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Child and Adolescent Depression in the Family

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 Couple and Family Psychology: Research and Practice © 2012 American Psychological Association
2012, Vol. 1, No. 3, 161–184 2160-4096/12/$12.00 DOI: 10.1037/a0029916

Child and Adolescent Depression in the Family

Kevin D. Stark, Kelly N. Banneyer, Leah A. Wang, and Prerna Arora

University of Texas

There are numerous individual, familial, and environmental factors that impact the
onset of depressive disorders in youth. This article presents an overview of these factors
and describes our own research evaluating a possible model of how disturbances in
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

family functioning could lead to the development of depression in youth. Given that
This document is copyrighted by the American Psychological Association or one of its allied publishers.

families are often implicated in the development and maintenance of depressive

disorders in youth, it has been argued that maximally effective treatments for youth
should include families. Thus, a review of empirically evaluated treatments that involve
parental/familial participation for youth with depression is presented. These treatments
vary widely in number of meetings, format, and content. Finally, it is proposed that the
greatest benefit to including a parent or family component is improving the mainte-
nance of treatment effects. To support this hypothesis, data from one of our own
investigations is presented.

Keywords: children, families, depression

Depression is a significant mental health con-
cern among youth. Reports of the 12-month
prevalence rate for depression in childhood
range from 1% to 3% (Costello, Erklani, &
Angold, 2006) to approximately 8.3% during
adolescence (Substance Abuse and Mental
Health Services Administration [SAMHSA],
2009). The National Institute of Mental Health
reported that 11.2% of adolescents (aged 13–17
years) have experienced a depressive disorder at
some point in their lives (Merikangas et al.,
2010). During childhood, depression affects
both genders equally (Goodyer, 2010); how-
ever, during adolescence, there is a sharp in-
crease in the prevalence of depression among
female individuals to nearly a 3:1 ratio com-
pared with their male counterparts (SAMHSA,
2009). Not only does depression have a recur-
rent course, but youth depression is also a
strong predictor of depression in adulthood and
of long-term functional disability (Weissman et
al., 1999). Youth that suffer from depressive
Kevin D. Stark, Kelly N. Banneyer, Leah A. Wang, and
Prerna Arora, Department of Educational Psychology, Uni-
versity of Texas.
Correspondence concerning this article should be ad-
dressed to Kevin D. Stark, University of Texas, Department
of Educational Psychology, Sanchez Building, Room 254,
Mail Code D5800, Austin, TX 78712. E-mail:
Kevinstark@mail.utexas.edu
161
disorders present with a negative change in
mood state and are at an increased risk for
academic underachievement, substance abuse,
and somatic symptoms (Waslick, Kandel, &
Kakouros, 2002). Most concerning is the fact
that depressed youth are at an increased risk for
suicide (Gould, King, & Greenwald, 1998).
Given the severity and life-threatening nature
of depressive disorders, it is important to de-
velop maximally effective treatments. To im-
prove the effectiveness of psychosocial inter-
ventions, some clinicians and researchers have
begun to integrate parents into treatments for
depressed youth. These treatments vary widely
in content from psychoeducation to parent train-
ing (PT), family therapy, or some combination
of these interventions. They also vary widely in
the number of meetings attended by family
members as well as the format of treatment.
Inclusion of the family in the treatment of
depressed youth is, in part, predicated on re-
search that indicates that disturbances in the
family, or the family’s way of managing
changes and stressful events, may contribute to
the development and maintenance of depressive
disorders. Thus, research that evaluates differ-
ent familial factors that contribute to the devel-
opment of depression during childhood is dis-
cussed. Subsequently, we review treatment
outcome literature for youth that has included a
parent or family intervention component. Fi-
 162 STARK, BANNEYER, WANG, AND ARORA
nally, we describe our own relevant research
and propose that the greatest benefit to includ-
ing a family or parent component is improving
the maintenance of treatment effects.
Individual and Familial Factors That
Influence the Course of Depression in
Youth
Child Factors
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
From a systems perspective, reciprocal rela-
tionships exist between the child, his or her
parents, family, and other contextual variables
to impact the etiology, evolution, and resolution
of problems such as depressive disorders. Sev-
eral reviews have examined individual child
factors that influence onset of depression, in-
cluding genetic predisposition, child tempera-
ment, and negative cognitive style (Alloy et al.,
2001; Garber & Robinson, 1997; Goodman &
Gotlib, 1999). Genetic predisposition to mood
disorders interacts with a negative or stressful
family environment to produce depressive dis-
orders (Eley et al., 2004). Negative child tem-
perament can also interact with family distur-
bances or a mismatch with parent temperament
to create an increased risk for depression (Muf-
son, Nomura, & Warner, 2002). Children with
negative temperaments are more sensitive to
criticism from significant others and interper-
sonal conflict (Belsky, 2005). Negative cogni-
tions are also related to depression in that youth
with negative cognitive styles interpret family
interactions more negatively, which can in turn
lead to negative interactions, and the combina-
tion leads to depression (Alloy, Abramson,
Smith, Gibb, & Neeren, 2006).
Parent Factors
A substantial body of research has demon-
strated an increased prevalence of major depres-
sive disorder (MDD) in the offspring of de-
pressed parents (Hughes & Asarnow, 2011;
Weissman, Warner, Wickramaratne, Moreau, &
Olfson, 1997), with a direct effect of parental
depression on offspring depression (Nomura,
Wickramaratne, Warner, & Weissman, 2002).
The relationship between parental and child de-
pression is bidirectional (Hughes & Asarnow,
2011): children’s depressive symptoms improve
when depressed mothers improve from treat-
ment (Weissman et al., 2006), and mothers’
depressive symptoms improve when their de-
pressed children respond to treatment (Kennard
et al., 2008).
Family psychiatric history and genetics partly
explain the link between parental and offspring
depression, but there is also a significant envi-
ronmental component. Specific behaviors and
parenting styles have been linked to the devel-
opment and maintenance of depression in youth
(Alloy et al., 2006). These behaviors can be
exacerbated when parents have depression. Re-
jection, hostility, withdrawal, and overcontrol
have been observed in depressed parents (Love-
joy, Graczyk, O’Hare, & Neuman, 2000). De-
pressed parents are more self-absorbed and less
attentive to the needs of their children, have
difficulty communicating and maintaining dis-
ciplinary consistency, and are often more criti-
cal and negative (see Kaslow, Deering &
Racusin, 1994 for a review of this research). In
fact, children of depressed mothers report neg-
ative self-concepts that may be attributable to
their internalization of maternal criticism
(Jaenicke et al., 1987). Furthermore, depressed
parents have a tendency to withdraw or disen-
gage, which reinforces depressed children’s low
self-esteem (Inoff-Germain, Nottelmann, &
Radke-Yarrow, 1992). Thus, a vicious cycle
may exist in which depressed parents are overly
critical of their children. The criticism is inter-
nalized into the child’s self-concept, and this
negative self-concept is further reinforced by
continued criticism and parental withdrawal of
affection.
Impaired social and interpersonal skills
and/or specific symptoms of depression may
inhibit depressed parents’ abilities to appropri-
ately engage with, and meet needs of, their
children (Restifo & Bögels, 2009). Such prob-
lematic parenting may partially explain the re-
lationship between parental depression and psy-
chopathology in children (Bifulco et al., 2002).
In addition, parents who are depressed and
model poor ineffective coping skills or negative
cognitive styles are more likely to have children
who also struggle with ineffective coping and
negative thinking (Garber & Flynn, 2001).
Poor parent– child attachment due to depres-
sion in a parent, an attractor pattern, a temper-
amental mismatch, or another reciprocally re-
lated variable can have a strong negative impact
on the onset and maintenance of depression in
 CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY
youth (Sexson, Glanville, & Kaslow, 2001).
Not only does poor parent– child attachment
increase the risk for depression, but poor attach-
ment between mothers and children also is as-
sociated with higher rates of suicidal ideation
(Essau, 2004).
Absence of a parent has been linked to higher
levels of depression in youth (Garber & Flynn,
2001). Instability in the family structure and
family disruption after the concrete or ambigu-
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ous loss of a parent due to death (Weller,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Weller, Fristad, & Bowes, 1991), incarceration
(Bocknek, Sanderson & Britner, 2009), military
deployment (Huebner, Mancini, Wilcox, Grass
& Grass, 2007), divorce (Hoyt et al., 1990), and
child maltreatment [e.g., physical or sexual
abuse, neglect (Toth, Manly, & Cicchetti,
1992)] can also lead to depression in youth. The
loss of a parent combined with traumatic cir-
cumstances surrounding that loss increases the
likelihood of poor psychosocial functioning in
children (Dowdney, 2000). This can be espe-
cially true when children experience an ongoing
uncertainty about the status and safety of the
absent parent, such as if the absent parent is
incarcerated or deployed (Bocknek et al., 2009;
Huebner et al., 2007). These children are more
likely to internalize stress and develop depres-
sion because of lack of clear social support for
grief (Boss, 2007).
Family Factors
A number of family factors can become prob-
lematic, depending on the degree to which they
are present within the family, including com-
munication, support, conflict, cohesion, and en-
gagement in social or recreational activities.
Families of depressed children are characterized
by lower frequencies (Stark, Humphrey, Crook,
& Lewis, 1990) and more negative patterns of
communication (Sheeber, Hops, & Davis,
2001), although it is not clear where the disrup-
tion in communication occurs. Also, lower lev-
els of support within the family are associated
with an increased risk for depression (Stice,
Ragan, & Randall, 2004). Families of depressed
youth also are characterized by lower levels of
cohesion and less involvement in social and
recreational activities (Stark et al., 1990).
Family conflict has repeatedly been linked to
depression in youth (Formoso, Gonzales & Ai-
ken, 2000; Kane & Garber, 2004). In younger
163
adolescents, there is a relationship between con-
flict about autonomy and depressive symptoms
(Allen et al., 2006). This conflict may be part of
the normal individuation process or it may be
due to parental overcontrol and overprotective-
ness that have been associated with depression
(Parker, 1993). Conflict between fathers and
children is linked to more persistent child de-
pressive symptoms (Sanford et al., 1995). Mar-
ital conflict is also related to increased severity
of depression (Cummings, Keller, & Davies,
2005) and has been suggested to have the great-
est negative impact on children and adolescents
(Cummings, 1994; Hudson, 2005).
Cognitive-Interpersonal Pathway to the
Development of Depressive Disorders
There are often stressors or disturbances in
the family systems of depressed youth. How-
ever, the mechanism through which these stres-
sors or disturbances contribute to the develop-
ment of a depressive disorder is still unclear.
We will briefly describe a potential model for
the development of depressive disorders that
takes family variables into account. In a later
section, results of an investigation designed to
provide an initial evaluation of this model are
reported.
We propose that one of the pathways that
lead to development of depression is the cogni-
tive-interpersonal pathway derived from the
cognitive model of depressive disorders (e.g.,
Beck, Rush, Shaw, & Emery, 1979). Within this
model, children are believed to be active infor-
mation processors who construct their percep-
tions and derive meaning from their interactions
with the world. The child’s beliefs, especially
core beliefs (those that form first, and are most
central), guide the information processing sys-
tem. The strongest core beliefs are those about
the self, the interpersonal world, and the future.
Core beliefs have the largest web of intercon-
nections with other beliefs and the greatest im-
pact on attention, memory, and meaning mak-
ing. Children’s belief systems are constantly
developing and being shaped by learning expe-
riences and other environmental events.
Critical core beliefs are formed within the
context of the family. The cognitive–interper-
sonal model posits that the information process-
ing system, through its ability to construct
meaning from experiences, derives a message
 164 STARK, BANNEYER, WANG, AND ARORA
from direct statements made by caregivers, af-
fectively laden interactions with family mem-
bers, and life experiences in general. Beliefs are
also communicated through conversations with
parents, expectations/family rules, and through
patterns of reinforcement and punishment
within the family. They are also communicated
to the child through consistent parental behav-
ior. These family messages are instrumental in
the formation, elaboration, and development of
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beliefs. If a message is perceived and processed
This document is copyrighted by the American Psychological Association or one of its allied publishers.
enough times, it becomes internalized as a be-
lief. In addition to guiding the cognitive system,
beliefs guide behavior and activate affective
structures. The child’s behaviors and affect in-
teract with one another, the belief system, and
the environment. Thus, the family environment
impacts the child through its influence on the
developing belief system, and the belief system
impacts the family through the child’s behavior
and affect.
Core beliefs, once they have become struc-
turalized, guide the construction of new beliefs;
the meaning that is constructed from new expe-
riences is biased to fit with existing beliefs,
whereas information that is inconsistent with an
existing belief is ignored, discounted, or dis-
torted to fit the core belief. Children seek out,
attend to, and construct meanings from events
that are consistent with existing beliefs. When
information processing is rigidly distorted in a
maladaptive way, a psychological disorder, be-
havior problem, or adjustment difficulty is
likely to develop. When a child’s belief system
centers around the belief that I am unlovable,
worthless, or helpless, and the family system
supports one or more of these beliefs, a depres-
sive disorder is likely to develop.
Summary
The aforementioned research highlights a va-
riety of familial and environmental factors (e.g.,
depressed parent, absence of a parent, distur-
bances in the family) that are associated with
the development of depression in youth. In the
case of a depressed parent, there may be a direct
path from parental depression to child depres-
sion, possibly owing to a genetic predisposition
in the child interacting with the disturbances in
the family environment that stem from the par-
ent’s depression. Families of depressed youth
are described as being less communicative,
lower in support and cohesion, and to be char-
acterized by greater levels of conflict. These
disturbances may interact with child factors
such as a negative temperament or a depresso-
genic cognitive style to produce a depressive
episode. The cognitive-interpersonal pathway
was proposed as a possible contributor to the
development of depressive disorders. Given the
importance of families in the development of
depression in children, we now turn to a review
of treatments that have included a parent or
family component in the treatment of depressed
youth.
Depression Treatments for Youth
Child-Focused Treatments
Psychosocial treatments for depressed youth
have been studied extensively since 1980
(Kaslow, Baskin, & Wyckoff, 2002). Treatment
typically includes pharmacotherapy, psychoso-
cial interventions, or a combination of both.
Antidepressant medication, especially selective
serotonin reuptake inhibitors, have proven ef-
fectiveness, but can also be controversial, given
their potential risks. Hammad, Laugren, and
Racoosin (2006) conducted a meta-analysis of
randomized placebo-controlled studies and
found the use of antidepressant medication in
pediatric populations to be associated with a
modestly increased risk of suicidality. How-
ever, another meta-analysis showed that antide-
pressant medications are efficacious, and their
benefits appear to be much greater than risks
from suicidal ideation/suicide attempt (Bridge
et al., 2007).
Among psychosocial interventions for de-
pressed youth, cognitive– behavioral therapy
(CBT) and interpersonal therapy for adolescents
(IPT-A), presented either in a group or individ-
ual format, have emerged as the most effica-
cious treatment (Lewinsohn, Clarke, Hops &
Andrews, 1990; Clarke, Rohde, Lewinsohn,
Hops, & Seeley, 1999; Rosselló & Bernal,
1999). CBT is based on the cognitive model and
the idea that depressed individuals have nega-
tively biased cognitive processing that stems
from dysfunctional beliefs about the self, the
world, and the future. CBT combines the cog-
nitive theoretical framework with behavioral
modules; it aims to alleviate negative affect
through both cognitive restructuring and behav-
 CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY
ioral activation and to reduce stress through
problem-solving and coping skills (Beck,
2005). IPT-A is based on the idea that depres-
sion occurs in an interpersonal context; it seeks
to decrease depressive symptoms by improving
communication and other interpersonal skills
(Mufson, Gallagher, Dorta & Young, 2004a).
The techniques most commonly used in IPT-A
include psychoeducation, encouragement of af-
fect expression, communication analysis, role-
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playing, and interpersonal problem solving
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(2004a). Successful treatment protocols of both
CBT and IPT-A focus on addressing acute
symptoms of depression, as well as addressing
and ensuring the maintenance of treatment ef-
fects, owing to the high levels of reoccurrence.
Although CBT and IPT-A are effective in
reducing depression as compared with wait-list
control (WLC) condition and other treatment as
usual (TAU), it is important to note that im-
provement is usually seen in 50%– 60% of cases
under controlled research conditions (Gladstone
& Beardslee, 2009). A meta-analysis conducted
by Weisz, McCarty, and Valeri (2006) reported
a modest overall effect size (.34) for current
psychotherapy treatments for youth depression.
It is notable that this effect size is considerably
lower than those found for treatments of other
child and adolescent disorders. There is clearly
room for improving the efficacy and quality of
impact of psychosocial treatments for depressed
youth.
Parent Involvement in Treatments for
Depressed Youth
Parra et al. (2011) presented several reasons for
including family components in treatments for
youth depression. They believe that it is necessary
to involve the family in treatment because family
influences “are among the strongest and most con-
sistent risk factors” for youth depression (2011, p.
382). Additionally, family factors such as parental
psychopathology, marital conflict, and negative
parent– child relationships negatively affect youth
treatments, causing poor attendance, early termi-
nation, and insufficient adherence to treatment
recommendations (Parra et al., 2011).
Owing to these observed relationships, re-
searchers have recently argued that integrating
the family into treatments for depressed youth is
the best clinical practice (Larner, 2009). Even
the current Practice Parameters from the Amer-
165
ican Academy of Child and Adolescent Psychi-
atry for childhood depression emphasize the
importance of including the family in each
phase of treatment (Birmaher & Brent, 2007).
However, a review by Sander and McCarty
(2005) reported that of all current youth treat-
ments for depression, 68% focus solely on the
youth, 18% consider parents as partners, and
11% view parents as agents of change. Another
review by David-Ferdon and Kaslow (2008)
found that 7 of 10 studies examining interven-
tions for depression in children over the previ-
ous 10 years included a parent component, but
none seemed to incorporate standard family
therapy with all family members present.
Among studies targeting adolescent depression,
they found only 10 of the 18 outcome studies
included a parent/family intervention compo-
nent. In conclusion, some treatments that in-
clude parental components have been evaluated,
but the literature is not consistent, and the effi-
cacy of this practice has not been substantiated.
Depression Treatments for Youth That
Include a Parental/Familial Component
We review 25 treatment studies for depressed
youth that include a parent or family component
(Refer to Table 1). Currently, depression treat-
ments incorporate parental and familial partici-
pation in a variety of ways, with parents serving
different roles and with varying session formats
(Diamond & Josephson, 2005). The studies re-
viewed are divided first by focus. The first sec-
tion discusses those that focused on the whole
family. The remaining sections report studies
that focused on therapy for the individual child,
but still involved parents in some way. This
group is divided further into studies that in-
cluded family therapy sessions, individual ther-
apy for parents, parent psychoeducation, sup-
port, or therapy groups, groups of multiple
families that share the experience of having a
depressed child, or some combination.
Family Focused Therapies
First, eight treatment studies are reviewed
that are “family focused.” These treatment pro-
tocols all used a different kind of therapy, but
shared the fact that parents were included in
every session their child attended. The only
exception is the study by Tompson et al. (2007),
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Table 1 166
Treatment Studies Involving a Parent Component for Youth With Depression
Length of youth Length of parent Youth age Main results at
Study Treatment conditions treatment Parent component component range N posttreatmenta
Lewinsohn et al., 1990 1. Group CBT 7 weeks YF ⫺ PG 7 weeks 14–18 59 1⫽2
2. Group CBT ⫹ Parent 14 sessions (2 hours 7 sessions (2 hours 1, 2 ⬎ 3
3. WLC each) each)
Brent et al., 1997 1. Individual CBT 12–16 weeks 1. YF ⫺ FI 1 and 3. Up to one x̄ ⫽ 15.5b 35 Diagnosis: 1 ⬎ 3
2. SBFT 12–16 sessions 2. FF hour over first 3 Remission: 1 ⬎ 2, 3
3. Individual nondirective Plus 2–4 booster 3. YF ⫺ FI sessions
supportive therapy sessions 2. All sessions
Clarke et al., 1999 1. Group CBT 8 weeks YF ⫺ PG ⫹ FG 8 PG sessions (2 14–18 123 1⫽2
2. Group CBT ⫹ Parent 16 sessions (2 hours hours each) 1, 2 ⬎ 3
3. WLC each) 2 FG sessions (2
hours each)
Asarnow et al., 2002c 1. Group CBT 5 weeks YF ⫺ FG 1 session (90 minutes Grade 4–6 23 1 ⬎ 2d
2. WLC 10 sessions each)
Clarke et al., 2002 1. Group CBT ⫹ Parent ⫹ 8 weeks YF ⫺ PG 3 sessions 13–18 88 1⫽2
HMO care 16 sessions (2 hours
2. HMO care only each)
Diamond et al., 2002 1. ABFT 12 weeks FF All sessions 13–17 32 1⬎2
2. WLC 12 sessions (60–90
minutes each)
Muratori et al., 2003 1. PP 11 weeks YF ⫺ FI 6 sessions 6–10 58 1⫽2
2. TAU 11 sessions
Nelson et al., 2003 1. CBT, face to face 8 weeks YF ⫺ PI All sessions 8–14 28 1⫽2
2. CBT, videoconference 8 sessions (60–90 Rate of decline: 2 ⬎ 1
minutes each)
STARK, BANNEYER, WANG, AND ARORA

