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Final Report

Choosing Healthy Actions and Thoughts (CHAT): A randomized trial of the influence of a school-based

universal mental health promotion program on depressive symptomatology and associated cognitive

and behavioral mediators

RG 160106-023

Co-Principal Investigators:

Kathryn Short, Ph.D., C. Psych. Evidence-Based Education and Services Team

Hamilton-Wentworth District School Board

Charles Cunningham, Ph.D. Department of Psychiatry and Behavioural Neurosciences

Jack Laidlaw Chair in Patient Centred Health Care Faculty of Health Sciences, McMaster University

Offord Centre for Child Studies

Co-Investigator:

Michael Boyle, Ph.D. Canada Research Chair in the Social Determinants of Child Health

Professor, Psychiatry & Behavioural Neurosciences, McMaster University Offord Centre for Child Studies

A Collaboration between the Hamilton-Wentworth District School Board and Hamilton Health Sciences

Submitted to the Provincial Centre of Excellence for Child and Youth Mental Health at CHEO

October 15, 2009

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The CHAT Team CHAT Steering Committee Charles Cunningham, Psychology, Hamilton Health Sciences Kathy Short, E-BEST, HWDSB Michelle Bates, Social Work, HWDSB Anne Chaffee, Psychology, HWDSB Lesley Cunningham, Social Work, HWDSB Tracy Weaver, E-BEST, HWDSB CHAT Advisors Michael Boyle, Hamilton Health Sciences Antonio Polo, University of Chicago John Weisz, Judge Baker Children’s Center, Harvard Medical School CHAT Facilitators Katherine Anderson, Teacher, HWDSB Richard Brooks, Teacher, HWDSB Suzanne Brown, Teacher, HWDSB Danielle Buist, Psychology, HWDSB Roma Buwalda, Teacher, HWDSB Lois Campbell, Psychology, HWDSB Heather Carter, Psychology, HWDSB Jeff Child, Teacher, HWDSB Andrea D'Addario, Psychology, HWDSB Catriona Decaire, Teacher, HWDSB Bruna DiFlavio, Teacher, HWDSB Vicki Earle, Social Work, HWDSB Rose Giammichele, Teacher, HWDSB Diana Feltham, Teacher HWDSB Bruno Galassi, Teacher, HWDSB Gail Glenny-Burke, Social Work, HWDSB Suzy Graham, Teacher, HWDSB Carni Grewal, Teacher, HWDSB Joel Gunell, Teacher, HWDSB Matt Henry, Teacher, HWDSB Michelle Hudon, Teacher, HWDSB Bill Hughey, Teacher, HWDSB Alison Hutchinson, Teacher, HWDSB Shayla Kellie, Teacher, HWDSB

Maxine Lane, Social Work, HWDSB Dorothy Lo, Teacher, HWDSB Heather MacGillvary, Teacher, HWDSB Sue Mackrory, Teacher, HWDSB Paul Menicanin, Teacher, HWDSB Steve McCann, Social Work, HWDSB Julie Morgan, Social Work, HWDSB Ben Nywening, Social Work, HWDSB Eileen O’Shea, Social Work, HWDSB Laura Pergentile, Teacher, HWDSB Ashleigh Reynolds, Teacher, HWDSB Elaine Saunders, Psychology, HWDSB Diane Sayers, Social Work, HWDSB Dale Scott, Teacher, HWDSB Randy Shiga, Social Work, HWDSB Carla Sikora, Teacher, HWDSB Theresia Stephens, Teacher, HWDSB Nelson Stewart, Teacher, HWDSB Lori Swarz, Psychology, HWDSB Sue Terzis, Teacher, HWDSB Sarah Vanderkooy, Social Work, HWDSB Julie Warriner, Teacher, HWDSB Dave Wilkinson, Teacher, HWDSB Jessica Whittle, Teacher, HWDSB

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CHAT Students Heather Bucciachio, E-BEST, McMaster Applied Research Practicum Student Aarti Chelliah, E-BEST, McMaster Applied Research Practicum Student Laura Cook, Social Work Student, McMaster University Amanda Kalbfleisch, E-BEST, McMaster Applied Research Practicum Student Bernice Kan, E-BEST, McMaster Applied Research Practicum Student Soula Kritikos, E-BEST, McMaster Applied Research Practicum Student Leilani Llacuna, E-BEST, McMaster Applied Research Practicum Student Leslee Lovelace, Social Work Student, McMaster University Andrea Markovic, E-BEST, McMaster Applied Research Practicum Student Rachel McVittie, E-BEST, Honours Thesis Student, Psychology, McMaster University Michelle Mulock, E-BEST, McMaster Applied Research Practicum Student Caroline Parkin, E-BEST, Postdoctoral student, Offord Centre for Child Studies Amanda Semley, Social Work Student, McMaster University Julia Smith, E-BEST, McMaster Applied Research Practicum Student Jennifer Tekpetey, E-BEST, McMaster Applied Research Practicum Student Andrea Zimmerman, Social Work Student, McMaster University Other Contributions Social Work Services - leadership with respect to implementing the high-risk protocol Control School Teachers – facilitated CHAT measurement with grade 7 and 8 classes Grade 8 Teachers – facilitated 6 and 12 month follow-up testing with their classes E-BEST – data extraction and management

The CHAT Steering Committee would like to express thanks to everyone who contributed to this initiative. We are extremely grateful for the passion and care

that each individual brought to this work.

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Choosing Healthy Actions and Thoughts (CHAT): A randomized trial of the influence of a school-based universal mental health promotion

program on depressive symptomatology and associated cognitive and behavioral mediators

Executive Summary

Though childhood depression can be serious and difficult to treat (Weisz et al., 1997), many children respond positively to cognitive behavior therapy (Lewinsohn & Clarke, 1999; Michael & Crowley, 2002; Weisz et al., 2006). Attempting to intervene early,

before negative depressive cycles begin, holds much appeal. Providing such programming universally, in school settings, can offer benefits for the many children

who never seek treatment for their emotional struggles. Depression prevention studies, while promising, have yielded mixed findings (Merry et al., 2004). Programs of longer

duration, facilitated by trained mental health professionals, within organizationally ready school settings require testing (Pössel, 2005). In this randomized trial, Choosing

Healthy Actions and Thoughts (CHAT), a school-based universal depression prevention program, was tested. 1183 students from 25 schools participated over the two years of

the CHAT trial. Students randomized to CHAT received 20 classroom sessions designed to prevent the onset of depression and related internalizing disorders. Before

and after the program, and at 6 and 12-month follow-up, students completed questionnaires related to coping strategies, mood/anxiety, and hope. Parents also reported on child symptomatology and indicators of academic functioning, such as

student attendance and report card grades, were examined. To support the dissemination of this program, consumer preference modeling methods were used to

simulate an optimal implementation strategy.

The primary analyses from this study reveal that students both the CHAT and Usual Class condition reported similar progress with respect to their self-ratings of mood, anxiety, coping skills, and hope. Both groups showed similar gains in their social –emotional development over the course of the trial. Though the primary results are disappointing, they align with an emerging literature in this area. Study limitations,

interpretations and next steps are described. In addition, lessons learned, and enablers and barriers to implementation of a manualized mental health promotion program in

school settings, are articulated. Secondary analysis, including academic indicator data (attendance, report card grades, learning skills), and subgroup analyses, will be detailed

in a separate report.

