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                 Contextual Emotion-Regulation Therapy for
             Childhood Depression: Description and Pilot Testing
                           of a New Intervention

             Objective: To pilot test the acceptability and efficacy of contextual emotion-regulation therapy (CERT), a new, developmen-
             tally appropriate intervention for childhood depression, which focuses on the self-regulation of dysphoria. Method: Two
             samples of convenience (n = 29, n = 2) served to verify some CERT constructs; it was then operationalized in a treatment
             manual. To pilot test CERT, 20 children (ages 7Y12; 35% girls) with DSM dysthymic disorder (mean duration 24.4 months)
             entered an open, 30-session, 10-month, 4-phase trial, with 6- and 12-month follow-up. Assessments included independent
             clinical evaluations and self-rated questionnaires. Results: Fifteen children completed therapy, four were administratively
             terminated, and one dropped out. Completers did not clinically differ from the rest, but they were more likely to have better
             educated and less depressed mothers and intact families. At the end of treatment, 53% of the completers had full and 13%
             partial remission of dysthymia (remission from superimposed major depression was 80%). By 6- and 12-month follow-up,
             79% and 92% had full remission of dysthymia (p G .0001). Self-reported depressive and anxiety symptoms significantly
             declined by the end of treatment (p G .001) and remained so throughout follow-up. Conclusions: CERTenables clinicians to
             Bmatch[ the intervention to children_s emotion regulatory needs and symptoms and was readily accepted by families. The
             promising results suggest the need for a randomized trial. J. Am. Acad. Child Adolesc. Psychiatry, 2006;45(8):892Y903. Key
             Words: childhood depression, dysthymia, emotion regulation, treatment.

 The nonsomatic treatment of depressive disorders in                                      (Compton et al., 2004; Curry, 2001; Kendall and
 juveniles continues to be a mental health priority                                       Choudhury, 2003; Michael and Crowley, 2002).
                                                                                          However, research in this area has focused typically
    Accepted March 14, 2006.                                                              on adolescents 12 years of age and older and short-term
    Drs. Kovacs and Tumuluru are with the Department of Psychiatry, University
 of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic,
                                                                                          interventions for episodes of major depressive disorder
 Pittsburgh; Dr. Sherrill is with the National Institute of Mental Health,                (MDD; e.g., Curry, 2001). Although in terms of sheer
 Bethesda, MD; Mr. George and Ms. Pollock are with the University of                      numbers, children 12 years old and younger with
 Pittsburgh Medical Center; Dr. Ho is with CYKE, Inc., Atlanta.
                                                                                          chronic depression represent a minority of the popu-
    This article is based on work that was completed while Dr. Sherrill was at the
 University of Pittsburgh. Views expressed within this article represent those of the     lation of depressed juveniles, there are several reasons
 authors and are not intended to represent the position of National Insitute of           why they should be targeted for intervention research.
 Mental Health (NIMH), National Institutes of Health (NIH), or the                           In clinically referred children, dysthymic disorder
 Department of Health and Human Services (DHHS).
    This study was supported by NIMH grant 5R21 MH55244; preparation of                   (DD), one form of chronic depression, lasts almost
 the manuscript was supported by NIMH Program Project grant 5P01                          4 years on average, and about 18% of youngsters with
 MH56193. The authors thank Melina Orsini-Young, M.S.W., for her                          MDD have episodes longer than 1.5 years (Kovacs
 participation in the study and an anonymous reviewer for helpful suggestions.
    Correspondence and requests for the treatment manual, parents_ manual, and            et al., 1997). Such extended periods of depression are
 unpublished assessment tools to Dr. Maria Kovacs, WPIC, 3811 O_Hara Street,              likely to have deleterious functional and developmental
 Pittsburgh, PA 15213; e-mail: kovacs@pitt.edu.                                           consequences across the elementary school years, a pe-
    0890-8567/06/4508-0892Ó2006 by the American Academy of Child
 and Adolescent Psychiatry.                                                               riod during which various basic skills must be acquired.
    DOI: 10.1097/01.chi.0000222878.74162.5a                                               In addition, protracted dysphoric mood at a young age

 892                                                                                    J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
www.cuwai.com                                                              NEW TREATMENT FOR CHILDHOOD DEPRESSION