De Cuyper et al., 2004c 1. Group CBT ⫹ Parent 16 weeks YF ⫺ PI 1 session 9–11 20 1⫽2
2. WLC 16 sessions (60 minutes
each)
Mufson et al., 2004a 1. Group IPT-A ⫹ Parent 12 sessions (90 minutes YF ⫺ FI 4 sessions 13–17 6 Decreased DSM-IV
each) symptoms
Increased CGAS score
Mufson et al., 2004b 1. IPT-A ⫹ Parent 12–16 weeks YF ⫺ FI 1–3 sessions Grade 9–12 63 HAM-D: 1 ⬎ 2
2. TAU 12 sessions (35 minutes
each)
TADS Team, 2004 1. Fluoxetine 12–16 weeks YF ⫺ PI ⫹ FI 2 PI sessions 12–17 439 3⬎1⬎2⬎4
2. CBT 2 and 3. 15 sessions 1–3 FI sessions
3. Fluoxetine ⫹ CBT (50–60 minutes each)
4. Placebo
(table continues)
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Table 1 (continued)
Length of youth Length of parent Youth age Main results at
Study Treatment conditions treatment Parent component component range N posttreatmenta
Clarke et al., 2005e 1. TAU ⫹ SSRI ⱕ9 CBT sessions YF ⫺ PG Monthly PG sessions 12–18 152 1⫽2
2. TAU ⫹ SSRI ⫹ CBT Phone call booster
sessions
Kovacs et al., 2006 1. CERT 10 months FF All sessions 7–12 15 Full remission: 53%
30 sessions Partial remission: 27%
Melvin et al., 2006 1. CBT 3 months YF ⫺ PI ⫹ FI 12 PI sessions 12–18 73 1⫽2⫽3
2. Medication 14 sessions (50-minutes 2 FI sessions
3. CBT ⫹ Medication each) 3 PI booster sessions
3 monthly booster
sessions
Sanford et al., 2006 1. TAU ⫹ FPE 6 months FF All sessions 13–18 41 1ⱖ2
2. TAU 12 sessions
1 booster session
Goodyer et al., 2007f 1. SSRI ⫹ TAU 1 and 2. 28 weeks 1 and 2. YF ⫺ FI 1. ⱕ3 sessions 11–17 208 1⫽2
2. SSRI ⫹ TAU ⫹ CBT 9 TAU sessions 2. All CBT sessions
2. 19 CBT sessions
Tompson et al., 2007 1. FFI ⫹ CBT 3–5 months FF 10–14 FF sessions 9–14 9 Remission: 67%
12–16 sessions (60 YF ⫺ PI 1 PI session
minutes each)
Brent et al., 2008 1. New SSRI 12 weeks 1 to 4. YF ⫺ FI 1–4. 3 FPE FI 12–18 233 2⫽4⬎1⫽3
2. New SSRI ⫹ CBT 2 and 4.12 sessions sessions
3. Venlafaxine 2 and 4. 3–6 CBT FI
4. Venlafaxine ⫹ CBT sessions
Dietz et al., 2008 1. Family-based IPT Weekly sessions 1 and 2. YF ⫺ All sessions with FI 9–12 16 1⫽2
2. Family-based IPT ⫹ Open-ended FI ⫹ PI Phase 1 with PI
Medication x̄ ⫽ 14
Kennard et al., 2008c 1. Medication management MM: 6 months YF ⫺ FI 2 partial sessions 11–18 46 Relapse: 1 ⬎ 2
CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY

