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Section 16
Social Skills Training to Reduce Depression in Adolescents

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Introduction
Depression and depressive disorders remain a pervasive problem in Western society (Albert & Beck, 1975; Schulterbrandt & Raskin, 1977; Rehm, 1981). The extent to which this problem affects adolescents has recently generated substantial research (Kendall, Cantwell, & Kazdin, 1989; Kazdin, 1990). Both DSM-III and DSM-IHR have employed the same criteria to define depression in adolescents as in adults. Applying these criteria to emotionally disturbed adolescents reveals that the depressive disorders are common (i.e., estimated incidence ranges from 15 to 30%) (Schulterbrandt & Raskin, 1977; Costello, 1981; Weiner, 1982; Kazdin, 1990).

Beck's Cognitive Theory of Depression (1979) has served as a heuristic model for understanding depressive disorders in several studies. Depression is described primarily as a disorder of cognition, resulting in impaired affect and behavior (Beck, Rush, Shaw, & Emery, 1979). The model explains how cognitive errors in interpersonal interactions lead an individual to view current life experiences primarily as negative, resulting in the development of the depressive syndrome. In addition, the model describes how applying idiosyncratic schemas to life circumstances maintains the depressive syndrome. Within this model, treatment of depression requires the modification of the client's cognitions. The treatment process is further facilitated by focusing on other components of the depressive syndrome (e.g., behavior). Treatments consistent with Beck's model of depression and its treatment have shown promise (Rehm, 1981; Kazdin 1990).

Social skills therapeutic programs are designed to alter maladaptive social/interpersonal behaviors as well as the inappropriate cognitive evaluations associated with social behavior. Appropriate social skills consist of: (1) the ability to organize cognitions and behaviors into an integrated course of action directed toward culturally acceptable social and/or interpersonal goals; and (2) the ability to continuously assess and modify goal-directed behavior to maximize the likelihood of reaching particular goals (Goldstein, 1981).

One specific social skills program, Structured Learning Therapy (SLT), presents a comprehensive treatment approach with adolescents (Goldstein, Spraffin, Gershaw, & Klein, 1980). SLT includes skill instruction, modeling, role playing, and performance appraisal. Goldstein (1981) defined his treatment as the planned systematic teaching of specific behaviors that help an individual function appropriately in interpersonal contexts. Along with behavior modification, the program strives to modify distorted perceptions about social interactions, as well as the individual's ability and potential. Research examining social skills treatments that contain procedures similar to SLT suggest that the treatment is effective for a variety of social/ interpersonal problems. For example, SLT's efficacy has been reported for treating: social isolation and social withdrawal (Jackibchuk & Smeriglio, 1976; La Grecca & Sanogrossi, 1980); unassertive behavior (Denney, 1975; La Fromboise & Rowe, 1983); and aggressive behavior (Camp, Blom, Herbert, & Van Doormeade, 1977; Huey & Rank, 1984; Goldstein, Apter, & Harotunian, 1984). In addition, social skills treatments have been reported to be equal in effectiveness to traditional psychotherapies in treating depression and hyperactivity (Hersen, Bellack, Himmelhoch, & Thase, 1984; Fleming & Thornton, 1980; Kazdin, Esveldt-Dawson, & Matson, 1983).

Finally SLT appears to be more readily employable for various groups, compared to traditional psychotherapies, and has helped improve the psychosocial functioning of both males and females of diverse ages and ethnic backgrounds (La Fromboise & Rowe, 1983; Hersen et al., 1984; Huey & Rank, 1984). Consequently, social skills treatment may be a useful therapy for clients who have difficulty in traditional psychotherapy (e.g., ethnic minorities and teenagers).
This project represents an initial evaluation of the effectiveness of SLT with a clinically depressed sample of adolescents. SLT was applied to an ethnically mixed, inner-city, adolescent sample; two hypotheses were examined: (1) SLT is an effective method for treating depression in inner-cmty ethnic minority and white adolescents; and (2) SLT is equally effective for male and female adolescents in alleviating depressive disorders.

