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Presented by: Kristie Ladegard, MD, Monica Morris, LCSW and Elizabeth Milhaupt, LCSW Denver Health School Based Health Centers.

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Presentation on theme: "Presented by: Kristie Ladegard, MD, Monica Morris, LCSW and Elizabeth Milhaupt, LCSW Denver Health School Based Health Centers."— Presentation transcript:

1 Presented by: Kristie Ladegard, MD, Monica Morris, LCSW and Elizabeth Milhaupt, LCSW Denver Health School Based Health Centers

2 Kristie Ladegard, MD, Denver Health Child Psychiatrist At 9 School Based Health Centers (SBHC) in Denver, CO Family Crisis Center (FCC) Substance Abuse Treatment Education & Prevention program (STEP) Outpatient Behavioral Health Monica Morris, LCSW, Denver Health Mental Health Therapist Abraham Lincoln High School SBHC, Denver, CO Elizabeth Milhaupt, LCSW, Denver Health Mental Health Therapist Place Bridge Academy SBHC, Denver, CO The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: “No relationships to disclose”

3 Background Mental health referral process Susie’s story Mental health assessment Self-injurious behaviors vs. suicidal ideation Claire’s story De-escalating techniques Jacob’s story Questions

4 After receiving a grant in 1987, Denver Health opened their first school based health center in the Denver Public School District (DPS) at Abraham Lincoln High School in 1988. In 1993, Denver Health partnered with the Mental Health Corporation of Denver (MHCD) to provide comprehensive mental health services to DPS. Currently, there are 15 health centers located in Denver Public Schools across Denver and we continue to grow. Our centers provide primary care, mental health, reproductive health education and insurance enrollment assistance services to DPS students Each center is staffed by medical and mental health professionals that specialize in pediatrics and adolescent medicine

5 Suicidal Homicidal Acutely Psychotic Gravely Disabled Self harm thoughts/ behaviors Comorbidity Stable on medication Mild to moderate symptoms No improvement after 3 months Symptoms worsen after 1 month Medication change needed

6 Change in function Grades slip Truancy Self harm/ ideation Anger/ aggression Acting out Drug/ alcohol use Suicidal ideation/ homicidal ideation Self report of physical or emotional abuse Limited support system Withdraw socially/ activities

7 12-year-old Caucasian female presenting to clinic for sports physical. Depression questionnaire (PHQ-9) reveals symptoms of depression. Due to the positive depression screen the nurse practitioner performs a mental health evaluation. Susie reports having difficulty falling asleep because she’s "thinking about things." Spends a lot of time by herself at home. Susie reports not liking herself and doesn’t think she has a good future. Brief risk assessment reveals she had suicidal thoughts a few months ago but denies current thoughts. NP notices a couple scars on Susie’s forearm and she admits to cutting but hasn’t for a couple months. Admits in the past her father would drink heavily and yell at her and her mother. Reports having flashbacks and nightmares at least two times a week. Admits to having trouble in the hallways because she is easily agitated and startles easily whenever she hears loud noises. Mental Status Exam reveals Susie sometimes hears voices calling her name and sometimes has visions of people.

8 MOC admits her daughter’s behavior has worsened over past 3 months. All agree to initiate Prozac 10mg daily. At 2 week follow up, Susie says she continues to feel sad and all agree increase to Prozac 20mg. Two weeks later, Susie reports some mood improvement but continues to worry frequently and dose then increased to 30mg daily. Susie reports being more irritable and agitated, school reports Susie has started cussing out her teachers. MOC reports Susie doesn’t sleep until midnight most evenings and is more aggressive. Susie reveals she has started cutting again. NP and MOC agree the Prozac is not helping. The family doesn’t have insurance so NP recommends Celexa because it is cost-effective. A month later, virtually all of Susie’s aggressive and self-injurious behaviors have ceased. Susie referred to outpatient mental health for therapy and med management.


