Nate Snyder, Danny Penrod and Morgan Barker, all 12 years old, have participated in a kid-friendly cognitive behavior skills-building therapy program. Danny says deep-breathing exercises have helped him through some stressful moments on the school bus.
There might have been blood on the birthday cake if the fist fight had erupted just a few hours earlier.
John Hutson was tired of being harassed, especially in front of so many other kids at the sleepover. The name-calling picked up around 3 a.m., after dodgeball and video games. John warned one of the other nine-year-olds that he was tired of being called “stupid” and “weak.” And he finally proved he wasn’t with a stranglehold, a blow to the stomach and a full-scale fist fight that ended with both boys swinging fists wildly on the floor.
Two years later, John breathes. He counts. He leaves the room if he needs to calm down. He hasn’t been able to shake all the blood he’s seen on television in recent months, most of it at the hands of young men, and he’s promised himself there must be a better way to deal with anger.
“It scares me what a person is really capable of doing,” said John, who is now 11 years old. “When I get mad, my adrenaline is out there and it’s horrible. But I’ve learned how to stop and breathe.”
Learned. That’s the word mental health professionals would point out, that coping with anxiety and adversity is a skill that can be taught and practiced. As the nation struggles to pinpoint what might help prevent violence in the wake of the Sandy Hook Elementary School shooting in Newtown, Connecticut, the conversation has largely focused on gun control and general demands for better mental healthcare in the United States. Far less attention has been paid to specific ideas or interventions that can help change the way a young person thinks or behaves before they turn to violence.
But a new program piloted at John’s middle school on the outskirts of Chillicothe, Ohio, may help prove that short bursts of therapeutic exercise, even if practiced in a standard health class, can drastically improve an adolescent’s chances of dealing with stress in environments as diverse as inner-city Los Angeles and rural Kentucky.
The program is called COPE, short for Creating Opportunities for Personal Empowerment. The kid-friendly program takes key concepts from cognitive behavior therapy, a branch of psychotherapy shown to be quite effective at treating anxiety disorders and clinical depression, and incorporates them into lesson plans that nearly any teacher or health professional can deliver.
John is an active participant in his COPE class. He struggled with his anger and sought counseling for it in the past. The class has given him new ideas for channeling his feelings away from violent acts like hitting. "I've learned how to stop and breathe," he said.
Developed by Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FAANP, FNAP, FAAN, The Ohio State University’s chief wellness officer and dean of the College of Nursing, the program teaches students to examine the negative or distorted thoughts that pop into their minds and then change them into more realistic or positive ones that will improve their mood and, hopefully, their actions. The ultimate goal is that some teens, especially those in areas of the country where mental health counseling is scarce or nonexistent, will learn to develop strategies for dealing with early stage anxiety and depression before those conditions spiral out of control.
Preliminary results from a COPE clinical trial in Phoenix that’s being funded by the National Institutes of Health show that the program helps students improve not only their mental health, but their lifestyle behaviors, social skills and academic performance.
The program at John’s school launched just a few weeks after Adam Lanza forced his way into Sandy Hook on Dec. 14 and opened fire. The coincidental timing reminded Melnyk why she developed this program in the first place. One out of four or five children and young adults have a mental health problem in the U.S. today, but less than 25 percent of them receive any type of treatment.
“If you look back at the history of the shooters, they all had mental health problems,” said Melnyk, a longtime psychiatric mental health nurse practitioner and one of the nation’s leaders in evidence-based healthcare research. “If we can identify and get to these kids earlier, we actually can help many more of them and prevent serious tragedies from happening.”
Thinking. Feeling. Behaving.
The classroom doors lock behind the students just in case someone dangerous comes into Huntington Middle School or the adjoining elementary school. The mascot, an old-fashioned huntsman complete with coonskin cap and a hunting musket, stands guard on a mural near the front entrance.
But on a recent school day, Terri Eldridge’s COPE class felt safe for other reasons. She turned down the lights and asked the sixth graders to close their eyes and “go to a happy place.” After a few moments, she asked them where they were. “A baseball game.” “McDonald’s.” “The beach ... no, hold on, NOT the beach because I got stung by a jellyfish there. Maybe Hawaii.”
Eldridge explained that’s just one strategy for escaping stress momentarily when life gets rough. “We all have negative thoughts. And when negative things come into our lives, it can help to think about this triangle.”
On the board at the front of the room, each corner of a triangle was labeled with a word: Thinking. Feeling. Behaving. “What’s it mean?” she asked the group, which had already been through lessons that included specific ways to change negative thought into positive ones, strategies to stop worrying and tips for resolving conflicts with friends.
