schools were randomly assigned (within their respective schools) to the prevention program, and 40 subjects were randomly assigned (within their respective schools) to an assessment-only control condition. All at risk subjects were interviewed with the Children's Assessment Scale, and any subjects who were currently depressed or had suffered a previous depressive episode were excluded (currently depressed subjects were referred for treatment), as were subjects with attention deficit hyperactivity disorder or conduct disorder.

At the end of the intervention, there were no differences between the two groups on depressive symptoms or attributional style. However, at the 6-month follow-up interview (CAS interview), 18% of the assessment-only control subjects had developed MDD or dysthymia, whereas only one (3%) of the prevention program subjects had developed either disorder. Arnarson and Craighead are currently evaluating their prevention program with 96 at-risk (as previously defined) students in six schools in Iceland. They are also developing a similar program for use with 16-to 18-year-old students in a commercial or trade school setting.

Beardslee and associates, following the IOM stages, first studied risk and resilience, then developed pilot interventions and conducted a large efficacy trial, and are now exploring the effectiveness phase. Their prevention programs were designed to be public health interventions and useful to all families in which a parent is depressed. The programs are to be used by a range of health practitioners, including internists, pediatricians, school counselors, and nurses, as well as by mental health practitioners such as child psychiatrists, child psychologists, and family therapists. Moreover, this approach includes a strong emphasis on treatment, given that so much depression is undiagnosed and untreated.

A variety of studies from different theoretical points of view have in common the finding that children of depressed parents are at risk for depression and other conditions. Rates of depres sion are two to four times higher in children of depressed parents than those for children of parents with no illness (Beardslee, Versage, & Gladstone, 1998). To understand the transmission of depression, it is important to recognize that in many instances, depression in parents serves as an identifier of a constellation of risk factors that, taken together, cause poor outcomes. In Rutter's classic epidemiologic studies, six factors were identified, including maternal psychiatric disorder. When only one was present, there was no increased risk to the child, but when two or more risk factors were present, the risk went up dramatically. In a random HMO sample over a 4-year period, Beardslee and associates (1996) demonstrated that the same principles were evident in predicting who became depressed. They devised an adversity index consisting of parental major depression, parental nonaffective illness, and a prior history of disorder in the child. When no risk factors were present, less than 10% of the children became ill. When all three were present, 50% of the children became ill, with a gradation in between.

In studying resilience, Beardslee and associates identified three characteristics that described resilient children of depressed parents. The three characteristics, which were incorporated into the preventive intervention, were (1) support for activities and accomplishment of developmental tasks outside of the home; (2) a deep involvement in human relationships; and (3) the capacity for self-reflection and self-understanding, in particular, in relationship to the parent's disorder. Resilient youth repeatedly said that understanding that their parent was ill, that the disorder had a name, and that they were not to blame for it contributed substantially to their doing well. This, then, became a central part of the preventive intervention.

Initial studies of these intervention programs revealed that they were safe and feasible, and that families believed them to be helpful. In an initial random assignment study of the first 20 families enrolled, promising effects were observed 6 months after intervention, and a further follow-up study of parents' reports showed sustained effects over 3 years. In addition, pilot studies revealed that greater benefits were associated with the clinician-facilitated intervention

than with the lecture condition. More recent reports on a portion of the sample at the third assessment point have indicated that both conditions resulted in family improvements, and that parents in the clinician-facilitated condition reported significantly greater levels of assessor-rated and self-reported change in family understanding and problem-solving strategies than did participants in the lecture condition.

Most recently, Beardslee, Gladstone, Wright and Cooper (2003) presented findings from follow-up interviews conducted with their entire sample of families at the fourth data point, nearly 2.5 years after intervention. They chose this interval because it was long enough to begin to see substantial, sustained changes in several main domains hypothesized to be affected by participation in the prevention programs. They focused on effecting change in a mediating variable that they described as parental child-related behavior and attitude change.

Results revealed several important findings about the primary prevention of depression and other forms of psychopathology in children at risk for dysfunction due to parental mood disorder. They found that these programs did have long-standing effects in how families problem solve about parental depression (i.e., behavior and attitude change). There was evidence that the clinician-facilitated program was initially more beneficial than the lecture program, and that the amount of change in parent's child-related behaviors and attitudes increased over time. They also found that children reported an increased understanding because of the intervention. They found a significant relation between the amount of child-related behavior and attitude change manifested by parents and the amount of change in understanding manifested by children, even though change was rated entirely separately by assessors blind to the knowledge of the other subjects' reports. Finally, they found that children who participated in the intervention programs reported decreased internalizing symptomatology over time.

After the success of the randomized trial, Beardslee and associates examined the mechanisms by which change took place. Briefly, they found that when families did make changes, they talked repeatedly about depression. Often, breaking the silence about depression led the families to talk and strategize successfully about many other things. This process was named the “emergence of the healer within.” Similarly, they found that what works for a child at 12 does not work for the same child at 16. In this sense, understandings of depression change both as the course of parental illness changes and as children grow and mature. Finally, many parents, despite the negativism and self-doubt of depression, end up functioning effectively as parents. In essence, they made peace with their disorder and moved on.