Anxiety and Depression in Children and Adolescents

Thomas J. Huberty

Anxiety and Depression in Children and Adolescents

Assessment, Intervention, and Prevention

Thomas J. HubertyDepartment of Counseling and Educational Psychology School Psychology ProgramIndiana UniversityBloomington, IN, USA

ISBN 978-1-4614-3108-4 e-ISBN 978-1-4614-3110-7DOI 10.1007/978-1-4614-3110-7Springer New York Dordrecht Heidelberg London

Library of Congress Control Number: 2012932615

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To Marsha, my life partner, soul mate, and best friend for her love, patience, support, and encouragement

To Christopher, who reaffi rms my faith and hope in our children and youth

In memory of my mother

vii

Preface

Anxiety and depression are two of the most prevalent mental health problems of childhood and adolescence, affecting up to as many as one-third of children and youth over their lifetimes, but also are among the most under-identifi ed or misdi-agnosed syndromes and disorders. They are also highly comorbid with each other and other disorders and are diffi cult to differentiate for clinical and research pur-poses. They present challenges in assessment, intervention, and consultation in clinical, community, and school settings. Because the conditions are so prevalent, complex, and comorbid, this book was conceptualized as an attempt to address the complexity from a combination of considering relevant research and applying that information to practice.

The book is based on principles and research in developmental psychopathology as the organizing theme, refl ected in Part I that focuses on foundations with consid-erations for assessment and intervention. The fi rst chapter describes major principles, concepts, and research in developmental psychopathology, with emphasis on protec-tive and risk factors, vulnerability, and resilience. Historically, development has been conceptualized in fi ve domains or contexts: (a) genetic factors, (b) biological factors, (c) cultural factors, (d) social factors, and (e) family factors. In this book, a sixth contextual factor has been added: schools, because children spend approximately one-fourth of their waking hours in school. Moreover, many of the emotional and behavioral problems of children and youth are related to school functioning and as many as half of mental health referrals originate from academic-related issues. Schools not only teach literacy skills, but are also major contributors to the develop-ment of social skills and competence, arguably making schooling the most important infl uence on children apart from the family. Thus, the chapter is organized around six contexts: genetic, biological, cultural, social, family, and school.

In Chap. 2 , the developmental psychopathology and contextual themes are applied to anxiety and anxiety disorders, with emphasis on understanding the normal developmental aspects of anxiety. Unlike many disorders, anxiety is a normal devel-opmental process that not only occurs in all people on almost a daily basis, but can be adaptive. When anxiety becomes so severe that it impairs personal, social, occupational,

viii Preface

or academic functioning, interventions may be needed . The chapter summarizes the research with regard to the six contexts and concludes with implications for clinical practice.

Chapter 3 follows a similar format, recognizing that depression and mood disor-ders do not have the normal developmental progression as does anxiety. The third chapter follows the organization of Chap. 2 with regard to the six contexts and con-cludes with a discussion of clinical implications.

Chapter 4 addresses the important concept of emotion regulation, an area that has received increased research and practice attention in the last decade. Emotion regulation refers to the ability of a child to learn how to manage emotions and learn appropriate ways of expression. Some regulation processes are based on genetic and biological factors, but they are highly infl uenced by environmental factors, particu-larly parents, teachers, and peers who have strong infl uences on the development of regulation skills.

Part II contains two chapters that address how to conduct differential diagnosis of anxiety and depression, with emphasis on DSM-IV criteria. In Chap. 5 , the pri-mary anxiety disorders are discussed: Separation Anxiety Disorder, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Social Phobia (Social Anxiety Disorder), Specifi c Phobia, Posttraumatic Stress Disorder, and Panic Disorder. Prevalence and epidemiology data are presented, along with primary symptoms and secondary features, comorbid disorders, differential diagnosis considerations, and typical assessment profi les. Chapter 6 follows the same format with discussion of Major Depressive Disorder, Dysthymia, and Bipolar Disorder. Both chapters conclude with discussion of a developmental psychopathology perspective on the anxiety and depressive disorders, respectively.

