Overview of Depression in Children and Adolescents

Depression is one of the most common mental health disorders in youth (Ghandour et al., 2019). In the case study above, Jamie is experiencing Major Depressive Disorder (MDD), which goes beyond the feeling of depression or sadness. With MDD, there is a distinct change and impairment in the functioning of a person, alongside a combination of symptoms. Specifically, for a Major Depressive Episode (MDE), the mood is sad (or irritable) or there is a loss of interest in activities for at least two weeks. In addition to one of these symptoms, youth experiencing depression will exhibit a combination of other symptoms, including changes in sleep patterns, levels of appetite, energy levels, motor activity, difficulty with concentration, feelings of excessive guilt or worthlessness, and/or suicidal ideation. In children and adolescents, the characteristics of these symptoms vary and emerge in various times across development.

There is also a lot of heterogeneity in depression, representing huge variability in how it can be experienced and expressed (Thapar et al., 2012). For example, youth can experience a single episode, while others might experience recurrent episodes. Youth with depression can also experience what is considered unipolar depression and bipolar depression (Kupfer et al., 2012). These terms are not in the current lexicon of the Diagnostic and Statistical Manual-5 (DSM-5; APA, 2013), although historically they have demonstrated a core concept. The old term of unipolar depression refers to the low side, such as low mood, anergia, and anhedonia (Kupfer et al., 2012). The opposite side (or pole) is the high side, such as elevated states of affect and energy, that can usually represent a manic or hypomanic state. It is during this elevated state of affect that a person may experience grandiose thoughts, increased energy, increased goal-directed activity, engage in high-risk behaviors, at times may lead to hospitalization.

How Depression Develops in Youth

There are various theories that help explain the etiology of depression, ranging from biological, stressful life events, interpersonal, and psychological explanations (see Bernaras and colleagues, 2019, for an overview). Biological theories view depression as being linked to genetics, serotonin dysfunction (Kraus et al., 2017); endocrine or inflammatory issues (Clarke & Currie, 2009); and sleep disorders like insomnia (Sivertsen et al., 2014). Psychosocial theories explain depression as resulting from disrupted attachments (Reinecke & Simons, 2005); from learned negative behaviors (Antonuccio et al., 1989); and from learned helplessness (Abramson et al., 1978) and negative cognitions (Beck et al., 1979). Stressful life event theories argue that stress can influence the manifestation of depressive symptoms (Frank et al., 1994; Sokratous et al., 2013). Seeing multiple theories covering multiple domains fits within a developmental systems lens, there is no single causality with depression (Bernaras et al., 2019), with multiple individual and ecological factors influencing the development of depression. Individual children, adolescents and adults may each have their own unique constellation of influences on their depression. It can be useful to have a multifactorial understanding of the causes of depression as you try to understand each individual and family whom you work with.

Let’s break down some of the indicators for Jamie. Her mom stated that most of Jamie’s symptoms began to emerge around 14. What could fit a biological explanation? One factor could be physiological and hormonal changes due to puberty. Also, Jamie’s mom expressed that she also experienced MDD, and so heritability and genetics could be another factor. With Jamie’s grades, one can wonder if the depression influenced her school functioning, or if difficulties with school contributed to negative thought patterns, such as “I was always the top of my class in my middle school years, and now I am not that smart.” We will talk more about perpetuating factors for Jamie’s depression in later sections, but getting an overall sense of what could have precipitated her depressive episode can guide how we tailor our interventions for her.

There are several risk factors for depression. Some common ones include heritability, negative family relationships, stressful life events, peer victimization via bullying, and child maltreatment. Adolescent age and the female gender are associated with increased vulnerability for depression (Thapar et al., 2012). Adolescents who experience clinical depression are at higher risk for suicide and non-suicidal self-harm, substance use to self-medicate mood and lifelong depressive episodes (Clarke & DeBar, 2010). In a meta-analysis of risk factors across the lifespan, Köhler and colleagues (2018) identified the following risk factors as having convincing evidence: environmental stressors, exposure to childhood maltreatment, obesity, sedentary behavior, and sleep disturbances. Köhler and colleagues (2018) also identified a study by Lu and colleagues (2012) that showed co-occurring asthma as a risk factor for pediatric depression. In reports about the ACTION study, a small-group CBT program for girls with depression or persistent depressive disorder, Stark et al. (2010) describe cognitive vulnerabilities for depression: the tendency toward rumination, a negative attribution bias, few problem-solving skills, and negative inferences about the self. Family level factors that can protect against depression include having a stable, attuned adult in the child’s life and protective community factors include social support outside the family and safe neighborhoods (Van Voorhees et al., 2008). Cairns and colleagues (2014) reviewed risk factors that were modifiable during adolescence without professional intervention, and they found that substance use, dieting, negative coping strategies, and weight were modifiable, and related modifiable protective factors included healthy diet and sleep. As we will see in the intervention section, modifiable factors like healthy lifestyle changes will be incorporated into Jamie’s treatment.

Developmental Systems Considerations for Depression

There is a variance in how and when depression emerges across the lifespan. Childhood depression is less prevalent and rates of depression for both boys and girls are similar. Depressive disorders in infants and very young children are considered relatively rare, and diagnosis takes specialized diagnostic training with an alternative diagnostic manual rather than the DSM which has poor reliability for younger children (Egger & Emde, 2011). The Zero to Five manual (2016) has specifically been developed to provide more valid and reliable criteria for diagnosis in children under five years old, in particular with zero- to three-year-old children, with an emphasis on changes in play, social interest, and sleep, factors that often times can be mischaracterized by caregivers as a behavioral issue (Luby, 2009).

Prevalence of depression has been estimated to be between 1% to 3% up to age 13 and closer to 6% percent in adolescents (National Institute of Mental Health [NIMH], 2019). By adolescence, prevalence increases, and girls are twice as likely than boys to be diagnosed with depression (NIMH, 2019). While depression could be underdiagnosed in males and similarly overdiagnosed in girls, the increased prevalence of depression is quite clear with research demonstrating that the risk of depression increases two to four times during adolescence (Hopkins et al., 2015).

Let’s consider the case vignette, Jamie. It is important to note the role of her developmental tasks and her symptoms. During adolescence, a teen is typically trying to expand their worldview as they attempt to develop more autonomy. This involves learning new things in school and expanding social networks and engaging socially with the world around them. Jamie’s social network appears small, so the support for positive reinforcers from her environment or providing social feedback could be limited. The isolation she desires and is engaging in is likely increasing and reinforcing her feelings of sadness. This is where we can pick up from our previous discussion of risk and resilience factors.

Jamie may have some biological vulnerabilities, but there appeared to be some stressful life events leading up to her start of high school. She had wavering support at home with her mom’s new job that required overtime hours. From our vignette, it seems like the depression was maintained through a lot of interpersonal factors. Her then boyfriend became distant from her after she set some boundaries regarding physical intimacy. Her friend Dennis, while an emotional support, was an influence on her with drinking and occasional cannabis use. Her mom still works long hours, and her sister is out frequently. What do all these interpersonal factors mean for how we approach intervention? Hold this in your mind as we explore options.

