Child and Adolescent Characteristics that Impact on Therapy

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Child and Adolescent Characteristics that Impact on Therapy


Caroline L. Donovan and Sonja March


Introduction


This chapter describes background knowledge that a therapist should possess when working with youth who experience internalizing disorders. The chapter has four major foci. First it will discuss knowledge about the internalization of psychopathology, its presentation in youth, and the impact of comorbidity on treatment. The influence of cognitive, social, and emotional developmental issues on therapy will be presented next. Then the discussion will center around the impact of individual differences among young people on therapy, with a particular focus on demographic variables, health conditions, and learning disorders. Finally, the chapter will examine the impact on therapy of environmental factors (parental psychopathology, parenting style, and conflict) and life events (stressful life events, trauma, and bullying).


Internalizing Psychopathology in Young People


Presentation in youth


Young people, like adults, may be afflicted with any of the anxiety and mood disorders outlined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA 1994) as well as with separation anxiety disorder and selective mutism, which are placed in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” Males and females are equally likely to have mood disorders in pre-adolescence, but by adolescence females are twice as likely to experience depression (Avenevoli, Knight, Kessler, and Merikangas 2008). With respect to anxiety disorders, girls are more likely to have an anxiety disorder than boys, although the differences are not large (Costello, Egger, and Angold 2005).


The presentation of mood and anxiety disorders may be somewhat different in youth from what it is in adults. For instance, for youth with mood disorders, DSM-IV adjusts time and symptom requirements. For dysthymia, symptoms need only be present for one year rather than two, while for depression youth may show irritability rather than depressed mood and failure to make expected weight gain rather than weight loss during depressive episodes. It has also been found that depressed children are more likely to present with somatic complaints than adolescents and adults, that girls tend to display more hypersomnia and reduced appetite during adolescence, and that suicide risk peaks during middle adolescence for girls and during late adolescence for boys (Avenevoli et al. 2008). Finally, for preschool children, anhedonia may manifest itself as a difficulty to enjoy play activities, and preoccupation with negative thoughts may manifest themselves as preoccupation with play themes (Luby 2010).


DSM-IV also suggests differences in the presentation of anxiety disorders in youth by comparison with adults. In specific phobia (SP) crying, tantrums, freezing, or clinging may be evident; the child may not realize that his or her fear is excessive or unreasonable; and the duration of symptoms must be at least six months. The “other” category of phobias may include avoidance of loud sounds or of costumed characters. For social phobia (SoP) crying, tantrums, freezing, or shrinking away from social situations with unfamiliar people may occur; there must be evidence that the child can develop and maintain social relationships with familiar others; the anxiety must be triggered by same-age peers as well as by adults; the child may not realize that his or her anxiety is unreasonable or excessive; and the symptoms must be present for at least 6 months. In obsessive compulsive disorder (OCD) the child may not recognize that the obsessions and compulsions are excessive or unreasonable, while in generalized anxiety disorder (GAD) only one of the six core symptoms must be present for diagnosis. For post-traumatic stress disorder (PTSD) the response may be expressed through disorganized or agitated behavior, and the re-experiencing of the event may be evidenced by repetitive play involving the trauma theme, frightening dreams where the child fails to recall or recognize the content, or episodes of re-enactment of the trauma. Thus it is evident that there are differences between the presentation of mood and anxiety disorders in youth and the presentation of the same disorders in adults.


Comorbidity


When youth show symptoms of anxiety or depression, they frequently show symptoms of other disorders as well. for anxiety disorders, comorbidity with other anxiety disorders is most common (Ollendick, Jarrett, Grills-Taquechel, Hovey, and Wolff 2008), and our own research suggests that 89 percent of the youth involved in treatment for anxiety disorders hold more than one clinical-level anxiety diagnosis. Comorbid mood disorders are also common: 10 to 15 percent of anxious youth display comorbid depression (Garber and Weersing 2010). When comorbid depression is present in anxious youth, the young person tends to be somewhat older, the anxiety is more severe, and family dysfunction is higher (O’Neil, Podell, Benjamin, and Kendall 2010). Finally, externalizing disorders such as attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD) are commonly comorbid with youth anxiety (Ollendick et al. 2008). Angold, Costello, and Erkanli (1999) suggest that around 10 percent of youth with an anxiety disorder have comorbid CD or ODD and that anxiety and ADHD co-occur at a rate three times higher than what would be predicted by chance.


