Evidence-Based Psychotherapies for
Depressed Adolescents: A Review and
Adolescent depression is an important public health problem that affects up to 20% of adolescents. Depression may take a number of forms, all of which can have varied effects on personal satisfaction, family and peer relations, and school achievement. The presence of depression is correlated with teenage substance use, risky sexual activity, and dangerous behaviors. Accidents and suicide, especially, are major sources of morbidity and mortality in the teenage years. Reliance upon scientific study of child psychopathology has spawned the creation of advanced therapies that target characteristics of depression. Many of these therapies guide adolescents and their significant others to learn new skills to combat the condition. Such methods have been shown to be effective, and they hold great promise in helping adolescents recover from depression and its consequences. Primary care clinicians and mental health practitioners would benefit from becoming familiar with these therapies and methods.
• Describe four evidence-based psychotherapies for adolescents.
• Describe the interpersonal, behavioral, and cognitive skills that are the focus of change in the treatment programs.
• Determine how to select mental health practitioners who can deliver evidencebased psychotherapy for depressed adolescents.
• Give examples of how depressed adolescents are different from other adolescents in their responses to negative
events and interpersonal conflicts.
Primary care physicians and psychiatrists.
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The last two decades have seen a dramatic change in the treatment approaches used to address adolescent depression. Research studies on the characteristics of adolescents with depression have pinpointed problems in thinking, behavior, and social interactions that are linked to the disorder and its symptoms. Clinical researchers have used this information to develop specific treatments for depression that have been put to the empirical test with good results. This article reviews the rationale, treatment content, and effectiveness of four structured and targeted treatments for depression in youth as they have been applied to adolescents. The approaches include cognitive-behavioral therapy, primary and secondary control enhancement therapy, interpersonal psychotherapy for adolescents, and systemic-behavioral family therapy. Each of these methods contributes to improvements in rates of depression and depressive symptoms for adolescents with all forms of depression, including major depressive disorder. Thus, they provide advances in the care of the depressed adolescent. Their status in relation to the use of medication and their limits are discussed. Provided is a set of guidelines for primary practitioners to facilitate teenage engagement in therapy and make selections for referrals sources.
A major change in the psychological treatment of adolescent depression has occurred during the last 15–20 years. Methods with the greatest empirical support to date are characterized by several aspects. First, following a pattern established in the treatment of adult depression, treatments have become less focused on the past, more directive, more involved in training skills, and more involved in emphasizing current inter personal interactions and the interplay of behavior, thoughts, and mood. This shift is essential because prior efforts with nondirective therapies, supportive therapies, and general family therapies have very little documented effectiveness for depression in adolescents, especially for major depression. Second, because surveys have highlighted a high point prevalence of depressive disorders or depressive symptoms in adolescence (2% to 9%), and a high teenage lifetime inci dence (20%), the field has been spurred to find methods that go beyond simple support to provide true recovery from the condition. Next, while investiga tions also document the negative impact that depression has upon school performance, social relations, and risk for suicide, the importance of quick treatment responses has fostered the creation of relatively brief interventions. Finally, to facilitate research on effectiveness, but also to facilitate a rapid rate of learning for therapists, approaches have utilized treatment protocols with highly detailed and specific manuals. Thus, the appear ance of therapy for adolescents with depression has changed dramatically from one in which the adolescent guides therapy while a therapist listens and reflects, to one in which the therapist guides the adolescent to improve skills and coping strategies in a collaborative process. This process follows a flexible, but recommended order of steps.
Three forms of primarily individual treatment with some associated family involvements have been developed and evaluated in the last decades: cognitive-behavioral therapy (CBT),1 primary and secondary control enhancement training (PASCET),2 and interpersonal psychotherapy for depres sion in adolescents (IPT-A).3 A form of family therapy that contains elements of CBT, but also stresses building parenting skills and altering conflictual family relations has also been formu lated and tested.1 These approaches, described as “targeted treatments” in a more extensive review by Sherrill and Kovacs,4 have shown increased impact with depressed youth when compared to wait-list control and non specific, supportive therapies (Figure). These approaches show great promise for helping adolescents. Although recovery rates from depression are relatively high when youth are kept out of treatment or are provided with non specific therapies, the evidence-based treatments that target skills and cop ing efforts show a significant advan tage that reaches a vast majority of adolescents in immediate review and follow-ups.