10 Symptoms Mood Sleep Appetite Energy Suicide/ homicidal ideation Focus/ concentration Decreased interest/ anhedonia Feelings guilt, hopelessness, worthlessness Special Considerations Academic performance Truancy Drugs/ alcohol Decreased motivation Social isolation Oppositional Cutting Somatic complaints Eating disorder Running away Hearing voices Visions Risky Sex

11 Irritable or cranky mood Boredom, loss of interest in sports, video games; giving up favorite activities Failure to gain weight as normally expected; overeating and weight gain especially in teens Changes in sleep patterns; delays in going to or falling asleep; refusal to wake for school; early morning awakening Difficulty sitting still, pacing, or very slowed down with little spontaneous movement 1

12 Persistently tired, feels lazy Self-critical; blaming oneself for things beyond one’s control; “no one likes me, everyone hates me”; feels stupid Decline in performance in school due to decreased motivation and ability to concentrate; frequent absences Frequent thinking and talking about death; writing about death; giving away favorite toys or belongings 1

13 Approximately 4% to 8% in adolescents with male to female ratio of 1:2 Approximately 2% in children with male to female ratio of 1:1 2 Risk of depression increases by a factor of 2 to 4 after puberty especially in females 3 Cumulative incidence by age 18 is approximately 20% in community samples 4 Approximately 5% to 10% children and adolescents have subsyndromal symptoms of MDD 5

14 Comorbidity is common; 40% to 90% of youth with depressive disorder also have other psychiatric disorders and up to 50% have two or more comorbid diagnoses 5 Most frequent comorbid diagnoses are: Anxiety disorders Disruptive behaviors ADHD Substance use disorders 5

15 Prozac (Fluoxetine) is the most studied and is the only FDA approved antidepressant to treat MDD in children younger than 7 years 6 Zoloft (Sertraline) has shown to provide efficacy in one of two randomized controlled trials (RCTs) 6 Celexa (Citalopram) has one positive randomized control trial for treatment of depression 6 Do not use doses higher than 40mg. Lexapro (Escitalopram) FDA approved for treatment of depression ages 12-17 (some insurances won't cover unless tried 2 other SSRI's) has two positive randomized control trials 7

16 Wellbutrin (Bupropion) no RCTs, small open-label studies have suggested effectiveness in treating adolescent depression, Contraindicated with presence of seizure disorder and bulimia 5 Remeron (Mirtazepine) no RCT's Effexor (Venlafaxine) shown to be superior to placebo in adolescents but not children 6 Avoid Paxil; investigators found that suicidal thoughts and attempts were roughly twice as high among children and adolescents taking Paxil in the United Kingdom than among those taking a placebo (3.2% vs. 1.5%) 8 Tricyclic Antidepressants (TCA's) are not recommended due to lack of proved efficacy along with the risk of cardiac arrhythmia, and can be fatal after an overdose 6 Monoamine Oxidase Inhibitors have a lack of published data demonstrating efficacy in children and adolescents They also have multiple significant drug and food interactions. 9

17 Share decision making with client and family Review side effects: Most common with SSRI's include gastrointestinal symptoms, sleep changes, restlessness, headaches, diaphoresis, changes in appetite, and sexual dysfunction 5 Medication commitment Continue for at least 4-8 weeks See client after 2 weeks with therapist visiting in between medication follow up appointments

18 The Food and Drug Administration (FDA) published in 2004 a "black box" warning on all antidepressants, indicating an increased risk of suicidality in children and adolescents given antidepressant medications The FDA found that after reviewing 23 clinical trials with more than 4300 child and adolescent patients being treated with 9 different antidepressants that the rate of suicidal thinking and behaviors were 2% for patients on placebo verses 4% among patients on antidepressants No completed suicides occurred in these studies A more recent study found the risk to be around 3% in those on medication and 2% in those on placebo 10

19 Since the FDA issued a black box warning, there has been a decline in antidepressant use, but an increase in completed suicides in adolescents in both the United States and the Netherlands. Although it is not clear how these trends are related this is the first increase in suicide rate reported in over a decade 11

20 The consequences of childhood and adolescent depression are serious Patients may have ongoing problems in school, at home, and with their friends 40% will go on to have a 2nd episode of depression in 2 years Increased risk for substance abuse, eating disorders, and teen pregnancy It is estimated that depression increases the risk of a first suicide attempt by at least 14 fold 8 With careful monitoring, the development of a safety plan, and the combination of medication with psychotherapy, the risk of suicide can be managed