Part III focuses on assessment of anxiety and depressive disorders, with Chap. 7 presenting a summary of clinical assessment measures that are useful with internal-izing disorders. This chapter emphasizes general principles of clinical interviewing, observation, and standardized rating scales and multidimensional measures. In Chaps. 8 and 9 , more detailed description of the assessment of anxiety and depres-sion are presented, including measures specifi c to each condition and how they are used with other assessment procedures. At the end of each chapter, a case study is provided that includes results from a psychological assessment.

Part IV contains Chaps. 10 – 13 that discuss interventions and prevention of anxi-ety and depression. Chapter 10 presents cognitive–behavioral therapy (CBT) as the primary direct intervention method for anxiety, as well as exposure, systematic desensitization, manualized CBT programs, and pharmacotherapy. Suggestions for conducting clinical and sample interview dialogues are presented. In Chap. 11 , a similar format is followed for interventions for depression and mood disorders, with discussion of three primary therapeutic interventions: CBT, Interpersonal Psychotherapy, and Positive Psychotherapy. Discussion of treatment of the anxious-depressed syndrome that has features of both anxiety and depression is presented. Content about the relative effectiveness of CBT and medications is provided, as well. Discussion of intervening with suicidal children and adolescents is presented. Finally, the case example introduced in Chap. 9 is revisited with attention to devel-oping interventions based on the assessment data.

ixPreface

Part IV also includes Chap. 12 , which addresses school-based interventions for anxiety and depression. Emphasis is placed on screening for anxiety and depression and using a three-tier, problem-solving approach to interventions that can be done is schools. Primary topics include providing direct, indirect/consultative, and sys-tems interventions in schools that are feasible and acceptable to school personnel, students, and parents.

The last chapter in Part IV addresses approaches toward prevention of anxiety and depression. Many of the mental health prevention programs for children and youth, including anxiety and depression, have been implemented in school settings, consistent with the perspective that schools provide the best opportunity to reach large numbers of youth. Community-based prevention programs also exist; there-fore, discussion includes general principles for developing effective prevention pro-grams. Descriptions of evidence-based prevention programs for anxiety and depression at the universal, selected, and indicated levels are presented.

Part V contains one chapter that addresses legal issues in educating anxious and depressed students in schools. Children and youth with anxiety and depression often are not identifi ed, but may need help to progress in school. The Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973 (Section 504) are the primary avenues for providing special education services and accommodations for students who have disabilities. The chapter is organized primarily around the IDEA and its defi nition of Emotional Disturbance and how children and adolescents who are depressed or anxious may or may not be served in special education. Issues regarding eligibility, evaluations, and procedural issues are discussed within the context of illustrative court cases and the author’s extensive experience as an administrative law judge/independent hearing offi cer for due process hearings under the IDEA and Section 504.

In closing, the author hopes that the reader fi nds the book to be a relatively com-prehensive treatment of anxiety and depression in children and adolescents, and that it will be informative with regard to current research, how research is linked with practice, and how the practitioner can apply research in everyday practice. Hopefully, the practitioner will gain valuable information that can be used to provide services to anxious and depressed children and adolescents using evidence-based practices from a developmental psychopathology perspective. The book may be useful for graduate students in clinical, counseling, and school psychology and related disci-plines who are interested in anxiety and depression and how to use evidence-based concepts and literature in their work. Ultimately, our goal should be to help children and youth become psychologically healthy and happy adults. They deserve no less than our best efforts.

Bloomington, IN, USA Thomas J. Huberty

xi

Acknowledgments

The author wishes to acknowledge the support and encouragement of Judy Jones, Senior Editor at Springer, in the development of this book. She has been exception-ally helpful, insightful, and supportive in the development and production of this work, which is sincerely appreciated. Appreciation is also given to Garth Haller at Springer for his help in the production of the book.

Appreciation is extended to Michael Axelrod, Ph.D., for reviewing some of the chapters and providing valuable feedback.

Appreciation is also given to Kevin McDowell, J.D., Deputy Attorney General for the State of Indiana for his careful and insightful review and suggestions for Chap. 14 , Legal Issues in Educating Anxious and Depressed Students, as well as for his friendship and mentoring in special education law over many years.