This article reviews how these treatments have achieved this promise and where they stand in relation to other treatments for adolescent depression. The review describes the theoretical rationale behind each treatment package, provides a brief description of the treatment components contained in each package, and reviews the findings from controlled clinical studies.
Characteristics of Depression in Adolescence
Targeted treatments have been cre ated to address emotional, behavioral, cognitive, and social characteristics of adolescents who suffer from depression or show depressive symptoms. These characteristics have been found in empirical studies of adolescents with depression when compared to other adolescents or generated from assumptions about functioning found in depressed adults. Among a number of documented differences between youth with and without depressive qualities, adolescents with depression are less effective than others in emo tion regulation. They have trouble managing tension and anxiety; have weak problem-solving skills; engage in fewer enjoyable activities and limit their social contacts; and have think ing patterns that are generally negative in viewing themselves, their surround ings, and their future prospects. They engage in rumination and do not seek out the counsel of others to challenge their thinking patterns.5 In interpersonal relationships, adolescents that are depressed are considered to be poor at resolving conflicts or obtaining full satisfaction in relationships. This leads to them being distressed, unsup ported, and unhappy about their social circumstances. Poor social relations or problems in an important social relation are assumed to contribute to the emergence of depression, but are alsobelieved to persist during the course of the illness.6 The treatments that are evidence based may emphasize one of these characteristics, but usually these treatments incorporate interventions that address several characteristics.
Several forms of CBT recognize that adolescents who are prone to depression or are experiencing depression have a characteristic set of distortions in thinking and a diminished set of effective behaviors for coping with stress and seeking pleasant experiences. Compared to other youth who are not depressed or who are less likely to have depressive reactions to stress, adoles cents with depression are more likely to have negative beliefs about themselves, view their surroundings as being harsh, unfulfilling, or unaccepting, and con sider their prospects for future change to be minimal if not worse than they already are. This negative cognitive triad was formulated by Beck and colleagues7 in studies of depressed patients, and has been confirmed in numerous studies of adults, adolescents, and children as being highly associated with depression and depressive symptoms.8 For example, a depressed adolescent may make a mistake in school and conclude that the mistake reflects his or her status as “a total failure who will never get anything right.” In response to their depressed mood and lower levels of energy because of physiological changes in depression, adolescents become withdrawn. Diminished levels of activity lead to further decreases in mood and pessimism. Other data sug gest that adolescents with depression experience limited positive reinforce ment. This occurs because of the limited energy depressed adolescents have for activities when the physical components of the illness strike, or because of reduced resilience following stressful life events. Depressed adolescents are also less effective at obtaining positive responses from people and their envi ronment because they are less skilled in problem solving and managing their reactions.9,10 Based on effective methods used with depressed adults, treat ments have been developed to help adolescents learn ways to alter or, at least, review their thinking, increase their level of positive activities, and increase their social and problem-solving skills.
One form of CBT that has received considerable research review is based on Beck’s model of depression. It emphasizes increasing positive activities and altering thinking style in reac tion to negative events. In a treatment package of 12–16 sessions, adolescents and their parents are presented with psychoeducation to build their under standing of depression and the likely cognitive distortions that are present in depression. Following psychoeducation, adolescents are individually instructed in a step-wise fashion to notice their automatic negative thoughts, consider how to label the thoughts as distorted or overly pessimistic, and decide how to challenge the veracity of the thoughts they have about themselves and their surroundings. Additionally, adolescents are instructed in regulat ing their emotions by learning how to identify their feelings and how to use activities and distractions to improve their mood. Finally, adolescents are shown methods to solve problems in a logical, calm manner so that they can proactively avoid or resolve negative situations. Therapists use a flexible manual for intervention that incorporates one psychoeducational session; several sessions to learn how to notice automatic negative thoughts and chal lenge the true interpretations of events and the adolescent’s capabilities; several sessions to increase positive activities and learn to schedule them on a regular basis; and several sessions to teach emotion management and problem-solving methods. The adolescent is actively engaged in using methods between sessions so that he or she is able to provide “self-directed” therapy for more effective coping.
