Book summary of Child and Adolescent Therapy: Cognitive-Behavioral Procedures - Kendall - 4th edition

Which therapies can be used for young children and adults? - Chapter 1

What is the use of theories in the treatment of young children and adults?

Specified theories based on empirical research can be used as a guide for the design, the implementation and the evaluation of treatment programs for children and adolescents. An important aspect of these guiding theories is that they are based on empirical research. These theories can help us in clinical work and in empirical evaluation.

The most direct and useful theories for clinical work are theories that explain the processes of change. Because of the focus is on young people, theories focusing on psychological change and aspects of human development that develop during childhood are important.

The ability to recognize and solve a problem is an essential component of adequate adaptation. Therefore, many psychological treatments for young people focus on problem solving, as this is an important basis for the quality of psychological health. Problems are common, and can arise without provocation or effort. However, solutions are less common, often requiring employment of cognitive strategies (arising from a person's active use of thought and therefore costing time and effort). These cognitive problem-solving strategies arise from experience, observation and interaction with others. Intentional and planned interventions can maximize these strategies. Information processing plays a role in this. Dysfunctional information processing requires attention and modification. Correcting erroneous information processing and learning strategies to overcome this are valuable steps in the treatment of psychological disorders for young people.

Our emotional states, both positive and negative, affects our cognitive and behavioural skills and are therefore important in cognitive behavioural therapy (CBT). Positive and negative emotions are not extremes of the same continuum. Both have their own continuum. Emotions can sometimes interfere with problem solving. Learning about the nature and regulation of emotions is important for one's state of well-being. Effective cognitive problem solving requires an understanding of the experience and modification of emotions, so effective interventions require recognition, consideration and therapeutic attention from emotional states.

Psychosocial problems are interpersonal (social) and involve adapting maturing psychological states and changing family roles. Social relationships are therefore important for healthy psychological adjustment. Therapy is also an interpersonal process, and therefore social and interpersonal domains are important in clinical interventions.

Involving parents in the treatment increases the likelihood of positive outcomes of the treatment. However, although parents play a crucial role, the nature of this involvement may vary depending on the type of problems and the level of child development (increasing parental control is useful, for example, in conduct problems, but not with anxiety problems).

CBT often follows a manual-based or structured treatment. This gives direction and organization to treatments based on what is known about a disorder. This empirical basis optimizes the outcomes of treatment in young people. It also helps therapists in being focused on their goals and provides a pace and sequential steps towards achieving goals. This does not mean that such treatments should be inflexible and rigid, instead the intention is to apply them with some flexibility. The general treatment strategies should be adhered to, but personal adjustments should also be incorporated into the treatment process.

So the theory emphasizes helping young persons by adjusting cognitive information processing in a social context, through the use of structured, behavioural-oriented treatments, with attention to emotional states and the involvement of the young persons. If necessary, members of a social group are involved. A guiding theory is necessary, but not sufficient. Empirical evidence for an intervention is also important.

What is the cognitive and behavioural perspective?

The cognitive and behavioural perspective consists of an integration of cognitive, behavioural, emotion-focused and social strategies. It does not value only a single model, but considers the relationships between cognition and behavior, the emotional state and overall functioning of the organism in a larger social context. Therefore, cognitions, emotions, action and the social environment are all involved in psychological difficulties and disorders, but for each disorder, the influence of each domain can vary. Because behavioural patterns occur in specific and often interpersonal environments, CBT focuses on the social context.

Parents: consultants, employees or co-clients?

Parents are often involved in the treatment, even though there is a great need for empirical evidence about what the most optimal nature of their involvement is. Parents can be consultants and provide information about the nature of the problem. However, if parents themselves have any contribution to the child's problem, they become co-clients in the treatment itself. The parents become employees when they assist in the implementation of the treatment. More research is needed into the ideal form of involvement and parental role in relation to the age of the child and the disorder.

What is known about the role of the attitude of the therapist?

A therapist’s attitude refers to the mental attitude of a therapist. A therapist is a coach, and is supportive but demanding. The therapist as a coach can be described by three concepts:

• Therapist as a consultant/employee: The therapist is a person who does not have an answer to everything, but has ideas that are worth trying. Aims to develop the client's skills (e.g. problem solving). The child/adolescent and therapist communicate in a collaborative and problem-solving way.
• Therapist as a diagnostician: Integrating data and judging it with a background of knowledge about psychopathology, normal development and psychologically healthy environments in order to make meaningful decisions. Information from parents/teachers is valuable, but not sufficient. Multiple, different sources and the knowledge of the diagnostician must be taken into account in order to determine the nature of the problem and the treatment plan.
• Therapist as a teacher: A therapist helps the patient to learn and improve cognitive skills and emotional development during an intervention. A good teacher makes students think for themselves, a good coach is involved, active and involved in the cognitive and behavior process of the individual.

Thus, the attitude of the cognitive-behavioural therapist has a collaborative quality (therapist as consultant), which integrates and decodes social information (therapist as diagnostician) and who learns through experiences with involvement (therapist as a teacher). A high quality intervention ensures that the client can attach meaning to the experiences and the way in which he/she will behave, feel and think in the future.

What about cognitive functioning and adaptation in young people?

Within psychopathology and psychological therapy, cognitive functioning relates to social information processing. Cognition is a complex system consisting of multiple facets:

• Cognitive content: information that is represented or stored currently (the content of cognitive structures) (first reaction to experience).
• Cognitive processes: processes that explain how the cognitive system works (e.g. how we receive and interpret experiences).
• Cognitive products: the resulting cognitions, which arise from the interaction of information, cognitive structures, content and processes. For example, causal attributions.

Psychopathology may be related to problems in the areas above. Effective therapies should consider all of the above factors as relevant and related to the individual client. Cognitive content, processes and products play a role in the meaning of events in an individual's environment (something happens, someone reacts, interprets the situation, has certain thoughts and feelings about it). Cognitive structures arise as accumulation of experiences in memory that serve to filter or screen new experiences. Cognitive schemas are themes of these structures, which makes a child anxious, for example. When a child learns that the dentist can be painful, he or she may become scared when he or she has to go to the dentist later. Cognitive structures can involve automatic cognitive and trigger information processing of events. Cognitive products reflect the influence of existing cognitive structures. In therapy, a young person should be helped to form cognitive structures that will have a positive impact on their future experiences.

Distortions and deficits

Dysfunctional cognitions are maladaptive, but not all dysfunctional cognitions are the same. Understanding the nature of the cognitions is important for treatment. Regarding cognitive processes, a difference should be made between cognitive deficiencies (absence of thinking/processing when it is useful, e.g. in impulsivity/ADHD – deficiencies) and cognitive biases (dysfunctional thought processes, e.g. in the case of anxiety/depression – distortions). When looking at disorders, it is often possible to determine whether there are deficiencies or distortions because of over- or under-control. In under-control, one is less able to inhibit oneself, and there are deficiencies in behaviour, such as ADHD, impulsivity and aggression (externalizing problems). For example, individuals with these characteristics can experience problems in activating, planning, and monitoring cognitive processes. In children with problems in overcontrol, there are biases, such as anorexia, anxiety and mood disorders (internalizing problems). For example, individuals with anxiety may have distortions about how people view them, or what is expected from them.

1. In behavioural differentiation, it is important to take into account under- and overcontrol.
2. Cognitive differentiation should look at deficiencies and biases.
3. There are meaningful relationships between under- and overcontrol.

How can one develop coping?

The role of cognitive concepts (expectations, attributions, self-talk, beliefs, biases, deficiencies, schematics) are emphasized in the development of both adaptive and maladaptive behavior and emotional patterns. These concepts also play a role in the processes of behavioural change. Little is known about the organization and interrelationship of these cognitive concepts. A potential model needs to be a development model, organized by time. Time plays a large role because cognitions can occur before, during and after events. See Figure 1.1 on page 16 for the model: Attributions are formed over and over, usually shortly after the event. These last briefly but can have long-term impacts. Repeated behavioural events (especially events with high emotional impact) can result in cognitive consistency (cognitive structures, attribution style, and beliefs). These are more stable than a single attribution and therefore more predictive of the behavior. This also creates life expectancy. The higher the emotional intensity in an event, the greater its impact on the development of cognitive structures. Therapy should therefore focus on creating behavioural experiences with positive emotional intensity.

When do we need interventions?

Psychologically sound adaptation, as naturally ensued, is built on dealing with challenges in life. When someone is on the right track in terms of adaptation, interventions are unnecessary. However, when someone experiences problems in different domains, one can acquire skills to deal with this in therapy. The goal is then to make the client better prepared for inevitable difficulties in life, by acquiring skills for problem solving.

What are rational expectations of the therapist?

Mental health professionals often expect to be able to help all clients. This expectation is irrational and maladaptive, because therapy is not a cure for all problems. Rational expectations that therapists can have are for example the belief that interventions can help towards successful adaptation, and that clients benefit from the skills learned in therapy. However, there is not always success in therapy and relapses can occur. Also, therapy is not a cure for psychopathology, but a management strategy. Moreover, therapy does not lead to ideal outcomes for every participant.

Positive outcomes after therapy are often explained by 'the power of positive thinking'. However, it is more about diminishing negative thinking. Moreover, individuals who always think positively are not always psychologically healthy. Having negative thoughts is normal when it happens once in a while. It is a matter of adjusting the ratio of negative and positive thinking in therapy to a healthy relationship. In a healthy individual, that ratio is 2:1, in someone with depression the ratio is 1:1.

After therapy, there may also be ‘latent effects’; positive outcomes that do not show themselves immediately after treatment but only at a later point in development.

In addition, there may be ‘spill-over’ effects, which means that positive outcomes associated with the treatment of the child are also present for the parents, sisters/brothers or other individuals who were not target of treatment.

How can change be conceptualized?

How do we conceptualize the changes needed in therapy? It is not that existing cognitive structures should be obliterated. Instead, therapy helps to create new schemes and strategies rather and replace previous dysfunctional structures. This can be reached by exposure to multiple events simultaneously and focusing on cognitive and emotional processes.

What can be concluded?

It is important to take into account the fact that children are often sent to mental health services, while adults seek out help themselves. Because of this distinction, it is important to create a nice, affective environment and also create motivation in children that did not seek out help for themselves. Trust, respect and the child-therapist relationship is essential for the therapeutic process.

What is known about aggression in children? - Chapter 2

Aggression refers to a set of primary inter-personal actions such as verbal or physical behaviors that are destructive to others. Only when aggression is severe, frequent and/or chronic, this is an indication of psychopathology. Children with aggression are often diagnosed with oppositional defiant disorder (ODD) or conduct disorder (CD), but periodic or chronic anger outbursts can also comorbid with other disorders (e.g. ADHD, PTSD, dysthymic disorder). Due to the intense negative effect this can have on others, children with aggression are more likely to be referred to mental health care than children with other forms of psychopathology. Research shows that aggression is fairly stable during childhood, and more consistent than other behaviors. Children who exhibit many different types of aggression in different situations are most at risk of a continuous disorder. This involves the accumulation of problem behaviour with the risk of various negative outcomes such as drug use. Troubled young people often differ on multiple dimensions of their peers (not just aggression). It is important to take into account at the same time common negative outcomes and comorbidity of risk factors, because these factors increase the risk of problems in adjustment.

What are mediating processes?

Cognitive behavioural therapy (CBT) focuses on the biases and deficiencies in the cognitive processes of events, emotion regulation and aggression in children.

There is a socio-cognitive model of how aggression develops in children. In turn, a distinction is made between distortions and deficiencies. In the model, the child is confronted with a potentially aggression provoking event. There are three sets of internal activities that contribute to the child's behavioural response:

1. Perceptions and ratings: The emotional and physical reactions of the child to this event do not depend on the event itself, but on the child's perceptions and interpretation of the event. These perceptions and interpretations can be correct or erroneous and can arise from the child's previous expectations, selective attention to certain aspects of the child and cues of an event.
2. Arousal: when an event is experienced negatively, a child will experience physical arousal. This is in reciprocal interaction with the child's ratings, because the child then has to assess the emotional value of an event in a state of arousal. This in turn affects;
3. Social troubleshooting: Determining a behavioural response to the event is influenced by the child's cognitive activities.

What are social-cognitive factors?

Social cognitive ratings

Social cognitive valuations refer to cues and attributions to other people's intentions. Aggressive kids code cues and intentions in a different manner compared to ‘normal’ kids: they see less relevant cues and pay particular attention to hostile cues. They are 50% more likely to see provocations as hostile rather than neutral. These hostile attributions are addressed by negative feelings. This hostile attribution bias has been found in both pre-adolescents and adolescents, suggesting that difficulties in valuations that develop early in socialization are established by experiences at home and with peers. Aggressive boys also underestimate their own aggressiveness, because of their distorted perception and interpretation of others they can justify their own reaction.

Social problem solving

Social problem solving has to do with target selection, generation of alternative solutions (socio-cognitive product), considering consequences of solutions (social cognitive product) and the behavioural implementation of solutions. Guys with high aggression generate fewer alternative solutions, and both guys with high and medium aggression experience difficulties in coming up with effective solutions. Also, aggressive children are more likely to have solutions that include direct action and physical aggression. Their solutions are less verbal and contain fewer compromises. They expect aggressive behavior to lead to rewards, a positive outcome, less aversive behavior from others and don’t see how harming it can be to other people. They also often think that positive and prosocial behaviour will be less effective. These beliefs regarding aggressive behavior lead to deviant processing of social cues.

Individual differences in the social cognitive processes of aggressive children

Children who exhibit reactive aggression (impulsive response to provocation) can have many different problems in social cognition, such as in encoding, in attributions and in social problem solutions. Compared to other children, they are less often bullied and are often raised harshly. They have more deficits in executive cognitive functioning. Children who exhibit proactive aggression are more offensive, less emotional and have higher levels of psychopathy. Their primary social cognition is that aggression works better. They have a greater risk for delinquency and aggression in adolescence.

What are cognitive mechanisms?

The mechanisms used for manipulating information relate to attention, the release of memories from long- and short-term memory, concept formation and problem solving processes. External information refers to cues from the environment, internal information is present in psychological cues and images, thoughts or beliefs from memory. Attentional processes assist other operations and can therefore have a major impact on the quality of other cognitive functioning and products. Deficits in attention processes are linked to aggression. ADHD is also the most comorbid disorder of conduct disorder. These disorders are linked to activating behavior, instead of inhibiting behavior, and can come with many problems.

What are schematic propositions?

Schematic propositions are ideas and thoughts stored in memory, which have a direct influence on how new information or cognitive products are processed. Schemes are conservative, because old beliefs are stronger than new beliefs. They are also self-centred, because they are based on personal experiences. When people have stronger schemes, perceptions are more strongly filtered and therefore more distorted. Schematic propositions related to aggressive behavior are goal values, generalizing outcome expectations and self-esteem. For example, aggressive guys place more value on dominant and wrecking goals. To achieve these goals, they use more aggression and less negotiation. This shows the direct effect of goals (schematic propositions) on problem solving (cognitive products). These individuals also often believe that aggression increases their self-esteem, prevents negative perception, that victims do not suffer and that aggression is a legitimate response. Aggressive children are also very sensitive to issues related to self-esteem.

What are some non-cognitive influences on aggression?

Psychophysiology and arousal

Boys with ODD have a lower heart rate compared to non-aggressive peers, which increases greatly during provocation and frustration. Their cognitive processes are negatively affected by this arousal. As the level of physical arousal increases, aggressive guys show more hostile attributions.

Influence of parents, peers and teachers

Family of aggressive children show high levels of aversive behavior, maladaptive parenting styles and high parental conflicts. The social cognitive products and schematic propositions of children are often affected by this and this can lead to more aggression. Also, aggressive children often take over an attribution bias from their parents. The behaviour and cognition of parents are strongly related to the social cognitive processes and behavior of their children. Interventions should therefore focus on both parents and children. A child’s relationship with peers is also important and can affect their aggression (such as when there are deviant peers, or when a child feels rejected by peers).

How can we detect aggression in children?

It is important to identify which factors are related to aggression in a child. This information can then be used in guiding the treatment plan. To obtain a good representation of the behaviour, as many sources of information as possible should be used.

Behaviour-assessment scales

The best way to easily assess the severity of a problem is by using a behavioural assessment scale. By doing so, it is possible to identify many types of behaviours, including low frequency behaviours. It also takes little time and it takes into account the perception of others (teachers, parents) on the child’s problems. The Behavior Assessment System for Children second edition (BASC-2) is suitable for children from 2,6 years to 18,11 years. This scale includes parent, teacher and self-assessment. The BASC-2 also signals which adaptive skills should be improved.

Interviews

Interviews can be very helpful in determining situational variables related to aggressive behavior. It is useful when there are similar versions for children and parents. For example, there is the Child Assessment Schedule. In children with serious aggression problems, a less structured interview can also be helpful, especially for discovering attributions and reasoning styles.

Behavioural observations

Behavioural observations can help to provide important information about aggression. The measuring instruments mentioned before may be subject to perception bias or can induce motivation to deny problems. Comparing information obtained from observation, checklists and interviews is the best, thus complementing each method with each other.

Peer-ratings

Many aggressive children have problematic relationships with peers, and they are often judged less socially competent. Evaluations of peers can help to identify a subgroup of aggressive, socially rejected children who are at increased risk of developing serious problems. However, there are also aggressive children who are socially accepted and have high self-esteem. As a result, they will be less motivated for undergoing treatment.

How can we evaluate social-cognitive/affective characteristics?

The social-cognitive styles of aggressive and non-aggressive children differ from each other. The purpose of social cognitive assessment is to increase the clinician's understanding of the social information processing of aggressive children.

Social-cognitive products

Dodge (1980) has developed tools to measure encoding in aggressive children. She created videos of hypothetical situations and used the children's response to evaluate the following:

• Retrieval of cues free of interaction
• Recognition of events that actually happened
• Misinterpretations of events
• Attributions and expectations regarding hypothetical future behavior.

Other questions about the way of thinking of aggressive children relate to their way of communicating and solving social situations and how their social information processing affects their problem solving strategies. Evaluation should take into account the type of social task, the persons involved and the visible intentions.

Schematic propositions

Schematic propositions are measurements of the child's relative evaluation of social goals (dominance, revenge, avoidance, etc). This can help clinicians to determine the consistency between a child's social behavior and goals. Knowledge regarding social goals has implications for treatment.

Valuations of internal arousal

Aggressive children often tend to label their own negative affective arousal (such as shame, fear, sadness) as anger.

What are other domains of functioning of the aggressive child?

Determining parental functioning and parenting styles is necessary to obtain a complete picture of behavioural influences. For example, the adjustment of the parents can be measured to determine which social problem solutions models there are for the child and to what extent parents are sensitive to interventions. Parental depression, stress and adaptation can be measured. Measuring the extent to which the child is exposed to hostile parental experiences is also useful. The child's cognitive/academic level should also be determined. Mapping obstacles and frustrations in the learning environment may explain why children are seen as defensive, deviant or argumentative. It is also important to identify the willingness of parents regarding involvement in the treatment.