The author also expresses his gratitude to former and current graduate students at Indiana University, who have provided inspiration in the development of this book.

xiii

Contents

Part I Foundations

1 Foundations of Developmental Psychopathology ................................ 3Historical Context of Child and Adolescent Psychopathology ................ 3The Emergence of Developmental Psychopathology .............................. 4Core Concepts in Developmental Psychopathology ................................ 5Developmental Continuity ....................................................................... 6Developmental Pathways ......................................................................... 7Equifi nality and Multifi nality ................................................................... 9Risk and Protective Factors ...................................................................... 9Categorical Classifi cation vs. Developmental Psychopathology ............. 9The Contexts of Developmental Psychopathology .................................. 13The Genetic Context ................................................................................ 14The Biological Context ............................................................................ 15The Cultural Context ................................................................................ 16The Social Context ................................................................................... 17The Family Context ................................................................................. 17The School Context .................................................................................. 18Risk and Protective Factors from a Contextual Perspective .................... 18Resilience ................................................................................................. 19Vulnerability............................................................................................. 20Diathesis–Stress Models of Vulnerability ................................................ 20Resilience, Risk, and Vulnerability .......................................................... 21Diagnosis and Classifi cation in a Developmental Psychopathology Perspective ................................................................... 22Behaviors, Signs, Symptoms, Syndromes, and Disorders ....................... 23Comorbidity ............................................................................................. 24The Course of Typical Development ....................................................... 25

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Implications of Developmental Psychopathology for Clinical Practice ................................................................................. 26

Assessment ........................................................................................... 26Intervention .......................................................................................... 27Consultation ......................................................................................... 27Prevention ............................................................................................ 27

Implications of Developmental Psychopathology for Anxiety and Depression ..................................................................... 28

2 The Developmental Psychopathology of Anxiety ................................ 29Developmental Considerations ................................................................ 29Characteristics of Anxiety ........................................................................ 30Trait and State Anxiety ............................................................................ 31

Characteristics of Anxiety .................................................................... 32Cognitive Symptoms ............................................................................ 32Behavioral Symptoms .......................................................................... 33Physiological Symptoms ...................................................................... 34

Positive and Negative Affect .................................................................... 34Conceptualizing the Development of Anxiety Disorders ........................ 35Contextual Infl uences and the Development of Anxiety and Anxiety Disorders ............................................................................. 37

Genetic Context ................................................................................... 37Biological Context ............................................................................... 38Temperament ........................................................................................ 39Cultural Context ................................................................................... 40Social Context ...................................................................................... 41Family Context ..................................................................................... 43School Context ..................................................................................... 45

Developmental Pathways of Anxiety Disorders ...................................... 46Specifi c Anxiety Disorders ...................................................................... 47Clinical Implications of a Developmental Psychopathology Perspective on Anxiety Disorders ............................................................ 48Conclusion ............................................................................................... 53

3 The Developmental Psychopathology of Depression .......................... 55Characteristics of Depression .................................................................. 56Negative Cognitive Triad ......................................................................... 58All-or-None Thinking .............................................................................. 58Learned Helplessness ............................................................................... 58Attributional Style .................................................................................... 59Scar Hypothesis ....................................................................................... 60Contextual Infl uences and the Development of Depression and Mood Disorders ................................................................................. 61

Genetic Context ................................................................................... 61Biological Context ............................................................................... 62Temperament ........................................................................................ 63

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Cultural Context ................................................................................... 63Social Context ...................................................................................... 64Family Context ..................................................................................... 65School Context ..................................................................................... 66

Developmental Pathways of Depression and Mood Disorders ................ 68Specifi c Depression and Mood Disorders ................................................ 71

Major Depressive Disorder .................................................................. 71Dysthymia ............................................................................................ 72Bipolar Disorder ................................................................................... 73

Clinical Implications of a Developmental Psychopathology Perspective on Depression and Mood Disorders ..................................... 74Conclusion ............................................................................................... 75

4 Emotion Regulation ............................................................................... 77The Case of Aaron ................................................................................... 77The Concept of Emotion Processing ........................................................ 78Returning to Aaron’s Case ....................................................................... 79The Concept of Emotion Regulation ....................................................... 80Emotion vs. Emotion Regulation ............................................................. 80

Emotion as a Mediator or a Moderator ................................................ 82Emotion Regulation in Multiple Contexts ............................................... 83