        may interfere with the structural and functional               problems (e.g., acute suicidality), and includes a module
        maturation of cortical and subcortical brain circuits,         on coping skills training.
        a normative process that continues into adolescence
        (Casey et al., 2000; Durston et al., 2001). Finally,           Framework and Rationale
        among youngsters, DD typically predates subsequent                The relationships between stress and coping and
        MDD (Kovacs et al., 1994) and thus represents one of
                                                                       between stress and depression, which have been exten-
        the earlier manifestations of vulnerability to major
        mood disorders.                                                sively documented, serve as a general framework for the
           One likely reason for the lack of psychological             treatment. Within this framework, CERT posits that
        intervention trials with clinically depressed children is      problems in the adaptive self-regulation of distress and
        that available treatments generally are not developmen-        dysphoria compromise a child_s ability to cope and fa-
        tally appropriate or sensitive (see Weisz et al., 1992), a     cilitate the emergence of clinical depression. The specific
        concern specifically noted with regard to the cognitive-       assumptions of CERT are that dysfunctional self-
        behavioral therapies (Hammen et al., 1999; Kendall and         regulation of distress and dysphoria, a key characteristic
        Choudhury, 2003). The emphasis on short-term inter-            of depressed children, developmentally precedes the
        ventions for MDD probably reflects various constraints         onset of depressive disorder; stress, along with contextual
        imposed by health care insurers as well as a range of          variables, interact with preexisting regulatory difficulties
        practical and clinical issues (e.g., Weisz et al., 1997).      to enable progression of dysphoric emotion to dysphoric
        Thus, the relative scarcity of treatment trials with           mood and then to a depressive disorder; ongoing affective
        chronically depressed children is likely to mirror a           distress (dysphoria, irritability, anhedonia) maintains
        combination of factors along with the belief that brief        the depressive syndrome and therefore its reduction
        intervention may be inappropriate for dysthymia. Con-          must be a salient treatment target; and dysfunctional
        sequently, there is scant empirical information about          regulatory responses to distress and dysphoria can be
        whether and how long-term depression in childhood can          identified and remediated.
        be ameliorated. In the present article, we describe a new         The CERT explanatory paradigm is presented to
        intervention, developed specifically for school-age de-        families as the following themes: (1) the child_s Bmood
        pressed children, and report on its application to treat       problems[ are likely to have come about gradually, along
        chronic depression. The goals of this open pilot testing       with earlier signs of sensitivity to even small, everyday
        trial were to assess the intervention_s acceptability          distress elicitors (i.e., has had difficulties in the adaptive
        (willingness to remain in treatment) and efficacy              down-regulation of distress), (2) the depressive episode
        (diagnostic and symptom severity outcomes).                    has been preceded by one or more stressors or difficulties
                                                                       (distress elicitors), representing either a major negative
                                                                       event or an accumulation of minor hassles, (3) given that
                                                                       this child has been historically sensitive to distress elici-
                                                                       tors, as well as specific contextual issues, he or she has
           CERT, which focuses on the self-regulation of distress      been unable to modulate or down-regulate the dysphoric
        and dysphoria, was inspired by a combination of clinical       emotion, leading to protracted negative mood, which has
        observations, the literature on stress and coping, and         adverse effects on the parentYchild and other relation-
        a developmental approach to emotion regulation. It is a        ships, and (4) protracted negative mood and its social
        goal-directed and problem-focused intervention, with a         repercussions negatively affect other areas of functioning,
        strong didactic emphasis. The intervention_s explanatory       contributing to a spiral of symptoms, which culminate in
        paradigm and its application to chronic depression have        clinical depression.
        been operationalized in a working treatment manual,               Examples are used to reframe the child_s emotion
        which also addresses practical issues (e.g., basic thera-      regulatory difficulties and depressive symptoms in the
        peutic stance, effective use of language with children),       context of stress and coping, which helps families to
        provides Bhow to[ guidance (e.g., introducing the              anchor key CERT concepts in their daily lives. The
        explanatory framework, selecting target symptoms and           treatment goals are identified as helping the child to
        intervention techniques, reframing mood-related in-            recover from his or her current depressive disorder
        cidents in terms of emotion regulation), notes special         (symptom reduction) and become more skilled at

        J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006                                                               893

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.

 regulating dysphoric emotions and in responding to                 the scene, finding some distracter, or trying to engage
 distress-eliciting situations (Bcoping skills training[ with       caregivers_ help for distress relief. The increasing so-
 an emphasis on adaptive emotion regulatory responses).             phistication of language, cognitive, and interpersonal skills
                                                                    gradually enables children and adolescents to master a
 Development of Emotion Regulatory (ER) Responses                   variety of additional ER responses, which can involve their
    A major conceptual basis of CERT is that starting in            own thought processes (cognitions), more strategic
 infancy and continuing thereafter, ER responses in general         discourse and interaction with caregivers or peers, or
 and those evoked by distress and dysphoria in particular           manipulation of features of their environment. In general,
 unfold as part of a complex normative developmental pro-           the family context and the social Bregulators[ therein play
 cess within a social context (e.g., Kopp, 1989; Thompson,          key roles in the unfolding and use of distress-specific ER
 1994). How this process takes place, what its key com-             responses during childhood, whereas peers as Bsocial
 ponents are, and how salient features are best defined or          regulators[ become important in adolescence.
 measured have been topics of lively debates during the                Overall, the developmental literature reveals several
 past 15 years or so. Kopp_s 1989 article on the regulation         important features of the normative unfolding of distress/
 of distress and negative emotions in infancy has served as         dysphoria self-regulation. First, the vast majority of ER
 an important stimulus for research on this construct. A            responses to distress, which human beings display, are
 monograph entirely dedicated to the development of                 products of learning, having been molded and shaped by
 emotion regulation (Fox, 1994), a special issue of the             social context in general, and the family context in par-
 journal Child Development 10 years later (March/April              ticular. Second, a wide variety of behaviors and actions
 2004), as well as various books on this topic (e.g., Bradley,      can serve as ER responses, which typically (but not
 2000; Garber and Dodge, 1991) reveal both the                      invariably) become increasingly sophisticated with age.
 multifaceted nature of ER and the variety of approaches            Correspondingly, caregiver-initiated ER responding is
 used to study it.                                                  gradually replaced by self-initiated responding. Third, as
    There is general consensus that distress or dysphoria           a normal part of development, children_s ER repertoires
 can elicit a variety of regulatory responses that can serve to     become larger, come to include mostly functional but
 diminish or alleviate it, that multiple interactive processes      also some dysfunctional responses, and are characterized
 are involved (or called upon) in any given ER response,            by ER response deployment, which is both flexible and
 and that the nature of the response or its component               context sensitive. Fourth, there are considerable indi-
 elements vary as a function of developmental stage. There          vidual differences in ER responses to distress and dys-
 also is considerable agreement that the ability to refocus         phoria, which are likely to represent a combination of
 attention away from the source of distress or dysphoria,           innate physiology, history of ER response acquisition and
 or the associated feelings, represents a primary ER re-            deployment, and personal resources. Finally, ER
 sponse, starting in early childhood, and that refocusing of        responses can occur at various points along an emotion
 attention can be achieved through a variety of actions and         experience and can be defined in various ways.
 behaviors. Although ER responses are typically initiated
 by caregivers for distressed infants and toddlers, children        CERT and the Regulation of Dysphoria
 become increasingly able to self-regulate such negative               In CERT, emotion regulation is defined as responses,
 emotions. For example, during infancy, dysphoria and               which may serve to interrupt, lessen, diminish and ter-
 distress are modulated mostly through input from                   minate, or maintain, accentuate, and prolong the emotion.
 caregivers who achieve that goal by various actions (e.g.,         Adaptive or functional ER responses to dysphoria serve to
 gentle touching, coddling, rocking, attempts to distract the       down-regulate it and therefore enable the child to feel
 infant, feeding). With the emergence of basic skills (e.g.,        better, whereas maladaptive or dysfunctional responses
 ambulation, motor coordination, language, attention                exacerbate or prolong the negative mood (and thereby
 focusing), toddlers and young children gradually master            engender other problems). Thus, one of the goals of
 a repertoire of responses that they can initiate and deploy        CERT is to identify the specific ways in which a given child
 to modulate or terminate their own feelings of sadness or          has historically responded to dysphoria or distress elicitors
 distress. Thus, a distressed young child can alleviate that        in various contexts and the types of ER responses that have
 emotion by self-soothing, turning to play activity, leaving        been useful.