One boy looked at the triangle on the board and shouted out, “If you think good thoughts, you’ll feel good and you’ll behave good.”
“Right,” Eldridge said. The triangle is the bedrock of cognitive behavior therapy and can serve as a reminder that a person’s thought patterns are directly linked to how they feel and the actions they take. This type of therapy and the skills-building COPE program that it inspired also places emphasis on goal setting, problem solving and stress reduction, all of which go a long way toward helping a young person boost self-esteem, reduce depression and anxiety, and control anger.
On this particular day, Eldridge’s students were learning about stress, what it is, how to recognize it and how to handle it without making themselves sick. A workbook for the class put it bluntly: “NEGATIVE THOUGHTS can cause STRESS and STRESS can cause NEGATIVE THOUGHTS,” complete with a diagram of a wheel to emphasize how vicious that cycle can be.
"Patterns of thinking, particularly negative patterns, often lead to much of the
depression we see today," Eldridge said.
This group of students knew a thing or two about all kinds of stress, from parents, homework, siblings and peer pressure. They were also well versed in some of the things that calm a person down, like chewing gum, breathing deeply, taking a walk, mostly physical things.
What many of them hadn’t considered is that reducing stress and negative thoughts can also happen by thinking differently. Another diagram showed the steps: "Stressor -> Negative to stop -> Replace the negative with a positive thought -> Positive emotion & behavior.”
Melody Roop, 12 years old, walks to lunch at Huntington Middle School in Chillicothe, Ohio. She is a high-performing student with few stresses in her life outside of academics.
Not all of the kids believed the diagram would work for them or that they even needed it. But after a little practice, the tip ended up working for Melody, a classic over-achiever. Melody spends a lot of her time feeling jittery and nervous about tests and homework even though she consistently gets straight As.
Late at night, when she starts telling herself that she’ll probably fail a big test in the morning, Melody now forces herself to remember that she’s studied hard, knows her stuff and there’s a very good chance she’ll do well on it. The trick helps her sleep a little better, and more often than not, she aces the test.
Simply changing the way she thinks helped Melody calm down. But if an adolescent’s thoughts are more extreme, if they cause excessive worry or sadness, for example, the knee-jerk reaction of many primary-care doctors is to prescribe an antidepressant or similar drug.
And that’s a problem, Melnyk said, because those drugs only work when there’s a chemical imbalance in the brain. And chemical imbalances “are far from the only cause of depression and anxiety. Patterns of thinking, particularly negative patterns of thinking, often lead to much of the depression we see today,” she said.
Especially if those negative thoughts are also fueled by environment.
“We feel lesser.”
On a clear day in this part of Ohio, all the rolling hills, old farm houses and local landmarks with names like the “Ancient Ohio Trail” and “Old Man’s Cave” draw tourists by the thousands, especially in the fall and spring. But in the dead of winter, things get quiet here as the sky turns gray.
Lesser. That’s the word John’s mother Paula used to describe the self-esteem in Huntington Township. “We feel lesser, so our kids feel lesser because we pass that on to the next generation,” she said.
Paula is a fourth-grade teacher at Huntington Elementary School, who has plastered her walls with posters about positive-thinking and the need for better self-image. “Attitude’s a big thing, and you’ve got to have a positive mind to do it,” she said. But she knows how hard that can be.
Paula said both she and her son have benefitted from his participation in the COPE class by being able to discuss his actions and feelings more openly. She said the program would help give students a self-esteem boost that can sometimes be lacking in this part of Ohio.
While many parents in the area work for Kenworth trucking, the local medical center or the paper mill, about three out of five students in the school district are “economically disadvantaged," meaning their parents’ incomes are so low they qualify for free or reduced-cost lunch, a percentage considerably higher than the statewide average of a little more than two in five.
Worries about having the basics, such as food, housing and gas money, can “make performance of everyday activities like coming to school difficult,” said Nina Andrews, a longtime school psychologist in neighboring Hocking County. “And this can decrease a student's self-esteem and increase their worries about the future, which can put them at great risk for developing depression or anxiety symptoms.”
Much of the region also qualifies as a "mental health professional shortage area." This federally designated title indicates that there are not enough healthcare providers to meet the basic needs of the community. Nearly 90 million Americans live in an area that falls into that category.
In the last 10 years, state and federal funding for mental-health services to the region has plummeted by 70 percent, according to Juni Frey, director of the mental health board that serves Chillicothe and the surrounding area. "It very difficult for anyone without to access to [health coverage] to access treatment through a community mental health center," she said.