Genetic Context ................................................................................... 83Biological Context ............................................................................... 84Brain Stem ........................................................................................... 85Limbic System ..................................................................................... 86Prefrontal Cortex .................................................................................. 86Cultural Context ................................................................................... 87Social Context ...................................................................................... 89Family Context ..................................................................................... 90School Context ..................................................................................... 91

Emotion Regulation in Anxiety ............................................................... 93Implications for Clinical Assessment .................................................. 95Implications for Intervention ............................................................... 96

Emotion Regulation in Depression and Mood Disorders ........................ 96Implications for Clinical Assessment .................................................. 97Implications for Intervention ............................................................... 98

Conclusion ............................................................................................... 98

Part II Differential Diagnosis

5 Differential Diagnosis of Anxiety Disorders ........................................ 101Historical Context of Child and Youth Anxiety Disorders ...................... 101DSM-IV Criteria for Anxiety Disorders .................................................. 102Separation Anxiety Disorder .................................................................... 102

Prevalence Rates and Epidemiology .................................................... 103

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Primary Symptoms............................................................................... 104Secondary or Related Features ............................................................. 105Comorbidity ......................................................................................... 105Differential Diagnosis Considerations ................................................. 106Young Children .................................................................................... 106Adolescents .......................................................................................... 107Psychological Assessment Profi les ...................................................... 107

Generalized Anxiety Disorder ................................................................. 107Prevalence and Epidemiology .............................................................. 108Primary Symptoms............................................................................... 109Secondary or Related Features ............................................................. 109Comorbidity ......................................................................................... 109Differential Diagnosis Considerations ................................................. 111Psychological Assessment Profi les ...................................................... 112

Obsessive–Compulsive Disorder ............................................................. 112Prevalence Rates and Epidemiology .................................................... 112Primary Symptoms............................................................................... 113Secondary or Related Features ............................................................. 114Comorbidity ......................................................................................... 115Differential Diagnosis Considerations ................................................. 116Psychological Assessment Profi les ...................................................... 117

Social Phobia (Social Anxiety Disorder) ................................................. 117Prevalence Rates and Epidemiology .................................................... 118Primary Symptoms............................................................................... 118Secondary or Related Features ............................................................. 119Comorbidity ......................................................................................... 120Differential Diagnosis Considerations ................................................. 120Typical Assessment Profi les................................................................. 121

Specifi c Phobia ......................................................................................... 122Prevalence and Epidemiology .............................................................. 122Primary Symptoms............................................................................... 122Secondary or Related Features ............................................................. 123Comorbidity ......................................................................................... 124Differential Diagnosis Considerations ................................................. 124Typical Assessment Profi les................................................................. 124

Posttraumatic Stress Disorder .................................................................. 125Prevalence and Epidemiology .............................................................. 125Primary Symptoms............................................................................... 128Secondary or Related Features ............................................................. 128Comorbidity ......................................................................................... 128Differential Diagnosis Considerations ................................................. 129Typical Assessment Profi les................................................................. 130

Panic Disorder .......................................................................................... 130Prevalence Data and Epidemiology ..................................................... 131Primary Symptoms............................................................................... 132

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Secondary or Related Symptoms ......................................................... 132Comorbidity ......................................................................................... 133Differential Diagnosis Considerations ................................................. 134Typical Assessment Profi les................................................................. 134

A Developmental Psychopathology Perspective on Differential Diagnosis of Anxiety Disorders ........................................... 135

Distinguish Between Normal and Pathological Anxiety ..................... 135Age of Onset ........................................................................................ 136Developmental Comparisons ............................................................... 136Genetic and Family History Context ................................................... 136Biological Context ............................................................................... 137Cultural Context ................................................................................... 137Social Context ...................................................................................... 137Family Context ..................................................................................... 138School Context ..................................................................................... 138

Conclusion ............................................................................................... 138

6 Differential Diagnosis of Depression and Mood Disorders ................ 139Historical Context of Childhood Depression and Mood Disorders ......... 139Perspective I: Depression Cannot Exist in Childhood ............................. 139Perspective II: Depression in Childhood Is Masked ................................ 140Perspective III: Depression in Childhood Is Transitory ........................... 140Perspective IV: Depression in Childhood Parallels Depression in Adulthood ......................................................................... 141DSM Historical Perspectives on Childhood Depression ......................... 141