(MM) 2. 3 months ⱕ3 whole sessions Time to relapse: 2 ⬎

2. MM ⫹ CBT 8–11 sessions 1
ⱕ3 booster sessions
Fristad et al., 2009f 1. MF-PEP ⫹ TAU 6 months PG ⫹ FG All sessions 8–11 165 Mood Severity Index:
2. WLC ⫹ TAU 8 sessions 1⬎2
Diamond et al., 2010c,g 1. ABFT 12 weeks 1. FF All sessions 12–17 66 1⬎2
2. EUC
(table continues)
167
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168

Table 1 (continued)
Length of youth Length of parent Youth age Main results at
Study Treatment conditions treatment Parent component component range N posttreatmenta
Garoff et al., 2012 1. FIPP 1. 30 weeks 1. YF ⫺ PI 1. 30 weeks 8–15 72 Mean CDI: 2 ⬎ 1
2. SIFT ⱕ30 sessions 2. FF ⫹ PI 15 PI sessions
2. ⱕ10 sessions 2. 4 PI sessions
9 FI sessions
Luby et al., 2012 1. PCIT-ED 12 weeks 1. FF 1 and 2. All sessions 3–7 29 1⫽2
2. DEPIh 14 sessions 2. PG
Note. Interventions identified as either family focused (FF) or youth focused (YF) with additional meetings between individual families and therapists (FI), families meeting in
groups (FG), parents meeting with a therapist individually (PI) or parents meeting in groups (PG). CBT ⫽ cognitive behavioral therapy; WLC ⫽ waitlist control; SBFT ⫽ systemic
behavior family therapy; HMO ⫽ health maintenance organization; ABFT ⫽ attachment-based family therapy; PP ⫽ psychodynamic psychotherapy; TAU ⫽ treatment as usual;
IPT ⫽ interpersonal psychotherapy; DSM-IV ⫽ Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994); CGAS ⫽
Children’s Global Assessment Scale (Shaffer et al., 1983); HAM-D ⫽ Hamilton Depression Rating Scale (Williams, 1988); TADS ⫽ The Treatment for Adolescents with Depression
Study; SSRI ⫽ selective serotonin reuptake inhibitor; CERT ⫽ contextual emotion-regulation therapy; DD ⫽ dysthymic disorder; MDD ⫽ major depressive disorder; FPE ⫽ family
psychoeducation; FFI ⫽ family-focused intervention; MF-PEP ⫽ multifamily psychoeducational psychotherapy; MSI ⫽ Mood Severity Index (see Fristad et al., 2003); EUC ⫽
enhanced usual care; FIPP ⫽ focused individual psychodynamic psychotherapy; SIFT ⫽ systems integrative family therapy; PCIT-ED ⫽ parent-child interaction therapy - emotion
development; DEPI ⫽ developmental education and parenting intervention.
STARK, BANNEYER, WANG, AND ARORA

