Maternal Borderline Personality Disorder Severity and Parenting Behaviors During Conflict Discussions With Adolescent Offspring.

Examining the impact of maternal borderline personality disorder (BPD) on parent-child interactions could elucidate pathways of intergenerational risk and inform intervention. The current study used an expanded version of the Observing Mediational Interactions to investigate (a) associations between maternal BPD symptom severity and mediational parenting behaviors during conflict discussions with clinically referred early adolescent offspring (N = 56, age = 10-15, 54% female) and their mothers, and (b) the potential moderating role of early adolescent BPD symptom severity in those associations. Consistent with hypotheses, mothers with higher levels of BPD symptom severity engaged in fewer positive emotional/attachment-based behaviors and more negative (i.e., invalidating, controlling, coercive, or insensitive) parenting behaviors. Only parent-reported, but not self-reported, adolescent BPD severity moderated these associations; maternal BPD severity was significantly associated only with negative parenting in dyads with low-to-moderate levels of parent-reported adolescent BPD severity. We discuss implications including targeting attachment-based and negative parenting behaviors in intervention.

Psychometric properties of the Observing Mediational Interactions (OMI) coding system during mother-adolescent conflict discussions.

Background: Observational assessments of parent-adolescent conflict can guide interventions to prevent and reduce conflict and mental health problems. The authors identified the Observing Mediational Interactions (OMI) as a particularly useful coding system for examining parent-adolescent conflict. The OMI is the observational measure used in the Mediational Intervention for Sensitizing Caregivers (MISC) and quantifies emotional (attachment-based) and cognitive (learning-based) behaviors during caregiver-child interactions. Objective: The overall aim of the current study was to tailor and evaluate the OMI specifically for observing conflict interactions. Method: Conflict discussions between 56 clinical youth aged 10-15 years and their mothers were coded using the OMI. Reliability, construct validity, and associations with affect following the conflict discussion were examined. Results: Analyses revealed that the OMI demonstrated adequate internal consistency, interrater reliability, and construct validity in terms of associations with an alternate observational measure and parent-reported family functioning and stress. Additionally, mothers who engaged in fewer negative parenting behaviors reported greater positive affect following the conflict discussion, controlling for baseline affect. Conclusions: Taken together, findings support the use of the OMI in future studies. While further research should attempt to extend findings to other populations and settings and elaborate the coding instructions as needed, researchers can use the OMI to inform ongoing adaptations of MISC and identify targets for prevention and intervention more broadly.

Operationalizing intimacy and identity aspects of personality functioning in relation to personality disorder in adolescents.

According to dimensional models of personality pathology, deficits in interpersonal (intimacy and empathy) and self (identity and self-direction) function (Criterion A) are core to all personality disorders. These aspects of personality functioning (Criterion A) have seldom been evaluated for how they might relate to one another in the context of personality pathology in adolescents. Moreover, the use of performance-based measures to evaluate aspects of Criterion A function remains an untapped resource. Therefore, the present study aimed to evaluate relations between two features of Criterion A, maladaptive intimacy and maladaptive (or diffused) identity, in adolescence. For intimacy, we leverage a performance-based approach to studying intimacy, operationalized in a developmentally relevant way (perceived parental closeness). For identity, we rely on a validated self-report measure of identity diffusion. We examined the relationship between these features with each other and their relations with borderline features. Additionally, we explored whether identity diffusion mediated the expected relationship between perceived parental closeness and borderline features. We hypothesized that greater distance in perceived parental closeness would be associated with higher levels of borderline features, as well as higher levels of identity diffusion, and that identity diffusion would account for the relationship between intimacy and personality pathology. The sample included 131 inpatient adolescents (M age = 15.35, 70.2% female). Results indicated that intimacy, operationalized as perceived parental closeness, with both mothers and fathers was significantly associated with levels of identity diffusion and borderline features. In addition, greater feelings of closeness with parents were associated with lower severity of borderline features via healthier identity function. Implications of the results, limitations, and future directions are discussed.

Attitudes, Clinical Practices, and Perceived Advocacy Needs of Professionals With Interests in Personality Disorders.