 894                                                              J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
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           Within the framework of CERT, ER responses to                another. On the contrary, the individually tailored
        dysphoria are grouped into four interconnected domains:         approach of CERT accommodates the fact that a given
        biological, behavioral, cognitive, and social/interpersonal.    ER response (e.g., provision of physical comfort) may
        This concept is presented to families as Bsources of emotion    help one child to regain emotional homeostasis, but have
        regulation[ or Btypes of control processes[ that can help a     the opposite effect on another child and that there are
        child to feel better. The Bbiological[ domain of ER is          age-related differences in regulatory competencies (e.g., a
        defined as the physiological infrastructure underlying          7-year-old_s ER repertoire is less likely than that of a
        emotions and ER, or the Bphysical processes[ in one_s           11-year-old to contain adaptive cognitive responses).
        body, which also involves a child_s innate sensitivity and      Third, because ER responding is shaped across develop-
        possibly high reactivity to emotion elicitors. The Bbe-         ment through learning and practice, didactics and
        havioral[ regulatory domain is presented to families as         rehearsal are key components of CERT.
        Bways of acting or what you do[ to manage or control               Another salient feature of CERT is the emphasis on the
        dysphoria, including responses such as walking away from        Bcontext[ of symptoms and ER responses. The
        a distressing situation, turning to play activity, doing        Bcontextual mapping[ of a symptom or problem scenario
        physical exercise, playing music, doing chores, and working     (i.e., constructing a detailed account of a distress-eliciting
        on a project. The Bcognitive[ regulatory domain is              incident) enables the therapist to select a point of
        described to children as Bwhat goes on in your head[            intervention (for that given complaint), which may be the
        that can help to feel better, including conjuring up some       ER response, some nonmood depressive symptom, or
        image to counter the dysphoric emotion, helpful Bself-          environmental features. Throughout treatment, the
        talk,[ focusing attention on neutral or positive topics, and    ongoing goals are to identify the given child_s habitual
        changing how you think about what makes you sad, such           adaptive and maladaptive responses to persistent dys-
        as minimizing its significance. The Bsocial/interpersonal[      phoria and daily events that exacerbate it (the latter being
        ER domain, which entails enlisting other people as the          typically exemplified by problem scenarios brought into
        means to down-regulate one_s own dysphoria, is presented        sessions); pinpoint to families ER responding that up-
        as Bhow other people can affect you or help you to feel         regulates (rather than modulates) or has no effect on the
        better.[ This domain includes both the types of inter-          emotion or mood; reinforce or teach age-appropriate,
        actions whereby others can help modulate a given child_s        adaptive, dysphoria-specific regulatory responses; and
        distress, such as the child getting a hug or being physically   reframe the child_s difficulties using a general ER and
        comforted, talking to a parent or teacher about the             coping perspective.
        dysphoria, and engaging a peer in play or some project,            If the existing repertoire of adaptive ER responses to
        and effective ways of recruiting social regulators such as      dysphoria is inadequate, then the child_s inclination
        the use of explicit language. Consistent with the im-           toward one versus another ER domain is used to
        portance of context in the experience and regulation of         remediate deficits. For example, a child who is social by
        emotions (e.g., Thompson, 1994), the treatment also con-        nature would be taught adaptive ways of recruiting
        siders environmental manipulation and the use of external       Bsocial regulators[ as one way to feel better when he or
        resources as (behavioral) regulatory responses.                 she feels sad. Alternatively, with a child who has a clear
                                                                        preference for thinking (but may not be socially inclined),
        Salient Features of CERT                                        various cognitive ER responses would be explored. To
           The developmental ER perspective of CERT had                 facilitate adaptive ER response deployment, any number
        several implications for its implementation. First, because     of strategies can be used including social modeling,
        ER is Bboth an individually based and a relational              differential reinforcement, paired-associate learning, and
        phenomenon[ (Grolnick et al., 1996) and the use of              depending on the child_s age and skills, didactics focusing
        social agents to regulate distress is a major ER domain         on cognitive processes (i.e., alternative explanations, visual
        (Hofer, 1994), at least one caregiver had to actively           imagery). If the child_s history reveals past deployment
        participate in the child_s treatment. Second, because           of adaptive regulatory responses to dysphoria, then the
        developmental perspectives highlight individual differ-         goal is to reinforce them and ensure a facilitative context.
        ences, no assumptions were made about one ER domain             For example, if a child had been able to self-regulate
        or set of regulatory responses being more important than        distress/dysphoria in the past by engaging in physical

        J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006                                                                895

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.