a
Main result comparisons based on rates of diagnosis at posttreatment unless otherwise specified. b Range not available. c Inclusion criteria for study included elevated depression
symptoms and not a depression diagnosis. d After removal of outlier. e Study did not include specific data on the parent information sessions. f Parental participation for part
of child session. g Suicidal sample. h DEPI condition did not include youth participation.
 CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY
which began treatment with an individual ther-
apy session for both the child and parents sep-
arately, before bringing them together for all
remaining sessions. The treatments all targeted
youth depression, but importantly, many also
were designed to improve family functioning
and communication patterns and increase cop-
ing skills.
Attachment-based family therapy.
Attachment-based family therapy (ABFT; Dia-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
mond & Siqueland, 1995; Diamond, Reis, Dia-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
mond, Siqueland, & Isaacs, 2002) combines
aspects from attachment theory (Bowlby, 1969;
Kobak & Sceery, 1988) with structural family
(Minuchin, 1974), multidimensional family
(Liddle, 1999), contextual (Boszormeny-Nagy
& Sparks, 1984), and emotion-focused (Green-
berg & Johnson, 1988) therapies. The goals of
ABFT are to repair poor parent– child attach-
ment and promote autonomy, thus improving
negative family environments. Another purpose
is to help youth learn effective coping skills
through a newly enhanced attachment relation-
ship with their parent(s). ABFT includes five
treatment tasks to be achieved over 12 weeks:
the Relational Reframe Task, the Adolescent
Alliance-Building Task, the Parent Alliance
Building Task, the Attachment Task, and the
Competence-Promoting Task [see Diamond et
al. (2002) for a more thorough description].
Diamond et al. (2002) compared the 12-week
ABFT treatment to a 6-week WLC condition in
a sample of 32 adolescents (aged 13–17 years)
with an initial diagnosis of MDD. Participants
in the ABFT condition (n ⫽ 16) showed a
significant decrease in the presence of a diag-
nosis of MDD, with 81% no longer meeting
diagnosis criteria at posttreatment, compared
with the WLC group, which had 47% no longer
meeting diagnostic criteria. Participants in the
ABFT condition showed a significant de-
crease in depression and state anxiety symp-
toms as well as level of family conflict com-
pared with youth in the control condition. In a
different study, Diamond et al. (2010) com-
pared an ABFT treatment with an enhanced
usual care condition for 66 adolescents with
suicidal ideation. They found that youth in the
ABFT condition showed significantly less
suicidal ideation and depressive symptoms at
posttreatment compared with the enhanced
usual care condition.
169
Family-focused intervention. Family-
focused intervention (FFI; Tompson et al.,
2007) combines family systems and cognitive–
behavioral models to target preadolescent youth
with depression and their families. Common
family components of CBT for depression in-
clude psychoeducation, behavioral activation,
expressed emotion, problem -solving, commu-
nication, and contingency management (Hughes
& Asarnow, 2011). The treatment protocol used
by Tompson et al. (2007) incorporated many of
these strategies and emphasized behavioral ac-
tivation, which is preferred by school-age chil-
dren (Asarnow, Scott, & Mintz, 2002). Along
with CBT methods, the FFI treatment used in-
terpersonal techniques aimed at helping fami-
lies change their interactional patterns.
In an initial trial, Tompson et al. (2007) con-
ducted FFI with the families of nine youth (aged
9 –14 years). Families were taught concepts
slowly over 12–16 sessions in a 3- to 5-month
period. Educational material was first presented
using handouts. Next, families practiced imple-
menting the concepts in general scenarios be-
fore role-playing the application of their new
skills to their own family interactions. Finally,
they were given homework to complete to-
gether. Throughout treatment, children and their
parents worked to improve communication,
practice new ways of relating to one another,
and problem-solve specific family issues to re-
duce stress and increase family support and
coping. The results were promising; six of the
nine children no longer met diagnostic criteria
for depressive disorders after the acute treat-
ment phase, and by 9 months after treatment,
seven of the nine had recovered.
Contextual emotion-regulation therapy.
Contextual emotion-regulation therapy (CERT;
Kovacs et al., 2006) is an individually adaptive
program that focuses on the child’s ability to
functionally self-regulate dysphoria and distress
to facilitate the ability to cope with these neg-
ative emotions that can lead to depression. The
goals of CERT for the child are symptom re-
duction and coping skill enhancement through
an emphasis on adaptive emotion regulatory
responses. In therapy, the child learns emotion
regulation skills in biological, behavioral, cog-
nitive, and social/interpersonal domains to
downregulate feelings of dysphoria. At least
one parent is an active participant in all treat-
ment sessions and is instructed to serve as an
 170 STARK, BANNEYER, WANG, AND ARORA
“assistant coach” to the therapist. Parents are
given a parent manual that includes the different
“rules of coaching.” For the symptom reduction
portion of CERT, the therapist chooses different
techniques from the following domains: fo-
cused, problem solving-oriented, behavioral, in-
terpersonal, and/or cognitive. In the coping
skills training portion, the therapist uses didac-
tic aids to help the child further develop emo-
tion regulation skills.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
CERT was piloted with 20 youth (aged 7–12
This document is copyrighted by the American Psychological Association or one of its allied publishers.
years) with a diagnosis of dysthymic disorder
(DD). The trial consisted of 30 sessions over 10
months, in the four distinct phases discussed
earlier in the text. Fifteen youth completed the
trial; 53% of these children reached full remis-
sion of DD, and an additional 13% reached
partial remission. Also, self-reported anxious
and depressive symptoms significantly de-
creased from pre- to posttreatment.
Parent– child interaction therapy.
Parent– child interaction therapy (PCIT; Brink-
meyer & Eyberg, 2003) is a dyadic treatment
that uses an in vivo teach and coach approach to
enhance positive relationship development and
firm and nurturing parenting of young children.
It is developmentally appropriate for young
children and has been proven effective in other
preschool-onset disorders (Thomas & Zimmer-
Gembeck, 2007). Through PCIT, parents are
coached and encouraged to be the “arm of the
therapist.” PCIT involves both the parent and
child together in the sessions, and is usually
divided into two modules: child-directed inter-
action (CDI), and parent-directed interaction
(PDI). During CDI, families learn positive play
techniques and work on self-efficacy through
giving effective commands. In the PDI portion
of therapy, parents learn how to set limits ef-
fectively and handle noncompliance and disrup-
tive behavior in a firm but nonpunitive manner.
Luby, Lenze, and Tillman (2012) adapted
PCIT for preschool-onset MDD and examined
its effectiveness as compared with parental psy-
choeducation in a pilot study of 54 children with
preschool-onset MDD (aged 3–7 years). They
called their intervention PCIT-ED to highlight a
third module, emotion development, that was
included in their PCIT treatment. A total of 19
patients assigned to the PCIT-ED condition
completed a 14-session treatment protocol over
12 weeks. The CDI and PDI modules were
limited to four sessions each. The remaining
sessions focused on the direct teaching of emo-
tional competence, including emotion recogni-
tion and emotion regulation strategies. The goal
of these sessions was to have the parent learn to
be a more effective emotion guide and regulator
for their child. Results of the study showed that
according to parent symptom reports, children
in both the PCIT group and the psychoeduca-
tion group showed significant decreases in de-
pression severity. According to parent inter-
views (Preschool Age Psychiatric Assessment;
PAPA; Egger, Ascher, & Angold, 1999), there
was a significant decrease in depression severity
for only the PCIT group. However, no differ-
ences in posttreatment PAPA MDD severity
sum scores between groups were found. The
authors acknowledge that this was a preliminary
study and not sufficiently powered to detect
differences between treatment groups.
Systems-integrated family therapy.
Systems integrated family therapy (SIFT; Byng-
Hall, Campbell, & Papadopoulos, 1996) is a
manualized therapy that focuses on changing fam-
ily interaction patterns and was developed follow-
ing the systemic perspective of family therapy.
Every third session was a parent-only session fo-
cusing on coparenting, and all other sessions were
family sessions. Time-limited SIFT was exam-
ined in a recent study of 72 participants, with 34
in the SIFT condition (Garoff, Heinonen, Pe-
sonen, & Almqvist, 2012). The researchers
found that SIFT was just as effective as the
focused individual psychodynamic psychother-
apy (PP) condition, which is based on psy-
chodynamic therapy and included separate par-
ent meeting session with the therapist to work
on the parents’ own issues. Although the fami-
ly-focused condition did not prove to be supe-
rior overall, the researchers stated that SIFT
may be more effective in a sample of younger
children.
Systemic behavior family therapy.
Systemic behavior family therapy (SBFT; Brent
et al., 1996) involves a combination of func-
tional family therapy (Alexander & Parsons,
1982) and Robin and Foster’s (1989) problem-
solving model. The first phase of SBFT draws
on functional family therapy and focuses on
clarifying treatment concerns, optimizing treat-
ment engagement, and identifying dysfunc-
tional behaviors. The second phase of SBFT
draws on the problem-solving model. It focuses
on communication, problem-solving skills, cog-
 CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY
nitive restructuring of family members’ exag-
gerated beliefs, and family interaction improve-
ment. Results of an investigation evaluating the
efficacy of SBFT relative to child-focused CBT
are reported later.
Family psychoeducation. Family psy-
choeducation (FPE) is a form of adjunctive
maintenance treatment that, in the case of ado-
lescent depression, aims to increase knowledge
about and understanding of depressive disorders
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and their impact on the family. FPE also seeks
This document is copyrighted by the American Psychological Association or one of its allied publishers.
to strengthen family communication, increase
supportive interactions, improve coping and
problem-solving skills, and cultivate better
management of crises and relapses.
Sanford et al. (2006) conducted an explor-
atory study of the acute treatment effects of 12
sessions of FPE over 6 months in a sample of 31
adolescents (16 in the FPE group). The 12 ses-
sions were divided into five phases. Phase 1
involved treatment orientation, assessment of
family factors, and goal setting. During the next
three sessions, the therapist worked to educate
the family about adolescent depression, with the
goal of fostering greater empathy and under-
standing for the depressed adolescent. Phase 3
focused on promoting positive communication
and interactions between the parents and the
depressed adolescent. Sessions 8 to 11 com-
prised Phase 4, and concentrated on family
problem solving. The last phase involved a re-
view of newly acquired skills and a pragmatic
family discussion about potential barriers to
continued improvement. Results showed that
there were trends to significance of FPE plus
TAU exceeding TAU in this clinical population.
In addition, positive treatment effects on family
and social functioning were observed in the FPE
group, suggesting the utility of continued eval-
uation of FPE as a supplementary treatment.
Youth-Focused Therapies With Individual
Family Sessions
Ten studies are reviewed that included individ-
ual family sessions with the child and parents and
sometimes other family members. Most of these
studies include a maximum of three to six family
sessions in addition to youth-only sessions (Mu-
ratori, Picchi, Bruni, Patarnello, & Romagnoli,
2003; Mufson et al., 2004b; Treatment for Ado-
lescents with Depression Study (TADS) Team,
2004; Brent et al., 2008; Kennard et al., 2008). A
171
study by Brent et al. (1997) required the least
amount of family involvement (up to 1 hour of
psychoeducation over the first three sessions),
whereas Goodyer et al. (2007) and Dietz, Mufson,
Irvine, and Brent (2008) included parents in at
least part of every youth session.
Of these 10 studies, six involved a youth
component that was CBT focused (Brent et al.,
1997; TADS Team, 2004; Goodyer et al., 2007;
Brent et al., 2008; Kennard et al., 2008; Melvin
et al., 2006). The family part of the study by
Brent et al. (1997) only included a psychoedu-
cation component; the TADS Team (2004) in-
corporated psychoeducation, family problem
solving, family issues and conflict, and manag-
ing negative affect in the family sessions. In the
treatment used by Brent et al. (2008), the family
component involved psychoeducation, improv-
ing family problem solving and communication,
decreasing criticism, and increasing support.
The remaining studies did not specify the ma-
terial that was covered in the family sessions
(Goodyer et al., 2007; Kennard et al., 2008;
Melvin et al., 2006).
The other four studies involved youth treat-
ments focused on IPT-A (Mufson et al., 2004a,
2004b; Dietz et al., 2008) and PP (Muratori et
al., 2003). The family components in the IPT-A
studies involved either two intensive family ses-
sions that covered gathering background infor-
mation about the youth’s depressive symptoms
and significant relationships (Mufson et al.,
2004a) or one to three family sessions that cov-
ered unspecified content (Mufson et al., 2004b).
The IPT-A study focusing on preadolescents
included parents and children together in part of
every session to establish goals, practice com-
munication, and discuss the integration and ef-
fect of these skills at home (Dietz et al., 2008).
In contrast, the family component in the PP
treatment put forth by Muratori et al. (2003)
aimed to “clarify the present parent– child inter-
actions in relation to the parents’ past, to modify
parents’ misconceptions, and to improve empa-
thy with the child” (p. 333) over five sessions.
Youth-Focused Therapies With Individual
Parent Sessions
Seven studies (including four previously
mentioned) had an individual parent compo-
nent. Authors may have chosen to include par-
ents separate from their children because inter-
 172 STARK, BANNEYER, WANG, AND ARORA
ventions that address parents’ cognitive styles,
enhance their coping skills, improve their par-
enting skills, or reduce depression in parents
could have substantial effects in preventing de-
pression in children (Gillham et al., 2006).
Three of these studies required just one or two
of these parent-only sessions (De Cuyper, Tim-