Experts in personality disorders (PDs) generally prefer dimensional diagnostic systems to categorical ones, but less is known about experts' attitudes toward personality pathology diagnoses in adolescents, and little is known about public health shortfalls and advocacy needs and how these might differ geographically. To fill these gaps, the International Society for the Study of Personality Disorders surveyed 248 professionals with interests in PDs about their attitudes toward different diagnostic systems for adults and adolescents, their PD-related clinical practices, and perceived advocacy needs in their area. Results suggested that dimensional diagnostic systems are preferable to categorical and that skepticism about personality pathology in adolescents may not be warranted. The most pressing advocacy need was the increased availability of PD-related services, but many other needs were identified. Results provide a blueprint for advocacy and suggest ways that professional societies can collaborate with public health bodies to expand the reach of PD expertise and services.

Levels of Personality Functioning Questionnaire 12-18 (LoPF-Q 12-18): Factor Structure, Validity, and Clinical Cut-Offs.

The Levels of Personality Functioning Questionnaire 12-18 (LoPF-Q 12-18) is the only self-report measure informed by the Level of Personality Functioning (Diagnostic and Statistical Manual of Mental Disorders [5th ed.; DSM-5; American Psychiatric Association, 2013]) Alternative Model of Personality Disorders developed for adolescents. The present investigation includes two studies evaluating the English LoPF-Q 12-18. In Study 1, single-factor and bifactor structures (unidimensional severity criterion and four specific factors: identity, self-direction, empathy, intimacy) were evaluated in an ethnically diverse community sample (N = 453; age 10-18; 57% female). Study 2 used a community control (n = 298; age 10-18; 54.4% female) and clinical sample (n = 94; age 11-18; 58.5% female) to examine reliability, validity, and clinical utility. Study 1 results supported the bifactor model, with a robust general factor and little multidimensionality caused by the group factors, suggesting an essentially unidimensional structure. Study 2 revealed good internal consistency and construct validity and provided clinical cut-offs, supporting the use of the LoPF-Q 12-18 total score in research and clinical applications.

Does coding internal working models of attachment have to be so hard?

The Child Attachment Interview (CAI) has demonstrated promise in youth, yet widespread use is thwarted by the need for interview transcription, face-to-face training, and reliability certification. The present study sought to examine the empirical basis for these barriers. Thirty-five archival CAIs were re-coded by: (1) expert coders (i.e., trained and reliable) without access to transcripts, (2) trained coders who had not completed reliability training, and (3) novice coders who had no formal training. Agreement with consensus classifications was computed with the expectation of moderate agreement. Results supported coding by experts without transcription of the interview. Near-moderate agreement preliminarily supported the use of trained coders who have not attempted reliability certification with appropriate caveats. While moderate agreement was not achieved for novice raters, findings suggest that self-paced training options for the CAI may hold future promise. These contributions erode a number of significant barriers to the current use of the CAI.

Maternal interpersonal problems and attachment security in adolescent offspring.

BACKGROUND: Research on parent-level factors linked to adolescent attachment security would inform interventions to prevent or reduce youth psychopathology and other negative outcomes. The current study examined one relevant parent-level variable: maternal interpersonal problems. Interpersonal problems, a key characteristic of personality pathology, are well described by the interpersonal circumplex (IPC) and have been shown to be associated with maladaptive adult attachment in close/romantic relationships; however, studies have not examined relationships with offspring attachment. Therefore, the first aim of the current study was to examine the relationship between maternal interpersonal problems and adolescent attachment insecurity. Based on previous evidence that parents' recalled bonding with caregivers is associated with the quality of bonding and attachment with offspring, the second aim was to examine whether mothers' recalled bonding with their own mothers partially explained this relationship. METHODS: Participants included 351 psychiatric inpatient adolescents (Mage = 15.26, 64.1% female) and their biological mothers. Logistic regressions tested whether maternal interpersonal problems were associated with Child Attachment Interview classifications (secure vs. insecure; secure vs. preoccupied vs. dismissing; not disorganized vs. disorganized). A mediation model (N = 210) tested whether the relationship between maternal interpersonal problems and adolescent attachment was mediated by the mother's recalled maternal bonding. RESULTS: Maternal interpersonal problems were associated with insecure (vs. secure), dismissing (vs. secure), and preoccupied (vs. secure) attachment. There was no significant relationship between maternal interpersonal problems and disorganized attachment. Mediation analyses showed that maternal interpersonal problems were indirectly related to adolescent attachment security via the mother's recalled maternal care, though only a small amount of variance (7%) in adolescent offspring attachment was accounted for by the model. CONCLUSIONS: Results provide the first evidence that maternal interpersonal problems are associated with higher likelihood of insecure attachment in adolescents. Therefore, researchers could consider drawing upon the IPC literature to further examine mechanisms of intergenerational risk and to tailor interventions aimed to improve parent-child relations and attachment. Additionally, findings highlight the mediating role of the mothers' recalled experiences with caregivers in the transmission of risk, suggesting attachment-based or mentalization-based interventions may be helpful for mothers with interpersonal problems and personality pathology.

