"Jennifer" is a 13-year-old Caucasian female adolescent living in a middle-class family, with college-educated parents and a 16-year-old sibling. Her parents described her as "carefree" until the onset of irritability at age 11, the end of fifth grade. With the transition to middle school, increased academic demands, and more challenging peer relationships, Jennifer's irritability worsened, and she began having aggressive outbursts.
Her parents first sought outpatient treatment at age 12 for Jennifer's verbally and physically aggressive behaviors at home. Prior to referral for IPT-MBD, she and her parents participated in weekly therapy focused on behavioral management for approximately 11/2 years. She also received pharmacological treatment. Past medication history included previous selective serotonin reuptake inhibitor (SSRI) and stimulant trials. During the course of this outpatient treatment, she had four psychiatric hospitalizations, for physical aggression toward parents and for suicidal ideation, and a day hospital admission following one of the inpatient admissions. Neuropsychological testing revealed average IQ on the major domains of the Wechsler Intelligence Scale for Children-Fourth Edition and a specific weakness in her visual-spatial processing abilities, as well as mild variability in performance on measures assessing attention, executive functioning, and memory. Jennifer also had been diagnosed recently with expressive and pragmatic language disorders.
Her parents tried to maintain a unified approach to parenting; however, at times her father would take on the role of peacekeeper within the family, whereas Jennifer's mother felt they were too accommodating of Jennifer's behaviors. Her mother played a more nurturing role, and Jennifer turned to her for reassurance and support. Jennifer had a more joking/humor-based relationship with her father. Jennifer's sister felt resentful that Jennifer was the focus of the attention in the family due to her behavioral and mood symptoms and was critical of how Jennifer interacted with their parents. At times Jennifer's sister tried to take on a parenting role with Jennifer, which led to verbal altercations between them. Jennifer's parents struggled with how to manage her aggressive behaviors at home, resulting in crisis agency home visits, emergency room visits, and hospitalizations, in addition to outpatient treatment.
K-SADS-PL diagnoses at the initial visit included current SMD, attention deficit/hyperactivity disorder (ADHD), generalized anxiety disorder, and a past history of major depressive disorder (two episodes). The autism spectrum disorder (ASD) screen was completed as part of the K-SADS-PL. The screening items include questions about development of language, stereotypes, inflexible adherence to routines/rituals, restricted interests, and impairment in nonverbal behaviors (i.e., eye contact, range of facial expressions). Jennifer did not meet criteria for having any ASD symptoms on the K-SADS-PL. Her baseline CGI-Severity was 5, "markedly ill." The outbursts consisted of physical aggression one or two times per month toward parents and verbally aggressive outbursts on average three times per week, with impairment in peer, school, and home settings. She had milder outbursts several times per day, which consisted of yelling at her parents. Her baseline CDRS-R T score was 61.5, with T scores 65 and above, indicating increasing likelihood of having a depressive disorder. In addition to attending a school with a small class size, Jennifer's teachers made accommodations regarding her academic work, such as extra time for testing, preferential seating near the teacher, regular check-ins with teachers regarding homework, and extended deadlines for missing work. She began IPT-MBD treatment on a stable dose of an SSRI:escitalopram 20 mg daily:and an atypical antipsychotic:risperidone 0.25 mg in the morning and 0.5 mg in the evening; neither was changed during the 20 weeks of therapy.