21 In 2009 the U.S Preventative Services Task Force published a paper calling for an annual depression screening for all teen ages 12-18 The Institute of Medicine and National Research Council also issued a paper calling for evidenced-based screening of adolescents and highlights primary care settings as a key location for screening PHQ-9 was developed by researchers at Columbia University and is an easy and effective screening tool


23 Self-Injurious Behaviors “Self Injury is intentional, non-life threatening, self effected bodily harm or disfigurement of a socially unacceptable nature, performed to reduce psychological distress.” 12 Self Injury is a coping mechanism; it is an attempt to survive and manage the affect of an overwhelming experience or emotion. Injuries are generally non-life threatening, repeated pattern of self-injury. Must assess plan, means, and intent Intent is to escape pain or terminate consciousness There is rarely chronic repetition; some repeatedly overdose Persistent feelings of helplessness and hopelessness, little or no future casting, all or nothing thinking 13 Other lethal means Suicidal Ideation

24 14 year old female presenting to the clinic for gastrointestinal distress for 3 rd time this week Claire seems very tense and agitated during evaluation Claire reports feeling anxious about school and her mother often Feels nauseous and has butterflies in her stomach; reports that her body tenses and she has difficulty focusing. Claire admits to spending two hours daily cleaning her house to "keep her mind off of what happened in the past". Claire reports being sexually assaulted a year ago by her stepfather. Since then, reports having flashbacks, nightmares and insomnia Avoids places, people, or things that remind her of the trauma and sometimes has anger outbursts Describes mood as either angry or sad most days and has feelings of helplessness Risk assessment reveals history of suicidal thoughts but denies any current SI/HI.

25 Prescribed Prozac 10mg daily to target her anxiety/ mood symptoms. A month on the 10 mg dose, the medicine seems to help some but she was still getting angry with her mother most days. PA increases Prozac to 20mg daily. Mother reports that Claire is still yelling at her, aggressive towards her sisters, and seemed to be more restless around the house. PA, Claire, and mother agree to discontinue Prozac and is placed on Zoloft 25mg daily. Two weeks later Claire reports some reduced moodiness and irritability and dose is increased to 50mg. Six weeks later, Claire seems stable on the 50 mg. Clair and mother report her mood symptoms have improved significantly. Claire says she is happier and less irritable and school reports she is completing her work more consistently.

26 Symptoms Worries Obsessive thoughts Nightmares Avoidant behaviors Panic attacks Sleep Focus/ concentration Suicide/ homicidal ideation Special Considerations Somatic complaints Social isolation Truancy Academic performance Drugs/ alcohol Decreased motivation Oppositional Hearing voices Visions

27 6 to 20% diagnosed with MH have a anxiety diagnosis One sample of adolescents and young adults indicated that the overall lifetime prevalence of PTSD in the general youth population was 9.2%. A recent national sample of adolescents (12–17 years old) indicated that 3.7% of male and 6.3% of female adolescents met full diagnostic criteria for PTSD. Children with PTSD often have comorbid psychiatric conditions. PTSD commonly occurs in the presence of depressive disorders, ADHD, substance abuse, and other anxiety disorders 14 Prevalence rates for having at least one childhood anxiety disorder vary from 6% to 20% over several large epidemiological studies 15

28 Anxiety disorders are highly comorbid with other anxiety disorders and with other psychiatric disorders including depression, ADHD and substance abuse. Other commonly co-occurring conditions include oppositional defiant disorder, learning disorders, and language disorders. Comorbid disorders may affect functioning and treatment outcome. They should be assessed and may benefit from being treated concurrently with the anxiety disorder. Clinical studies have shown that as many as one third of children with ADHD have co-occurring anxiety disorders. Children with anxiety disorders are at greater risk of alcohol abuse in adolescence. Comorbid alcohol abuse/dependence in adolescents should be assessed and considered in treatment planning with anxiety disorders 15