Tests of the impact of this treatment compared with other interventions have shown favorable results with clinic-referred cases. Adolescents were enrolled in CBT or a form of family therapy designed to address problems found in the families of depressed adolescents (systemic-behavioral fam ily therapy [SFBT]) or nondirective supportive therapy (NST). The thera pies are carried out for 12–16 sessions over 12 weeks with opportunity for up to four booster sessions after imme diate follow-up assessment. At the end of the initial treatment program, CBT showed substantial advantage in reducing the rate of major depressive disorder (MDD) when compared to NST, (17% versus 42%) and helped those with MDD at the beginning of the trial to recover from the condition. Adolescents with MDD who were treat ed with CBT had a recovery rate of 65% while those in SBFT and NST had simi larly lower rates of recovery (38% and 39% respectively).11 Less effective out comes were predicted by the presence of anxiety disorders in conjunction with depression, a high level of cogni tive distortions, and a stronger sense of hopelessness at the beginning of treatment.12 At 2-year follow-up there were no statistically significant differences among the treatment groups in the rates of MDD, even though the numbers favored CBT (6% compared to 23% for SBFT and 26% for NST). Conclusively, CBT was perhaps effec tive in helping adolescents during the episode even though adolescents in other conditions showed some recovery in the long term. Considering the nega tive impact that depression has upon school performance, social adjust ment, and substance use, reducing the length of depressed episodes is a con siderable benefit.1
Another form of CBT that has been developed and carefully scrutinized has stressed combat of diminished posi tive experiences by helping adolescents engage in an increased number of pos itive activities and interactions. The treatment takes the form of a group psychoeducational effort entitled the Adolescent Coping with Depression Course (CWD-A). In this program, ado lescents participate in either a group of 14 sessions spread over 7 weeks (CWD A), or in a group that adds 7 sessions of parent groups to the adolescent group (CWD-A+P). The intervention seeks to teach emotion regulation by hav ing adolescents learn to monitor their mood and learn relaxation procedures. Participants expand on their behavioral repertoire by increasing pleasant activi ties and social contacts. Adolescents also practice constructive thinking strategies to counteract their negative cognitive set. To address social prob lems and possible skills deficits, ado lescents are taught specific social skills for conversations and friendship main tenance, assertive skills for problem interactions, and methods for commu nicating more effectively. They are also instructed to use logical problem-solv ing skills before selecting a choice with the the best possible outcome. This is done by expanding the number of alter native responses that they consider and by reviewing the choices for potential consequences.
A number of randomized trials of CWD have been conducted with good results. When compared to waiting list control groups, those adolescents that participated in CWD had reductions in self-reported depression and global functioning, and fewer of them met the criteria for a diagnosis of depres sion immediately after the intervention. There was no difference in these rates for adolescents that participated in the group by itself and those who par ticipated in the adolescent and parent group. The first study of this approach found recovery to occur in 46% of the CWD groups compared to 5% in the wait-list control, while a second study found rates of 67% for CWD groups and 48% for wait-list controls. Follow-up data also found no differ ences after 2 years similar to the other form of CBT discussed.13 Expansion of the program to depressed adolescents who also had conduct disorders found improved recovery at post-intervention assessment at less robust rates (26% versus 14% for a control condition).14 Thus, the program would qualify as one that is solidly efficacious because of strong results in initial tests and replications.15
Primary and Secondary Control Enhancement Therapy
PASCET shares many qualities with CBT, however, its expanded emphasis on skills building and effectiveness warrant special attention. PASCET is designed for youths between 8 and 15 years of age. Two collections of proce dures for enhanced control and cop ing are used to integrate individual, family, and school contacts to work on skills and thoughts. The basic premise is that a child or adolescent learns skills to control situations that can be influenced by another youth, as well as thinking skills for managing situations that cannot be altered. Adolescents are given extensive psychoeducation to learn and practice the skills involved. Primary skills suggest that the child “ACT” differently. Youth are directed to use Activities that solve problems; perform Activities that are enjoyed; take steps to Calm oneself; use methods that demonstrate Confidence; and build Talents to improve effectiveness in desired areas such as sports or aca demics. Children and adolescents are also directed to use THINK skills to: Think positively; obtain Help from a friend to gain perspective on problems; Identify good aspects of even difficult situations; engage in No replaying of negative events; and Keep thinking to make sure all alternatives have been considered. Imagined situations and situations from the youth’s experience are used to help determine how he or she might apply the skills.
