(p. 251) Special Topics in FB-IPT
FB-IPT is an effective treatment for preadolescent depression, but the success of its formulation and implementation depends on careful consideration of the home environment, school factors, and individual strengths and weaknesses of both the preadolescent and the parent as they relate to their ability to engage in the treatment process. In our experiences, there are several clinical challenges that are unique to working with this age group and inherent in working dyadically with preadolescents and their parents. In this chapter we outline seven specific clinical challenges common to working with depressed preadolescents: school avoidance, therapy noncompliance, identification of comorbid diagnoses during treatment, suicidality, divorce and custody issues, multiple caregiver involvement in treatment, and parental psychopathology. We describe these challenges and strategies to manage each issue when conducting FB-IPT.
Managing School Avoidance
One of the most common issues brought up by parents of depressed preadolescents is difficulty attending school. We define school avoidance in depressed preadolescents as a problem attending school that is directly related to symptoms of depression. It is not classic school refusal stemming from a primary anxiety disorder related to separation anxiety, generalized worries about performing academically in the school setting, or fears of being negatively evaluated by teachers and peers.
As listed in Therapist Tips 18.1, school avoidance secondary to depression can be related to sleep disturbance, amotivation, poor (p. 252) concentration, and/or problems with peers. Preadolescents who have difficulty falling asleep at night may have trouble getting up for school. They may be fatigued and have difficulty concentrating in school, which can impair their ability to understand the information being presented in class. Additionally, decreased motivation can impair the quality or completion of homework. Depressed preadolescents often experience somatic complaints such as headaches and stomachaches that also can contribute to missing school. Many depressed preadolescents have difficulty initiating and sustaining positive peer relationships, which can make school a very lonely place and lead to school avoidance. Sometimes preadolescents fall into a pattern in where they start missing significant amounts of school and/or fall behind on academic work. Falling behind or doing poorly in schoolwork may be additional stressors that further increase depressed preadolescents’ reluctance to attend school.
When there are consistent problems attending school or falling behind academically, you may have already addressed its link to depression in the context of the limited sick role during the initial phase of treatment. If problems with school avoidance persist, you will need to revisit the problem in the middle phase with the preadolescent and parent. Remind them that the problem attending school is related to depression, which can impair the preteen’s ability to carry out the responsibilities normally expected of her. See Therapist Tips 18.2 for questions to ask the parent to help understand the link between depression, any school problems, and school attendance. The goal is to help identify ways the parent can help the child get to school. This often requires a good understanding of the circumstances surrounding the preadolescent’s school avoidance. (p. 253)
Once you have a good understanding of the factors contributing to the school avoidance, you will engage in active problem-solving to address the issues at hand. You may say to the preadolescent,
Sometimes when preteens get depressed, they fall into a pattern of having trouble completing homework and attending school regularly. This can happen because the symptoms of depression make it hard to fall asleep at night and can get in the way of concentrating, which is necessary to understand the schoolwork. Let’s make a plan for helping you sleep better, which may help with getting your schoolwork done and let you feel better about going to school.
Oftentimes school avoidance in depressed preadolescents necessitates communicating with the preteen’s school. If the parent feels comfortable contacting the school directly, you can ask the parent to call the teacher to discuss the preadolescent’s situation. Coach the parent to provide the teacher with some psychoeducation about depression and to ask for help in securing appropriate accommodations for the preadolescent. If the parent is not comfortable speaking with the school or if you are concerned that the parent is not able to contact the school directly, request permission to contact the school. It also can be very helpful to have an initial school meeting involving you, the parent, and teachers. One of the benefits to a school meeting is that you can ensure that the parent(s) and teachers understand their roles in helping the (p. 254) preadolescent regularly attend school, as well as discuss more formal academic accommodations that may be appropriate for preadolescents with medical conditions.
When you speak to the school on the phone or during a school meeting, provide psychoeducation about the impact of depression on the preteen’s ability to complete school work and/or attend school. Talk to the teacher about potential accommodations he or she can offer that may help the preadolescent get back on track academically and improve her ability to be successful at school. This may include a modified class schedule or extra time for completing homework assignments. For preadolescents with many somatic symptoms, educate involved school personnel that depressed preadolescents do have more headaches and stomachaches but that we do not want them to leave school when they feel this way. You can negotiate a plan that the preadolescent can go to the school nurse for 5 to 10 minutes, but she then needs to return to class unless she has a fever or vomits. The teacher can also take a more active role in helping the preadolescent have more positive social interactions by strategically placing her with other students with similar interests. Identifying a support person at school—such as a school counselor, school nurse, or teacher—with whom the preadolescent can talk during the school day can also be helpful in keeping her in school when she feels sad or frustrated. Encourage the parent to become more involved in the preadolescent’s schoolwork and to start having more frequent communication with the school so he or she can track the child’s progress. See Therapist Tips 18.3 to identify helpful strategies to promote more regular school attendance in depressed preadolescents.