Method
Design

Two studies were conducted that employed the same design. A sample of adolescent subjects was randomly assigned either to a treatment or control group. All Subjects received a biweekly group treatment and were prescreened for clinical depression prior to being accepted for treatment. Subjects were also evaluated using depression, self-esteem, and general psychological functioning measures prior to treatment, immediately following treatment, and 6-8 weeks after the final treatment session.

Subjects
One hundred adolescents, aged 14-19 years were screened as potential subjects. They were primarily from low to middle socioeconomic status families living in an urban area of northwest Ohio. Subjects selected met the criteria for major depression or dysthymic disorder from DSM-IIIR. Subjects also scored above the criterion on either the CDI (12) or Face Valid Depression Inventory (16). Twelve were randomly assigned to the treatment group, and the remaining six served as controls.

Eleven were African-American (6 males, 5 females), two were Hispanic (1 male, 1 female), and five were white (2 males, 3 females). There were 2 males and 4 females in the control group, and 7 males and 5 females in the treatment group.

Measures
All adolescents were evaluated by a battery of measures prior to treatment, immediately following treatment, and 6-8 weeks after the final treatment session. Measures included the Children's Depression Inventory (CDI) (Kovacs & Beck, 1977), Face Valid Depression Inventory (FDI) (Mezzich & Mezzich, 1979), Beck Depression Inventory (BDI) (Beck, Ward, Mendelson, Mack, & Erbaugh, 1961), and the Coopersmith Self-Esteem Inventory (SEI) (Coopersmith, 1967, 1981).

Two multidimensional personality measures were also included. They were the Personality Inventory for Children (PIC) (Wirt, Lachar, Klinedinst, & Seat, 1977) depression, withdrawal, and social skills subtests, and the Minnesota Multiphasic Personality Inventory (MMPI) (Hathaway & McKinley, 1967; Hoffman & Butcher, 1975; Overall & Gomezmont, 1974; Hedlund, Won Chu, & Powell, 1975). The MMPI used adolescent norms reported by Colligan, Osborne, Swenson, & Offord (1983).

Clinician Ratings
A licensed clinical psychologist and an advanced graduate student, both with child and adolescent clinical experience, evaluated profiles of adolescent responses on test data to obtain holistic impressions of the adolescents' progress in treatment. Raters were presented before and after treatment profiles of the subjects. The clinicians rated the subjects on degree of improvement, success of treatment, and group placement.

Procedures
Subjects who met the selection criteria were randomly assigned to either the treatment or control group. Each group was led by two therapists.

Treatment sessions followed the outline of SLT presented in Goldstein's Skillstreaming the Adolescent (1980). Treatment consisted of a discussion of the skill to be covered, instruction on use of the skill, and group leader modeling of the skill. The adolescents then role played the use of the skill in social interactions typical of their familial environment. All subjects role played each session, then received feedback from peers and group leaders. Subjects were also encouraged to practice the skill at home and/or in their community.

The control group participated in Art and Imagery exercises. They were also given the opportunity to express themselves through their creative work and to discuss their feelings.

Results
Data were analyzed to address two major questions: (1) Is social skills treatment effective for depression in adolescents? and (2) Is SLT equally effective for male and female adolescents?

Treatment and control groups did not differ significantly on any pretreatment measure. Additionally, males and females in the treatment group did not significantly differ on pretreatment measures. Thus, both groups began at a comparable level of functioning. In addition, Pearson product moment correlation coefficients reflect expected relationships among various categories of measures (i.e., high internal consistency and inverse relationships between pathological scales and self-esteem).

Treatment effects were analyzed in two phases. First, a series of t-tests was conducted on holistic clinical judgments of improvement and success. Second, a series of t-tests was conducted on self-esteem, and depression measures to evaluate their main effects of treatment, time, and gender.