What is the Coping Power Program (CPP) and how can it be used for aggressive children?

The Coping Power Program (CPP) focuses on social cognitive difficulties of aggressive children. It is designed to be used in school, from sixth to eighth grade. It consists of 34 sessions for the child and 16 sessions for the parents, spread over 16 to 18 months. Sessions with the child last 45-60 minutes and parental sessions last 90 minutes. There are up to 6 children in a group and a maximum of 12 parents. By making minor adjustments, the program can also be used in clinical situations. In addition to the group sessions, each child has 6-8 individual session of half an hour. The group form in which the treatment takes place has the advantage that reinforcement by a group of peers is often more effective in children than dyadic reinforcement or reinforcement by adults. However, this increases the possibility of iatrogenic effects, and therefore it is important that group leaders keep a close eye on the behaviour of the participants during the sessions. The socio-cognitive difficulties the programme focuses on include increased attention to hostile cues, the tendency to interpret intentions as hostile, a dominance-oriented orientation in social goals, problem-solving strategies aimed at action, a lack of verbal bargaining and the belief that aggression is rewarding.

The parental component

The CPP aims to improve the parent-child relationship. The effective parent exercises include teaching appropriately rewarding behavior towards the child, using effective instructions and rules, applying consequences in reaction to inappropriate behavior, developing constructive communication and developing stress management strategies. They are also informed of the skills their children learn so that they can reward their children when they see them use the skills. Each session consists of an opening, an interactive presentation of the topic in that session, and a conclusion in which homework is provided. During the opening phase, the homework is discussed and parents are stimulated to react to the previous sessions. Group cohesion and community involvement is also stimulated.

Pragmatic and logistical problems

Although group therapy is preferred, individual therapy can also be indicated. For example, a child could need this before joining the group therapy. Also, individual therapy can be beneficial when the child has underwent successful group therapy, but needs some more therapy. The CPP can be made suitable for individual therapy, but little will change in terms of the content. For some activities, the absence of peers is a problem, and the therapist will then have to take a more active role. Group therapy also requires a large space, with a chalkboard and a poster board. There should be as few visual and auditory distractions as possible in the environment, and group rules must be made clear in the first session.

Self-managing skills

Children need to be taught more competencies with regard to observing and identifying internal states related to affective arousal. This is achieved through modelling, observation, structured exercises and group discussions. Environmental cues of aggression and physical aspects of aggression arousal need to be identified. Children are taught that people differ in their internal experience or response to aggression and that they exhibit different cues of aggression arousal. The children are taught self-monitoring strategies to increase awareness of environmental triggers and affective and physical states. Also, cognitive self-control strategies are taught, such as verbal mediation to help regulate behavior. They also become familiar with the concept of internal dialogues or ‘self-talk’, in order to reduce aggression arousal. Other self-control techniques such as visualisation, distraction and relaxation are also discussed. By creating awareness of triggers that provoke aggression, it is possible for children to use the self-managed skills they learned in therapy.

During therapy

Hierarchical exposure to stimuli of increasing threat, behavioural exercises and group discussions encourage children to learn and practice cognitive and affective self-reflection and self-monitoring strategies. The therapist should provide anticipatory guidance to validate children's frustration in learning a new skill, because learning a new skill is not always easy and can lead to frustration. Members of the group should also be reminded that these skills require a lot of practice.

Social perspective-taking skills

Children with externalizing disorders experience self-centred and distorted perceptions of social situations, in which there are difficulties in integrating their own and others perspectives. As a result, they are at high risk of developing dysfunctional social relationships. Perspective-taking exercises help to increase the understanding of other people's feelings, emotional states, thoughts and intentions. For example, one important point is to differentiate cognitive and affective processes based on similarities and differences between people.

Social problem-solving skills

Aggressive children experience difficulties in solving interpersonal problems. The CPP helps in identifying conflict situations as problematic and increases their repertoire of responses. It uses a model with three components: problem identification, generating multiple responses and evaluating and predicting the consequences of their actions. This model is taught using various techniques such as modelling, instruction, group discussions and role-playing. An important aspect here is to identify problematic situations early, before a situation escalates. The CPP also helps to improve qualitative and quantitative aspects of coping.

Process variables in the CPP

Three process variables are central to the CPP: a behavioural management system (where the group's social microcosm is used to promote prosocial behaviour and facilitate group cohesion), objective activities (targets are set each week on certain behaviours, this makes the process concretized and provides structure to increase generalization of the treatment effect), and use of the interpersonal here-and-now situation to increase development of group context (in-vivo possibilities to work with children on aggression control problems, which arise from tensions between group members – 'hot' processing).

Anger Coping Program

The anger coping program is the predecessor of the CPP. Treatments reduce aggression among primary school boys and increase self-esteem. However, assessments by teachers and peers showed there to be no improvement. In order to maintain progress in self-esteem, problem solving skills and lower levels of drug use at follow-up sessions, ‘booster' treatments consisting of six sessions is important. Without this booster sessions, there is a high chance on a relapse.

Coping Power Program

The effectiveness of the CPP is supported by empirical evidence. There has been a significant reduction in the risk of self-reported delinquency, parent-reported substance abuse and teacher-reported behavioural problems of the child. This effect is increased when both the child and parents have participated. Another study shows significant effects on children's social competence and aggressive behavior after CPP. A version of the CPP for aggressive children who are deaf and the Dutch version of the CPP are also proven to be effective. A study carried out in school setting shows the importance of intensive training for leaders.

What is the role of clinical and treatment characteristics as predictors of outcomes?

In terms of treatment characteristics, adding a target component leads to lower levels of aggression and disturbed behavior. There is also evidence that homework assignments in CBT have a similar positive effect. There are also more improvements in 18-session treatments compared to 12 sessions treatments.

Mediatiors

The effects of the CPP are at least partly mediated by changes in the social-cognitive processes (hostile attributions, decision-making processes), the schemas (beliefs) of the children (boys), and parental processes. Children show less problem behaviors in the first year after the CPP, and this is strongly influenced by improvements in the way in which they see the social world, and by their expectations of consistent and predictable parental responses.

What are the implications of research into CBT outcomes?

As mentioned earlier, research shows positive and promising effects of CBT such as the CPP. However, due to mixed follow-up findings, it is important that more research is carried out. This research should include long-term follow-up with control conditions, and also include child and treatment characteristics that influence the outcome of treatment, attention to contextual factors in the development and evaluation of programs and intensive CBT programmes for aggression in childhood.

What are some problems and what are recommendations?

Ethnic and community context

Different ethnic and community factors limit the generalization and consistent use of Coping Power strategies for aggressive boys and adolescents. For example, there are difficulties in using the CPP for African-Americans- low-income individuals. These parents may directly or indirectly promote the use of physically aggressive problem solving strategies because of their dependence on physical punishment or they can actively teach their children to use aggressive solutions when faced with problems. Another factor that can limit the effectiveness of treatment is that a child gets mixed signals regarding the use of aggression by parents and other authority figures such as teachers. Also, when a child has experienced trauma, the long-term use of problem solving strategies will be significantly limited.

Adaptation of CPP for young primary school children

To make CPP appropriate for younger children, group leaders need to change the structure and content of the sessions. Children in this age group are less proficient in group behaviour, are more self-centred in perspective-taking and are less skilled in problem-solving.

Adaptation of CPP for mid to late adolescence

Also, when adapting CPP for adolescents, group leaders need to change the structure and content of the sessions. In this group, the role of peers is an important factor.

What are the future directions for CBT?

The greatest limitation of previous CBT programs and research in aggressive children is neglecting the role of caregivers, especially parents. It is important that caregivers are involved: this is a critical aspect for the treatment effects and in maintaining the positive effects of treatment over time. Behavioural training for parents and teachers can also be helpful. Moreover, this can change the biases in ratings and social problem-solving in parents, to which children respond and from which they learn. Also, the emphasis on cognitive schematics and processes can ensure successful use of self-instruction or problem-solving. To make CBT suitable as a prevention program, risk factors for developing childhood aggression should be identified.

Aggression refers to a set of primary inter-personal actions such as verbal or physical behaviors that are destructive to others. Only when aggression is severe, frequent and/or chronic, this is an indication of psychopathology. Children with aggression are often diagnosed with oppositional defiant disorder (ODD) or conduct disorder (CD), but periodic or chronic anger outbursts can also comorbid with other disorders (e.g. ADHD, PTSD, dysthymic disorder). Due to the intense negative effect this can have on others, children with aggression are more likely to be referred to mental health care than children with other forms of psychopathology. Research shows that aggression is fairly stable during childhood, and more consistent than other behaviors. Children who exhibit many different types of aggression in different situations are most at risk of a continuous disorder. This involves the accumulation of problem behaviour with the risk of various negative outcomes such as drug use. Troubled young people often differ on multiple dimensions of their peers (not just aggression). It is important to take into account at the same time common negative outcomes and comorbidity of risk factors, because these factors increase the risk of problems in adjustment.

What is known about Attention-Deficit-Hyperactivity-Disorder (ADHD)? - Chapter 3

What is this chapter about?

Research on cognitive behavioural therapy (CBT) for children with ADHD has not really been carried out in recent years. The last twenty years have mainly emphasized the power of pharmacological treatment, especially in terms of short-term outcomes. Indeed, many have concluded that medication is the only option of treating ADHD and that interventions aimed at behaviours are not important in dealing with the main symptoms of ADHD. However, the authors of this book believe that the role of cognitive behavioural treatment is extremely important. However, in previous versions of this book they made a few points, which are important to keep in mind:

1. Cognitive mediation (verbal interference) is not effective in ADHD.
2. However, psychosocial treatments do have a positive impact on ADHD and are the only evidence-based treatment when the child or parent has an aversion to medication.
3. Medication has no healing effect: the benefits of medication disappear when the medication is stopped. Moreover, the results of medications do not spread to intra-individual, familial, academic or peer-related contexts.
4. Medication combined with psychosocial evidence-based interventions has better effects compared to just pharmacological treatment. Behavioural interventions are therefore an important part in dealing with ADHD.
5. Common comorbid disorders in ADHD benefit little from medication alone.
6. Adding self-management-based components to the treatment can increase positive outcomes of treatment.
7. Generalization of treatment remains far-fetched in ADHD.

The more the authors learn about ADHD, the clearer it becomes that ADHD-related problems are not limited to childhood, that the main deficits of ADHD lead to reduced self-awareness of problems in functioning, and that the current arsenal of empirically supported treatments is not sufficient.

Behavior, cognition or both?

Behavioural treatment contains a number of cognitive elements, they are not just focused on behavior. For example, the cognitions of individuals are part of the behavior. Therefore, cognitive strategies can be important in achieving a goal. Effective behavioural management programs should depend not too much on external rewards, but on planning, problem-solving and self-management skills. Thus, cognitions are an essential part of behavioural programs. There is also no clear separation between behavioural and cognitive elements of good psychosocial interventions; the aim is to come up with an integrated cognitive and behavioural treatment plan.

What are the foundations of ADHD?

Clinical characteristics and prognosis

In ADHD, the areas of attention deficit/disorganization, hyperactivity/impulsivity or both, which start early, are pervasive and impaired. Critics state that ADHD has been over-diagnosed in recent years, yet the validity of ADHD is proven by important characteristics such as diagnostic reliability, coherence of the syndrome and cross-cultural manifestations. ADHD is divided into three subtypes; the inattentive type, the hyperactive/impulsive type and the combined type. In epidemiological studies, the inattentive type is most common, but in clinical services the combined type is most common. The prevalence is about 5-8% in school-age children, and ADHD is more common in boys. ADHD has many consequences in the areas of functioning that predict life success, such as academic achievement.

Comorbidity

ADHD is more often than not associated with one or more additional disorders. About half also have a disorder in the aggressive spectrum, such as ODD or CD. This goes hand in hand with a long-term risk for continued antisocial behaviour. Internalizing disorders can also occur along with ADHD. There is also evidence that in women eating disorders are linked to ADHD. Comorbid disorders have important implications for the responses on treatment. About 1/4 of young people with ADHD also have a learning disability. Therefore, for this subgroup, treatments that address academic problems are important.

Determination and evaluation

There are many children who exhibit inattention, hyperactivity or impulsivity for other reasons than ADHD. A differential diagnosis of ADHD cannot be done quickly or easily, because the history of the child and the family is important in forming a symptom picture. It is important to use multiple methods and informants in determining ADHD and to look at multiple situations. Ordered scales are a good first step in the evaluation process but not enough to base a diagnosis on. It is also possible to test for learning patterns, comorbid disorders and family interaction patterns. Information from relationships with peers can also provide a lot of information.

Risk factors and underlying mechanisms

There is not one etiological pathway that leads to ADHD. ADHD is highly hereditary, genes largely determine individual differences in the type of symptoms. Biological factors such as low birth weight may also be related to ADHD. However, psychobiological risk factors do not exclude the influence of environmental factors. Interactions between these factors are probably very important in the development and presentation of ADHD. Despite the biological trepidation of ADHD, family socialization is critical in forming aggressive and antisocial comorbidity. If ADHD is not treated, it will lead to a lifelong pattern of compromised functioning.

What are behavioural and cognitive treatments for ADHD?

Linking shortages to procedures

Children with ADHD have a lack of behavioural control, show no intrinsic motivation for completing tasks, do not have adequate levels of rules-based behaviour and respond inconsistently to typical home and school situations of reward. Intervention programmes should therefore use regular and consistent reinforcement to achieve skills, behavioural management and ultimately intrinsic motivation.

Types and outcomes

There are several behavioural interventions for ADHD:

Direct possibilities (contingency) management

Positive and aversive opportunities are implemented in the environment, such as special education and summer school. Response-cost capabilities in behavioural and academic goals are important. Major effects of contingency management have been found, but these have low generalizability and are only applicable in the specialised situation in which treatment takes place.

Clinical behavioural therapy

Clinical behavioural therapy is the most commonly used form of procedures for disruptive and attention-related issues. Parents and teachers are consulted in different strategies. The goal is to make the child's environment more structured, consistent and more positive. This has great advantages, but not as big as contingency management. Moreover, results are often assessed by parents and teachers, and these assessments are often more positive compared to direct observation of a child’s behavior. Generalization is also a problem here.

Cognitive behavioural interventions

Cognitive or cognitive behavioural interventions are often performed directly with the child or in a small group. Common treatments include:

• Self-instruction (for increasing verbal mediation and self-control)
• Problem-solving (to provide a schedule for better planning of social and academic behaviour)
• Self-empowerment (to be less dependent on adult sources of reward)
• Error coping (so that the child learns to lead himself away from mistakes or problematic situations).

However, it has been shown that young people with ADHD react poorly to these treatments. Adding cognitive components to treatment is only useful when combined with behavior contingency management. On its own, no advantageous outcomes are known, although we do not have much knowledge on the long-term outcomes.

Social skills training

Social skills training is primarily designed to teach how to communicate with peers. This form of treatment is usually performed in small groups with group discussions, behavioural exercises and rewarding social behavior to promote better interpersonal relationships. Early manifestations of social skill training are not an entire evidence-based treatment for ADHD and the outcomes are mixed. It seems that outcomes are better when they are combined with cognitive strategies.

Contingency management and clinical behavioural therapy focuses on the child's external environment, while cognitive, mediational and social skill training focus on inner cognitions and psychological treatment. However, the difference between the two is not very clear, in the end both types of treatment have the same goal.

What is known about medication?

Medication is so effective that that psychological treatment of ADHD has to be compared to treatment based on medication. Medication has clear benefits on the main symptoms of ADHD, however, there are large individual differences in the response to medication. In addition, benefits only occur as long as medication is still taken. In this respect, it is comparable to contingency management or clinical behavioural therapy, the results of which do not appear to be lifelong. However, medication can also have side-effects and is not sufficient in normalizing functioning. The clinical boundaries of pharmacological interventions therefore ensure that psychological and behavioural treatment continue to be developed and studied. However, several studies have shown that medication is superior to behavioural treatment and that behavioural treatment alone does not seem to be effective. Other studies have shown that long-term results are greater after behavioural treatment compared to pharmacological treatment. Mixed results have been found in combined treatment. Factors related to outcomes may also differ from those associated with the aetiology of ADHD.

What are some clinical illustrations?

Coordination and cooperation are essential characteristics of treatments for ADHD, due to the multiple problems of these individuals in different contexts.

Intervention for social skills

Social skills training (SST) includes coordination by combining a social skills group with parent groups. Participants participate in 8 sessions that last 90 minutes. The goal is to improve relationships with peers and adults by focusing on:

• Deficits in skills and achievement
• Recognition of verbal and non-verbal social cues
• Learning adaptive responses to problem situations
• Promoting generalization

It uses a lot of rewards and cognitive elements. The skills that need to be learned are first discussed and modelled, after which role play and free play (such as outdoor play, sports) are used to practice the skills. Reinforcement (rewards) are used to motivate the children. Parents receive similar instructions and observe the sessions through a one-way mirror. They learn to strengthen their children's social cognitive skills at home.

Self-evaluation procedures

Two essential skills for academic, social and behavioural competence are self-monitoring and self-evaluation of one's own performance in the context of initial goals. Hinshad and colleagues evaluated these procedures. The purpose of self-evaluation training is that the reward process that is used as encouragement during treatment, is taken over by the children themselves. Problem solving should be highlighted to encourage generalisation of skills maintenance. Group leaders start by introducing a skill (e.g. collaboration, keeping attention, helping others), which are discussed and whose main points are written down. Then role-playing games take place in which rewards are provided. The participants then have to think for themselves how someone else would judge their behaviour using the 'match game'. The goal is to reduce adult empowerment with an increase in self-evaluation. Applying the match game in other situations can allow for generalization of self-evaluation skills.

Aggression management

Children with ADHD tend to overreact and to distort interpretations and interpersonal provocations. As a result, they have a high probability on reactive aggression, which comes with a higher risk on interpersonal rejection. It is important to use cognitive and behavioural treatments. In aggression management, group leaders should determine which cues make children aggressive. The children's ideas about ways of responding are written down and discussed (what ideas are/are not good). Then, a 'spontaneous' argument is called to provoke discussion in the group. Afterwards, the steps of the provocation are followed and the conflict can be solved in a healthier way. In another phase of the training, it is discussed how the children can recognize that they are getting angry and can select an alternative behaviour. The selected strategies are repeatedly practiced during provocation. Clinical sensitivity and the skills of the group leader are important to make the provocations appropriate.

What are mediators and moderators of treatment outcomes?

Moderators are pre-existing characteristics that affect the outcome of treatment. Mediators are variables that occur during treatment and explain why the treatment works. The age and level of development of the child should be seen as a main moderator and therapeutic strategies must adapt accordingly. It may be that cognitive strategies do not work well because children with ADHD continue to function at a lower level than befitting their chronological age even as they age. Also, the comorbidity with other disorders is an important moderator and can affect the outcomes of the treatment. The clinical challenge is to find the type of behavioural, cognitive and pharmacological intervention that is beneficial in the children with ADHD who need a good intervention the most. Important mediators appear to be the parenting style and social skills within the family. Family socialization is therefore an important part of the treatment.

What are the conclusions?