Once the school is involved in helping the preadolescent manage her difficulties attending school, work closely with the parent and the preadolescent to adhere to the plan. If homework is a part of the problem, have the preteen work on homework at night with a parent’s support. If there have been problems with peers, begin setting up interpersonal experiments to help the preadolescent develop new friendships. If involving the school and parent more closely does not improve the preadolescent’s school attendance, you may consider alternative options. At certain times it may be helpful to talk to the parents about contacting the school district to request a 504 plan, which will ensure that teachers follow certain accommodations and modifications for students with a medical condition.
Therapy Noncompliance or Strategies for Engaging Ambivalent Preadolescents
Therapy for depressed preadolescents is usually adult-initiated, either because parents or teachers notice changes in a preadolescent’s mood or functioning or because of an event like a suicidal gesture or disclosing thoughts of death to another child or adult. Preadolescents often have ambivalent feelings about attending therapy appointments, and they usually need some coaching to become engaged in therapy. They may not know what to expect and may even view therapy as a punishment for misbehavior. While you will provide psychoeducation about depression and the purpose of therapy at the initial assessment, some preadolescents may remain uneasy and reticent. Here we describe several strategies to engage ambivalent preadolescents in FB-IPT.
(p. 256) Preadolescents vary greatly in their desire and cognitive/emotional ability to engage in meaningful therapy work. The inclusion of parents through the dyadic structure of FB-IPT is designed to improve preadolescents’ engagement in treatment. Preadolescents are expected to meet with you individually for just 20 minutes of the session, and parents share participation dyadic sessions. This decreases pressure on the preadolescent to be focused and engaged and increases the parent’s responsibility for generalizing the therapy skills to situations outside of the sessions. Within the FB-IPT framework, there is flexibility, so that you can adjust sessions to the cognitive and emotional level of each preadolescent.
You want to coach parents to be mindful about how they talk to their child about attending therapy. Preadolescents will notice parents’ negative comments about therapy. Remind parents to give their preadolescent permission to talk about what is going on at home, even if it does not paint the parent in the most positive light. We also suggest that the parent can make therapy a more positive experience by scheduling an enjoyable activity before or after therapy (i.e., stopping for a hot chocolate or a meal) or trying to make the most of the time they spend traveling to therapy appointments (i.e., listening to music together, talking about mutual interests).
For preadolescents who do not want their parents to leave sessions, you can allow the parent to stay for the individual component of the session, but try to coach the preadolescent to take a more active role even though the parent is present. As the preadolescent gets to know you better and begins to talk more in therapy, suggest that she try meeting with you individually. Remember to praise the preadolescent for her efforts in making changes or trying something new, no matter how small.
For a preadolescent who does not want to talk or frequently says, “I don’t know,” you may reassure her that you will only meet with her individually for half the session to allow time to talk to her parent individually or to have her parent join a dyadic session. The shortened session may remind the preteen that the session is a manageable period of time and the time frame may encourage her to actively participate (i.e., “I know meeting one-on-one is hard for you. It’s hard for a lot of kids to talk to a grown-up by themselves about their feelings. The good news is that we (p. 257) only have about 20 minutes of one-on-one time before we meet together with your mom. Do you think you could tell me more about the fight with your brother now and then I’ll do more of the talking when we meet with Mom?”). Alternatively, you may want to increase parental involvement in sessions after have tried these strategies and the preadolescent remains hesitant/resistant to engage in individual meetings. Spend more time meeting with the parent and preadolescent together during the initial part of the session, gather more information about the events in the past week, and then elicit feedback from the preadolescent based on the parent report (i.e., “Your dad said you seemed really angry when you guys didn’t go to Pizza Hut for dinner. Tell me more about what happened”). With preadolescents who completely refuse to come into the room or who are developmentally less mature, meet with the parent individually, teach him the FB-IPT skills, and have the parent model using them with the preadolescent, either in session or at home.
