For a personality disorder to be diagnosed in adolescence, the problems have to be present for a year. There are four main areas of deficit:
There are several symptoms of borderline personality disorder (BPD):
It is essential to assess how severe the symptoms are. The guidelines for personality disorder are treatment using DBT (1), mentalization-based treatment (2) or schema-focused therapy (3). In dialectical behaviour therapy (DBT) there is a constant search for balance between the different theories on which it is based:
It is an efficacious treatment for BPD as well as for depressed older adults and individuals with eating disorders. It focuses on teaching skills for enhancing emotion regulation (1), distress tolerance (2) and building a life worth living (3).
Dialectical strategies include balancing irreverent and reciprocal communication, as well as acceptance-based and change-based interventions. Reciprocity includes listening and understanding (1), self-disclosure (2) and a sincere warmth (3). Irreverent includes obtaining attention for a subject (1), shifting the affective response (2) and introducing a new perspective (3). Dialectical strategies may be effective through enhanced orienting responses (e.g. by remaining attentive to what is happening, cognitive processing, attention and learning may be influenced) and in vivo learning and modelling.
There are several assumptions of DBT:
The biosocial theory of BPD holds that the transaction between a biological tendency toward emotional vulnerability and an invalidation in the rearing environment produces a dysregulation of the patient’s emotional system. Emotional vulnerability includes a predisposition for heightened sensitivity and reactivity to emotionally evocative stimuli and a delayed return to baseline emotional arousal.
The DBT programme consists of four things:
There are several phases of DBT treatment:
During pre-treatment, the commitment to the treatment must be ensured. This tends to vary over time and thus strategies need to be re-used and commitment needs to be renewed. There are several goals of the pre-treatment stage:
Individual psychotherapy always follows the same structure:
Mindfulness refers to intentionally directing attention to the present moment experience with an attitude of curiosity and acceptance. It includes focusing on the process of emotion regulation (1), validation (2) and being conscious of the present. The skills can be augmented through training. Mindfulness may be especially useful in adolescence as self-regulation and executive functioning strongly develops during this period.
The effects of MBIs on executive functions are moderated by age. Older adolescents may benefit more from MBIs than younger children due to the window of opportunity (i.e. the period between 14 and 18 years characterized by increases in self-reflection, social-perspective taking and greater interest in the self and others). Having more training in mindfulness is associated with fewer negative behaviours, meaning that the dose of MBI is a moderator. However, younger children have greater improvements than older children or adolescents. The beginner’s mind refers to opening oneself to an experience as if it were the first experience.
DBT makes use of behavioural therapy techniques (e.g. contingency management) and dialectical techniques (e.g. using different perspectives; using metaphors). In DBT, it is important to combine validation, problem-solving and dialectics.There are several aspects in DBT that should be combined and are specific to DBT:
Validation includes explaining behaviour as relevant and meaningful within the context (1), explain the behaviour as logical based on experiences (2) and label the behaviour suited for achieving a specific goal (3). There are several mechanisms of change of validation:
The chain analysis is conducted to determine the antecedent events that increased the likelihood that an aversive behaviour would occur (1), the prompting events (2) and the consequences (3). It focuses on moment-to-moment changes in external conditions, emotions, thoughts, behaviours and consequences. There are several potential mechanisms of change:
Consultation at patient refers to the therapist coaching the patient how to cope with the environment. It may generalize the learned skills to new environments. This has several effects:
When using environmental interventions in DBT, it is essential to preserve trust between the therapist and the patient (e.g. give general information but not specific about the patient).
Opposite action involves determining that an emotion is unjustified or interferes with behaviour (1), being exposed to emotionally evocative stimuli (2), blocking the behaviour prompted by the emotion’s action urge (3) and substituting a behaviour that is inconsistent with the action tendency compelled by the emotion (4). It aims to target emotion dysregulation and targets a broad range of emotions. There are several potential mechanisms of change:
Skills training occurs during the first six months of treatment and consists of weekly, open group sessions of 1.5 hours with 4-6 participants. The goal is to train new behavioural skills in a structured way without distractions of crisis interventions or motivational issues. It trains several things:
Skills training makes use of a training programme (1), short behavioural and solution analyses (2), role play (3), homework (4) and keeping a journal (5). Consultation by phone allows the patient to call the therapist when crisis behaviour has not occurred yet. The goals are to allow the patient to ask for help effectively (1), provide direct support (2), recover the therapeutic relationship in case of feelings of conflict (3) and bring good news (4).
