994), 76 they may also need to educate their schools' staff about the symptoms associated with depression, and the consequences of these students not receiving early intervention. Assessment. Only about one-third of the counsellors (36.2%) have assessed students for depression. The main reason for this is likely most do not perceive assessment to be part of their current role (65.8%). However, as both "Lack of time" and "Too large a student-to-counsellor ratio" were identified as the greatest barriers to assessment, both these factors may also be contributing to this result. It is interesting that more counsellors used projective techniques to assess students for depression (66.7%), than the DSM-IV criteria (60.0%) or standardized assessment instruments (40.0%), given there is no research supporting the validity of using projective techniques for this purpose. Nevertheless, this finding is consistent with Clarizio's and Payette's (1990) study of school psychologists which found that only 51% of the subjects were using DSM-III criteria for depression. There are a number of possible explanations for this. As nearly all counsellors referred depressed students elsewhere, they may have used projective techniques as an informal device to determine whether depression is a possibility, rather than a certainty. Other possible explanations are the lack of availability of standardized instruments, and the lack of training in how to use standardized instruments and the DSM-IV criteria, as both were identified as barriers to assessment. A final contributing factor may be that a large proportion of B . C . counsellors went through the Masters of Counselling Psychology program at the University of British Columbia. This program provides elementary school counsellors with training in the use of projective techniques, but does not train them in the use of standardized assessment instruments, as it is assumed this role will be carried out by school psychologists. 77 However, i f counsellors do perceive assessment of students for depression to be part of their role, they need information and training on the different types of assessment techniques. About three-quarters of the counsellors indicated information (75.1%), and training (72.7%) on the use of assessment techniques would help them to better assist depressed students. Treatment. As discussed earlier, treatment of depressed students requires knowledge about selecting and implementing effective treatment strategies. About two-thirds of the counsellors (64.9%) indicated they had treated student depression in the last two years. A n unexpected result was the vast majority (81.2%) indicated they found some treatment methods to be more effective than others, despite the lack of research comparing the effectiveness of different therapeutic approaches. Art and play therapy were the most commonly identified as being more effective (52.1%), even though there is no research on the effectiveness of either of these techniques. A number of factors may account for this result. Counsellors may have reported the methods they generally find to be more effective for all student issues rather than just depression, as this study did not verify that the reported treatment strategies were used with these specific students. A more likely explanation is many B . C . counsellors have been trained in art and play therapy during their Master's programs, but have not been trained in some of the other techniques. A large proportion of B . C . elementary school counsellors obtained their Master's degrees from the Counselling Psychology program at the University of British Columbia, a program which places a strong emphasis on play and art therapy. A final possibility is counsellor reports may be accurate. Art and play therapy may actually be the most 78 effective treatment techniques for assisting depressed students. Unfortunately, there are no published studies which have evaluated the effectiveness of either of these approaches. Consequently, research needs to be done on both these techniques so that counsellors can make an informed decision on whether to use play and art therapy with depressed children. Just over a quarter of the counsellors (28.1%) identified cognitive-behavioral therapy as being a more effective treatment strategy. This may be because although preliminary research supports the effectiveness of this approach (Kahn et al., 1990; Stark et al. , 1987), counsellors have found it to be less effective than play and art therapy. However, a more plausible explanation is many counsellors may lack training in the use of cognitive-behavioral methods. Very few counsellors reported family therapy (9.9%) to be more effective, even though effective treatment of childhood depression may require the involvement of other family members (Harrington et al., 1990). This is probably because most B . C . counsellors do not perceive using family therapy as part of their role (Samis, 1991), and therefore, have not used it with depressed students. Another significant finding is about two-thirds of counsellors have treated depressed students (64.9%), while only one-third have assessed students for depression (36.2%). As treatment should be individually tailored based upon an assessment of the students' depression, psychosocial functioning, and family environment (Harrington, 1992; Reynolds, 1990), it is important that counsellors ensure that depressed students have been adequately assessed before implementing a treatment program. The various barriers to assessment discussed earlier may account for this result. In addition, these counsellors may be referring depressed students elsewhere for assessment. 