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Choosing Healthy Actions and Thoughts (CHAT): A randomized trial of the influence of a school-based universal mental health promotion

program on depressive symptomatology and associated cognitive and behavioral mediators

FINAL REPORT Depression is prevalent amongst children and youth Depression affects 1 in 5 Canadian children (Milin, Walker, & Chow, 2003). Moreover, 33% of Canadian youth report feelings of distress in their daily lives (Manion, Davidson, Clark, Norris, & Brandon, 1997). Untreated, depression can become more persistent and severe (Lewinson & Clarke, 1999), resulting in significant personal impairment and societal costs (Costello et al., 2002; Fergusson, Horwood, Ridder, & Beautrais, 2005; Foster, 2005). By 2020, this disorder is expected to become the second leading cause of disability worldwide (Murray & Lopez, 1996). The link between depressed mood and suicidal behavior makes these statistics even more concerning (Bostwick & Pancratz, 2000). In the U.S. and Canada, 19% of youth report suicidal ideation (Grunbaum et al., 2002; Manion et al., 1997); suicide is the second leading cause of death among Canadian adolescents (Health Canada, 1999). Psychosocial interventions work Psychosocial interventions based on cognitive behavioral (CBT) principles have emerged as a promising approach to the treatment and prevention of depressive disorders (Clarke et al., 2001; Kazdin & Weisz, 1998; Seligman, 1995; Waddell, Hua, Garland, Peters, & McEwen, 2004; Weisz, McCarty, & Valeri, 2006). Although early systematic reviews of CBT trials for children’s depression revealed impressive results (Lewinsohn & Clarke, 1999; Michael & Crowley, 2002; Reinecke, Ryan, & DuBois, 1998), more recent reviews show more modest, but still robust, outcomes (Weisz, McCarty, & Valeri, 2006). Children and youth do not tend to access treatment Despite the availability of effective interventions, few depressed children receive treatment (Leaf et al., 1996; Links, Boyle, & Offord, 1989; Rohde et al., 1991). Moreover, because of embarrassment, peer pressure, and social stigma, 43% of youth report they would not seek help with stress and mood from mental health professionals (Manion et al., 1997). The development of effective prevention programs is, therefore, critical (Canadian Institute for Health Information, 2009; O’Connell, Boat & Warner, 2009; Offord, Kraemer, Chmura, Kazdin, Jensen, & Harrington, 1998). Indeed, the National Institute of Mental Health (NIMH) Psychosocial Intervention Development Workgroup (Hollon, 2002) recommended that preventing the onset and recurrence of depressive episodes was a key priority.

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Can youth depression be prevented? Several research teams working with at risk youth have developed promising depression prevention programs (Clarke et al., 2001; Beardslee & MacMillan, 1993; Cardemil, Reivich, & Seligman, 2002; Weisz, 2006; Greenberg, Domitrovich, & Bumbarger, 2001). These studies suggest that increasing cognitive and behavioral coping skills reduces depressive symptoms (Munoz et al., 1993; Gillham, Shatte, & Freres, 2000) and curtails the onset of clinical episodes (Clarke et al., 1995, 2001; Seligman, Schulman, DeRubeis, & Hollon, 1999). In a randomized trial, for example, Cardemil et al., (2002) showed that a 12-week group focusing on explanatory style, goal setting and problem solving reduced negative cognitions, hopelessness, and depressive symptoms. The program was effective for children with both mild and severe mood difficulties and gains were maintained at 6-month follow-up. While prevention programs targeting high risk youth are promising, there is increasing interest in universal delivery of depression prevention programs (Pössel, 2005) and school-based mental health promotion services that bolster protective factors (Browne, Gafni, Roberts, & Byrne, 2004; Herman, Merrell, Reinke, & Tucker, 2004; Levesque & Manion, 2006; Storch & Crisp, 2004). Schools are especially well-positioned for mental health promotion Given that children and youth spend a substantial part of each day within the school setting, these communities become a natural and important venue for mental health service delivery (Canadian Council on Learning, 2009; Minister’s Advisory Group, 2009). In their Final Report of the Standing Senate Committee on Social Affairs, Science and Technology, Senators Kirby and Keon state that the potential for this platform for mental health promotion should be recognized and that, in fact, the “development of the school as a site for the effective delivery of mental health services is essential” (Kirby & Keon, 2006, p. 138). Schools are an important venue for universal mental health promotion for several reasons (Kirby & Keon, 2006; Levesque & Manion, 2006; Meldrum, Venn, & Kutcher, 2009). (1) School-based services have the potential to maximize positive mental health development for all children. (2) Universal programs reduce the logistical barriers limiting service utilization (Kazdin, Holland, & Crowley, 1997), and eliminate the stigma associated with programs targeting high-risk youth, these programs may be especially pivotal for students who avoid seeking treatment (Burns, et. al., 1999; Hoagwood & Olin, 2002; Kratochwill & Shernoff, 2003). (3) Because attendance and classroom expectations support course and homework completion, students are more likely than clinic-referred children to receive a critical dose of the intervention and less likely to discontinue treatment (Kazdin et. al., 1997; Kazdin, Mazurick, & Bass, 1993). (4) Universal programs can encourage peers to address the school-based social processes (e.g. bullying or social isolation) that may contribute to depressive episodes (Kaltiala-Heino et al., 1999). (5) Higher risk students may benefit from observing emotionally skilled peers model good coping behavior and attitudes (Lowry-Webster, Barrett, & Dadds, 2001).

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Does school-based depression prevention programming work? A recent review of school-based interventions designed to enhance academic, social, and emotional learning revealed that these programs yield significant benefits (Payton, et al, 2008). Recognizing the potential of universal school-based programs, teams from Australia (Merry, McDowell, Wild, Bir, & Cunliffe, 2004; Shochet et al., 2001; Spence, Sheffield, & Donovan, 2005), Germany (Pössel, Horn, Groen, & Hautzinger, 2004), the U.S. (Clarke et al., 1995, 2001; Freres, Gillham, Reivich, & Shatte, 2002) and Canada (Short & Cunningham, 2003; Short, 2005) have explored the delivery of skills-based cognitive and behavioral coping programs to combat depression in schools. Most of these programs are designed for students in 7th to 10th grade, and teach CBT-based skills such as increasing pleasant activities, problem-solving, and cognitive reappraisal of negative events (Pössel, 2005). Jane-Llopis et al. (2003) reported an average effect size of 0.31 for universal depression prevention programs. More effective programs included competence-enhancing techniques, involved more than 8 sessions, and were delivered by a health care provider. More recent reviews, however, suggest that, although some early results showed promise, considerable study is required before these programs could be recommended (Horowitz & Garber, 2006; Merry, McDowell, Hetrick, Bir & Muller, 2004; Payton et al., 2008). Spence and colleagues (2005), for example, reported that the initial benefits of an 8-week, teacher-led, program were not sustained at 2, 3, and 4-year follow-up. Such findings have led some researchers to question the value of universal depression prevention, given the resource investment required (Spence & Shortt, 2007). Several factors may have limited the impact of the universal school-based depression prevention programs studied to date. First, although the duration of these programs ranged from 8 to 15 sessions, longer more intensive programs appear to yield better outcomes (Pössel, 2005). Second, although classroom teachers conducted a number of school-based prevention programs, systematic reviews suggest that mental health professionals obtain larger effects (Pössel, 2005). Third, many studies have employed a narrow range of outcome measures (Burns et. al., 1999). CBT, however, may have much broader effects. CBT for anxiety disorders, for example, yields a significant reduction in depressive symptoms (Barrett, Duffy, Dadds, & Rapee, 2001; Flannery-Schroeder, Choudhury, & Kendall, 2005; Kendall et al., 1997; Manassis et al., 2002; Mendlowitz et al., 1999; Muris, Meesters, & Melick, 2002). Similarly, CBT for depression reduces symptoms of anxiety (Weisz et al., 2006). Finally, we do not know the extent to which organizational and facilitator receptivity limited the implementation and dissemination of these programs (Barwick et al., 2005; Botvin, 2004; Dusenbury & Hansen, 2004; Greenberg, 2004; Pentz, 2004). A trial, exploring a more intensive classroom-based depression prevention program is warranted. The present study examines outcomes associated with this type of program, Choosing Healthy Actions and Thoughts (CHAT).