The consultation with the team includes a weekly meeting by all the therapists. There are several goals:
In DBT, there are systemic contacts for parents and caregivers and this has several goals:
During DBT, there is evaluation and monitoring of goals and this determines when the treatment is concluded.
For childhood anxiety disorders, CBT is the most effective treatment. As these disorders are strongly related to attention problems (e.g. only focusing on the negative), mindfulness may be beneficial. The main goal of mindfulness-based treatment include helping the child and system recognize triggers for anxiety and identiy skills to use in those situationswhile working to reduce heightened physiological arousal. Anxious children need to regulate anxiety and avoidance independently but they require systemic support and reinforcement.
Mindfulness could also lower the stress in caregivers which allows forbetter parenting, facilitating progress in the child. It also allows the parents to become a model for their child in how to apply mindfulness skills in stressful situations. Self-compassion is an integral part of mindfulness interventions and consists of three components:
People who are high on self-criticism may experience fear of compassion (i.e. intense pain that is released because the unconditional love that is practiced reveals the conditions under which one was unloved in the past). Self-compassion may serve as a mediator in mindfulness interventions as it may decrease rumination and emotion suppression and increase positive psychological qualities because self-compassion increases the ability to deal with negative emotions. In DBT, there are several proposed mechanisms of change of mindfulness:
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Youth Intervention: Theory, Research, and Practice – Lecture 0 (UNIVERSITY OF AMSTERDAM) 
There are several major principles of youth interventions:
Children not referring themselves leads to problems with client motivation and problem awareness. There are three levels of youth intervention:
Treatment refers to targeting youth with symptoms at (sub)clinical level or those with a diagnosis. Heterogeneity in complaints exist because of three reasons:
The question is always where one should intervene when a child presents with complaints. Efficacy refers to whether an intervention works in a controlled, laboratory setting. Effectiveness refers to whether an intervention works in clinical practice. An evidence-based intervention refers to an intervention where there is at least some evidence regarding the efficacy and effectiveness. However, there is no clear guideline for when something is evidence-based as it is a continuum. Most include at least two studies with the following:
There are several ways in which a treatment can be considered well-established:
Or alternatively, when a large series of single-case designs have been used, it must demonstrate efficacy with:
When an experiment is used, it must be conducted with treatment manuals (1), characteristics of the sample must be specified (2) and the effects must be demonstrated by at least two different teams (3).
An intervention is probably efficacious when there are at least two experiments that show that the treatment is superior to the waiting list control-group or when the treatment is well-established but has not been investigated by at least two teams. Alternatively, a treatment is probably efficacious when a small series of single-case design experiments meet well-established treatment criteria. An intervention is an experimental treatment when treatment has not been tested in trials meeting criteria for methodology.
Evidence-based practice refers to using evidence-based interventions and using available knowledge about the effectiveness and efficiency of a method in carrying out an
.....read more Youth Intervention: Theory, Research, and Practice – Lecture 1 (UNIVERSITY OF AMSTERDAM) Children should have at least five symptoms for a period of two weeks including either the first or the second one to be diagnosed with major depressive disorder:
There are also some secondary symptoms:
Physical complaints (e.g. headaches; stomach aches) are more common in children. Substance use (e.g. alcohol; drugs) is more common in adolescence. The prevalence of major depressive disorder is 2.8% in school-age children (i.e. 6-12 years) and 5-6% in adolescents (i.e. 13-18 years). However, compared to adults, children and adolescents are still underdiagnosed and undertreated.
The general guideline for mild to moderate depression is psychosocial treatment. For severe depression, the guideline is a combination of psychosocial treatments and medication. However, one should be cautious with using medication with children and adolescents as there is an increased suicide risk with medication use. This may be because the medication increases impulsiveness. It should always be used in the context of extensive case conceptualization and in consultancy with a psychiatrist.
Beck’s cognitive theory of depression states that depression is the result of negative cognitions. There are automatic negative interpretations of ambiguous situation and cognitive errors (e.g. “bad things happen because of me”). This leads to negative schemes (e.g. “I am unlovable) which leads to depression. The negative beliefs are activated when faced with stressful circumstances and this interferes with coping and positive mood. There is black and white thinking, selective observation, overgeneralization and personalization of negative events (i.e. personal attribution). Depressogenic thinking is resistant to disconfirmation, partially due to the enduring styles of information processing that promote belief maintenance (e.g. focus on negative information).