bremont, Braet, De Backer, & Wullaert, 2004;
TADS Team, 2004; Tompson et al., 2007),
whereas four called for a more intensive parent
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
component (Nelson, Barnard, & Cain, 2003;
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Melvin et al., 2006; Dietz et al., 2008; Garoff et
al., 2012). Four of these studies, including all of
the studies that involved one or two parent-only
sessions, focused mostly on cognitive– behav-
ioral approaches.
Studies evaluating treatments by Nelson et al.
(2003); Melvin et al. (2006); Dietz et al. (2008)
and Garoff et al. (2012) included more parental
involvement. Nelson et al. (2003) divided treat-
ment sessions between time for the therapist to
meet with the child and time for the therapist to
meet with the parent(s). The parent sessions
consisted of developing parent skills in the areas
of positive parenting, discipline, anger manage-
ment, linking thoughts with feelings, problem
solving, and family activities (Nelson, Barnard,
& Cain, 2006). In their study, Melvin et al.
(2006) provided 12 individual therapy sessions
for parents that served as companion sessions to
their adolescent’s treatment. Importantly, these
sessions included both adolescent-focused par-
ent therapy (consisting of psychoeducation,
goal setting, behavior management, communi-
cation skills training, and problem solving), and
parent-focused therapy (consisting of goal set-
ting, relaxation training, and cognitive therapy).
In the study by Dietz et al. (2008) about family
based IPT, parents met individually with a ther-
apist before meeting as a family at the end of
each session in Phase 1 of the treatment, which
typically consisted of four sessions. These par-
ent-only meetings consisted of discussing child
concerns, family stressors, and the role of the
child in the family. Furthermore, the study by
Garoff et al. (2012) called for heavy parent
involvement in both study conditions that were
evaluated. The individual therapy condition (fo-
cused individual PP) included biweekly parent
therapy sessions over the course of the child’s
treatment, whereas the family therapy condition
(SIFT) included four individual parent sessions
in addition to the nine family-focused therapy
sessions.
Youth-Focused Therapies With Parent and
Family Group Sessions
The last seven studies reviewed included ses-
sions with groups of parents, groups of families,
or both. Four studies using CBT to target ado-
lescent depression invited parents to attend
three sessions (Clarke et al., 2002), seven ses-
sions (Lewinsohn et al., 1990), eight sessions
(Clarke et al., 1999), or an unspecified number
of monthly sessions (Clarke et al., 2005). Par-
ents in these groups were informed about the
general topics discussed in youth sessions, and
provided with an overview of the skills and
techniques their children were learning in CBT
along with the rationale for their use. Parent
groups were designed to provide advice, educa-
tion, new problem-solving strategies, and sup-
port (Cottrell, 2003). The parents’ own depres-
sion was not directly discussed in these parent
meetings (Clarke et al., 2002).
The results of these studies showed that ad-
olescents whose parents were involved in treat-
ment improved as much as those whose parents
were not invited to participate (Lewinsohn et
al., 1990; Clarke et al., 1999); adolescents in the
condition that included parent involvement
through CBT improved as much as those receiv-
ing HMO care (Clarke et al., 2002) and TAU
(Clarke et al., 2005). Although these findings
suggest that parent involvement may not be
beneficial above and beyond individual treat-
ment for youth, it is important to remember that
these studies only examine one method for in-
volving parents in treatment, and the parent
groups were not the primary focus of interven-
tion. In addition, reports of attendance are in-
complete and range from “not perfect” to
“sparse.”
Three additional studies containing parent
and family groups placed an emphasis on psy-
choeducation. The study by Luby et al. (2012),
reviewed previously for assigning PCIT to the
treatment group, provided a “Developmental
Education and Parenting Intervention” (DEPI)
to the control group. Parents in the DEPI con-
dition met in small groups for 1-hour sessions
over 12 weeks. In DEPI, parents learned about
early childhood social and emotional develop-
ment, without their children present. Session
 CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY
topics included growth, nutrition, safety, parent-
ing practices, and cognitive, language, and brain
development. Although this group did not re-
ceive the benefit of live coaching or supervised
practice with learned behavioral techniques as
did those in the PCIT condition, children whose
parents participated in the DEPI group still
showed a significant reduction in depressive
symptoms. It is important to note, however, that
40.7% of the families assigned to the DEPI
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group dropped out of the study before attending
This document is copyrighted by the American Psychological Association or one of its allied publishers.
a single DEPI session, likely because of the
perceived need among those families to pursue
a more intensive treatment for their children
(Luby et al., 2012).
The last study was a large randomized con-
trolled trial (RCT) conducted by Fristad, Ver-
ducci, Walters, and Young (2009). It involved
families with 8- to 12-year-old children meeting
criteria for MDD, DD, or bipolar disorder. The
RCT was built on a previous study that called
for six weekly 75-min sessions of multifamily
psychoeducation groups (Fristad, Goldberg-
Arnold, & Gavazzi, 2002). In that treatment
protocol, the first three sessions were allocated
for family education in large groups, whereas
the latter three sessions were more process ori-
ented and included breakout sessions by age-
group. Before the RCT, researchers decided to
extend the content covered, and thus extend the
intervention to eight weekly 90-min sessions.
They also began to refer to it as multifamily
psychoeducational psychotherapy (MF-PEP).
The RCT by Fristad et al. (2009) consisted of
165 children, 30% of whom were diagnosed
with MDD or DD (70% had bipolar disorder). It
compared TAU ⫹ MF-PEP to TAU ⫹ WLC.
Each of the eight sessions in this protocol began
and ended with parents and children together.
During the middle portion of each session, par-
ents and children met in separate groups. The
content for each of the eight sessions is explic-
itly defined (see Goldberg-Arnold, & Fristad,
2003; Fristad, Gavazzi & Mackinaw-Koons,
2003) and tends to focus on information (in-
cluding entire sessions on medication options,
and working within mental health and school
systems of care), social support, and skill build-
ing (problem solving, communication, and cop-
ing skills). Other features of this program in-
cluded parent and child workbooks, homework
assignments, and in vivo social skills rehearsal
through supervised play for participating chil-
173
dren. Results showed that participation in the
MF-PEP ⫹ TAU group was associated with
lower scores on the Mood Severity Index at
follow-up in intent-to-treat analyses compared
with WLC ⫹ TAU group.
Finally, there were also two studies that
called for just one or two family group sessions
as part of the child-focused intervention. Clarke
(1999) included two joint sessions where the
parent and adolescent groups met together in
addition to the separate weekly group sessions
discussed in the Individual Parent section ear-
lier in the text. During these large group family
sessions, participants practiced conflict reduc-
tion skills on salient issues. As you may recall,
parent involvement in this treatment modality
was not associated with significantly enhanced
improvement.
Asarnow et al. (2002) conducted the other
study that included family group sessions. They
completed a trial with depressed youth (grade
4 – 6) that compared a CBT group treatment
condition with a WLC condition. The treatment
condition involved one 90-min family session
focusing on information about the interven-
tion, promotion of a supportive family envi-
ronment, youth accomplishment, and how to
generalize what the children were learning in
treatment to real-world settings. This family
session occurred at the end of the youth treat-
ment. In this session, the families also
watched a video the youth had created little
by little over the course of treatment. The
video showcased all of the new skills the
youth had learned throughout the interven-
tion. The researchers concluded that the group
CBT condition was superior to the WLC con-
dition in decreasing youth depression.
Summary
All of the studies involving a family-focused
treatment were effective at decreasing youth
depression suggesting that these interventions
may have promise, but it is unclear whether
these benefits are beyond those of individual-
focused therapy. When looking at the studies
using CBT, none that compared group CBT for
youth to group CBT for youth with parental
involvement found any significant benefit of
including parental involvement. Only one study
actually compared parent involvement with no
parent involvement, and the researchers found
 174 STARK, BANNEYER, WANG, AND ARORA
that youth-focused individual CBT was more
effective than a family condition (SBFT; Brent
et al., 1997). Studies involving IPT-A were ef-
ficacious, but did not compare IPT-A with pa-
rental involvement with IPT-A without parental
involvement.
As in previous descriptions of this literature
(Clarke et al., 1999; Sanford et al., 2006; David-
Ferdon & Kaslow, 2008; Hughes & Asarnow,
2011), our review could not provide a definite
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
answer for whether including parents in treat-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ment for youth depression has benefits above
and beyond conducting therapy with only the
depressed youth. This is in part due to the very
preliminary nature of this area of research.
Many of the interventions (e.g., Kovacs et al.,
2006; Luby et al., 2012; Tompson, 2007) are in
early stages of development and thus have only
been pilot tested to determine whether the par-
ticipants report improvements. The greatest lim-
itation is that the research designs used by in-
vestigators did not compare a FFI with another
active treatment. In the many studies that inte-
grated individual and parent or family interven-
tions, the designs used by the investigators did
not allow them to tease out the impact of the
parent or family component relative to the child
component.
Evaluation of the ACTION Treatment
Program
The literature indicates that child-focused in-
terventions are effective for treating depressed
youth. However, there is a need to develop more
effective treatments that positively impact a
larger percentage of children and produce a
greater improvement in the affected child’s
quality of life. Furthermore, given that depres-
sive disorders are episodic and likely to recur, it
is especially important for an intervention to
produce lasting improvements that prevent fu-
ture episodes. Long-term evaluations of the
maintenance of treatment effects are virtually
nonexistent in the literature. Some of the re-
search (e.g., Diamond et al., 2002; Kovacs,
2006; Nelson et al., 2006) suggests that includ-
ing parents and/or the family in the intervention
may represent one way to enhance efficacy. In
addition, including parents and/or family in the
intervention may produce changes in the family
as well as improvements in depression. By im-
proving the family environment and parental
behaviors that contribute to the depressive dis-
order, maintenance of treatment effects may be
enhanced. Our literature review did not find a
study that evaluated whether the addition of a
family or parent component to an already effec-
tive child-focused intervention could produce
improvements beyond those achieved through
the child-focused intervention alone. Further-
more, none of the investigations reviewed eval-
uated the long-term maintenance of treatment
effects. We have completed a treatment out-
come study that addresses these major gaps in
the literature (Stark, Stapleton, Arora, Krum-
holz, & Fisher, 2012).
The relative efficacy of child-focused CBT
was compared with child-focused CBT ⫹ PT
and a minimal contact control (MCC) condition.
The methods and results are described in detail
elsewhere (Stark et al., 2012). The child and PT
interventions have been manualized (Stark et
al., 2006; Stark, Simpson, Yancy & Molnar,
2007 respectively) and are delivered in a group
format. The child intervention consists of 20
group and two individual meetings completed
over 11 weeks. The PT intervention consists of
eight PT and two individual family meetings
completed over the same 11-week period. Child
participants attended every other parent meeting
to facilitate parental skill acquisition, and they
attended both family meetings. Child group
meetings lasted 45– 60 min, and the parent
group meetings lasted 60 –90 min.
Impact of Treatment on the Family
There were a multitude of therapeutic goals
for the PT, including some that were specific to
the family, such as (1) creating a positive affec-
tive environment, (2) teaching parents to man-
age child behavior predominantly through pos-
itive strategies, (3) improving communication
through teaching empathic listening and other
skills, (4) reducing conflict through family
problem solving and conflict management
skills, and (5) identifying and changing family
interactions that contribute to the development
of negative core beliefs. Results indicate that
the intervention was effective at changing the
family environment as girls whose parents par-
ticipated in the training reported significant pre-
to posttreatment improvements in their families
in cohesion, communication, conflict, and fam-
ily sociability. Girls who completed the CBT or
 CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY
MCC conditions solely reported improvements
in conflict. Primary caregivers’ ratings also in-
dicated that cohesion, communication, and so-
ciability improved in families where parents
participated in PT, whereas these three charac-
teristics of the family environment declined in
the MCC condition. Similarly, communication
and cohesion decreased over the course of treat-
ment in families where the girls completed
CBT. Caregivers of girls in all three conditions
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
reported a significant decrease in conflict within
This document is copyrighted by the American Psychological Association or one of its allied publishers.
the family from pre- to posttreatment, suggest-
ing that learning that their daughters were
depressed led to some changes in family inter-
actions. From both the child and parent perspec-
tives, results indicated that participation in the
parent skills training and family meetings pro-
duced significant improvements in the family
environment. Over the same time, girls who did
not receive treatment or solely received CBT
reported that their family environments became
less healthy.
We further hypothesized that improvements
in the family environment along with comple-
tion of sessions designed to help parents in the
PT condition identify and change interactions
that contribute to the development of negative