29 Consider medication when (1) anxiety disorder symptoms are moderate or severe (2) impairment makes participation in psychotherapy difficult (3) psychotherapy results in partial response 2 Prozac (Fluoxetine) has one RCT for SAD, GAD, and SP 6 has an open label study for Post Traumatic Stress Disorder (PTSD) symptoms in Turkish children that were in an earthquake 14 Zoloft (Sertraline) has one RCT for GAD 6 and one RCT for GAD, SP, and SAD which showed that combination treatment (psychotherapy plus medication) was more effective than either medication or psychotherapy alone 16 Luvox (Fluvoxamine) has one RCT for Separation anxiety disorder (SAD), Generalized anxiety disorder (GAD), and Social Phobia, (SP). Children and adolescents with less comorbid depressive symptoms had the best response. 6

30 Paxil (Paroxetine) has one RCT for Social Phobia 6 Celexa (Citalopram) has an open label study that was shown to be effective for Post Traumatic Stress Disorder (PTSD) 9 Effexor (Venalfaxine) has one RCT for GAD and SP 15 Anafranil (Clomipramine) a TCA, has one RCT for Obsessive Compulsive Disorder but not other childhood anxiety disorders 15 Other TCAs have not been found effective for childhood anxiety disorders 15 Buspar (Buspirone) may be an alternative to SSRI's for GAD in youth but has no published controlled trials 15

31 Benzodiazepines have not shown efficacy in controlled trials in childhood anxiety disorders. Have cognitive side effects which may impair learning and school performance. Can cause physical dependence. Contraindicated in adolescents with substance abuse 15 Clonidine (Catapres) has 2 open studies that have been found to decrease anxiety, impulsivity, and PTSD hyper arousal symptoms in children with PTSD 14 Inderal (Propranolol) has an open study that showed a decrease in re-experiencing and hyper arousal symptoms in children with PTSD symptoms 14 Desyrel (Trazodone) no RCT’s often used for insomnia related to depression or anxiety Minipress (Prazosin) no RCT’s, positive case studies in adolescents, used for nightmares and insomnia in adolescents with PTSD 17

32 Although all antidepressants have a black box warning, no individual childhood anxiety study has found a statistically significant increase in suicidal thoughts or behaviors 6 The Research Units on Pediatric Psychopharmacology Anxiety Study Group (RUPP) indicate that clinicians should consider increasing SSRI doses for patients, if significant improvement is not achieved by the 4th week of treatment 15 May consider a medication-free trial for children who have a significant reduction in anxiety or depressive symptoms (sxs) on an SSRI and maintain stability in these sxs for one year. The trial off should be during a low stress period and should be restarted if the child or adolescent relapses 15

33 Tree Meditation Visual Container Deep Belly Breathing Light Stream Bilateral tapping Emotional Freedom Technique (EFT)

34 Diaphragmatic or belly breathing encourages full oxygen exchange and is one of the body’s most strongest abilities to self heal. Slows the heartbeat and can help to lower or stabilize blood pressure 18

35 1. Place hand on lower belly 2. Breathe in through nose for count of 3 (blowing up belly like a balloon) 3. Hold for a count of 2 4. Breathe out through mouth for count of 5 (releasing air in belly) 5. Repeat 5- 10 times 6. Can add visualization by breathing in a color representing calm and out a color representing the stressor, filling your body with the calm color.

36 15-year-old high school sophomore seen in school clinic after getting into a physical altercation with a peer. School reports he has been suspended three times this year. Jacob admits to failing all of his classes. Jacob and his mother confirm he has struggled academically since the first grade. Jacob struggles with completing assignments, is forgetful, talks during class, is disorganized and engages in impulsive behaviors. Teachers have expressed some concern about ADHD behaviors several times over the years. Past PCP placed him on Strattera but discontinued usage after two weeks with no marked improvement in behavior.

37 Completed Vanderbilt scale showed high scores in inattention and hyperactivity. NP prescribed Jacob Methylphenidate 10mg one tab po BID. At 2 week follow up, Jacob states his mood has been fluctuating; he feels fine in the morning but gets more irritable during lunch time. Teachers report he is getting more work done in their classes but is more disruptive and oppositional around 10:30 am and 2pm. NP discontinued Methylphenidate and prescribed Concerta 36 mg po q am. Since starting the Concerta, Jacob’s academic performance and behavior improved and he has received no school disciplinary actions.