• ADHD is a chronic disorder characterized by inhibition dysregulation as a result of genetic and prenatal risks associated with the family and school environment. It has substantial impact on multiple domains in life and is likely cumulative, requiring intensive intervention in childhood.
• Procedures based on cognitive self-instruction methods are not effective in influencing the symptoms of ADHD. The use of exclusive cognitive elements is not empirically supported in ADHD.
• More traditional behavioural treatments (contingency management, clinical behavioural therapy) are the basis of effective psychosocial interventions, despite their relatively weaker effects compared to medication and despite problems of generalization.
• More research into cognitive improvements is needed.
• There is currently no treatment that is entirely sufficient for ADHD.

Do the current approaches fit in with the needs of children with ADHD?

The main characteristics of behavioural interventions seem to align with the disorganized style and stimulus-based nature of children and adolescents with ADHD. However, it is not clear from some treatments whether they really counteract the underlying problems of ADHD. Future adjustments should ensure longer-lasting effects and more generalisation. Treatment that focuses on intrinsic motivation and self-regulation is preferable to behavioural approaches that focus on extrinsic ratification and forming the environment. Cognitive approaches have proved extremely difficult in children with ADHD. Integrated cognitive behavioural treatments have better effects. Generalization remains the most critical problem.

Research on cognitive behavioural therapy (CBT) for children with ADHD has not really been carried out in recent years. The last twenty years have mainly emphasized the power of pharmacological treatment, especially in terms of short-term outcomes. Indeed, many have concluded that medication is the only option of treating ADHD and that interventions aimed at behaviours are not important in dealing with the main symptoms of ADHD. However, the authors of this book believe that the role of cognitive behavioural treatment is extremely important.

How can we deal with aggression in children and adolescents? - Chapter 4

What is this chapter about?

Although official statistics of aggression and violence have shown decrease, many believe that aggression is still one of the most significant problems of current time. It is one of the most common reasons for referral to health care. In the United States, approximately 2–6% of adolescents have conduct disorder. And 35-50% of those who exhibit aggressive behavior are referred for treatment. These juveniles are a risk group, since about 80% of them are later diagnosed with a psychiatric disorder. There are also many other negative consequences. For example, aggressive young people are at high risk of adult crime, alcoholism, drug abuse, unemployment, divorce and mental illness. This group of young people leads to enormous costs (education, legal systems, health care, social services, etc.). In the United States, the greatest threat to life is not disease, but violence.

Boys are more likely to engage in physically aggressive behavior and other antisocial behavio compared to girls. In girls, infrequent aggressive behavior is often related to abuse and violence at home or in relationships. Although only a small proportion are life-course-persistent offenders, early aggression are predictive of problems in adulthood. There is often an atmosphere of fear and intimidation in communities where aggression is common. Children who experience harassment or relational aggression are more likely to develop internalizing problems and difficulties in controlling anger. Thus, a cycle of aggressive behavior can arise in which victims of aggression become aggressors. Although average aggressive behavior decreases with age, severely aggressive behavior that start early seem to be fairly stable. There are three types of development in aggression:

1. Lifelong aggression/life-course-persistent aggression: starts early and persists into adulthood. This is the largest group of aggressive individuals. Aggression often begins with neuropsychological deficits that interfere with self-control and language. This makes these children more vulnerable to environmental difficulties such as poor parenting practices. This indicates continuity.
2. Adolescence-limited aggression: this type of aggression starts around puberty and persists into adolescence, but does not last until adulthood. This type of aggression is also less extreme. These young people have stronger family ties and are less likely to drop out of school. Their aggression is often less consistent across different situations. This indicates discontinuity.
3. Late-onset aggression.

The view that early aggression is stable is not entirely correct. Systematic interventions can change aggressive behavior. There are two evidence-based interventions that seem promising for severely aggressive children, family/parent-oriented therapy derived from social learning theory and child-oriented cognitive behavioural interventions. This chapter focuses mainly on the latter.

What are theories, concepts, central characteristics and categorization of aggression?

Interest in various traditional theories of aggression has diminished. Some theories view aggression as behavior that falls under instinctive control, other theories view aggression as an expression of a deadly instinct, and other theories view aggression as produced from frustration. Aggressive behavior stems from an interaction between different factors; child-level factors, contextual factors, community influences and cultural factors. Taking into account that aggressive behavior can only be understood from various related factors, it is important to take into account the following:

• Genetic influences account for 50% of the variance of aggression.
• Aggression can be a function of the behavioural activation (BAS) which encourages behaviour and responses to signals and rewards/punishment. There is also a behavioural inhibition system (BIS), which is responsible for fear and withholding behaviour.
• Different family factors can also play a role in aggression.
• Parental crime and antisocial personality, family instability, divorce, antisocial family values and unemployment can also contribute to the problem.
• Community factors such as poverty, crime in the environment and low socio-economic status can be a 'toxic' basis for aggression.
• School, peers and media also affect potential risk factors. Being part of an ethnic group is associated with aggression in the U.S.

There are several theories about aggression. Social learning theory states that aggressive behavior is learned through experience and observation. The cognitive-behavioural model views anger as an intense emotional response to frustration or provocation characterized by autonomic arousal, changes in the central nervous system and cognitive labelling of the physiological arousal of anger. Aggression is thus seen as ‘the bad one’ of the potentially overt expressions of experiencing anger.

It is important to understand the different terms used to describe aggressive behavior. Anger is the internal experience of a private, subjective event that has cognitive and physiological components. Aggression is categorized as physical aggression (physical or psychological damage) or relational aggression (social and psychological damage). Aggression causes less serious harm than violence, which stands for aggressive behaviors that cause serious harm. In the DSM-IV-TR, ODD and CD are distinguished. There are probably more useful ways to categorize aggressive behavior, such as distinguishing different levels of anger and aggression. For example, it is important to distinguish between verbally threatening others and acting out the threats. Also, a therapist's assessment may be influenced too much by the experience of parents and teachers. It has also been shown that certain ethnic groups receive more serious diagnoses when they are interviewed in English rather than in their own language. There are several relevant dimensions in anger, aggression and violence in the clinically usable classification system:

• Level 1, The impatient/awkward/irritating child: these children whine, complain and get angry when they hear 'no' or are challenged. They raise their voices, hold their breath and turn red. This is controlled anger.
• Level 2, The stubborn/dramatic child: these children stubbornly refuse to follow requests. They get angry and show verbal aggression like name-calling. This can often convince parents that their child is out of control, while they are only expressing their anger verbally.
• Level 3, The threatening child and the start of harm: at this level, children are becoming increasingly angry and their verbal aggression also involves threats to injure and kill family members and animals. However, this is not acted out: this child limits to verbal aggression. However, there may be minimal damage to objects that are of no value. So the child clearly thinks about how far it goes, although parents can again interpret this behavior as being out of control.
• Level 4, The child who goes a step further: these children deliberately express their aggression towards non-living, valuable objects by destroying things or causing them serious damage (smashing windows/walls, etc.). Threats are also made to people, but there is no real physical harm to others. Most parents believe that their child is very dangerous and very intimidating, yet these children have some cognitive and behavioural control in the form that their verbal aggression towards others and physical aggression towards non-living objects does not escalate to physical aggression towards others.
• Level 5, The attacking child: this child engages in verbal threats which goes along with physical aggression. However, this is not about violence or serious body injury. Physical injuries of this level are minimal, and it is more about damage accidentally inflicted rather than on purpose. It is important to distinguish between intentional and accidental harm to others. Parents of these children are often anxious that their child will lose control and physically hurt someone.
• Level 6, The violent child: these children show violent behavior that cause serious harm to others. They deliberately throw objects or attack others with the intention of hurting them, and weapons can also be used. It is important to notice that violence at this level is intentional. Parents feel intimidated, hopeless or even emotionally or physically abused by their children.

How about Cognitive Behavioural Therapy (CBT) for dealing with anger and aggression?

CBT consists of several components: problem-solving and social skills training, coping models, role-playing, in-vivo experiences and assignments, affective education, homework assignments and operant conditioning. In addition, various self-control strategies are used to teach the child to inhibit aggressive behavior through the use of cognitive processes and they are also taught alternative behaviours and skills. The effectiveness of CBT in dealing with aggression is supported by research.

The cognitive-behavioural model of anger

The cognitive-behavioural model provides a framework for the therapist to understand the child and his/her family, but also for the child to understand which behaviours are problematic. The model is based on the idea that the emotions and subsequent actions of the child are regulated in the way they perceive, process and mediate events in the environment. The problems or events themselves do not directly determine how a person feels or what they do in a particular situation. Instead, experiences of the emotion of anger reflect a person's integration of cognitive processes of physiological events. Anger is constructed by interacting physiological, affective, cognitive and verbal components. Individuals thus experience anger at a continuum that goes from adaptive to maladaptive states, which is expressed in aggression and violence. Aggressive youth do not have the psychological resources to deal with problems and therefore react aggressively. The cognitive-behavioural model therefore also focuses on improving skills. Thus, the child must learn the necessary skills to respond in more adaptive ways in problem situations. To do this, the child must be taught alternative ways of responding, or the cognitions of the child regarding anger provoking situations must change.

The therapeutic relationship and stress vaccination paradigm in aggression

The therapist should also have a model on the variety of interventions so that he/she can draw up an effective therapeutic treatment plan. The stress vaccination model is such a model. Aggressive youngsters are a challenge to therapists due to their dysfunctional beliefs, self-expressions and ways of dealing with others. They believe that no one understands them, especially since they feel that others often challenge them to use aggression. They often don't want to come to therapy when others want them to and have negative ideas about the therapist. CBT is based on collaborative empiricism, which means that a collaborative relationship with the child is created, so that the therapist and the child work together to reduce aggression. This is essential because angry young people often see adults as the enemy and themselves as victims. Again, the gold standard can be used in the formal determination of more methods, informants, situations and processes. This is also useful in setting therapeutic goals during treatment. Case formulation is a collaborative process in which the therapist and the child/his family come together to a relationship with regard to the problems that led to therapy. The therapeutic relationship improves when the clinician understands the relevant factors that target the client's aggression. There are gender differences in how anger and aggression is experienced: girls internalize aggression earlier, while boys externalize aggression in the form of aggressive behaviors. Girls who do participate in antisocial behavior and aggression often have a family background of physical and sexual abuse. There are two other key factors that are important in understanding aggression; the type of aggressive behavior of the client (open vs. relational) and the client's perception of the purpose of his/her aggression (proactive/reactive). Boys are more likely to show overt aggression (direct verbal and physical harm), while girls are more likely to exhibit relational aggression (indirect means of harm, e.g. manipulation or gossiping). Due to technological changes, relational aggression such as cyberbullying is now common, of which girls are more likely to be victims. In the case of reactive aggression, the client is convinced that he/she has already been harmed. They see their aggression as just and necessary. This often goes hand in hand with deficits in emotion regulation management in girls. In case of provocation, boys are more likely to react with aggression and girls are more likely to improve the situation by other means. Proactive aggression occurs without provocation, it is some kind of manipulation. The goal is to get benefits from it. Proactive aggression is often characterized by lack of empathy and cold-bloodedness.

This book talks of four phases of treatment. The diagnostic (assessment) phase involves a precise multi-methodical process to identify external environmental stimuli or internal 'triggers'. Diagnostics helps the clinician to understand the connections between cognition, emotion and behavior, but it will also help to achieve a collaborative alliance with the child. In the second phase, the educational phase, the child learns about their own feelings of anger and how aggressive behavior can counter them. The child becomes more aware of how the anger experience can lead to maladaptive behavior. This involves self-observation and self-monitoring of autonomous and physiological processes. In the third phase, the skills acquisition phase, teach children to deal with anger. The earlier self-observation not only increases the child's awareness of 'triggers', but also helps to recognize chains of maladaptive cognitions, physiological responses and behavior. In the application phase, children are exposed to problematic situations so that they can practice their new skills. Prevention of relapse should be planned in order to create generalization and maintenance of the treatment effects.

Keeping your cool is one of the five most commonly used CBT strategies used in aggressive children. It is a structured yet flexible programme. The guide goes along with an instructional video. The programme can be used as a primary or secondary intervention, both individually and in a group, as prevention and intervention. Effective strategies include skills training, social problem solving, thinking skills and social perspective-taking. The guide also uses empirically supported procedures such as self-talk, relaxation training, problem solving, assertiveness training and humour. Relaxation training consists of isolating muscle groups and comparing feelings of relaxation and tension. It helps to reduce anxiety, depression and anger, but it also increases a child's positive attitudes. It is probably more effective for physical than cognitive symptoms. It also increases interpersonal assertiveness. The idea behind this is that aggressive individuals have difficulties standing up for themselves in an appropriate assertive way. Research has proven it to be effective in reducing self-reported aggression and increasing appropriate interactions with teachers, improving empathy, self-control and taking others into account. Humour is a bit controversial, however despite discussion about its use, there's plenty of research on the effectiveness of humour. The authors think that humour is effective not only in reducing tension and anger, but also in improving the therapeutic relationship in terms of cooperation. The five specific intervention strategies in the guide help children to identify problematic situations early, become more aware of environmental cues and better process them, and in obtaining different anger management skills that they can rely on in difficult situations.

Phase 1: Diagnostics (case formulation)

Diagnosing anger in children is a multi-dimensional process. The initial decision relates to who meets the therapist before the interview, some therapists believe it is better to see the child first while other prefers to see the parents or the whole family first. The authors recommend seeing the entire family during the initial session, because this prevents the child from thinking that something is being planned in secret and that they are in trouble. If there are different cultures, the culture must be taken into account. The therapist should be familiar with family structures, gender roles and specific protocols in the culture. Another advantage of seeing the whole family is that interactions between the family members can be observed, which provides a lot of information. After the initial session, the parents and the child can be seen separately. More detailed information about the anger can emerge here. It is important that the child does not feel that it has to defend him or herself. The therapist probably needs a 'warm-up' period with the child, especially when the client and therapist differ in ethnicity this period is essential. The therapist must form an alliance with the child against a common enemy, the anger/aggression. This is likely to occur slowly and indirectly. Also, the clinician must determine how anger is understood and expressed when the family is of a different ethnicity (when, for example, it is justified, culturally sound and when it exceeds the limits of what adaptive behavior is in that culture). Especially in aggressive children, the therapist must be patient and supportive, these children answer open questions with just a few words, and do not speak much. Confrontation increases the child's belief that he or she has to defend him or herself. At this stage, it's mainly about understanding the child, rather than challenging or correcting him or her. An interview technique that can be used is to play a movie, where the child can tell a scene and stop it, rewind it and edit it. In young children, drawing is more appropriate. Other possibilities to identify anger in children is with the use of self-reports. Anger is an internal state of arousal laid out by thoughts, attitudes and emotions, so these self-reports reflect experiences and expressions of anger. Internal states and emotions are difficult for teachers or parents to identify. By using self-reports it is assumed that the child has the will and possibilities to report his/her internal feelings. However, for this, a cooperative relationship between the therapist and the client during the diagnostic phase is important.

A good self-reporting tool for anger is the ChIA: Children's Inventory of Anger. This measurement instrument consists of 38 items with a four-point scale, concerning different situations that provoke anger. Another self-report is the STAXI: the State-Trait Anger Expression Inventory has good psychometric properties and is most commonly used. This instrument uses an age-standard reference and can be used for children, adolescents and adults. The STAXI distinguishes six anger scales. In order to combine information about the child's anger from parents and teachers, the CBCL (Child Behavior Checklist) can be useful. This tool gives adults the opportunity to assess the observed behavior in the child. The BASC (Behavioural Assessment System for Children) is also widely used. These tools can be very useful because they provide information about the child from different perspectives. Moreover, children are sometimes unaware of their own behavior, denying it or minimizing their own role. Role-playing games regarding anger provoking situations can also be useful. It is important to agree about rules in advance.

Phase 2: Educational phase (cognitive preparation)

This phase is an extension of the first phase, and it has four main objectives:

1. To continue forming a collaborative relationship with the child against a common enemy such as anger,
2. To help the child further understand the nature of his/her anger and aggression,
3. To quickly recognize the cognition-affective-behaviors in the anger-arousing reaction-chain
4. To continue to identify and recognize environmental stimuli or problems that provoke the anger aggression response pattern.

The Keeping Your Cool guide provides specific tasks that allow the therapist to teach the child about his/her own experience of anger but also to set the stage for how intervention strategies in the skills acquisition phase can work. The personality and experience of anger of an individual can be presented in the ABC of personality; A. how someone thinks (about an external event, problem or trigger, antecedent/activating event), B. how one feels (a chain of thoughts, images that result in internal feelings, cognitive processes, beliefs), C. how a person behaves (consequences, result). The ABC model can be used to provide an anger-provoking situation to help to gain insight into the specific ABC’s.

Phase 3: Skills acquisition phase (learning the anger management games)

The third phase is intended to provide the child with specific techniques, both cognitive and behavior, to use during the coping process. Self-management strategies at the cognitive, affective and behavioural level are taught, such as anger-reducing self-talk, relaxation techniques, problem-solving skills, assertiveness training and humour. In this phase, it is explained that aggression is provoked not only in environmental events, but also by the way these events are received and processed. Children with aggression appear to have a self-centred and distorted perception of social situations. They pay the most attention to hostile cues in interacting with others. These children often assume hostile intentions in the other, and this distorted perspective in aggressive youths explains why they often react impulsively and aggressively in many different situations. In the guide, to learn how to deal with distorted perspectives, there is an exercise called the 'perspective check', to increase understanding of other people's feelings and emotional states. The purpose of the exercise is to accurately identify similarities and differences between individuals for alternative interpretations of social cues and what another person thinks or feels. The basic goal is to make adolescents understand that people have different perspectives, which can be misunderstood. This will teach people to better evaluate other people's intentions. More examples of exercises in this phase are given on page 117 in the book.

Phase 4: Application training (practice, practice, practice...)

While the young person becomes more and more skilled with the skills from phase 3, the therapist gives the young person the opportunity to practice these skills in controlled situations. Being highly skilled in all five anger management skills is not necessary, instead it is better to practice first with one or a few and then practice other skills. Role-playing tasks are used to test whether the youngster has mastered the new skill well enough. If it turns out that the child is skilled enough, the therapist can use ‘barbs’ (annoying comment) and ‘give-and-get’ tests. The child's reaction to these tests is observed to test whether they are skilled enough. Homework is also useful, and this is the main mechanism of achieving generalization of treatment.

What are future directions?

Involving parents in the treatment of children and adolescents can be helpful. However, more research into the implication of active parental involvement in individualized treatments is needed. Some research has already been carried out, and the involvement of parents in treatments seems to be a good idea, as the family plays a crucial role in the development of the child. However, there may be difficulties in parental participation in treatment. The more people involved, the harder it is for the therapist. Moreover, parents are found to be difficult to persuade to participate and attrition rates are high. Moreover, parents of aggressive children themselves can be just as difficult to work with. Often parents are also exhausted by their own children, so they prefer not to participate in the therapy. Despite these difficulties, parental participation can have great benefits, such as generalization of treatment. Other key questions concern which interventions are most effective for specific children, how parent components can be integrated into individual treatment and which conditions of the therapeutic interventions maximize the effect. Continuous empirical evaluation is also important.