PASCET has been tested in school settings with good results for children and youths. The youths involved were identified as having symptoms linked to depression without necessarily meeting diagnostic criteria. On self-report measures, youths that participated in the program had decreased rates of depressive behaviors, feelings, and thoughts when compared to controls at both immediate post-evaluation and at 9 month follow-up.16 Application with a clinical sample of youths from mental health clinics that meet diagnostic criteria is being conducted currently. This study does not focus exclusively on adolescents, so its application to adolescents by themselves and with older adolescents will have to be surmised.
Interpersonal Therapy for Depressed Adolescents
IPT-A is an adaptation of interper sonal therapy (IPT), which is a highly effective method for treating adult depression. IPT and IPT-A are based on the idea that interpersonal conflicts or problems in managing transitions in relationships maintain depression even if that depression is initially caused by physical factors. Short-term focused therapy uses psychoeducation and an extensive analysis of an adolescent’s interpersonal relationships to explore sources of conflict or stress. The heavy emphasis that adolescents place on their peer and family relationships makes the treatment particularly important for this phase of development. Since adolescents find the method highly relevant and practical, engagement may be easier than other forms of evidence based treatment.
In treatment, adolescents can be seen individually, in meetings with their parents, or in groups. Adolescents are asked to consider five areas of interpersonal interactions, including separation from parents, authority problems with par ents, developing dyadic relationships, loss of relatives and friends, and rela tionships in single-parent families. Each area is explored for problems, and one area about which the adolescent feels most distressed is selected for the focus of a 12-session program. In each ses sion, adolescents are asked to provide indications of their mood, report on the status of the relationship area, and engage in active problem solving to find alternative means of resolving conflict and obtaining satisfaction in the area of concern. When indicated, adolescents may be provided with social skills training to improve their negotiation, communication, and relationship main tenance skills.
Tests of IPT-A have found good results when conducted in the setting in which treatment was created. In a controlled clinical trial with random assignment, IPT-A in comparison to clinical monitor ing (CM)—operationalized as monthly 30-minute meetings with a therapist to review symptoms and functioning—was much more effective in contributing to remission from depression. More ado lescents completed the course of IPT-A (88%) than the CM condition (46%). Additionally, at the end of the treatment period 88% of adolescents in IPT-A no longer met the criteria for depression, against 58% from the CM group. A second use of IPT-A, with a sample of adolescents enrolled in treatment in Puerto Rico using a Spanish-language version, found that IPT-A resulted in significantly diminished depressive symptoms when compared to a wait list control group, but no difference when compared to an equally effective course of CBT.17 However, those in IPT-A reported higher levels of self-esteem and social functioning when compared to the CBT group. Extending the approach for use in school mental health clinics, Mufson and colleagues18 reported rates of recovery between 50% and 75% depending on the measure used for students that participated in IPT-A, in comparison to rates of 10% to 25% recovery for adolescents that received treatment with a usual, typically sup portive and nondirective approach. This study was conducted with experi enced therapists who received a relatively brief round of training in IPT-A, suggesting that the program has much promise for dissemination. Thus, IPT-A is another form of treatment that has good empirical standing.
Systemic-Behavioral Family Therapy
Family therapy designed specifically for depressed adolescents emphasizes the repair of inappropriate interactions between the adolescent and his or her parents, poor communication among the parties, and weak problem-solving skills for the conflicts encountered as adolescents move to independence. Adolescents and their parents meet together and learn how to describe their problems with one another in open non-aggressive fashions. The family is directed to use careful, active listening skills with one another so that they can become supports for each other. Additionally, family mem bers are directed to negotiate problems using calm, logical problem-solving approaches. If there are changes that parents wish to see in their adolescent’s actions, contracts and use of rewards are developed and monitored by thera pists. As noted above, the effectiveness of SBFT is not distinctly different from NST in contributing to recovery from MDD at post-intervention assessment. However, SBFT has been found to have a positive affect on improving family relations and diminishing conflict, so it may offer assistance in those cases in which family conflict is the main source of stress in a adolescent’s life.11,12
Comparative Studies Among Evidence-Based Therapies and Status in Relation to Medication
Comparisons between evidence based approaches are limited. As noted above, CBT and SBFT show a similar impact on rates of depression, but they also demonstrate specific effects and may be used to match the refer ring circumstances. Adolescents who have participated in CBT report fewer cognitive distortions in their analysis of stressful events, while adolescents treated with SBFT report less family conflict and distress in family interactions.15 A single study that compared CBT to IPT-A found that both were equally effective in reducing depres sion in relation to a wait-list control.17