Comorbidity is also very common in youth with mood disorders. Comorbidity with anxiety disorders is most commonplace, with 25–75 percent of depressed youth also being diagnosed with an anxiety disorder (Angold et al. 1999, Garber and Weersing 2010). Rates of comorbid externalizing disorders seem to vary considerably across studies: ranges between 0 and 79 percent are found for CD and ODD, and rates of 0 and 5 percent are found for ADHD (Angold et al. 1999). Of particular concern is the high rate of suicidal ideation and attempts evidenced in depressed teenagers (Kovacs, Goldston, and Gatsonis 1993). Indeed, when youth with depression have comorbid disorders, the onset of depression tends to be earlier and suicidal behavior tends to be more common (Lewinsohn, Rohde, and Seeley 1998). Furthermore, when depressed youth also demonstrate suicidality, both depression severity and impairment are greater (Barbe, Bridge, Birmaher, Kolko, and Brent 2004).


From the above discussion it would seem that comorbidity is associated with greater severity and impairment, or at least with more complex diagnostic profiles. But how does this impact on treatment? For anxiety disorders, the news is relatively good. The results of two large reviews suggest that, for the vast majority of studies, comorbidity is not predictive of poorer treatment outcome for youth with anxiety disorders (Nilsen, Eisemann, and Kvernmo 2012; Ollendick et al. 2008). Furthermore, it has been found that focusing treatment on the primary anxiety disorder also results in the reduction of comorbid anxiety disorders and of other comorbid disorders such as depression, ADHD, and ODD (see, e.g., Kendall, Brady, and Verduin 2001). It may therefore not be necessary (or efficient) for clinicians to attempt to incorporate treatment components for comorbid conditions; they should rather focus on treating the primary anxiety disorder and determine later whether additional treatment is required.


For youth suffering from mood disorders, the presence of comorbidity seems less clear in terms of its effect on treatment outcome. Some reviews and large-scale studies have concluded that comorbidity, and particularly comorbidity with anxiety, is associated with poorer outcome (e.g., Emslie, Kennard, and Mayes 2011; Ollendick et al. 2008), while others have found little effect (Nilsen et al. 2012). What is clear is that suicidality predicts poorer treatment outcome and is associated with dropout, and that treating depression does not necessarily lead to a reduction in suicidality or vice-versa (Barbe et al. 2004). Furthermore, it has been found that focusing on adolescent depression has the effect of also reducing anxiety symptoms, but not externalizing problems (e.g., Weisz, McCarty, and Valeri 2006). Thus it may not be necessary for clinicians to target comorbid anxiety in depression treatment (at least not initially), but treatment should include strategies aimed at reducing comorbid externalizing problems and should allow for specific considerations related to the importance of suicidality.


Developmental Issues


Children demonstrate numerous developmental changes as they mature. With respect to youth and development and its impact on therapy, questions that are often asked include: “At what age can you use CBT with children?” and “Do older children benefit more from CBT than younger children?” Overall, for youth with anxiety and depression, age does not seem to have a large effect on treatment outcome or dropout (Berman, Weems, Silverman, and Kurtines 2000; Emslie et al. 2011; Gonzalez, Weersing, Warnick, Scahill, and Woolston 2011; Nilsen et al. 2012), perhaps because it is a proxy for developmental level (Bolton and Graham 2005).


There is some consensus that children as young as 7 years – an age that roughly corresponds with Piaget’s concrete operational stage – can benefit from CBT (Stallard 2004). During this stage children learn to classify objects and put them in series, their mathematical abilities develop, they can play games that have rules, and they can use logic to solve problems. Children at this level begin to understand reversibility and generalizability and their previous egocentrism is reduced, so that they are able to view things from the perspective of another. Also around the age of 7–10 years, the child begins to regulate his or her emotions autonomously, is able to employ distancing strategies to manage them, has a better ability to use emotional expression to regulate his or her relationships, and becomes aware of being able to feel multiple emotions about the same person. Furthermore, the child becomes able to use information he or she has acquired about his or her own emotions and those of others across contexts, for the purpose of developing and maintaining friendships (Carr 2006). Hence many important cognitive and emotional changes occur around 7 years of age.