79 "Priority being given to acting out students" was identified as a "Moderate barrier" to treatment. Again, this may become even more of a problem as the student-to-counsellor ratio increases. A reduced student-to-counsellor ratio is likely the best way to address this barrier, as it would allow counsellors to adequately assist both groups of students. "Lack of knowledge about effective treatment strategies" was also identified as one of the largest barriers to treatment, which is somewhat of a paradox given that most counsellors claimed to have found some methods to be more effective than others. A n even greater surprise was "Information on effective counselling techniques for depressed students" was the most commonly identified factor (89.8%) which would help counsellors to assist depressed students. This is puzzling as less than two-thirds of the counsellors identified treating depressed students as part of their ideal (59.4%) and current (55.0%) roles. Why do counsellors who do not perceive treating depressed students as part of their role want information on effective counselling techniques? If they received more comprehensive training on effective treatment strategies for depressed students, would this increase the number who perceived treatment as part of their role? Further research is needed to answer these questions. Referral. Most counsellors (90.6%) have referred students to other resources during the last two years, with the two most frequent being mental health agencies (88.1%), and medical doctors (74.1%). The lower rate of referral to psychiatrists (66.1%) and private therapists (55.9%) is probably because these resources often require a medical or mental health referral. Counsellors identified "Wait lists for community resources" as the greatest barrier to referral. This suggests there are not enough resources for depressed students, which 80 seems to be the case as counsellors identified "Lack of community resources" as the second highest barrier to referral. "Lack of knowledge about community resources" was only perceived to be a "Small barrier", indicating most counsellors are familiar with the resources for depressed students within their communities. These results suggest a potential problem. If counsellors do become more effective at identifying depressed students, who will assist them, as it appears the resources for the number of depressed students currently being identified are already inadequate. W i l l counsellors be expected to provide intervention while students remain on wait lists for outside help? This question needs to be examined further by both counsellors and other professionals and agencies involved with children's mental health. Prevention. About three-quarters of the counsellors (74.1%) have engaged in activities aimed at preventing student depression during the last two years. Virtually all of them have done activities to develop students' problem-solving strategies (98.4%) and social skills (97.8%), two activities which may have an impact on preventing depression (Peterson et al. , 1993; Rice & Meyer, 1994). More than one-half the counsellors monitored groups of students at risk for developing depression. However, sexually and physically abused students are monitored by more counsellors (89.6%), than students with a depressed parent (70.9%), and students who have previously been depressed (67.2%), even though these are higher risk factors for depression (Hammen, 1991; Kovacs et al., 1984; Kovacs et al., 1994; Nolen-Hoecksema et al., 1992). Two plausible explanations are the high public awareness on the effects of physical and sexual abuse, and the fact that counsellors may not have been provided with information about the mental health status of parents and students. 81 Most counsellors have not educated staff (46.1%) or students (31.7%) about childhood depression as part of their prevention program, even though 82.0% indicated that "Greater staff awareness about childhood depression" would help them to better assist depressed students. Providing information about depression to both these groups may help to increase the rate of identification of depressed students. Lack of knowledge about childhood depression may explain why so few counsellors have engaged in these activities, as it was identified as a "Small barrier" to prevention. Furthermore, "Information on childhood depression" was the second most commonly identified factor (83.3%) which would help counsellors to assist depressed students, suggesting this hypothesis has some validity. Other factors which may be influencing lower participation in prevention activities are "Lack of appropriate facilities", "Role uncertainty", "Working with other school system professionals", and "Parent refusal to have students participate", all of which were rated as "Small barriers" to doing prevention activities. The results also suggest counsellors still do not have enough time for prevention activities as previously observed by Allan and Ross (1979), and Allan and Boland (1981). The most likely reasons for this are lack of time and an excessive student-to-counsellor ratio, both of which were rated as the highest barriers to doing prevention activities. The large number of counsellors (81.6) including "More time for prevention activities" on their list of factors which would help them to better assist depressed students further supports this position. It is unfortunate that counsellors perceive they do not have enough time for prevention activities as providing a comprehensive school-based prevention program may be one of the most effective ways of preventing childhood depression. 82 Counsellor Priorities. Counsellors were asked to identify which five factors they thought would most help them to assist depressed students. As already discussed, more counsellors perceived "Information on effective counselling techniques for depressed students" as being amongst the five most helpful (69.7%), than any other factor. Whether providing counsellors with information on effective counselling techniques for depressed students would result in more counsellors perceiving it as part of their role wil l have to be answered by future research. The next most common factor rated in the top five was a "Reduced student-to-counsellor ratio", which was included by over one-half the counsellors (56.7%). This is no surprise given that "Too large a student-to-counsellor ratio" was perceived to be one of the highest barriers to four of the five counsellor functions. Although prior research had already indicated a high student-to-counsellor ratio may be associated with counsellors being unable to implement their ideal role (Samis, 1991), this is obviously still an issue that needs to be addressed. The results of the current study suggest the average work load of 3 or more schools, and 800 or more students, seriously hampers the ability of elementary school counsellors to identify, assess, treat, and prevent student depression. If counsellors are to assist these students effectively, especially in the areas of identification and prevention, the student-to-counsellor ratio wil l need to be reduced significantly. The next most commonly included factors which would help counsellors to assist depressed students dealt with information, training, and community resources. "Workshops and conferences on childhood depression", "Information on childhood depression", "Training on assessing students for depression", and "Information on 83 effective assessment techniques" were all included in the five most helpful factors by about one-third of counsellors. These results suggest counsellors lack basic knowledge