Experiences Across Race and Ethnicity. Prevalence in rates of depression across race and ethnicity have varied across the years, at times suggesting that white youth have lower prevalence than non-white youth, yet studies have yielded mixed findings (Scott et al., 2015). According to a recent report by SAMHSA (2018), past year prevalence of Major Depressive Disorder for adolescents in the US were 16.9% for biracial youth, 16.3% for American Indian/Alaska Native youth, 14% for white youth, 13.8% for Hispanic/Latinx youth, 11.3% for Asian youth, and 9.5% for Black youth. Not only are there disparities in diagnosis, but also racial and ethnic minority youth receive less adequate care than their white counterparts (e.g., Cummings, Ji, Lally, & Druss, 2018).

The experiences of exposure to risk factors for racial and ethnic minority youth are unique, and as a result, require intervention that is adapted to their needs. Scott and colleagues (2015) review such considerations, pointing to examples like the emphasis on family and relationships in Latinx adolescents and how family disruptions can be particularly detrimental to these youth. Zou and colleagues (2021) report on the unique experiences of Asian youth in North America, citing that there can be acculturative stress, discrimination, and immigration status. Depression was found with Asian American youth who had immigrant status, faced academic challenges, perceived parent-child conflict and maternal disconnectedness, and perceived negative peer relations (Zou et al., 2021). In a depression prevention trial, Asian American youth benefited from treatment at the same rate as other racial groups (Marchand et al., 2010).

As cited in other chapters, minority stress theory (Meyer, 1995) can be used a model for the development of depression, as discrimination and other racial prejudice can constitute stressful life events, a known risk factor for depression. Intervention therefore should target the unique protective factors of these youth. Scott and colleague’s review (2015) identified protective mechanisms such as identity, self-esteem, religiosity, and maternal support as especially important for African American and Hispanic/Latinx adolescents at risk of depression. It is important to understand how culture and other minority identities play a role in the development, understanding, and maintenance of depression.

Experiences of LGBTQ+ Youth. Lesbian, Gay, Bisexual, Transgender, and Queer (among other identities) youth experience mental health concerns at higher rates than cis-heterosexual youth. According to a recent survey on LGBTQ+ youth mental health, 62% of LGBTQ+ youth had experienced symptoms consistent with a depressive disorder in the previous two weeks. Within the LGBTQ+ youth, those that are transgender or nonbinary, that number was 70%, compared to 53% of cisgender youth. (The Trevor Project, 2021). In addition, 42% of LGBTQ+ youth considered attempting suicide in the past year, and the number also increased to 52% for those that are transgender or nonbinary.

Russel and Fish (2016) note that LGBTQIA+ youth may have fewer intrapersonal skills to cope with minority stress from their experiences of discrimination. Difficulty with emotional regulation can lead to later symptoms of depression (Hatzenbuehler et al., 2008) and LGBTQ+ youth are more likely to experience rumination (Hatzenbuehler et al., 2008; Russel & Fish, 2016). It follows here that developing emotion regulation skills specific to coping with minority stress is crucial. Parental support of a youth’s sexual orientation and gender experience can be protective against depression (Ryan et al., 2010), an important factor to consider as you work with the youth’s caregivers.

After a few weeks of working with her clinician, Jamie shared that she might be attracted to other women. Jamie expressed that she has not let any of her friends or family know. She is worried that her mother might be too busy to care and is not sure if she would be supportive. She is planning on talking with Dennis in the near future. This situation is particularly stressful for Jamie and adds to the other stressors she has been experiencing in her relationships and school.

Assessment of Depressive Disorders

The disorders presented in this chapter all have in common a depressed or irritable mood. The amount of time spent being depressed, irritable, or both varies between each disorder. But once we can determine that the presentation has mostly to do with a depressed or irritable mood, then we have several decisions to make regarding what is being presented, for how long, and how the person experiences it. The presentation, duration, and severity of these disorders vary and provide the basis for differential diagnosis.

Clinical Features: Major Depressive and Persistent Depressive Disorders

Prevalence of MDD has been fairly well established, with an estimate of MDD at 3.2% in the age range from 3 to 17 (Ghandour et al., 2019). Similarly, Hopkins and her colleagues (2015) on behalf of the National Institute for Health and Care Excellence (NICE) Clinical Guidelines Update committee report that MDD affects around 2.8% of children under the age of 13 and 5.6% of 13- to 18-year-olds. Gender ratios of female to male are 1:1 until adolescence; however, risk of depression increases two to four times during adolescence with the prevalence ratio becoming 2:1 for female to male (Hyde et al., 2008). In terms of timeline, MDD requires a minimum of a two-week period of depressed (or irritable) mood or loss of interest, almost every day for most of the day. A community study of major depression in adolescents found a mean duration of depression episodes of 26 weeks, or around 6 months, with a median duration of 8 weeks (Lewinsohn et al., 1994), and these results are similar to adult cohort studies (Ten Have et al., 2017). Over a five-year follow-up study for adolescents with depression, about half of the sample reported a depressive disorder as a young adult (Lewinsohn et al., 2020). For full criteria for Major Depressive Disorder, consult the table provided by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2016).

Persistent Depressive Disorder (PDD) has been seen in about 0.6-4.6% of children and 1.6-8.0% of adolescents (Nobile et al., 2003). PDD for children and adolescents requires a minimum of one year of chronic low-level depression (or irritability) or loss of interest every day most days of the week, while a two-year length is required for adults (Nobile et al., 2003). With PDD, there is persistent and long-term depressed/irritable mood, and the mean episode duration is approximately 3 to 4 years (Nobile et al., 2003). A major depressive episode has been seen in children 2 to 3 years after the onset of PDD, and both MDD and PDD can be diagnosed concurrently. Consult the same SAMHSA (2016) resource for PDD criteria.

Jamie’s mom says that her daughter had depressive and irritable mood nearly every day. Jamie has been losing interest in activities that she used to enjoy and isolating more. She reported having thoughts of suicide from time to time, but expressed no plan or means. Jamie has said that she has trouble falling asleep every night, and her appetite has decreased. She reported having a lot of negative thoughts, such as thinking she was no good and that no one liked her in school. Based on what Jamie and her mom report, she fits the criteria for a diagnosis of Major Depressive Disorder.

Clinical Features: Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder (DMDD) is a relatively new disorder, debuting in the fifth version of the DSM (APA, 2013). DMDD is characterized by extreme temper outbursts that are frequent and not proportional to the situation, as well as chronic irritability. For example, having a delay in receiving an ice cream cone becomes a travesty. The earliest studies of DMDD shows that it is relatively uncommon after early childhood, and it frequently accompanies both another emotional and/or behavioral disorder (Copeland et al., 2013).

