A classroom-based intervention designed to reduce depression and stress by enhancing coping skills in late adolescence and early adulthood.
Blueprints: Promising
SAMHSA : 3.7
Kathryn Puskar, Ph.D.
415 Victoria Building
3500 Victoria St.
Pittsburgh, PA 15261
Phone: (412) 624-6933
Email: krp12@pitt.edu
Website: www.pitt.edu/~krp12/
Kathryn R. Puskar
University of Pittsburgh
Teaching Kids to Cope (TKC) is a 10-session psychoeducational group intervention designed to reduce depressive symptomatology and stress by enhancing the coping skills of adolescents. Each session lasts 45 minutes. Participants are guided through a process to discover their distorted thinking patterns and to test their thinking against reality using suggested approaches. They also explore and practice problem identification, alternate ways of viewing a situation, and alternate ways of reacting. The TKC program focuses on behavioral techniques but also incorporates cognitive components. The behavioral techniques aim to improve coping skills, which include activity planning, social skills training, assertiveness training, bibliotherapy, role-playing, conflict resolution, and relaxation training. The TKC incorporates experiential exercises such as trust-fall, buddy assignments, and role-playing situations from school and home. Art is incorporated into the sessions through drawing exercises. The cognitive components employ techniques such as externalization of negative voices, reframing, establishing idiosyncratic meaning, and cognitive rehearsal.
To improve access to the treatment for high school students seeking help, this intervention is offered during regular school days. Eligible students should score in the mid-range (at least 60) on the Reynolds Adolescent Depression Scale (RADS). The intervention is implemented by a psychiatric nurse in collaboration with the school nurse or guidance counselor.
Teaching Kids to Cope (TKC) is a 10-session psychoeducational group intervention designed to reduce depressive symptomatology and stress by enhancing the coping skills of adolescents. Group sessions are 45 minutes. To improve access to the treatment for students seeking help, this intervention is offered during regular school days. The intervention is implemented by a psychiatric nurse in collaboration with the school nurse or guidance counselor. The TKC program focuses on behavioral techniques but also incorporates cognitive components. The behavioral techniques aim to improve coping skills, which include activity planning, social skills training, assertiveness training, bibliotherapy, role-playing, conflict resolution, and relaxation training. The TKC incorporates experiential exercises such as trust-fall, buddy assignments, and role-playing situations from school and home. Art is incorporated into the sessions through drawing exercises. The cognitive components employ techniques such as externalization of negative voices, reframing, establishing idiosyncratic meaning, and cognitive rehearsal. The 10 sessions are structured as following:
An earlier version of the program collapsed the material into 8 sessions, as did a later adaptation aimed at reducing anger and aggression (Teaching Kids to Cope with Anger); however, these adaptations have not been certified by Blueprints. The anger-reduction adaptation generally used materials and techniques similar to the main program, though sessions were broken up into two portions: didactic, involving knowledge dissemination, and experiential, involving more hands-on activities. Sessions occurred weekly, moving from orientation and trust-building to teaching coping strategies before finishing with a focus on the health outcomes of anger and sources of social support.
The evaluations of Teaching Kids to Cope demonstrated the following significant program effects, comparing the intervention to the control group:
Significant risk and protective factors include:
All three evaluations of Teaching Kids to Cope employed similar study designs (Puskar et al., 2003; Hamdan-Mansour et al., 2009; Lamb et al., 1998). The studies employed a randomized controlled trial design with subjects having high scores on depression measures. While Puskar et al. (2003) recruited study subjects from three rural high schools located in the southwestern region of Pennsylvania, Hamad-Mansour et al. (2009) recruited the study sample from the University of Jordan and Lamb et al. (1998) recruited study subjects from one rural high school. All three studies employed small sample sizes of n=89 (Puskar et al., 2003), n=84 (Hamdan-Mansour et al., 2009) and n=46 (Lamb et al., 1998). The consented subjects were randomly assigned to the intervention (n=46, Puskar et al.; n=44, Hamdan-Mansour et al.; n=27, Lamb et al.) or the control group (n=43, Puskar et al.; n=40, Hamdan-Mansour et al.; n=19, Lamb et al.). Nurses with psychiatric mental health experience administered the intervention in small groups with group sessions lasting about 45 minutes. Subjects were evaluated at baseline (during the screening procedure), and at posttest (approximately 10-12 weeks following screening). While Puskar et al. (2003) evaluated true long-term effects (6-month and 12-month follow-ups), Hamdan-Mansour et al. (2009) conducted a follow-up assessment only 3 months after posttest. Lamb et al. (1998) conducted no follow-up beyond posttest. In addition to the core intervention, Puskar et al. (2003) administered a booster session 9 months after posttest to a random sample of 20 (43%) intervention group subjects.