The cognitive vulnerability model states that individuals at risk for depression selectively focus on and have better memory recall for negative rather than positive stimuli. A behavioural approach to depression holds that depression results from low levels of positive reinforcement and high levels of punishment and aversive control. This leads people to withdraw from negative interactions and avoid situations that may produce low positive reinforcement which, eventually, leads to a depressive cycle.
Theory is necessary because explaining the rationale behind a treatment makes it more understandable for a client and improves treatment adherence. The client needs to view the treatment as useful and needs to understand why
Cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) are two effective treatments and are
.....read more Youth Intervention: Theory, Research, and Practice – Lecture 2 (UNIVERSITY OF AMSTERDAM) There are three learning paths to fear:
There are three intervention techniques for anxiety:
The information processing theory holds that attention, interpretation and memory biases will lead to problematic cognitions. This means that an ambiguous situation (e.g. “seeing children laugh”) could be interpreted negatively (e.g. “they are laughing at me”) and this could lead to a memory bias (e.g. “I only remember people laughing at me when I wore this t-shirt”).
All treatment protocols for anxiety treatment starts psychotherapy. Next, the child is prepared for exposure by doing cognitive therapy or relaxation technique. Afterwards, there is conduct of modelling and exposure.
Cognitive-behavioural therapy is the most evidence-based prevention and treatment method for anxiety disorders. The recovery rate for anxiety disorders after using CBT is approximately 60%.
There are several principles (i.e. steps) of cognitive therapy for anxiety:
The goal of CBT is cognitive restructuring. Children also receive homework in CBT. The situation-thought feeling (the five G’s) is used to give insight for the client and is a tool for the therapist regarding treatment course:
The client has to identify all and elaborate on them. Detecting the negative thoughts can be done by using questionnaires or by using cartoons. People often find it difficult to formulate helping thoughts. Therapists can help them by provide the client with this or help them formulate it (e.g. give examples).
The presence of social anxiety disorder at pre-treatment leads to slower rate of change and poorer diagnostic outcomes when using CBT. This may be as group settings are more aversive for them. They may also show behavioural inhibition from infancy, making them more resistant to change. The therapeutic relationship may also be more problematic due to their SAD. Exposure may have opposite effects as social situations are more ambiguous and more difficult to interpret. This makes it difficult to see whether one’s initial interpretation was false.
Children with SAD may thus need a longer treatment programme and a more tailored programme that helps them disconfirm their negative social expectations (e.g. equip children with social skills prior to exposure). One way in which this can be
.....read more Youth Intervention: Theory, Research, and Practice – Lecture 3 (UNIVERSITY OF AMSTERDAM) Autism spectrum disorder is characterized by deficits in social communication and restricted, repetitive and/or sensory behaviours or interests. The severity levels should be specified.
In the 1970s, only 1.5% of the children with ASD achieved normal functioning. About 35% showed good adjustment but required some degree of supervision. The majority (i.e. 60%) remained severely handicapped. About 50% remained non-verbal throughout their lives. Currently, this is less than 10%. However, ASD does not need to be a life-long disabling condition. About 25% of the children can lose the diagnosis after treatment and most children can achieve positive outcomes with treatment. Children who lose the diagnosis will become similar to typically developing children.
There are several criteria for when an intervention is successful:
However, when an intervention is truly successful depends on the goals of the parents and the child. The intervention should aim to improve on these goals and should thus be matched to their goals.
Lovaas’ discrete trial training (DTT) demonstrated that behaviour modification treatment could lead to positive outcomes for children with ASD. This training makes use of operant techniques and breaks skills into small component and teaches the child one component at a time. According to Lovaas, children with ASD are unsuccessful in learning skills from the natural environment and the environment should thus include potent reinforcers and should be simplified. This means that every small step is rewarded. Though the training seems effective, there is a lack of generalization of learned skills (1), it leads to avoidance behaviour (2), there is a lack of spontaneity (3) and there is an overdependence on prompts (4). This could be because the treatment is very therapist-directed.
Applied behavioural analysis refers to the process of systematically applying interventions based upon learning theory principles to improve socially significant behaviours to a meaningful degree. It aims to change behaviour by investigating what is reinforcing the behaviour and it is the core of all interventions for ASD.