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The CHAT program The CHAT program is a video-guided, coping skills program developed for middle school youth. It is rooted in Act and Adapt, which is a clinical program designed to help at-risk children to manage academic and social stress and to prevent the onset of mood problems (Weisz et al., 1997; Weisz, Southam-Gerow, Gordis & Connor-Smith, 2003). Two types of skills are emphasized: behavioural (ACT) strategies to address controllable stress, and cognitive (ADAPT) strategies to help change negative thinking patterns when situations cannot be changed. With close consultation and support from Dr. Weisz, the Act and Adapt program was translated into an approach that could be delivered universally in classrooms. It was piloted within the Hamilton-Wentworth District School Board (HWDSB), in grade seven classes, over three years. The most recent version of the CHAT program has been matched to expectations from the Ontario Curriculum and session lengths have been modified to suit school schedules. CHAT Staffing A .5 FTE Project Coordinator and a .25 FTE Project Assistant supported the CHAT trial. In addition, in 2006-2007, 18 mental health consultants from HWDSB Psychological Services (7) and Social Work Services (11), and 18 grade seven teachers, served as the Program Implementation Team in schools. In 2007-2008, 16 consultants (7 psychological consultants and 9 social workers) and 16 teachers were involved as program facilitators. A Research Team that included the co-Principal Investigators, the Project Coordinator and two program co-facilitators was also created for the project. This Team met regularly throughout the trial to ensure that research and program protocols were followed. Decisions, and particularly protocol violations, were documented. McMaster University students who were completing practica within Social Work or E-BEST were invited to attend research meetings as part of their training program. In addition, a fourth year thesis student working with E-BEST, who completed a study related to modeling of educator preferences for depression prevention programming, participated in research meetings during 2007-2008. CHAT Training and Support All facilitators attended a full-day training workshop in October 2006 and November 2007. During this session, participants:

were oriented to issues related to adolescent depression, received overview information about cognitive-behavioral interventions, learned about the CHAT program and viewed related session materials, observed live session role-plays, planned a session with their co-facilitator, presented their session to the training group, and received constructive feedback.

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CHAT Implementation during the RCT Two cohorts of students participated in the trial. From October 2006 through April 2007, and November 2007 through May 2008, in CHAT condition classes, the classroom teacher and a mental health facilitator collaboratively delivered the program in 20 sessions during regular curriculum time (typically, 45-minute, weekly sessions). In each session students watched a video segment, discussed the situation and its relation to their own experiences, and discussed alternative ways of coping. Students practiced skills in role-playing exercises and completed homework to consolidate learning. Weekly information sheets informed parents about the CHAT skills that students were learning, and suggested ways to encourage the use of these strategies at home. Instead of CHAT, students assigned to the Usual Class condition participated in Teacher Advisor Group or Health and Physical Education programming. The individual teacher designs the content for this class. In some cases, packaged social skills or career building programs are used, but not always. Project Summary and Hypotheses The primary outcome of this study is to provide evidence related to the effectiveness and feasibility of CHAT as a school-based mental health promotion program. A secondary, related, outcome emerges from an examination of consumer preferences about implementation of evidence-based approaches to enhancing social emotional learning in the school setting. The information gathered through these innovative methods will assist in further refinements to the CHAT program and in the marketing of such programs within the educator, parent and student audience. Primary Outcome

1. Students in classes randomized to CHAT will report fewer depressive and anxious symptoms than students in classes randomized to Usual Class.

Secondary Outcomes

1. Students in classes randomized to CHAT will report using more primary and secondary control enhancement skills, and higher hope scores, than students in classes randomized to Usual Class.

2. Students in classes randomized to CHAT will exhibit better attendance, higher

grades, and stronger composite student learning skills than students in classes randomized to Usual Class.

3. Parents of students in CHAT will report that their child shows fewer depressive and

anxious symptoms than those in Usual Class.

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Methods Recruitment In spring 2006, all HWDSB principals were made aware of the CHAT trial. There were 53 eligible schools in the district (i.e., schools with grade seven classes) and follow-up contacts were made with principals in each of these schools. An information session was held for interested schools and, upon request, individual school visits were made to provide additional detail to middle school staff. Information about the program was also posted on the HWDSB internal communication system. In total, 20 schools committed to participation in 2006-2007. For the second cohort, all schools that participated in the trial the previous year were invited to continue. Other schools that expressed an interest in CHAT were also included. 14 schools participated in 2007-2008. Randomization Classrooms were randomly assigned to the CHAT or Usual Class condition. In 2006-2007, 14 of the 20 schools had two grade seven classes. In these cases, one class was randomly assigned to CHAT, and one was assigned to Usual Class. Two schools had three classes. In these cases, each class was randomly assigned to CHAT or Usual Condition. The four remaining schools had only one grade seven class. Some of these classes were used to serve as an alternate condition for the “orphan” classes that emerged in the step above. Every attempt was made to find a demographically matched pairing. The schools and randomization results are listed below: CHAT Condition Usual Class Condition A.A. Greenleaf 1 class 1 class Balaclava 1 class (for Flam. Ctr.) Chedoke 1 class 1 class Dalewood 1 class (for Mt. Hope) Eastdale 1 class Flamborough Centre 2 classes 1 class Gatestone 1 class 1 class Highview 1 class 1 class Lawfield 1 class 1 class Lisgar 1 class 1 class Memorial* (Hamilton) 1 class 1 class Mountain View 1 class 1 class Mount Albion 1 class 1 class Mount Hope* 1 class Queen Mary 1 class 2 classes (1 for Eastdale) R.A. Riddell 1 class 1 class Ryerson 1 class 1 class Templemead 1 class 1 class Viscount Montgomery 1 class 1 class Winona 1 class 1 class 19 classes 19 classes * school dropped out of the trial

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In 2007-2008, there were 16 participating classes, in 14 schools. The school randomization is detailed in the table below: CHAT Condition Usual Class Condition A.A. Greenleaf 1 class 1 class Cardinal Heights 2 classes 2 classes Chedoke 1 class 1 class Eastdale 1 class Flamborough Centre 1 class 1 class Highview 1 class 1 class Hillcrest 2 classes 2 classes Memorial (Hamilton) 1 class 1 class Memorial (Stoney Creek) 1 class 1 class Queen Mary 1 class 1 class Ryerson 1 class 1 class Sanford 1 class 1 class Templemead 1 class 2 classes

(1 for Eastdale) W.H. Ballard 1 class 1 class 16 classes 16 classes Study Design The study was conducted using two cohorts; one began in Fall 2006, and one in Fall 2007. CHAT was delivered, weekly, from October/November through April/May. Dependent measures were collected before the program began, at the completion of the program, and six and twelve months following program termination. Attendance and report card data has been extracted on participating students for each year that they were in the trial. Tracking and fidelity checks were done during program implementation. The protocol is illustrated below: Pre-Test Post-Test 6 month

Follow-Up 12 month Follow-Up

CHAT Mood Anxiety Coping Hope

Attendance Report Cards

Mood Anxiety Coping Hope



Usual Class


Attendance Report Cards




Data was gathered from students using on-line survey technology (Perseus Software, housed within HWDSB firewall). The questionnaire package was group administered, in the school’s computer lab, with a CHAT Research Team member reading each item aloud to ensure student understanding and secure responding. Students entered their own participant code, date of birth, and gender prior to completing the questionnaire items.

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Measurement Students completed the following questionnaires: Children’s Depression Inventory Revised Children’s Anxiety and Depression Scale Perceived Control Scale for Children Secondary Control Scale for Children Children’s Hope Scale Parents of participating students were also invited to provide information during the trial. Questionnaire packages were sent home in sealed envelopes with students, and were returned directly to E-BEST by mail. Parents completed the following questionnaires: Children’s Depression Inventory – parent version Student Help Questionnaire (information re: treatment for psychological / medical problems) Depression. To be consistent with Act and Adapt protocols in Boston, the Child Depression Inventory (CDI) was used (Kovacs, 1980). The CDI is a 27-item scale tapping affective, behavioral and cognitive domains. It has solid psychometric properties within non-clinical populations, and is sensitive to treatment effects (Carey et al., 1987; Saylor, Finch, Spirito, & Bennett, 1984). Because the study was conducted universally, in a public school setting, the question referring to suicidal ideation was deleted (α=.88-91; Cole & Jordan, 1995; Cole & Martin, 2005). The parent version of the CDI was also administered (Appendix A). This scale is stable over time (r=.74) and internally consistent (α=.85-.87; Cole et al., 1998; Cole, Hoffman, Tram, & Maxwell, 2000; Wierzbicki, 1987). Parents were also asked about their child’s mental health history and use of mental health services (Appendix B). Composite Depression and Anxiety. Though highly correlated with the CDI (r=.84, p<.01), the RCADS is more closely tied to DSM-IV diagnoses and measures a wider range of anxiety disorders (e.g. separation anxiety disorder, social phobia, generalized anxiety disorder) (Appendix C). The psychometric properties of this 47-item scale have been proven in both community (Chorpita et al., 2000; de Ross, Gullone, & Chorpita, 2002) and clinic samples (Chorpita, Moffitt, & Gray, 2005) (e.g.,α=.78-.88). Behavioral and Cognitive Coping. CHAT teaches students to solve problems, increase pleasant events, set goals, and relax. It is hypothesized that CHAT prevents depression, and possibly anxiety, via these mediating skills. Coping behavior was measured using the 24-item Perceived Control Scale for Children (Weisz, Southam-Gerow, & McCarty, 2001; Appendix D). In previous pilots, test-retest reliability was .73, and α=.87-.91. This is comparable to other studies using this measure (e.g., α=.88; Weisz et al., 2001). Cognitive coping skill was measured using Weisz’s 20-item Secondary Control Scale for Children (Appendix E). In prior pilots internal consistency was .92-.94 and test-retest reliability was .73.