An evaluation of the aggression-focused adaptation of the program (Teaching Kids to Cope with Anger; Puskar, Ren & McFadden, 2015), not certified by Blueprints, also used a randomized controlled trial, with participants assessed at baseline, posttest, and at 6- and 12-month follow-up. Rather than selecting subjects with already high baseline scores on the outcome, all non-special education freshman and junior students demonstrating English competency at 3 participating rural Midwestern high schools were eligible. Of 179 youth consenting, 160 (89%) were retained through the 12-month follow-up.
Study 1
Puskar, K., Sereika, S., & Tusaie-Mumford, K. (2003). Effect of the Teaching Kids to Cope (TKC) program on outcomes of depression and coping among rural adolescents. Journal of Child and Adolescent Psychiatric Nursing, 16(2), 71-80.
Study 2
Hamdan-Mansour, A. M., Puskar, K., & Bandak, A. G. (2009). Effectiveness of cognitive-behavioral therapy on depressive symptomology, stress and coping strategies among Jordanian university students. Issues in Mental Health Nursing, 30, 188-196.
Individual: Stress*
Individual: Coping Skills*, Problem solving skills*, Skills for social interaction
*
Risk/Protective Factor was significantly impacted by the program
See also: Teaching Kids to Cope Logic Model (PDF)
The first two studies and the adaptation study (Puskar et al., 2003; Hamdan-Mansour et al., 2009; Puskar, Ren, & McFadden, 2015) conducted no subgroup analysis. Puskar et al. (2003) evaluated the program with a sample of predominantly white (99%), female (82%) adolescents. However, similar program effects were observed by Hamdan-Mansour et al. (2009) with a gender-balanced sample (55% males; 45% females) of Jordanian college students. In the Lamb et al. (1998) study, female intervention participants had a significant decrease in depressive symptoms compared to female control participants at posttest. No effect of the program was found for male students.
Group leaders of TKC (master's-level nurses with psychiatric mental health experience including group therapy and adolescent work) will be trained in group skills such as facilitating communication, adolescent behavior, and content of each TKC session. The training will consist of viewing videotapes on Conducting Groups with Adolescents, Yalom (Expert on Group Therapy) Principles of Group Therapy, Adolescent Development, and establishing rapport issues of working with adolescents. Several articles on facilitating adolescent groups will be provided. Training is one day (8 hours) at a cost of $1,000 plus travel expenses, for up to 16 participants.
Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.
Training is one day at customer's site at a cost of $1,000, plus travel expenses, for up to 16 participants. Contact Kathryn Puskar for more information on training:
Manuals can be purchased for $15.00 each. The manual details the content (topics) of each of the ten sessions. Role plays, case scenarios, and assignments are included. For purchase, contact Kathryn Puskar:
None
None
There are no ongoing costs, unless additional manuals and new training of group leaders become necessary.
Group leaders with master's-level training in mental health nursing should have an adequate amount of relevant experience and training, such as in group dynamics and group process, to offer this intervention.
Group facilitators should have access to a room large enough to accommodate a group of 6-12 youth. A white/marker board for the group leader to present material should be available.
None
Detailed checklists are available at no charge to assess intervention adherence and facilitator competence.
None
No information is available
No information is available
In this example, a high school uses its nursing staff with mental health training to implement the Teaching Kids to Cope intervention. Four sessions, each with 10 students, are delivered during the school year.
| On-site training | $1,000.00 |
| Trainer travel expenses | $1,000.00 |
| Leader manual | $15.00 |
| Total One Year Cost | $2,015.00 |
With four sessions of 10 students each, 40 students would receive the intervention during Year One. The cost per student would be $50.38.
The actual unit cost will vary depending on the number of sessions delivered within the school year and whether existing staff are available to deliver the program.
Teaching Kids to Cope (TKC) is a school-based mental health intervention targeted to youth with depression symptoms, and can potentially be billed to Medicaid for Medicaid-eligible participants or other private insurance for those not Medicaid eligible. In addition, school district professional development and health funds as well as core mental health funding streams may be options for supporting costs not Medicaid billable or populations not eligible for Medicaid.