about childhood depression, and are not being adequately trained in the use of assessment techniques for depression. About a third of counsellors included "More community resources" (31.9%) and "Shorter wait lists" for these resources (31.9%) in their top five. Problems with both these areas were also perceived to be the greatest barriers to referring depressed students. If all depressed students are to receive adequate intervention, community resources for these students must be increased.' Problems involving other professionals were included in the top five by only a quarter of counsellors, indicating this is not as much a priority. These factors were " A team approach between school and community personnel" (26.5%), and "Greater staff awareness about childhood depression" (25.6%). The most likely candidates for assisting depressed students, and educating staff about childhood depression are the counsellors themselves, so it makes sense that first learning about depression themselves would be a greater priority for counsellors than educating other staff. A "Clear policy on the role of counsellors in assisting depressed students" was included in the top five by only a small proportion of counsellors (14.3%) even though over one-half indicated that it would be helpful (58.0%). This seems to imply that counsellors feel confident enough in how they currently perceive their role to be effectively assisting depressed students. However, because counsellors are split on whether they should be assessing or treating depressed students, these areas need to be further investigated. As counsellors have strongly indicated that a reduced work load; lower student-to-counsellor ratio; and knowledge about assessment instruments, criteria, 84 and effective treatment strategies would have an impact on their ability to assist depressed students, these factors may also be confounding counsellor role perceptions. Therefore, counsellors should be asked about their role perceptions, once these areas have been addressed, to see i f the apparent split is related to any of these problems. If not, further exploration wil l be needed in order to determine why this split exists. Four factors were included in the top five by less than 15% of the counsellors. These are "More adequate working space", "Greater community awareness of childhood depression", "Less priority being given to acting out students", and "Information on available community resources". As neither "Lack of appropriate facilities", nor "Lack of community awareness about childhood depression" were perceived to be that great a barrier to implementing the counsellor functions, these results are consistent. However, "Priority being given to acting out students" was perceived to be one of the largest barriers to both identification (M=3.10), and treatment (M=2.88) of depressed students. The main reason for its low ranking may be that counsellors believe a lower student-to-counsellor ratio would have more of an impact on their ability to assist depressed students, than having to choose between the two groups of students. Limitations of the Study The participants in this study all worked in the B . C . public elementary school system; therefore, the results can only be generalized to this group. It is possible that the 25.5% of counsellors who did not return the questionnaire included counsellors who had the highest work loads, and did not wish to spend valuable time completing the questionnaire. It may also include those who knew the least about childhood depression, those who were not assisting depressed students, and those who did not perceive assisting 85 them to be part of their role. Preliminary interviews and piloting of the questionnaire suggested that counsellors who knew little about childhood depression, and who did less for these students, felt more threatened by the study and were more reluctant to participate. Documentation was not used to verify whether counsellors had actually engaged in the activities they reported in this study, thus limiting the internal reliability and external validity of these results. Also, how they answered the questions may have applied to their practices in general, rather than specifically to how they assisted depressed students. As counsellors may have consulted with others while completing the survey, or may not have answered all questions honestly, these factors may also threaten the validity and reliability of the results. The questionnaire used for this study has not been used in any other research; therefore, there is no basis for assessing its external reliability. Also, because the subjects' understanding of the questions was not verified, counsellors may have interpreted various questions differently than the researcher expected. This poses a potential threat to the internal validity, although piloting of the questionnaire helped to offset this to some degree. The use of closed questions may have resulted in missing important data, threatening the internal validity. However, piloting the questionnaire, interviewing counsellors, and using the literature helped to anticipate possible answers. If this questionnaire were to be used again, several changes should be made in order to enhance the validity of the results. Question #8 "Part I" should be split into two questions, one on undergraduate degrees and one on graduate degrees, as many counsellors who had graduate degrees did not report their undergraduate degrees. 86 Question #9 "Part II" should be more specific. Asking counsellors about whether "childhood depression has been a topic" for various professional activities did not indicate how well these activities had actually covered childhood depression. This topic may only have been briefly mentioned during some of these activities, without providing enough information to significantly impact on the ability of counsellors to assist depressed students. Therefore, counsellors should also be asked to rate how helpful the information they derived from each activity was. The word "treating" in Questions #12, 13, 22, and 23 "Part III" may have been interpreted in the "medical" sense. This may have influenced the results. This might also explain why only a slight majority included it as part of their role; whereas, most felt more information on effective counselling techniques would help them to better assist depressed students. Unfortunately, this change in terms was not caught until after the survey was completed. Some counsellors may perceive their treatment interventions as "counselling techniques", rather than "treatment strategies". A consistent use of the former term may result in more valid results. In question #23 "Part III", "art therapy" and "cognitive therapy" were the most commonly ranked as being more effective treatment strategies. As both were listed as examples of treatment strategies, they may have been overrepresented for this question. In order to avoid this bias, future surveys should list all of the possible techniques identified in this study. A number of counsellors wrote they believed depression to be a symptom, not a disorder. Therefore, there should be a question which asks counsellors whether they agree with using the DSM-IV criteria for defining depression. 