Although official statistics of aggression and violence have shown decrease, many believe that aggression is still one of the most significant problems of current time. It is one of the most common reasons for referral to health care. In the United States, approximately 2–6% of adolescents have conduct disorder. And 35-50% of those who exhibit aggressive behavior are referred for treatment. These juveniles are a risk group, since about 80% of them are later diagnosed with a psychiatric disorder. There are also many other negative consequences. For example, aggressive young people are at high risk of adult crime, alcoholism, drug abuse, unemployment, divorce and mental illness. This group of young people leads to enormous costs (education, legal systems, health care, social services, etc.). In the United States, the greatest threat to life is not disease, but violence.

What about anxiety disorders in young people? - Chapter 5

What is this chapter about?

Prevalence of anxiety disorders in young people range from 2.4% to 17%. If children experience anxiety, this increases the likelihood of comorbid diagnoses, psychopathology in adulthood and lower adaptive functioning in different domains. However, mild anxiety is part of normal development, so it is important to place fear within the normative context.

What is normative development?

During development, the content of children's fears change, and this reflect changes in their perceptions. Fears begin with a more global, imaginary, uncontrollable fear and become more specific, differentiated and realistic with time. There are several fear factors, so the Fear Survey Schedule for Children-Revised (FSSC-R) distinguishes between:

• Fear of failure and criticism.
• Fear of the unknown.
• Fear of injury and small animals.
• Fear of danger and death.
• Medical fears.

Although age and gender differences exist, the factors are quite robust across age, gender and even nationalities. Between different cultures one has to be careful with generalization, yet there appear to be more similarities than differences between different cultures. The most common fears in children often turn out to be the same. As children get older, their fears usually decrease. Many young people experience fears that relate to performance, but when this does not get in the way of their functioning this is reasonable. Fear is an expected part of functioning, except when it is so exaggerated that it interferes with functioning. The focus in this book is on three anxiety disorders; generalized anxiety disorder (GAD); separation anxiety disorder (SAD) and social phobias (SP). In SAD, extreme fears occur when there is separation from a bonding figure, so they do not want to be separated from a caregiver. In SP, the source of the fear is social evaluation, with the fear of being humiliated by others. GAD is characterized by serious, uncontrolled concerns in various domains.

What are characteristics of anxiety?

Anxiety consists of behavioural, somatic, cognitive and emotional elements. The most prominent behavioural response is avoidance, but also a more trilled voice, rigid stature, crying, nail biting and thumb sucking are anxiety reactions. Physiologically, young people with fears can show an increase in the activity of the autonomic nervous system, sweating, diffuse abdominal pain, a run-in face, stomach pain and chills. The cognitive distress consists of serious worries and anxious thinking. The specific nature of cognitive care varies by anxiety disorders. These concerns are difficult to verify. With regards to diagnostics, the duration of the symptoms is important. For SAD, symptoms should be visible for at least 4 weeks, but for SP and GAD they should be visible for at least 6 months. With regard to treatment, a distinction must be made between cognitive biases and cognitive deficits. Deficits refer to the deficits in cognitive abilities (lack of precaution), biases refer to dysfunctional thinking (presence maladaptive thinking). Emotionally, anxious children react differently. For example, they have less understanding of how their own emotions can be hidden or changed. Therefore, methods are used to manage emotional expressions, which limits anxious children in understanding the regulation and modification of their own emotions. Results show that anxious children experience emotions as more intense and view themselves as less successful in managing emotions. Moreover, they show a dysregulation in the management of emotion and less adaptive coping.

What about family?

Research shows that children with anxiety disorders are more likely to have parents with anxiety symptoms, mood disorders and other psychopathology. In addition, it appears that parents of anxious children encourage potentially maladaptive patterns of response through direct discussion with their children, modelling anxious behavior, and exhibiting controlled and protective behavior (which reduces the anxious child's control and psychological autonomy). It also appears that after family discussions the avoidance behaviour of an anxious child increases, and this phenomenon is called the ‘family extension of the avoidance and aggression response’ (because it is also visible in aggressive children) and has implications for the type of intervention that is applied. This all confirms the empowering role of the family in potentially contributing to anxious behavior. Moreover, anxious and depressed children describe their families as less supportive, cohesive and democratic when making a decision and also as having more conflicts. Different therapy models try to address parental control and the desire for autonomy of the child. For example, in the 'transfer of control model’, both parents and children are taught new skills, and parental involvement is a mediator.

How about diagnoses?

The DSM-IV is a categorical classification system and can be used for the diagnosis of anxiety disorders. A minimum number of symptoms is required for a diagnosis. The Child Behavior Checklist is an alternative, an empirically obtained, dimensional system of classification. Symptoms on this checklist include anxious-depressed, schizoid, somatic symptoms and shyness. The DSM-IV combines characteristics of categorical and dimensional approaches by identifying essential symptoms of a disorder and allowing it to merge with non-essential variations of symptoms. Although the DSM-IV is certainly an improvement on the DSM-IIV, problems remain. For example, the start, development and context of anxiety symptoms and information about the child's development, medical, school, social and family history must also be taken into account, and this is not the case in the DSM-IV. A reliable and valid measuring tool for symptoms in different domains should:

• Discriminate between disorders.
• Evaluate the intensity of symptoms.
• Combine different types of methods.
• Evaluate therapeutic change.

Although no instrument is perfect, there are several acceptable diagnostics instruments available. These are shown below.

What are measurement methods?

The clinical interview

The clinical interview is one of the most commonly used methods for determining anxiety disorders, and they can range from structured to unstructured. The semi-structured interview provides the necessary structure for a clinical setting and also offers possibilities for elaboration when this is seen as appropriate by the clinician. The ADIS-C/P, the Anxiety Disorder Interview Schedule for DSM-IV – Child and Parent versions is such a semi-structured interview. By using this interview, the DSM-IV anxiety disorders can be diagnosed. It is semi-structured in that it provides the clinician with room to take information from the interview and observations. The parent version can help to obtain information about the child's history. The child version looks at the symptoms. Diagnoses are based on the level of severity from both interviews and the similarity of identification of pathology from the child and parent version. It has good psychometric properties and clear, clinically sensitive sections for various anxiety disorders. The K-SADS, the Schedule for Affective Disorders and Schizophrenia in School-Age Children, can also be used. The Diagnostic Interview for Children and Adolescents (DICA) and the Diagnostic Interview Schedule for Children-IV(DISC-IV) are also possibilities. Not all of them are intended to specifically diagnose anxiety disorders.

Self-reports

Self-reports can help to establishe the perspective of the young person regarding his/her symptoms, which is important given the subjective nature of anxiety. The advantages of this are that it is easy to administer and not expensive. A negative point is that they cannot be the only base for establishing a diagnosis. Moreover, they do not always focus on the specific situation of anxiety disorders in childhood, thus they do not focus on the fears specific to the child. Without such information, it is difficult to tailor treatment to specific problems of the child. In addition, few self-reporting tools have adequate normative data for different development stages of the child. In addition, the instrument may not properly reflect the child's internal state, or children may respond in a socially desirable way. Several self-reporting tools are mentioned on page 151.

Behavioural observations

During the diagnostical phase, many structured and unstructured observations are taken, during interviews for example. Unstructured observations are important but can be limited by an observational bias and a lack of observation training. More structured observations are made during BAT’s: Behavioural Avoidance Tasks. The child is then directly observed by trained people in natural settings such as at school. However, structured observations are again limited by the absence of standardised procedures; there is no comparison material. Therefore, observations are not sufficient for making a diagnosis.

Parent, teacher and clinician review scales

Reports from parents and teachers provide additional important information, but are limited in identifying internalizing disorders. There is also little agreement between parent and child reports of anxiety. The CBCL has acceptable reliability, validity and normative data. This instrument consists of 118 items. There is also a version that is suitable for teachers, which allows a comparison of the anxious behavior at home and at school. However, it should be taken into account that the teacher may not see the behaviour of an anxious child as a problem. Thus, these instruments provide useful information but are not related to the DSM categories. More instruments like this are mentioned on page 154.

Physiological recordings

Physiologically determining anxiety takes a lot of time and money and there is often no adequate normative data available. Measurements can also be influenced by expectation effects, emotions and occasional motor activity. Nevertheless, measuring the autonomous responsiveness of anxious children can increase our understanding of physiological expression of anxiety and help obtain normative data in this area.

Family-related variables

Due to the influence of family factors in anxiety in young people, determining family factors can be useful. These include constructs such as control and protection. However, there are often psychometric limits. Multiple methodical approaches are needed to identify anxiety, consisting of interviews, self-reporting, reporting by parents and teachers, behavioural observations and family patterns and interactions.

What are the procedures and outcomes of treatment?

CBT in anxious children

CBT in anxious children integrates the aforementioned behavioural approaches (relaxation, role-playing, etc.) with an emphasis on cognitive information processing factors associated with everyone's individual fears. The purpose of treatment is to teach children to recognize the signs of anxious arousal, and to use these signs as a cue for deploying anxiety management strategies. Usually, the structured treatment program consists of 16 sessions, divided into skills training and skills exercise. The first part focuses on building four basic skills areas; recognition and evaluation of self-talk, problem solving skills, self-evaluation and rewards. During exposure tasks, children practice with the learned skills in anxiety-provoking situations. This gives the child the opportunity to develop a sense of self-competence, by allowing the child to demonstrate his/her skills in real situations. The child is taught to use the skills in different situations. Again, it is important to establish a cooperative relationship. During the treatment, the therapist functions as a model, as he/she demonstrates a skill in each new situation. He/she shows an anxious experience and how it can be handled. The child is then invited to participate in a role-playing game. In the end, the child is encouraged to do the role-playing alone. Role-playing games must represent situations that are relevant to the child. Self-disclosure of the therapist can also help. This means that thoughts or feelings are described aloud, which shows that feelings can be discussed openly.

What are components of CBT?

Psycho-education

Part of the psycho-education component is to help young people to identify and discriminate their own emotional states. Many young people with fears experience physical symptoms, which they interpret as being sick, instead of arising from their anxiety. Therefore, they are taught to identify when somatic symptoms are associated with anxiety or illness, so that they can better deal with anxiety and differentiate it from other conditions.

Relaxation techniques

The goal of relaxation is to teach children to develop awareness and control over their own physiological and muscle responses to anxiety. Large muscle groups are taught to relax through systematic, stress-lifting exercises. The increasing awareness of the own somatic reactions to anxiety gives the child the opportunity to see an excited physical state as an early warning signal and to initiate relaxation. A word can be attached to the relaxation, such as ‘calm’. This is called a self-produced cue, and is called cue-controlled relaxation. Adding imaginary or in vivo exposure tasks to the relaxation program increases the therapeutic outcome of relaxation.

Creating a cognitive coping model

Because cognitions are linked to emotions and behavior, dysfunction in behaviours or emotions can improve by identifying and challenging the child's distorted or unrealistic cognitions. Cognitive therapies change biased cognitive processes into more constructive ways of thinking. Strategies include reducing negative self-talk, generating positive self-awareness and creating a plan to deal with frightening situations. Cognitive modelling, practice, social empowerment and role-playing help create a coping model. The therapist works with the child to

• Remove characteristic misinterpretations of environmental events and
• Gradually and systematically build a framework of references with coping strategies.

It is essential to correctly determine the conceptualization of the dysfunctional thought structure. The purpose of a coping model is not to make all stress perceptions disappear forever. The power lies not necessarily in positive self-talk, but in reducing negative self-talk – a phenomenon called the power of non-negative thinking.

Problem-solving

Problem solving is also a component of the cognitive behaviour approach to anxiety. The goal is to train children so that they gain confidence in themselves when facing daily challenges. Troubleshooting can be divided into five parts:

1. What's the problem? A general orientation where the focus is on helping the child in understanding that problems and controlling impulses are part of everyday life.
2. What can I do about it? The child defines and formulates the problem into workable problems with goals.
3. What is likely to happen if I do these things? Alternative solutions are devised and assessed here. Good brainstorming skills can be learned by generating both pragmatic and unlikely alternatives.
4. Which solution works best? This is the stage in which the decision is taken, in which the child evaluates each alternative solution and chooses the most suitable, with which he/she takes action.
5. How did I do it? In the final phase, the chosen solution is evaluated.

Problem solving helps the child to quickly generate alternatives in situations that at first glance seem hopeless.

Contingency reinforcement

Contingency reinforcement is based on operant conditioning principles and works on the basis of rewards and reinforcements instead of anxiety reduction. Formation, positive reinforcement and extinction are commonly used contingency management procedures for reducing anxious behaviour. To counter the critical beliefs that anxious children have, the therapist rewards the child for his or her commitment and success.

Modelling

The roots of modelling lie in Bandura's social learning paradigm, in which non-anxious behavior is demonstrated in an anxious situation to illustrate effective behaviour for the child. Filming, life-like or participation modelling can be used. Some studies show a greater decrease in avoidance behavior in participation modelling compared to other types of modelling.

Procedures based on exposure

Exposure involves placing the client in a situation that evokes anxiety, imaginary or in vivo. The aim is to help the client acclimatise to the stressful situation and to provide opportunities in which coping skills can be practiced. In the case of gradual exposure, a hierarchical list of least to most fear-provoking situation is drawn up, working from bottom to top. This helps to give the child a sense of power. In continued exposure, the child is repeatedly exposed to frightening stimuli for longer period of time. This prevents the child from reacting with avoidance.

What are examples of a CBT program?

To make learning easier, CBT programs often use the FEAR principle.

F: Feeling Frightened?

One of the first steps in managing anxiety is to recognize anxious feelings and differentiate them from other emotions. With affective education, young people learn to recognize facial expressions, postures and physiological signals associated with different emotions, in themselves and others. Concepts are first introduced abstractly or to others before the focus is placed on the experience of the child himself. With the use of role-playing, emotions can be differentiated. Ultimately, children learn to recognize their own physiological expressions of fear by placing themselves in an imaginary anxious situation. Once they recognize their physiological symptoms, they can use this as a cue for the use of relaxation.

E: Expecting Bad Things to Happen?

In this step, young people are taught to identify thoughts that contribute to the anxious experiences. Self-talk, things that children say to themselves when they are afraid, is an important concept. This includes the expectations and attributions of the child about him/herself, others and situations. These expectations can include negative self-evaluations, perfectionist performance standards and concerns about what others think. To help children with their self-talk, cartoons with empty text bubbles can be used. If young people have identified anxious thoughts, the therapist can help them generate anxiety-reducing thoughts (coping) by, for example, asking questions about how likely something is really to happen. The aim is to develop an alternative information processing model based on coping. In addition, homework assignments, role-playing and exposure tasks are needed to give the child confidence in their own ability. Gaining self-confidence by exercises and thinking about what others think and feel helps the child to develop more confidence.

A: Attitudes and Actions That Can Help

In this step, young people learn to develop a larger plan for managing anxious situations. Problem solving is emphasized, in order not to overwhelm children with this, one can first start with non-threatening situations to introduce problem solving. As in the other steps, the therapist first engages in role-playing with an anxious situation that he/she has experienced himself, after which a situation is created based on the child’s experience. In young children, cartoons can be used, in which they have to think about what that character would do in an anxiety-provoking situation. The child can also be instructed to pretend to be the cartoon character.

R: Results and Rewards

Anxious children often have difficulty accurately evaluating themselves, setting extremely high standards for success. In the final step, they are taught to evaluate their own effort in coping. They are taught to judge themselves on the basis of their effort, instead of on the basis of the outcome of the situation. They learn to identify what they think they have done well and less well. They are also encouraged to compile a list of possible self-rewards.

Review of the FEAR plan and implementation of exposure tasks

To encourage young people to use the steps of the FEAR plan outside the sessions, they are encouraged to use a card/poster representing their personal version of the FEAR plan. This also helps young people to prepare for exposure tasks. Through imaginary and in-vivo exposure, young people are given the opportunity to practice their new skills in anxiety-provoking situations. Imaginary exposure is often used as an intermediate step to in-vivo exposure. The therapist presents a situation, notices the problem aspects and performs coping behavior. After that, the therapist helps the child to come up with the steps that can be used to approach the situation. Together they practice what might happen during in-vivo exposure when using these steps. After exposure, the child is assisted in evaluating his/her performance and in devising a reward. Although exposure takes place in a supportive environment, it is intended to challenge the child and induce anxiety. However, exposure tasks do not appear to have a negative effect on the therapeutic relationship. The therapist can increase the chance of participation of the child in exposure tasks by adding fun elements, which leads to a positive emotion during exposure tasks and has a good influence on the child's anxiety bias. With a creative twist, an anxious situation can seem more manageable. In addition, natural reinforcement may be involved.

On to Hollywood

The child also has to participate in the creation and production of a commercial about his/her experiences of the program. For example, a video, cassette or other creative expression to tell other children about how they deal with their anxiety. The idea is that this is a reward at the end of the program and helps to maintain treatment outcomes.

How can we work with families?

Therapists recognize the importance of parental involvement in helping a child overcome their fears. While the focus is mainly on helping the child to think and behave differently, it also encourages parents to take on a supporting role. Although the child-focused program does not have a separate family therapy, parents are provided information about the treatment, encouraged to be involved, given space for expressing concerns and sharing impressions about anxiety-inducing situations for the child. Parents can also attend part of a session and are invited to call the therapist if they have any questions or any helpful information. Given the important role that parents have, it is important that the therapist is aware of problems that families of anxious children may experience (increased risk of anxiety disorders and other pathology, specific problems in parenting such as being too protective and feelings of guilt about their child's problems). Parental involvement in anxious children seems to range from barely involved to being extremely protective. Too little involvement can lead to problems with the fulfilment of appointments at the therapy. Being too protective can again interfere with the child's performance on tasks related to self-confidence. It may be that parents are not aware of this and that the therapist should demonstrate the influence of parental behavior on the child's anxiety. The therapist can for example teach parents to formulate things differently, within a problem solving framework. Through a pragmatic discussion, the therapist can help the parents deal with their feelings of guilt about the child's fears. It should be stressed that the problem is not how the fears have developed, but how parents can now contribute to helping their child cope. If necessary, parents can discuss how their anxiety or other problems contribute to their child's problems, in which observations and suggestions on changing the parent-child interaction are useful. It is important to teach parents new ways of responding to their child's anxious behavior. Parents can be hypersensitive to their child's fears and, for example, become anxious themselves. Videos of sessions can show a parent how they contribute to the child's fears, when shown in a non-judgmental way it can help explain interaction patterns and may lead to behavior change. It is also important that effort is coordinated so that parents do not feel unnecessary when their child starts doing things themselves. If they show this to the child, this can act as a negative endorsement.

What are treatment outcomes?