Many school systems train school social workers, counselors or nursing staff to deliver TKC alongside a psychiatric nurse. In this way, existing staff resources can be redirected toward the program and then Medicaid can potentially support some of the costs associated with the psychiatric nurses.
If a state opts to cover TKC through Medicaid funds, state funds are needed to provide the required Medicaid state match.
Entitlements: Since TKC is a targeted intervention aimed at adolescents and young adults with symptoms of depression, Medicaid is a potentially important source of funding. When the TKC group leader is a Medicaid qualified mental health professional, Medicaid can be billed for eligible participants. Billing would be for group therapy unless the Medicaid agency elected to make TKC a Medicaid service.
Formula Grants: The core education and behavioral health formula funds are potentially options for needed start-up funding, or to cover ongoing staffing, technical assistance and fidelity monitoring costs that are not billable under Medicaid. They can also be used to pay for children not eligible for Medicaid.
Discretionary Grants: Grants that could potentially support TKC can be found in the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control (CDC) within the Department of Health and Human Services.
Foundation grants can be considered for the cost of initial training of group leaders or ongoing curricula purchases and to fill gaps in funding from public sources.
Kathryn R. PuskarProfessorUniversity of Pittsburgh415 Victorian Building, 3500 Victoria St.Pittsburgh, Pennsylvania 15261U.S.A.412-624-6933412-383-7293krp12@pitt.edu www.pitt.edu/~krp12/
A classroom-based intervention designed to reduce depression and stress by enhancing coping skills in late adolescence and early adulthood.
TKC was designed for high school adolescents and young adults displaying depression symptoms. Studies were conducted in high schools, and a Jordanian study was of college young adults.
The first two studies and the adaptation study (Puskar et al., 2003; Hamdan-Mansour et al., 2009; Puskar, Ren, & McFadden, 2015) conducted no subgroup analysis. Puskar et al. (2003) evaluated the program with a sample of predominantly white (99%), female (82%) adolescents. However, similar program effects were observed by Hamdan-Mansour et al. (2009) with a gender-balanced sample (55% males; 45% females) of Jordanian college students. In the Lamb et al. (1998) study, female intervention participants had a significant decrease in depressive symptoms compared to female control participants at posttest. No effect of the program was found for male students.
A lack of knowledge, coping skills, and problematic cognitive behavioral patterns can be considered risk factors for depression, while anger is the predominant risk factor for aggression.
Individual: Stress*
Individual: Coping Skills*, Problem solving skills*, Skills for social interaction
*Risk/Protective Factor was significantly impacted by the program
Teaching Kids to Cope (TKC) is a 10-session psychoeducational group intervention designed to reduce depressive symptomatology and stress by enhancing the coping skills of adolescents. Each session lasts 45 minutes. Participants are guided through a process to discover their distorted thinking patterns and to test their thinking against reality using suggested approaches. They also explore and practice problem identification, alternate ways of viewing a situation, and alternate ways of reacting. The TKC program focuses on behavioral techniques but also incorporates cognitive components. The behavioral techniques aim to improve coping skills, which include activity planning, social skills training, assertiveness training, bibliotherapy, role-playing, conflict resolution, and relaxation training. The TKC incorporates experiential exercises such as trust-fall, buddy assignments, and role-playing situations from school and home. Art is incorporated into the sessions through drawing exercises. The cognitive components employ techniques such as externalization of negative voices, reframing, establishing idiosyncratic meaning, and cognitive rehearsal.
To improve access to the treatment for high school students seeking help, this intervention is offered during regular school days. Eligible students should score in the mid-range (at least 60) on the Reynolds Adolescent Depression Scale (RADS). The intervention is implemented by a psychiatric nurse in collaboration with the school nurse or guidance counselor.
Teaching Kids to Cope (TKC) is a 10-session psychoeducational group intervention designed to reduce depressive symptomatology and stress by enhancing the coping skills of adolescents. Group sessions are 45 minutes. To improve access to the treatment for students seeking help, this intervention is offered during regular school days. The intervention is implemented by a psychiatric nurse in collaboration with the school nurse or guidance counselor. The TKC program focuses on behavioral techniques but also incorporates cognitive components. The behavioral techniques aim to improve coping skills, which include activity planning, social skills training, assertiveness training, bibliotherapy, role-playing, conflict resolution, and relaxation training. The TKC incorporates experiential exercises such as trust-fall, buddy assignments, and role-playing situations from school and home. Art is incorporated into the sessions through drawing exercises. The cognitive components employ techniques such as externalization of negative voices, reframing, establishing idiosyncratic meaning, and cognitive rehearsal. The 10 sessions are structured as following:
An earlier version of the program collapsed the material into 8 sessions, as did a later adaptation aimed at reducing anger and aggression (Teaching Kids to Cope with Anger); however, these adaptations have not been certified by Blueprints. The anger-reduction adaptation generally used materials and techniques similar to the main program, though sessions were broken up into two portions: didactic, involving knowledge dissemination, and experiential, involving more hands-on activities. Sessions occurred weekly, moving from orientation and trust-building to teaching coping strategies before finishing with a focus on the health outcomes of anger and sources of social support.