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Hope. Hopefulness is a protective factor for depression (Stark & Boswell, 2001; Seligman, 1995). It was hypothesized that CHAT would improve hope, which could mediate reductions in depressive symptoms. A brief 6-item version of The Children’s Hope Scale was used in this trial (Snyder et al., 1991; Snyder, Hoza, Pelham, et al., 1997; α=.70-.86; Appendix F). Student Attendance. As students learn to manage stressors, it is anticipated that health and school attendance should improve. Moreover, attendance should incrase if the program reduces depressive symptoms such as fatigue and negative self-worth (Kearney, 2001). Attendance records for each student participating in the trial were retrieved from the HWDSB Student Information System. The data was aggregated by month, and reviewed by cohort and condition for both the CHAT year (grade 7) and the follow-up year (grade 8). Academic Achievement. The literature suggests that students experiencing depression perform more poorly in school (Cole, 1990; Forehand, Long, Brody, & Fauber, 1986; Kovac & Devlin, 1998; Schwartz, Gorman, Nakomoto, & Toblin, 2005). Further, even non-depressed students can struggle in school because of emotional difficulties (Chapell et al., 2005). Report card grades and teacher-ratings of learning skills (Ontario Ministry of Education, 1998; α=.94, HWDSB) were used as markers of academic achievement. Program Benchmarks. Implementation issues are critical in bringing an evidence-based program to scale in a school district setting. In order to capture the practical issues emerging, following each session, the co-facilitation team met to debrief the strengths and weaknesses of the lesson. At that time, they were asked to record the degree to which they reached each of the specified session benchmarks. They were also encouraged to provide comments, with a view to informing any necessary program modifications and identifying potential barriers to future implementation (i.e., “If you omitted an activity, or departed from the manual in some way, please tell us why”). Facilitators were also asked to rate student classroom behavior on a scale of 1 to 5 during each session (Appendix G). Program Fidelity. In an attempt to ensure that the CHAT condition was indeed distinct from the Usual Care condition, trained McMaster University students interviewed teachers in both types of classes about the content of their Teacher Advisor Group instruction. Specifically, teachers were asked to report on the degree to which they offered instruction, “within the past week”, on five of the ACT and five of the ADAPT skills (Appendix H).

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Ethical Considerations This study was reviewed and approved by the Hamilton Health Sciences Research Ethics Board. Student and parent participation in the trial was voluntary, and parents had the option to indicate that they would prefer that their child not be involved in the CHAT program at all. Across 18 schools, and approximately 350 students, only 1 parent asked that their child be transferred to another TAG class during CHAT time (because that child had just experienced a trauma and was deemed fragile). Parents were advised that there are no negative outcomes (i.e. lower grades for their child) should they choose not to participate in, or withdraw from, the study. They were also informed that, should they provide consent for their child to participate in the evaluation; their child would also be asked to give assent. Although consent forms assured parents of privacy and confidentiality, they were advised that in high-risk situations (i.e. their child scores in the clinical range on the CDI, or child abuse is suspected), confidentiality would not be maintained. According to the high-risk protocol (see below), students with CDI scores more than 1.5 standard deviations above the mean were referred to the school Social Worker for follow-up with parents. Risks to participating were considered minimal. Students may have experienced discomfort with some questions, but they were told that they were free to skip items or withdraw from the study at any point. Social risks were kept to a minimum by ensuring privacy when filling out the questionnaires. Students were seated at computer terminals so that peers were unable to read their answers. There was no identifying information on the questionnaires. Data is presented anonymously in aggregate form. No deception was used in this research. Participants may have benefited from their involvement in that strategies for managing mood were reinforced on questionnaires. In addition, some students may have used this as an opportunity to ask for help, possibly receiving intervention earlier than they otherwise might have. This evaluation will assist the HWDSB in determining how to effectively teach students coping skills within a school setting. The larger scientific community will benefit from learning about the effectiveness of a universal mood management program and dissemination/knowledge uptake of evidence-based practices within a school setting. High-Risk Protocol It was anticipated, given the base rates for adolescent depression, that data collection for this study would uncover several students reporting a depressed mood. This possibility was raised with parents and with students during the consent/assent protocols. They were informed that if a child scored above a certain threshold on our questionnaire about depression, then the school’s Social Worker would contact the parent and would let them know about this situation and about potential resources that could be accessed for assistance. Students who scored 1.5 standard deviations or more above the mean on the Children’s Depression Inventory were flagged for this high-risk protocol.

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Modelling the Prevention Program Design Preferences of Educators Coinciding with the randomized trial, consumer preference modeling techniques were used to involve educators in the design of an optimal approach to the delivery of this type of school-based prevention program. Teachers and school-based mental health professionals were invited to complete an on-line discrete choice experiment (DCE). In DCEs, informants choose between multi-attribute service options (Orme, 2005; Ryan & Farrar, 2000). Because choice tasks prompt a consideration of the tradeoffs of competing alternatives, limit superficial processing, reduce social desirability biases, and mimic real world decisions, they are better approach to preferences than ratings (Phillips, Johnson, & Maddala, 2002; Ryan et al., 2001). These methods have been used to study children’s mental health services (Cunningham, et al., 2003; 2005a, b, c, 2006), undergraduate MD program design (Cunningham et al., in press), and school-based violence prevention (Cunningham et al., 2006a, b). This is the first application of these methods to the design of school-based depression prevention programs. The study team composed 15 actionable 3-level prevention program attributes. Each of 20 choice tasks presented three optional school-based prevention programs, each defined by two attribute levels. Latent class analysis was used to identify segments of educators with similar design preferences (Orme, 2005) and logistic regressions helped to identify the demographic and clinical characteristics of each segment. Hierarchical Bayes was used (Sawtooth Software, 2004) to compute parameter estimates for each participant (Allenby, Arora, & Ginter, 1995; Lenk et al., 1996; Orme, 2005), and multinomial logit computed importance scores and standardized utility value (Orme, 2005). Finally, randomized first choice simulations were used to model optimal school-based prevention program design (Orme, 2005).

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Results Information about Participants Rates of participation over time are found in the table below. There were a total of 1183 student participants in the trial. Note that 51% of participants in both conditions were girls, across both cohorts. All students were in grade seven at pre-test, and the mean age was 12 years old for both conditions. A total of 657 parents chose to participate in the trial; 345 in the CHAT condition and 312 in the control condition, over both cohorts.

Eligible students

Students with consent

Pre-test data

Post-test data

FU 1 data FU 2 data

CHAT 951 737 657 592 531 501

CONTROL

943

595

526

498

451

421

Program Information Fidelity analyses revealed a significant difference between the CHAT and Usual Class conditions, in winter (during ACT instruction), on the ACT skills (t(30)=2.77, p<.01) but not on the ADAPT skills, which had not been taught yet. Similarly, in spring (during ADAPT instruction) there were significant differences between groups on both ACT and ADAPT skills (t(23)=4.14, p<.001; t(23)=4.32, p<.001). November

March

Mean ACT score (sd)

Mean ADAPT score (sd)

Mean ACT score (sd)

Mean ADAPT score (sd)

CHAT

1.4 (.39)*

1.1 (.51)

1.6 (.44)

1.6 (.42)

Usual Class

.98 (.48)

.77 (.50)

.88 (.45)

.81 (.48)

* on a scale from 0-2 (“I rarely did this” to” I frequently did this”) These findings suggest that there are distinct differences between what is being offered during each condition, and that the CHAT teachers are adhering to the manual, offering each of the skills in sequence, as intended. This analysis was repeated for cohort two, with very similar results.