The core of all interventions for ASD is applied behavioural analysis. This refers to systematically applying interventions based on learning theory principles to improve socially significant behaviours to a meaningful degree. This approach aims to change behaviour by investigating what is reinforcing the behaviour:
ABA can focus on social skills (1), communication (2), play (3), behaviour (4), adaptive skills (5), motor skills (6) and cognitive skills (7), meaning that the focus of ABA in children with ASD can be very heterogeneous. These skills often develop naturally in typically developing children.
ABA attempts to understand and alter the environment to change behaviour using
.....read more Youth Intervention: Theory, Research, and Practice – Lecture 4 (UNIVERSITY OF AMSTERDAM) There are several guidelines for treating children with ADHD:
Behavioural intervention cannot be supported as a front-line treatment for core ADHD symptoms. This is especially the case in studies where the outcomes are blinded. However, parenting practices and conduct problems improve after behavioural interventions and this is often the main reason for referral, meaning that behavioural interventions serve their goal. Improving parents’ behaviour towards their children may improve child behaviour and improve the quality of the parent-child relationship.
Children who receive behavioural consultation are less likely to receive medication later that year. If they do receive medication, the dosages are lower compared to children who did not receive behavioural consultation. Using a low-intensity behavioural intervention as a first-line treatment reduces or eliminates the need for medication in children with ADHD.
There are several reasons why it is important to reduce the need for medication:
Adding medication secondary to initial behavioural treatment leads to better outcomes on primary outcomes than the other way around. Parents who began treatment with behavioural parent training had better attendance than those assigned to receive training after medication. The cost of starting with a low-intensity behavioural intervention is also lower. It is thus important to start with behavioural intervention.
Behaviour modification is teaches skills to parents, teachers and children to overcome some of the key functional impairments associated with ADHD. Effective treatments need to focus on peer relationships (1), parenting (2) and academic functioning (3). Combining recreational activities with educational activities increases children’s attendance.
Behavioural parent/teacher training is a mediation therapy. This means that the therapist trains the parent or teacher and this person then uses their newly learned skills on the child. This is done because interventions directly involving the child often have little effect due to self-regulation problems of children with ADHD. Using both parents may increase the consistency of the implementation of strategies and shared understanding of ADHD which may lead to better outcomes. However, the evidence for this is limited.
Barriers to parent training include situational factors (1), psychological factors (2), lack of awareness of programmes (3), unavailability of programmes (4) and issues with poor interagency collaboration (5). There are several moderators of treatment effect:
Youth Intervention: Theory, Research, and Practice – Lecture 5 (UNIVERSITY OF AMSTERDAM) When treating criminals in the past, severe punishments were used. Later, phrenology was used to diagnose people and electro convulsion therapy was used to treat people with a criminal history.
Durkheim stated that every society gets the criminality that it deserves. The cost of incarceration is higher than that of rehabilitation. Martinez stated that people who commit crimes should be locked up. According to him, it is impossible to treat criminals. Early (humane) treatment for criminals consisted of CBT. It was focused on treating the symptoms and did not include the families.
Static risk factors refer to risk factors that cannot be changed and are fixed. Dynamic risk factors refer to risk factors that are malleable. The interaction between risk and protective factors and the interaction between the individual and the environment is essential for criminality.
The age crime curve refers to criminal activity increasing during adolescence and peaking during late adolescence. This could be due to the maturity gap (i.e. a well-developed affective brain circuitry and a less developed prefrontal cortex control centre in the brain, combined with adult responsibilities).
The outcome of therapy is influenced by several factors:
There is a lot of innovation in the therapy of juvenile delinquents. This includes real-time biofeedback treatment and virtual reality treatment. Group therapy consists of treatment of aggression (1), improving social skills (2), making moral choices (3) and help meetings (4). However, it can lead to a lot of peer contagion, making it typically ineffective.
There are different forms of systemic treatments:
There are three stages of systemic treatments:
Building a therapeutic alliance takes time and it is important to be patient as the patients are typically not motivated to change. The alliance between the patient and all important people (e.g. parents; therapists; friends) and the alliance between these people is essential.
Understanding the common elements of treatments could render them more effective. Many treatments have common elements, yet a unique focus which allows for personalization. Knowledge of treatment mechanisms and identification of potent treatment techniques can support enhanced precision in matching systemic treatment to the needs of adolescents and their families.