If a treatment is effective, this means that the treatment is more effective than a control condition in a randomized clinical trial. A review shows that behavioural and cognitive behaviour procedures are the modalities most empirically proven in the treatment of anxiety disorders. While multiple studies show that adding a family component makes treatment more effective, another review shows that the benefits of engaging parents in treatment are not decisive. The way parents were involved in the treatments varied widely in the different studies. Future research should focus on which treatment is best for whom and under what circumstances. When looking at many studies together, it can be concluded that CBT is an empirically supported treatment for young people with anxiety. Research has also been carried out on CBT as a prevention programme for at-risk young people, and several studies serve as evidence for its effectiveness.

What about computers?

There are several reasons why computer assistance in treatments is attractive in working with anxious young people. Both computer-based (self-contained) and computer assistance (led by the therapist) in CBT has practical benefits: it reduces costs and can improve adhesion. Tracking data is easier and automatic. For example, there is the Camp Cope-A-Lot, a computer assisted program. The effectiveness of this has been supported, and even the youngsters themselves reported satisfaction with the program. Also a training DVD with session modules can be an option. However, more research is needed, as it has been shown that supervision during and after treatment is necessary for the quality application of the treatment. While much remains to be done in this area, there are reasons to be optimistic.

Prevalence of anxiety disorders in young people range from 2.4% to 17%. If children experience anxiety, this increases the likelihood of comorbid diagnoses, psychopathology in adulthood and lower adaptive functioning in different domains. However, mild anxiety is part of normal development, so it is important to place fear within the normative context.

What is known about Childhood Depression (The ACTION Treatment Programme)? - Chapter 6

What is the ACTION program?

The ACTION program is a manual-based group treatment but accompanies a case conceptualization for each participant. The action program presented here is a cognitive behavioural intervention for depressed girls, and there is also a parental component. Ideally, the girls learn coping, problem-solving, and cognitive restructuring skills while their home environment learns to support and apply the skills. The program has been adapted for young people who suffer from comorbid disorders. Although the manual is written for girls, the program can be adapted for depressed boys. With adjustments in procedures and activities, the program can also be used in individual patients. Before the programme is discussed, studies on psychosocial and pharmacological treatments are discussed.

What is known about psychosocial treatment outcomes from research?

Treatment in the community

Most depressed young people don't get treatments, and many of those who do get treatment, don’t get evidence-based treatment. Moreover, many follow only a few sessions and then stop. About half of the juveniles are treated with a combination of medication and therapy, 21% only with medication. Many researchers see a trend of reduced use of psychotherapy, towards increased use of pharmacotherapy. This suggests more of a replacement than complementary relationship between the two treatment types. Most receive treatment at a common health centre, private practitioner or therapist in a different setting. Few receive a 'state-of-the-art 'or evidence-based intervention. There is no evidence that supports the effectiveness of this form of psychotherapy, it is even said that it is as effective as no treatment at all. The standard treatment for depressed young people being treated in a health centre is a mix of primary psychodynamic procedures, with some cognitive and behavioural techniques in about 11 sessions. 35.8% only complete less than 8 sessions. Juveniles who had CBT as a treatment had scores near a normative sample. They therefore do significantly better compared to people treated at a common health centre. It is argued that the failure of community treatment may be due to the small number of sessions being followed, but research suggests otherwise. It has also been suggested that the effectiveness of CBT is due to the well-trained therapists, something that clinicians in the community setting do not seem to resemble. Even with well-trained therapists, community treatment is still minimally effective. So there is minimal evidence for the use of traditional therapy in young people with mood disorders.

What are protocol-based treatments?

State of the Art

Results of protocol-based treatments in depressed juveniles show that CBT can be effective, however, there is little existing research that supports it. Effective interventions have been found, but none of the empirically supported treatments has found its way into mainstream practice. One method of achieving this is to base treatments on a manual. The ACTION program has extensive therapist and structured treatment manuals. However, manuals must recognize the individuality of each child and every therapist, and some manuals do not achieve this goal. In practice there is a wide variety of training, theoretical orientation, experience, skills, interpersonal possibilities and other personal differences between therapists. Children also differ, making it necessary for a trained therapist to perform the treatment. The therapist should see the larger picture of the manual, so that it sees opportunities to apply the treatment strategies spontaneously. This allows the therapist to apply the treatment flexibly but well.

What are research-based interventions?

Psychosocial interventions

CBT has been identified as 'well-established' for both depressed children and adolescents, in accordance with the criteria for empirically supported treatments. Which variables predict improvement after tracking CGT? It seems that less severe depressive disorder before treatment, younger age, lower levels of parent-child conflict, lower levels of cognitive bias, less suicidal thoughts, less comorbid diagnoses, less hopelessness, much hope for improvement and better overall functioning predict a better treatment outcome. In the Treatment for Adolescents with Depression Study (TADS), the effectiveness of the SSRI fluoxetine, CBT, a combination of fluoxetine and CGT and a placebo, is compared in 439 adolescents diagnosed with depression (MDD; major depressive disorder). The CBT had both skills development sessions and modular sessions, so that flexible and developmental, individual treatment was possible. Also there were additional family sessions. After 3 months of treatment, results showed that the combination of CBT and fluoxetine was most effective. Only CBT was found to be less effective than fluoxetine treatment, and not significantly more effective than no treatment at all. After this study, treatment with CBT was therefore called into question. However, it is argued that the form of CBT used in TADS differs from other forms of CBT, for example, some did not include cognitive therapy. Perhaps differences in types of CBT explain differences in clinical progress.

Evaluation of the ACTION programme

The ACTION treatment program has been evaluated in a 5-year treatment study, with 185 girls between 9 -13 years of age with a diagnosed depressive disorder. They were randomized, and engaged in with or without parental-involvement training, or a minimal contact control condition (MCC). The majority had at least one comorbid disorder. CBT took place at school, during school hours. Parent training also took place at school, after school hours. The CBT consisted of 20 group and 2 individual sessions, over a period of 11 weeks. Parental training consisted of 8 group and 2 family sessions. The girls participated in half of the parental meetings. Therapists were well trained. They also spoke to each child's teacher or primary caregiver to get a picture of her well-being. In addition, each child was observed once a week during a free period. Various measurement instruments were used to diagnose depression. Cognitive functioning, family functioning, parental pathology and parental cognition were also identified. Results show that the ACTION program is extremely effective. Girls receiving active treatment report significantly less depression than girls in the MCC group. They also reported a significantly more positive picture of themselves and the future. In addition, 81 to 84% reported no more depressive disorder after treatment. The ACTION program has multiple components and it is not clear which component or combination of components produces the improvements in depression. The participants reported that the relationship with the therapist did not contribute to outcomes and that the coping skills training was the most effective for improvements. A study looking at how the treatment components are applied shows that collaborative behavior is related to reduction in depressive symptoms. The process of developing a therapeutic collaboration was effective to engage participants as effective members in treatment. In this study, behavior activity/interventions and the quality of positive reinforcement during the sessions are associated with the greatest reduction in depression symptoms after treatment. Several hypotheses have been drawn up about why behavioural interventions play a large role in explaining positive outcomes. It is possible that the active nature of behavioural interventions challenge negative thoughts and beliefs, and this also gives them the feeling that they have some kind of control over depressed moods. At the top, behavioural interventions focus on constructive, fun, relaxing and funny activities instead of maladaptive information processing strategies. Such involvement is likely to trigger positive thoughts and filter negative information. When looking at the video recordings of the sessions, it is concluded that a higher level of cognitive interventions is associated with persistent depressive symptoms. This can also be seen as the therapist himself working harder and applying higher quality cognitive interventions when he/she sees that the participant is not progressing.

What about pharmacological treatments?

Several SSRIs are superior to a placebo when treating MDD, and fluoxetine is most commonly used. In several studies, participants treated with fluoxetine reported significantly fewer depressive symptoms than those given placebo. However, depressed young people who are treated with an SSRI also experience 2-3% more suicidal events (thoughts, self-destructive behavior). They also have increased risk of developing a manic episode during treatment. A family history with suicide or bipolar disorder is associated with increased suicidal thoughts and manic reactions when a child is treated with SSRI. Patients treated with antidepressants should be closely monitored, especially during the treatment phase. Attention should be paid to worsening depression, increased suicidal thoughts and impulses, manic reactions, fears, irritation, hostility and impulsivity. When medication is combined with CBT, CBT appears to be a protective factor for suicidal activities and thoughts. Although the effect of suicidal thoughts and activities is statistically minimal, the social effect and effect on prescribing SSRIs is significant. As a result, many children who may benefit from medication do not receive medication. We need more research on this. In depressed juveniles with high levels of comorbidity and suicide, medication seems less effective. This has implications for the minimum amount of prescribed medication.

What are neurobiological correlates of symptom remission?

Neuroplasticity is a mechanism by which early stress can trigger functional neural changes and thus create depressive vulnerability. However, it can also have adaptive functional change, as neuroplasticity is also seen in reducing depression. Research has mainly been done on psychopharmacological treatment and changes in the brain. Few studies have focused on psychotherapy and brain change, but there are early indications that psychotherapy may also result in changes in neural areas. Healthy adults taking a dose of antidepressants show an information processing bias towards positive emotional information. Reducing symptoms after cognitive therapy can have an impact on another system. If it is indeed the case that CBT and SSRIs affect another system, this explains the beneficial impact of combined treatment. Furthermore, it has been shown that a high cortisol baseline slows recovery and predicts faster relapse.

How are outcomes measured?

There is a belief that decrease in symptoms stems as a result of changes in cognitive processes. It is therefore important to use a measurement instrument that establishes the feelings about the self, the world and the future of a child. The main beliefs of a depressed person are characterized by feelings of worthlessness and helplessness.

How is depression determined?

It is best to use multiple measurements and methods in determining depression. Among other things, self-reports can be used, such as the CDI and BDI. Also interviews such as the K-SADS and parent measurements like the CBCL are informative in determining depressive symptoms. The severity of symptoms is determined by combining information about frequency, duration and experience. Self-report is a good addition to the interview, and the child's answers can provide useful information about the subjective suffering of the child and this can guide the treatment. Results from the interview can provide information about the severity of the episode and the plan for more intense or long-term treatment can be based on this. Comorbid conditions can also be identified from the interview. Information about the presence of specific depressive symptoms may also be leading to treatment. It is also important to identify suicidal risks, and there is a section of the K-SADS that is about this. This is useful but represents only the starting point of more specific risk assessment.

How about related constructs?

Additional measurements look at variables related to depression and lead the development of the treatment plan. Multiple measurements have been developed to identify key cognitive variables, such as The Automatic Thoughts Questionnaire for Children (ATQ-C), consisting of 30 depression-related beliefs. The aforementioned CTI-C can also be used, which consists of three scales. The scores on the three scales can affect the treatment plan. The authors themselves developed a measuring tool for measuring coping and emotion regulation skills. The Matson Evaluation of Social Skills in Youth can be used to determine interpersonal behaviour. If a disruption in interpersonal functioning is identified, it is checked whether this is due to maladaptive beliefs or deficits in skills. Determining the family functioning is also important, because there is the belief that the family is a representation of the context in which the child learns essential cognitive and interpersonal skills. The therapist observes the family with the aim of identifying the interaction patterns that result in maladaptive beliefs, information processing errors and maladaptive interpersonal behaviors. The most effective method for this is perhaps observing the family interaction at a time of stress. The Family Messages Measure can also be used.

What is an example of the ACTION program in treating depression?

Overview

The ACTION program is a prototypical form of CBT in depressed youth. The primary components are suitable for men, women, children and adolescents. However, the design, treatment activity, specific coping skills, the emphasis on interpersonal relationships and illustrations in the treatment books are specific to girls aged 9-13 years.

Overview of the treatment of the child

The ACTION program follows a structured therapist manual. There is a session twice a week and this seems to increase the effectiveness of the intervention, it helps in remembering what has been discussed and reduces the time between homework and its evaluation. In the case of individual application, the number of sessions, the treatment components and the activities are adapted to the child, and the same basis is followed. The treatment is designed to be fun and engaged, while applying different skills and therapeutic concepts. Skills are learned through didactic presentations and experience activities, and they are practiced during the sessions and in homework. Application of skills is monitored by making workbook activities, and with a reward system it encourages the completion of homework. Different activities and homework help participants to become more aware of their personal experiences and emotions. They can use this in coping, problem solving and cognitive restructuring. Coping skills are taught for dealing with unpleasant emotions and other depressive symptoms, through activities that demonstrate that coping has an impact on their mood. Troubleshooting is taught to show that unwanted situations are within the child's control. The aforementioned five-step model of problem solving is taught (problem definition, target definition, generating solutions, thinking of the consequences and evaluation – extended in Chapter 5). The steps are defined in a developmental way, shown by the therapist and applied to hypothetical situations. Later, the therapist helps the participants to apply the model to their own real problems. It can also be practiced in the workbook. Participants are also taught to recognize their negative thoughts and evaluate them with a number of cognitive restructuring strategies. Again, within the sessions and with homework, young people have to assess their own thoughts and evaluate their validity with two questions: how can I look at the situation differently? What's the evidence? If a negative thought is realistic and reflects a situation that can be changed, the young person is encouraged to apply problem solving strategies. If the situation cannot be changed, coping strategies are more useful.

Therapist’s role

The therapist should form a conceptualization of the child's depressive disorder and make a plan in which the child is taught to effectively manage the depressive symptoms and change the core beliefs underlying the depression. In addition, the therapist should have an understanding of CBT, so that this can be applied to the conceptualization of the disorder of the child. Having an image of the bigger picture of CBT is necessary for effective treatment. Also, the ACTION program can only be applied effectively if the therapist understands depressive disorders and cognitive therapy. In addition, the therapist must make important decisions during the treatment (when can the material best be treated, to which participant is given attention at what time). If a child has said something, the therapist may ask himself if this is an opportunity to 1. To show the child that evidence from her life is contrary to her depressive conviction 2. To show that coping skills bring relief from depressive symptoms or 3. To help her solve a problem or recognize a problem solving situation. The therapist should look for possibilities where he/she can show the children that they can apply a skill in a real situation. Also, the therapist should be alert to negative beliefs and decide to restructure them now or later. In addition, pro-social behaviour must be recognized for so that it can be encouraged.

How is it implemented?

Group size

The authors suggest that 4 is a good group size for depressed 9-13 year old girls. This leads to the feeling of being in a group. It is also a good size to make sure that everyone gets sufficient attention.

Duration of sessions

The answer to how many sessions are needed for maximum effect is not yet empirically researched and difficult to answer. ACTION consists of 22 sessions of which 2 are individual. If necessary, individual sessions can be supplemented. In 9-10 year olds, a session lasts 50-60 minutes, at 11+ a session lasts 60-75 minutes.

Structure of the sessions

The sessions are structured and follow a sequence of events, providing a sense of security by allowing participants to know what to expect. It also helps during the session to focus on therapeutically relevant material.

Confidence

The sessions start with unstructured time to chat, to put participants at ease and create coherence. Especially with younger teens this is important, they need more time to get to know their peers and the therapist to gain confidence. If the discussion becomes therapeutically relevant, the therapist can join and continue with the program.

Target acquisition check-in

Each session asks the therapist if the participants have made progress in achieving their goals, and if this is a hot case, describe the progress. The group 'celebrates' progress with applause or other forms of recognition. If there are difficulties, the group can help with problem solving or the therapist can schedule an individual session. Sometimes too ambitious goals need to be broken up into sub-goals or an additional reward system is needed.

Coping skills activity

Children should experience that coping skills work before they believe in it. Experiencing the effects of coping skill also helps to restructure the belief that the child has no control over his/her feelings. The effectiveness of coping skills must therefore be demonstrated, this is done on the basis of short activities (e.g. an energising activity). All five categories of coping strategies must be demonstrated before the end of the ninth session.

Positive interpersonal behavior review

This part of the sessions is called 'catch the positive activity' and in it the therapist forms the behavior of the participants in order to obtain a new, positive conviction. The therapist uses social empowerment to make the participants behave in a way that maximizes their therapy experiences (listening, contributing, discussing, supporting etc). For some participants, it is important to endorse prosocial behaviour in order to avoid conflict. At the end, participants are asked what they have done well in the sessions and compliment themselves. They also learn to compliment others.

What are main components of the therapy?

Affective education

Affective education is the component in which people learn about depression and how to deal with it. It helps participants to become more aware of their own experiences of depression and use these experiences as cues for deploying cognitive strategies, problem solving or coping skills. CBT in depression is based on the fact that the child must have the cognitive ability to reflect, be introspective and have metacognitive possibilities about their own thinking. This is necessary for self-control and cognitive restructuring in treatment. However, this is based on speculation. To manage depression, participants learn three main strategies:

1. If the undesirable situation cannot be changed, coping skills must be used.
2. If the unwanted situation can be changed, troubleshooting must be used to improve it.
3. Catch negative thoughts and change them to more realistic and positive thoughts.

To use these strategies, young people need to recognize their unwanted emotions, problem experiences and negative thoughts. Identifying emotions can be taught with the ‘emotion detective', in which participants are taught to be more aware of their emotional experiences and how they react physically to them, what they think and how they behave (three B's: body, brain, behavior). A critical component is learning the relationship between negative thoughts and unwanted emotions and behaviors. Questions about connections between thoughts and emotions provide understanding of the relationship. The therapist can help the child become aware of the deeper meaning of events, thus helping her to become aware of beliefs. This leads to more elegant and meaningful possibilities to restructure key beliefs.

Setting goals

CBT has a collaborative approach in which the child is informed about the treatment goals and methods to achieve them. Central to this collaborative process is helping the participants identify targets for the therapy. The information about the diagnosis of the juvenile is used to create a case conceptualization, which is translated into treatment goals. This is a fluid process that can change if more is learned about the child. Individually, at most, three goals are set for treatment, tailored to the child's concerns. The therapist describes treatment procedures that will be helpful in achieving these goals. The child can choose whether to share her goals with the group or to keep them to herself. In the fourth sessions, goals are shared and thoughts about how each can achieve her goals are discussed. As mentioned earlier, the progress of the participants is determined at the beginning of each session. Progress is documented individually for each child in a visual way, for example with a map. No group card is used, since this can create competition or lead to negative feelings when someone is behind the rest. Seeing progress contributes to self-drive, which challenges the idea of helplessness.

What is coping skills training?

Coping skills training is a key component of the ACTION program. It uses five general categories of coping strategies, which teach coping focused on emotion. Coping skills training is emphasized at the beginning of the program because it immediately helps improve mood, activate behavior and participate positively in everyday life. It also increases their repertoire of emotion regulation strategies. This mood improvement makes it easier to learn things. The therapist chooses the coping skills that he/she sees as most necessary. Younger children need more active and distracting strategies, in older children the focus is more on coping with thoughts. Just talking about coping skills and how they work is not adequate, the participants need to experience the coping skills before they believe in the use of it and also start using it outside of therapy. The therapist chooses a moment when the participant(s) are sad, depressed, frustrated or anxious and then asks them to rate their own mood. After that, a coping activity is performed. Then they have to assess their mood again and are asked what they have learned. Also, the mechanism that makes the coping strategy work is discussed (doing something fun). However, therapeutic improvement depends on applying the skills outside the sessions, for which homework is given. With more severe depressed children, more success experiences are needed and it may take longer before they start applying the coping skills themselves.

What is problem-solving training?