Using rewards for working hard in therapy is another strategy to engage preadolescents in treatment. Since the length of time that you will be meeting individually with the preadolescent is only 20 minutes, we recommend that you start with the therapy tasks and then use playing a game as a reward for participating in therapy. “I know it’s hard to talk about what’s been going on at school. How about we agree to talk about it for 15 minutes and then we can play Uno for the last 5 minutes before we meet with your mom?” We do not recommend bringing out a game in the beginning of the meeting because you will run out of time to teach and rehearse the FB-IPT skills. By offering a compromise, you are also modeling the FB-IPT skills you are trying to teach. Therapist Tips 18.4 reviews strategies for preadolescents who are difficult to engage in sessions.
maggie I’m not coming into the room!
mom This is ridiculous Maggie. I took off of work to take you to this appointment. Just come into the office.
maggie No, I told you I don’t need to go to therapy.
therapist Okay, Maggie. I’m gathering that you and your mom aren’t on the same page about coming to see me.
maggie Good guess.
therapist Does this happen a lot at home? That you and Mom aren’t on the same page?
maggie All the time, yeah.
therapist So that’s what this type of therapy is actually all about. Therapy is not a punishment for something you did. It’s about helping you and your mom be on the same page more of the time so there is less fighting at home, which could help you feel happier. I could just meet with your mom, but I think it would be a lot more helpful if I were also able to hear your perspective on things, Maggie. Do you think you might be willing to come into my office and hear a little more of what this type of therapy is all about?
Identifying Additional Diagnoses in the Course of Treatment
Despite best efforts to complete a thorough pretreatment assessment of comorbid psychiatric issues, it is inevitable that more information will be revealed as you get to know the preadolescent better. Sometimes the resolution of depressive symptoms highlights other symptoms that can no longer be accounted for by depression. For example, problems concentrating are common among depressed preadolescents, but you would expect concentration to improve as other symptoms of depression improve. If concentration does not improve, it is important to consider whether the preadolescent is also suffering from symptoms of another disorder. Parents and preadolescents may be more forthcoming as they get to know you better and may provide information that makes you suspect that there are other issues at play. As was discussed in Chapter 4, there are some comorbid diagnoses that would require you to refer for (p. 259) more specialized treatment. For example, if you find out there is significant impairment due to an anxiety disorder—such as obsessive-compulsive disorder or posttraumatic stress disorder—you may need to refer the preadolescent for more specialized treatment. The two most common comorbid diagnoses that we see in our work with depressed preadolescents are attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), which we discuss in greater detail next (also see Therapist Tips 18.5).
Attention Deficit Hyperactivity Disorder
ADHD is one of the most common psychiatric problems in children, and studies have estimated rates of ADHD from 5.9% to as high as 11% in children (Polanczyk, Willcutt, Salum, Kieling, & Rohde, 2014; Thomas, Sanders, Doust, Beller, & Glasziou, 2015; Visser et al., 2014; Willcutt, 2012). Undiagnosed ADHD has been associated with academic problems, internalizing and externalizing disorders, problems with peers, and parent–child conflict (Cussen, Sciberras, Ukoumunne, & Efron, 2012; Ek, Westerlund, Holmberg, & Fernell, 2011; Lifford, Harold, & Thapar, 2008; Ostrander, Crystal, & August, 2006; Ostrander & Herman, 2006). ADHD may even be considered a risk factor for depression because depressive symptoms tend to emerge several years after the onset of ADHD symptoms (Daviss, 2008). Peer problems and parent–child difficulties have been shown to mediate the relationship between ADHD symptoms and depression (Humphreys et al., 2013).
A depressed preadolescent with underlying ADHD may have trouble completing schoolwork, managing time, and following directions from adults, all of which could be exacerbated by depressive symptoms. As the depressive symptoms improve in treatment, if there are continued problems sustaining attention, you may begin to suspect that there are underlying attentional issues. In this case, consider referring the preteen for an evaluation and possible treatment for ADHD. It is appropriate to continue to treat the preteen’s depressive symptoms with FB-IPT and augment treatment with relevant recommendations from an ADHD evaluation (i.e., stimulant medication).