The history of the development of the DMDD diagnoses stems from children and adolescents presenting with these symptoms and being diagnosed with bipolar disorder, a disorder characterized by mania or hypomania. Bipolar disorders present in youth by extreme irritability, happiness, or silliness, talking fast, having racing thoughts, grandiosity, and poor judgment (NIMH, 2020), and this disorder may often be misdiagnosed in children (NIMH, 2020). The Longitudinal Assessment of Manic Symptoms (LAMS) Study demonstrated how an initial bipolar diagnosis in children was not stable over time (Findling et al., 2010). In the study, a sample of children and adolescents diagnosed with a diagnosis of bipolar disorder were followed-up for reassessment every six months. Over the course of five years, the youth were reassessed every six-months, 75% of the participants did not meet criteria for bipolar disorder, even those who had elevated manic symptoms (Findling et al., 2010).

DMDD may be a more appropriate diagnosis for children where there is concern related to chronic irritability versus a specific bipolar disorder. The prevalence of DMDD is yet to be determined but in the last seven years, the data suggest rates of 0.8% to 3.3% (Bruno et al., 2019; Copeland et al., 2013;). For diagnostic criteria, consult the table included in the article by Baweja and colleagues (2019).

Assessment Tools for Depression in Youth

A recent review of freely available instruments (Becker-Haimes et al., 2019) reports four tools for measuring depression in youth that were tested among a representative sample. Psychometric properties of the measures included excellent internal consistency (α ≥ 0.90), and acceptable test–retest correlations (r ≥ 0.70, among other criteria (for rubric, consult Becker-Haimes et al., 2019). Structured tools for measuring depressive symptoms include the Mood and Feelings Questionnaire (MFQ; Angold et al., 1995), the Patient Health Questionnaire-9 (PHQ-9; Johnson et al., 2002), the Positive and Negative Affect Scale for Children (PANAS-C; Laurent et al., 1999), and the Revised Children’s Anxiety and Depression Scale (RCADS; Chorpita et al., 2005). Treatment monitoring is even more essential for children with depression, whose maladaptive belief system may lend itself to thinking things are worse than they actually are. Any rating system needs to be contextualized but also serve as iterative feedback for the youth as they progress through treatment. With DMDD, the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children has been used to diagnose DMDD by a NIMH research group (Copeland et al., 2013); however, these interviews have not been adapted for broad clinical use (Baweja et al., 2019).

At intake, Jamie was given the PHQ-9 by the intake clinician, and the treating clinician decided to continue using this to monitor treatment. Jamie and her mother’s symptom reports mapped onto the items on the PHQ-9, with Jamie feeling like she can’t have fun with people and therefore isolates (item #1); depressive and irritable moodiness (item #2); sleep difficulties (item #3); blaming thoughts (item #6); difficulty concentrating (item #7); and thoughts of suicide (item #9). She was in the moderate-severe range with a total score of 16. While she didn’t endorse other items on the PHQ-9, this tool is helpful to monitor the manifestation of new symptoms, the intensification of symptoms, or, hopefully with ongoing treatment, the reduction or remission of symptoms.

Intervention for Depressive Disorders

Several interventions for youth depression have been developed. Weersing, et al. (2017) reviewed the most recent evidence base for interventions for youth depression and categorized their evidence based on Southam-Gerow and Prinstein (2014)’s criteria. The criteria take into account the evidence for the treatment and the methodological rigor of the studies; categories include the following designations: well-established, probably efficacious, possibly efficacious, experimental, or questionable efficacy. They found that the evidence for child interventions is weak, and no treatment obtained a well-established or probably efficacious status. The following interventions for children are possibly efficacious: overall CBT, group CBT, technology-assisted CBT, and behavior therapy. The experimental interventions for children were individual CBT, psychodynamic therapy, and family-based intervention. For adolescents, overall CBT, individual CBT, group CBT, overall IPT, and individual IPT are well-established interventions. Group IPT received a probably efficacious status while family-based interventions and bibliotherapy CBT are possibly efficacious. Lastly, technology-assisted CBT was experimental. A recent meta-analysis of youth depression psychotherapy effects concluded that effects are modest, with no changes in over a decade (Eckshtain et al., 2020).

The most widely disseminated intervention for youth depression has been CBT, as well as antidepressant medication. CBT involves understanding how youth interpret situations, and how they think about the world, others, and self. However, mood disorders have also been linked to neurological functioning, in particular the neurotransmitter serotonin. The Treatment of Adolescents with Depression Study (TADS) suggests that medication can be helpful as a standalone treatment or in combination with psychotherapy (March et al., 2004). The study found that CBT plus fluoxetine (Prozac) displayed a 71% response rate; fluoxetine alone displayed a 60.6% response rate; CBT alone was 43.2%; and placebo was 34.8% (March et al., 2004). It is important to note that Selective Serotonin Reuptake Inhibitors (SSRIs), such as fluoxetine, have rare side effects that include increased suicidal ideation, so monitoring by the caregiver and the treatment team is critical during the first few weeks of taking the medication.

How should we proceed with our case study, Jamie? As we see with treatment options above, CBT, IPT, and/or medication seem like good options. In the world of CBT, clinicians can focus on the behavioral side of the intervention first and then tackle cognitive aspects. Therefore, behavioral activation could be a good first step for Jamie. Behavioral activation strategies like engaging in physical activities, increasing social engagement, taking up new activities or hobbies could break the negative behavioral loop that perpetuates depression (i.e., Jamie feels sad, wants to withdraw, and then feels worse in the long-term). Sometimes thoughts can get in the way of this, like “what if people think I look stupid when I go for a run?” or “No one is going to want to hang out with me.” Sometimes, treating the behavioral activation strategy as an experiment can be the best way forward. You can collaborate with Jamie to decide what she would like to do and encourage her to give it a try to get some data or information on whether or not it worked for her. For instance, let’s say that we used the TRAILS behavioral activation worksheet to brainstorm ideas of activities that could boost her mood. She was able to identify some people that she could hang out with (e.g., her cousin), and activities she would enjoy doing like making a collage from her parent’s leftover magazines and going window shopping. She identified some rewards for herself if she was able to do those activities, like watch an episode of her favorite Netflix show. Afterwards, you can discuss how she felt before, during, and after the experiment, as well as what thoughts appeared for her and what she learned from the experience.

On the cognitive side, a clinician may need to consider what negative automatic thoughts are coming up for Jamie when she is faced with a difficult situation and identify the impact that those thoughts have on her mood. The clinician can talk about how truthful and/or helpful these thoughts are and discuss ways to increase cognitive flexibility. A clinician can use a thought record to discuss with Jamie how to evaluate her thinking, what cognitive errors she typically falls into, and come up with a more helpful and/or balanced thought that she would use and is helpful and believable to her. Consider this potential exchange when talking to Jamie about a situation in which her friends were talking about going to a movie:

Jamie: “My friends haven’t invited me to the movies yet. And I don’t think they want me to be there.”

Clinician: “Tell me more about why you think that they don’t want you there.”

Jamie: “Well, why would they want me there? I don’t think they like me at all. Today, I walked into the cafeteria, and they were laughing at me.”