 activity, but recent environmental changes have con-             understood, it is reiterated that under some conditions
 strained him or her, the therapist and the family together       involving dysphoric emotion, solving the given problem
 identify alternative venues to enable deployment of that         may be the most practical and useful approach.
 ER response.
    To ensure active parental participation in CERT, the
 parent is asked to serve as an Bassistant coach[ and is
                                                                  PRETRIAL VERIFICATION OF
 provided with six Brules of coaching[ (e.g., Bcoaches are
                                                                  SELECTED CONSTRUCTS
 made, not born,[ Beven a coach can have a bad day[).
 The rules of coaching are included in a parent_s manual             Two samples of convenience served to explore aspects
 that summarizes basic CERT concepts. As an assistant             of the explanatory framework and ER responses, namely
 coach, the parent not only helps the child but also tries        19 psychiatrically referred (PR) children with various
 on a new role and new ways of interacting, which were            clinical diagnoses of depression (ages 7Y12 years; 63%
 envisioned to have positive effects both on the child_s          male; 58% living in single-parent homes), and 10 normal
 ER skills and the parentYchild relationship.                     controls (NC) with no history of psychiatric illness or
    In managing depressive symptoms other than mood,              treatment (ages 7Y12 years; 50% male; 40% living in
 the therapist can select from a broad array of focused,          single-parent homes). Members of the Treatment
 problem solvingYoriented, behavioral, interpersonal, and         Development Team, using a combination of a semi-
 cognitive techniques that have been widely described in          structured questionnaire and an open-ended interview,
 the literature as practical and useful. These techniques         individually interviewed the children about Bcauses[ of
 include teaching Bsleep hygiene[ as one way to counter           and ways to alleviate dysphoria in youngsters their age
 sleep disturbance, keeping a log to identify temporal            and about means of expressing such emotions to an
 features of symptoms such as fatigue, assigning pleasant         adult. Both groups cited aversive peer behavior (being
 social activities to counter withdrawal, teaching visual         teased, called names) as a salient cause of dysphoria
 imagery to counter negative thoughts about the self or           (42% and 60%, respectively), but only the PR children
 others, or designing behavioral experiments to explore           cited highly painful experiences (e.g., someone having
 new ways of responding.                                          died [11 of 19], being left or put in foster care [5 of
    During Bcoping skills training,[ the final phase of           19]). Some social/interpersonal response was most
 CERT, age-appropriate didactic aids are employed to              commonly cited as a way to modulate dysphoria,
 reinforce what has been learned about ER. For example,           including talking to someone (63% and 40%, respec-
 the therapist and the family together view film segments         tively). The PR children also generated ER responses
 depicting dysphoric emotions and the protagonists_ ER            such as Bdoing something fun[ (6 of 19) and someone
 responses (e.g., precued sections from The Lion King,            buying you something nice (3 of 19). Regarding
 Babe). A list of a priori defined questions and probes           methods to express dysphoric feelings, rated from
 posed by the therapist help children review appropriate          Beasy[ to Bdifficult,[ 70% of the NC children opined
 emotion-naming, recognize putative causes, and identify          that Btalking about it[ is somewhere in the middle
 ER responses that were adaptive (helped the protagonist          range, but only 37% of the PR children said so, and
 to feel better) and those that were not (made the                another 37% stated that it was Bdifficult.[ By rank
 protagonist feel more distressed or dysphoric). ParentY          order, both groups noted that talking about one_s
 child pairs also are helped to catalog dysphoria-eliciting       emotion was the hardest, and drawing pictures of faces
 contexts that have been historically troublesome for the         to show your emotion was relatively easy, but for the
 child, and how to prepare for them by the child_s                PR children, selecting an emotion-expression face from a
 ongoing adaptive use of ER responses. The importance             chart of faces was the easiest way to identify their emotion
 of contexts and strategies that help to initiate or maintain     to an adult. According to both groups, keeping a written
 positive emotions also are discussed. In short, the              notebook can help children track their daily emotions
 emphasis is on practicing adaptive regulatory responses          and moods (63% of the PR group; 80% of the NC), but
 to dysphoria to be able to prevent such an emotion from          only a minority stated that this would be easy (42% of
 Bgetting out of hand.[ In addition, by reviewing the             PR; 20% of NC), citing various barriers (e.g., Bhe_ll
 general coping framework within which problems can be            forget the paper[).

 896                                                            J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
www.cuwai.com                                                                          NEW TREATMENT FOR CHILDHOOD DEPRESSION

           In addition, during brief therapy with two psychi-                     CLINICAL TRIAL METHOD
        atrically referred children (a 9-year-old boy and an
        11-year-old girl, both with 2-year histories of depressed                 Subjects
        mood and associated problems), we piloted enrolling                          Children had to meet the following study entry criteria: ages
        the parent as an Bassistant coach[ or Bcotherapist[ and                   between 7 and 12 years; no evidence of major systemic medical
        techniques such as the young patients keeping mood and                    disorder, mental retardation, or psychosis; presence of chronic
                                                                                  depressive disorder; not receiving pharmacotherapy; and willingness
        activity logs, and involving parentYchild pairs in be-                    of at least one parent to actively participate in the treatment.
        havioral experiments. Parents were found to be most                       Recruitment efforts (at our child psychiatric outpatient referral units,
        receptive to intervention strategies that were developed in               various other child mental health clinics, and via community
                                                                                  advertisement) resulted in 101 initial phone screens; 36 children
        collaboration with them as Bco-therapists.[ The children                  then had a full evaluation; 20 met criteria and entered the treatment
        were able (with reminders) to complete mood logs that                     protocol. Treatment was provided free of charge. Families signed
        served to pinpoint diurnal variations (which, interestingly               informed consents, and children provided assents. The sample of
                                                                                  20 was 35% female, had a mean age at entry of 10.4 years (SD =
        were found to differ from initial parental perceptions),                  2.2 years), 90% were white, and 10% were African American or
        and activity logs that helped to identify behaviors that                  biracial; 90% lived in two-parent households and 80% lived in
        diminished dysphoria as well as parentYchild interactions                 intact families of origin. For 65% of the sample, educational
        that exacerbated it.                                                      attainment of the head of household was a college degree (or higher).
                                                                                  Of the children, 50% had a history of outpatient mental health
           In summary, the informal survey suggested that                         treatment; none had a history of psychotropic medication use or
        children recognize the relationship between dysphoria                     inpatient hospitalization.
        and stressful events. Many of the ER responses they                          Chronic depression was defined as the diagnosis of DD according
                                                                                  to either DSM-IV or DSM-III, in part because the validity of DSM-IV
        generated map onto those in CERT, with one exception                      DD criteria for youth has not yet been documented. Three cases with
        (traditional Bcognitive[ responses, e.g., thinking about                  clear Bdysthymia-like[ presentation (two were somewhat short of the
        the distress differently), were rare. However, this                       1-year duration at intake and one with chronic illness but one
                                                                                  symptom short) were formally diagnosed as depressive disorder not
        finding is age appropriate (M.K., unpublished manu-                       otherwise specified, but were considered for practical purposes as
        script). The results also suggested the advisability of                   having DD. At study entry, 16 subjects met criteria for both DSM-IV
        using visual aids to facilitate discourse about dysphoric                 and DSM-III DD and 4 met only DSM-III criteria. Duration of the
        emotion. All of these sources of information were used                    index episode was 24.4 months (SD = 11.9). Six children had a
                                                                                  superimposed MDD at intake (two others had previous MDD
        to produce a working treatment manual, subsequent to                      episodes) and 70% had nonaffective (anxiety and oppositional
        which we initiated the clinical trial.                                    defiant) comorbid disorders (Table 1).