The various changes that occur around the age of 7 may allow for a more successful implementation of particular CBT strategies. For instance, the ability to self-regulate or regulate his/her emotion autonomously may allow the child to engage in relaxation strategies when required. The emerging ability to move from the specific to the more general means that examples used during session might be more easily generalized to life outside the session. The child’s ability to take the perspective of others and to use the information learned about his/her own and others’ emotions may assist him/her in the successful learning and implementation of interpersonal skills, problem-solving strategies, and cognitive restructuring procedures.


Although 7 years is most commonly agreed upon as the age around which CBT may become useful, Stallard (2004) has argued that children as young as 5 years may also benefit. He suggests that, although CBT can be quite complex, it often is not when applied to children. Children of 5–6 years can articulate their thoughts and are able to talk to themselves. Furthermore, around the age of 5–7 children are beginning to regulate their emotions themselves and to use social skills to deal with their own emotions and those of others (Carr 2006). Thus Stallard (2004) suggests that children of 5 years can be taught less sophisticated, specific, and concrete cognitive techniques such as positive self-talk. Furthermore, given that children of this age have not yet mastered the ability to generalize, Stallard suggests providing them with information that helps them reach conclusions about specific problems they are experiencing outside the session. Thus clinicians should not necessarily reject out of hand the idea of simple cognitive techniques when working with 5–6-year-old children.


Rather than speak of age, or even of developmental level, it is perhaps more important for therapists to develop a sound conceptualization of the individual child case, as there is enormous variation in ability and developmental level among children. Indeed, it has been suggested by Bolton and Graham (2005: 17) that asking “What cognitive developmental level is needed for CBT?” is less useful than asking “What cognition is involved in the production and maintenance of the problem in the particular case?” For instance, if a child is not yet of a developmental level where he or she can engage in metacognition, then metacognitive processes will not be maintaining his or her anxiety or depression, and hence strategies targeting metacognitve processes will be unnecessary. In other words, “don’t fix it if it ain’t broke.” This points to the importance of both good assessment and strong case conceptualization. A thorough assessment of symptoms and of causal and maintaining factors is imperative, so that a sound case conceptualization can be made. For good CBT therapists, treatment is always based on conceptualization, and thus only cognitive and behavioral factors that are found to be contributing to the child’s issues should be targeted. Chapter 9 gives more details concerning case formulation and treatment planning.


Individual Differences


Regardless of developmental level, children display a myriad of individual differences that the therapist must take into account. In particular, the literature highlights the importance of familial culture and learning disabilities as potential determinants of treatment outcome.


Ethnicity


It is important for therapists to be aware of the ways in which a child’s ethnicity may impact upon the treatment of his or her internalizing disorder. There is some evidence to suggest that particular ethnic groups have higher rates of internalizing disorders (e.g., Twenge and Nolen-Hoeksema 2002) and are more likely to drop out of treatment (Gonzalez et al. 2011). Furthermore, although research is limited, it would seem that ethnicity is not highly associated with poorer treatment outcome for anxiety, but may be so for depression (Nilsen et al. 2012).


There are no exact guidelines as to how clinicians should work with clients who are from a culture that is different from their own. However, Harmon and colleagues (2006) discuss a number of issues that therapists should be aware of. Symptom expression may vary acoss cultures, and the family’s belief about the origins of a disorder may affect both treatment compliance and treatment outcome. In addition, the anxiety or the depressive disorder may be the result of prejudice or discrimination, and a history of prejudice or discrimination may lead to suspicion and lack of trust in the therapist. Therapists should also be aware of the family’s cultural practices in terms of organization and decision-making and should have knowledge of the child’s religion and acculturation. Indeed particular opinions, emotions, and behaviors may be prohibited or encouraged in various cultures, and attempts on the part of the therapist to increase or minimize these factors may result in a poor therapeutic alliance and in problems with treatment compliance and outcome. Thus therapists should educate themselves in the culture from which their clients come and should be aware of the various ways in which cultural beliefs and practices may impact on clients and on their progression through treatment.


Learning disorders

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Jan 18, 2017 | Posted by in PSYCHOLOGY | Comments Off on Child and Adolescent Characteristics that Impact on Therapy

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