The incremental utility of maladaptive self and identity functioning over general functioning for borderline personality disorder features in adolescents.

A debate has emerged regarding the nature of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Level of Personality Functioning (LPF; Criterion A) of the alternative model of personality disorder. The aim of the current study was to evaluate the distinctiveness of an aspect of LPF, namely, maladaptive self and identity function, from general psychosocial disability by evaluating its incremental utility over that of general psychosocial disability for personality disorder in adolescents. To this end, a measure of maladaptive self and identity function was administered alongside measures of general psychiatric impairment, peer problems, life satisfaction, and academic functioning in 2 samples of adolescents: a community-dwelling sample (n = 379; Mage = 14.70, SD = 1.74) and a sample of clinically-referred adolescents (n = 74; Mage = 15.05, SD = 1.47). Using hierarchical regression analyses to test our hypotheses, and consistent with the results from studies in adults, our findings showed that maladaptive self and identity function incremented general psychosocial disability in the association with borderline features with similar magnitude for clinical and community samples when considered together and separately. Results are discussed in the context of current views on the nature and meaning of LPF. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Interpersonal Problems in Parents and Adolescent Borderline Personality Disorder Features.

Research shows that parental personality pathology is associated with borderline personality disorder features and internalizing/externalizing symptoms in offspring. However, studies have been limited by DSM-IV-based assessments of parental personality pathology. The authors leveraged evidence that interpersonal problems described by the Interpersonal Circumplex align with Criterion A of the DSM-5 Alternative Model for Personality Disorders and therefore used a measure of interpersonal problems to capture parental personality pathology. The authors hypothesized that parental interpersonal problems would be associated with a latent variable of borderline features in adolescent offspring. They also examined whether this relation with offspring borderline features existed above and beyond relations with offspring internalizing/externalizing symptoms, age, and gender. The sample included 524 inpatient adolescents (Mage = 15.31, 62.4% female) and their parents (80.5% female). Parental interpersonal problems demonstrated unique relationships with adolescent borderline features and externalizing symptoms, but not internalizing symptoms. Implications of the results, limitations, and future directions are discussed.

Validation of the Emotional Tone Index for Families (ETIF): A Multi-Informant Measure of Emotional Closeness.

Despite the importance of emotional closeness (EC) in families, few researchers have accurately measured the construct in a systemic way. Additionally, existing measures rely on ratings from one informant, typically the mother, to provide information on closeness within the entire family system. We examined EC in 140 individuals (37 families) using the Emotional Tone Index for Families (ETIF), a novel, multi-informant measure that obtains bidirectional information about EC within every family relationship. The parent identified as most familiar with the family also completed two widely used single-informant measures: The McMaster Family Assessment Device and the Family Adaptability and Cohesion Evaluation Scales, version IV. The ETIF exhibited good test-retest reliability, high internal consistency, and concurrent validity with the single-informant measures. Though the primary respondent scores correlated highly with overall family closeness, results revealed only a modest association between closeness ratings within each dyad and parents rated higher levels of closeness toward their children than children rated closeness toward parents. These findings suggest that ratings from multiple informants provide valuable information about discrepancies in perceived closeness between family members and other complex family dynamics that cannot be captured by single-informant measures. Limitations, future directions, and implications for practice are discussed.