38 Symptoms Focus/ concentration Impulsivity Energy Oppositional behaviors Disruptive behaviors Mood Sleep Special Considerations Academic performance Truancy Substance use Social isolation Oppositional ADHD symptom scale Low self-esteem Suicide/ homicidal ideation

39 Combined Type: 6 or more symptoms of both hyperactivity-impulsivity and inattentive that have persisted for at least six months. Most children and adolescents with the disorder have the Combined Type. Predominantly Inattentive Type: 6 or more symptoms of inattention (fewer than six symptoms of hyperactivity-impulsivity) Predominantly Hyperactive Type: 6 or more symptoms of hyperactivity-impulsivity (fewer than six symptoms of inattention)

40 The prevalence of ADHD was found to be 6.7% by the U.S. National Health Interview Survey. The Centers for Disease Control and Prevention found the lifetime childhood diagnosis of ADHD to be 7.8% 19 It is commonly accepted that ADHD is more common in boys than in girls, at a ratio ranging from 2.5: 1 to 5.6: 1 9

41 It is well established that ADHD frequently is comorbid with other psychiatric disorders. Studies have shown that 54% to 84% of children and adolescents with ADHD may meet criteria for oppositional defiant disorder (ODD); a significant portion of these patients will develop conduct disorder. 15% to 19% of patients with ADHD will start to smoke or develop other substance abuse disorders. Depending on the precise psychometric definition, 25% to 35% of patients with ADHD will have a coexisting learning or language problem and anxiety disorders occur in up to one third of patients with ADHD 19

42 Stimulants are 1 st choice agents due to greatest efficacy with mild tolerable side effects. Double blind, placebo controlled trials in both children and adults 65% to 75% of subjects with ADHD were clinical responders to stimulants compared to 4% to 30% of subjects with placebo. Providers may choose methylphenidate or amphetamine since evidence suggests both are equally efficacious. Use short acting stimulants in small children (<16kg or < 35lbs) in weight. 19 Advantages of sustained release medications: 1) once a day dosing, 2) no interruptions for school, 3) periods of rebound and irritability are avoided, 4) have been shown to be equally efficacious as immediate release medications, 5) greater convenience, 6) confidentiality, 7) better compliance, 8) studies show long-acting Methylphenidate may improve driving performance in adolescents compared to short acting methylphenidate. 6

43 Side effects of stimulants to monitor include: 1) decreased appetite 2) sleep problems 3) irritability 4) headaches 5) stomachaches 6) skin picking 7) may develop tics 9 Although stimulants may lead to time –limited delay of growth in some children, no long-term effects on growth of final adult height are apparent. Children with stimulants achieve their predicted adult size 9 Monitoring of stimulants: before starting a stimulant it is recommended to get a physical exam, blood pressure, pulse, weight, and height. Once on a stimulant check height, weight, blood pressure and pulse initially after starting the medication, or when a change of dose is made, and when dose is established then check every 3 months 6 After starting the stimulant, may titrate upward every 1 to 3 weeks until symptoms of ADHD remit, or maximum dose is reached, or side effects are too severe.

44 Nonstimulant medications: Strattera (Atomoxetine), Wellbutrin (Bupropion), and alpha-adrenergic agents like Tenex, Clonidine and Intuniv Consider Strattera and other nonstimulant medications when: 1) patient cannot tolerate stimulant therapy, 2) active substance abuse, 3) have comorbid anxiety, 4) have cardiac problems but still check with a cardiologist Studies show that although Strattera is superior to placebo at week one of trials, the greatest effects were observed at week 6, therefore it is important to maintain a full therapeutic dose for at least several weeks to obtain the full effect 19 Stimulants should not be used in children and adolescents with preexisting heart disease or symptoms suggesting significant cardiovascular disease unless cleared and evaluated by a cardiologist. This may include: history of severe palpitations, fainting, exercise intolerance not accounted for by obesity, or strong family history of sudden death, postoperative tetralogy of Fallot, coronary artery abnormalities, and subaortic stenosis 19