17

Descriptive Findings - Coping Skills Primary Control Scale for Children

Pre-Test Post-Test FU1 (6mos) FU2 (12 mos) CHAT Total score

58.3 (9.2) n=630

Total score 59.8 (9.6) n=580

Total score 60.8 (10.5) n=531

Total score 61.9 (9.8) n=464

Academic 21.0 (3.5)

Social 18.1 (4.0)

Behavior 19.2 (4.4)

Academic 21.1 (3.5)

Social 19.1 (3.8)

Behavior 19.5 (4.5)

Academic 21.3 (3.7)

Social 19.6 (4.2)

Behavior 20.0 (4.6)

Academic 24.1 (4.0)

Social 19.8 (3.9)

Behavior 20.3 (4.3)

Control Total score 58.8 (9.3) n=515

Total score 60.4 (9.2) n=477

Total score 61.3 (9.2) n=451

Total score 61.5 (10.7) n=392

Academic 21.2 (3.5)

Social 18.1 (4.5)

Behavior 19.6 (4.2)

Academic 21.5 (3.4)

Social 18.8 (4.3)

Behavior 20.1 (4.1)

Academic 21.5 (3.4)

Social 19.5 (4.3)

Behavior 20.3 (4.1)

Academic 24.1 (4.3)

Social 19.6 (4.5)

Behavior 20.3 (4.3)

Secondary Control Scale for Children

Pre-Test Post-Test FU1 (6mos) FU2 (12 mos) CHAT

Total Score 39.3 (10.9)




Control





The findings suggest that similar gains were observed, from pre-testing through follow-up testing, for both primary and secondary coping, for both the CHAT and control conditions.

18

Descriptive Findings - Mood Children’s Depression Inventory – Student Self-Report Pre-Test Post-Test FU1 (6mos) FU2 (12 mos) CHAT

Total Score 7.4 (7.1) Negative mood 1.8 (1.9) Interpersonal problems .7 (1.2) Ineffectiveness 1.3 (1.6) Anhedonia 2.5 (2.6) Negative self-esteem 1.1 (1.4)

Total Score 6.5 (6.7) Negative mood 1.6 (1.9) Interpersonal problems .8 (1.2) Ineffectiveness 1.3 (1.7) Anhedonia 2.1 (2.3) Negative self-esteem .9 (1.3)



Control





The findings suggest that similar gains were observed, from pre-testing through follow-up testing, for self-reported depressed mood, for both the CHAT and control conditions.

19

Descriptive Findings - Anxiety Revised Children’s Anxiety and Depression Scale Pre-Test Post-Test FU1 (6mos) FU2 (12 mos) CHAT

Total Score 21.0 (12.4) Gen Anx 4.5 (3.0) Panic 4.7 (4.2) Soc Anx 9.2 (5.1) Sep Anx 2.6 (2.6)




Control





The findings suggest that similar gains were observed, from pre-testing through follow-up testing, for self-reported anxiety, for both the CHAT and control conditions. Descriptive Findings - Hope Children’s Hope Scale Pre-Test Post-Test FU1 (6mos) FU2 (12 mos) CHAT

19.8 (6.1) 21.1 (6.0) 21.3 (6.4) 22.3 (6.6)

Control

20.0 (6.0) 20.8 (6.1) 21.3 (6.3) 22.3 (6.5)

The findings suggest that similar gains were observed, from pre-testing through follow-up testing, for self-reported hope, for both the CHAT and control conditions.

20

Primary and Secondary Outcome Analyses The assessment data collected in the CHAT Study form a hierarchical or multilevel structure. The hierarchy consists of four levels: level 1 units are repeated assessments over time nested within students; level 2 units are students nested in classrooms; level 3 units are classrooms nested in schools; and level 4 are individual schools. Data collected in this way violate the assumption of independence: repeated assessments are expected to be more similar within versus between students; and student responses may be different between classrooms and between schools. Accordingly, special statistical models are needed to analyze such data – models that allow for clustering (non-independence of observations) within students, classrooms and schools. To assess intervention effects on student emotional-behavioural functioning over time, the statistical software MLwiN 2.10 (Rasbash et al., 2009) was used to develop growth curve models that properly accounted for the hierarchical data structure. In growth curve analysis, there are two steps: first, repeated assessments are modeled as a function of time (number of months since baseline in this study) to estimate individual trajectories that include a starting point (baseline) and change per unit of time or growth (trajectory) for each student; and second, between-group differences (intervention versus control) are estimated at baseline and for rates of change. To account for the hierarchical data structure, residual variation must be allocated to each level after the model is fit. In the present case, level 1 residual variation arises from within-subject differences in response; level 2 residual variation arises from between-subject differences in response; level 3 residual variation arises from between-classroom differences in response; and level 4 arises from between-school differences in response. The intervention ‘effect’ is located at the classroom level since this was the unit of allocation (i.e., all of the students located in intact classrooms experienced the intervention or served as controls). With only three data points and no evidence of non-linear change in the observed data, a four-level growth model was specified for each developmental indicator. The levels were school, classroom, student, and repeated assessments. The regression coefficient for change (slope) was specific as a random effect at level 3 (i.e., the regression of time on behaviour was allowed to vary from one student to the next). No control variables were specified: randomization achieved balance between the intervention and control groups on important characteristics.

21

Outcome Findings The means, standard deviations and sample sizes on the observed scores for the intervention and control groups are displayed below. Differences between the groups at baseline are very small. There is some improvement on all of the measures for both groups (i.e., increases on positive measures and decreases on negative measures). Observed outcomes for students in the intervention and control groups: Outcomes Baseline

x (sd) [n] Post-test x (sd) [n]

Follow-up 1 x (sd) [n]

Follow-up 2 x (sd) [n]

PCS_Sum Intervention Control

58.3 (9.2) [657] 58.7 (9.4) [526]

59.7 (9.7) [592] 60.3 (9.2) [498]

60.8 (10.5) [531] 61.3 (9.3) [451]

61.5 (9.9) [501] 61.4 (10.5) [421]

SCS_Sum Intervention Control

39.4 (10.8) [657] 39.8 (10.7) [526]

42.5 (10.7) [592] 42.0 (10.8) [498]

43.6 (10.5) [531] 42.3 (11.5) [451]

44.0 (11.1) [501] 43.5 (11.8) [421]

CDI_Total Intervention Control

7.5 (7.2) [657] 7.4 (6.9) [526]

6.6 (6.8) [592] 6.6 (6.5) [498]

6.3 (7.5) [531] 6.5 (7.0) [451]

6.6 (8.1) [501] 6.2 (7.3) [421]

RCADS_Sum Intervention Control

21.0 (12.4) [657] 21.5 (13.4) [526]

18.2 (11.5) [592] 18.3 (11.6) [498]

16.7 (12.3) [531] 16.8 (11.3) [451]

16.3 (13.2) [501] 16.3 (12.6) [421]

The results of the growth curve analysis are displayed below. Growth represents the amount or rate of change per month. There are no statistical reliable differences in growth between the groups in any of the measures. On a standardize scale, the net effects associated with the intervention are all less than 0.08. Estimated growth (changes in outcome per month), between-group differences in growth and estimated difference at follow-up expressed as both raw and standardized scores: Outcome measure Group

Growth

∆ in growth (95% CI)

χ2 (1df) (p-value)

∆ at follow-up raw (standardized)

PCS_Sum Intervention Control

0.156 0.140

0.016 (-0.051 to 0.083)

0.22 (0.64)

0.273 (0.029)

SCS_Sum Intervention Control

0.245 0.200

0.045 (-0.037 to 0.127)

1.16 (0.28)

0.770 (0.072)

CDI_Total Intervention Control

-0.039 -0.059

0.020 (-0.033 to 0.073)

0.54 (0.46)

0.342 (0.048)

RCADS_Sum Intervention Control

-0.265 -0.321

0.056 (-0.038 to 0.150)

1.36 (0.24)

0.958 (0.074)