The theoretical rational for the Teaching Kids to Cope (TKC) intervention was outlined in detail by Puskar et al. (1997). The TKC intervention is based on the premise that underlying adolescent problems is a unique set of behavioral and cognitive dimensions that reflect adolescent development. The TKC intervention combines a developmental framework with group therapy. Since adolescence is a time of intense peer relationships, teenagers tend to work well in groups. This form of therapy provides a sense of familiarity and security that may be lacking in individual and family therapy. The therapeutic factors incorporated into the TKC intervention include a combination of behavioral and cognitive techniques, which are used to alter dysfunctional patterns. As such, the intervention is designed to reduce the frequency of maladaptive responses and to teach new cognitive and behavioral skills.
All three evaluations of Teaching Kids to Cope employed similar study designs (Puskar et al., 2003; Hamdan-Mansour et al., 2009; Lamb et al., 1998). The studies employed a randomized controlled trial design with subjects having high scores on depression measures. While Puskar et al. (2003) recruited study subjects from three rural high schools located in the southwestern region of Pennsylvania, Hamad-Mansour et al. (2009) recruited the study sample from the University of Jordan and Lamb et al. (1998) recruited study subjects from one rural high school. All three studies employed small sample sizes of n=89 (Puskar et al., 2003), n=84 (Hamdan-Mansour et al., 2009) and n=46 (Lamb et al., 1998). The consented subjects were randomly assigned to the intervention (n=46, Puskar et al.; n=44, Hamdan-Mansour et al.; n=27, Lamb et al.) or the control group (n=43, Puskar et al.; n=40, Hamdan-Mansour et al.; n=19, Lamb et al.). Nurses with psychiatric mental health experience administered the intervention in small groups with group sessions lasting about 45 minutes. Subjects were evaluated at baseline (during the screening procedure), and at posttest (approximately 10-12 weeks following screening). While Puskar et al. (2003) evaluated true long-term effects (6-month and 12-month follow-ups), Hamdan-Mansour et al. (2009) conducted a follow-up assessment only 3 months after posttest. Lamb et al. (1998) conducted no follow-up beyond posttest. In addition to the core intervention, Puskar et al. (2003) administered a booster session 9 months after posttest to a random sample of 20 (43%) intervention group subjects.
An evaluation of the aggression-focused adaptation of the program (Teaching Kids to Cope with Anger; Puskar, Ren & McFadden, 2015), not certified by Blueprints, also used a randomized controlled trial, with participants assessed at baseline, posttest, and at 6- and 12-month follow-up. Rather than selecting subjects with already high baseline scores on the outcome, all non-special education freshman and junior students demonstrating English competency at 3 participating rural Midwestern high schools were eligible. Of 179 youth consenting, 160 (89%) were retained through the 12-month follow-up.
Although conducted in different countries, two evaluations of Teaching Kids to Cope produced largely similar findings (Puskar et al., 2003; Hamdan-Mansour et al., 2009). In both studies, students in the intervention group reported a decrease in depressive symptoms compared to a control group at posttest. In addition, Hamdan-Mansour et al. (2009) demonstrated a significant decline in stress symptoms among intervention group participants. With regard to coping strategies, Puskar et al. (2003) found significant program effects for 1 of 8 subscales (seeking guidance and support), an effect that was maintained up to 1 year after program completion. In contrast, Hamdan-Mansour et al. (2009) found significant effects for 4 of 8 subscales with higher mean scores for seeking social support, planful problem solving, positive reappraisal, and lower means scores for escape-avoidance. Lamb et al. (1998) found no impact of the program on depressive symptoms or life events, however intervention participants reported greater usage of the supportant coping style than the control participants at posttest. Further, when examining the effect of gender, female intervention participants had a significant decrease in depressive symptoms compared to female control participants at posttest.