Even for those with insurance, it can be difficult. Take John's case. When Paula wanted to find a counselor for him, she had to drive all the way to Columbus, an hour away. "That's the closest place to be able to go to get specific counseling for adolescents," she said.
Many parents here don’t have that option. It would mean several gallons of gas in addition to fees for the counseling itself.
Even with COPE classroom training, something was needed to help screen and treat more young people a little closer to home. Perhaps something as simple as the nurse’s station at Huntington Middle School.
A Place in the Schools
It was 11:40 a.m. in the nurse’s station just down the hallway from the cafeteria, prime time for part-time school nurse Rachel Willis.
A seven-year-old said his head was hot. Behind him, a middle-schooler, fresh from gym class, had a twisted wrist. Headaches. Backaches. Upset stomachs.
Rachel pivoted between them, unscrewing bottle caps, checking paperwork, putting her palm to red-hot foreheads. The bell rang again and several of the kids moped back to their next class. She took a deep breath.
Rachel had been told that mental-health screening will soon be added to her list of duties that already included vision screening, immunizations, medication distribution and chronic disease management.
She will be conducting mental-health screenings as part of the continuing COPE program there. The COPE program has been developed so that anyone can be trained to deliver it, according to Melnyk. It can also be amended to fit school and state standards.
“I would be curious to know how many of them even have a primary care doctor around this area,” Rachel said. “I might be the only health professional that they see.”
As part of COPE, students will soon be screened discreetly at the beginning and end of the program to see if they have acute anxiety or depressive symptoms that need to be monitored. If so, and if the in-class COPE program doesn’t help, they can then be referred to professionals in the school or the surrounding area for follow-up care.
It’s one of the reasons Principal Alice Kellough immediately said, “Yes,” when she got the call that Huntington Middle School had been selected to pilot COPE. Among the things that excited Kellough most about the program was how easily the curriculum could be delivered by nearly any education or healthcare professional, including teachers, counselors and school nurses.
Eldridge, Huntington’s official COPE teacher, said the standardized coursework fit within her health classes without much strain, especially because the essentials, lesson plans, workbooks and a one-day training for instructors, were provided by Melnyk’s team at Ohio State through a grant.
So far, about 96 sixth graders completed a nine-week version of the course. Seventy-four eighth graders will begin an expanded, 15-week version this spring. By including all students in the COPE coursework and screening, there’s a greater likelihood that even students who internalize their anxiety or depression will be helped, not just the ones who act out in the classroom and may have been referred to a school psychologist already.
The middle school had nothing close to this in previous years, aside from a couple of pages in the health textbooks about feelings and a bullying prevention program. “There’s just such a crying need for resources for these children,” Kellough said. "They come to us and they just don't know how to think in a healthy way about themselves and their relationships. It's a recipe for disaster. And there’s only so much you can do in the core curricular areas.”
There are specific aspects of this area that made COPE particularly appealing to Kellough. For starters, Huntington Local School District is very rural, a collection of single-family dwellings, mom-and-pop groceries and the school. “The school is the community,” she said. “We’ve become the be-all, do-all. We take care of everything.”
But she also believes that when it comes to the mental health of young people, the problems facing her students aren’t unique to rural communities.
It’s an American cultural problem, she said. “Our parents value their children. They love their children. But I just think that there [is] a growing number of students who don’t have a moral foundation. The crying need is that right and wrong are becoming very blurred for them.”
Adolescent Stuff
12-year-old Devon Carroll and his best friend have a ritual.
The bell rings, students flood into the hallway, Devon runs up to his friend and slams him into the locker, “hockey-style.”
“We’ll check each other, just goofing around,” he said. “I would never hurt anyone.”
The teachers don’t like it. But it’s the rough behavior that turns more violent that most worries Eldridge. Fist fights, schoolyard bullying, shouting matches at the lockers, a lot of it stems from students feeling like they “have no resources left,” she said.
“When they resort to that, I feel like students have tried to deal with problems in another way, but maybe they just aren’t equipped with the know-how to deal with them,” Eldridge said, “So, they reach the end of their rope quicker than maybe they will now that they’ve gone through COPE.”
Granted, not all of the kids in Eldridge’s class see the point in mental-health training. Nate Snyder said there’s never been anything in his life that’s made him mad or sad. Devon laughed at the idea of closing his eyes and going to a happy place: “I would never think to do that. I would never remember.”