core beliefs would lead to the participants per-
ceiving fewer negative messages about the self,
world, and future (cognitive triad; Beck, 1967)
from their primary caregivers (Funk & Stark,
2012). We hypothesized that girls in the CBT ⫹
PT group, relative to girls in the CBT and MCC
groups, would experience the greatest improve-
ment in perceived parental messages. Results
were not as straightforward as expected. Per-
ceived parental messages improved for girls
who completed CBT only and the MCC condi-
tion, but not for those in the CBT ⫹ PT group.
The initial results were surprising and suggested
a negative effect of the PT component.
As treatment was being conducted, therapists
noted that parents often failed to attend meet-
ings despite the therapists’ best efforts to get
them to attend. Meetings were conducted in
their daughters’ schools at a time that all parents
agreed to be convenient, and dinner, child care,
and transportation (when necessary) were pro-
vided. As illustrated in Table 2, 58.2% of the
caregivers attended four or fewer meetings,
with 35.4% never attending any of the meetings.
If a child’s parents did not attend the meetings,
then they did not receive the PT. In addition, the
175
Table 2
Attendance of Parent Training Meetings for
Primary Caregivers Who had Daughters That
Completed Treatment
Number of PT meetings Percent of primary
attended N caregivers
8 8 10.1
7 13 16.5
6 6 7.6
5 6 7.6
4 6 7.6
3 3 3.8
2 4 5.1
1 5 6.3
0 28 35.4
Note. This table includes all caregivers who could have
attended the PT meetings.
therapists noted during supervision that the girls
whose parents did not attend the PT meetings
made negative comments about their parents or
themselves during the child group meetings
immediately after a missed parent training
meeting. Thus, we hypothesized that failure to
participate in PT had a negative impact on treat-
ment. Based on the cognitive-interpersonal
pathway model, caregivers who did not regu-
larly attend meetings were communicating a
message to their depressed daughters about the
daughter herself and about her treatment. Their
daughters’ core beliefs about the self before
treatment were “I’m unlovable, worthless,
and/or helpless” (Beck et al., 1979). Conse-
quently, they were actively constructing a
meaning about parental attendance that would
be consistent with these core beliefs (e.g., “If
my parents don’t attend the meetings and other
girls’ parents do, then I must not be important/
valuable/lovable enough to my parents”;
“Treatment must not be important”; “As usual,
there is nothing that I can do to get my parents
attention and affection.”). Analyses comparing
participants whose parents attended at least six
meetings with those whose parents completed
fewer than six meetings revealed a significantly
greater pre- to posttreatment improvement in
parental messages and a significantly larger ef-
fect of perceived messages from mothers on
girls’ beliefs about self, world, and future. Thus,
completing at least six of the parent training
meetings produced significant reductions in
negative parental messages about the child, and
 176 STARK, BANNEYER, WANG, AND ARORA
failure to attend parent training meetings ap-
peared to communicate a negative message to
the child about the self, world, and future.
Evaluation of the Cognitive-Interpersonal
Pathway
Using the girls who participated in treatment
along with a random sample of participants
(Funk & Stark, 2012), we evaluated the cogni-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
tive-interpersonal pathway model and found
This document is copyrighted by the American Psychological Association or one of its allied publishers.
support for it. Perceived messages from mater-
nal caregivers about the self, world, and future
were related to the girls’ cognitive triads, and
the girls’ cognitive triads were related to sever-
ity of depressive symptoms. Additionally, per-
ceived maternal messages about self, world, and
future were not directly related to severity of
depressive symptoms; rather, there was an indi-
rect relationship with severity of depressive
symptoms through the girls’ cognitive triad.
These results provide cross-sectional evidence
to support the cognitive-interpersonal pathway
model of the development of depressive disor-
ders. However, a longitudinal investigation is
necessary to provide a more definitive evalua-
tion of the developmental aspect of the model.
Relative Impact of PT
Our research suggests that the family envi-
ronments of depressed youth are characterized
by elevated conflict, lack of cohesion and sup-
port, and maladaptive communication. In addi-
tion, parents of depressed youth act in a nega-
tive way that contributes to the development
of the depressive cognitive triad that, in turn,
contributes to the development of depression. If
these family factors contribute to the develop-
ment and maintenance of depression, then fail-
ing to change the families of youth who are
being treated for depression should reduce the
overall effectiveness of the treatment and in-
crease the risk that the treated youth will not
maintain therapeutic gains and eventually expe-
rience another depressive episode. In contrast,
helping parents learn how to create a cohesive
and supportive family with adaptive communi-
cation, the ability to manage conflict, and en-
gage in social activities should support the new
skills, emotion regulation strategies, and posi-
tive beliefs developed during treatment. Fur-
thermore, helping parents to create a positive
affective tone in the family and to act in a way
that builds healthy core beliefs should help fa-
cilitate change and maintenance of treatment
effects. Thus, we hypothesized that at posttreat-
ment, participants in both the CBT and the
CBT ⫹ PT condition would experience signif-
icant improvements in depressive symptoms,
and that there would be a trend toward greater
improvement for girls whose parents completed
the PT. We further hypothesized that, owing to
the improvements in the family, participants
whose parents completed the PT would be more
likely to maintain treatment effects and possibly
continue to improve over time.
Results at posttreatment indicated that girls
who completed CBT with or without PT were
significantly less depressed than they were at
pretreatment, and that they were significantly
less depressed than those who completed the
MCC condition. More than 80% of the girls in
CBT and CBT ⫹ PT treatments no longer met
diagnostic criteria for a depressive disorder at
posttreatment, whereas 47% of the girls in the
MCC condition were no longer depressed at
posttreatment. Thus, although the treatments
were very effective and produced significantly
more change than naturally occurs owing to the
passage of time, there was no advantage for
girls in the parent training condition relative to
girls who completed CBT.
Owing to the episodic nature of depression,
an effective treatment is one that prevents the
development of future episodes. We hypothe-
sized that the improvements in the family that
result from PT would enhance the maintenance
of treatment effects. Results indicated that girls
in both treatments maintained their improve-
ments up to 4 years after completion of
treatment. Thus, there did not appear to be an
advantage to including the parent training com-
ponent. These findings were somewhat surpris-
ing, given how positive the parents were about
the training and how much the families ap-
peared to improve. Hence, we completed ex-
ploratory analyses to see whether we could de-
termine why there did not appear to be any
advantage to participating in the PT. Once
again, we thought that poor parental attendance
could have contributed to the equivalent results.
Parents who did not attend the meetings did not
receive the treatment, so they could be reducing
the overall impact of PT, or failure to attend
could be having a negative impact on treatment
 CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY
outcome. Results supported this hypothesis, as
girls who had a caregiver who attended eight
meetings had the steepest decline in depressive
symptoms and continued to improve over 4
years, and those who had a caregiver who at-
tended at least six meetings maintained their
improvements and, in fact, continued to im-
prove to a moderate degree over 4 years. In
contrast, girls who had a caregiver who attended
fewer than six PT meetings, on average, expe-
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rienced a slight decrease initially in depressive
This document is copyrighted by the American Psychological Association or one of its allied publishers.
symptoms, but then generally suffered from an
increasing rise in depressive symptoms over
time with each additional meeting the caregiver
was unable to attend.
Overall, results indicated that girls who had
at least one parent who attended six or more
parent training meetings continued to improve
over the 4 years after treatment, whereas girls
whose parents attended fewer than half of the
meetings maintained their improvements for a
year and then started to relapse. Thus, there is
an advantage to including PT in treatments for
depressive disorders in youth because it en-
hances the maintenance of treatment effects and
there appears to be an unexpected negative ef-
fect on the children when their parents fail to
attend the meetings.
Discussion
Families of depressed youth have been de-
scribed as less communicative, lower in support
and cohesion, and to experience more conflict
(Stark et al., 1990). Conflict, in particular, ap-
pears to have an especially powerful and dele-
terious impact on youth that places them at risk
for developing a depressive disorder. Elevated
levels of unresolved conflict could lead children
to describe their families as less supportive, less
cohesive, and less communicative. It also is
possible that the impact of unresolved conflict is
magnified in families that are not supportive,
cohesive, and communicative. How does con-
flict in the family negatively impact a child? Is
it through the stress created by the conflict, or
the negative affect that it engenders, or is con-
flict only destructive when it becomes a per-
sonal attack? For example: “You are a selfish,
inconsiderate, spoiled brat.” “I wish you were
never born.” What is the impact on the devel-
oping sense of self of repeatedly hearing such
statements? Is it the frequency of hearing these
177
personal attacks, or is it the associated affect
that makes them so powerful? Perhaps it is the
combination of the two. To date, research also
has not determined the locus of the conflict.
Does the conflict that leads to depression have
to be between the affected child and a parent or
can it be between the parents, the parents and
another sibling, or the affected child and a sib-
ling? It is clear that a great deal of research is
needed to better understand how conflict can
contribute to the development of depressive
disorders.
Having a depressed parent places offspring at
risk for developing a depressive disorder. The
path from parental depression to child depres-
sion may be more direct and genetically linked,
or it may be indirect and due to a combination
of an environmental disturbance interacting
with the genetic predisposition. Depressed par-
ents have been described as rejecting, hostile,
withdrawn, overcontrolling (Lovejoy et al.,
2000), critical (Asarnow et al., 1993), and dis-
engaged (Inoff-Germain, 1992). This style of
interaction may act as the stressor that interacts
with child factors such as a genetic predisposi-
tion, negative temperament, or a depressogenic
cognitive style to produce a depressive episode.
It also is possible that a depressed parent models
ineffective coping and problem-solving skills as
well as a negative cognitive style, which are
then learned by their offspring. This skill deficit
may place the children at risk for developing a
depressive disorder, as they are ineffective in
dealing with the stress of the environment.
There are multiple pathways that lead to the
development of depressive disorders. Research
that identifies these pathways is necessary, as it
can guide the development of more effective
interventions and the development of preven-
tion programs. We have hypothesized that chil-
dren, owing to their developing information
processing systems, internalize the negativity of
disturbances in the family into their belief sys-
tem, and that this depressogenic cognitive style
interacts with stress to produce a depressive
episode. Preliminary empirical support was
found for this model (Funk & Stark, 2012). It is
expected that this model is too simplistic and
would have more explanatory power if it in-
cluded an evaluation of the child’s and primary
caregiver’s emotion regulation skills and abili-
ties, problem-solving skills, interpersonal skills
and abilities, and the child’s and primary care-
 178 STARK, BANNEYER, WANG, AND ARORA
giver’s beliefs about these important skills and
abilities.
Clinical researchers from various theoretical
camps (e.g., CBT, psychodynamic, etc.) are de-
veloping interventions that include the family or
parents in treatments for depressed youth. A
number of these interventions appear to enhance
efficacy, including those by Diamond (2002),
Tompson et al. (2007), and Kovacs et al. (2006),
whereas other investigators do not report any
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
benefits of including families or parents in the
This document is copyrighted by the American Psychological Association or one of its allied publishers.
interventions (e.g., Garoff et al., 2012) or report
negative effects (e.g., Brent et al., 1997). How-
ever, the efficacy of family and parent interven-
tions has not been compared with the efficacy of
other established treatments. Thus, it is not yet
evident whether they offer an improvement
over existing child-focused treatments. Further-
more, the designs of the investigations do not
enable researchers to determine whether the ad-
dition of family or parent components to the
treatment contribute uniquely to the efficacy of
the interventions.
Addition of parents and/or families into in-
terventions for depressed youth adds cost to the
treatment. It increases the time demands on the
therapist, as he or she has to provide meetings
for the child and parents. To help reduce the
additional time demands of working with par-
ents, we have conducted parent meetings in
groups. Parents stated that they liked the group
format, as it became their social and recre-
ational outlet. They developed friendships, en-
joyed the adult conversation and break from
child care, and they derived pleasure from shar-
ing a meal with other parents “without the has-
sle of cleaning up.” However, the group format
may not have been ideal for many of the parents
because attendance was not adequate for a little
more than half of the parents, whereas atten-
dance of individually scheduled family meet-
ings in the home were very well attended.
Working with families increases the complexity
of scheduling, as inclusion of both caregivers
(when there are two or more) and siblings be-
comes necessary. This may not be possible with
some families, as the parents work multiple jobs
that are scheduled so that only one parent
is home at any given time. Attendance of meet-
ings is the most basic aspect of treatment and is
related to outcome and the maintenance of treat-