87 A number of counsellors wrote that mental health or medical professionals should be consulted when doing assessment and treatment, or that they already do this. Therefore, questions about these areas should be added. Other barriers identified by counsellors which could be added to question #21 "Part III" are lack of training on how to use assessment techniques for depression, and lack of available standardized assessment instruments for depression. Finally, for question #32 "Part U l " asking counsellors to choose the three factors which would be most helpful, instead of the five, may result in a greater division in ranking of the various factors, thus giving a clearer picture of how counsellors perceive the importance of each factor relative to the others. Recommendations Many of the more practical implications are most pertinent to B . C . elementary school counsellors. However, it is probable that some of these apply to counsellors from other regions as well, especially in regards to knowledge about childhood depression, and practices which would help these particular students. Therefore, other regions may wish to consider the merits of these recommendations. As far as is known by the author, this is the first study to examine in-depth school counsellors knowledge, practices, and perceived role in assisting depressed students. As a consequence, there are many questions that arise from this study which require further research. Thus, it is hoped this study generates future research which wil l ultimately lead to all depressed elementary school students being assisted both promptly and adequately. Recommendations relating to counsellors. Given the findings of this study, the recommendations for elementary school counsellors are as follows: 88 1. The results show the excessive student-to-counsellor ratio is having a negative impact on the ability of counsellors to adequately assist depressed students. A stronger effort needs to be made to reduce the ratio to 500 students per counsellor as recommended by Samis (1991). Until this occurs, depressed students wil l continue to be underserved. 2. The division between counsellors on assessing and treating depressed students needs to be explored further. Is it that some counsellors do not perceive they should assess and treat students under any circumstances, or are current barriers affecting how they perceive their role in regards to these functions? Are counsellors doing a preliminary screening for depression, and then referring depressed students elsewhere for formal assessment? Do counsellors provide additional treatment for depressed students in addition to that provided by mental health or medical professionals? The reasons for this division need to be determined i f counsellors are going to adopt a role policy which is consistent, and ensures that all depressed students are adequately served. 3. Elementary school counsellors need to be provided with information so they can better assist depressed students. More specifically, they need to be provided with up to date information on the etiology of childhood depression, the criteria for the depressive disorders, and assessment and treatment methods which are appropriate for these students. A l l these factors should be addressed during university training and in workshops and conferences for those already in the field. 4. If counsellors do decide assessment for depression is to be part of their role, they will need to be trained in the use of standardized assessment instruments for depression, and the DSM-IV criteria. This needs to be addressed in undergraduate or 89 graduate course work, and professional development activities for those already in the field. 5. If treatment of depressed students is part of the role of elementary school counsellors, they need to ensure depressed students are adequately assessed, including psychosocial functioning, and family environment, so that a treatment plan appropriate to each individual student can be implemented. They also need to be given more information on effective treatment strategies for childhood depression. 6. Once counsellors have become more educated about childhood depression, they need to educate other staff members both on identification of potentially depressed students, and the importance of referring these students promptly. Early referral may lead to an increase in the rate of treatment of depressed students, and prevent some of the more serious consequences associated with childhood depression. 7. Counsellors need to advocate for an increase in community resources for depressed students. This wil l become especially critical i f counsellors begin to identify a higher proportion of depressed students. Given the negative effects of student depression on all aspects of functioning, including psychological, social, and academic, not providing prompt services to these students is unacceptable. Recommendations for future research. There are several possibilities for future research. It would be worthwhile to repeat this study with B . C . secondary school counsellors as the incidence of depression in adolescence is even greater than in childhood, as is the risk of suicide attempt and completed suicide. Elementary school counsellors have indicated which functions they believe should be part of their role in assisting depressed students. However, they have also indicated 9 0 that with their current work assignments, not enough time is available to adequately implement all of these functions. Therefore, it may be more realistic to establish which of the possible range of services would be the most effective in assisting depressed students. This can be done by examining this issue in a broader context by taking into account the views of parents, administrators, school board personnel, government policy makers, and other professionals involved with children's mental health. Counsellors were not asked whether they consistently used the practices they reported with all depressed students. Further research is needed to establish whether this is the case. The