22

Consumer Preference Modelling Findings Our grant submission included a proposal to conduct a consumer preference modelling study related to educator choices for packaging of depression prevention programming in schools. This study was conducted by an Honours Psychology student at McMaster University, under the supervision of the co-Principal Investigators. Though the sample size was small, and a broader investigation is planned, this initial pilot yielded useful findings. Specifically, this social marketing research identified two segments of education professionals in relation to their preferences for this type of programming. A smaller “implementation-sensitive” group chose program attributes that coincided with efficient use of time and energy (e.g., brief training courses, shorter and less frequent sessions). The larger “evidence-sensitive” group was most interested in programs that are closely linked to scientific findings and include rigorous components. It was determined that the implementation sensitive group was significantly more likely to have worked in education for 5-15 years. In contrast, those at the beginning of their careers (who may be more idealistic, and willing to take risks), and those who have been in the field for more than 15 years (and may be more confident in their skills) preferred attributes that aligned with scientific findings and program rigour, even if this meant a greater investment of time and energy. Both groups indicated that they preferred CHAT as currently delivered to a more economical alternative. There were no differences between respondents who have facilitated CHAT and those who are CHAT-naïve. Additional Analyses The Research Team will continue to explore the rich data from this randomised trial. Academic outcome data (attendance, grades, learning skills) will be presented in a subsequent report. In addition, selected subgroup analyses will be conducted (high risk sample, gender effects, etc.).

Discussion CHAT is a universal depression prevention program that is delivered over 20 sessions in grade seven classrooms by a classroom teacher and a school mental health professional. HWDSB engaged in several years of piloting with this program, in collaboration with researchers at UCLA and Judge Baker Children’s Center, prior to conducting the present randomised trial. The program was aligned explicitly with Ontario Curriculum expectations. The current study was a two-year project, involving 1183 students, in 25 schools, randomised to condition (35 classrooms per condition). Measures were taken at pre-test, post-test, and 6- and 12-month follow-up. Students were deemed to be equivalent across conditions, on key measurables, at the time of baseline testing. Benchmark and fidelity checks suggest that facilitators implemented the CHAT program as intended, with relatively few departures from the manual. Contrary to hypotheses, findings suggest that the gains made in CHAT classrooms over the course of the study were no greater than those in the Usual Class condition, on measures of mood, anxiety, coping, and hope.

23

While disappointing, these findings are consistent with a growing number of studies in this area. It appears that universal depression prevention programming, on balance, does not have a significant impact on overall student social-emotional functioning, even under “high dose” conditions (high-quality program, large number of sessions, involvement of a mental health professional). The CHAT Team will examine the impact of the program on academic indicators; report card grades, learning skills, and attendance, and will detail these findings in a separate report. In addition, the team is currently collecting data from study participants who have now moved into secondary school to determine if the CHAT program skills begin to have their impact during these years, perhaps activated by the stress inherent in this transition. The CHAT Team also intends to consider other variations and additions to the program that might enhance the impact of depression prevention programming. For example, it has been determined that booster sessions are a critical component to effective substance use programming (Botvin, 1998), and this may similarly apply to the transfer of mood management skills. Another potential feature to consider includes the incorporation of an active parent component to assist with the generalization of skills to home and community environments. Application of the CHAT program to at-risk populations also warrants further study, as does consideration of a secondary school version of the program. The CHAT Team will consider such possibilities when determining next steps. There are some study limitations to consider when interpreting the findings from the current trial. Conducting a large randomised trial within a busy school district setting comes with a unique set of challenges. The CHAT Team documented protocol violations and clinical issues as they arose. While, by and large, the program was implemented with fidelity, facilitators routinely reported that they were unable to cover all aspects of every session within the designated time frame, despite several revisions to the manual over the past decade. Program content was prioritised for each lesson, and facilitators always managed to deliver the top-ranked concepts. However, some lessons were reportedly rushed or split across several periods of the school day. Other, more difficult issues also arose, such as a mismatch between teacher and program, or teacher and facilitator, which resulted in some schools leaving the trial, and others struggling through it with varying degrees of success. It is difficult to know for certain if students in these classes received an optimal delivery of program content. Another limitation was the measurement itself. Students deemed many of the tools used to be quite repetitive, and they complained frequently about this. While they were monitored as closely as possible during the assessment sessions, with up to 30 students at a time completing the on-line surveys, it is possible that a number of students did not take this task seriously enough to provide their true perspectives. Future studies in this area might benefit from a mixed method approach, through which students, facilitators, and parents could give voice to their opinions about the program in more open-ended forums. The strong positive feedback that the CHAT Team received anecdotally, and spontaneously, from students, staff and parents suggests that, at least for some participants, the program was important to them. Capturing this feedback systematically, through qualitative methods, could be valuable.

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The CHAT Team learned much about implementation of a manualized mental health promotion program within a school district setting during the course of this trial. Key lessons include:

1. University – school district collaboration is essential as both parts of the team bring unique and important contributions to the project.

2. Starting with an evidence-based, manualized, program provides an excellent

starting place for implementation.

3. Organizational and school readiness is critical (participants must perceive a need for the program, a comfort with the approach, an understanding of the need for fidelity, and a willingness to embrace social-emotional learning within the school day).

4. Alignment with the Ontario Curriculum was an important program feature for

teachers.

5. Frequent communication with key stakeholders, before, during, and after the trial was essential (teachers, social workers, parents, students, trustees, principals, superintendents).

6. Dedicated roles, particularly a Project Coordinator and Research Assistant, were

essential in ensuring that protocols were enacted as planned.

7. Comprehensive training and ongoing clinical and program support for facilitators was essential.

8. A thoughtful high-risk protocol was a necessary part of this program and

evaluation. Many parents expressed gratitude for this service, as their child’s concerns were, in many cases, brought to their attention for the first time.

9. The CHAT program provided an excellent learning opportunity for local university

students. Including students in research team meetings, data collection, and program facilitation created a unique training forum.

10. The implementation and evaluation of a manualized mental health promotion

program requires the participation and energy of many diverse professionals (specialists in mental health service delivery in schools, researchers, teachers, administrators, curriculum consultants, etc.). It is possible, and necessary, to work across departments, schools, and organizations in order to effectively deliver this type of programming in school boards.

25

The following enablers facilitated the process of implementation of this evidence-based intervention within the school district setting: Evidence-based core intervention (Act and Adapt), with engaging features for

students and teachers (e.g., teacher manual, DVD, student work books) Dedicated, passionate, multidisciplinary, HWDSB team Support and encouragement from UCLA / Judge Baker Children’s Center Strong and complementary collaboration between Hamilton Health Sciences / Offord

Centre for Child Studies and HWDSB Support from senior management within the school district Seed funding from the school district during pilot phases of the project Attention to the need for close communication with schools and other stakeholders Alignment to the Ontario Curriculum so as to ensure teacher comfort with the

program material Co-facilitation model that included mental health and teaching professionals E-BEST platform for promoting research use and the uptake of evidence-based

practices in HWDSB Opportunity to share information with school officials about mental health and links

to student engagement and achievement Funding for the randomized trial from the Provincial Centre of Excellence for Child

and Youth Mental Health at CHEO Barriers that arose during the implementation and evaluation of CHAT that may be characteristic of efforts to embed evidence-based practices within school districts include: Because the development, implementation, and evaluation of an evidence-based

program is not a typical district activity, there may not be dedicated positions or funding streams to support this work

There was no road map for implementation of evidence-based practice in schools when the CHAT Team began this journey in 1999, resulting in many blind alleys and hard lessons along the way

The mobilization and development / readiness work within the district took several years

Insufficient funding at the outset of the project resulted in a slower than desired rate of progress

Schools struggled with the randomization process (e.g., they had some teachers that were enthusiastic about the program and these were not always the classrooms assigned to this condition, they had some classes that they felt “needed” the program and did not receive it, etc.).