Clinician: “Hmm, tell me the details of what happened. What are the facts?”

Jamie: “Well, I walked into the cafeteria, went to our table, and when I got there, they looked at me and were laughing, so I just went and sat at another table”.

Clinician: “Ok, let’s think through some possibilities. I wonder, last week we talked about cognitive errors, and you identified several that you typically fall into. Do you think one of those was present in this situation?”

Jamie: “Well, now that you mention it, I think I might have jumped to conclusions. Amanda is usually telling jokes. You know what, they have gym together the period before, and the gym teacher is a bit silly. He probably did something goofy and were laughing at that. But it really felt like they were laughing at me, it just hurt.”

Clinician: “Got it, so it sounds like there might be other things going on, but your immediate interpretation was assuming that they were laughing at you. What might be a coping thought that would be helpful for you to keep in mind for next time something similar happens?”

Jamie: “Maybe my friends are laughing at a joke, and I won’t know until I sit with them.”

By challenging these thoughts and beliefs, we can attempt to open up some possibilities for Jamie. Jamie has been in treatment for 4 months now, and she is finding some improvements. Her PHQ-9 score is down to a 10 (moderate range). She states that she still feels down and still has some self-blaming thoughts, but she’s not really having the suicidal thoughts she had before. Her sleep has improved, and she thinks that is helping with her concentration in school. “I’m not as tired as I was when I first saw you; like I’m still tired, but not where I’m falling asleep in school or feel like too tired to deal with the thoughts in my head. I feel like I can just push back and move on, the thoughts are annoying but I’m dealing with it better.”

This type of mild symptom reduction can go a long way for the persistence of depression. Jamie does have more work to do, especially knowing that she will eventually disclose her sexual orientation to her mom. “I feel like I am in a better spot to actually bring it up, but I’m not ready just on a personal level, like nothing to deal with my depression. I’m just not there yet, but at least I know I don’t feel so guilty about myself and who I am.”

Clinical Dialogues: Child and Adolescent Depression with Guy Diamond, PhD

Sean E. Snyder, LCSW: Thanks for joining us today. We know that you’re one of the co-creators of Attachment-based Family Therapy, and it would be great to get your expertise on depressive disorders with children and adolescents. To start, we will talk about engagement.

Adolescents commonly feel guilt and self-blame with depression. Parents can also self-blame or feel like they’re walking on eggshells with their child who may have depression or suicidal ideation, and these parents may feel like their child’s depression is their fault. So how do you join with families, given these themes and the circumstances that bring them to treatment with you?

Guy Diamond, PhD: In a broad context, there’s a couple strains of thought. First, we like to ask what is the source of depression in adolescence? We believe in a wide range of psychological science, and we certainly believe in temperament and genetics and biology, of course, but for a lot of kids, the depression seems to be more circumstantially driven: bad home environments, bullying, sexual identity issues. So, the driving questions are, “if depression is biological, what do you do about it? If it’s psychosocial, what do you do about it?” My team tries to balance a nature/nurture attitude in intervention, because we believe in medication, and we believe in psychosocial intervention. Unfortunately, with medication, it’s not always effective for adolescents. In this and other cases, we consider the nurture and contexts of psychosocial intervention.

Our primary strategy is centered on how we can improve the context of their life to be less depression promoting. As a team, we ask ourselves, “What can we do to improve their context?” For us, the basic stance is derived from attachment theory, where the assumption is that if a kid has a secure base relationship with their parents, they can turn to them for support when they are upset. The child can share difficult emotions without fearing rejection or humiliation or shaming, and they feel better about themselves. We know from attachment theory that kids internalize a sense of whether the world is a trustworthy place. They internalize questions like “am I’m worthy of love?” I think for Bowlby, that his theory of psychological development is if someone is treated well and attended to, and if their emotional needs are attended to, then they internalize a sense of the world as being comfortable and safe.

We capitalize on that attachment assumption in our therapy. The way we invite families into treatment is that we’re worried as a care provider, particularly for a depressed suicidal adolescent. We are worried that they have lost their voice, that they feel things deeply and sometimes feel they’ve been treated unfairly and have things that they aren’t happy about. But instead of saying something about it, these kids withdraw, or they get overwhelmed by difficult emotions, and at worst, they cut themselves or turn to suicide. So, we’re interested in helping kids come back to the surface, figure out how to stand up for themselves, how to have a voice, and how to articulate their emotions better. So, rather than feeling overwhelmed by emotional distress, they can actually articulate it, talk about it, share it, and feel more able to understand it better. That’s what we’re interested in helping the teen do.

Our pitch to the parents is that they are the developmental cauldron. They are the foundation of what helps the child develop a sense of self, a sense of security, and the ability to talk about their feelings. So, we’re trying to resuscitate or repair the attachment relationship in this therapy, so that kids can once again have a secure base to turn to for support as they go out and explore in the world. In general, that kind of stance is our basic invitation to families into therapy. It’s not a blame model. It’s not a pathology in the family model. Instead, it’s one where families aren’t the cause of the problem. They’re the medicine to fix the problem. That’s our phrase; we say it to the parents all the time. We think from an attachment point of view, that caregiving is as strong and instinctual an impulse as attachment.

Attachment is really the kids’ need to go to their parents for comfort. Like in old times, the old saber tooth tigers outside the cave; as a child, they don’t even think about it, they just run to mom and hide behind her skirt. In modern times, I fall off my bike and scrape my knee. I’m scared I’m anxious, and I run up the stoop jump in mom’s lap, or in dad’s lap. She rubs my head. He calms me down, regulates my emotions, and I go off and play. So, the attachment instinct is the kid’s innate biologically wired-in survival tool.

Snyder: Right, attachment is a behavior system, and it’s activated when fear is activated. The attachment system is definitely activated from both sides: child seeking protection and the parent’s protection instinct.

Diamond: They don’t think about it. They just run to mom and look for comfort, in the same way that parent’s caregiving instinct is as biologically wired-in. We as parents, we don’t sit there on the stoop watching him fall off the bike thinking, “He’ll be fine with a scraped knee, big deal!” No, we drop what we are doing, we’re down the street before he hits the ground. We’re catching him and we didn’t even think about it. It comes down to “my son’s in trouble, go! My daughter’s hungry, take my plate.” That’s the instinctual drive.

That caregiving instinct can get clouded with depression, with economic distress, with marital problems. The attachment instinct gets clouded with child thoughts of “they have failed me before, so I don’t run up on the porch anymore because I know I’m just going to get laughed at and told to stop crying. I’m a boy.” And so, things can happen that make the attachment instinct and the caregiving instinct not work so well. And our therapy with ABFT is about improving that instinct, on resuscitating it, revising it, and helping people feel that the instinct is trustworthy again.

Snyder: The clinician invites both the child and caregiver to come together and frames the encounter like you said, “the family is what’s the medicine” or the family is what’s going to foster healing. I am glad to hear that you reference various ecological processes like economic stress, marital issues, that can interfere with basic human drives, like the need to be comforted and the need to comfort the child. It’s a get back to basics approach.