results suggest counsellors are divided on whether assessment of students for depression should be part of their role, with a number writing they refer depressed students elsewhere for assessment. Further research is needed in order to determine whether counsellors, school psychologists, mental health, or medical professionals should be primarily responsible for assessing students for depression. Counsellors were also divided on whether they should be treating depressed students; therefore, who should be responsible for providing primary treatment also needs to be further examined. Counsellors perceived that art and play therapy were the most effective techniques for treating student depression. Research needs to be done on both these techniques to establish whether these are in fact the most effective ways to treat student depression. The vast majority of counsellors indicated they had referred depressed students to other professionals or agencies. However, it is not clear i f they referred students for both assessment and treatment, or whether all depressed students were referred. Additional research is needed to establish how counsellors decide when to refer depressed 91 students, and what services they expect to be provided by the referral agency or professional. 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Secondary school professionals' ability to identify depression in adolescents. Adolescence. 23. 73-83. McClellan, J. & Trupin, E . (1989). Prevention of psychiatric disorders in children. Hospital & Community Psychiatry, 40. 630-636. McCracken, J.T., Shekim, W . O . , Kashani, J .H . , et al. (1989). Depressive Disorders in rural nine-year-old children: Prevalence and characteristics. Manuscript submitted for publication. Madak, P.R. , & Gieni, C L . (1991). Half-time elementary school counsellors: Expectations of role versus actual activities. Canadian Journal of Counselling. 25. 317-331. Marciano, P . L . , & Kazdin, A . E . (1994). Self-esteem, depression, hopelessness, and suicidal intent among psychiatrically disturbed inpatient children. Journal of Clinical Child Psychology. 23. 151-160. Morse, C . L . , & Russell, T. (1988). How elementary school counselors see their role: A n empirical study. 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Psychological Bulletin. 117. 450-468. Welch, I., & McCarroll, L . (1993). The future role of school counsellors. The School Counselor. 41. 48-53. Werthamer-Larsson, L . (1994). Methodological issues in school-based services research. Journal of Clinical Child Psychology. 23. 121-132. APPENDIX A Request for Counsellor Names First Follow-up Request Second Follow-up Request 100 November 17, 1994 Dear Head of Student Services/ Supervisor of Elementary Counsellors: I am an M . A . candidate in the Department of Counselling Psychology at the University of British Columbia. Under the direction of Dr. John Allan (Faculty of Education; phone 822-5259), I am carrying out a study which wil l examine the role of elementary school counsellors in servicing depressed students. The data gathered from this study will provide information about the practices elementary school counsellors are using to service depressed students, the factors that hinder their ability to service these students, and the factors that would facilitate their ability to better service these students. Counsellors will also be asked to describe what they perceive their role to be servicing depressed students. This information wil l be obtained by asking each participant to complete a questionnaire specifically designed for this study. I would greatly appreciate it i f you could send me a listing of the E L E M E N T A R Y SCHOOL COUNSELLORS working in your district during the 1994-95 school year, along with the names and addresses of the schools in which they work, so that I can mail them my brief questionnaire. Please mail the list of names and addresses to: Dr. John Allan University of British Columbia Faculty of Education Department of Counselling Psychology 5780 Toronto Road Vancouver, B . C . V6T 1L2 The goals of this project are to assist elementary school counsellors in servicing depressed students, to help them become better informed about childhood depression, and to provide recommendations in regards to the training of elementary school counsellors. The results of this survey wil l be forwarded to supervisors of elementary school counsellors participating in this study. Thank-you in advance for your cooperation and commitment to improving the effectiveness of our profession. Yours sincerely, Jackie Farquhar M . A . Candidate Dept. of Counselling Psychology University of British Columbia 101 January 13, 1995 Dear Head of Student Services/ Supervisor of Elementary School Counsellors: I am an M . A . candidate in the Department of Counselling Psychology at the University of British Columbia. Under the direction of Dr. John Allan (Faculty of Education), I am carrying out a study which will examine the role of elementary school counsellors in assisting depressed students. A review of the current literature suggests that childhood depression effects a substantial number of elementary school students. I have been awarded a research grant by the Faculty of Education, in order to complete this project. The information for this study will be obtained by asking each participant to complete a brief questionnaire specifically designed for this study. Participants wil l be asked about the practices they are currently using to assist depressed students, what they perceive their role should be in assisting depressed students, and what would be most helpful in allowing them to better assist depressed students. A summary of the results will be sent to all participating school districts. In November 1994, I wrote to you requesting a list of the E L E M E N T A R Y SCHOOL COUNSELLORS in your district, along with their mailing addresses. As I have not yet received a reply, I would like to make another request for this information. I wish to begin mailing my questionnaire by the middle of February 1995. If your district does not currently employ elementary school counsellors, or does not wish to participate, please let us know. The lists of elementary school counsellor names and addresses, or your reply, should be mailed to (NOTE: N E W ADDRESS): Dr. John Allan University of British Columbia Faculty of Education Department of Counselling Psychology 2125 Main Mal l Vancouver, B . C . V6T 1Z4 Thank-you for your cooperation and commitment to improving the effectiveness of our profession. Yours sincerely, Dr. John Allan Jackie Farquhar 102 February 10, 1995 Dear Head of Student