Inter-rater reliability of the clinical judgments was determined by computing Pearson correlation coefficients between the two judges. Reliabilities exceeded r = .80 for the success and improvement ratings. The third rating, whether the subjects were in the treatment or control groups, was not reliably made by the judges, and therefore was not used in subsequent analyses.

The most experienced clinician's ratings were used as the criterion for holistic judgment. A significant between-group difference was found using success ratings that were based on subject profiles with information from all three assessment sessions (t = 3.02, p < .01). The treatment group was rated moderately successful (mean = 4) for the SLT group, and unsuccessful (mean = 1.6) for the control group. This significant difference suggests that score configurations of treatment subjects provide more evidence for change than do such configurations for control subjects.

Gender Differences
Due to limitations of the sample size, gender differences could be examined only in the experimental group, which included seven males and five females. A series of t-tests was first conducted to determine whether males and females differed on holistic ratings of improvement and success, as well as on depression and self-esteem measures.

The clinical judgments revealed three significant gender differences. Male treatment subjects were rated as more successful than females when judges relied upon pre- and post-treatment data (t = 2.33, df = 9, p < .04), and when judges included follow-up data (t = 2.88, df = 7, p < .04). In addition, judges rated males as more improved than females when they based their judgments on data including follow-up assessments (t = 2.82, df = 10, p < .02). Five of the six males were rated as having improved, while only one of five females was similarly rated. Formal gender analyses were not conducted on the control subjects. However, it is important to note that clinicians did not rate any of the six controls as improved using either set of data.

A series of t-tests comparing gender means of the formal test data for each assessment session also revealed significant differences. Males were significantly less depressed than females on the FDI at post treatment (t = 2.30, df = 9, p < .04) and follow-up (t = 2.69, df = 8, p < .02). No significant gender difference were revealed for the treatment subjects on the SEI.

Examination of the within-treatment changes across assessment periods highlights the gender differences found for each assessment session. Female treatment subjects actually exhibited significantly higher depression, as measured by the FDI between the pre- and pest-treatment assessments (t = 2.80, df = 4, p < .05), while male treatment subjects exhibited significantly lower depression across assessments. On the CDI, males' depression level decreased between pre- and pest-treatment assessments (t = 2.44, df = 8, p < .02). These subjects (3 of 5) generally continued to function at a nondepressed level through the follow-up assessment period. Improvement, as measured by the FDI, appeared to be a more gradual process. The males' reduced level of depression is revealed by comparing pre-treatment and follow-up assessment scores (t = 1.91, df = 8, p < .05). On this measure, 5 of 6 male treatment subjects were functioning at a nondepressed level at the follow-up assessment. Male treatment subjects also improved significantly from pre- to pest-treatment assessment on general self-esteem (t = 2.42, df = 6, p < .05), and from post-treatment to follow-up assessments on social self-esteem (t = 3.83, df = 6, p < .01).

Discussion
Results of this study provide only preliminary evidence on the two hypotheses because of the small sample size.

These results support the prediction that the treatment subjects would improve more than the control subjects. Treatment subjects were rated by clinicians as having received moderately successful treatment, whereas the control subjects were rated as having received unsuccessful treatment. Still, the significance of this finding is more clearly elucidated in the context of subjects' gender.

Results reveal differential clinical ratings and depression levels for male and female treatment subjects. The females' depression levels remained relatively unchanged, similar to the control group, whereas male subjects exhibited significant levels of depression following treatment. Males also exhibited improvement in some aspects of self-esteem.

A possible explanation may be rooted in adolescent social and inter-personal maturation (Locksley & Douvan, 1979; Weissman & Klerman, 1971). Both Kohlberg (1974) and Mischel (1974) report that females develop physical, cognitive, and interpersonal skills earlier in adolescence than do males. Consequently, different processes may lead to the development and maintenance of depressive disorders in male and female adolescents.