                                                                        TABLE 1
                                               Clinical Characteristics of the Sample at Four Time Points

                                       All Subjects at Intake                                    Treatment Completers
        Variables                            (N = 20)           Intake (n = 15)      Tx End (n = 15)       6-Mo FU (n = 14)         12-Mo FU (n = 13)
        Diagnosis present (no., %)
          DD                                 20 (100)              15 (100)                7 (47)                 3 (21)                   1 (8)
          MDD                                 6 (30)                5 (33)                 1 (7)                     0                        0
          Anxiety disorder                    8 (40)                7 (47)                 5 (33)                 3 (21)                   1 (8)
          ODD                                 9 (45)                6 (40)                 6 (40)                 2 (14)                   2 (15)
        Children_s self-rated symptoms
          (mean, SD)
          Depression (CDI)                  16.3 (10.1)          16.6 (10.7)            4.3 (6.8)               5.0 (7.6)                5.3 (7.2)
          Anxiety (RCMAS)                   15.0 (6.7)           15.3 (6.7)             4.7 (5.9)               4.5 (5.4)                5.3 (5.6)
        Mothers_ clinician-rated symptoms
          (mean, SD)
          Depression (HRS-D)                11.8 (6.5)            9.9 (5.6)             7.0 (3.9)               3.8 (3.4)                6.0 (3.2)
          Anxiety (HRS-A)                   10.7 (5.0)            9.5 (4.5)             7.7 (3.2)               4.2 (3.3)                6.5 (5.4)

           Note: Results of statistical analyses are in the text. Tx = treatment; FU = follow-up; DD = dysthymic disorder; MDD = major depressive
        disorder; ODD = oppositional defiant disorder; CDI = Children_s Depression Inventory; RCMAS = Revised Children_s Manifest Anxiety
        Scale; HRS-D = Hamilton Rating Scale for Depression; HRS-A = Hamilton Rating Scale for Anxiety.

        J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006                                                                                    897

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.

 Assessment and Diagnostic Procedures                                          treatment, follow-up evaluations included independent (but not blind)
                                                                               K-SADS interviews, and parent- and child-rated questionnaires.
    Psychiatric diagnoses at intake, end of treatment, and 6- and
                                                                                  Participating were three therapists, whose psychotherapeutic
 12-month follow-up were derived via the Schedule for Affective
                                                                               experiences ranged from 5 to 7 years (their highest academic degrees
 Disorders and Schizophrenia for School-Age Children (K-SADS;
                                                                               were Ph.D., M.D., and M.S.W.). The treatment room included
 Kaufman et al., 1997), which was administered by trained, in-
                                                                               visual aids that were age appropriate for children (e.g., wall poster
 dependent clinicians to the parent about the child and then separately
                                                                               depicting the regulatory domains as rooms of a house with pertinent
 to the child about him- or herself. The results were reviewed by at
                                                                               ER Btools[ noted in each ER room) and a poster that listed the
 least one other experienced clinician to ensure consensus diagnoses. At
                                                                               Brules of coaching.[ Each session involved the parentYchild pair.
 the end of treatment and follow-up evaluations, remission of a given
                                                                               Sessions were tape recorded and reviewed in weekly meetings by the
 disorder was defined operationally (Kovacs et al., 1984) as being free
                                                                               Treatment Development Team to ensure adherence to the basic
 of clinically significant and impairing symptoms (i.e., no more than
                                                                               explanatory framework, identify protocol features that needed to be
 one symptom and few, if any, subclinical symptoms of the particular
                                                                               clarified, and discuss any modifications that may be warranted.
 disorder remaining), and maintenance of this essentially asymptom-
                                                                               Intersession telephone contacts were allowed if needed to verify or
 atic state continuously for a minimum of 2 months. For behavior
                                                                               confirm some element of treatment.
 disorders, the minimum time frame for remission was at least
 3 months. Partial remission was defined as no longer meeting full
 diagnostic criteria for the specific disorder but the persistence of a
 subsyndromal clinical picture.                                                RESULTS
    During treatment, independent evaluators conducted monthly
 symptom assessments of the child via the Follow-up Depression and             Characteristics of Completers Versus Noncompleters
 Anxiety Scales for Youths (FDS-Y, and FAS-Y, respectively). These
 clinician-rated scales were derived from the Interview Schedule for              Of the 20 cases, 15 completed the protocol. Four were
 Children and Adolescents (Sherrill and Kovacs, 2000) and entail               administratively terminated owing to too many missed
 standard probes regarding symptom frequency and intensity. Based              sessions (defined a priori as three out of four consecutively
 on separate interviews with the child and with the parent about the
 child, the clinician provides an overall rating for each symptom
                                                                               scheduled sessions, without extenuating circumstances)
 ranging from 0 = none to 3 = severe (pervasive/constant, impairing/           and one dropped out (noncompleters were provided with
 disrupts functioning). The FDS-Y (26 items) has a potential score             clinical referrals as needed). Completers averaged 30.6
 range of 0 to 78; the FAS-Y (11 items) has a potential score range of         (SD = 6.5) sessions across a mean interval of 12.2 months
 0 to 33. Clinical evaluators were aware that the children were
 participating in a treatment protocol.                                        (SD = 2.6); noncompleters averaged 6.2 (SD = 4.7)
    Children completed the Children_s Depression Inventory (CDI;               sessions. Children who completed the protocol and those
 Kovacs, 2003) and the Revised Children_s Manifest Anxiety Scale               who did not were demographically similar, with two
 (RCMAS; Reynolds and Richmond, 1985) about themselves at
 preset time points. Parents (typically mothers) completed the Beck            exceptions: completers were more likely to be living in
 Depression Inventory (Beck et al., 1988) about themselves and                 intact families of origin (p = .03) and have better-educated
 other questionnaires and were evaluated by independent clinicians             parents (p G .01).
 via the Hamilton Rating Scales for Depression (HRS-D; Hamilton,
 1967a) and Anxiety (HRS-A; Hamilton, 1967b) at start of
                                                                                  The two groups did not differ with regard to past
 treatment, its end, and at follow-up. Per the protocol, clinically            treatment, diagnostic composition, and illness dura-
 depressed parents were referred for treatment, which was available            tion at intake, rates of comorbid psychiatric diagnoses,
 gratis by prior arrangement.                                                  or severity of self-rated depressive and anxiety symp-
                                                                               toms. However, mothers of noncompleters versus com-
                                                                               pleters had higher levels of depression at study entry,
 Treatment Protocol                                                            both by self-rating (mean Beck Depression Inventory
    As an intervention for chronic depression, we designed a 30-session,       score: 17.2, SD = 5.6 versus 7.7, SD = 6.4, respectively,
 multiphase, 10-month protocol as follows: phase IVmonth 1: intense            p = .02) and clinical evaluation (mean HRS-D score:
 treatment, one to two sessions per week (up to eight sessions); phase         17.6, SD = 6.0 versus 9.9, SD = 4.5, respectively p = .03).
 IIVmonths 2Y 4: regular treatment, one session per week (up to
 13 sessions); phase IIIVmonths 5 Y 6: tapered treatment, one session          In the set of completers, three mothers and two fathers
 every 2 weeks (up to five sessions); phase IVVmonths 7Y10:                    were in treatment (for a variety of problems) when their
 maintenance treatment, one session/month (up to four sessions).               children entered the protocol (two of these mothers
 The first three phases were limited to 26 sessions owing to past research
 (with adults) that suggested that by session 26, the vast majority of
                                                                               and one of these fathers continued their treatment dur-
 patients show some improvement (Howard et al., 1986). The                     ing CERT). Subsequent to the start of the protocol,
 maintenance phase (phase IV) was spaced across 4 months to provide            two other mothers and two other fathers entered se-
 time for the consolidation of newly learned skills. The protocol              parate treatment for themselves; of these, three were
 required evidence of symptomatic improvement at the 5- and 7-month
 points (defined via specific CDI cutoff scores for boys and girls) to         self-initiated and one was via referral by the CERT
 advance a child to the respective phase. At 6 and 12 months after end of      study coordinator.