(p. 260) Autism Spectrum Disorders
Individuals with an ASD experience higher rates of comorbid internalizing and externalizing disorders (Woodman, Mailick, & Greenberg, 2016). It is not uncommon to encounter preadolescents who present with depression and who also have an underlying ASD that has been undiagnosed. This is not uncommon: ASD is more difficult to diagnose in higher functioning children (Magnuson & Constantino, 2011; Mazzone, Ruta, & Reale, 2012). During the pretreatment assessment and initial phase of treatment, you will gather a lot of information about the preadolescent’s interpersonal style and history of social interactions at home, in school, and with peers prior to the onset of this depressive episode. Some preadolescents demonstrate interpersonal deficits that predate their current depression, and some preteens have difficulty engaging in perspective taking or social problem-solving skills needed for FB-IPT. In such situations, it may become clear that these interpersonal deficits are better accounted for by an ASD (i.e., rigidity, not noticing social cues, few friendships, preference for solitary activities over social interactions, difficulty with routine transitions). Take the time with the parents in the initial phase of treatment to gather information about the nature of the preadolescent’s interpersonal problems, how long they have been going on, and even request permission to talk with teachers about the preadolescent’s social functioning with peers.
Although it may be uncomfortable to broach this topic with parents, you should introduce the possibility that the preadolescent’s long-standing difficulties with social interactions may indicate the presence of another condition an ASD. Parents may have information to share regarding previous recommendations for an evaluation, an elementary school teacher who may have asked about ASD, or a previous evaluation that produced inconclusive findings. At times, you may need to make a recommendation for neuropsychological testing or a referral for an Autism Diagnostic Observation Schedule (ADOS) assessment in order to rule-out an ASD. FB-IPT is not a recommended treatment for depressed preadolescents with comorbid ASD, primarily because difficulties engaging in perspective taking will make it hard for preadolescents with ASD to conceptualize and use FB-IPT skills. Therefore, if a preadolescent is diagnosed with an ASD, we recommend transferring her to services specific to ASD and to continue providing the preadolescent and her family with (p. 261) support and clinical monitoring until they establish care with a new treatment team.
therapist Elena, I’d like to talk to you one-on-one for a few minutes.
mom Okay, sure.
therapist As we’ve talked about before, Louis struggled in a number of areas even before he was depressed.
mom Yes, he’s never been an easy kid.
therapist I’m beginning to wonder if some of the things he struggles with—rigidity, not picking up on social cues, trouble with friendships, preference for solitary activities over social interactions, difficulty with routine transitions—are actually related to another underlying condition. Sometimes kids who struggle from a young age with these problems are diagnosed with an autism spectrum disorder.
mom Wait, are you saying that Louis is autistic?
therapist I’m not saying anything for sure, but I do think that some of the issues he struggles with could fall into the category of an autism spectrum disorder. There is a tremendous range of functioning among kids with this diagnosis.
mom This is a lot for me to take in. First depression and now autism.
therapist You’re right; but remember, we need more information to make that diagnosis. I would like you to think about it scheduling an appointment for Louis to get a formal assessment, called an ADOS, to see what’s going on.
mom I’m going to need to talk to Louis’s father about this. I don’t know. I do remember one of Louis kindergarten (p. 262) teachers making a comment about him missing a lot of social cues. And he does have a hard time with transitions.
therapist I can certainly appreciate that this is a lot to process. You don’t have to make a decision right now. We can talk more about it after you have a chance to talk to Louis dad.
Managing an Escalation in Non-Suicidal Self-Injury and Suicidality
FB-IPT is an effective treatment for preadolescents who demonstrate a passive death wish or passive suicidal ideation (SI) with a vague plan and who can contract for safety (see Therapist Tips 18.6). You will routinely monitoring depressive symptoms and suicidality during each session with the parent and preadolescent. You also need to carefully distinguish non-suicidal self-injury from suicidal intent, which is hard to do in this age group. Clarify whether there is any intent to die by asking, “When you were ___________________, what were you thinking or feeling? Did you want to die when you were _____________________?” If the preadolescent endorses non-suicidal self-injury (NSSI), you need to assess the triggers for the self-harm behaviors. Within the FB-IPT framework, examine whether the NSSI is an attempt to communicate feelings or whether it has another purpose. If it is being used as a form of communication, you can help the preadolescent develop other methods of communicating feelings to her family and peers that do not involve self-harm. If it is a means of managing feelings or a lack of feeling, help the preadolescent begin to link emotions to the situational triggers with the goal of improving recognition of emotions and expression of these in her significant relationships. If the frequency and level of risk associated with the self-harm increases, we recommend an evaluation for a higher level of therapeutic intervention.