Services/ Supervisor of Elementary School Counsellors: In January I wrote to you about a research project which wil l examine the role of British Columbia elementary school counsellors in assisting depressed students. Counsellors who participate in this study wil l be asked what they perceive their role to be in assisting depressed students, and what practices they currently use to help these students. The information will be obtained by asking elementary school counsellors to complete a brief questionnaire specifically designed for this study. I am an M . A . candidate in the Department of Counselling Psychology at the University of British Columbia, under the direction of Dr. John Allan (Faculty of Education). I have been awarded a research grant from the Faculty of Education, in order to complete this project. As mentioned above, I wrote to you in January requesting a list of the E L E M E N T A R Y SCHOOL COUNSELLORS in your district, along with their mailing addresses. As I have not yet received a reply, I would like to make a final request for this information, as I will begin mailing my questionnaire this month. Counsellors who participate in this study will anonymously return their completed questionnaires by mail, and have the right to withdraw from the study at any time. A summary of the results will be sent to all participating school districts. If your district does not currently employ elementary school counsellors, or does not wish to participate, please let us know. The lists of elementary school counsellor names and addresses, or your reply, should be mailed to (NOTE: N E W ADDRESS): Dr. John Allan University of British Columbia Faculty of Education Department of Counselling Psychology 2125 Main Mal l Vancouver, B . C . V6T 1Z4 Thank-you for your prompt reply. Yours sincerely, Dr. John Allan Jackie Farquhar A P P E N D I X B Cover Letter Questionnaire 104 February 27, 1995 Dear Colleague: I am seeking your support for a research project examining The Role of British Columbia Elementary School Counsellors in Assisting Depressed Students. At present, there are no studies which have investigated this area; therefore, I am interested in your views about this important issue. The purpose of the enclosed questionnaire is to gather information on what you believe your role should be in assisting depressed students, how you currently assist depressed students, and what factors affect your ability to help these students. This information wil l be used to make recommendations about: (a) the role of British Columbia elementary school counsellors in assisting depressed students, and (b) changes that would help counsellors to better assist these students. This project is being partially funded by a research grant from the Faculty of Education, U . B . C . I am an M . A . candidate in the Department of Counselling Psychology at U . B . C , under the supervision of Dr. John Allan (Faculty of Education; phone 822-5259). I would be grateful i f you could spare some of your time in order to complete this questionnaire. Piloting results indicate that it should take no more than 20 to 25 minutes to complete. Do not put your name on the questionnaire. When you have completed it, first place it in the provided blank envelope, and then in the pre-addressed stamped return envelope. The two envelopes wil l be separated upon receipt. This wil l ensure the confidentiality of your responses; no connection will be made between any individual and his or her responses. A l l returned questionnaires wil l be shredded, once this study has been completed. Please mail the completed questionnaire within two weeks of receiving it. Completion of the questionnaire assumes that you have consented to participating in this study. At any given time, you have the right to refuse to participate or withdraw, without any consequences to your professional status. A final report on the results wil l be forwarded to supervisors of elementary school counsellors who participate in this study. Thank-you for your time and contribution to this important issue. Yours sincerely, Dr. John Allan Dept. of Counselling Psychology University of British Columbia Psychology Jackie Farquhar M . A . Candidate Dept. of Counselling University of British Columbia BRITISH COLUMBIA ELEMENTARY SCHOOL COUNSELLOR SURVEY: Y O l ' R ROLE IN ASSISTING DEPRESSED STUDENTS Jackie Farquhar The University of British Columbia 1995 106 Page 1 BRITISH COLUMBIA ELEMENTARY SCHOOL COUNSELLOR SURVEY Dear Colleague: This questionnaire asks about your role in assisting depressed students. Although many counsellors do not specifically focus on depression, when providing services for their students, we are still interested in describing the full range of opinions, knowledge, and practices of British Columbia elementary school counsellors. A summary of the results from this study will be forwarded to elementary school counsellor supervisors in each participating school district. PART I: GENERAL INFORMATION Directions: Please fill in the appropriate responses to questions 1-11. 1) What is your sex? • male • female 2) What is your age? • 20 - 24 • 35 - 39 • 50 - 54 • 65 or more • 25 - 29 • 40 - 44 O 55 - 59 • 30 - 34 • 45 - 49 • 60 - 64 3) For what percent of time are you currently employed as an elementary school counsellor? 4) How many schools are you responsible for? 5) What is the approximate total number of students that attend the schools you are responsible for? • less than 400 0 400-799 • 800-1199 • 1200-1599 • 1600-1999 • 2000 or more 6) How many years have you been employed as an elementary school counsellor? 7) Which region of the province do you work in? O East Kootenay • Fraser Valley • North Coast • Northern Interior • West Kootenay • South Coast • Peace River • Okanagan • Mainline-Cariboo • Greater Vancouver • Vancouver Island North • Vancouver Island South 8) Which of the following degrees or diplomas do you have? • B.A. • B.Sc. • B.Ed. • B.S.W. • Other Bachelor degree • M.Ed. • M.A. • M.S.W. • M.Sc. • Other Masters degree • Ed.D. • Ph.D • Diploma in Guidance Studies PART II: CHILDHOOD DEPRESSION Many elementary school counsellors have not been given information about Major Depressive Disorder and Dysthymic Disorder, two depressive disorders which frequently occur in children. In order to have a common frame of reference for this questionnaire, student depression is defined as the presence of either of these disorders. Please use the criteria for each presented below, when answering the items in this questionnaire. 