Diamond: Yeah, for a therapist, that mindset helps because the therapist is thinking, “Well, what should I focus on? There are 1000 things I could focus on in a family.” It gives direction, where the therapist is going to focus on repairing trust, increasing emotional flexibility, helping the kid revise their internal working model of the parent to say, “it used to be that I couldn’t trust my mom or dad, but boy, after Guy’s work with her, he or she has kind of learned some skills, and she’s back in the saddle, and maybe I could trust her next time.”

Now, repairing attachment may not solve everything, but it is, we believe, a foundational pillar of strength that a kid feels the feeling that they have a secure base to turn to, whether they’re 3 or whether they’re 16. We know that in adolescence attachment is just as important as in earlier stages of childhood. It looks different, it manifests differently, but it’s no less of a fixture of their psyche. So, we’re trying to establish that so that then the family is a better team, and they can work on all the other problems like school failure, being bullied, or sexual identity.

Snyder: And when problems arise, if the attachment is disrupted, guilt and blaming can be a core family process. So, with intervention, the core of the matter is developing the trust between the family again.

Diamond: Yes, trust. If a child can say “I trust my mom,” then they know they can talk to her about sexual identity or about bullying. The child can turn to her for support, can ask her to help them manage their medicine. A teen may think, “I’m not doing very well. But before I wouldn’t let her manage my medicine. Screw her, she’s just controlling me. With treatment, that turns into “My mom is on my side, and I need help, because I keep forgetting to take the medicine. Mom, could you give it to me every day?” That’s what we’re trying to revitalize and get to.

Snyder: It’s like recalibrating and kind of getting things realigned and a lot of it, as you mentioned, is based on trust. That trust then can change how a child thinks or behaves.

So, my next question is something I get a lot with trainees and students that I’ve supervised. Trainees (and frankly, non-trainee clinicians as well) struggle with confidentiality and the therapeutic alliance. Considering that trust is so critical in this process for the family, but also in the therapeutic relationship, how does your team approach or explain confidentiality to a child without them feeling like they need to censor themselves or just keeping in mind the maintenance of trust within the therapeutic context?

Diamond: We definitely don’t have the same philosophical constraints that, let’s say, psychodynamic therapy has, which really thinks the clinician relationship with a patient is so sacred that if I were to even talk to their mother, they would feel violated. For a family therapist, they have always dealt with multiple alliances. It’s just the nature of what we do. I think the way we do it, in part, has to do with transparency. We’re very clear. I mean, what we say when we meet alone with the youth (because we split parents and youth into separate sessions before coming back together again in ABFT), we say, “Look, what we talk about between you and me is private. Obviously if you talk about hurting yourself or others, I’m obligated to report that, you need to know that. But stuff you tell me, I’m not going to go run and tell your mom or dad. My goal is that you tell your mom or dad anything’s that’s important, that is getting in the way of your relationship. I’m going to encourage you; I’m going to help you figure out how to talk to your parents about that. It doesn’t mean you have to tell them that you’re smoking pot or that you have a boyfriend already. Unless those are becoming dangerous things, my job is to help you help your mom to learn how to listen better so you can talk to her about things that are important. We’ll go slow; we’ll work it out together.”

Snyder: Because I think as newer clinicians are developing skills, the fallback is always about the relationship. That makes a lot of sense. The therapeutic relationship is important, but it’s not just for us as clinicians; that child needs a therapeutic relationship with their caregivers, where they feel supported enough to turn to them.

Diamond: It’s partly also we see ourselves, as Winnicott said, as transitional objects. It’s important for them to feel trusting of me as their therapist and connected with me, and I want that. You open up your heart in therapy, and then I’m going to try to transfer that over to the parent, because that has long-term implications, rather than a psychotherapy relationship that’s short-term and once a week.

Snyder: Maybe we as clinicians over-value our role in the client’s life. I mean obviously we are important in a therapy context, but we are not the ones that live with the child. Maybe this focus on the relationship with the clinician is part of a rescue fantasy or countertransference or our stuff. I appreciate you discussing this point, because the process is so important with all of this.

What about the other side of the family, how do you talk to the caregiver or parent around these issues of confidentiality?

Diamond: I could say the counterpart to what I just told you I say to the kid. There are two things we can say. On the one hand, our therapy in the beginning tilts a little bit more taking the adolescent side. We’re not child-saving therapists though. In the beginning, we are trying to help the kid have a voice, which means having them identify what makes them mad, what makes them sad, and helping them say it. We’ve done a study where we interviewed parents after the first session and asked, “Does it feel like the therapist is taking the kid’s side?” and the parents actually say, “I’ve never seen him talk so much in therapy, so I see why you’re doing it! He usually sits here quietly, won’t say anything. He’s never talked to anyone the way he talked to you today.”

And a lot of that comes because we just lean in and say, “of course, you’re pissed off, of course you don’t want to be close to her because it sounds like you’ve been hurt. I want to understand why.” So, we try to understand their point of view, and every family therapist is struggling with walking a fine line of where it seems like blaming the parent when you’re saying mom could have a role in what’s happening with the child. You got to take her side too, recognize what they’re doing, saying things like “You’re a fantastic mom, I see how committed you are, and I see how much you love this kid. I do see there’s a few things I could help you with that might make it easier for him to come to you.” Generally, we are balancing alliances. I think we do say to parents, “Look if your kid feels like he can’t trust me in private, he’s not going to talk to me. So, don’t ask me to reveal things to you. Anything that’s important, we’re going to talk about together. But please don’t prod me because you’re just going to undermine my credibility and handicap the process with your child talking in therapy.”

Snyder: And I liken the idea to where sometimes it’s like explaining to the parents like “Maybe it’s a little uncomfortable in the beginning, but there will be a long-term gain. You might feel a certain way about the process, like I’m siding with the child but it’s for the long-term goals we have.” There is a lot of relational assessment going on: the types, the quality of relationships. On a symptom and functioning level, are there standard assessments that you use, for instance standard screeners like the PHQ-9 or the RCADS or suicide screeners like the Columbia?

Diamond: A lot of our work is in the context of a clinical trial, so we’re trying to measure change over time. In clinical practice, we encourage our students or trainees to say, “Look, I gotta know how severe this depression is right now.” We do brief screeners that we repeat over time, so every couple of weeks we give it out again. Now, we happen to have our own assessment tool that we’ve developed over 15 years that’s a multi-dimensional web-based screening tool. We give the kid an iPad in the beginning, and he fills it out and it covers depression, suicide, substance use, psychosis, trauma, sexual identity, access to a gun, bullying, and family relationships. It gives us a full psychosocial assessment. It’s a screener, not a diagnostic tool, and we use that to inform our interview with the kid. For instance, we would say, “Hey, it looks like on the questionnaire, you said this, can you tell me more about it?”