After the participants have a better understanding of their emotions, they are taught that some undesirable situations can be changed with problem solving strategies. The five-step troubleshooting model is usually introduced in the fifth session. During this session, the group creates a list of problems that girls their age usually encounter and look at which of these problems can be changed. It is important to recognize as a first step whether a problem is within or outside their control, because that determines whether problem solving or coping will be used. The five components of problem solving are as mentioned above education (problem definition), modelling (target definition), coaching (planning), practice (thinking of consequences) and feedback (self-evaluation). These steps have been discussed at length in Chapter 4. The feeling of helplessness must be combated by looking at evidence in life experiences that demonstrates that the participants can overcome problems. Participants are also taught coping skills to improve their mood before applying problem-solving strategies, and when they become frustrated or angry. Depressed youth are likely to minimize their success, so it is important that the therapist evaluates the outcome in the beginning. The participants learn the problem solving strategies easily, but making sure that they actually apply them is a more difficult part. Direct learning, activities, games, appearances and role-playing games can be used. Learning during a fun activity is a good option, especially since it improves mood at the same time. Participants are instructed to apply problem-solving at least once between sessions and share their experience. Sometimes negative thoughts get in the way of problem solving, and then it is important that the therapist first uses cognitive restructuring strategies to eliminate the cognitive blockages.

What is cognitive restructuring?

A primary goal of the ACTION program is to change the negative distorted thinking to more positive and realistic thinking. To do this, the core beliefs that lie in the depressive mind must be identified, then a plan should be developed that provides the child with corrective learning experiences that help evaluate and change the dysfunctional beliefs. The previously drawn up case conceptualization can help to draw up hypotheses about the possible core beliefs. This also requires listening to the meanings that the child deduces from daily experiences. Direct restructuring consists of learning to identify, evaluate and replace negative thoughts. This is learned later in the treatment because it requires self-focus, which is easier when coping and problem solving have already been addressed. The girls can then better handle the confusion/frustration that comes with self-focus.

How can a positive sense of the self be developed?

Developing a positive sense of self is the last component of the ACTION programme, because the other skills can be used in self-improvement and recognizing the positive aspects of themselves. The self-evaluation of depressed youth is often unrealistic and unreasonably negative, therefore they should be taught to evaluate themselves in a more reasonable and positive way. The self-card can help with this; this is a circle in which each part must be filled with one of their strengths. The therapist also tells the child what others think are her/her strengths. Group members also give each other positive feedback. Sometimes a child's negative self-evaluations are accurate, and then they can benefit from change.

What is the ACTION kit?

The ACTION kit has been developed to help remind children of the central therapeutic concepts, it consists of a set of five color-coded maps:

1. A simple schematic representation for when coping skills, problem solving and cognitive restructuring should be used.
2. A visual representation of how the three B's should be used to identify emotions.
3. A visual representation of the five categories of coping skills.
4. The five problem-solving steps (5p's).
5. The two "what questions" that lead cognitive restructuring (what's another way to think about it? What is the proof?).

Furthermore, each kit contains a ''catch-the-positive' ball and a form with personal goals, including plans on how these goals can be achieved. During the sessions, the therapist uses her/his own kit to suggest how it can be used.

What is the role of homework?

Homework is designed to help children apply the skills they have learned in real situations outside of treatment. The workbook structures the homework, each exercise consists of applying a skill learned during that session. Many children do not like to do therapeutic homework and should be encouraged with the use of a reward system during the sessions. If it is not possible to do homework, the therapist can take an individual session where a plan to complete the homework is created. If this doesn't work out, e-mails and phone calls can be used as reminders.

What about parental training?

Parental training is designed to support the child treatment component. Parents learn how to support their child's effort to learn and apply therapeutic skills. The parents also indirectly learn the same skills. Lastly, parents learn to improve their behavioural management and communication to reduce conflict and help children to identify and change their negative thoughts. A session lasts about 90 minutes, and the structure is the same as that of the child sessions. One addition is that the therapist gives the parents a description of the skills the children have learned, and the parents try to learn to use the same skills.

Skills taught to parents

Before parents are taught skills, they are given information about depression and how it can be effectively treated. To create a more positive environment, parents are taught and trained to use reinforcement to encourage desired behavior. They are also instructed to reduce the use of punitive or coercive strategies. They are instructed to keep an eye on their reinforcement at home, and the children come up with a reward menu. By doing so, parents also learn about fun things to do with their child. If the child agrees, the goals are discussed with the parents. Parents are also taught different communication skills, such as empathetic listening. Both parents and children learn to initiate a conversation. Parents are also taught to keep it short, not to be accusatory, to be specific, to make comments about feelings and to give possible options. This is done through modelling, role-playing and practicing with the child. Parents are also taught the same five problem-solving steps, in order to deal with misconduct and conflicts in the family. Daughters teach their parents these steps and play a game to demonstrate it. Conflict resolution skills are taught, in families with depressed children there are often more conflicts and this adds to the time the child needs to recover from a depressive episode. For example, parents are taught to structure and use a family gathering to reduce conflict. Parents are also taught how to have a meaningful role in helping their child capture, evaluate and restructure negative thoughts and beliefs..

The ACTION program is a manual-based group treatment but accompanies a case conceptualization for each participant. The action program presented here is a cognitive behavioural intervention for depressed girls, and there is also a parental component. Ideally, the girls learn coping, problem-solving, and cognitive restructuring skills while their home environment learns to support and apply the skills. The program has been adapted for young people who suffer from comorbid disorders. Although the manual is written for girls, the program can be adapted for depressed boys. With adjustments in procedures and activities, the program can also be used in individual patients. Before the programme is discussed, studies on psychosocial and pharmacological treatments are discussed.

How can we deal with suicidal behaviour in adolescence? - Chapter 7

What is this chapter about?

Rates of attempted suicide rise from childhood to adolescence. Although empirical data for explaining the sharp increase in suicide during adolescence is missing, it is suggested that this is due to increased vulnerability to environmental stress due to rapid psychological, biological and social changes in this developmental period. Developmental changes in adolescence can also contribute to the onset of mood and substance abuse disorders, which in turn is associated with suicidal behavior. An honoured suicide attempt is one of the best predictive factors of successful suicide and future suicide attempts. Several studies have shown that 33 to 64% of young people who have committed suicide have already attempted suicide before.

What is the cognitive behavioural model of suicidal behavior?

From a cognitive behavioural perspective, suicidal behavior is equivalent to other form of psychopathology because it results from erroneous learning experiences that are reflected in maladaptive cognition, behaviors and emotions. On page 236 you can see an image of the model of suicidal behaviour in adolescence drawn up by the authors. In the model, stress as a result of interpersonal conflicts, negative life events or worsening psychiatric symptoms act as a trigger for suicidal crisis (suicidal thoughts) in a vulnerable adolescent. In an attempt to deal with this, distorted thinking can arise and result in cognitive errors (e.g. catastrophic thinking) and a negative view of oneself and the future. Depending on the level of cognitive biases and repetition of the trigger, the adolescent can devise solutions for the trigger. This solution is often ineffective and causes more problems. Suicidal youngsters appear to have more difficulties in generating alternatives in case of problems and choosing or implementing effective alternatives. This difficulty with problem-solving leads to more distorted thinking and affective stress such as psychological arousal, anger and exacerbating the current state of mind. Suicidal adolescents have less capacity to regulate their internal states and use regulatory skills less often compared to their peers. In response to cognitive biases, deficits and affective arousal, the adolescent may exhibit maladaptive behaviors, such as passive and aggressive communication and behavior. Other adolescents may seek refuge in alcohol and drugs or self-harm to dissociate themselves from the situation. If the problem is not solved, the adolescent may also experience passive suicidal thoughts (I better be dead, no one cares about me), which with time turns into active suicidal thoughts (I want to commit suicide). Depending on factors such as the level of impulsivity, the possibilities, presence of support and so on, the adolescent may decide to attempt suicide.

How is suicidal behaviour determined?

When interviewing an adolescent shortly after a suicide attempt, five related aspects need to be understood: the idea of suicide attempt, the method of suicide attempt, the intention of the suicide attempt, the haste (precipitant) of the suicide attempt and the reasons for the suicide attempt.

Idea formation of the suicide attempt

The duration and complexity of the idea formation may differ in adolescents, some plans are long and detailed and others do it in a glimpse of impulsiveness. There are several tools to determine this, but when they are not available the therapist can ask questions about the frequency, disclosure, duration and specificity of the suicide plans.

Method and lethality of the suicide attempt

The method for suicide attempt is often determined by possibilities and availability, and most adolescents try it by an overdose. Other attempts may suggest a higher likelihood of recurrence and ultimately success of suicide. It is important to identify and remove the presence of resources for committing suicide.

Intention for the suicide attempt

It is important not to be misled by an attempt with a low-risk method, but to ask the adolescent about the two biggest aspects of the attempt: the expected outcome and the planning of the suicide attempt. For this, the SIS can; Suicide Intent Scale can be used. If the adolescent is still suicidal after the suicide attempt, the therapist should ask about his/her specific plans for the future.

Hasty suicide attempts and reasons for the attempt

The stressors of suicide attempts in adolescence are often everyday stressors, especially interpersonal conflicts. These seemingly small stressors are often received as the final straw for individuals struggling with other risk factors. The seriousness of a suicide attempt should not be underestimated because of the underestimated nature of the stressors of the attempt.

What is the current state of art with regard to treatment of suicidal behavior?

Individual therapy

In a study of CBT and problem-oriented supportive therapy for suicidal adolescents, participants of both conditions reported significant reduction in suicidal ideating and depression after 3 months. After 6 months, there is still improvement but the levels of suicidal ideating and depression are somewhat higher than at 3 months.

Integrated individual psychological therapy and pharmacotherapy

The effectiveness of individual psychotherapy combined with pharmacotherapy in suicidal adolescents has also been studied. Adolescents were divided into three conditions; antidepressants, cognitive behavioural therapy for suicide prevention or a combination of both. All participants in the CBT condition showed a significant decrease in suicidal ideating. Other studies also show that CBT is effective as a treatment for suicidal adolescents.

Family therapy

Several studies show decrease in suicidal imaging after family therapy, but only for adolescents without depressive disorders. Another study suggests that the effects of family therapy will diminish after 3 months.

Group therapy

Several studies show that group therapy in combination with routine care is no different from just routine care in reducing depression or suicidal thoughts. One study shows reduced self-harm if one also engaged in group therapy. Because of the inconsistent results, more research is needed.

What are problems in the treatment of adolescents with suicide attempts?

Adolescents who make suicide attempts vary greatly in their attendance rate at treatment. In addition to having motivational problems, the families who participate in the treatment often have many sources of stress and other adverse conditions in their lives that make participating in treatment difficult. Early in treatment, efforts should be made to increase motivation, overcome obstacles and develop a strong therapeutic cooperation relationship. In addition, interventions should be flexible enough to treat young people with different psychiatric presentations. After all, suicidal behaviour is common without other, comorbid psychopathology, but it also commonly combined with depression, anxiety, disruptive behaviour or substance abuse. Finally, it is known that there is a strong familial transmission of mental health problems, including suicide. In order to successfully interfere, it is important to determine rates of psychopathology in parents and refer parents if necessary. A focus on parenting skills and family work is also important.

How does treatment of suicidal behavior in adolescence proceed?

The treatment protocol for adolescents with suicidal behavior makes use of cognitive behavioural strategies to change maladaptive cognitions and behavior underlying suicide, substance abuse and other common forms of converging psychopathology. Motivational interview techniques are integrated to increase the involvement of the adolescent and the parents in treatment. The protocol has a manual and consists of individual sessions with the adolescent, family sessions and parent training sessions. The family sessions focus on communication, problem solving, behaviour and positive family interactions. The individual sessions focus on suicide and on possible substance abuse. The treatment can be adapted to the individual necessities of the adolescent and the family. Each individual session has the same structure; the session begins with the detection of suicidal thoughts or behavior and substance abuse since the previous session. If the adolescent is at risk of suicidal behavior, the current state of is established. There is also a no-suicide contract, each adolescent is asked if he/she can guarantee to do nothing about it until the next session. Most of the sessions follow cognitive behavioural build-up as discussed in previous chapters, with homework, introducing skills, looking back at previously learned skills, and practicing with skills.

How does a session proceed?

The first session focuses on developing coherence, provides an overview of treatment methods, safety procedures and setting goals. The therapist works with the adolescent to create a list of personal reasons to live and the adolescent is instructed to create a coping card. For the coping card, the adolescent generates a list of strategies that he/she can use in difficult situations and also includes contact numbers in case of emergencies.

Treatments

Parents are given an overview of the treatment methods so that they know what to expect. The importance of the prescribed medication is also discussed.

Loyalty to the treatment

Due to the large dropout rates in treatment of suicidal adolescents, an attempt is first made to increase commitment. For example, the adolescent receives psycho-education about suicidal behaviour. Families are encouraged to visit the sessions and finish the entire program. Expectations are discussed and the adolescent is asked about what he/she thinks. Possible obstacles are also discussed, and the therapist must be prepared to discuss/refute several factors that hinder the loyalty to the treatment (stigmas, concerns, etc.).

Pragmatic safety information

The parents discuss the importance of parental supervision, obtaining emergency services and keeping their home safe. The effect of drugs and alcohol on inhibition is also discussed. It is also stressed that the parents and not the adolescent, are responsible for giving the medication to the child. The importance of safety procedures is stressed, as it is not uncommon for families to reject them.

What about problem-solving?

Problem-solving deficits include limited flexibility, difficulty generating alternative solutions and limited opportunities to identify positive consequences of possible solutions. The 'SOLVE' system has been developed as troubleshooting training, S for selecting a problem, O for devising options, L for possible outcomes (likely options), V for the best solution (very best one) and E for evaluating. After this has been taught, it can be used to deal with problem that preceded the suicide attempt. The adolescents often have difficulty in generating options and become suicidal. Adolescents are encouraged to include suicide as an option, which shows that it is safe to talk about this.

What about cognitive restructuring?

Many cognitive biases arise from psychiatric disorders that are present. The ABCDE acronym is used to help adolescents recall the steps of cognitive restructuring. This is introduced as a skill to deal with negative beliefs and thoughts. A stands for activating an event, an event with a negative or positive association should be thought of. B stands for beliefs, so the beliefs that the adolescent has, and often these are irrational. C stands for consequences of feelings, after an event the adolescent may feel disappointed or depressed. D stands for disputing, in these steps the beliefs must be challenged. To do so, two questions can be asked: is this conviction true? And if so, is this belief helpful?. E stands for effect, if an adolescent has an effect on something this might be the changed. Even though the events may not be able to be changed, the adolescent does have an influence on his/her negative thoughts.

What is affective regulation?

Affective regulation techniques involve training the adolescent in recognizing stimuli that provoke negative emotions and to reduce psychological arousal through self-talk and relaxation. The adolescent is asked to come up with a plan to stay calm when he/she notices triggers of negative thoughts. This can be done, for example, by self-calming behaviour and positive statements about themselves. Parents are informed about this so that they can assist in the adolescent's coping plan. The chain analysis is also discussed; a functional analysis combined with problem solving, cognitive restructuring and affective regulation techniques. This can be used when the adolescent indicates suicidal behavior. Weak and strong links in the chain are identified and the exercise ends with reflective questions. The goal is that the adolescent then has a better understanding of a suicidal episode and a plan to address and prevent it.

What about family sessions and parental training?

Family sessions are necessary for addressing suicidal behavior. It is important that the family follows communication sessions and investigates the circumstances of a suicide attempt. Explanations for the suicide attempt of the parents and adolescent are examined and possible discrepancies is discussed. The therapist helps the parents and adolescent in understanding each other's explanations. Family sessions help to take away the focus on the adolescent. The main goal is to adjust communication patterns and negative interactions. In parental training, in which the parents are alone with the therapist, are helpful. Parental care is discussed and certain skills are taught. Signs of suicide are discussed and parents are taught how to deal with it. Parental obstacles to involvement in the treatment are also addressed, including the motivation interview.

Rates of attempted suicide rise from childhood to adolescence. Although empirical data for explaining the sharp increase in suicide during adolescence is missing, it is suggested that this is due to increased vulnerability to environmental stress due to rapid psychological, biological and social changes in this developmental period. Developmental changes in adolescence can also contribute to the onset of mood and substance abuse disorders, which in turn is associated with suicidal behavior. An honoured suicide attempt is one of the best predictive factors of successful suicide and future suicide attempts. Several studies have shown that 33 to 64% of young people who have committed suicide have already attempted suicide before.

How can we treat obsessive-compulsive disorder (OCD)? - Chapter 8

What are phenomenological aspects of OCD in childhood?

Obsessive-compulsive disorder (OCD) is a chronic condition and has a prevalence of approximately 0.5-2% in childhood and adulthood.

The DSM-IV-TR describes the essential characteristics of OCD as stressful, time-wasting and interfering with normal functioning. Obsessions are repetitive, persistent, pervasive and stressful thoughts, images or upwellings. Compulsive behaviors are defined as repetitive behaviors or mental actions performed in response to an obsession and designed to reduce stress or prevent harm. Most obsession relates to anxiety or other negative outcomes concerning themselves or others and/or concerns about bacteria, infection and disease. Obsessions can also arise from precision, symmetry or fear of humiliation. Common rituals include praying, mental counting or arranging. The majority experience both obsessions and compulsive behaviors. Although it is classified as anxiety disorders, not every individual with OCD experiences anxiety. OCD usually occurs between 8-11 years and in multiple domains, it can have a significant negative impact on psychological functioning. Often it goes along with other psychiatric disorders, such as Gilles de la Tourette.

How is OCD diagnosed in childhood?

Evaluation should be done carefully and concern both current and old OCD symptoms, the current severity of symptoms, related deficiencies in functioning and the diagnosis of comorbid disorders. It is also important to evaluate the strengths of the child and family. It is helpful to send the family a package of self-reporting questionnaires. The primary diagnostic tools for OCD in children are the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) and the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS).

Anxiety Disorders Interview for Children (ADIS-IV)

A semi-structured interview for the diagnosis of anxiety disorders and related diagnoses for the age of 8-17 years. This instrument has good psychometric properties. This instrument is often used in clinical research.

Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS)

This tool is based on combined information from observations and parent and child reports. A checklist is used. It seems like a valid scale but there are still questions regarding the factor structure.

Child Behavior Checklist – Obsessive-Compulsive Scale (CBCL)

The CBCL is one of the most widely used instruments. The 8-item OCD scale provides a quick, reliable screening of OCD symptoms.

Child OCD Impact Scale – Revised (COIS-R)

The COIS-R is a self-reporting tool that identifies OCD-specific functional deficits. This tool consists of both parent and child reports. A total score is generated from the two scores.

Multidimensional Anxiety Scale for Children (MASC)

The MASC is a self-reporting tool consisting of four factors and six subfactors. It is a good dimensional tool to measure comorbid anxiety. It has good psychometric properties.

Children’s Depression Inventory (CDI)

The CDI is a self-report questionnaire consisting of 27 items and it is available in both a child and parent version. It is a good tool for determining comorbid depressive symptoms.