A pesar de la importancia de la cercanía emocional en las familias, pocos investigadores han medido con precisión el constructo de una manera sistémica. Además, las herramientas de medición existentes dependen de las valoraciones de un informante, normalmente la madre, para proporcionar información sobre la cercanía dentro de todo el sistema familiar. Analizamos la cercanía emocional en 140 personas (37 familias) usando el Índice de Tono Emocional para las Familias (ITEF), una herramienta de medición novedosa que obtiene información bidireccional sobre la cercanía emocional dentro de cada relación familiar por parte de varios informantes. El progenitor identificado como el más familiarizado con la familia también completó dos evaluaciones de un solo informante ampliamente utilizadas: el Dispositivo de McMaster de Evaluación Familiar (McMaster Family Assessment Device) y las Escalas de Evaluación de la Cohesión y la Adaptabilidad Familiar (Family Adapatability and Cohesion Evaluation Scales), versión IV. El ITEF demostró buena fiabilidad de prueba-reprueba, una alta coherencia interna y validez simultánea con las evaluaciones de un solo informante. Aunque los puntajes del encuestado principal se correlacionaron en gran medida con la cercanía familiar general, los resultados revelaron solo una asociación modesta entre las valoraciones de cercanía dentro de cada díada, y los padres indicaron niveles más altos de cercanía hacia sus hijos de lo que los hijos lo hicieron hacia sus padres. Estos resultados sugieren que las valoraciones de varios informantes proporcionan información valiosa acerca de las discrepancias en la cercanía percibida entre los miembros de la familia y otra dinámica familiar compleja que no puede captarse mediante las mediciones de un solo informante. Se explican las limitaciones, las futuras direcciones y las implicancias para la práctica.

Barriers to care for adolescents with borderline personality disorder.

Intervention for borderline personality disorder (BPD) in adolescence is crucial as early onset of the disorder predicts more severe course, and intervention 'late' in the course of the disorder is associated with more negative outcomes. In spite of this, access to services is poor. This is because several unique barriers to accessing care exist for adolescents with BPD. In this article we highlight key barriers to care for adolescents with BPD utilizing a conceptual model for understanding health care access that emphasizes the interaction between patient and health care system characteristics. We conclude with proposed recommendations to address these identified barriers.

DSM-5 anxious distress specifier in patients with bipolar depression.

BACKGROUND: DSM-5 introduced the anxious distress specifier in recognition of the significance of anxiety in patients who are depressed. Studies have supported the validity of the specifier in patients with major depressive disorder (MDD). In this report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the validity of the specifier in patients with bipolar depression. METHODS: Forty-nine patients with a principal diagnosis of bipolar depression and 369 with MDD were evaluated with semi-structured diagnostic interviews, including the DSM-5 Anxious Distress Specifier Interview (DADSI). The patients were rated on measures of depression, anxiety, and irritability, and completed self-report measures. RESULTS: The majority of patients with bipolar depression met the DSM-5 anxious distress specifier, no different than the frequency in patients with MDD. The DADSI was significantly correlated with other measures of anxiety, and more highly correlated with other measures of anxiety than with measures of depression and irritability. Patients with panic and generalized anxiety disorder scored higher on the DADSI than patients without an anxiety disorder. CONCLUSIONS: The results of our study indicate that anxious distress is common in patients with bipolar depression and support the validity of the DSM-5 anxious distress specifier.

Is the DSM-5 anxious distress specifier sufficient for measuring anxiety in depressed patients? Implications for measurement-based care.

BACKGROUND: We examined whether a self-report measure of the DSM-5 anxious distress specifier, the Clinically Useful Depression Outcome Scale Anxious Distress Specifier Subscale (CUDOS-A), was as valid as a broader measure of the severity of anxiety, the Clinically Useful Anxiety Outcome Scale (CUXOS), in patients with depression. METHODS: Two hundred ninety-four patients with major depressive disorder were administered a semi-structured interview. The patients completed self-report measures of depression, anxiety, and irritability. Sensitivity to change was examined in a subset of patients. RESULTS: Both the CUDOS-A and CUXOS were more highly correlated with measures of anxiety than with measures of the other symptom domains. Patients with anxiety disorders scored significantly higher on both measures than did patients with no current anxiety disorder. Both measures were equally correlated with measures of coping, general well-being, and functioning. A large effect size of treatment was found for both measures (CUDOS-A: d = 1.2; CUXOS: d = 1.3). CONCLUSIONS: Both the CUDOS-A and CUXOS were valid self-report measures of anxiety symptom severity in patients with depression. Because anxiety is common in patients with depression, the addition of a small number of items assessing the DSM-5 anxious distress criteria should be added to depression measures and used in measurement-based care efforts.