When treating depressed adolescents with thoughts of self-harm, you will be relying on the preadolescent to communicate with her parent and for the parent to take the appropriate steps to ensure the child’s safety. Therefore, you want to be certain that you have educated the parent to check-in regularly with the child about safety and the steps (p. 263) to take in the event of an emergency. You also want to spend more time talking about distraction and self-soothing techniques—such as listening to music, watching TV, or going for a walk with a parent—that the preadolescent can use to manage suicidal thoughts at home.
If there is a worsening of symptoms or if the preadolescent continues to demonstrate significant suicidality after four weeks, we recommend that you refer to a psychiatrist to evaluate the need for medication as an adjunctive treatment. There are times when, due to immediate stressors, a preadolescent’s symptoms may worsen. In some cases, it may be appropriate to schedule an extra session in a week to help with the preteen cope with that particular crisis and to monitor her suicidality. It is often possible to continue with FB-IPT as prescribed once the preadolescent’s suicidality has been stabilized.
At other times, it may be necessary to refer the preadolescent to a higher level of care such as an intensive outpatient program, partial hospitalization, or inpatient hospitalization. If a preadolescent has a specific plan to kill herself or has engaged in any type of suicidal behavior, she likely needs a higher level of care and should be evaluated (p. 264) immediately in a psychiatric emergency room. Similarly, a higher level of care may also be needed if there is an increase in the frequency and severity of NSSI.
Divorce and Custody Issues
During the initial meeting with parents who are separated or divorced, it is important to ask about custody arrangements and ongoing legal proceedings. You will use this information to plan how to (a) manage issues of confidentiality regarding information about the preadolescent and (b) involve the parents in the treatment sessions, as well as understand the impact of the separation/divorce on the child’s depression (see Therapist Tips 18.7). Custody arrangements can impact which parent brings the child for treatment and the continuity of the parental work across sessions. It is challenging to conduct FB-IPT if a different parent brings the preteen for appointments each week due to the logistics of shared custody arrangements (i.e., one week spent with mother, alternative week with father). Parents who are undergoing custody determinations through the court as part of divorce proceedings may have differing expectations for the therapist’s role in sharing information about the preadolescent, as this may affect custody decisions. It is common for the parent initiating treatment for the depressed preteen to hope the therapist will be able to provide an expert opinion to support that parent’s custody choice. Similarly, it is common for the parent who did not initiate treatment to want equal time in bringing the preadolescent for sessions, to share his side of the story, and/or to demonstrate his commitment to the child’s therapy. Consider involving the other parent in treatment as clinically appropriate and with the custodial parent’s permission. Present it as an opportunity for both parents to come together to help their child, and educate them that more cooperation among them as co-parents will only benefit their child and that their focus needs to be on the child and not on their own conflicts. It is important to ensure that the parent(s) with legal custody give consent to treatment and to clarify expectations in regard to any legal proceedings during or after the course of treatment. (p. 265)
Strategies to Address Multiple Caregiver Involvement in Treatment
Ideally, FB-IPT should be conducted with the preadolescent and one identified caregiver so there can be continuity in teaching the FB-IPT skills and helping the preadolescent use the skills at home. If both parents can attend the sessions regularly, this can be even more helpful in supporting skills use outside of the sessions, but this is often not possible. Even having the same parent attend weekly can prove difficult for families who are balancing busy schedules and for families with multiple caregivers (divorced parents, grandparent involvement). When you introduce the preteen and family to the structure of FB-IPT, explain that the parent’s role in the treatment is to help build communication and problem-solving skills in the child and family with a goal of strengthening the parent–child relationship. At this time, discuss the importance of having parent/guardian consistency from session to session and ask the parent if it is realistic for one parent/guardian to bring the preadolescent to weekly sessions. Emphasize that consistent parental attendance will help FB-IPT be most effective. The time-limited nature of FB-IPT may help parents manage the potential stress of regularly attending weekly therapy appointments (i.e., long commute, missing work).
If it is not realistic for one parent to attend weekly sessions with the preadolescent, problem-solve with the parents to identify ways that they can work together to promote continuity in their co-parenting, (p. 266) or by adding additional sessions to meet with one or both parents (see Therapist Tips 18.8). With your help, divorced or separated parents can share the work of the treatment and identify their respective roles in supporting their depressed preadolescent.