107 Page 2 MAJOR DEPRESSIVE DISORDER The presence of five (or more) of the following symptoms for at least a two week period. At least one of the five must be either (a) or (b): a) depressed mood or irritable mood b) markedly diminished interest or pleasure in activities c) significant weight change, change in appetite, or failure to make expected weight gains d) insomnia or oversleeping e) increase or decrease in psychomotor activity f) fatigue or loss of energy g) feelings of worthlessness or excessive or inappropriate guilt h) diminished ability to think or concentrate or indecisiveness i) recurrent thoughts of death, suicide ideation, or suicide attempt, or a specific plan for committing suicide (APA, 1994) * DYSTHYMIC DISORDER Depressed or irritable mood for at least half the days (183) over a one year period. During this time, the student is never free from symptoms for a period of two months or longer. Also, at least two of the following while depressed: a) poor appetite or overeating b) sleep disturbances or oversleeping c) low energy or fatigue d) low self-esteem e) poor concentration or difficulty making decisions f) feelings of hopelessness (APA, 1994) * 9) Please indicate whether or not childhood depression has been a topic in any of the following activities you have participated in: (Check the appropriate box for each item.) a) courses 1 have taken • no • yes • not sure b) workshops 1 have attended • no • yes • not sure c) discussions with colleagues • no • yes • not sure d) conferences 1 have attended • no • yes • not sure e) journals 1 have read • no • yes • not sure f) books 1 have read • no • yes • not sure g) other written materials 1 have read • no • yes • not sure h) videos or TV shows 1 have watched • no • yes • not sure i) other (please specify) 10) Prior to reading this questionnaire, had you ever been provided with the criteria for Major Depressive Disorder? • no • yes • not sure 11) Prior to reading this questionnaire, had you ever been provided with the criteria for Dysthymic Disorder? • no • yes • not sure 108 Page 3 PART 111: COUNSELLOR ROLE IN ASSISTING DEPRESSED STUDENTS NOTE: PLEASE USE THE FOLLOWING DEFINITIONS WHEN ANSWERING THE REMAINDER OF THE QUESTIONS. IDENTIFICATION Identification is recognizing that a student's symptoms or behaviours may be indicative of Major Depressive Disorder or Dysthymic Disorder. ASSESSMENT Assessment of a student is using a specific instrument or set of criteria to determine whether or not a student is actually depressed. Examples: Children's Depression Inventory. DSM-IV criteria for Major Depressive Disorder and Dysthymic Disorder provided earlier. TREATMENT Treatment is providing intervention for students who either you or someone else had identified as being depressed. Examples: Art therapy and cognitive behavioral therapy. PREVENTION Prevention is participating in activities aimed at preventing student depression. Examples: Monitoring an abused child for symptoms of depression. Educating other staff members about childhood depression. 12) Here are some potential school counsellor functions. Please indicate which, if any, you believe should be part of the ideal role of elementary school counsellors: a) identifying depressed students • no • yes b) assessing students for depression O no • yes c) treating depressed students O no • yes d) referring depressed students to other professionals or agencies • no • yes e) engaging in prevention activities • no • yes 13) Please indicate whether or not the following potential counsellor functions are part of your current role as an elementary school counsellor: a) identifying depressed students • no • yes b) assessing students for depression O no • yes c) treating depressed students • no • yes d) referring depressed students to other professionals or agencies • no • yes e) engaging in prevention activities • no • yes 109 Page 4 14) During the past two years, did you identify any students who you suspected or knew were depressed? • yes • no - if no, please go to Question #18 15) During the past two years, approximately how many of these students did you identify? (specify number) 16) After having read the criteria for Major Depressive Disorder and Dysthymic Disorder, to what extent would you change, or not change, your estimate of the number of students you saw during the last two years, who may have been depressed? • much less than I identified • somewhat less than I identified • no change • somewhat more than I identified • many more than I identified 17) Depressed students may come to your attention in a number of ways. Please indicate which of the following referred the students in question #15 to you: a) student's parentis) • no • yes b) student came to see me • no • yes c) principal • no • yes d) school based team • no • yes e) teacher • no • yes f) school psychologist • no • yes g) other students • no • yes h) other (please specify) 18) Please indicate the extent to which each of the following is, or is not, a barrier to your identifying depressed students: (Check the box which is most applicable for each item.) not a barrier small barrier moderate barrier large barflec not enough time lack of knowledge about childhood depression being new to the school(s) lack of referral by teachers uncertainty about whether identification of depressed students is part of my role loo l.ir'i" a iiinem-io-counM."! <r i.it o priority i- . j iM-n to stud"nti t-.ho act nut other (please specify) 110 Page 5 19) During the last two years, have you assessed students for depression? • yes O no - if no, go to Question # 21 20) Please indicate how you assessed these students? a) used a standardized instrument such as the Children's Depression Inventory • no • yes b) used DSM-III-R or DSM-IV criteria for Major Depressive Disorder or Dysthymic Disorder • no O yes c) used projective techniques such as the House-tree-person • no • yes 21) Please indicate the extent to which each of the following is, or is not a barrier to your assessing students: not a barrier small barrier moderate barrier ; large barrier parent reluctance to have student assessed lack of knowledge about how to use assessment instruments/criteria too large a student-to-counselior ratio lack of time uncertainty about whether assessment of students is part of my role other (please specify) 22) Treatment is providing intervention for students who are depressed. During the last two years, have you treated depressed students? • yes • no - if no, go to Question #24 23) Have you found any methods to be more effective than others when treating depressed students? • no • yes (please list which ones) I l l Page 6 24) Please indicate the extent to which each of the following is, or is not, a barrier to your treating depressed students: not a barrier smalt barrier moderate