 898                                                                         J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
www.cuwai.com                                                              NEW TREATMENT FOR CHILDHOOD DEPRESSION

        Changes in Children_s Diagnostic Status                           As an alternative approach, we used longitudinal
           At end of treatment, eight of the 15 completers             modeling procedures (restricted maximum likelihood
        (53.3%) had full remission of the chronic depression           models) on completers_ CDI and RCMAS scores at
        and two (13.3%) were in partial remission (by K-SADS).         four time points: intake, end of treatment, and 6- and
        Five of these 10 patients also had had superimposed            12-month follow-up (Table 1). Similar to the results
        MDD, which was in full remission in four (80%). From           from paired t tests, the results were highly significant
        among the seven patients with initial comorbid anxiety         both for the model of depressive symptoms (F3,38 = 7.41
        disorder, three were in full remission, but another patient    p G .001) and the model of anxiety symptoms (F3,38 =
        developed an anxiety disorder postintake and was in            11.57 p G .001).
        episode at end of treatment (Table 1). All six patients           We also examined clinician-rated symptom severity
        with oppositional defiant disorder continued to meet full      patterns across the course of therapy at key treatment
        diagnostic criteria.                                           transition points (1, 4, and 7 months and treatment
           Remission of dysthymia continued across the follow-up,      end). Overall, repeated-measures analyses of variance
        with 79% of the available completers remitted by               suggested significant changes across time in children_s
        the 6-month follow-up and 92% by the 12-month                  clinician-rated depression (FDS-Y ratings; F3,12 = 6.81,
        follow-up. For comorbid anxiety disorders, the cumu-           p = .006) and anxiety (FAS-Y ratings; F3,12 = 7.49,
        lative rates of remission were 79% by the 6- and 92%           p = .004). Profile contrasts, comparing evaluations at
        by the 12-month follow-up (Table 1). Mantel-Haenszel           each given time point with those at the next time point,
        x2 analyses of the distribution of cases meeting full          revealed that levels of depressive and anxiety symptoms
        diagnostic criteria at intake, end of treatment, and 6- and    dropped significantly from the 1-month to the 4-month
        12-month follow-up confirmed statistically significant         assessments (F1,14 = 13.07, p = .003 for FDS-Y; F1,14 =
        decreases in the rates of DD (x2 = 27.85, p G .0001),          10.64, p = .006 for FAS-Y) and evidenced more gradual
        MDD (x2 = 10.26, p = .001), Bany depressive disorder[          and statistically insignificant declines from 4 to 7 months,
        (x2 = 27.85, p G .0001), and Bany anxiety disorder[ (x2 =      and from 7 months to the end of treatment (F1,14 = 3.88
        5.46, p = .02).                                                and 0.04 for FDS-Y; and 0.92 and 0.05 for FAS-Y; all
                                                                       p > 0.05). Thus, the most dramatic decrements in symp-
                                                                       toms occurred during the first 4 months of the treatment.
        Changes in Children_s Symptom Severity                         Using clinically rated depressive symptoms, Figure 1 illus-
            Using the 20-patient intent-to-treat sample (and           trates the changes during treatment relative to pretreat-
        carrying forward the last scores of noncompleters),            ment levels. To generate the figure, the intake K-SADS
        we found that self-rated depressive symptoms (CDI) de-         (current ratings) was used to estimate symptom severity
        clined from being in the clinical range at entry (mean =       at entry by summing across 22 items that had counter-
        16.3, SD = 10.1) to normal levels (mean = 5.2, SD = 6.7)       parts in the FDS-Y. In turn, the relevant FDS-Y items
        by end of treatment (paired t test = 4.81, p G .001).          were rescaled onto a 3-point scale.
        There was a parallel, statistically significant pretreatment
        (mean = 15.0, SD = 6.7) to posttreatment (mean = 6.7,
        SD = 7.8) decrease in levels of anxious symptoms (paired       Changes in Maternal Symptoms
        t test = 5.48, p G .001) as quantified by the RCMAS. The          We used longitudinal statistical procedures (restricted
        findings were similar for the 15 completers (Table 1):         maximum likelihood models) to examine data from the
        there were highly significant pre/post changes in their        clinical evaluations of mothers of completers (HRS-D
        levels of depression (CDI scores, paired t test = 4.45,        and HRS-A scores; Table 1) at intake, end of treatment,
        p G .001) and anxiety (RCMAS scores, paired t test =           and 6- and 12-month follow-up. According to the results,
        6.97, p G .001). Treatment gains were maintained across        levels of maternal depression (HRS-D scores) and anxiety
        time, as suggested by comparing end-of-treatment scores        (HRS-A scores) significantly diminished across time
        to those at the 6- and 12-month follow-up for the CDI          (F3,31 = 4.71, p = .008, and F3,32 = 3.90 p = .018,
        (t = j0.34, and t = j0.14, respectively, both not              respectively). However, because four mothers had been
        significant) and the RCMAS (t = 0.58 and t = j0.64,            receiving their own treatment separately from the CERT
        respectively, both not significant).                           protocol, we reran the analyses using only the remaining