How should the severity of depression be rated on self-report depression scales?

Almost all depression measures have been developed without discussing how to best conceptualize and assess the severity of depression. The most valid rating format of depression severity scales is unsettled and has been little studied. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the validity of alternative approaches towards rating the severity of depressive symptoms. Data was collected using TurkPrime. One hundred eighty-five participants currently in treatment for a mental health problem completed a self-report measure of depression and rated the symptoms on two 4-point ordinal scales assessing symptom frequency and symptom intensity. The respondents also rated their global level of depression severity and completed a measure of psychosocial functioning and quality of life. The symptom ratings based on intensity and frequency were highly correlated with each other, and equally highly correlated with subjects' global rating of overall severity of depression, as well as ratings of psychosocial functioning and quality of life. A composite index of severity based on the sum of frequency and severity ratings was no more highly correlated with the external validators. The results of the present study suggest that ratings of depressive symptoms based on either symptom intensity or symptom frequency are equally valid.

The Privileged Status of Knowing Mechanistic Information: An Early Epistemic Bias.

Four studies with 180 5-7 year olds, 165 8-11 year olds and 199 adults show that young children appreciate the distinctive role played by mechanistic explanations in tracking causal patterns. Young children attributed greater knowledge to individuals offering mechanistic reasons for a claim than others who provide equally detailed nonmechanistic reasons. In Study 1, 5-7 year olds attributed greater knowledge to those offering mechanistic reasons. In Studies 2 and 3, all ages (5-7 and adults for Study 2; 5-7, 8-11 and adults for Study 3) assigned greater knowledge to those offering mechanistic reasons about causally central features than those offering nonmechanistic reasons. In Study 4, all ages (5-7, 8-11, adults) modulated the epistemic bias as a function of embedding goals.

Should childhood conduct disorder be necessary to diagnose antisocial personality disorder in adults?

BACKGROUND: Antisocial personality disorder (ASPD) is the only DSM personality disorder that requires a diagnosis of conduct disorder (CD) during childhood. Previous research comparing adults diagnosed with ASPD with adults who meet all ASPD criteria except for a history of CD (referred to in this study as adult antisocial syndrome [AAS]) have reported mixed results. This study sought to clarify the differences among adults with ASPD, adults with AAS, and a large psychiatric outpatient control group. METHODS: A series of semi-structured interviews were conducted with 2,691 psychiatric outpatients. We compared groups on demographic variables, psychiatric comorbidity, symptom presentation, parental history, and psychosocial morbidity. RESULTS: Significant differences were found among ASPD, AAS, and controls in regard to demographic variables, comorbidity, symptom presentation, and parental history. The ASPD and AAS groups were similarly impaired with respect to global functioning, occupational and social functioning, and suicidality. CONCLUSIONS: Findings suggest that by including a history of CD in ASPD criteria, our diagnostic system excludes an important group of later-onset patients who also require attention and resources. Implications, limitations, and future directions are discussed.

Reliability and validity of a self-report scale for daily assessments of the severity of anxiety symptoms.

BACKGROUND: To evaluate the efficacy of rapidly effective treatments it is necessary to use measures that are designed to assess symptom severity over short intervals. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we modified our previously published anxiety scale and examined the reliability and validity of a daily version of the Clinically Useful Anxiety Outcome Scale (CUXOS-D, D indicates daily version). METHODS: Two thousand four hundred and ninety-one patients presenting for treatment to a partial hospital program completed the CUXOS-D as part of their initial paperwork and on a daily basis thereafter. Test-retest reliability was examined in 50 patients who completed the CUXOS-D twice on the same day. A subset of 73 patients was interviewed by a trained rater who administered the Hamilton Anxiety Rating Scale (HAMA) at baseline and on the day of discharge. RESULTS: The CUXOS-D had high internal consistency and test-retest reliability and was more highly correlated with another measure of anxiety symptoms than depressive symptoms. CUXOS-D scores progressively declined during the course of treatment, and scores on each successive day were significantly lower than the preceding day. The change in CUXOS-D scores was significantly correlated with a change in HAMA scores (r = 0.61, p < .001). A large effect size was found for both measures (CUXOS-D: d = 1.22; HAMA: d = 0.93). DISCUSSION: In a large sample of partial hospital patients mostly diagnosed with mood and anxiety disorders, we demonstrated some aspects of the reliability and validity of the CUXOS-D.