Only recently has one of the evidence based therapies been studied in relation to the most effective class of medi cations, the selective serotonin reup take inhibitors. In a comprehensive study conducted in several research centers, four conditions were randomly compared to one another with 439 adolescents who met the criteria for MDD. During 12 weeks of treatment, adolescents were randomly assigned to either placebo medication, CBT alone, fluoxetine alone, or CBT in combina tion with fluoxetine. Fluoxetine was administered in doses from 10–40 mg/ day depending on clinical response and side effects. Placebo doses were also advanced from 10–40 mg/day in a simi lar pattern. CBT was provided in 50–60 minute sessions at a rate of 15 sessions during the 12-week treatment phase. Most CBT sessions were individual, but two parent-only sessions emphasized psychoeducation about depression, and between 1 and 3 conjoint adoles cent and parent sessions were held to address conflicts or concerns.19
The results found that both medica tion conditions (alone and in combination with CBT) were superior to CBT alone and to placebo in facilitating clinical improvement. Statistically, CBT was not significantly different in comparison to placebo, while the combined treat ment and fluoxetine alone were significantly different than placebo in facilitat ing improvement on a broad range of depressive symptoms. CBT, when used in combination as well as alone, was better at reducing suicidality than were the two conditions in which CBT was lacking (fluoxetine alone and placebo). Rates of improvement for the four conditions were as follows: fluoxetine and CBT combined, 71%; fluoxetine alone, 61%; CBT alone, 43%; and placebo, 35%.
The results strongly suggest that the combined use of medication and CBT should be provided to adolescents with MDD, especially if there is significant suicidality present. CBT alone does not seem warranted for adolescents that meet the criteria for MDD, although it did reduce suicidality. It did not have a significantly different impact on other depressive symptoms. Further research with a long-term follow-up is being conducted with the sample to determine if CBT reduces or delays relapse when it is part of the package, as opposed to medication alone. This is feasible as CBT has been shown to have a significant impact in delaying relapse and enhancing recovery from a second episode of depression in adolescents.14
Despite the low level of recovery documented for CBT in relation to the placebo condition, the use of CBT may still be necessary. Although careful study has suggested that increases in suicidality with the use of medication in the early phases of treatment is man ageable with close monitoring,20 many parents and adolescents are reluctant to utilize medications for depression. CBT may provide benefits during the time that reluctance to participate in medication therapy is addressed, through careful discussions of the risks and benefits. It can be implied that CBT may also benefit from further development, as would medication efforts for severe forms of adolescent MDD, because even at their best the combined treatments left over 25% of adolescents with limited improvement.
The data indicate that forms of CBT and IPT are more effective than non specific forms of supportive therapy, generic family therapy, and relaxation treatments. These latter therapies are in turn more effective than no treatment at all for varied forms of depression in adolescents. Neither CBT nor interpersonal psychotherapy have been tested against medication alone for these varied forms of depression. However, in the case of MDD, it appears that CBT alone is not any more effective than placebo responses and is less effective than medication alone or medication in combination with CBT. CBT in conjunction with medication seems to provide a boost in impacting suicidal ideation after short-term follow-up. Its impact in long-term responsivity and diminishing relapse effects is yet to be determined.
Recommended Guidelines for Primary Care Practitioners
The collected data suggest that the targeted psychotherapies described in this article show more promise than generic or supportive therapy in helping adolescents recover from depres sion. Yet, instruction and experience in these forms of therapy is not wide spread. No form of these therapies have been developed for pediatricians or family medical practitioners, even though advanced experience in CBT has been shown to have a signifi cant affect in depression treatment.21 However, there are guidelines for two groups of primary practitioners that can be suggested based on the review. These guidelines are for practitioners with psychotherapy training and expe rience, or for practitioners who wish to facilitate treatment referrals and help adolescent patients get engaged in mental health care.
If done with diligence and care, practitioners with psychotherapy expe rience can add treatment components that are part of the effective packages. Workshops, training books, and super vision in these methods are becoming more widely available. For example, the manuals and training materials for coping with depression are avail able on a dissemination Web site22 that is intended to expand the use of this approach. Treatment approaches that are supported have characteristic components that can be incorporated in care. Candidates for inclusion are listed for critical review in the guide lines and summarized in the Table. In considering these elements of treat ment, however, it must be clear that only the full treatment packages have been tested and the impact of any component by itself is unknown.