26

Knowledge Mobilization The CHAT Team has created a Knowledge Mobilization (KM) plan that will continue to be implemented, with the help of the E-BEST Knowledge Mobilization and Implementation Science Lab. Following up from an interim sharing event held in fall 2008, the first strategy will be to convene a meeting CHAT Team contributors and stakeholders to discuss the study findings and potential next steps. Bottom-Line Actionable Messages (BLAMs) will be created for a number of additional key audiences with potential interest in the CHAT trial outcomes. The CHAT Team will continue to describe the study implementation and findings within academic forums (e.g., Short et al., 2009), and with wider professional audiences (e.g., Short et al., 2009). Summary The CHAT randomized trial has been conducted within the HWDSB with very few departures from the original proposal. Over two school years, 25 schools, and 70 classes, participated in this trial (35 CHAT classes, and 35 control). Both cohorts completed pre- and post–measurement, and follow-up testing at 6 and 12-months. Benchmark surveys indicated that the program was largely delivered in accordance with the manual, and fidelity checks showed that the two conditions were significantly different. As proposed, a consumer preference modelling study was conducted in parallel with this trial. Though the primary study findings suggest no significant impact of the CHAT program on student self-reported mood, anxiety, coping skills, or hope, the iterative process of implementation and evaluation of CHAT has led to many discoveries that are relevant to the transport of evidence-based protocols into school district settings. When classrooms serve as laboratories, and school-based mental health professionals take on an evidence–brokering role, it is possible to bring science to practice in a meaningful way for teachers and students. Submitted on behalf of the Research Team by: Kathy Short, Ph.D., C.Psych. Clinical Child Psychologist Manager, Evidence-Based Education and Services Team Hamilton-Wentworth District School Board

27

Appendix A Parent CDI Survey

Parent CDI Items: My child feels alone all the time Nothing for my child is fun at all My child does not have any friends My child does not want to be with people at all My child thinks he/she looks ugly My child cannot make up his/her mind about things My child thinks he/she can never be as good as other kids My child worries about aches and pains all the time My child thinks nothing will ever work out for him/her My child has to push himself/herself to do his/her homework My child does very badly in subjects he/she used to be good in My child never does what he/she is told My child gets in fights all the time My child never has fun at school My child has trouble sleeping every night My child feels like crying everyday My child hates himself/herself My child is sad all the time My child thinks he/she is bad all the time My child thinks nobody really loves him/her Things bother my child all the time My child thinks all bad things are his/her fault My child thinks he/she does everything wrong My child is sure that terrible things will happen to him/her Most days my child does not feel like eating My child is tired all the time

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Appendix B Student History Questionnaire

To see if CHAT is helping students who are having difficulties, it is important for us to know the kinds of other help that your child may have received for mood, anxiety, attention, learning, or behavioral difficulties. You may skip any items

that make you uncomfortable. Your responses will be kept in the strictest confidence.

1. Has your child ever received medication for mood, anxiety, attention, learning,

or behavioral difficulties? Circle yes or no.

Yes No (skip to question 4)

2. What is the main reason medication was prescribed? __ Mood __ Anxiety __ Attention Deficit Hyperactivity Disorder __ Learning __ Other behavioral/emotional __ Another reason _____________________________

3. Is your child currently receiving medication for mood, anxiety, attention, learning, or behavioral difficulties?

Yes No 4. Has your child ever received any special help at school for any difficulties?

Yes No (skip to question 8) 5. What kind of help?

__ Individual Educational Plans known as IEPs __ Tutoring __ Special testing __ Counseling __ Special help in the classroom or resource room __ Referrals for help outside of school, or __ Speech, occupational therapy __ Other _____________________________

29

6. What is the main reason for this special help?

__ Mood __ Anxiety __ Attention-Deficit Hyperactivity Disorder __ Learning __ Other behavioral/emotional __ Other _____________________________

7. Is your child currently receiving special help at school for any difficulties?

Yes No 8. Other than counseling at school, has your child ever received any counseling,

therapy, or in-home case management?

Yes No (skip to question 13) 9. What kind of help did your child receive?

__ Individual therapy or counseling __ Group therapy __ In-home case management __ Other ________

10. What was the main reason for receiving this service?

__ Mood __ Anxiety __ Attention Deficit Hyperactivity Disorder __ Learning __ Other behavioral/emotional __ Other _____________________________

30

11. Who did your child see?

__ Pediatrician __ Family doctor __ Nurse __ Psychologist __ Psychiatrist __ Social worker __ Counselor __ Other ________________________

12. Is your child currently receiving any counseling, therapy, or in-home case

management?

Yes No

13. Have you or your partner, attended any group, class, or counseling to help manage your child?

Yes No 14. What did you or your partner attend?

__ Parent support group __ Parent training classes or groups __ Parent counseling, guidance or training individually __ Referral for additional help __ Other ___________________________________

Adapted from Services for Children and Adolescents – Parent Interview

Peter S. Jensen, M.D.

Kimberly Hoagwood, Ph.D. Margaret T. Roper, M.S. L. Eugene Arnold, M.D.

Carol Odbert, B.S.

31

Appendix C Revised Children’s Anxiety and Depression Scale

Please put a circle around the word that shows how often each of these things happen to

you. There are no right or wrong answers. 1. I worry about things . . . . . . . . . . . . 2. I feel sad or empty ……………..

Never Sometimes Often Always Never Sometimes Often Always

3.

When I have a problem, I get a funny feeling in my stomach . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

4.

I worry when I think I have done poorly at something . . . . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

5.

I would feel afraid of being on my own at home. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

6.

Nothing is much fun anymore . . . . . . . . . . . . Never Sometimes Often Always

7.

I feel scared when I have to take a test . . . . . . Never Sometimes Often Always

8.

I feel worried when I think someone is angry with me . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

9.

I worry about being away from my parents . . Never Sometimes Often Always

10.

I get bothered by bad or silly thoughts or pictures in my mind . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

11.

I have trouble sleeping . . . . . . . . . . . . . . . . . Never Sometimes Often Always

12.

I worry that I will do badly at my school work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

13.

I worry that something awful will happen to someone in my family . . . . . . . . . . . . . . . . . Never Sometimes Often Always

14.

I suddenly feel as if I can't breathe when there is no reason for this . . . . . . . . . . . . . . . Never Sometimes Often Always

15.

I have problems with my appetite . . . . . . . . Never Sometimes Often Always

32

16.

I have to keep checking that I have done things right (like the switch is off, or the door is locked) . . . . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

17.

I feel scared if I have to sleep on my own . . Never Sometimes Often Always

18.

I have trouble going to school in the mornings because I feel nervous or afraid . . Never Sometimes Often Always

19.

I have no energy for things . . . . . . . . . . . . . . Never Sometimes Often Always

20.

I worry I might look foolish . . . . . . . . . . . . . Never Sometimes Often Always

21.

I am tired a lot . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

22.

I worry that bad things will happen to me . . Never Sometimes Often Always

23.

I can't seem to get bad or silly thoughts out of my head. . . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

24.

When I have a problem, my heart beats really fast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

25.

I cannot think clearly . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

26.

I suddenly start to tremble or shake when there is no reason for this . . . . . . . . . . . . . . . Never Sometimes Often Always

27.

I worry that something bad will happen to me . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

28.

When I have a problem, I feel shaky . . . . . . Never Sometimes Often Always

29.

I feel worthless . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

30.

I worry about making mistakes . . . . . . . . . . Never Sometimes Often Always

31.

I have to think of special thoughts (like numbers or words) to stop bad things from happening. . . . . . . . . .. . . . . . . . . . . . . . . . . Never Sometimes Often Always

33

32.

I worry what other people think of me . . . . . Never Sometimes Often Always

33.

I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) . . . . . . . . . . .. . . . . . . . . . . . . . Never Sometimes Often Always

34.

All of a sudden I feel really scared for no reason at all . . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

35.

I worry about what is going to happen . . . . . Never Sometimes Often Always

36.

I suddenly become dizzy or faint when there is no reason for this . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

37.

I think about death . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

38.

I feel afraid if I have to talk in front of my class . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

39.

My heart suddenly starts to beat too quickly for no reason . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

40.

I feel like I don’t want to move . . . . . . . . . . . .

Never Sometimes Often Always

41.

I worry that I will suddenly get a scared feeling when there is nothing to be afraid of

Never Sometimes Often Always

42.

I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) . . . . . . . . . . . . . . . . Never Sometimes Often Always

43.

I feel afraid that I will make a fool of myself in front of people . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

44.

I have to do some things in just the right way to stop bad things from happening . . . . . . . . . Never Sometimes Often Always

45.

I worry when I go to bed at night . . . . . . . . . . Never Sometimes Often Always

46.

