Programs that Work

Primary and Secondary Control Enhancement Training

Program Info

Outcome Areas

Healthy and Safe Children

Indicators

Children not experiencing anxiety or mood disorders, such as depression

Topic Areas

     Age of Child
       Early Childhood (0-8)
       Middle Childhood (9-12)
     Type of Setting
       Elementary School
       Middle School
     Type of Service
       Health Care Services
       Youth Development
     Type of Outcome Addressed
       Mental Health

Evidence Level (What does this mean?)

Promising

Program Overview

The Primary and Secondary Control Enhancement Training (PASCET) program is an eight-session child depression treatment program. The theoretical background for the program is based on managing depression through a two-process model of control. Primary control involves rewarding oneself by identifying enjoyable activities and making objective, modifiable goals (such as school achievement or relationships with peers) that conform to one's wishes. Secondary control involves rewarding oneself or avoiding negative thoughts or self-punishment by adjusting one's beliefs or interpretations in response to objective, nonmodifiable conditions (such as parental divorce). The approach of PASCET is that depression may be addressed, in part, by applying primary control when faced with distressing conditions that are modifiable and using secondary control when confronted with conditions that are not.

Program Participants

Elementary school-age children in grades 3–6.

Evaluation Methods

PASCET has been evaluated in a single comparison group study conducted in the early 1990s (Weisz et al., 1997). The sample of 48 students was drawn from three elementary schools with a total population of about 500 students in grades 3 through 6. A three-step selection procedure was used. First, all children for whom researchers had parental consent completed the Children’s Depression Inventory (CDI), a self-report of depression symptoms. Second, teachers and counselors were asked to identify any children whom they believed had significant problems involving depression. In the last step, children who had been nominated by their teachers or counselors, or scored 10 or higher on the CDI, participated in individual clinical interviews on the Revised Children’s Depression Rating Scale. The semistructured interviews were conducted by trained interviewers and covered such depression-related symptoms as unhappiness, guilt, and low self-esteem. Children included in the final sample met one or both of the following criteria: (1) a CDI score of 11 or higher, suggesting elevated depression; and/or (2) a clinical interview score of 34 or higher (i.e., above the 80th percentile for elementary school-age children in previously established scale norms). A total of 51 children met these criteria, and 3 chose not to participate in the study. The resulting sample included 26 boys and 22 girls, with 30 Caucasian (63 percent) and 18 ethnic minority (primarily African American) children. The average age of the students was 9.6 years, and the average CDI score was 18.1, which was the 91st percentile of previously established scale norms.

Within each school, 16 children who could be accommodated in treatment (given available therapists, a room or appropriate space in the school to conduct the intervention, and scheduling availability) were randomly selected from the pool of 48 students to receive the intervention, with the remaining 32 students assigned to the no-treatment control condition. At pretest, the treatment and control groups did not differ significantly in gender, ethnic composition, age, CDI scores, or clinical interview scores. PASCET was implemented during school hours in rooms in, or adjacent to, the school. Children were treated in four small groups of fewer than six children per group, with each group led by two cotherapists.

Posttest outcomes were assessed on the CDI and clinical interview within 18 days after the last treatment session. A nine-month follow-up assessment was also conducted for 29 children (60.4 percent) from the original sample. No significant differences were found between study dropouts and completers on pretest variables such as gender, ethnicity, age, CDI, or clinical interview scores.

Key Evaluation Findings

At the initial posttest, Weisz et al. (1997) reported the following:

From pretest to posttest, children’s self-reported CDI scores dropped about twice as much in the treatment group as in the control group, a difference that was statistically significant.

Comparisons of posttest CDI scores, with the analysis controlling for pretest scores, showed that scores were significantly lower (i.e., children were less depressed) in the treatment group than in the control group.

Assessment of the clinical interview scores revealed that the treatment group decline of 12.06 from pre- to posttest was significantly larger than the control group decline of 3.94. However, a different statistical test, which controlled for pretest scores, did not indicate a significant difference in mean posttest scores between groups.

The authors also assessed the extent to which children moved from above the normal range on the CDI and the clinical interview at pretest to within the normal range after treatment. Treatment-control group differences were significant for the CDI, but not for the interview scores. From pretest to posttest, 50 percent of the treatment group, compared with 16 percent of the control group, moved from above to within the normal range on the CDI.