The depressed adolescent can be helped by taking a more active approach. An increase in activities in general and an increase in activities that in the past had provided the adolescent with pleasure and a sense of mastery should be negotiated and scheduled.
General Interpersonal Interactions
In interpersonal relations, the adolescent can also be encouraged to become more communicative, more assertive, and more active in solving problems that are present. Efforts to build communication skills, assertiveness skills, and interpersonal problem-solving and negotiation skills can be incorporated through practice in therapy sessions.
Methods to improve emotion man agement with a particular focus on anxiety and despondency can be taught and applied so that the adolescent is able to cope more effectively. The goal of diminishing the number of episodes of unresolved negative emotions is central to most approaches.
Adolescents can be directed to notice the content and style of their cognitive reactions to events. Their reactions are likely to be inaccurately pessimistic or critical. A systematic means of noting those reactions, critically reviewing their accuracy, and learning to question and replace them is essential for decreasing depressive experiences. Guided instruction in doing this can be provided.
Instruction and practice in problem solving skills helps the adolescent alter outcomes and can provide hope. The depressed adolescent can be taught to approach difficult situations more effectively by learning to generate alter native ideas, evaluate their potential consequences, and implement solutions that seem most desirable.
Family support can be fostered through psychoeducation to help parents and others recognize that depression is an illness, not a choice. Family members can be directed to be calmer and less critical in interactions while they support application of the behaviors that are likely to diminish depression. Contracts for change with the use of rewards for altered response can be negotiated and implemented to diminish family conflict and improve functioning.
For practitioners interested in referring patients to others for treatment, several steps are useful: Actively help the adolescent enroll in therapy. Adolescents in general, depressed adolescents in particular, and even adolescents who have made injuri ous suicide attempts are notoriously difficult to engage in therapy. Direct guidance for the adolescent and demys tification of the therapy process may facilitate participation in treatment.
Consider several different steps:
1. Explore options at the adolescent’s school. Getting help in-house is often the easiest step for an adoles cent to take. Many school health clinics have added mental health components in the last decade and they are often informed of recent treatment developments.
2. Provide easy to read literature that explains therapy to adolescents. The American Psychological Association, the American Academy of Child and Adolescent Psychiatry, and the Association for the Advancement of Cognitive and Behavior Therapies have brief booklets and Web site information directed toward adolescents. Help the adolescent under stand that there will be talking in sessions, but practical steps are likely to be used to improve the adolescent’s situation.
3. Attempt to have a therapist meet the adolescent in your office. It may be easier for the adolescent to have contact on neutral ground. This may give the adolescent a chance to ask questions without committing to a “therapy” contact. Some practitioners may be willing to do this or be supported by their agencies to engage in such outreach.
Question your referral sources on their therapy practices. Expect your referral sources to obtain continuing education so that they are informed and trained in the most effective methods available. With the growth of empirically tested methods during the last decades, strictly adhering to a particular orientation to treatment is no longer acceptable. Expect to hear a clear outline of treatment plans for depression in adolescents before using the source for assistance.
Turn to careful and guided use of medi cations if the adolescent and the parents are interested in that route and if no viable therapy options are readily avail able. This recommendation is especially important for those suffering from MDD.
Even at their best, the application of targeted therapies over a relatively short period of time results in recovery of between 70% and 87% of adoles cents who participate. It is possible that a substantial minority of adolescents with depression require longer care. This is also true for medication treat ments. Persistent follow-up and evaluation of an adolescent’s status following a bout with depression is required. Despite advances, the field has far to go to meet the needs of the large number of adolescents (20%) who will suffer from depression. PP
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22. Download Site for Youth Depression Treatment and Prevention Programs. Available at: www.kpchr.org/public/acwd/acwd.html. Accessed August 22, 2005.
Dr. Gallagher is assistant professor of psychiatry and director of cognitive behavior therapy training in the Division of Child and Adolescent Psychiatry at New York University (NYU) School of Medicine in New York City.
Disclosure: Dr. Gallagher recieved grant support from McNeil Pharmaceuticals.
Please direct all correspondence to: Richard Gallagher, PhD, NYU Child Study Center, 215 Lexington Ave, 13th Floor, New York, NY 10016; Tel: 212-263-5840; Fax: 212-263-3690; E-mail: email@example.com.