And then we use that web-based tool at mid treatment with an abbreviated battery, with just a couple of the domains like depression, suicide, trauma and if its outpatient, we’re doing substance use. It helps us to show a kid, “In the beginning, you had a 45 on depression and now you have a 22. We’re going in the right direction.” Or by mid treatment, we say “Well, you started at a 45, and now you’re at a 62; what’s going on here?” Maybe it’s time we bring the psychiatrist in to augment some of what we’re doing with medication.

I think that the general best practice guidelines really is psychotherapy first, and in fact, in pediatrics, the recommendation is supportive therapy, about 2 to 4 weeks of supportive therapy, and if symptoms don’t change, then you start to ramp up to CBT or a family therapy. Generally, the recommendation is six weeks of psychotherapy, and if that doesn’t work, add medication. That is the general best practice guidelines, and most clinical folks will say, “If I get a severe enough kid, I’m doing medication, day one. I’m not going to wait for this kid to get way too depressed. I need something to turn down the volume a little bit so I can do engage them in therapy.” Most studies suggest psychotherapy plus medicine is the best route for a more severely depressed kid.

We try to track symptom change over time as an additional viewpoint. We hand the assessment out, and then we discuss it with the kid. Look, you’re still struggling with this. What’s going on? Or you’re sleeping better. You’re not crying. Or you are still really having a negative view of yourself and hopelessness. Maybe when we’re finished with a little bit of this family work, we should do a little CBT to try and target some of those negative cognitive processes. We always start with family because if we can get the family more supportive, it’s easier to learn CBT skills. Consider the kid who lives in a family where their parents are screaming at them all the time, and they come to a therapist, and the therapist tries to tell them to challenge their automatic thoughts, and then they go home, and they are getting screamed at again. Not going to be effective there.

Snyder: I like how you have a multi-dimensional perspective because depression is one aspect of this kid’s life. Clinicians have to take this broader focus because the presenting problem does not happen just in a vacuum. And the point about measurement is for it to be clinically relevant, so it provides context and the content for the sessions.

When suicide pops up on a screener, how do you triage? There’s the SAFE-T model, but each agency has to determine how they use it depending on their screening and risk formulation strategies. What’s your protocol like?

Diamond: We have a really robust, fully developed suicide protocol. If a kid says he’s suicidal and we pull out a screen, we get some measure of the severity, and then we debate: can we manage this kid on an outpatient level? Is this severe enough where we need to send them to the emergency room? Way too many therapists get frightened and just send them to the emergency room when it’s counter indicated. The emergency room is traumatic; a hospital is traumatic and not very treatment oriented. We like to think about “what do we have to do in order to keep this kid outpatient?” The hospital is never a positive experience in the American health system.

So, for a youth to stay outpatient, we evaluate warning signs. We do a safety plan. We do a family-based safety plan. We try to include the parents in the safety plan, then we use the safety plan to manage the situation. For instance, if he’s feeling suicidal, he goes to his mom and his mom says, “Okay, let’s look at the safety plan: going for a walk, playing with your dog.” These little simple things on the safety plan are really a distraction to reduce the stress of a pending crisis. It’s not a therapy, and it’s based on the assumption that most kids who think about suicide or attempt suicide have thought about it for about 30 minutes and then the idea goes away. It’s an impulsive act generally, and the safety plan is a distraction for 30 minutes. For instance, things like, go for a walk. That was 20 minutes and I have a little blood in my head now. Okay, I’m not thinking about it anymore. I’ll go back to play with my dog and take a shower or listen to music or call a friend, go see my mom, go call Guy. The Safety Plan really is such an attempt to get someone through that short little stressor.

Snyder: It’s flattening the suicide risk curve. Eventually the crisis will resolve, so the safety plan is intended to delay stress from peaking. And the family context is critical to support the use of the safety plan.

Diamond: And yes, there are definitely kids that need to go to the hospital. Plenty may need that, but most kids don’t need to go. I don’t want to be overly flippant here.

Snyder: It makes sense. The default clinical position shouldn’t be hospitalization or the emergency room. We need to support people in their natural settings.

Now, going back to the multidimensional assessment and therapeutic approach. There’s a lot of comorbidity with clients, especially in community mental health settings. So, do you see gains in other areas of the client presentation when you complete treatment?

Diamond: And we know comorbidity is the rule, not the exception. A lot of our kids are certainly struggling with anxiety. We see a lot of substance use. We have a lot of kids with trauma history, about a third of our kids have a sexual abuse history, and about a third of our kids are LGBTQ or questioning their sexuality. So, there are a number of domains that we think about and incorporate into the therapy as needed. My CBT friends, they always joke with me, and they say, “Guy, where’s the suicide treatment in family therapy?” For us, we see suicide as a symptom of stress and we’re trying to get to the stress: “My mom’s an alcoholic, and I can’t live with her. I get bullied at school because I’m gay. I’m in special ed learning classes, and I feel I’m not as smart as my brother.” We’re always trying to address these broader thematic things in the service of improving the parent-child relationship. We see reductions in anxiety in neuro studies; we see reductions in substance use. We’ve seen some reduction in post-traumatic stress symptoms. Our assumption is that as kids feel more protected and have a secure base, that the general level of psychopathology distress goes down.

Snyder: This reminds me of the active ingredients of CFTSI for trauma recovery, where the goal is we’re getting a family on the same page, so the kid knows how to ask for help related to their trauma symptoms, and the parent knows when to offer assistance, as opposed to smothering the kid or avoiding them. The theme throughout your intervention is “if we can get that holding environment, if we can get that base security.” It can set the stage to take care of a lot of other things.

Diamond: Bringing attachment theory in family therapy is one of our unique contributions, and it’s a way of helping to think about what we do in family therapy work. But the other I think innovation of the model has been to put some system programmatic structure around family therapy. The way we have broken the model into tasks, into sequences of work helps the family therapy student feel like, “Oh, it’s not just, go in the room and see what happens, and debate about who’s going to talk first and…”

Snyder: “…am I going to set up an enactment?”

Diamond: With our structure, we lay out that there’s actually a progression of work, like “this week I’m working with the child on these types of emotions, and then next week I’m going to work on attachment narratives, and now I’m going to bring them back together.” And I think it’s given a structure to what can be a pretty amorphous experience for that room full of people. And I think a lot of people say to us, “I do exactly what you do in treatment, but where you just do it in 16 weeks, it takes me a year to do it.” There’s a roadmap to make these conversations happen in our training.

I’ll say one last thing. And I always say in the training to a room full of therapists, I say “You’ve come out of your therapy room and gone to the water cooler in your work on agency and said, ‘I just had the best session. We finally got to the real heart of it and the truth, and the kid was crying, and dad leaned over and hugged him. It was so satisfying.” And I say to my trainees with that scenario, “We make that session happen in every case around week 10.”  The old model is engineered where we’re not going to get to that type of session early. In our work with ABFT, 90% of the cases by week 10 are having conversations that are at the heart of the matter. And I think for a family therapist that’s an innovation.