Validity of the DSM-5 anxious distress specifier for major depressive disorder.

BACKGROUND: DSM-5 introduced the anxious distress specifier in recognition of the clinical significance of anxiety in depressed patients. Recent studies that supported the validity of the specifier did not use measures that were designed to assess the criteria of the specifier but instead approximated the DSM-5 criteria from scales that were part of an existing data base. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the validity of the specifier diagnosed with a semistructured interview. METHODS: Two hundred sixty patients with a principal diagnosis of major depressive disorder were evaluated with semistructured diagnostic interviews. The patients were rated on clinician rating scales of depression, anxiety and irritability, and completed self-report measures. RESULTS: Approximately three-quarters of the depressed patients met the criteria for the anxious distress specifier. Patients with anxious distress had a higher frequency of anxiety disorders, particularly panic disorder and generalized anxiety disorder, as well as higher scores on measures of anxiety, depression, and anger. The patients meeting the anxious distress subtype reported higher rates of drug use disorders, poorer functioning during the week before the evaluation, and poorer coping ability compared to the patients who did not meet the anxious distress specifier. Moreover, anxious distress was associated with poorer functioning and coping after controlling for the presence of an anxiety disorder. CONCLUSIONS: The results of the present study indicate that anxious distress is common in depressed patients and support the validity of the DSM-5 anxious distress specifier.

What is anxious depression? Overlap and agreement between different definitions.

Anxiety is common in depressed patients. However, a problem with the research on the significance of anxiety in depressed patients is that anxiety has been characterized in different ways. Little research has examined the concordance and overlap between the various definitions of anxious depression. With research on the DSM-5 anxious distress specifier just beginning, it will be important to understand how defining anxious depression according to DSM-5 agrees with previously studied definitions. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the association between the DSM-5 anxious distress specifier and 6 other approaches towards defining anxious depression. Three hundred thirty-one patients with a principal diagnosis of major depressive disorder were evaluated with semi-structured diagnostic interviews. The mean number of anxious depression definitions met was 4.7 (SD = 2.1). Only 4.2% (n = 14) of the 331 patients did not meet any anxious depression definition, and 28.1% (n = 93) met all 7 definitions. The level of agreement between the definitions was significant, albeit modest (median kappa = .28). The modest association between the different definitions of anxious depression suggests that the results based on one approach towards subtyping may not generalize to the DSM-5 anxious distress specifier. It therefore cannot be assumed that the DSM-5 anxious distress specifier is valid just because other definitions of anxious depression have been shown to be valid.

Depression and substance use disorders in the offspring of depressed parents as a function of the parent's borderline personality disorder symptomatology.

BACKGROUND: Parental major depressive disorder (MDD) and borderline personality disorder (BPD) are associated with increased risk of offspring psychopathology. It is unclear whether BPD in depressed parents infers greater risk than depression alone. We hypothesized that BPD features in depressed parents would be associated with higher morbid risk of offspring MDD and substance use disorders (SUDs). METHODS: Participants included 912 psychiatric outpatients with a principal diagnosis of MDD. Semi-structured interviews determined diagnoses of parents and their 2,011 reported offspring. We compared the offspring's morbid risk of MDD and SUDs based on whether their parents had BPD, ≥1 BPD criteria, and by each criterion. RESULTS: Offspring of parents with ≥1 BPD criteria had higher morbid risk of MDD and SUDs. Differences were insignificant when comparing by BPD diagnosis. Anger and impulsivity were associated with increased risk of MDD, and emptiness was associated with increased risk of SUDs. CONCLUSIONS: Results suggest that BPD features confer additional risk to offspring beyond that of parental depression alone. Parental anger and impulsivity may be particularly important in determining risk of MDD, and parental feelings of emptiness may be particularly important for risk of SUDs. Limitations, future directions, and treatment implications are discussed.