        J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006                                                              899

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.


                                                                                        CERT is a new intervention for childhood depres-
                                                                                    sion that provides therapists and families with an ex-
                                                                                    planatory framework that is conceptually meaningful,
                                                                                    clinically sensible, and developmentally appropriate. It
                                                                                    builds on emotion self-regulation and focuses on self-
                                                                                    regulatory responses to distress and dysphoria, which
                                                                                    unfold across development, are important for adaptive
                                                                                    functioning, and appear to be dysfunctional in
                                                                                    individuals with depressive disorders across the life
                                                                                    span. It highlights the importance of parental involve-
                                                                                    ment in treatment and offers one way to facilitate it.
                                                                                    Because it incorporates commonly used intervention
                                                                                    techniques and is manual based, CERT can be taught to
                                                                                    therapists. The generally positive overall results of this
                                                                                    pilot study underscore the feasibility of our approach
                                                                                    and suggest the need for a larger, randomized trial of the
                                                                                    efficacy of CERT.
                                                                                        The importance of adaptive self-regulation of dys-
 Fig. 1 Clinician-rated severity of children_s depressive symptoms during
                                                                                    phoria and distress, which is the ultimate target of CERT,
 treatment. Error bars represent the 95% upper confidence interval of the mean.
                                                                                    is supported by extensive developmental research address-
                                                                                    ing the years of childhood (Fox, 1994; Kopp, 1989) and
                                                                                    ER skills remain critical across the life span (Gross, 1998).
                                                                                    There is evidence that clinically depressed youngsters have
 11 mothers. In this subgroup, changes in levels of maternal                        fewer and less effective ER skills for managing negative
 symptoms from intake and through the follow-up were                                emotions than do their nonaffected peers (Garber et al.,
 not significant (HRS-D: F3,24 = 1.99, p = .143; and HRS-                           1995). Because dysregulated affect is a salient feature of
 A: F3,25 = 2.24, p = .109).                                                        depressive disorders, all empirically supported treatments
                                                                                    of depression have components that target aspects of
                                                                                    emotion regulation. However, cognitive-behavioral inter-
 Parental Treatment and Changes in Children_s                                       ventions and interpersonal psychotherapy, which have
 Symptom Severity                                                                   been specifically used with depressed youngsters (e.g.,
    Can parents_ own treatment account for the signifi-                             Brent et al., 1997; Mufson et al., 1999; Stark et al., 1987)
 cant symptomatic improvement of the children? To                                   represent Bdownward extensions[ of treatments that were
 examine this issue, we reanalyzed children_s depressive                            originally designed for adults. Furthermore, none of them
 and anxiety symptom scores, using only cases whose                                 emphasizes ER as the key organizing principle in its
 mothers were not receiving psychiatric treatment during                            delivery or case formulation, defines ER from a develop-
 the CERT study. The improvement in symptoms of                                     mental perspective, takes into account the diverse ways in
 depression and anxiety in this subgroup of young                                   which dysphoria can be regulated, or strategically engages
 patients remained statistically significant across the four                        the parent as an emotion regulatory agent and treatment
 time points (restricted maximum likelihood model on                                ally. In contrast, by viewing dysregulated mood as the key
 11 subjects CDI: F3,28 = 6.73, p = .002; and RMAS:                                 feature of depressive disorders and highlighting that ER
 F3,27 = 11.13, p G .001). Significant symptom im-                                  responses are developmentally acquired, CERT guides
 provement also was observed for the subset of cases                                clinicians to focus on a child_s history of ER response
 who did not have either parent in treatment during                                 acquisition and deployment. By acknowledging the di-
 the CERT protocol (n = 8; CDI: F3,20 = 4.88, p = .011;                             versity of responses that serve to down-regulate dysphoria
 and RMAS: F3,19 = 4.20, p = .019).                                                 and individual (including age-associated) differences in