At the nine-month follow-up, Weisz et al. (1997) found:

CDI scores dropped about three times as much from pretest to follow-up in the treatment group as in the control group, a statistically significant difference.

Comparisons of CDI scores at follow-up, controlling for pretest scores, also showed that scores were significantly lower in the treatment group than in the control group.

Analysis of the clinical interview scores found that the treatment group decline from pretest to follow-up was statistically significant and over three times as large as the control group decline. Despite this difference, an alternative statistical approach that examined nine-month interview scores, while controlling for pretest scores, showed no significant difference between groups.

With regard to children moving from above the normal range to within the normal range on the CDI and the clinical interviews, the differences between the treatment and control groups were significant for both the CDI and the interview scores. From pretest to posttest, 62 percent of the treatment group, compared with 31 percent of the control group, moved from above to within the normal range on the CDI. Similarly, 69 percent of the treatment group, compared with 24 percent of the control group, moved from above to within the normal range on the clinical interview.

Probable Implementers

Public and private elementary and middle schools

Funding

Previous research on the effects of PASCET has been supported by grants from the National Institute of Mental Health.

Implementation Detail

Program Design

PASCET consists of eight 50-minute sessions guided by a detailed therapist’s manual. Session activities (e.g., role-play, games, and a video) and weekly homework for children are outlined in a children’s practice book containing illustrations and reminders of key points.

Curriculum

Sessions 1-6 of PASCET focus on teaching and practicing primary and secondary control coping methods. The sessions emphasize two primary control skills:

identifying and conscientiously engaging in activities that the child finds enjoyable

skill building through goal setting and practice in activities that the child values.

The sessions also teach three secondary control skills:

identifying and modifying depressive thoughts

cognitive techniques for mood enhancement (e.g., finding a "silver lining" in an otherwise bad experience)

relaxation and positive imagery.

In Session 7, a therapist meets with each child individually to discuss themes of the program in relation to specific characteristics of the child and his or her situation. In Session 8, children serve as contestants in a "quiz show," in which they review the overall lessons of PASCET.

Staffing

The program requires training of therapists prior to beginning the intervention. Additionally, in presession meetings, therapists role-play the sessions with other therapists, providing the intervention using the manual, practice book, and a written list of specific session objectives. The program is delivered by two therapists, both of whom are present at each session. During each session, one therapist serves as group leader and the other plays a supporting role, including monitoring adherence to the program and ensuring that each section of the material is covered. In the program as evaluated, six therapists implemented the program, including five doctoral-level students in clinical psychology and one licensed faculty member.

Issues to Consider

This program received a "promising" rating, due in large part to the small sample size used in the evaluation. Despite the small sample size, the study used a randomized control design and retested participants nine months after completion of the program, finding significant and sizable program effects on reducing levels of child self-reported depression.

While results for PASCET are promising, the sample used to investigate program effects was not severely depressed to begin with, so it would not be appropriate to claim that the intervention is effective at alleviating clinical levels of depression. Furthermore, although posttest and nine-month follow-up scores on the CDI (controlling for pretest scores) were significantly lower for treatment than control group children, no significant differences were found between groups for the clinical interview scores. The authors suggest that this discrepancy may reflect the CDI’s greater sensitivity to recent changes in symptoms, given that children are asked to report on their symptoms and feelings over the past two weeks.

It should be noted that the program developer also served as the evaluator for the program.

Example Sites

Los Angeles, CA

Contact Information

John R. Weisz
President and CEO, Judge Baker Children’s Center
Professor of Psychology, Harvard Medical School
53 Parker Hill Avenue
Boston, MA 02120-3225
phone: (617) 278-4299
fax: (617) 730-5440
email: jweisz@jbcc.harvard.edu

Available Resources

Previously, Dr. Weisz has offered workshop training sessions for mental health professionals interested in implementing the PASCET program. Training includes instruction on program delivery, video illustrations, group exercises, and role-play.

Bibliography

Weisz, John R., Christopher A. Thurber, Lynne Sweeney, Valerie D. Proffitt, and Gerald L. LeGagnoux, "Brief Treatment of Mild-to-Moderate Child Depression Using Primary and Secondary Control Enhancement Training," Journal of Consulting and Clinical Psychology, Vol. 65, No. 4, 1997, pp. 703-707.

Last Reviewed

February 2007

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