The evaluation of the anger-focused adaptation of the program (Puskar et al., 2015) revealed a marginally significant group difference in anger expression at 12-month follow-up; however, it is unclear whether the effect was positive or iatrogenic. This adaptation has not been certified by Blueprints.
The evaluations of Teaching Kids to Cope demonstrated the following significant program effects, comparing the intervention to the control group:
Significant risk and protective factors include:
A formal mediator analysis was not conducted by any study.
The studies did not report effect sizes.
The study results may be generalizable to adolescents and young adults with depressive symptoms in the U.S. and Jordan, though the U.S. studies were limited to schools in rural areas, with a population density between 2,500 and 7,000.
The three studies evaluating Teaching Kids to Cope share some of the limitations.
Limitations of the study investigating the anger-focused adaptation of the program (Puskar et al., 2015) include:
For more background on the program, see Puskar, K., Lamb, J., & Tusaie-Mumford, K. (1997). Teaching Kids to Cope: A preventive mental health nursing strategy for adolescents. Journal of Child and Adolescent Psychiatric Nursing, 10(3), 18-28.
Blueprints: Promising
SAMHSA : 3.7
Kathryn Puskar, Ph.D.
415 Victoria Building
3500 Victoria St.
Pittsburgh, PA 15261
Phone: (412) 624-6933
Email: krp12@pitt.edu
Website: www.pitt.edu/~krp12/
Certified Puskar, K., Sereika, S., & Tusaie-Mumford, K. (2003). Effect of the Teaching Kids to Cope (TKC) program on outcomes of depression and coping among rural adolescents. Journal of Child and Adolescent Psychiatric Nursing, 16(2), 71-80.
Certified Hamdan-Mansour, A. M., Puskar, K., & Bandak, A. G. (2009). Effectiveness of cognitive-behavioral therapy on depressive symptomology, stress and coping strategies among Jordanian university students. Issues in Mental Health Nursing, 30, 188-196.
Lamb, J. M., Puskar, K. R., Sereika, S. M., & Corcoran, M. (1998). School-based intervention to promote coping in rural teens. American Journal of Maternal Child Nursing, 23(4), 187-194.
Puskar, K. R., Ren, D., & McFadden, T. (2015). Testing the 'Teaching Kids to Cope with Anger' youth anger intervention program in a rural school-based sample. Issues in Mental Health Nursing, 36, 200-208.
Evaluation Methodology
Design:
Recruitment /Sample size:
Study subjects were recruited from four rural high schools located in the southwestern region of Pennsylvania. Due to delays in screening in one of the schools, three schools provided subjects for the intervention study. To be eligible for participation in the intervention study, students had to (a) be at least 13 years of age, (b) live in a rural area with a population density of 2,500 to 7,000, (c) score in the mid-range (at least 60) on the RADS depression scale, and (d) have no history of a death of a family member or friend during the past year. From a volunteer sample of 624 students, 107 (17.1%) met selection criteria to participate in the study. Of those eligible, 89 (83.1%) consented to participate and were subsequently randomized.
Study type/Randomization/Intervention:
The study employed a randomized controlled trial design. Of the 89 consented subjects, 46 (53.9%) were randomly assigned to intervention, and 43 (48.3%) to the control group, using "permuted block randomization within school sites." Subjects assigned to the intervention were placed into groups at their particular school, with group sessions lasting about 45 minutes during regular school time. Group leaders were master-level nurses with psychiatric mental health experience including group therapy and adolescent work. A booster session was randomly administered 9 months after posttest to 20 (43%) intervention subjects.
Assessment/Attrition:
Subjects were evaluated using a battery of 11 instruments at four time points: at baseline (during the screening procedure), at posttest (approximately 10-12 weeks following screening), as well as 6-month and 12-month after posttest (follow-up).
Both groups experienced similar rates and patterns of attrition. Overall, 8 (18.6%) control and 10 (21.7%) intervention subjects dropped out of the study. Attrition occurred prior to posttest assessment (n = 7, 38.9% of dropouts) and during the follow-up period (n = 11, 61.1% of dropouts).
Sample characteristics:
Subjects were primarily female (n = 73, 82.0%), white (n = 88, 98.9%), and on average 16 years of age (range: 14.1 -18.3 years). Most were in 9th (n = 32, 36.0%) and 10th (n = 28, 31.5%) grades and were participating in academic programs (n = 77, 86.5%), although not taking advanced placement courses (n = 68, 76.4%). A majority of the subjects lived with both natural parents (n = 60, 70.8%), had at least one sibling (n = 79, 88.8%), and were either first (n = 24, 27.0%) or second (n = 38, 42.7%) in birth order.