Snyder: With systems of care too, if we can be more efficient, even with our family therapies and individual treatments, we can increase our reach, so then maybe our wait lists might not be as long. There can be systemic spillover effects, just by sequencing and supporting the clinicians in that way.

Diamond: It’s a real plan. I think students find that when they follow the structure, it lets them really get interpersonal. Students who follow the structure find themselves having conversations they never thought they would have. The structure of the model gets them there. It’s not just their own intuition, but it’s the structure that allows the clinician to shine and help make some meaningful change.

For folks interested in the model, please look us up at our website at the Center for Family Intervention Science or ABFTtrianing.com at Drexel University, and we will help you get trained and supervised in ABFT.

References

Abramson, L. Y., Seligman, M. E., & Teasdale, J. D. (1978). Learned helplessness in humans: Critique and reformulation. Journal of abnormal psychology, 87(1), 49–74.

Alsaad, A. J., Azhar, Y., & Al Nasser, Y. (2020). Depression in children. In StatPearls. StatPearls Publishing.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Antonuccio, D. O., Ward, C. H., & Tearnan, B. H. (1989). The behavioral treatment of unipolar depression in adult outpatients. Progress in behavior modification, 24, 152–191.

Baweja, R., Mayes, S. D., Hameed, U., & Waxmonsky, J. G. (2016). Disruptive mood dysregulation disorder: current insights. Neuropsychiatric disease and treatment, 12, 2115–2124. https://doi.org/10.2147/NDT.S100312

Bernaras, E., Jaureguizar, J., & Garaigordobil, M. (2019). Child and adolescent depression: A review of theories, evaluation instruments, prevention programs, and treatments. Frontiers in psychology, 10, 543. https://doi.org/10.3389/fpsyg.2019.00543

Bruno, A., Celebre, L., Torre, G., Pandolfo, G., Mento, C., Cedro, C., … Muscatello, M. R. (2019). Focus on disruptive mood dysregulation disorder: A review of the literature. Psychiatry research, 279, 323–330. https://doi.org/10.1016/j.psychres.2019.05.043

Cairns, K. E., Yap, M. B., Pilkington, P. D., & Jorm, A. F. (2014). Risk and protective factors for depression that adolescents can modify: A systematic review and meta-analysis of longitudinal studies. Journal of affective disorders, 169, 61–75. https://doi.org/10.1016/j.jad.2014.08.006

Clarke, D. M., & Currie, K. C. (2009). Depression, anxiety and their relationship with chronic diseases: A review of the epidemiology, risk and treatment evidence. The medical journal of Australia, 190(S7), S54–S60. https://doi.org/10.5694/j.1326-5377.2009.tb02471.x

Center for Behavioral Health Statistics and Quality (2018). 2017 National Survey on Drug Use and Health: Methodological summary and definitions. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Copeland, W. E., Angold, A., Costello, E. J., & Egger, H. (2013). Prevalence, comorbidity, and correlates of DSM-5 proposed disruptive mood dysregulation disorder. American journal of psychiatry, 170(2), 173-179.

Cummings, J. R., Ji, X., Lally, C., & Druss, B. G. (2019). Racial and ethnic differences in minimally adequate depression care among Medicaid-enrolled youth. Journal of the American Academy of Child and Adolescent Psychiatry, 58(1), 128-138.

Diamond, G. S., Wintersteen, M. B., Brown, G. K., Diamond, G. M., Gallop, R., Shelef, K., & Levy, S. (2010). Attachment- Based Family Therapy for adolescents with suicidal ideation: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 49(2), 122–131. https://doi.org/10.1016/j.jaac.2009.11.002

Diamond, G., Creed, T., Gillham, J., Gallop, R., & Hamilton, J. L. (2012). Sexual trauma history does not moderate treatment outcome in Attachment-Based Family Therapy (ABFT) for adolescents with suicide ideation. Journal of family psychology, 26(4), 595–605. https://doi.org/10.1037/a0028414

Eckshtain, D., Kuppens, S., Ugueto, A., Ng, M. Y., Vaughn-Coaxum, R., Corteselli, K., & Weisz, J. R. (2020). Meta-analysis: 13-year follow-up of psychotherapy effects on youth depression. Journal of the American Academy of Child and Adolescent Psychiatry, 59(1), 45-63.

Egger, H. L., & Emde, R. N. (2011). Developmentally sensitive diagnostic criteria for mental health disorders in early childhood: The diagnostic and statistical manual of mental disorders—IV, the research diagnostic criteria—preschool age, and the diagnostic classification of mental health and developmental disorders of infancy and early childhood—revised. American psychologist, 66(2), 95–106. https://doi.org/10.1037/a0021026

Findling, R. L., Youngstrom, E. A., Fristad, M. A., Birmaher, B., Kowatch, R. A., Arnold, L. E., Frazier, T. W., Axelson, D., Ryan, N., Demeter, C. A., Gill, M. K., Fields, B., Depew, J., Kennedy, S. M., Marsh, L., Rowles, B. M., & Horwitz, S. M. (2010). Characteristics of children with elevated symptoms of mania: The Longitudinal Assessment of Manic Symptoms (LAMS) study. Journal of clinical psychiatry, 71(12), 1664–1672. https://doi.org/10.4088/JCP.09m05859yel

Frank, E., Anderson, B., Reynolds, C. F., 3rd, Ritenour, A., & Kupfer, D. J. (1994). Life events and the research diagnostic criteria endogenous subtype: A confirmation of the distinction using the Bedford College methods. Archives of general psychiatry, 51(7), 519–524. https://doi.org/10.1001/archpsyc.1994.03950070011005

Ghandour, R. M., Sherman, L. J., Vladutiu, C. J., Ali, M. M., Lynch, S. E., Bitsko, R. H., & Blumberg, S. J. (2019). Prevalence and treatment of depression, anxiety, and conduct problems in US children. Journal of pediatrics, 206, 256–267.e3. https://doi.org/10.1016/j.jpeds.2018.09.021

Hatzenbuehler, M. L., McLaughlin, K. A., & Nolen‐Hoeksema, S. (2008). Emotion regulation and internalizing symptom in a longitudinal study of sexual minority and heterosexual adolescents. Journal of child psychology and psychiatry, 49(12), 1270-1278.

Hopkins, K., Crosland, P., Elliot, N.,& Bewly, S. (2015). Diagnosis and management of depression in children and young people: Summary of updated NICE guidance. British medical journal, 350, h824. https://doi.org/10.1136/bmj.h824

Hyde, J. S., Mezulis, A. H., & Abramson, L. Y. (2008). The ABCs of depression: integrating affective, biological, and cognitive models to explain the emergence of the gender difference in depression. Psychological review, 115(2), 291–313. https://doi.org/10.1037/0033-295X.115.2.291

Köhler, C. A., Evangelou, E., Stubbs, B., Solmi, M., Veronese, N., Belbasis, L., Bortolato, B., Melo, M., Coelho, C. A., Fernandes, B. S., Olfson, M., Ioannidis, J., & Carvalho, A. F. (2018). Mapping risk factors for depression across the lifespan: An umbrella review of evidence from meta-analyses and Mendelian randomization studies. Journal of psychiatric research, 103, 189–207. https://doi.org/10.1016/j.jpsychires.2018.05.020

Kupfer, D. J., Frank, E., & Phillips, M. L. (2012). Major depressive disorder: New clinical, neurobiological, and treatment perspectives. Lancet, 379(9820), 1045–1055.