 900                                                                              J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
www.cuwai.com                                                              NEW TREATMENT FOR CHILDHOOD DEPRESSION

        that regard, CERT makes it possible to match the delivery      (e.g., Brent et al., 1997). Thus, our study is among the
        of the treatment to a given child_s needs and competen-        first to enlist parents in each session of an intervention,
        cies. By organizing ER responses into meaningful do-           with a clearly defined role that is focused on the
        mains, CERT provides one useful way to characterize ER         depressed child_s ER needs.
        repertoires for distress management.                              Several preliminary findings are worthy of note. First,
           Although partly for practical reasons, CERT_s presen-       at the end of treatment, the rate of remission of super-
        tation of ER, ER domains and responses, and contextual         imposed MDD (80%) was high, suggesting the useful-
        factors that affect them is somewhat simplified, its           ness of CERT for nonchronic depression. Second, the
        emphasis is supported by recent research directions on         finding that the rate of remission of DD was 53% at
        mood disorders (Davidson et al., 2002). Furthermore,           end of treatment and that it took an additional 6 to
        some of the initial premises that guided CERT have been        12 months for another 40% of cases to achieve full
        extended into a more comprehensive model of vulner-            remission underscore the recalcitrant nature of chronic
        ability to juvenile-onset depression (M.K., unpublished        depression. This finding also may partly mirror the fact
        manuscript). In the extended model, the Bbiological[           that our patients already had illness durations somewhat
        regulatory domain is redefined as the neurophysiological       longer than 2 years, on average, at study entry. Survival
        underpinning of ER, with an emphasis on relevant brain         analyses of time to recovery from depression generally
        cortical and subcortical circuits. A fourth (Bsomatic-         suggest that the probability of recovery in any given time
        sensory[) regulatory domain has been defined to                interval is typically higher earlier in the illness and
        accommodate ER responses that rely on physical-sensory         becomes less likely as time goes by (e.g., Kovacs et al.,
        modalities to self-regulate dysphoria. The extended model      1994); in other words, at the start, we had a sample with a
        acknowledges more fully the relations of ER responding         low likelihood of recovery. Notably, even our lengthy
        and brain Bemotion circuits[ and that individual differ-       protocol did not accommodate the needs of about 20%
        ences in brain circuitry may contribute to why some            of the youths, whose treatments were somewhat extended
        children find it more difficult than others to down-           during the tapering or maintenance phases. Third, al-
        regulate dysphoria, and why a given ER response may            though comorbid disorders were not targeted by CERT,
        Bwork[ for some children but not for others.                   the somewhat higher rate of recovery from anxiety
           Given that the field of psychotherapy for depressed         disorders by the end of treatment (two of seven)
        children has been generally bereft of developmentally          compared to that from oppositional defiant disorders
        based interventions (Weisz et al., 1992), it is hoped that     (zero of six) is worthy of note. This may possibly suggest
        CERT represents only one of several new initiatives to         that the ER responses and problem-solving approaches
        design treatments for that age group. Results of this          considered in CERT may have some relevance to con-
        open trial provide initial evidence of the feasibility and     ditions that have dysregulated mood, such as persistent
        apparent clinical efficacy of CERT for chronic depres-         anxiety, as a salient feature. This conclusion must be
        sion in childhood. The finding that 75% of the enrolled        viewed with caution owing to the small overall sample
        families completed this lengthy protocol suggests its          size and the number of those with comorbid disorders.
        acceptability. It is notable that the retention rate across       Underscoring the importance of monitoring parental
        our 10-month intervention was comparable to that               psychopathology among clinically referred depressed
        reported for the 12-week, open, pilot trial of Inter-          youngsters (Ferro et al., 2000; Hammen et al., 1999),
        personal Psychotherapy for Adolescents (79%; 11 of             depression was a notable feature of noncompleter
        14 patients; Mufson et al., 1994).                             mothers, in spite of the availability of free treatment for
           Parental involvement is a well-established component        parents (separate from the CERT study). Other char-
        of evidence-based interventions for children with              acteristics of noncompleter mothers (e.g., lower level of
        disruptive behavior disorders (see Chorpita et al., 2005)      education, more likely to be a single parent) echo
        and increasingly so for those with anxiety disorders (e.g.,    findings from various treatment studies (e.g., Curry,
        Ginsburg et al., 2004). In contrast, the involvement of        2005) that socioeconomic resources of families affect
        parents in manual-based treatment trials for depressed         children_s treatment responses. Ways in which CERT
        youths has entailed either adjunctive group sessions (e.g.,    can be modified to accommodate parents with sub-
        Clarke et al., 1999) or systemic family therapy                optimal resources certainly warrants attention.

        J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006                                                             901

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.

    In most research trials, decisions about length of           at least a 4-month treatment period as advisable for
 treatment, which is typically brief, appear to be guided        children with chronic depression.
 by considerations other than clinical need (Kovacs and
 Sherrill, 2001). This presents a challenge when patients        Disclosure: The Children_s Depression Inventory (CDI) is published by
 suffer from a chronic disorder and when an intervention         Multi-Health Systems, Inc., for which Dr. Kovacs receives royalties. The
 seeks to apply a developmentally based paradigm                 other authors have no financial relationships to disclose.
 because both imply the need for time. However, it
 can be argued that the lengthy protocol we piloted is           REFERENCES
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                  Scaling Up Promising Interventions: Feasibility of Screening Adolescents for Suicide Risk in BReal-World[ High School
                  Settings Denise Hallfors, PhD, Paul H. Brodish, MSPH, Shereen Khatapoush, PhD, Victoria Sanchez, DrPH, Hyunsan Cho,
                  PhD, Allan Steckler, PhD

                  Objectives: We evaluated the feasibility of a population-based approach to preventing adolescent suicide. Methods: A total of 1323
                  students in 10 high schools completed the Suicide Risk Screen. Screening results, student follow-up, staff feedback, and school
                  responses were assessed. Results: Overall, 29% of the participants were rated as at risk of suicide. As a result of this overwhelming
                  percentage, school staffs chose to discontinue the screening after 2 semesters. In further analyses, about half of the students
                  identified were deemed at high risk on the basis of high levels of depression, suicidal ideation, or suicidal behavior. Priority
                  rankings evidenced good construct validity on correlates such as drug use, hopelessness, and perceived family support. Conclusions:
                  A simpler, more specific screening instrument than the Suicide Risk Screen would identify approximately 11% of urban high
                  school youths for assessment, offering high school officials an important opportunity to identify young people at the greatest levels
                  of need and to target scarce health resources. Our experiences from this study show that lack of feasibility testing greatly contributes
                  to the gap between science and practice. American Journal of Public Health 2006; 96(2):282Y287.

        J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:8, AUGUST 2006                                                                                                     903

  Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.

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