ment effects.
The most important finding of our research
(Krumholz & Stark, 2012) was that PT en-
hanced the maintenance of treatment effects,
but this was only true when parents completed
the majority (at least six) of the parent training
meetings. More specifically, when parents at-
tended six or more meetings, their daughters not
only maintained the improvements that they
made, but also continued to improve over 4
years. In contrast, girls whose parents attended
fewer than six meetings were similar to the girls
in the CBT-only condition. They reported a
slight improvement in symptoms over the first
year after treatment, and then the benefits of
treatment dissipated over time. The fewer the
number of parent training meetings completed,
the less likely the girls were to maintain their
improvements over the following 4 years. Thus,
a critical question for researchers and clinicians
is how do you improve parental attendance?
Similarly, when there are two parents, does
attendance of both caregivers enhance out-
come? Given the complex structure of families,
the multitude of possible attendees is endless.
When you have single-parent families, is there
an advantage to including the noncustodial par-
ent? What about including stepparents, grand-
parents, live-in partners, and other extended
family members who may be caregivers? It is
important for researchers to first identify parent
and family interventions that enhance treatment
outcome and maintenance of treatment effects.
Then it is important to determine who the nec-
essary and sufficient participants in the process
and what the most effective ways to maximize
attendance of the meetings are.
Another important finding was that the PT
produced improvements in the family environ-
ments after treatment. Research is yet to deter-
mine whether these improvements alone en-
hance treatment outcome or the maintenance of
treatment effects. Although we expected the PT
to also produce improvements in parent– child
interactions that contribute to the development
of the cognitive triad, this was only true when
the parents attended six or more of the parent
training meetings. Furthermore, failure of par-
ents to attend the majority of the meetings ac-
tually had a negative impact on perceptions of
parent– child interactions. We expected it to be
neutral or have a “nonimpact” on outcome, but
it had a negative impact. How can we explain
this? The CBT and the PT were conducted in
 CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY
groups. Thus, there was discussion about the
parent training meetings during the child group
meetings. The girls whose parents did not attend
the meetings had a negative reaction to this.
Consistent with the cognitive-interpersonal
pathway model, it appears as though the girls
constructed a negative interpretation about their
caregiver’s failure to attend the meetings. They
appeared to draw negative conclusions about
the self such as “I’m not loveable if other kids’
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
parents attend the meetings and mine don’t.”
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Adding parents to child treatments for de-
pression clearly increases the complexity of the
process. When parents are included in the treat-
ment, there appears to be a metamessage about
the child that is related to parental participation.
When parents fail to participate, this sends a
very negative message that adversely impacts
treatment. When parents participate, changes in
the family are produced and the maintenance of
treatment effects is enhanced. It behooves re-
searchers and clinicians to pay attention to the
metamessages that are communicated during
treatment.
References
Alexander, J., & Parsons, B. V. (1982). Functional
family therapy. Pacific Grove, CA: Brooks/Cole
Publishing Co. doi:10.1037/11621-000
Allen, J. P., Insabella, G., Maryfrances, R. P., Smith,
F. D., Land, D., & Phillips, N. (2006). A social-
interactional model in the development of depres-
sive symptoms in adolescence. Journal of Consult-
ing and Clinical Psychology, 74, 55– 65. doi:
10.1037/0022-006X.74.1.55
Alloy, L. B., Abramson, L. Y., Smith, J. M., Gibb,
B. E., & Neeren, A. M. (2006). Role of parenting
and maltreatment histories in unipolar and bipolar
mood disorders: Mediation by cognitive vulnera-
bility to depression. Clinical Child and Family
Psychology Review, 9, 23– 64. doi:10.1007/
s10567-006-0002-4
Alloy, L. B., Abramson, L. Y., Tashman, N. A., Ber-
rebbi, D. S., Hogan, M. E., Whitehouse, W. G., &
Morocco, A. (2001). Developmental origins of cog-
nitive vulnerability to depression: Parenting, cogni-
tive, and inferential feedback styles of the parents of
individuals at high and low cognitive risk for depres-
sion. Cognitive Therapy and Research, 25, 397–
423. doi:10.1023/A:1005534503148
Asarnow, J. R., Goldstein, M. J., Thompson, M., &
Guthrie, D. (1993). One-year outcomes of depres-
sive disorders in child psychiatric in-patients:
Evaluation of the prognostic power of a brief mea-
179
sure of expressed emotion. Journal of Child Psy-
chology and Psychiatry, 34, 129 –137. doi:
10.1111/j.1469-7610.1993.tb00975.x
Asarnow, J. R., Scott, C. V., & Mintz, J. (2002). A
combined cognitive-behavioral family education inter-
vention for depression in children: A treatment devel-
opment study. Cognitive Therapy and Research, 26,
221–229. doi:10.1023/A:1014573803928
Beck, A. T. (1967). Depression: Clinical, experimen-
tal, and theoretical aspects. New York: Harper &
Row.
Beck, A. T. (2005). The current state of cognitive
therapy: A 40-year retrospective. Archives of Gen-
eral Psychiatry, 62, 953–959. doi:10.1001/
archpsyc.62.9.953
Beck, A. T., Rush, J., Shaw, B. F., & Emery, G.
(1979). Cognitive therapy of depression. New
York, NY: Guilford.
Belsky, J. (2005). Differential susceptibility to rear-
ing influence: An evolutionary hypothesis and
some evidence. In B. Ellis, & D. Bjorklund (Eds.),
Origins of the social mind: Evolutionary psychol-
ogy and child development (pp. 139 –163). New
York, NY: Guildford.
Bifulco, A. T., Moran, P. M., Ball, C., Jacobs, C.,
Baines, R., Bunn, A., & Cavagin, J. (2002). Child
adversity, parental vulnerability and disorder: Ex-
amination of inter-generational transmission of
risk. Journal of Child Psychology and Psychiatry
and Allied Disciplines, 43, 1075–1086. doi:
10.1111/1469-7610.00234
Birmaher, B., & Brent, D. (2007). The AACAP
Work Group on Quality Issues. Practice param-
eter for the assessment and treatment of children
and adolescents with depressive disorders. Jour-
nal of the American Academy of Child & Adoles-
cent Psychiatry, 46, 1503–1526. doi:10.1097/chi
.0b013e318145ae1c
Bocknek, E. L., Sanderson, J., & Britner, P. A.
(2009). Ambiguous loss and posttraumatic stress
in school-age children of prisoners. Journal of
Child & Family Studies, 18, 323–333. doi:
10.1007/s10826-008-9233-y
Boss, P. (2007). Ambiguous loss theory: Challenges
for scholars and practitioners (Special issue on
ambiguous loss). Family Relations, 56, 105–111.
Boszormeny-Nagy, I., & Sparks, G. M. (1984). In-
visible loyalties. New York, NY: Brunner/Mazel.
Bowlby, J. (1969). Attachment. New York, NY: Ba-
sic Books.
Brent, D., Emslie, G., Clarke, G., Wagner, K. D.,
Asarnow, J. R., Keller, M., . . . Zelazny, J. (2008).
Switching to another SSRI or to Venlafaxine with
or without cognitive behavioral therapy for adoles-
cents with SSRI-resistant depression: The TOR-
DIA randomized controlled trial. Journal of the
American Medical Association, 299, 901–913. doi:
10.1001/jama.299.8.901
 180 STARK, BANNEYER, WANG, AND ARORA
Brent, D. A., Holder, D., Kolko, D., Birmaher, B.,
Baugher, M., Roth, C., & Johnson, B. A. (1997). A
clinical psychotherapy trial for adolescent depres-
sion comparing cognitive, family, and supportive
therapy. Archives of General Psychiatry, 54, 877–
885. doi:10.1001/archpsyc.1997.01830210125017
Brent, D. A., Roth, C., Holder, D., Kolko, D. J.,
Birmaher, B., Johnson, B. A., & Schweers, J.
(1996). Psychosocial interventions for treating ad-
olescent depression: A comparison of three psy-
chosocial interventions. In E. D. Hibbs, & P. S.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Jensen (Eds.), Psychosocial treatment for child
This document is copyrighted by the American Psychological Association or one of its allied publishers.
and adolescent disorders: Empirically based strat-
egies for clinical practice (pp. 187–206). Wash-
ington, DC: American Psychiatric Press Inc. doi:
10.1037/10196-008
Bridge, J. A., Iyengar, S., Salary, C. B., Barbe, R. P.,
Birmaher, B., Pincus, H. A., & Brent, D. A.
(2007). Clinical response and risk for reported
suicidal ideation and suicide attempts in pediatric
antidepressant treatment: A meta-analysis of ran-
domized controlled trials. Journal of the American
Medical Association, 297, 1683–1696. doi:
10.1001/jama.297.15.1683
Brinkmeyer, M., & Eyberg, S. (2003). Parent-child
interaction therapy for oppositional children. In
A. E. Kazdin, & J. Weisz (Eds.), Evidence-based
psychotherapies for children and adolescents (pp.
204 –223). New York, NY: Guilford.
Byng-Hall, J., Campbell, D., & Papadopoulos, R.
(1996). Manual: Systems Integrative Therapy
(SIFT—The basis for an integrative approach).
London: Tavistock Clinic.
Clarke, G., Debar, L., Lynch, F., Powell, J., Gale, J.,
O’Connor, E., . . . Hertert, S. (2005). A randomized
effectiveness trial of brief cognitive-behavioral ther-
apy for depressed adolescents receiving antidepres-
sant medication. Journal of the American Academy
of Child & Adolescent Psychiatry, 44, 888 – 898.
doi:10.1016/S0890-8567(09)62194-8
Clarke, G. N., Hornbrook, M., Lynch, F., Polen, M.,
Gale, J., O’Connor, E., . . . Debar, L. (2002).
Group cognitive behavioral treatment for de-
pressed adolescent offspring of depressed parents
in a health maintenance organization. Journal of
the American Academy of Child & Adolescent Psy-
chiatry, 41, 305–313. doi:10.1097/00004583-
200203000-00010
Clarke, G. N., Rohde, P., Lewinsohn, P. M., Hops,
H., & Seeley, J. R. (1999). Cognitive behavioral
treatment of adolescent depression: Efficacy of
acute group treatment and booster sessions. Jour-
nal of the American Academy of Child & Adoles-
cent Psychiatry, 38, 272–279. doi:10.1097/
00004583-199903000-00014
Costello, E. J., Erklani, A., & Angold, A. (2006). Is
there an epidemic of child or adolescent depres-
sion? Journal of Child Psychology and Psychiatry,
47, 1263–1271.
Cottrell, D. (2003). Outcome studies of family ther-
apy in child and adolescent depression. Journal of
Family Therapy, 25, 406 – 416. doi:10.1111/1467-
6427.00258
Cummings, E. M. (1994). Marital conflict and chil-
dren’s functioning. Social Development, 3, 16 –36.
doi:10.1111/j.1467-9507.1994.tb00021.x
Cummings, E. M., Keller, P. S., & Davies, P. T.
(2005). Towards a family process model of mater-
nal and paternal depressive symptoms: Exploring
multiple relations with child and family function-
ing. Journal of Child Psychology and Psychiatry,
46, 479 – 489. doi:10.1111/j.1469-7610.2004
.00368.x
David-Ferdon, C., & Kaslow, N. J. (2008). Evidence-
based psychosocial treatments for child and ado-
lescent depression. Journal of Clinical Child &
Adolescent Psychology, 37, 62–104. doi:10.1080/
15374410701817865
De Cuyper, S., Timbremont, B., Braet, C., De
Backer, V., & Wullaert, T. (2004). Treating de-
pressive symptoms in schoolchildren: A pilot
study. European Child & Adolescent Psychiatry,
13, 105–114. doi:10.1007/s00787-004-0366-2
Diamond, G., & Josephson, A. (2005). Family-based
treatment research: A 10-year update. Journal of
the American Academy of Child & Adolescent Psy-
chiatry, 44, 872– 887. doi:10.1097/01.chi
.0000169010.96783.4e
Diamond, G. S., Reis, B. F., Diamond, G. M.,
Siqueland, L., & Isaacs, L. (2002). Attachment-based
family therapy for depressed adolescents: A treat-
ment development study. Journal of the American
Academy of Child & Adolescent Psychiatry, 41,
1190 –1196. doi:10.1097/00004583-200210000-
00008
Diamond, G. S., & Siqueland, L. (1995). Family
therapy for the treatment of depressed adolescents
(special issue: Adolescent Treatment: New Fron-
tiers and New Dimension). Psychotherapy, 32, 77–
90.
Diamond, G. S., Wintersteen, M. B., Brown, G. K.,
Diamond, G. M., Gallop, R., Shelef, K., & Levy,
S. (2010). Attachment-based family therapy for
adolescents with suicidal ideation: A randomized
controlled trial. Journal of the American Academy
of Child & Adolescent Psychiatry, 49, 122–131.
Dietz, L. J., Mufson, L., Irvine, H., & Brent, D. A.
(2008). Family-based interpersonal psychotherapy
for depressed preadolescents: An open-treatment
trial. Early Intervention in Psychiatry, 2, 154 –161.
doi:10.1111/j.1751-7893.2008.00077.x
Dowdney, L. (2000). Annotation: Childhood be-
reavement following parental death. Journal of
Child Psychology and Psychiatry and Allied Dis-
 CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY
ciplines, 41, 819 – 830. doi:10.1111/1469-7610
.00670
Egger, H., Ascher, B., & Angold, A. (1999). Pre-
school Age Psychiatric Assessment (PAPA): Ver-
sion 1.1. Durham, NC: Department of Psychiatry
and Behavioral Sciences, Center for Developmen-
tal Epidemiology, Duke University Medical
Center.
Eley, T. C., Sugden, K., Corsico, A., Gregory, A. M.,
Sham, P., McGuffin, P., & Craig, I. W. (2004).
Gene– environment interaction analysis of sero-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
tonin system markers with adolescent depression.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Molecular Psychiatry, 9, 908 –915. doi:10.1038/sj
.mp.4001546
Essau, C. A. (2004). The association between family
factors and depressive disorders in adolescents.
Journal of Youth and Adolescence, 33, 365–372.
doi:10.1023/B:JOYO.0000037630.01098.d4
Formoso, D., Gonzales, N. A., & Aiken, L. S. (2000).
Family conflict and children’s internalizing and
externalizing behavior: Protective factors. Ameri-
can Journal of Community Psychology, 28, 175–
199. doi:10.1023/A:1005135217449
Fristad, M. A., Gavazzi, S. M., & Mackinaw-Koons,
B. (2003). Family psychoeducation: An adjunctive
intervention for children with bipolar disorder. Bi-
ological Psychiatry, 53, 1000 –1008. doi:10.1016/
S0006-3223(03)00186-0
Fristad, M. A., Goldberg-Arnold, J. S., & Gavazzi,
S. M. (2002). Multifamily psychoeducation groups
(MFPG) for families of children with bipolar dis-
order. Bipolar Disorders, 4, 254 –262. doi:
10.1034/j.1399-5618.2002.09073.x
Fristad, M. A., Verducci, J. S., Walters, K., &
Young, M. E. (2009). Impact of multifamily
psychoeducational psychotherapy in treating
children aged 8 to 12 years with mood disorders.
Archives of General Psychiatry, 66, 1013–1021.
doi:10.1001/archgenpsychiatry.2009.112
Funk, C. L., & Stark, K. D. (2012). The relations
between parent training, family messages, cogni-
tive triad, and girls’ depressive symptoms. Manu-
script submitted for publication.
Garber, J., & Flynn, C. (2001). Predictors of depres-
sive cognitions in young adolescents. Cognitive
Therapy and Research, 25, 353–376. doi:10.1023/
A:1005530402239
Garber, J., & Robinson, N. S. (1997). Cognitive
vulnerability in children at risk for depression.
Cognition and Emotion, 11, 619 – 635. doi:
10.1080/026999397379881b
Garoff, F. A., Heinonen, K., Pesonen, A., &
Almqvist, F. (2012). Depressed youth: Treatment
outcome and changes in family functioning in in-
dividual and family therapy. Journal of Family
Therapy, 34, 4 –23. doi:10.1111/j.1467-6427.2011
