Table 1.

Treatment course.

Sessions	Parent Psychotherapy	Child Psychotherapy	Medication Management
1–3	Focused on socialization to treatment and the CBT model, building insight into symptoms, and introducing behavioral skills to address depression (behavioral activation) and anxiety (relaxation techniques) [14]. Started behavioral activation.	PMT: Focused on understanding the child patient’s symptom history and current functional issues related to symptoms. Introduced common reasons for child misbehavior. Instructed caregivers on use of one-on-one time with the child and praising appropriate behaviors [15].	Parent: Trialed extended-release methylphenidate 18 mg. Continued trazodone 100 mg qhs, buspirone 15 mg BID, sertraline 100 mg. At follow-up, the parent reported good tolerability and possible early benefits. Child: Increased fluoxetine in 10 mg increments to 30 mg. Family reported symptom improvement. Teacher Vanderbilt scores assessed after 1 month of school were not concerning for ADHD-related symptoms. Continued to monitor for ADHD-related symptoms with caregivers.
Scores	Depression: 20 (Severe) Anxiety: 27 (Moderate)	Anxiety: 79 (Clinical) Depression: 70 (Clinical) ADHD: 80 (Clinical)
4–6	Continued with behavioral activation. Identified barriers: Poor recall, distractibility, and perfectionism. Trialed strategies to address these barriers. Introduced cognitive strategies for depression [14].	PMT: Problem-solved issues around one-on-one time, limiting screen time. Supported skills in praise, effective instruction, consistency, and approach to lying/reinforce telling the truth.	Parent: Methylphenidate was increased to 36 mg. Continued other medications. Child: Decreased fluoxetine to 20 mg due to concern for behavioral activation at 30 mg. Teacher requested to repeat Vanderbilt assessments after having more time with the patient and observing poor concentration and worsened school performance.
Scores	Depression: 16 (Severe) Anxiety: 20 (Moderate)	Anxiety: 76 (Clinical) Depression: 70 (Clinical) ADHD: 78 (Clinical)
7–9	Focused on continuing to use cognitive strategies for depression. Continued with behavioral activation, including building motivation and addressing impact of ADHD symptoms. Identified and worked to address her desire for additional support outside of her family.	PMT: Introduced reward system and discussed reinforcement schedule. Discussed approaches to lower engagement in reward system. Supported continued implementation of previously introduced strategies, such as one-on-one time, enthusiastic praise for appropriate behaviors, and actively ignoring non-dangerous, attention-seeking behaviors.	Parent: Increasing methylphenidate led to unwanted, ego-dystonic, and intrusive thoughts of suicide as well as zoning in on one thing for an unnecessary length of time. Methylphenidate was stopped and bupropion XL 150 mg was started for alternative treatment for ADHD and augmentation of depression treatment. Continued other medications. Child: Repeat parent and teacher Vanderbilts were consistent with ADHD inattentive type. Continued fluoxetine 20 mg, and started methylphenidate HCl 10 mg.
Scores	Depression: 16 (Severe) Anxiety: 16 (Mild)	Anxiety: 67 (Borderline) Depression: 63 (Normal) ADHD: 80 (Clinical)
10–12	Reviewed treatment plan, including progress towards treatment goals and plan for therapy going forward. Made plans to incorporate other therapy modalities due to mixed response to cognitive strategies and to reduce frequency of appointments to limit stress.	PMT/CBT: Problem-solved behavior around use of screens. Worked with both to develop skills in calm-down techniques. Recommended that parents request a 504 given ADHD and GAD diagnoses in addition to her medical diagnoses.	Parent: Parent did not perceive any change in symptoms on bupropion and preferred an alternate stimulant trial. Stopped bupropion and started lisdexamfetamine 10 mg with plans to increase by 10 mg every 2–3 weeks. Continued other medications. Child: Had good tolerance of methylphenidate HCl and slight initial improvements in behavior. Increased to 20 mg to target inattention and hyperactivity. Continued fluoxetine 20 mg.
Scores	Depression: 18 (Severe) Anxiety: 20 (Moderate)	Anxiety: 64 (Normal) Depression: 66-B (Borderline) ADHD: 78 (Clinical)
13–16	Introduced acceptance and commitment (ACT) model and incorporated ACT strategies, including values, committed action, and cognitive defusion [16]. Continued working on strategies to address ADHD symptoms. Transitioned to individual focused therapy.	PMT/CBT: Stopped reward system due to child’s refusal to comply. Introduced two-choice method to use instead. Caregivers reported that with consistent prompting, the child patient will perform calm-down techniques. Provided psychoeducation about emotional development and validating and labeling emotions. Made joint plans to transition out of therapy due to improvement.	Parent: Had improvement in mood/executive functioning with lisdexamfetamine; however, experienced increasing symptoms of depression. Increased lisdexamfetamine to 40 mg and sertraline to 150 mg in sequence. Symptoms of ADHD improved, but depression remained moderately severe. Cross-titrated sertraline 150 mg to duloxetine 60 mg for refractory depressive symptoms. Experienced initial partial improvement. Dose was increased to 90 mg. Continued other medications. Transitioned to individual medication management. Child: Improved daytime ADHD symptoms, but struggled in evenings with homework assignments and emotional dysregulation. Started afternoon methylphenidate IR 5 mg. Continued other medications. Transitioned to individual medication management.