barrier targe barrier priority being given to acting out students lack of adequate facilities lack of knowledge about effective treatment strategies uncertainty about my role in treating depressed students lack of time too high a student-to-counsellor ratio noncooperation of professionals within the school system noncooperation of community professionals parent reluctance to have student treated other (please specify) 25) During the past two years, have you referred students who you suspect are depressed to other professionals or agencies? • yes • no - if no, go to Question #27 26) Please indicate to which of the following professionals or agencies you have referred the students in Question #29: a) school based team • no • yes b) hospital • no • yes c) psychiatrist • no • yes d) medical doctor • no • yes e) school nurse • no • yes f) private therapist • no • yes g) mental health agency • no • yes h) other (please specify) Page 7 Please indicate the extent to which each of the following is, or is not, a barrier to your referring depressed students: not a barrier small barrier moderate barrier (arg'e.barfief . lack of cooperation from community professionals/agencies lack of community resources for depressed students too high a student-to-counsellor - - ' ratio - •' '• length of wait lists for community resources lack of knowledge about community resources that rrt3y be ainilnhk-lack of knowledge about criteria for L h i l ili-»• i l i1«nif'.ion other (please specify) Have you engaged in activities specifically aimed at preventing student depression during the past two years? • yes • no - if no, please go to Question #30 Please indicate which, if any, of the following activities aimed at preventing depression you have engaged in during the last two years: a) educating students about depression • no • yes b) educating other staff members about childhood depression • no • yes c) providing counselling for students at risk for developing depression• no • yes d) developing students' social skills • no • yes e) developing students' problem -solving strategies • no Dyes Monitoring any of the following groups of students for symptoms of depression: f) students from single parent families • no • yes g) students who have been physically or sexually abused • no • yes h) students with a parent who is depressed • no • yes i) students who have previously been depressed D no • yes 113 Page 8 30) Please indicate the extent to which each of the following is, or is not, a barrier to your engaging in activities aimed at preventing student depression: not a barrier small barrier moderate barrier large barrier lack of appropriate facilities lack of time uncertainty about my role in preventing student depression too large a student-to-counsellor ratio lack of knowledge about childhood depression working with other professionals within the school system parentis) refusal to have student - participate ' ' - — other (please specify) 31) Here are some possible ways of addressing barriers counsellors may experience when assisting depressed students. Please indicate, using a check mark, which would help you to better assist depressed students: a) more information on childhood depression b) more information on counselling techniques which are effective in assisting depressed students c) more knowledge about available community resources for depressed students d) more time for prevention activities e) workshops and seminars on childhood depression f) a team approach to childhood depression with community and school personnel g) a clear policy on the role of elementary school counsellors in assisting depressed students h) a reduction in student-to-counsellor ratio i) an increase in community resources for depressed students j) greater community awareness about childhood depression _ k) greater staff awareness about childhood depression I) more information on effective assessment techniques for childhood depression m) more appropriate space for working with students n) shorter wait lists for community resources o) training on how to assess students for depression p) less priority being given to acting out students q) other r) other 32 Of the options you checked in question #31, please indicate, by letter, which FIVE would be most helpful to you in assisting depressed students, (i.e., w; z; v; x; u). 114 Page 9 33) Is there anything else, that we have not asked, that you think we should know? * American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). APPENDIX C First Follow-up Letter Second Follow-up Letter 116 April 10, 1995 Dear Counsellor: We hope that you had a relaxing and enjoyable Spring Break. In March, we sent you a questionnaire entitled The Role of British Columbia Elementary School Counsellors in Assisting Depressed Students. We would be grateful i f you could take the time to complete and return the questionnaire within the next week. So far, about 48% of the questionnaires have been returned. Your voice on this issue is important, as we would like to hear from all elementary school counsellors. This would make our results truly representative of the whole province. Thank you for taking the time to participate in this study. Yours sincerely, Dr. John Allan Department of Counselling Psychology, U . B . C . Jackie Farquhar M . A . Candidate Department of Counselling Psychology, U . B . C . 117 May 8, 1995 Dear Counsellor: In March we sent the enclosed questionnaire to you as part of a study on The Role of British Columbia Elementary School Counsellors in Assisting Depressed Students. This questionnaire was mailed to 337 elementary school counsellors. At present, about 38% of you have not yet voiced your views on what you believe your role should be. Your participation is important, because we wish our results to accurately reflect the complete range of opinions and practices that currently exist in the province. The validity of our results diminishes with each counsellor that does not participate. Childhood depression is a serious problem that is beginning to be addressed by various professions and organizations. Therefore, the results of this study wil l be sent to each school district, the B . C . S . C . A . , the B . C . T . F . , the Ministry of Education, and the Ministry of Health, and may have a direct impact on your future role. Thus, it is important that our report be truly representative of aU British Columbia elementary school counsellors. We would greatly appreciate your taking the time to complete this questionnaire. If you have already done so, we thank you for your participation. Sincerely yours, Dr. John Allan Jackie Farquhar 

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