.00541.x
181
Gillham, J. E., Reivich, K. J., Freres, D. R., Lascher,
M., Litzinger, S., Shatté, A., & Seligman, M. E. P.
(2006). School-based prevention of depression
School Psychology Quarterly, 21, 323–348. doi:
10.1521/scpq.2006.21.3.323
Gladstone, T. R. G., & Beardslee, W. R. (2009). The
prevention of depression in children and adoles-
cents: A review. The Canadian Journal of Psychi-
atry, 54, 212–221.
Goldberg-Arnold, J. S., & Fristad, M. A. (2003).
Psychotherapy with children diagnosed with early-
onset bipolar disorder. In B. Geller., & M. Del
Bello (Eds.), Bipolar disorder in childhood and
early adolescence (pp. 272–294). New York, NY:
Guilford Publications, Inc.
Goodman, S. H., & Gotlib, I. H. (1999). Risk for
psychopathology in the children of depressed
mothers: A developmental model for understand-
ing mechanisms of transmission. Psychological
Review, 106, 458 – 490. doi:10.1037/0033-295X
.106.3.458
Goodyer, I., Dubicka, B., Wilkinson, P., Kelvin, R.,
Roberts, C., Byford, S., . . . Harrington, R. (2007).
Selective serotonin reuptake inhibitors (SSRIs)
and routine specialist care with and without cog-
nitive behavior therapy in adolescents with major
depression: Randomised controlled trial. British
Medical Journal, 335, 142. doi:10.1136/bmj
.39224.494340.55
Goodyer, I. M. (2010). Depression in childhood and
adolescence. In C. L. Cooper, J. Field, U. Gos-
wami, R. Jenkins, & B. J. Sahakian (Eds.), Mental
Capital and Wellbeing. Oxford: Wiley-Blackwell.
Gould, M. S., King, R., & Greenwald, S. (1998).
Psychopathology associated with suicidal ideation
and attempts among children and adolescents.
Journal of the American Academy of Child &
Adolescent Psychiatry, 37, 915–923. doi:10.1097/
00004583-199809000-00011
Greenberg, L. S., & Johnson, S. M. (1988). Emotion-
ally focused couples therapy. New York, NY:
Guilford.
Hammad, T. A., Laugren, T., & Racoosin, J. (2006).
Suicidality in pediatric patients treated with anti-
depressant drugs. Archives of General Psychiatry,
63, 332–339. doi:10.1001/archpsyc.63.3.332
Hoyt, L. A., Cowen, E. L., Pedro-Carroll, J. L., &
Alpert-Gillis, L. J. (1990). Anxiety and depression
in young children of divorce. Journal of Clinical
Child Psychology, 19, 26 –32. doi:10.1207/
s15374424jccp1901_4
Hudson, J. L. (2005). Interparental conflict, violence
and psychopathology. In J. L. Hudson, & R. M.
Rapee (Eds.), Psychopathology and the Family
(pp. 53– 69). Qxford, UK: Elsevier Science.
Huebner, A. J., Mancini, J. A., Wilcox, R. M., Grass,
S. R., & Grass, G. A. (2007). Parental deployment
and youth in military families: Exploring uncer-
 182 STARK, BANNEYER, WANG, AND ARORA
tainty and ambiguous loss. Family Relations, 56,
112–122. doi:10.1111/j.1741-3729.2007.00445.x
Hughes, J. L., & Asarnow, J. R. (2011). Family
treatment strategies in adolescent depression. Psy-
chiatric Annals, 41, 235–239. doi:10.3928/
00485713-20110325-07
Inoff-Germain, G., Nottelmann, E. D., & Radke-
Yarrow, M. (1992). Evaluative communications
between affectively ill and well mothers and their
children. Journal of Abnormal Child Psychology,
20, 189 –212. doi:10.1007/BF00916548
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Jaenicke, C., Hammen, C., Zupan, B., Hiroto, D.,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Gordon, D., Adrian, C., & Burge, D. (1987). Cog-
nitive vulnerability in children at risk for depres-
sion. Journal of Abnormal Child Psychology, 15,
559 –572. doi:10.1007/BF00917241
Kane, P., & Garber, J. (2004). The relations among
depression in fathers, children’s psychopathology,
and father-child conflict: A meta-analysis. Clinical
Psychology Review, 24, 339 –360. doi:10.1016/j
.cpr.2004.03.004
Kaslow, N. J., Baskin, M. L., & Wyckoff, S. C.
(2002). A biopsychosocial treatment approach for
depressed children and adolescents In N. J. Kaslow
(Ed.), Comprehensive handbook of psychotherapy:
Integrative/eclectic (Vol. 4, pp. 31–57). New
York, NY: Wiley.
Kaslow, N. J., Deering, C. G., & Racusin, G. R.
(1994). Depressed children and their families.
Clinical Psychology Review, 14, 39 –59. doi:
10.1016/0272-7358(94)90047-7
Kennard, B. D., Emslie, G. J., Mayes, T. L., Night-
ingale-Teresi, J., Nakonezy, P. A., Hughes, J. L., &
Jarrett, R. B. (2008). Cognitive-behavioral therapy
to prevent relapse in pediatric responders to phar-
macotherapy for major depressive disorder. Jour-
nal of the American Academy of Child & Adoles-
cent Psychiatry, 47, 1395–1404. doi:10.1097/CHI
.0b013e31818914a1
Kobak, R. R., & Sceery, A. (1988). Attachment in
late adolescence: Working models, affect regula-
tion and representations of self and others. Child
Development, 59, 135–146. doi:10.2307/1130395
Kovacs, M., Sherrill, J., George, C. J., Pollock, M.,
Tumuluru, R. V., & Ho, V. (2006). Contextual
emotion-regulation therapy for childhood depres-
sion: Description and pilot testing of a new inter-
vention. Journal of the American Academy Of
Child and Adolescent Psychiatry, 45, 892–903.
doi:10.1097/01.chi.0000222878.74162.5a
Krumholz, L. S., & Stark, K. D. (2012). Maintenance
of treatment effects from cognitive-behavioral
therapy and parent training on family functioning
and girls’ depressive symptoms. Manuscript sub-
mitted for publication.
Larner, G. (2009). Integrating family therapy in ad-
olescent depression: An ethical stance. Journal of
Family Therapy, 31, 213–232. doi:10.1111/j.1467-
6427.2009.00468.x
Lewinsohn, P. M., Clarke, G. N., Hops, H., & An-
drews, J. (1990). Cognitive-behavioral treatment
for depressed adolescents. Behavior Therapy, 21,
385– 401. doi:10.1016/S0005-7894(05)80353-3
Liddle, H. A. (1999). Theory development in a fam-
ily-based therapy for adolescent drug abuse. Jour-
nal of Clinical Child Psychology, 28, 521–532.
doi:10.1207/S15374424JCCP2804_12
Lovejoy, M. C., Graczyk, P. A., O’Hare, E., & Neu-
man, G. (2000). Maternal depression and parent-
ing: A meta-analytic review. Clinical Psychology
Review, 20, 561–592. doi:10.1016/S0272-
7358(98)00100-7
Luby, J., Lenze, S., & Tillman, R. (2012). A novel
early intervention for preschool depression: Find-
ings from a pilot randomized controlled trial. Jour-
nal of Child Psychology and Psychiatry, 53, 313–
322. doi:10.1111/j.1469-7610.2011.02483.x
Melvin, G. A., Tonge, B. J., King, N. J., Heyne, D.,
Gordon, M. S., & Klimkeit, E. (2006). A compar-
ison of cognitive-behavioral therapy, sertraline,
and their combination for adolescent depression.
Journal of the American Academy of Child &
Adolescent Psychiatry, 45, 1151–1161. doi:
10.1097/01.chi.0000233157.21925.71
Merikangas, K. R., He, L., Burstein, M., Swanson,
S. A., Avenevoli, S., Cui, L., . . . Swendsen, J.
(2010). Lifetime Prevalence of mental disorders in
U.S. adolescents: Results from the National Co-
morbidity Study-Adolescent Supplement (NCS-A).
Journal of the American Academy of Child &
Adolescent Psychiatry, 49, 980 –989. doi:10.1016/
j.jaac.2010.05.017
Minuchin, S. (1974). Families and family therapy.
Cambridge, MA: Harvard University Press.
Mufson, L., Gallagher, T., Dorta, K. P., & Young,
J. F. (2004a). A Group Adaptation of Interpersonal
Psychotherapy for Depressed Adolescents. Amer-
ican Journal of Psychotherapy, 58, 220 –237.
Mufson, L., Dorta, K. P., Wickramaratne, P., No-
mura, Y., Olfson, M., & Weissman, M. M.
(2004b). A randomized effectiveness trial of inter-
personal psychotherapy for depressed adolescents.
Archives of General Psychiatry, 61, 577–584. doi:
10.1001/archpsyc.61.6.577
Mufson, L., Nomura, Y., & Warner, V. (2002). The
relationship between parental diagnosis, offspring
temperament and offspring psychopathology: A
longitudinal analysis. Journal of Affective Disor-
ders, 71, 61– 69. doi:10.1016/S0165-
0327(01)00375-5
Muratori, F., Picchi, L., Bruni, G., Patarnello, M., &
Romagnoli, G. (2003). A two-year follow-up of
psychodynamic psychotherapy for internalizing
disorders in children. Journal of the American
Academy of Child & Adolescent Psychiatry, 42,
 CHILD AND ADOLESCENT DEPRESSION IN THE FAMILY
331–339. doi:10.1097/00004583-200303000-
00014
Nelson, E. L., Barnard, M., & Cain, S. (2003). Treat-
ing childhood depression over videoconferencing.
Telemedicine Journal and E-health, 9, 49 –55. doi:
10.1089/153056203763317648
Nelson, E. L., Barnard, M., & Cain, S. (2006). Feasibility
of telemedicine intervention for childhood depression.
Counselling and Psychotherapy Research, 6, 191–
195. doi:10.1080/14733140600862303
Nomura, Y., Wickramaratne, P. J., Warner, V., &
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Weissman, M. (2002). Family discord, parental
This document is copyrighted by the American Psychological Association or one of its allied publishers.
depression and psychopathology in offspring: Ten-
year follow-up. Journal of the American Academy
of Child and Adolescent Psychiatry, 41, 402– 409.
doi:10.1097/00004583-200204000-00012
Parker, G. (1993). Parental rearing style: Examining
for links with personality vulnerability factors for
depression. Social Psychiatry and Psychiatric Ep-
idemiology, 28, 97–100. doi:10.1007/BF00801738
Parra, G. R., Buckholdt, K. E., Olsen, J. P., Jobe-
Shields, L., Davis, G. L., & Gamble, H. L. (2011).
Targeting family risk factors in the context of
facing youth depression: A survey of psycholo-
gists. The Family Journal: Counseling and Ther-
apy for Couples and Families, 19, 381–388. doi:
10.1177/1066480711419801
Restifo, K., & Bögels, S. (2009). Family processes in
the development of youth depression: Translating
the evidence to treatment. Clinical Psychology Re-
view, 29, 294 –316. doi:10.1016/j.cpr.2009.02.005
Robin, A. L., & Foster, S. L. (1989). Negotiating
Parent-Adolescent Conflict: A Behavioral-Family
Systems Approach. New York, NY: Guilford
Press.
Rosselló, J., & Bernal, G. (1999). The efficacy of
cognitive-behavioral and interpersonal treatments
for depression in Puerto Rican adolescents. Jour-
nal of Consulting and Clinical Psychology, 67,
734 –745. doi:10.1037/0022-006X.67.5.734
Sander, J. B., & McCarty, C. A. (2005). Youth de-
pression in the family context: Familial risk factors
and models of treatment. Clinical Child and Fam-
ily Psychology Review, 8, 203–219. doi:10.1007/
s10567-005-6666-3
Sanford, M., Boyle, M., McCleary, L., Miller, J.,
Steele, M., Duku, E., & Offord, D. (2006). A Pilot
study of adjunctive family psychoeducation in ad-
olescent major depression: Feasibility and treat-
ment effect. Journal of the American Academy of
Child & Adolescent Psychiatry, 45(4), 386 – 495.
doi:10.1097/01.chi.0000198595.68820.10
Sanford, M., Szatmari, P., Spinner, M., Munroe-
Blum, H., Jamieson, E., Walsh, C., & Jones, D.
(1995). Predicting the one-year course of adoles-
cent major depression. Journal of the American
Academy of Child & Adolescent Psychiatry, 34,
183
1618 –1628. doi:10.1097/00004583-199512000-
00012
Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P.,
Fisher, P., Bird, H., & Aluwahlia, S. (1983). A
children’s global assessment scale (CGAS). Ar-
chives of General Psychiatry, 40, 1228 –1231. doi:
10.1001/archpsyc.1983.01790100074010
Sexson, S. B., Glanville, D. N., & Kaslow, N. J.
(2001). Attachment and depression. Implications
for family therapy. Child and Adolescent Psychi-
atric Clinics of North America, 10, 465– 486.
Sheeber, L., Hops, H., & Davis, B. (2001). Family
processes in adolescent depression. Clinical Child
and Family Psychology Review, 4, 19 –35. doi:
10.1023/A:1009524626436
Stark, K. D., Humphrey, L. L., Crook, K., & Lewis,
K. (1990). Perceived family environments of de-
pressed and anxious children: Child’s and maternal
figure’s perspectives. Journal of Abnormal Child
Psychology, 18, 527–547. doi:10.1007/
BF00911106
Stark, K. D., Simpson, J., Schnoebelen, S., Hargrave,
J., Glenn, R., & Molnar, J. (2006). Therapist’s
Manual for Action. Broadmore, PA: Workbook
Publishing.
Stark, K. D., Simpson, J., Yancy, M., & Molnar, J.
(2007). Parent Training Manual for Action.
Broadmore, PA: Workbook Publishing.
Stark, K. D., Stapleton, L., Arora, P., Krumholz, L.,
& Fisher, M. (2012). Evaluation of Cognitive be-
havioral therapy with and without parent training
for the treatment of depressed girls. In preparation.
Stice, E., Ragan, J., & Randall, P. (2004). Prospective
relations between social support and depression:
Differential direction of effects for parent and peer
support. Journal of Abnormal Psychology, 113,
155–159. doi:10.1037/0021-843X.113.1.155
Substance Abuse and Mental Health Services Ad-
ministration (SAMHSA). (2009). Results from the
2008 National Survey on Drug Use and Health:
National Findings (NSDUH Series H-36, HHS
Publication No. SMA 09 – 4434). Rockville, MD:
Office of Applied Studies.
TADS Team. (2004). Fluoxetine, cognitive-behav-
ioral therapy, and their combination for adoles-
cents with depression: Treatment for Adolescents
with Depression Study (TADS) randomized con-
trolled trial. The Journal of the American Medical
Association, 292, 807– 820. doi:10.1001/jama.292
.7.807
Thomas, R., & Zimmer-Gembeck, M. J. (2007). Be-
havioral outcomes of parent-child interaction ther-
apy and triple P-positive parenting program: A
review and meta-analysis. Journal of Abnormal
Child Psychology, 35, 475– 495. doi:10.1007/
s10802-007-9104-9
Tompson, M. C., Pierre, C., Haber, F. M., Fogler, J.,
Groff, A., & Asarnow, J. (2007). Family-focused
 184 STARK, BANNEYER, WANG, AND ARORA
treatment for childhood-onset depressive disor-
ders: Results of an open trial. Clinical Child Psy-
chology and Psychiatry, 12, 403– 420. doi:
10.1177/1359104507078474
Toth, S., Manly, J. T., & Cicchetti, D. (1992). Child
maltreatment and vulnerability to depression. De-
velopment and Psychopathology, 4, 97–112. doi:
10.1017/S0954579400005587
Waslick, B. D., Kandel, R., & Kakouros, A. (2002).
Depression in children and adolescents: An over-
view. In D. Shaffer, & B. D. Waslick (Eds.), The
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
many faces of depression in children and adoles-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
cents (pp. 1–36). Washington, DC: American Psy-
chiatric Publishing.
Weissman, M. M., Pilowsky, D. J., Wickramaratne,
P. J., Talati, A., Wisniewski, S. R., Fava, M., &
Rush, A. J. (2006). Remissions in maternal depres-
sion and child psychopathology: A STAR*D re-
port. The Journal of the American Medical Asso-
ciation, 295, 1389 –1398 doi:10.1001/jama.295.12
.1389
Weissman, M. M., Warner, V., Wickramaratne, P.,
Moreau, D., & Olfson, M. (1997). Offspring of
depressed parents: 10 years later. Archives of Gen-
View publication stats
eral Psychiatry, 54, 932–940. doi:10.1001/
archpsyc.1997.01830220054009
Weissman, M. M., Wolk, S., Wickramaratne, P.,
Goldstein, R. B., Adams, P., Greenwald, S., &
Steinberg, D. (1999). Children with prepubertal-
onset major depressive disorder and anxiety grown
up. Archives of General Psychiatry, 56, 794 – 801.
doi:10.1001/archpsyc.56.9.794
Weisz, J. R., McCarty, C. A., & Valeri, S. M. (2006).
Effects of psychotherapy for depression in children
and adolescents: A meta-analysis. Psychological
Bulletin, 132, 132–149. doi:10.1037/0033-2909
.132.1.132
Weller, R. A., Weller, E., Fristad, M., & Bowes, J.
(1991). Depression in recently bereaved prepuber-
tal children. The American Journal of Psychiatry,
148, 1536 –1540.
Williams, J. B. W. (1988). A structured interview
guide for the Hamilton Depression Rating Scale.
Archives of General Psychiatry, 45, 742–747.
Received July 13, 2012
Revision received July 30, 2012
Accepted August 3, 2012 䡲