Male adolescents appear to run a fairly structured and consistent developmental course. The major task for males during adolescence is to gain mastery of their physical body and to exhibit environmental control through external achievement (Al-Issa, 1982; Locksley & Douvan, 1979; Weiner, 1982). Males suffering from depressive disorders would be expected to have difficulty demonstrating social competence and/or self-mastery. Depressed males often appear either physically awkward or lacking in social/interpersonal skills.

Responses to this awkwardness by adults and peers usually consist of strong sanctions, punishment, and negative reinforcement. Modification of male behavior in the form of improved social judgment, interpersonal skills, and self-mastery leads to improved academic achievement and social status. Moderate improvement in male functioning will usually receive positive responses from both peers and adults.

Additionally, male social networks tend to be flexible, and based primarily on current functioning. Therefore, male adolescents can improve their social status as their interpersonal functioning improves.

Conversely, female adolescents run a less structured and more inconsistent developmental course. Their major task during adolescence is to develop interpersonal competence and to become comfortable with their physical appearance and sexual identity (Al-Issa, 1982; Locksley & Douvan, 1979; Macoby & Jacklin, 1974; Weiner, 1982; Weissman & Klerman, 1979). Depressed females would be expected to have difficulty during this maturational process, exhibiting excesses in their dress, grooming, and physical state (e.g., weight loss or gain). In addition, females may use sarcasm and flirtatious behavior as a way of communicating dissatisfaction and/or of obtaining desired goals.

Responses from peers and adults to the female's incompetence is variable. At times the adolescent's behavior is considered as attractive and thus permissible, whereas the same behavior in other settings may be viewed as inappropriate and thus undesirable. Consequently, the female does not always receive a consistent message about her behavior. Improved behavior of female adolescents also receives inconsistent feedback.

Adolescent females in general are expected to be competent interpersonally. Therefore, a female adolescent who had been depressed, upon achieving appropriate functioning, would receive only minimal attention for her accomplishment.
Adolescent female peer groups also are quite different from their male counterparts. In general, these peer groups are less flexible, and are primarily based on long-term functioning. Consequently, improved functioning will often not facilitate immediate social acceptance by females. Therefore, depressed females will probably receive less attention and stature from competent behavior than from incompetent behavior.

In addition, one potential consequence of SLT may be to elicit more assertive behavior. Participants often learn to self-evaluate according to an internal set of values and norms that take into account social demands and expectations. Assertive behavior is usually considered a positive characteristic for males; however, assertiveness in females is not consistently viewed as positive in western society.

Consequently, it is suggested here that for SLT to be an effective treatment, it must meet the different gender-related developmental needs of the adolescents. Males would thus be best helped by: (1) receiving guidance in developing competent social behavior and in evaluating their social environment; (2) having a safe environment to practice new social skills; (3) having a safe peer group in which to achieve social status; and (4) having a caring role model to encourage success.

Most adolescent females have more social knowledge than do their male peers. The primary benefits they may accrue from SLT include the ability to internalize an appropriate criterion for self-evaluation (i.e., one which allows them to strive for high goals while being comfortable with the possibility of failure). These potential benefits include: (1) receiving reinforcement and feedback from peers and group leaders; (2) developing a long-term perspective for goal attainment; (3) developing trust in peers and leaders; and (4) learning to work cooperatively rather than competitively with peers.

The results of this study suggest that SLT in its present format is able to meet these goals for males but not for females. Future research will seek to replicate these findings and also vary the length of treatment time to determine if this leads to improvement in females. Finally, single-gender treatment groups will be used to determine if the results are partially due to female subjects being less candid about problems and needs because of the presence of males in the treatment group.
- Reed, Michael K.; Social Skills Training to Reduce Depression in Adolescents; Adolescence, Summer 1994, Vol. 29, Issue 114.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #2
The preceding section contained information about social skills training to reduce depression in adolescents. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 16
The major task during female adolescence is to develop interpersonal competence and to become comfortable with their physical appearance and sexual identity.  What would depressed females be expected to have difficulty with during this maturational process? Record the letter of the correct answer the CEU Answer Booklet.

 

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