Measures:
Validity of measurements:
All measures and scales have been used in prior published work and reliability and validity has been established.
Primary outcomes:
Reynolds Adolescent Depression Scale (RADS): The RADS is a self-report measure of depressive symptomatology that consists of 30 items with a four-point Likert response scale (alpha=.91-.96).
Coping Response Inventory-Youth Form (CRI-Y): The CRI-Y is a 48-item self-report instrument developed to assess how adolescents cope with a wide variety of stressful life events. The CRI-Y can be used to evaluate coping of four approach scales (Logical Analysis, Positive Reappraisal, Seeking Guidance and Support, and Problem Solving), and four coping avoidance scales (Cognitive Avoidance, Resignation or Acceptance, Seeking Alternative Rewards, and Emotional Discharge) that measure cognitive and behavioral efforts directed at managing a stressful situation (alpha range among subscales .69 to .79).
Analysis:
Repeated-measures analysis using mixed modeling methods was employed to assess the direct effect of the intervention on depressive symptomatology and coping over time. However, it is unclear whether the random effects account for both clustering within groups and within schools. Comparisons at specific time points were performed using linear contrasts.
The authors point out that since logical analysis and positive reappraisal styles of coping significantly differed between the treatment groups at screening, "baseline values were included as fixed covariates in the repeated-measures analysis when modeling these coping outcomes." It is unclear whether the study controlled for baseline scores in the other models.
Intention-to-treat: Given the lack of detail on reasons for attrition, it is difficult to evaluate compliance with the intent-to-treat principle.
Outcomes
Implementation fidelity:
To ensure implementation fidelity, all sessions were audiotaped and an expert group therapy consultant reviewed a random sample of approximately one third of the sessions. Adherence to the protocol as well as appropriate group therapy interventions was validated. However, no results of this validation were reported.
Baseline Equivalence:
No significant differences were found between the two treatment groups on socio-demographic factors. However, a group difference emerged on baseline levels for the use of certain coping strategies. The intervention group reported higher levels of logical analysis (p=.028) and positive reappraisal coping (p=.044) compared to the control group, but these were controlled in the analysis.
Differential attrition:
No test for differential attrition provided in the article. The authors were later contacted and asked for this information. Their subsequent analyses showed no significant differences by demographic characteristics (sex, race, age, birth order, number of siblings, numbers of males and females in the household) and baseline values of key outcome variables (depression and coping).
Posttest:
Depression symptoms: A significant (p<.05) group x time interaction for depressive symptoms (RADS) was found. Adolescents in the intervention group reported a decrease in depressive symptoms by 9% compared to adolescents in the control group at posttest.
Coping strategies: For coping styles, as measured by the CRI-Y form, a significant (p<.05) group x time interaction was found only for 1 out of 8 subscales (Seeking Guidance and Support). The mean scores for Seeking Guidance and Support were significantly higher for intervention subjects compared to control subjects at posttest. In addition, a significant (p<.05) group main effect was observed for problem solving. However, since the group x time interaction and the main effect for time were not significant, it is unclear whether the group main effect allows conclusions regarding the benefit of the program.
Long-term effects (12 months after posttest):
Depression symptoms: No significant differences were found between the intervention groups with and without the booster intervention and the control group at 12-month follow-up.
Coping strategy: Program effects on the Seeking Guidance and Support subscale of the coping style index (CRI-Y) were sustained up to one year after posttest. Adolescents in the intervention group were seeking more guidance and support during times of depression compared to adolescents in the control group, even 12 months after the intervention had been completed (the difference was not significant at the 6-months follow-up). This effect was similar for individuals that did and did not receive the booster intervention.
Limitations
Evaluation Methodology
Design:
Recruitment/Sample size:
Participants were recruited from the University of Jordan through public advertisement and announcements. Screening included all individuals who expressed interest in participating in the study. Those who met the inclusion criteria became the participants of the study. To be eligible for participation in the study, students had to have a total score of at least 15 out of 63 on the Beck Depression Inventory, indicating moderate to severe depression. The other inclusion criteria reflected the demands of the study protocol: ability to read, write, and speak Arabic; absence of significant hearing or visual impairment; and ability to come to the research site ten times over the ten weeks of group therapy sessions. Of the 564 student volunteers, 84 (15.6%) met the inclusion criteria, consented to participate, and were subsequently randomized.