There are six mechanisms (i.e. common elements) of systemic treatment:
Youth Intervention: Theory, Research, and Practice – Lecture 6 (UNIVERSITY OF AMSTERDAM) Traditionally, a specific learning disability (SLD) referred to a discrepancy of one to two standard deviations between intellectual functioning and academic functioning. However, the amount of discrepancy was arbitrary (1), older children were favoured (2), higher IQs were favoured (3) and it was failure-based (4). Currently, the definition holds that achievement in key academic areas is substantially below the age norm and in excess of sensory deficits, linguistic processes, attention and memory. The prevalence is 2 to 10%.
Response to intervention (RTI) refers to a tiered system in which a failure to respond to an intervention is the criterium for identification of specific learning disabilities. This indicates the need for more specific and intensive intervention. First, there is screening for risk (e.g. simple tests of basic pre-reading skills) and assessment of family history of reading and language difficulties. After this, there are several tiers:
In the Netherlands, there are three different but similar tiers:
A child moves to the next tier if the progress in a tier is inadequate. The three-tier model is the most common model of RTI and is defined by three sequentially ordered intervention strategies. It aims at early identification of at-risk children.
All tiers depend on continuous monitoring of student progress as this determines the eligibility for a given tier. It thus does not look at an IQ-achievement discrepancy. A diagnostic classification depends on the outcomes of different interventions. The majority of children who identified as at-risk at first scored average after one or two semesters of tutoring (i.e. tier 1). This means that most struggling readers can become average-level readers if they are provided with effective intervention.
Almost all children identified as at-risk for long-term reading difficulties in first grade had the same characteristics:
This means that not dyslexia but poor education was
.....read more Youth Intervention: Theory, Research, and Practice – Lecture 7 (UNIVERSITY OF AMSTERDAM)For a personality disorder to be diagnosed in adolescence, the problems have to be present for a year. There are four main areas of deficit:
There are several symptoms of borderline personality disorder (BPD):
It is essential to assess how severe the symptoms are. The guidelines for personality disorder are treatment using DBT (1), mentalization-based treatment (2) or schema-focused therapy (3). In dialectical behaviour therapy (DBT) there is a constant search for balance between the different theories on which it is based:
It is an efficacious treatment for BPD as well as for depressed older adults and individuals with eating disorders. It focuses on teaching skills for enhancing emotion regulation (1), distress tolerance (2) and building a life worth living (3).
Dialectical strategies include balancing irreverent and reciprocal communication, as well as acceptance-based and change-based interventions. Reciprocity includes listening and understanding (1), self-disclosure (2) and a sincere warmth (3). Irreverent includes obtaining attention for a subject (1), shifting the affective response (2) and introducing a new perspective (3). Dialectical strategies may be effective through enhanced orienting responses (e.g. by remaining attentive to what is happening, cognitive processing, attention and learning may be influenced) and in vivo learning and modelling.
There are several assumptions of DBT:
Youth Intervention: Theory, Research, and Practice – Lecture 8 (UNIVERSITY OF AMSTERDAM)Trauma refers to a normal response to an abnormal event. About 14% of the children exposed to a trauma develop PTSD. The probability of developing PTSD increase the longer and more severe the traumatic events are.
PTSD includes several symptoms:
The symptoms need to last for at least a month. For late-onset PTSD, the symptoms need to have an onset of 6 months after the traumatic event. The intrusion symptoms in children are represented in pretend play (e.g. playing the traumatic experience). Regressive behaviour (e.g. going back a developmental step) is common in children with PTSD.
There are several risk factors to develop PTSD:
There are also several secondary sources of stress as a risk factor:
There are also several risk factors in children:
Ehler and Clarke’s cognitive model of PTSD states that persistent PTSD only occurs if individuals process the traumatic event and/or consequences in a way which produces a sense of serious, current threat. People with persistent PTSD are unable to see the trauma as a time-limited event that does not have global implications for their future. There are two key processes that lead to this sense of threat:
The perception of current threat is accompanied by intrusions and other re-experiencing symptoms when activated. This motivates a series of behavioural and cognitive responses that are intended to reduce perceived threat and distress in the short-term but prevent cognitive change. This maintains the disorder.
The emotional processing theory states that posttraumatic symptoms reflect the development of a problematic fear structure comprising many stimuli, responses and meaning representations. There are maladaptive responses when this is triggered.
The social cognitive theory focuses on the impact of trauma on pre-existing or developing beliefs about one’s self, others and the world. According to this theory, trauma-related feelings
.....read more
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