What is the behavioural conceptualization of OCD?

The conceptualization of behaviour in OCD involves ‘obsessions’ which are intrusive, unwanted thoughts, images or urges that elicit a significant and rapid increase in anxiety. Compulsive behaviors are seen as overt behavior which are designed to reduce these negative feelings. These behaviors are negatively endorsed by their ability to reduce stress.

What about exposure and response prevention?

The most effective form of behavioural therapy, exposure plus response prevention (ERP) is to systematically elicit a person's obsessive fears through in-vivo or imaginary exposure of objects and situations. During this in-vivo exposure, the patients are encouraged not to use compulsive behaviours (this is called response prevention). Research with adults show that both components are necessary in treatment. ERP is usually performed during the sessions, but the child is encouraged to practice in the natural environment.

What is a cognitive conceptualization of OCD?

The cognitive perspective regards cognitive factors as important etiological and maintaining factors of OCD. These factors consist of distorted cognitive ratings of risk, responsibility for harm and pathological levels of self-doubt. This is related to the thought-action-fusion (TAF) concept, which is defined as the tendency to see negative thoughts and actions as equivalents. This makes it difficult to ignore negative thoughts and lead patients to respond anxiously.

What are cognitive interventions?

The increasing validity of adding a cognitive intervention to ERP is not yet clear. Although there are studies showing that cognitive interventions are effective, more recent work shows that ERP in combination with cognitive therapy does not increase outcomes. However, it has been shown to be useful to reduce dropout rates in therapy. Cognitive techniques are often used to increase adherence to the ERP (this is almost standard in treatment). This includes constructive self-talk, cognitive restructuring and the development of independence (minimizing obsessive aspects).

What are family factors in the treatment of OCD?

It is clear that family influences on OCD operate on multiple levels. There appears to be a strong genetic component in OCD that starts as early as childhood, so the child is likely to have a parent with OCD or other anxiety and depression disorders. In addition to passing on the genes, this also creates a home environment that is likely to maintain or worsen the child's symptoms. This is probably done by confirming the fears and rituals/avoidance behavior of the child. Also, these families often have other characteristics that can reduce the success of therapy, such as participation in or relief of rituals, less use of positive problem solving, less warmth, higher levels of emotions and more parent-child conflict. When the OCD of the child is complicated by maladaptive aspects in the family environment, it is necessary to involve some form of family participation in the treatment. The exact nature of family interventions vary per case but the most important goals are correcting negative attributions about the child, reducing involvement of parents/sisters/brothers in OCD symptoms, minimizing reinforcement of the avoidant behavior and increasing family communication and problem solving strategies.

What are developmental factors in the treatment of OCD?

Treatment success depends heavily on the suitability of the intervention for the level of development of the child in question. The most successful CBT protocols of adult treatment models have been adapted for children and adolescents. This has to do, for example, with the difficulty of describing specific obsessions and role the obsessions have in provoking rituals. In CBT for children with OCD, four things are important:

1. Behavioural reward systems for adherence;
2. A greater emphasis on psycho-education;
3. The use of age-capable metaphors to facilitate cognitive restructuring;
4. Greater family involvement in treatment.

What are treatment strategies?

Various treatment strategies are illustrated below.

Psycho-education

During the first phase of treatment, the focus is on teaching the patient and his/her family about OCD and on describing the treatment process. Most of this is done together with the parents and the child. The goal is to address feelings of stigma and shame, and feelings of anger, guilt and hopelessness in the family. The family needs to gain faith in the therapist. It is important to explain the rationale of the therapy, so that the family understands and accepts this. This can be important for adherence and therefore the success of the intervention.

The creation of a symptom hierarchy

Creating a hierarchy of symptoms provides a framework for developing individual exposure tasks and the order in which these tasks will be performed. The symptoms checklist of the previously discussed CY-BOCS can be useful in this. The initial symptom should be a concrete behavior that is associated with relatively little stress and can be easily replicated in therapy.

Exposure and response prevention

It is important that exposure tasks during the sessions are realistic and can lead to generalization to other environments. When a task starts, the child is encouraged to stay in touch with the anxious stimulus and not use any related rituals or anxiety-reducing actions. Using the fear thermometer, the child's anxiety thermometer determines how the child feels every 30-60 seconds. It is good to make graphic image of this as an endorsement for the child. When the task is completed in the session, the child is instructed to run it several times a week in the natural environment.

Addressing obsessions

Exposure tasks claim to be obsessions in the absence of compulsive behaviors. ''shaping'' procedures can also be used, in which an anxious situation is imagined, written down, told aloud, retold by therapist and listened to on a tape. Other strategies can be used to change the emotional charge of an obsession, such as singing, rhyming or changing anxious images into fun/humorous images (e.g. replacing a knife with a carrot in a memory).

Contingency management

Contingency management methods are used to increase adherence, for example through behavioural reward and social reinforcement. The nature of the reward depends on the age and preference of the child.

What is the status of empirical support?

Open clinical trials

Early studies (with many shortcomings) have found evidence for the use of ERP in treating OCD in childhood. This was followed by more developmental, structured studies in which similar results were found. This provided preliminary evidence regarding treatments.

Controlled studies

Four controlled studies evaluated the results of CBT in OCD in childhood. Several cognitive therapies seem to provide significantly better outcomes than a waiting list condition (a control condition). Current research continues and there is preliminary evidence that positive results of CBT are visible after 36 months of finishing treatment. However, there was no control group, so more research is needed into the effectiveness of treatments for children with OCD.

Rates of attempted suicide rise from childhood to adolescence. Although empirical data for explaining the sharp increase in suicide during adolescence is missing, it is suggested that this is due to increased vulnerability to environmental stress due to rapid psychological, biological and social changes in this developmental period. Developmental changes in adolescence can also contribute to the onset of mood and substance abuse disorders, which in turn is associated with suicidal behavior. An honoured suicide attempt is one of the best predictive factors of successful suicide and future suicide attempts. Several studies have shown that 33 to 64% of young people who have committed suicide have already attempted suicide before.

What is known about eating disorders and obesity in children? - Chapter 9

What is this chapter about?

Eating disorders and obesity cause functional deficiencies, reduce quality of life and are difficult regarding social adjustment. In addition, it heightens the risk on disease and mortality. Obesity also poses major health risks such as diabetes, heart disease, hypertension, gallbladder disease, psychosocial problems and certain cancers. Children with eating disorders or obesity often have difficulty with things like hunger and satiety, body satisfaction, the use of unhealthy weight-loss methods, binge eating and dietary restrictions. In addition, there is an interplay between eating disorders and obesity, the development of one condition increases the chance of developing the other condition.

What are eating disorders?

Eating disorders are serious psychological conditions. These diseases are common in women and usually occur in adolescence, the two most well-known diagnoses are anorexia nervosa and bulimia nervosa. Anorexia is characterized by extremely low body weight, distorted body images and fear of weight gain. Bulimia is characterized by normal or overweight body weight, and persistent and repetitive binges followed by compensatory behaviors such as vomiting. Binge-eating disorder (BED) is characterized by persistent and repetitive eating episodes without compensatory behavior. Eating disorders are the third most common chronic disease in female adolescents, anorexia is more common in younger adolescents and bulimia in older adolescents. Eating disorders are characterized by high levels of relapse and are often chronic. To reach full recovery, early interventions are necessary.

What bout prevalence, medical complications and psychosocial characteristics?

Anorexia nervosa

The prevalence of anorexia is approximately around 0.5%, the starting age is usually between 14-18 years. Due to starvation, medical conditions arise, which in the most severe cases can lead to mortality. The mortality rate for women with anorexia is 12 times higher compared to the normal population. Medical conditions include not having menstruation, dehydration, and delayed puberty. Most medical conditions can be restored by increasing body weight, but deficits on growth can be permanent. Comorbid psychological disorders and symptoms include anxiety disorder, social withdrawal, OCD, poor relationships with peers, loss of sex drive and increased risk of suicide.

Bulimia nervosa

Bulimia often begins later in adolescence, the prevalence is approximately between 1-4.2%. Medical complications can arise from vomiting (including anorexia) or the use of laxatives, pee pills and intestinal rinses. This can include stomach tears, stomach and esophagus irritations and bleeding, intestinal abnormalities and pancreatitis. Comorbid psychological conditions include anxiety disorders, depressive disorders, substance abuse and other addictions, borderline and impulsive behaviors.

Binge-eating disorder (BED)

Binge eating disorder (BED) often begins in late adolescents or early twenties, prevalences are between 0.7-3%. In overweight individuals, prevalence is between 5-40%, depending on which diagnostic method is used. Binge eating disorder often goes hand in hand with obesity. Psychological comorbidities include depressive disorder, alcohol abuse, anxiety disorders, impulsive behaviors, borderline, avoidant personality disorder and obsessive compulsive personality disorder.

How about CBT for eating disorders?

CBT is the most effective psychological treatment for eating disorders, and CBT as a treatment is more confirmed for bulimia than for the other two eating disorders.

CBT for bulimia

The current CBT version for bulimia is seen as the preferred treatment of bulimia. The underlying theory is that social pressure to want to be thin leads to too much value and focus on body weight and shape. Thus, an extreme diet is maintained, resulting in increased hunger and feelings of shortage which in turn can lead to binge eating. To compensate for this, extreme forms of weight control are applied (which is usually vomiting). This cycle causes a lot of stress and decreased self-esteem, which in turn results in even more extreme diets. The primary goal of CBT is to break this cycle by following a normal diet and adjusting dysfunctional thoughts. In the first phase, the goal is to develop a strong therapeutic relationship, educate about bulimia and educate patient about the nature and structure of CBT. Behavioural techniques such as weighing and self-monitoring of food intake are introduced. In the second phase, the behavioural techniques are continued to use and cognitive techniques are also introduced (problem solving, cognitive restructuring). The final stage consists of preventing relapse and preparing for a relapse.

What can research tell us?

More than 20 randomised controlled trials (RCTs) have been conducted and provide evidence for the effectiveness of CBT in reducing the main characteristics of bulimia. CBT is found to be more effective compared to both pharmacological therapy and other psychotherapies. CBT combined with medication is even more effective than CBT or medication on its own.

CBT in anorexia

The underlying theory in using CBT for anorexia patients is that for these patients, their self-worth is primarily defined by their body weight and shape. These beliefs develop from an interaction between specific personality variables (perfectionism, unstable state of mind) and the internalization of a socio-culture model of beauty. Variables that maintain the disorder include fear of gaining weight, fear of sexuality, feelings of success and self-control through weight loss, family problems and positive social empowerment. CBT for anorexia patients is different than CBT for bulimia patients. The first stages of treatment focuses mainly on psycho-education, self-monitoring and increasing motivation skills. The second phase focuses on biased beliefs and cognitive procedures. The third phase focuses on relapse prevention techniques. For example, important differences between CBT in bulimia and anorexia lie in cognitive interventions. In anorexia, these are aimed at much broader personal and interpersonal areas than bulimia.

Inconsistent results have emerged from five controlled studies. The CBT condition has shown more success, equal success or worse outcomes compared to other treatments. More and better research is needed to clarify this.

CBT in binge eating disorder

CBT in binge eating disorder is a modified version of the CBT model for bulimia, adapted to the specific behaviors and cognitions associated with binge eating disorder. Chronic eating patterns are central here, so for example, healthy self-control is focused. Distorted cognitions regarding form/weight, self-worth and negative affectivity are aspects in maintaining binge eating. The same three-phase model is applied, first introducing behavioural strategies and self-monitoring, then challenging distorted beliefs and learning cognitive skills. Finally, treatment focuses on relapse prevention.

CBT in binge eating disorder has been tested individually as well as in group form. It has shown to lead to a significantly greater reduction in binge eating compared to waiting list conditions (control conditions). Compared to other treatments, CBT shows slightly better outcomes.

Trans-diagnostic CBT

Although CBT has proven to be successful in treating eating disorders, there is a group of non-responders and individuals who show relapse. Clinical perfectionism, low self-esteem, poor regulation strategies and high interpersonal problems contribute to this. By addressing these four things in the treatment, better outcomes are likely to be achieved. Transdiagnostic CBT has been developed for this purpose. Transdiagnostic CBT takes place in four phases, first patients receive education about treatment and necessary behavioural changes are identified. The second phase looks at what barriers there are to change. Phase three focuses on reducing maladaptive behaviours and negative psychopathology. In the fourth phase, treatment is maintained and relapse prevented.

Transdiagnostic CBT has been tested in a Randomized Controlled Trial (RCT). Transdiagnostic CBT has better outcomes than regular CBT and a waiting list control condition. This form of CBT is therefore more effective for individuals with many interpersonal problems, high clinical perfectionism, low self-esteem and poor regulation strategies.

What about family-based therapies?

Two primary models of family therapy have been developed: the Maudsley approach and the behavior family system therapy (BFST). The Maudsley approach was developed first and is based on the assumption that individual, family and social cultural influences interact with each other and maintain the disorder. In the first phase, the family receives education about the dangers of wrong nutrition. The goal at this stage is to show the child and parents that it is a disease, and that it is not a characteristic of the child. In the second phase, normal eating and maintaining weight is the goal. In the final phase, problems related to other areas, such as puberty and socialization, are addressed. BSFT is similar to the Maudsley approach and divided into four phases:

1. Diagnosis.
2. Checking the rationale.
3. Weight gain.
4. Weight maintenance.

Randomized Controlled Trials have shown that both types of family therapies are superior to individual therapy. No significant difference has been found between the two family therapies.

How can CBT be used in anorexia, bulimia and binge eating disorder?

It is clear that CBT is effective in treating bulimia and binge eating disorder, and is promising in the treatment of anorexia. The question is which components of CBT are suitable for young people with eating disorders and which modifications are necessary. The three phases in which CBT has been broken up have been described before. This structure is successful in adults and can also be used in adolescents. CBT should be approached from a developmental perspective, with increased emphasis on the context in which eating disorders develop and are maintained. Parental involvement is strongly encouraged.

Approach

Adolescents are dealing with various developmental problems, which are likely to affect the nature and frequency of experienced problems. Eating disorders usually develop during adolescence and may have to do with developmental factors and post-pubertal changes. Therefore, it is recommended that CBT accounts for these developmental problems. CBT also takes into account the level of cognitive development of the child/the juvenile, as CBT is centralized around cognitions. If children do not meet certain criteria, the cognitive and behavioural techniques used must be adapted to their cognitive level. Another modification of CBT may be the inclusion of the social context in treatment, since cognitive development of adolescents takes place in the social context by modelling and reinforcement.

Parental engagement

Involving parents in the treatment is highly recommended. This can vary from parents as co-clients or consultants. Brothers and sisters also need to be involved. Parental participation has a positive impact on treatment and can also be important outside of the sessions. Parents can facilitate an environment in which behavioural modifications take place. Parental involvement is important, but treatment should also focus on working towards the independence of the adolescent.

What are problems and adaptations specific to adolescents with eating disorders?

Motivation is crucial for adherence to therapy, but a lack of motivation is common in individuals with eating disorders. To overcome these barriers, different techniques are recommended. It is important that children come to therapy voluntarily and are not forced. It is also important that the adolescent has a sense of belonging to the therapist. Finally, it is important to express acceptance, understanding and empathy towards the patient.

What about obesity in children and adolescents?

Definitions and background

In recent years, children and adolescents have become increasingly overweight and obese. Given the amount of health problems this leads to, obesity is seen as an epidemic since 1998. Childhood obesity often continues into adulthood, as do the associated psychological and medical problems.

Prevalence, medical complications and psychosocial characteristics

About 31% of children and adolescents between 2-19 years of age fall within the overweight/obese class based on their BMI. This is coupled with cardiovascular disease and risks and increases the risk of diabetes. In addition to the physical effects of being overweight, it also comes with many psychosocial problems, such as depression, anxiety, feelings of worthlessness and increased behavioural problems. Discrimination and bullying are also common. Overweight children are seen as less competent and social and have a lower quality of life in terms of physical, emotional, social functioning.

Early interventions

The intervention methods used to treat childhood obesity are parallel to those used in adults. Nevertheless, treatment shows better outcomes in children. Perhaps weight loss has to do with self-motivation, something parents can help their children with. Early treatment can also reduce or reverse negative effects of obesity. It is therefore important to intervene as early as possible.

Current evidence: multiple lifestyle components intervention

Overweight and obesity covers multiple facets, requiring multidimensional intervention. In addition, interventions should be targeted, as universal interventions are not effective in overweight. Research suggests that a multidimensional approach focused on lifestyle intervention is the most successful option for treating overweight and obesity, as well as preventing excessive weight gain in young people. These are active treatments with the aim of changing everyday activities.

What are family based behavioural interventions for overweight and obesity?

Studies suggest that family-based behavioural interventions are effective in treating obesity in children and adolescents. In addition, these shows long- and short-term maintenance effects. Programs focus on two weight-related goals:

1. Weight loss.
2. Weight maintenance (prevention of further weight gain).

Treatments aimed at weight loss are intended for older children and adolescents with a BMI above the 95^th percentile. As obesity worsens, a more intense and longer intervention is recommended. Behavioural components and cognitive components (problem solving, restructuring) are central.

What are weight-loss interventions?

In weight loss interventions, the 'energy balance equation' is used, consisting of three components:

1. Weight gain is the result of positive energy balance.
2. Weight loss is the result of a negative energy balance.
3. Weight maintenance results from a neutral energy balance.

Programs differ in the use of diets and physical activities.

Diet/energy intake modification

Research shows that children with obesity consume more calories and experience food as empowering. Change in diets are the key components of effective treatment, as are successful prevention and weight maintenance. Epstein's Traffic Light Diet is perhaps the most evaluated diet, where children receive education about nutrition and food is grouped based on three colours that dictate how healthy they are.

Physical activity/energy consumption modification

Bringing about change in physical activity increases the long-term effects of treatment. It is recommended that children and adolescents perform physical activity for at least 60 minutes a day or reduce 'stagnant' behavior such as watching television.

Skills for behavioural change

Typical behavior weight loss methods include stimulus control strategies and self-monitoring of eating and physical activities. Stimulus control refers to restructuring the home to increase desired behavior and reduce unwanted behavior. This requires parental involvement and support (e.g. putting healthy food in accessible places and unhealthy food in less accessible places). A reward system can also be used, as long as rewards are not in forms of food or money.

What is the role of the parent?

Parental involvement is an important feature of treatment, especially because obesity may have arisen partly from the environment. Having an overweight parent increases the risk of being overweight for the child. Parents can help support their children in healthy eating habits, physical activities and healthy life changes. Self-treatment that only targets parents of overweight children has proven to be effective. It is clear that parental involvement is important.

What is the role of cognitive components?

Studies focused on problem solving skills and cognitive restructuring show that the addition of these components to treatment can provide better weight reduction outcomes. Although behavioural components are central, cognitive components can be a good complement to treatment.

What is meant by 'weight maintenance'?