45 DSM-IV TR and V: DSM-V was released at the annual APA’s meeting May 2013. Depressive Disorders DSM-IV diagnoses: Anxiety Disorders DSM-IV diagnoses: ADHD DSM-IV diagnosis: New info added to the ADHD diagnosis in the DSM-V: Other changes from DSM-IV TR to DSM-V: Vanderbilt Assessment Scales (VAS) as referenced in the ADHD vignette: VAS assessment and follow up forms for Parent and Teacher in English and Spanish: De-Escalating Techniques: Tapping, container & light stream: &id=9082:three-strategies-for-closing-incomplete- sessions&catid=47:refinements-to-eft&Itemid=3212 &id=9082:three-strategies-for-closing-incomplete- sessions&catid=47:refinements-to-eft&Itemid=3212


47 Kristie Ladegard, MD Monica Morris, LCSW Elizabeth Milhaupt, LCSW Denver Health School Based Health Centers: 303-602-8958

48 1 ParentsMedGuide.Org. Retrieved from 2 Birmaher B, Ryan ND, Williamson DE et al. (1996), Childhood and adolescent depression: a review of the past ten years. Part I. Journal American Academy Child Adolescent Psychiatry 35: 1427-1439. 3 Angold A, Costello EJ, Worthman CM (1998), Puberty and depression: the roles of age, pubertal status and pubertal timing. Psychol Med 28: 51-61. 4 Lewinsohn PM, Rohde P, Seeley JR (1998), Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications. Clinical Psychological Review 18: 765-794. 5 American Academy of Child and Adolescent Psychiatry, (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. Journal of the American Academy of Child and Adolescent Psychiatry (46)11 (1503-1526) 6 Sadock J.Benjamin, Sadock A. Virginia (2009) Concise Textbook of Child and Adolescent Psychiatry. Pataki SC, Ahmad S, eds. Philadelphia: Lippencott Williams and Wilkins 7 Forest Laboratories, Inc. (December 2012). Lexapro Prescribing Information. Retrieved from

49 8 American Academy of Child and Adolescent Psychiatry. (2010) FDA Action on Paxil. _action_on_paxil 9 Dulcan K. Mina, Wiener M. Jerry (2006) Essentials of Child and Adolescent Psychiatry. Dulcan KM, Wiener MJ, eds. Washington D.C.: American Psychiatric Publishing Incorporated. 10 Bridge JA, Iyengar S, Salary CB., Barbe P, Birmaher B, Pincus HA, Ren L, & Brent DA. (2007). Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. Journal of the American Medical Association 297: 1683-1696 11 Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, ErkensJA, Herings RMC, Mann JJ, Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents American Journal of Psychiatry 164:1356-1363, September 2007 12 Walsh, B. W. (2006) Treating Self Injury: A practical guide, Guilford Press 13 Walsh, B. W & Rosen, P. (1988). Self mutilation: Theory, research, and treatment. New York: Guilford Press. 14 American Academy of Child and Adolescent Psychiatry (2010), Practice Parameter for the Assessment and Treatment of Children and Adolescents with Post Traumatic Stress Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, (49)4 414-430

50 15 American Academy of Child and Adolescent Psychiatry, (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders. Journal of the American Academy of Child and Adolescent Psychiatry (46)3 267-283 16 Compton S (2010), Child Adolescent Anxiety Multimodal Study (CAMS); rationale, design, and methods. Child and Adolescent Psychiatry Mental Health 4:1 17 Strawn J etal (2009), Prazosin Treatment of an Adolescent with Posttraumatic Stress Disorder. Journal of Child and Adolescent Psychopharmacology Volume 19:599-600 18 Harvard Medical School (May 2009). Take a deep breath. 9/May/Take-a-deep-breath 19 American Academy of Child and Adolescent Psychiatry (2007), Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry (46)7 894-921 Rohde P, Lewinsohn PM, Seeley JR (1991), Comorbidity of unipolar depression: II. Comorbidity with other mental disorders in adolescents and adults. Journal of Abnormal Psychology 100: 214-222. Fombonne E, Wostear G, Cooper V, Harrington R, Rutter M (2001), The Maudsley long term follow-up of child and adolescent depression 1. Psychiatric outcomes in adulthood. Br J Psychiatry 179: 210-217.

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