Then there’s Danny Penrod. He’s one of the sixth graders in Eldridge’s COPE class and a self-described “pretty jolly person.” But it makes him really angry when one of his best friends stares and pokes at him. In the past, Danny didn’t think twice about responding with a swift punch to the arm.
After COPE, “I would stop myself right before I would hit him, and I would just calm myself down with deep breathing,” he said. “I would just tell myself, ‘Don’t do it. Don’t do it.’” (He admits he sometimes still goes ahead with it anyway, “but not as much.”)
Not exactly criminal behavior -- just adolescent stuff.
But reaching a young person early, when potential depressive or violent symptoms show up as “just adolescent stuff," is crucial, according to Andrews, the psychologist from Hocking County.
Adolescence is a time of great change in the brain, which is “pruning” at that age, Andrews pointed out. As the brain erupts with growth during the preteen years and early adulthood, the frequently used connections become stronger and those used less often are pruned back.
That’s why it’s such a critical time for young people as they develop life-long patterns of thought and a sense of self-worth, and therefore such an important period for the “cognitive behavior therapy” skills-building strategies stressed in the COPE program.
Findings from a series of four studies have indicated that teens who receive COPE training “reported significant decreases in depression, anxiety, anger and destructive behavior as well as increases in self-concept and personal beliefs about managing negative emotions.” Initial assessments show that is as true for a group of primarily white students in Ohio as it is for Hispanic teens studied in Arizona.
For her part, Eldridge believes the majority of the students learned a technique they’ll use in the future, whether they realize it or not.
“Some of my students have lost parents in the last year, and some of them have parents in jail, and for them, it probably resounded more effectively,” she said.
“I just had to gut it up and cope”
Long before she created COPE, Melnyk was one of those kids.
She was 15 years old when her mother sneezed, burst a blood vessel in her brain and died.
“I could do nothing to help her, and I personally suffered from terrible post-traumatic stress disorder,” she said. “I don’t think I slept through the night fully for about three years after her death, re-living that nightmare over and over, again and again.”
In 1972, about six months after her mother died, Melnyk’s relatives took her to their family doctor’s office, where she explained that she still couldn’t sleep and felt very anxious and jittery. The doctor wrote a prescription for Valium, an anti-anxiety drug, and said, “Just give her one of these and she’ll sleep fine.”
Melnyk did as she was instructed but felt groggy the next morning and vowed to never take another. She knew from that moment that “I just had to gut it up and cope on my own without any mental health counseling or any help whatsoever at all.”
A few years down the line, Melnyk was working as a nurse practitioner in an in-patient child and adolescent psychiatric unit and noticed a startling pattern. Children and adolescents were being admitted with the same problem: they had visited their primary-care providers several times with regular headaches and stomach aches, but they were never asked key mental health questions. Those issues then progressed into very serious mental health conditions.
In the wake of the massacre in Newtown, Connecticut, Melnyk saw the developing discussion around mental health as a glimmer of hope that things might finally change. For the first time in a long time, she said, the nation was looking for serious answers.
While she acknowledges that COPE is not the solution to the systemic problems plaguing the U.S. mental health care system, she believes it can play a part, primarily because it’s so easy for nearly any teacher or healthcare professional to roll it out.
In addition to the middle- and high-school versions of the program -- which schools in Delaware, West Virginia and Arizona have implemented at a cost of $50 per student -- Ohio State University has transformed COPE into a freshman-level college course. An adult version is in the works. Melnyk’s long-term goal is to create a nonprofit geared toward helping schools throughout the country adopt the program.
“My hope is that every child and teen and college student in this country is able to get these skills as part of their standard curriculum,” she said. “If they could learn them just like they learn math and history and social studies, they will use for them for the rest of their lives.”
Breathe
The skill that will probably stick with John most is the idea of getting away to think.
And he knows just the place. It’s an old, beat-up lawnmower, “one with smokestacks on it,” in his backyard, he said.
John’s a thoughtful kid. He spends a lot of his time worrying about things like whether he’ll be friends with his sister when they grow up since they fight all the time. He’s stopped playing a lot of violent video games because they make him feel “uneasy.” He worries quite a bit about his own temper.
“But when I’m on my lawnmower I don’t think about anything bad,” he said. “I just think about stuff that is so happy ... no world with violence, no unnecessary killing, nothing like that.”
On his lawnmower, John can understand the world and his own emotions a little better. He can breathe.
PBS NewsHour Health Support Provided By The Kresge Foundation and the Robert Wood Johnson Foundation.
For more information about the COPE program, contact Bernadette Melnyk at melnyk.15@osu.edu.
Written by Jason Kane