Study type/Randomization/Intervention:
The study employed a randomized controlled trial design. Using a permuted block randomization design, the 84 students were assigned to the intervention group (n=44; 52%) and control group (n=40; 48%). Students in the intervention group received the program in ten sessions (one session per week) with each session lasting 45 minutes. Group leaders were master-level nurses who had experience in psychiatric and mental health nursing. Each group consisted of 11 students and groups met at the mental health laboratory of the school of nursing.
Assessment/Attrition:
The participants were evaluated at three time points: at pretest during screening, posttest (10 weeks after pretest), and 3 months after posttest (follow-up).
Attrition was minimal and occurred only for the control group for which 4 students dropped out after having been randomized.
Sample characteristics:
The overall sample consisted of 46 (55%) males and 38 (45%) females. The majority of the students were not working (n = 73, 87%), not smoking (n = 54, 64%), and none of them reported parent use of alcohol or drugs. More than one third (35%) of the students were in their first year; 27%, 25%, and 13% were in their second, third, and fourth year of college, respectively. The study provides no details on the socio-economic background of the students. It can be assumed that regarding racial/ethnic classification all students were of Arabic background.
Measures:
Validity of measurements:
The instruments were translated from English to Arabic. A back-translation from Arabic to English by an independent language expert was employed to evaluate the translation quality. A pilot test using a sample of 15 Jordanian students was conducted to evaluate readability and comprehension of the scales. In addition, the authors point out that "the scales also have been checked for cultural variations."
Primary outcomes:
Analysis:
The authors employed repeated measures mixed models to examine the effect of treatment on depression, stress, and coping over time. The repeated measure models implicitly control for baseline scores of the dependent variable.
Intention-to-treat: The study complied with the intent-to-treat principle.
Outcomes
Implementation fidelity:
To ensure adequate mental health capability, the group leaders received three training sessions by an expert psychiatric nurse who designed the original TKC program. The sessions were audiotaped and videotaped to assess and monitor implementation fidelity. The group leaders maintained records and notes of the sessions and had to fill out progress reports after each session. However, no quantitative measures and evaluation of implementation fidelity were presented.
Baseline Equivalence:
Pretest scores on the three measures were compared using a series of one-way ANOVA tests. The analysis showed no significant difference between the groups. However, the subscale analysis (Table 3) revealed significant (p<.05) baseline differences for two coping style domains (planful problem solving; escape-avoidance).
Differential attrition:
Attrition was low (4.8%), which might be the reason why a test for differential attrition was not performed.
Posttest:
Depression and stress: The interaction between group x time demonstrated significant program effects on both measures of depression and stress. Compared to the control group, the students in the intervention group evidenced a reduction in perceived stress (p<.001), and a decrease in depression levels (p<.001). These effects were significant both at posttest and the 3-month follow-up assessment.
Coping strategies: An investigation of program effects on coping strategies revealed a significant increase in the use of approach coping strategies (p<.001), relative to the control group. However, the group x time interaction for avoidance coping strategies was not significant (p=.75).
An analysis of the different components of the coping strategy subscales demonstrated significant (p<.001) group x time interactions for 3 of 4 domains of the approach coping subscale. Students in the intervention group had higher mean scores for seeking social support, planful problem solving, and positive reappraisal. In addition, a significant (p<.001) group x time interaction was reported for 1 of 4 domains of the avoidance coping subscale, for which intervention students demonstrated lower scores for escape-avoidance.
Long-term effects:
The study did not collect long-term, follow-up data beyond 3 months after posttest and therefore was not able to demonstrate sustained effects.
Limitations
Evaluation Methodology
Design:
Recruitment/Sample size: It appears that one rural school was selected for this study. All consenting students in grades 9 through 12 (n=222) were surveyed during health class using the Reynolds Adolescent Depression Scale and those who scored in the moderate to high range for depressive symptoms (n=86; 38.7%) were eligible for this study. Of these students, 46 (53.5%) provided written consent and were enrolled in the study.
Study type/Randomization/intervention: Students were randomly assigned to intervention (n=27) or control conditions (n=19). Intervention students received the 8-week program delivered in a group format by a mental health nurse with no prior connections to the school.
Assessment/Attrition: Students were assessed at baseline and at immediate posttest. The overall attrition rate was 10.9% with one student from the control condition, and 4 students from the intervention condition, dropping out before the end of the intervention.
Sample Characteristics: Sample characteristics were provided for the completer sample only. The average age of the 41 students was 15.8 years. The students were predominantly White (95.1%) and 56.1% were female.