DSM-I .................................................................................................. 141DSM-II ................................................................................................. 142DSM-III ................................................................................................ 142DSM-III-R ............................................................................................ 142DSM-IV/DSM-IV-TR .......................................................................... 143

DSM-IV Criteria for Depression and Mood Disorders ............................ 143Depressive and Mood Episodes ........................................................... 144Manic Episode ..................................................................................... 145Hypomanic Episode ............................................................................. 147

Major Depressive Disorder ...................................................................... 147Primary Symptoms............................................................................... 148Secondary or Related Symptoms ......................................................... 149Prevalence Data and Epidemiology ..................................................... 150Comorbidity ......................................................................................... 152Differential Diagnosis Considerations ................................................. 153Typical Assessment Profi les................................................................. 154

Dysthymia ................................................................................................ 154Primary Symptoms............................................................................... 156Secondary or Related Symptoms ......................................................... 156Prevalence Data and Epidemiology ..................................................... 156

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Comorbidity ......................................................................................... 157Differential Diagnosis Considerations ................................................. 157Typical Assessment Profi les................................................................. 158

Bipolar Disorder ....................................................................................... 159Primary Symptoms............................................................................... 159Secondary or Related Symptoms ......................................................... 160Comorbidity ......................................................................................... 161Differential Diagnosis Considerations ................................................. 162Typical Assessment Profi les................................................................. 163

A Developmental Psychopathology Perspective on Differential Diagnosis of Depression and Mood Disorders ................ 163

Age of Onset ........................................................................................ 164Developmental Comparisons ............................................................... 164Genetic and Family History Context ................................................... 164Biological Context ............................................................................... 164Cultural Context ................................................................................... 165Social Context ...................................................................................... 165Family Context ..................................................................................... 165School Context ..................................................................................... 166

Conclusion ............................................................................................... 166

Part III Assessment

7 Methods of Assessment .......................................................................... 169Developmental and Family History ......................................................... 169Behavioral Observations .......................................................................... 170

Clinical Observations ........................................................................... 172Interviews ................................................................................................. 172

Semistructured Interviews.................................................................... 173Empirically Based Syndromes ................................................................. 174DSM-IV-Oriented Scales ......................................................................... 175

Structured Diagnostic Interviews ......................................................... 175Diagnostic Interview Schedule for Children-IV .................................. 175The Initial Clinical Interview ............................................................... 176Mental Status Examinations ................................................................ 176

Behavior Rating Scales ............................................................................ 178Empirically Based Syndrome Scales ....................................................... 179DSM-Oriented Scales .............................................................................. 179Interpretation of Behavior Rating Scales ................................................. 182Personality Inventories ............................................................................. 184

Minnesota Multiphasic Personality Inventory ..................................... 184Personality Inventory for Children: Second Edition ............................ 185Personality Inventory for Youth ........................................................... 186Student Behavior Survey...................................................................... 187Adolescent Psychopathology Scale ..................................................... 188Interpretation of Personality Inventories .............................................. 188

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Self-Report Measures ............................................................................... 189Self-Esteem/Self-Concept Measures ................................................... 190Multidimensional Self-Concept Scale ................................................. 190Self-Perception Profi le for Children .................................................... 190Self-Perception Scale for Adolescents ................................................. 191Piers–Harris Self-Concept Scale II ...................................................... 191

Conclusion ............................................................................................... 192

8 Assessment of Anxiety ........................................................................... 193Developmental and Family History ......................................................... 193Interviews ................................................................................................. 193

Child Interviews ................................................................................... 193Cognitive Symptoms ............................................................................ 194Behavioral Symptoms .......................................................................... 194Physiological Symptoms ...................................................................... 195Parent Interviews .................................................................................. 195Cognitive Symptoms ............................................................................ 195Behavioral Symptoms .......................................................................... 195Physiological Symptoms ...................................................................... 196Teacher Interviews ............................................................................... 196Cognitive Symptoms ............................................................................ 196Behavioral Symptoms .......................................................................... 196Physiological Symptoms ...................................................................... 197Structured Diagnostic Interviews ......................................................... 197

Observations............................................................................................. 199Syndrome-Specifi c Measures ................................................................... 199