I would feel scared if I had to stay away from home overnight . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

47. I feel restless . . . . . . . . . . . . . . . . . . . . . . . . . Never Sometimes Often Always

34

Appendix D Perceived Control Scale for Children

After each statement, please circle whether it is “very false”, “sort of false”, “sort of true” or “very true” for you. 1. I can get good grades if I really try.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE 2. I can make friends with other kids if I really try.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE 3. I can not stay out of trouble no matter how hard I try.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE 4. I can do well on tests at school if I study hard.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE 5. I can not get other kids to like me no matter how hard I try.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE 6. Even if I try to follow the rules I will get in trouble for my behavior.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE 7. I can get good marks for my homework if I really work at it.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE 8. If other kids are mean to me, I can not make them stop.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE 9. If I try to behave, adults will like the way I act.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE 10. I can not succeed at school no matter how hard I try.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE 11. I can be popular with kids my age, if I really try.

VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE

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12. Even if I try to act right, I will still get yelled at for the things I do. VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE

13. I can not get good grades no matter how hard I try.


14. I can get other kids to like me if I try.


15. If I try hard to behave the right way, I will not get yelled at.


16. I can not do well on tests at school even if I study hard.


17. I can not make friends with other kids no matter how hard I try.


18. I can stay out of trouble if I really try.


19. I can not get good marks for my homework, even if I work hard at it.


20. If other kids are mean to me, I can get them to be nice.


21. Even if I try to behave, adults won’t like the way I act.


22. I can succeed in school if I try.


23. Even if I try, I can not be popular with kids my age.


24. If I try to behave, I can keep myself out of trouble.


36

Appendix E Secondary Control Scale for Children

After each statement, please circle whether it is “very false”, “sort of false”, “sort of true” or “very true” for you. 1. I can usually find something good to like, even in a bad situation.


2. If I make a bad grade, I can find ways to feel better about it.


3. If another kid is mean to me, it’s hard for me to get over it.


4. When I feel bad about something, I cannot change the way I think about it. I just keep feeling bad. VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE

5. When I have a problem that I can’t change, I can do something to take my mind off it.


6. When something bad happens, I can’t talk to anyone about it. I just keep to myself and feel bad. VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE

7. When something bad happens, I can find a way to think about it that makes me feel better.


8. When I am in a bad situation, I usually can’t see anything good about it.


9. If I make a bad grade, I can’t stop feeling bad about it.


10. After a really hard day, I can make myself feel better by remembering some good things that happened. VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE

37

11. When bad things happen to me that I can’t control, there’s nothing I can do to feel better.


12. When I have a problem that I can’t change, I can’t stop thinking about it.


13. After a really hard day, I feel bad, and it’s hard to remember anything good that happened.


14. When I feel bad about something, I can find another way to look at it, and that makes me feel better. VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE

15. When I have bad thoughts about myself, I can usually figure out that the thoughts are not true, and then I feel better. VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE

16. When something bad happens, I keep worrying about how bad it is.


17. If another kid is mean to me, I will not let it bother me.


18. When something bad happens, I can talk to someone about it, and then I feel better.


19. When I have bad thoughts about myself, I can’t stop thinking those thoughts even if I try.


20. When bad things happen to me that I can’t control, there are lots of things I can do to feel better. VERY FALSE SORT OF FALSE SORT OF TRUE VERY TRUE

Appendix F Children’s Hope Scale

Directions: The six sentences below describe how children think about themselves and how they do things in general. Read each sentence carefully. For each sentence, please think about how you are in most situations. Place a check inside the box that describes YOU the best. For example, place a check in the box above "None of the time," if this describes you. Or, if you are this way "All of the time," check this box. Please answer every question by putting a check in one of the boxes. There are no right or wrong answers.

1. I think I am doing pretty well.

None of the time

A little of the time

Some of the time

A lot of the time

Most of the time

All of

the time

2. I can think of many ways to get the things in life that are most important to me.

None of the time


Some of the time

A lot of the time

Most of the time

All of

the time

3. I am doing just as well as other kids my age.

None of the time


Some of the time

A lot of the time

Most of the time

All of

the time

4. When I have a problem, I can come up with lots of ways to solve it.

None of the time


Some of the time

A lot of the time

Most of the time

All of

the time

5. I think the things I have done in the past will help me in the future.

None of the time


Some of the time

A lot of the time

Most of the time

All of

the time

6. Even when others want to quit, I know that I can find ways to solve the problem.

None of the time


Some of the time

A lot of the time

Most of the time

All of

the time

2

Appendix G CHAT Benchmarks Survey: 2007 - 2008

Excerpt from Summary Report What time of the day do you deliver CHAT sessions?

Response Chart Frequency Count

in the am 58.5% 79

in the pm 41.5% 56

Not Answered 3

Total Responses 138

Do you deliver CHAT during:

Response Chart Frequency Count

TAG 24.1% 32

Other class (please specify) 75.9% 101

Not Answered 5

Total Responses 138

Responses from “Other Class” above: Frequency Count

Advisor 2.9% 3

Computers 0.9% 1

Computers / Library 5.9% 6

Core 2.9% 3

English 22.7% 23

Health & Phys Ed 15.8% 16

Language 39.6% 40

Literacy 0.9% 1

Time convenient for co-facilitator 0.9% 1

Total Responses: 101

3

Session 2.1: For the following session components, please indicate if you:

Did all of this activity in CHAT time

Modified this activity

Did this activity outside of class time

Omitted this activity Total

Practice Assignment Review Count 11 2 0 0 13

% by Row 84.6% 15.4% 0.0% 0.0% 100.0%

Mood Rating Count 13 0 0 0 13

% by Row 100.0% 0.0% 0.0% 0.0% 100.0%

Session Objectives Count 11 1 0 1 13

% by Row 84.6% 7.7% 0.0% 7.7% 100.0%

Video Segment # 1 (Everybody is having a bad day) Count 13 0 0 0 13

% by Row 100.0% 0.0% 0.0% 0.0% 100.0%

Video discussion Count 12 1 0 0 13

% by Row 92.3% 7.7% 0.0% 0.0% 100.0%

Video Segment # 2 (Deciding to have fun helps everyone feel better)

Count 13 0 0 0 13

% by Row 100.0% 0.0% 0.0% 0.0% 100.0%

Video discussion Count 10 3 0 0 13

% by Row 76.9% 23.1% 0.0% 0.0% 100.0%

Personal Activity & Discussion Count 7 3 2 1 13

% by Row 53.8% 23.1% 15.4% 7.7% 100.0%

Practice Assignment Count 3 1 9 0 13

% by Row 23.1% 7.7% 69.2% 0.0% 100.0%

Total Count 93 11 11 2 117

% by Row 79.5% 9.4% 9.4% 1.7% 100.0%

Responses for: If you omitted an activity, or departed from the manual in some way, please tell us why:

Instead of focusing on one character in the video segments, we had the class focus on all three.... so it would be easier for them to follow along the storylines as the video progresses.

not enough time

student's need to plan to complete practice activity

Time constraints

We ran out of time but we will do it before the next CHAT class.

We were running out of time so some things had to be shortened. It was the second last day before the holidays

4

Behaviour (2.1): 1- Not Very 2 3-

Somewhat 4 5- Very Total Mean Std Dev

Overall, how manageable was student behavior in today's session?

Count 1 0 4 3 4 12 3.750 1.215

% by Row 8.3% 0.0% 33.3% 25.0% 33.3% 100.0%

Total Count 1 0 4 3 4 12 N/A N/A

% by Row 8.3% 0.0% 33.3% 25.0% 33.3% 100.0%

5

Appendix H. Program Fidelity Checklist

School: Teacher: Date: Interviewer:

Today, did you teach* your students:

Items 0

I rarely or never did

this

1 I sometimes did this

2 I frequently

did this

Example

Problem-solving skills

That doing something that they enjoy can help them feel less stressed

That helping others can make them feel better

That doing something to distract themselves can improve their mood

How to present themselves in a positive light

How to calm themselves during stressful situations

How to identify and challenge negative thoughts

How to change negative thoughts into more realistic and positive thoughts

How to get the social support they need

6

To look for the positives in a stressful situation

To let go of negative repetitive thoughts

To keep on trying when faced with a tough situation

Comments:

7

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