Measures: Depressive symptomology was examined using the Reynolds Adolescent Depression Scale, a self-report measure used in previous studies.
Life events were examined using the Life Events Checklist, a self-report tool that yields two values: a score indicating positive life change (a positive number) and one indicating negative life change (a negative number). A total score is calculated by adding these numbers.
Eight different coping styles were examined using the Jalowiec Coping Scale (confrontive, evasive, optimistic, fatalistic, emotive, palliative, supportant and self-reliant).
Analysis: Repeated measures MANOVA was used to examine the efficacy of the intervention on the outcome measures. Gender was examined as a moderator variable.
Intent-to-treat: Data were presented on the completer sample only. The researchers did not attempt to follow up with the attriters and therefore appear to have violated the intent-to-treat principle.
Outcomes
Implementation Fidelity: No information was provided on implementation fidelity.
Baseline Equivalence: No information was provided on baseline equivalence.
Differential Attrition: Although attrition differed by condition, the study reported that the differences were not significant. No information was provided about whether attrition differed by demographic or baseline outcome variables.
Posttest: No significant differences were found between conditions for depressive symptomology (marginal, p=.074) and life events. Of the eight coping styles examined, a significant difference was found between the conditions for one. The intervention condition reported greater usage of the supportant coping style than the control condition (p=.001).
When examining the interaction of gender with the intervention, female intervention participants had a significant decrease in depressive symptoms compared to female control participants at posttest. No effect of the program was found for male students.
Evaluation Methodology
Design
Recruitment: Three rural Midwestern public high schools consented to be included in the evaluation of the anger-management adaptation of the program. Students were eligible to participate if they had the ability to read and write in English and were not enrolled in special education programs, with 179 meeting these criteria.
Assignment: The study used stratified randomization to allocate participants to treatment (n=93) or control conditions (n=85), with grade level (freshman, sophomore, junior) and gender as the strata.
Assessment: Measures relating to anger experience and expression were collected at baseline, immediate posttest, and at 6- and 12-month follow-up. The study provided little information about retention other than noting that "the dropout rate was small (9.43%, n=19)."
Sample
Participants were mostly White (86%) and had a mean age of 15.6 years. The sample had a balanced gender distribution (52.5% female) and came from rural areas, with parents who typically did not have more than a high school education (about 14% had a Bachelor's degree) and worked in labor-intensive or service-providing industries.
Measures
Focusing on how participants express anger at a single point in time, all measures came from the State Trait Anger Inventory (STAXI-2), composed of 57 items and 12 subscales. Though all subscales were measured (and demonstrated good validity: a > 0.84), the evaluation focused on the 5 that relate to immediate reactions to anger:
Anger Expression-Out relates to the ability to suppress angry feelings before they are expressed toward things in the environment.
Anger Expression-In involves the ability to hold in or suppress angry thoughts and feelings.
Anger Control-Out is the ability to prevent expressing anger toward other persons or objects.
Anger Control-In has to do with being able to internally process anger, such as calming down or cooling off.
Overall Anger Index comes from combining the individual scores on the above measures.
Analysis
Two-sample independent t-tests were used to evaluate group differences in anger-expression outcomes at posttest and at 6- and 12-month follow-up. It does not appear than the analyses accounted for repeated measures within individuals, baseline outcome scores, or other baseline variables that may have differed between groups, though the alpha level was adjusted for multiple comparisons using Bonferroni correction.
The evaluation appeared to adhere to intent-to-treat, using all available data from participants, though not enough information was given regarding the timing of student dropout to be sure.
Outcomes
Implementation Fidelity: While implementation was not formally assessed, participants tended to view the program positively.
Baseline Equivalence: Sociodemographic measures were not tested for baseline equivalence, though group differences on outcome measures did not appear to be significant.
Differential Attrition: While the rate of attrition was fairly low (9.43%), there was no assessment of differential attrition.
Posttest/6- and 12-Month Follow-Up: No group differences emerged on any of the 5 outcomes at posttest or 6-month follow-up. One significant difference emerged at 12-month follow-up, with the treatment group achieving higher scores on the overall anger index than the control group (though the authors state the effect was only marginally significant after adjusting for multiple comparisons); however, it is unclear whether this is a positive or iatrogenic finding, as it was not stated whether high scores reflect increased anger regulation (positive) or greater anger expression (negative).
In subgroup analyses investigating whether the effect differed by grade level (freshman versus junior, sophomores appear to be omitted), the contrast failed to reach significance, despite trending toward significance among freshman (p= .06).