Revised Children’s Manifest Anxiety Scale-Second Edition .............. 200Multidimensional Anxiety Scale for Children ..................................... 200State–Trait Anxiety Inventory for Children ......................................... 201Internalizing Symptoms Scale for Children ......................................... 201Childhood Anxiety Sensitivity Index ................................................... 202Positive and Negative Affect Scale for Children ................................. 203Fear Survey Schedule for Children-II .................................................. 203Screen for Child Anxiety-Related Emotional Disorders ..................... 203

Assessment of Specifi c Anxiety Disorders .............................................. 203Social Phobia (Social Anxiety Disorder) ............................................. 204

Syndrome-Specifi c Measures ................................................................... 205Generalized Anxiety Disorder ............................................................. 205

Syndrome-Specifi c Measures ................................................................... 206Obsessive–Compulsive Disorder ......................................................... 206

Syndrome-Specifi c Measures ................................................................... 207Children’s Yale-Brown Obsessive–Compulsive Scale ......................... 207Leyton Obsessional Inventory-Child Version ...................................... 207

Syndrome-Specifi c Measures ................................................................... 208Separation Anxiety Disorder ................................................................ 209

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Syndrome-Specifi c Measures ................................................................... 209Specifi c Phobia ..................................................................................... 209

Syndrome-Specifi c Measures ................................................................... 210Children’s Anxious Self-Statement Questionnaire .............................. 210

Case Example ........................................................................................... 210Reason for Referral .............................................................................. 210Background Information ...................................................................... 210Interview Observations and Information ............................................. 211Mental Status ....................................................................................... 212Assessment Results .............................................................................. 213

Conclusion ............................................................................................... 218

9 Assessment of Depression and Mood Disorders .................................. 219Developmental and Family History ......................................................... 219Interviews ................................................................................................. 219

Child Interviews ................................................................................... 219Parent Interview ................................................................................... 221Teacher Interviews ............................................................................... 222Structured Diagnostic Interviews ......................................................... 223

Observations............................................................................................. 224Self-Report and Clinician Rating Scales .................................................. 224

Children’s Depression Inventory-2 ...................................................... 225Reynolds Child Depression Scale-2 ..................................................... 226Reynolds Adolescent Depression Scale-2............................................ 226Multiscore Depression Inventory for Children .................................... 227Children’s Attributional Style Questionnaire-Revised......................... 228Hopelessness Scale for Children .......................................................... 228Beck Hopelessness Scale ..................................................................... 228Children’s Depression Rating Scale-Revised ...................................... 229

Assessing Suicidality ............................................................................... 229Suicide Ideation Questionnaire ............................................................ 230

Assessment of Specifi c Syndromes ......................................................... 231Major Depression and Dysthymia ....................................................... 231Recommended Assessment Procedures/Batteries for Depression and Dysthymia ............................................................. 231Bipolar Disorder ................................................................................... 232

Case Example ........................................................................................... 234Reason for Referral .............................................................................. 234Background Information ...................................................................... 234Interview Observations and Information ............................................. 235Mental Status ....................................................................................... 235Assessment Results .............................................................................. 236

Conclusion ............................................................................................... 241

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Part IV Intervention and Prevention

10 Interventions for Anxiety Disorders ..................................................... 245Foundations of Cognitive–Behavioral Therapy ....................................... 246

The Development of Cognitive Schemata ........................................... 247Cognitive–Behavior Therapy with Children and Adolescents ............. 247The Initial Interview with the Anxious Child ...................................... 248Initial Discussion with the Child About the Referral ........................... 249

Conceptualizing Clinical Problems from a CBT Perspective .................. 250Cognitive–Behavioral Therapy for Anxiety Disorders ............................ 251

Research Evidence on Cognitive–Behavior Therapy for Anxiety ....... 251Analysis of the Dialogue .......................................................................... 254Exposure Component ............................................................................... 255

Exposure Hierarchies ........................................................................... 255Systematic Desensitization ...................................................................... 256Analysis of the Dialogue .......................................................................... 259Muscle Relaxation Training ..................................................................... 260Anxiety Intervention Programs ................................................................ 260

Feeling Frightened ............................................................................... 261Expecting Bad Things to Happen ........................................................ 261Actions and Attitudes ........................................................................... 261Results and Rewards ............................................................................ 262Evidence of Effi cacy for Family Intervention for Childhood Anxiety Disorders ................................................................................ 266Considerations for Involving Parents in Treatment for Child and Youth Anxiety Disorders ............................................... 267