Using the phone or telepsychiatry software to communicate with the parent who cannot attend can help maintain the integrity of FB-IPT. For example,
So, your mom will be bringing you to most of your sessions, but we know that she’s going to be traveling for work for a few weeks in March, so then your dad will be bringing you. We are going to keep Dad in the loop from the beginning by talking to him on the phone to help him understand what you’re working on, so when it is his turn to bring you in for sessions he will know what we are working on.
Other times, you may plan to work with one parent primarily but something may prevent that from actually happening (e.g., illness, work conflicts, other family obligations). Using the telephone or telepsychiatry to keep the parent abreast of what is being discussed in the sessions can be helpful, but is not a good situation for maximizing the effectiveness of FB-IPT.
In these situations, talk to the preadolescent to understand how she feels about her parent not being able to attend therapy sessions. Does her family tend to be chaotic and is an uninvolved parent part of the problem contributing to the preadolescent’s depressive symptoms? If at least one parent cannot attend sessions with the preadolescent, you need to speak directly with the parent about the impact inconsistent parental involvement has on the preadolescent and the effectiveness of the FB-IPT. You may wish to refer the family to another type of treatment that requires less parental involvement.
As noted in Chapter 1, preadolescent depression is associated with high rates of depressive disorders in parents that may contribute to negative family processes. Since FB-IPT requires significant parental involvement, it is important to understand parental psychopathology and its role in the preadolescent’s depression as well as its potential impact on treatment. Parental illness can be revealed during the initial assessment phase of treatment and may be gleaned from reports of interactions or behavior by the preadolescent. Depressed parents in particular can make the work of FB-IPT more difficult as the parent may be socially withdrawn or too irritable to effectively support the practice of new communication and problem-solving skills. You may need to meet separately with the parent and discuss your impressions about the interplay between the parent’s own mental health struggles and those of the preteen to lay the foundation for recommending that the parent seek his or her own treatment. As stated in the Parent Tips in Appendix D, it is important for parents to help themselves first in order to best help their child. You can present the analogy of “Putting on Your Own Oxygen Mask First,”
When traveling by plane, the flight attendant announces that in case of a sudden drop in cabin pressure, put the oxygen mask on yourself first, and then place the mask on your child. You can’t help your depressed preadolescent if you do not take care of yourself first.
While FB-IPT involves dyadic work with the parent and child, it may still be helpful for parents to have their own place to discuss their struggles separately in order to allow you to focus on the needs of the child. When explaining the recommendation for parents getting their own therapy, be sensitive to their possible feelings of guilt that they may have caused the child’s depression. Approach parents with a nonjudgmental attitude (p. 268) and join with them around the common goal of helping their child to feel better. Send the message that, despite their difficulties, they still play an important role in their child’s recovery. This stance will be crucial during the dyadic work in FB-IPT. In these circumstances, you also may need to provide increased coaching for the parent in using positive communication strategies with the child. Psychoeducation about the parent maintaining appropriate boundaries to avoid oversharing with the preadolescent or inadvertently using the preadolescent as support may also be helpful.
Understanding the influence of parent’s psychopathology is important for setting realistic treatment goals about the parent–child relationship. If a parent is very impaired by his or her illness, you may need to either revise the goals or identify other people in the child’s life with whom she can practice FB-IPT skills and obtain additional support. If only one parent is ill, you may want to meet separately with the other parent to discuss increasing his or her involvement in FB-IPT and additional sources of support for the preteen. If both parents are ill or if it is a single-parent family, identify other people in the child’s life who can take on a mentor role or be a greater source of support for the child’s treatment. (See Therapist Tips 18.9 for a list of strategies to address parental psychopathology.)
FB-IPT is an effective, flexible treatment that can be adapted for a wide range of individual preadolescents and family situations. This chapter illustrates how to manage certain clinical challenges that are common when working with preadolescents and their families, including school avoidance, therapy noncompliance, identification of comorbid diagnoses during treatment, suicidality, divorce and custody issues, multiple caregiver involvement in treatment, and parental psychopathology. We define each challenge, provide recommendations for managing each issue using FB-IPT, and advise when it is necessary to refer a child to a different treatment. While you may encounter other obstacles when working with preteens, we hope that you can apply some of the recommendations outlined in this chapter to the depressed preadolescents and their families with whom you work. (p. 270)