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4 y.o African-American girl
 Intact family, middle class, professional
 “bored by everything”
 Low energy, low interest, “whiny”
 Father: “She’s spoiled”
 Mother: “What’s wrong with her?”
Start with what is normative, allowing for
ethnic/cultural and SES differences
Thorough developmental history
(circumstances around pregnancy,
pregnancy, birth, developmental
milestones, relationship with partner)
Mom’s psychiatric history
Relationship history
Sadness/irritability* (across time, settings, people)
 Loss of sleep*
 Loss of appetite*
 Nightmares/night terrors
 Anhedonia*
 Agitation
 May rock
 Social withdrawal
 Somatic complaints
 May see delay or regression in milestones
1. 3-5 year olds
2. Anhedonia***
3. Lack of reactivity or brightening around
positive events
4. Psychomotor retardation
5. Strong family history of depression
6 More severe symptoms
Axis I Clinical Disorders
 Axis II Relationship Classification
 Axis III Medical and Developmental
 Axis IV Psychosocial stressors
 Axis V Emotional and Social Functioning
SAMHSA’s National Registry of EvidenceBased Programs and Practices
 Traditionally treatment for “disruptive
behavioral disorders, ages 2-8
 Adapted by Luby for use with depressed
 Short-term, approx. 15 weeks, 1 hour
 Live Coaching
Phase I: Relationship Enhancement
(Child Directed)
Nurturing the relationship, praise, reflection,
imitation, enjoyment
 Phase II: Discipline and Compliance
(Parent Directed)
Structure, consistency, compliance
13 y.o Caucasian girl
 Single mom, low to mid-SES
 “very moody”
 Journal: “depressing thoughts”
 Interest in end of the world books/movies
 “hard to reach”
Five or more of the symptoms present for 2
weeks and represents a change from
previous functioning
1. Depressed mood (irritability in children)*
2. Diminished interest *
3. Significant weight gain/loss
4. Insomnia/hypersomnia (nearly every day)
5. Psychomotor agitation/retardation
(nearly every day)
6. Fatigue/loss of energy
7. Feelings of worthlessness
8. Diminished ability to think or concentrate
9. Recurrent thoughts of death/SI
Major Depressive Disorder
 Persistent Depressive Disorder (formerly
known as Dysthymia)
 Adjustment Disorder with depressed
 Other Specified Depressive Disorder
 Unspecified Depressive Disorder
The development of emotional or
behavioral symptoms in response to an
identifiable stressor(s) occurring within 3
months of the onset of the stressor(s).
 Marked distress or significant impairment
 Once the stressor has terminated, the
symptoms do not persist for more than an
additional 6 months
Depressed mood for most of the day for at least 2
years (in children and adolescents, mood can be
irritable and duration must be at least 1 year).
Includes two or more of the following:
1. Poor appetite/overeating
2. Insomnia or hypersomnia
3. Low energy/fatigue
4. Poor concentration
5. Feelings of hopelessness
70-76% will have subsequent MDD
 69% “double depression”
 Hard to diagnose
 Hard to recognize for the individual
 Ego Syntonic
 Outcome uncertain
Significant distress or impairment in
social, academic/occupational/, or
other domains
 Does not meet full criteria for depressive
 Specify why doesn’t meet criteria (e.g.,
short duration, insufficient symtpoms)
“Viewing depression dimensionally
rather than categorically seems more
appropriate and captures their (children
and adolescents) experience… There is
no discrete separation between kids
diagnosed with depression and those
with subclinical symptom.” (Hankin, et. al.,2005)
Nearly 1/3 of all kids discharged from psych
hospitals carry the diagnosis (Blader, 2007)
 Rise in outpatient visits for suspected Bipolar
Disorder (Moreno, 2007):
1994-95 20,000
2002-2003 800,000
 Increase in atypical antipsychotics with
children (Olfson, 2006): 1993 201,000
2002: 1,224,000
“I have been a child psychiatrist for nearly
five decades and have seen diagnostic
fads come and go. But I have never
witnessed anything like the tidal wave of
unwarranted enthusiasm for the diagnosis
of bipolar disorder in children that now
engulfs the public and the profession.”
(Kaplan, 2011)
“Juvenile bipolar disorder is a serious
illness that is estimated to affect
approximately 1 percent to 4 percent of
children.” (Biederman,2004)
Over 200,000 copies sold, 3rd edition
“The shot that was heard around the
psychiatric world”
Popularized the notion of kids having BPD
Adults with BPD reported having first
episode in childhood/adolescence
Distinct period of abnormally and persistently elevated,
expansive or irritable mood (for one week)*** 3 or more
Inflated self-esteem*
Decreased need for sleep
More talkative
Flight of ideas
Increase in goal activity
Excessive involvement in pleasurable activity*
Low arousal in morning, more energetic
Abrupt mood swings multiple times a day
Intense temper tantrums
Poor frustration tolerance
Switch from irritable, easily annoyed, angry
to silly, goofy, giddy states
Low self-esteem
Social Withdrawal
Not Euphoria, but irritability
 Not episodic but more chronic and
 In children, significant comorbidity with
ADHD 60-80%
 Usually not grandiose
 Disruptive Mood Dysregulation Disorder?
(DSM-5, 2013)
less irritable than Bipolar;
 Bipolar less vindictive than
Conduct Disorder
 Conduct Disorder: Rage (Mick et
al., 2007)
Medication: Lithium, atypical
antipsychotics, mood stabilizers,
sometimes given together
1. Genetic (30-50%)
2. Interpersonal
3. Cognitive
4. Environment/attachment
5. temperament
 Peer
contagion (Prinstein 2007)
 Co-rumination
 Reassurance
(Rose, 2002)
Seeking (Joiner,
“Relatively stable tendency to excessively and
persistently seek assurances from others that one
is loveable and worthy regardless of whether
such assurance has already been provided”
(Joiner et al 1999)
Negative Triad (Beck, 1997) negative
thinking results in helplessness, hopelessness
and worthlessness
 Learned Helplessness (motivational,
cognitive and emotional challenges)
(Seligman, 1986)
 Negative Attribution Style (Abramson, 1999)
When something bad happens:
(internal, stable, global)
When something good happens:
(external, unstable, specific)
Parenting style: authoritative vs.
authoritarian, Expressed Emotion-Crit
 Parental Psychopathology
 Attachment
 Neglect and Abuse
 Violence
 Hostile environment
Anxiety (8 x more likely)
 ADHD/ODD (5 x more likely)
 PDD/Dysthymia (69% will have both)
 Eating Disorders
 Substance Abuse (MDD predates by
about 4 years)
1.Strong supportive family/parents
2. Academic Achievement
3. Good self-esteem
4. Religious faith
5. Strong ethnic identity
Parent-Child Interaction Therapy: 14-16 sessionsChild Directed Interaction/Parent Directed
Interaction, In vivo feedback sessions, Parental
involvement mandatory
Interpersonal Psychotherapy for Depressed
Adolescents(IPT-A): 12 weeks, 3 phases, Parental
Involvement recommended, grief/role disputes,
role transitions, interpersonal challenges
Cognitive Behavioral Therapy/Insight-oriented
Medication (Black Box Warning 2004, 2006)