Pharmacotherapy ...................................................................................... 268Medications Used to Treat Anxiety in Children and Adolescents ....... 268Antianxiety Medications ...................................................................... 269Evidence of the Effi cacy of Medications to Treat Anxiety Disorders in Children and Adolescents .................................. 269

Treatment of Specifi c Disorders .............................................................. 272Separation Anxiety Disorder ................................................................ 273Generalized Anxiety Disorder ............................................................. 273Obsessive–Compulsive Disorder ......................................................... 274Social Phobia (Social Anxiety Disorder) ............................................. 274Specifi c Phobia ..................................................................................... 275Posttraumatic Stress Disorder .............................................................. 275Panic Disorder ...................................................................................... 276

Case Example ........................................................................................... 276Presenting Problems ............................................................................. 277Test Data .............................................................................................. 277Cultural Context Variables ................................................................... 277History and Developmental Milestones ............................................... 278Cognitive Variables .............................................................................. 278Behavioral Antecedents and Consequences ......................................... 279

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Provisional Formulation ........................................................................... 279Anticipated Treatment Plan ..................................................................... 280Expected Obstacles .................................................................................. 281Conclusion ............................................................................................... 281

11 Interventions for Depression and Mood Disorders ............................. 283The Initial Interview with the Depressed Child or Adolescent ................ 284Cognitive–Behavior Therapy for Depression and Mood Disorders......... 285Monitoring Moods ................................................................................... 286Cognitive Restructuring ........................................................................... 287Analysis of the Dialogue .......................................................................... 291Linking Cognition, Behavior, and Physical Symptoms to Mood States ......................................................................................... 292Behavioral Activation, Pleasant Activity Scheduling, and Goal Setting ....................................................................................... 292

Behavioral Activation .......................................................................... 292Pleasant Activity Scheduling ............................................................... 293Goal Setting ......................................................................................... 293

Relaxation and Stress Management ......................................................... 295Social Skills and Confl ict Resolution Training ........................................ 295

Social Skills Training ........................................................................... 295Confl ict Resolution Training ................................................................ 297

Developing General Problem-Solving Skills ........................................... 297Developing Confl ict Resolution Skills ..................................................... 299Cognitive–Behavior Therapy Programs for Depressed Children and Youth .................................................................................. 299Interpersonal Psychotherapy .................................................................... 304

IPT with Adolescents ........................................................................... 304Initial Phase (Sessions 1–4) ................................................................. 305Middle Phase (Sessions 5–9) ............................................................... 305Termination Phase (Sessions 10–12) ................................................... 305

Positive Psychotherapy for Adolescent Depression ................................. 306Treatment of Pediatric Bipolar Disorder .................................................. 307Interventions for Suicidal Children and Youth ........................................ 308Treating the Anxious–Depressed Syndrome ............................................ 309Pharmacotherapy for Child and Adolescent Depression ......................... 310Evidence of Effi cacy of Combined Pharmacotherapy and Psychotherapy ................................................................................... 311Considerations for Developing Interventions for Child and Adolescent Depression ...................................................................... 314Considerations for Parent Involvement in Treatment of Child and Adolescent Depression ........................................................ 314Case Example ........................................................................................... 315

Presenting Problem .............................................................................. 315Test Data .............................................................................................. 316

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Cultural Context Variables ................................................................... 316History and Developmental Milestones ............................................... 316Cognitive Variables .............................................................................. 317Behavioral Antecedents and Consequences ......................................... 317

Provisional Formulation ........................................................................... 318Anticipated Treatment Plan ..................................................................... 319Expected Obstacles .................................................................................. 320Conclusion ............................................................................................... 320

12 School-Based Interventions ................................................................... 323Conceptualizing School-Based Interventions .......................................... 323Identifi cation of Mental Health Problems in the School Setting ............. 325School-Based Interventions from a Three-Tier Perspective .................... 327

Three-Tier Interventions within a Problem-Solving Approach ........... 328Direct, Indirect, and Systems Approaches to Interventions ................. 330Direct Services ..................................................................................... 331Indirect/Consultation Services ............................................................. 332Systems Approaches to Intervention ................................................... 334