Lewinsohn, P. M., Clarke, G. N., Seeley, J. R., & Rohde, P. (1994). Major depression in community adolescents: Age at onset, episode duration, and time to recurrence. Journal of the American Academy of Child and Adolescent Psychiatry, 33(6), 809–818. https://doi.org/10.1097/00004583-199407000-00006

Lewinsohn, P. M., Rohde, P., Seeley, J. R., Klein, D. N., & Gotlib, I. H. (2000). Natural course of adolescent major depressive disorder in a community sample: predictors of recurrence in young adults. American journal of psychiatry, 157(10), 1584-1591.

Lu, Y., Mak, K. K., Van Bever, H. P., Ng, T. P., Mak, A., & Ho, R. C. M. (2012). Prevalence of anxiety and depressive symptoms in adolescents with asthma: A meta‐analysis and meta‐regression. Pediatric allergy and immunology, 23(8), 707-715.

Luby J. L. (2009). Early childhood depression. American journal of psychiatry, 166(9), 974–979. https://doi.org/10.1176/appi.ajp.2009.08111709

March, J., Silva, S., Petrycki, S., Curry, J., Wells, K., Fairbank, J., Burns, B., Domino, M., McNulty, S., Vitiello, B., Severe, J., & Treatment for Adolescents With Depression Study (TADS) Team (2004). Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA, 292(7), 807–820. https://doi.org/10.1001/jama.292.7.807

Marchand, E., Ng, J., Rohde, P., & Stice, E. (2010). Effects of an indicated cognitive-behavioral depression prevention program are similar for Asian American, Latino, and European American adolescents. Behaviour research and therapy, 48(8), 821–825. https://doi.org/10.1016/j.brat.2010.05.005

Meyer I. H. (1995). Minority stress and mental health in gay men. Journal of health and social behavior, 36(1), 38–56.

National Institute of Mental Health. (2019) Major Depression. https://www.nimh.nih.gov/health/statistics/major-depression.shtml

National Institute of Mental Health. (2020). Bipolar Disorder in Children and Teens. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens/

Nobile, M., Cataldo, G. M., Marino, C., & Molteni, M. (2003). Diagnosis and treatment of dysthymia in children and adolescents. CNS drugs, 17(13), 927–946. https://doi.org/10.2165/00023210-200317130-00001

Pieper, D., Buechter, R. B., Li, L., Prediger, B., & Eikermann, M. (2015). Systematic review found AMSTAR, but not R (evised)-AMSTAR, to have good measurement properties. Journal of clinical epidemiology, 68(5), 574-583.

Reinecke, M. & Simons, A. (2005). Vulnerability to depression among adolescents: Implications for cognitive-behavioral treatment. Cognitive and behavioral practice, 12, 166-176. https://doi.org/10.1016/S1077-7229(05)80022-7

Russell, S. T., & Fish, J. N. (2016). Mental Health in Lesbian, Gay, Bisexual, and Transgender (LGBT) Youth. Annual review of clinical psychology, 12, 465–487. https://doi.org/10.1146/annurev-clinpsy-021815-093153

Scott, S. M., Wallander, J. L., & Cameron, L. (2015). Protective mechanisms for depression among racial/ethnic minority youth: Empirical findings, issues, and recommendations. Clinical child and family psychology review, 18(4), 346–369. https://doi.org/10.1007/s10567-015-0188-4

Sivertsen, B., Harvey, A. G., Lundervold, A. J., & Hysing, M. (2014). Sleep problems and depression in adolescence: results from a large population-based study of Norwegian adolescents aged 16-18 years. European child & adolescent psychiatry, 23(8), 681–689. https://doi.org/10.1007/s00787-013-0502-y

Sokratous, S., Merkouris, A., Middleton, N., & Karanikola, M. (2013). The association between stressful life events and depressive symptoms among Cypriot university students: A cross-sectional descriptive correlational study. BMC public health, 13, 1121. https://doi.org/10.1186/1471-2458-13-1121

Stark, K. D., Streusand, W., Krumholz, L. S., & Patel, P. (2010). Cognitive-behavioral therapy for depression: The ACTION treatment program for girls. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 93–109). The Guilford Press.

Substance Abuse and Mental Health Services Administration. (2016). DSM-5 changes: Implications for child serious emotional disturbance [internet]. https://www.ncbi.nlm.nih.gov/books/NBK519710/

Ten Have, M., Penninx, B., Tuithof, M., van Dorsselaer, S., Kleinjan, M., Spijker, J., & de Graaf, R. (2017). Duration of major and minor depressive episodes and associated risk indicators in a psychiatric epidemiological cohort study of the general population. Acta psychiatrica Scandinavica, 136(3), 300–312. https://doi.org/10.1111/acps.12753

Thapar, A., Collishaw, S., Pine, D. S., & Thapar, A. K. (2012). Depression in adolescence. Lancet, 379(9820), 1056–1067. https://doi.org/10.1016/S0140-6736(11)60871-4

The Trevor Project. (2021). 2021 national survey on LGBTQ youth mental health. West Hollywood, California: The Trevor Project.

The U.S. Preventive Services Task Force (2016). Final Recommendation Statement: Screening for depression in children and adolescents. Annals of internal medicine, 164, 360-366. https://doi.org/10.7326/M15-2957

Van Voorhees, B. W., Paunesku, D., Gollan, J., Kuwabara, S., Reinecke, M., & Basu, A. (2008). Predicting future risk of depressive episode in adolescents: The Chicago Adolescent Depression Risk Assessment (CADRA). Annals of family medicine, 6(6), 503–511. https://doi.org/10.1370/afm.887

Lu, W., Lindsey, M. A., Irsheid, S., & Nebbitt, V. E. (2017). Psychometric properties of the CES-D among Black adolescents in public housing. Journal of the society for social work and research, 8(4), 595–619. https://doi.org/10.1086/694791

Weersing, V. R., Jeffreys, M., Do, M. T., Schwartz, K. T., & Bolano, C. (2017). Evidence base update of psychosocial treatments for child and adolescent depression. Journal of clinical child and adolescent psychology, 46(1), 11–43. https://doi.org/10.1080/15374416.2016.1220310

Zero To Three Press. (2016). Dc:0-5TM: Diagnostic classification of mental health and developmental disorders of infancy and early childhood.

Zou, P., Siu, A., Wang, X., Shao, J., Hallowell, S. G., Yang, L. L., & Zhang, H. (2021). Influencing factors of depression among adolescent Asians in North America: A systematic review. Healthcare, 9(5), 537. https://doi.org/10.3390/healthcare9050537