Interventions for Anxiety and Depression in the School Setting ............. 335Direct Services for Anxiety and Depression ........................................ 335Indirect/Consultative Services for Anxiety and Depression ................ 338

Analysis of the Dialogue .......................................................................... 340Generating Interventions ...................................................................... 340Selection of Interventions .................................................................... 340Implementing the Interventions ........................................................... 341Evaluation of the Program ................................................................... 341Systems Approaches to Addressing Anxiety and Depression ............. 342

Conclusion ............................................................................................... 343

13 Building Resilience Through Prevention ............................................. 345The Concept of Prevention and Developmental Psychopathology .......... 346A Brief History of Mental Health Prevention Efforts .............................. 346Models of Prevention ............................................................................... 347Components of Effective Prevention Programs ....................................... 348Prevention of Childhood Anxiety Disorders ............................................ 350

Prevention Programs ............................................................................ 351Prevention Programs for Depression ....................................................... 352

Prevention Programs ............................................................................ 353Indicated Level ..................................................................................... 356

Positive Youth Development Programs.................................................... 356Goals .................................................................................................... 357Atmosphere/Environment .................................................................... 357Activities .............................................................................................. 357

School-Based Prevention Programs ......................................................... 358Social–Emotional Learning Programs ..................................................... 360

SEL Programs ...................................................................................... 362

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Preventing Child and Adolescent Suicide ................................................ 363Epidemiology ....................................................................................... 364Risk Factors ......................................................................................... 366Protective Factors ................................................................................. 366

Prevention ................................................................................................ 367Conclusion ............................................................................................... 368

Part V Legal Issues

14 Legal Issues in Educating Anxious and Depressed Children ............. 371Emotional Disturbance Category in the IDEA ........................................ 375DSM-IV Diagnoses vs. Educational Classifi cation ................................. 376Evaluations in Special Education ............................................................. 377Functional Behavioral Assessment .......................................................... 379Behavior Intervention Plans ..................................................................... 381Individualized Education Programs ......................................................... 381Implications for Anxious and Depressed Students .................................. 383

Eligibility ............................................................................................. 383Illustrative Court Cases ............................................................................ 384

Mars Area School District v. Laurie L., 827 A. 2d 1249 (Pa. Cmwlth, 2003) .............................................................................. 385Mr. I. v. Maine School Administrative Dist. No. 55, 480 F.3d 1 (1st Cir. 2007) .................................................................... 385A.E. v. Westport Board of Educ., 463 F.Supp.2d 208 (D. Conn., 2006) .................................................................................. 386Board of Educ. of Montgomery County, Maryland v. S. G., 230 Fed. Appx. 330 (4th Cir. 2007) ..................................................... 386Eschenasy v. New York City Dep’t of Educ., 604 F. Supp. 2d 639 (S. D. N. Y. 2009) .......................................................... 387K.M. v. Wappingers Central School District, 688 F.Supp.2d 282 (S.D. N. Y. 2010)............................................................. 388A.J. v. East Islip Union Free School District, 53 IDELR (E.D.N.Y. 2010).................................................................. 389Hansen v. Republic R-III School Dist., No. 10-1514, 2011 WL 181530 (8th Cir. 1/21/11) ............................................................. 390Evaluations ........................................................................................... 391Functional Behavioral Assessment ...................................................... 393Individualized Education Programs ..................................................... 394

Section 504 of the Rehabilitation Act of 1973 ......................................... 399Implications for Psychoeducational Assessment ..................................... 399Concluding Comments............................................................................. 401

xxvContents

Part VI Appendices

15 Appendices .............................................................................................. 405Appendix A: Family and Developmental History ................................ 405Appendix B: Mental Status Examination Form .................................... 416

Appendix C: Cognitive–Behavioral Therapy Case Conceptualization Worksheet for Children and Adolescents .............................................................. 418

Appendix D: Common Medications Used to Treat Anxiety Disorders .............................................. 422

Appendix E: Mood Monitoring Form ................................................... 424Appendix F: Common Medications Used to Treat Mood Disorders .... 425

References ....................................................................................................... 427

About the Author ........................................................................................... 459

Index ................................................................................................................ 461