Given that the prevention of further weight gain is a crucial component of weight control, weight maintenance interventions are important in maintaining a healthy weight. This also contributes to the long-term effects of treatment. Randomized studies show that this component is necessary for successful long-term weight management. The underlying theory is that behavioural components are effective in reducing weight, but that cognitive and social skills are needed to prevent weight gain. Without adequate cognitive long-term coping skills, negative cognitions make it very difficult to convert weight loss goals into weight maintenance goals.

What is the socio-ecological model and multiple levels, multiple components approach?

A promising line of research on weight maintenance follows the socio-ecological framework, which points to different context as influences on weight-related behaviours and suggests that obesity is due to individual/family, peers/social and community factors that interact with genetic probabilities. According to this model, weight gain follows due to contextual stimuli that have shown that obesity-supporting behaviors have not been modified. On page 309 you can see an image of the socio-ecological model for weight gain. This model consists of several levels, as does the socio-ecological model of Bronfenbrenner. On the individual level, things like self-regulation have an impact. On the social level, things like rewards affect healthy behaviors. Peers are also important, for example a lack of social support for physical activities and healthy eating can be negative. At the community level, for example, the neighbourhood affects obesity (presence of fast food restaurants, cost of (un)healthy food, etc).

Eating disorders and obesity cause functional deficiencies, reduce quality of life and are difficult regarding social adjustment. In addition, it heightens the risk on disease and mortality. Obesity also poses major health risks such as diabetes, heart disease, hypertension, gallbladder disease, psychosocial problems and certain cancers. Children with eating disorders or obesity often have difficulty with things like hunger and satiety, body satisfaction, the use of unhealthy weight-loss methods, binge eating and dietary restrictions. In addition, there is an interplay between eating disorders and obesity, the development of one condition increases the chance of developing the other condition.

What are interventions for young people who have experienced disasters and terrorism? - Chapter 10

What is this chapter about?

In recent years, devastating natural disasters and events of violence have shown how such potentially traumatic events affect children and adolescents. Exposure to such events can cause major stress and psychological deficiencies. Unfortunately, natural disasters occur in many parts of the world. Many children and adolescents are also exposed to terrorism. It is crucial to understand how this affects young people.

What are responses of young people to natural disasters and terrorism?

Natural disasters and terrorism are highly traumatic events for children and adolescents that can result in acute stress, symptoms of PTSD symptoms and PTSD. A period of 'shock' may be visible immediately after the event.

What is PTSD?

Diagnosis

Before diagnosing PTSD, an initial reaction of intense anxiety, helplessness or disorganized behavior must have occurred. In addition, there are specific criteria for three symptom clusters: re-experience of trauma (by example dreaming or thoughts), avoidance (avoiding thoughts, feelings, conversations and memories) and hyperarousal (difficulty sleeping, quickly irritated, quickly angry, overreacting, etc) Symptoms should last at least 1 month and go hand in hand with significant deficits in functioning. If symptoms last longer than 3 months, chronic PTSD is diagnosed.

The prevalence and development

The prevalence of PTSD following natural disasters and terrorism is difficult to determine, but is often high. It is estimated that this is approximately around 24-39%. This is likely to be even higher in the case of exposure to terrorism. While this is worrisome, research also shows that PTSD symptoms often decrease after the first year. Findings show a constant reduction in PTSD symptoms and diagnoses over time. However, a small group continues to suffer from (the symptoms of) PTSD.

What are other responses to disasters?

Other responses to trauma have also been identified, which often comorbid with PTSD (symptoms). For example, after trauma, the child's anxiety level increases, and this can be a pathway to forming phobias and other anxiety-based disorders. Symptoms of depression are also reported. Furthermore, safety concerns are often a response to disasters (e.g. not wanting to be separated from parents). In addition, there are often problems with sleep, somatic complaints and substance abuse (in adolescents).

How can we understand factors that determine children and adolescents response to disasters?

It is important to understand which factors play a role in the response of children and adolescents to different disasters before looking at possible interventions. Variables associated with the development of PTSD symptoms are divided into four categories:

1. Aspects of trauma exposure.
2. Pre-existing characteristics of the child.
3. Characteristics of the environment after the disaster.
4. The psychological resources of the child.

Aspects of trauma exposure

Several aspects of traumatic exposure affect children's reactions. The most important is the perceived presence of life threat, the greater this perceived threat is, the higher the reported PTSD symptoms. When disasters lead to death of loved ones, this is also associated with the development of PTSD symptoms. Also, the loss of possessions and disruption of daily life contributes to the PTSD symptoms. Research shows that self-second-hand media exposure can contribute to more PTSD symptoms in young people. Finally, the duration and intensity of the event affect the symptoms. In addition, when someone is exposed to multiple traumatic events, they often experience more stress compared to children who are exposed to one traumatic event.

What is the role of the child's pre-existing characteristics?

Characteristics of the child before the disaster can affect a child’s reactions after the disaster.

Sociodemographic variables

Children are more at risk of experiencing extreme psychological deficits after disasters, and young children are even more vulnerable to this than older children. Furthermore, girls more often report PTSD symptoms than boys after natural disasters or terrorism. Also, young people with low socioeconomic status (SES) often seem to have worse outcomes after disasters.

Psychological functioning

The psychological functioning of children before the disaster affects the psychological functioning afterwards. Depression, stress, anxiety and the coping style before the disaster affect psychological functioning after the disaster.

What are important aspects of the environment in which the child recovers?

Several aspects of the post-disaster recovery environment affect the child's response. Social support can minimize the stress after the disaster. The psychological functioning of the parents also affects the reaction after the disaster. In addition, major life events, such as illness or death within the family and separation for example, affect the persistence of the PTSD symptoms. Finally, the psychological sources of the child are associated with his/her reaction and recovery. This is mainly about coping skills. Coping strategies that are a reflection of poor emotion regulation often go hand in hand with higher levels of PTSD symptoms.

What are the current state of interventions for young people after experiencing a disaster?

It is helpful to organise interventions based on the time frame after the disaster:

1. The immediate aftermath of the event or the post-impact phase.
2. The short-term recovery period.
3. The long-term recovery phase.

1. Postimpact phase

The post-impact phase begins with a specific disaster and lasts for several weeks. During this phase, concerns are probably mainly about personal safety and physical necessities. At this stage, psychological interventions are short and focus on the present, with the aim of reducing or preventing long-term psychological difficulties. These are often interventions that affect all young people in that area. These people are provided with information. This could be psycho-educational material, for example. The evidence on its effectiveness is difficult to determine because controlled studies cannot be carried out.

2. Short-term recovery phase

Although many children recover from the original stress level in the first year after the disaster, there are also many children who continue to show PTSD symptoms after a year. At this stage, interventions can be useful, to encourage adaptation and to avoid long-term psychological difficulties. Few interventions have been designed for this phase. For example, existing interventions combine psycho-education with CBT to teach the child strategies to process the traumatic event in a supportive, structured way and to learn effective coping strategies. Exposure tasks may also be used.

3. Long-term recovery phase

A year or more after the disaster, most children are recovering but a significant minority experience persistent, chronic stress responses. Interventions at this stage after the disaster usually focus on young people with chronic PTSD.

What are evidence-based treatments for trauma?

Two treatments have been identified for this phase: trauma-focused cognitive behavioural therapy (TF-CBT) and the school version of this, cognitive behavioural intervention for trauma in schools (CBITS). For both treatments there is a lot of empirical support. TF-CBT involves education, exposure tasks and cognitive and behavioural procedures to process the trauma. Together, these interventions can provide a good model for a step-by-step approach to the treatment of children after disasters.

Cognitive behavioural treatments with children and young people

Multimodal trauma treatment (MMTT) is an exposure-based CBT program. This treatment focuses on:

1. Adjusting conditioned anxiety by means of exposure through trauma narration.
2. Modifying maladaptive trauma-related cognitions through positive self-talk and cognitive restructuring.
3. Learning adaptive coping strategies for annoying feelings and physical reactions.
4. Reducing simultaneously occurring symptoms such as anxiety, anger, depression and disturbed behavior.

School-based psychosocial interventions have also been developed. These therapies focuses on restoring the feeling of safety, mourning loss and renewing attachment, expressing adaptive disaster-related anger and concluding the disaster and then focusing on the future. EMDR (eye movement desensitization and reprocessing) is also suitable for the third stage of treatment. Stress-inducing memories are identified and restructured (cognitive restructuring).

In recent years, devastating natural disasters and events of violence have shown how such potentially traumatic events affect children and adolescents. Exposure to such events can cause major stress and psychological deficiencies. Unfortunately, natural disasters occur in many parts of the world. Many children and adolescents are also exposed to terrorism. It is crucial to understand how this affects young people.

What is trauma focused cognitive behavioural therapy for children who have been sexually abused? - Chapter 11

What is this chapter about?

Child sexual abuse is often defined as contact or interaction between a child and an adult or an older child, in which the adult engages in sexual behaviour with the child. This includes many types of age-inappropriate sexual interactions (exposure to porn, fondling) and more invasive behaviors such as oral-genital contact and penetration. A study shows that almost 1 in 10 children from childhood up to the age of 17 have experienced sexual abuse with or without oral-genital contact. Another study shows that approximately 7.9% of adult men and 19.7% of women were sexually abused as children.

What is the impact and what are moderators of sexual abuse?

Children and adults who have been sexually abused often show symptoms of psychopathology and impairment in many areas of functioning. Sexual abuse can interfere with normal social, emotional and sexual development. It can also affect a child's ability to develop appropriate affective regulation and social support networks. In children, symptoms such as poor self-esteem, increased self-blame, decreased confidence, school and learning difficulties and behavioural problems can occur. Weight problems and eating disorders, somatic disorders, dissociative identity disorder and borderline personality disorder may also arise. Sexual abuse is also associated with an increased risk of early puberty, risky sexual behavior and teenage pregnancy. Approximately 50% of children who have been sexually abused meet the criteria for post-traumatic stress disorder (PTSD). Also, a history of sexual abuse is associated with later psychological problems such as anxiety, depression, sexual problems and substance abuse. In addition, these individuals have an increased risk for suicide and violent victimization in adulthood. Not all victims of sexual abuse experience negative outcomes. However, there may also be a dormant effect, with negative effects not being experienced until much later.

Chronic and invasive abuse, the use of physical or psychological coercion and a close relationship with the offender are associated with higher levels of negative outcomes. Also, a negative parental reaction to the disclosure of the abuse by the child is associated with more stress. Also, the coping style of a child affects the outcomes of sexual abuse. Positive coping skills (constructive coping, seeking emotional support, cognitive restructuring) are associated with fewer symptoms of poor outcomes. Negative coping skills (self-destructive, avoidant coping) are associated with more negative outcomes. Also the attribution style, feelings of shame, previously existing psychopathology and temperament affect functioning after the abuse. Also family factors like parenting, parental psychopathology, strained parent-child relationships and family conflict are associated with increased symptoms after sexual abuse. The impact of sexual abuse varies from child to child.

What is known about trauma-focused treatment outcomes?

Trauma focused cognitive behavioural therapy (TF-CBT) has the most empirical support for effectiveness in treating PTSD and related difficulties in sexually abused children. The strength (efficacy) of TF-CBT has been compared to a client-oriented treatment for sexually abused children and adolescents. Although the children in both conditions show progress, families assigned to the TF-CBT approach appear to show significantly more progress for both the child and the parent in terms of levels of PTSD, depression, behavioural problems, feelings of shame, interpersonal confidence and credibility. Parents show progress in general depression, abuse-specific suffering, education and parental support for the child. Research indicates that the structure of TF-CBT is specifically helpful for children with a history of multiple traumas or comorbid depression. TF-CBT also produces positive results in different areas and in different populations (e.g. in the case of 11 November attacks, foster care).

What is an overview of TF-CBT?

TF-CBT is based on cognitive behavioural principles, this approach is not permanently established, instead it continues to develop as our scientific understanding of trauma and its impact continues to develop. Unique is the step-by-step approach that encourages structured sessions in a context of a trusted therapeutic relationship.

What about diagnostics?

Cautious diagnosis is critical in developing an individual treatment plan. The diagnostics before the treatment give a diagnostic picture of the client. Continuous informal diagnostics continue throughout treatment to guide treatment goals. Diagnostics after treatment is performed to ensure that the child and the family are ready to finish the therapy. It is important to involve both parents and child in diagnostics, since parental involvement can provide important information about the behavioural and emotional functioning of parents and child.

What should be determined before treatment?

It is important to determine whether trauma focused treatment is appropriate for the child. First, the history concerning the sexual abuse must be established. For example, child protection services are asked about the credibility of the sexual abuse. If the allegations have not been reported or investigated, this must first be reported before treatment is initiated. If it is clear that sexual abuse has taken place, determination before treatment can start. The purpose of this determination is to acquire information to develop a case conceptualization that can guide the treatment. This requires the collection of as much information as possible from different sources, a complete psychosocial history and parental history. Standardized measurement instruments should be used to determine abuse specific levels of functioning for parent and child. Other traumas should also be determined. The amount of self-disclosure of the child already provides information about level of avoidance that the child experiences. It should also be considered whether treatment should be started immediately or later (e.g. if the child is still in contact with the offender). Of course, the safety of the child is the highest priority.

What is standardized determination?

The use of standardised measurement instruments help to provide an idea of the functioning of the child and the parents compared to the 'normal' population’. The same instruments should be used before and after treatment. The CBCL and the BASC can be used to determine the general level of functioning and to identify symptoms that are often associated with sexual abuse. Various self-report tools can be used to diagnose internalizing disorders, such as the Child Depression Inventory (CDI). It is important to identify symptoms of PTSD, and for this a semi-structured interview like the K-SADS can be used. It can also be helpful to establish abuse specific perceptions, attitudes and behaviors. For example, The Children's Impact of Traumatic Events Scale (CITES) can be used. Sexual behaviour can also be established, for example with the Child Sexual Behavior Inventory (CSBI). The BDI-II can be used for the determination of parental depression, the Parental Emotional Reaction Questionnaire (PERQ) can be used for abuse-specific stress.

What is continuous informal determination?

Informal determination continues throughout the treatment and is used to test the validity of the hypotheses drawn up, to clarify questions concerning case conceptualization and to identify areas that need additional focus. It is helpful to determine to what extent the child can talk about the traumatic event and what the associated thoughts, feelings and physical sensations are. Before talking about the abuse, the child is encouraged to tell a positive non-abuse related event. This is useful because it:

• Helps in understanding and practicing skills needed to process traumatic memories later in the treatment;
• Gives the clinician the ability to determine the level of detail and skill expected when telling an abuse-related story;
• Helps children to provide more details when they are asked about their abuse experiences;
• Helps children to exercise in sharing details, thoughts, feelings and physical sensations;
• Provides information about the baseline of narrative-telling of the child;
• Provides therapeutic alliance.

After the child has learned to tell a positive event, the same process can be used to ask about the abuse. If the child now provides less detail, this provides information about the level of avoidance or level of suffering of the child.

What about treatment?

The treatment model of TF-CBT has been applied in both individual and group therapy format and consists of 8 to 16 sessions of about 90 minutes. In individual therapy, the sessions last 60 minutes and the course of treatment is more variable. Many children with comorbid diagnoses and a history of multiple traumas respond well to a relatively short duration of TF-CBT. In sessions with parents, an explanation of the diagnostic findings is given and an overview of the treatment plan is provided. To inspire hope among the parents, it is important to highlight the strengths of the child and explain how the treatment model will induce certain difficulties. During the individual sessions, parents and children work in parallel, both receiving education and skills. As soon as progress is visible, more time is spent on sessions with the parents and the child together.

What are PRACTICE components?

TF-CBT is a component-based approach, the components are summarized by the acronym PRACTICE: psycho-education and parenting skills, relaxation techniques, affective expression and modulation, cognitive coping, trauma narratives and processing, in vivo mastery of trauma reminders, conjoint parent-child sessions and enhancing future safety and development. Step-by-step exposure to abuse-related psycho-education begins immediately and continues during all stages of treatment, as does parenting training. The psycho-education and coping skills training (relaxation, affect regulation and cognitive coping) help parents and children prepare for more trauma-focused components that come later in treatment (trauma telling and processing). The final phase of treatment is designed to help clients develop personal safety skills, improve communication between parents and child, and integrate and look back on all knowledge and skills. See also Table 11.1 on page 353.

Psycho-education

Starting in the first session, parents and children receive psycho-education regarding the determination and treatment process. The therapist helps parents to see the child's difficulties in the light of normal responses to trauma and abuse. In the first session with the child, the term sexual abuse is created so that the child knows that there is a name for what happened. During treatment, the therapist provides information about the prevalence, characteristics and aetiology of sexual abuse. Things like a healthy sexuality are discussed at the end of therapy.

Upbringing skills

Behavioural managing skills are introduced during early stages of treatment. This provides a framework on social learning and helps parents to understand why their child shows certain behaviors after sexual abuse. They are also explained that these behaviours are not permanent, and can be changed. Parents are taught to respond effectively to their child's behavior and to focus on their child's strengths and social behaviors, rather than the symptoms and behaviors they are concerned about (this is called differential attention). It is also important that parents do not treat their child differently after the abuse (for example, by not having consequences after inappropriate behaviour because they feel guilty or feel sorry for their child). It explains that setting rules, structure and consistency helps in the recovery of the child.

Relaxation techniques

Children benefit from learning how to relax their bodies and thoughts. This helps anxious, avoiding children to actively manage their emotions and thus provides them a sense of control. Exercises must be adapted to the child's level of development. Breathing exercises or muscle relaxation may be discussed. It can be helpful to teach this to parents as well.

What about affective expressions and regulation skills?

Children

Sexual abuse can lead to intense and confusing emotions that cause additional anxiety in children. Providing information about emotions can be very helpful. Labelling emotions and understanding physical reactions to them helps children understand that there is nothing wrong with them or their body. Normalizing their reactions can also help to reduce anxiety. The vocabulary for naming emotions is also magnified. They also practice in identifying emotions in themselves and in others. If successful, the children will be encouraged to express their own emotions in an appropriate way. It emphasizes the importance of sharing feelings with others. Finally, they are asked about the child's abuse-related feelings.

Parents

For the parents, abuse can also lead to intense and confusing emotions. Recognizing, naming and expressing feelings is an important skill. Parents can express their own feelings about the abuse and are supported in identifying their child's emotions and how it affects their behaviour. It is important to accept the feelings of the parents, even if they are very angry. It is crucial that parents feel understood and accepted by the therapist.

What about cognitive coping skills?

Children

In the early stages of treatment, the focus of cognitive coping is on identifying and sharing underlying or automatic thoughts and how this affects our feelings and behaviors. It's about identifying, monitoring and sharing things that kids don't say out loud but that they do think. It explains how what the child thinks affects how he/she feels. This can give the child a greater sense of control over his/her emotions. The first step is to explain the relationship between thoughts, feelings and behaviors. When the child understands that he/she can interpret the same situation in different ways, they can be taught to turn negative thoughts into positive, more helpful thoughts. First, non-abuse related thoughts are the focus, and later abuse-related thoughts are the focus.

Parents

Cognitive coping are introduced to parents for similar reasons and in similar ways as in children. They are also taught the relationship between thoughts, feelings and behaviour and are taught that their dysfunctional thoughts determine the way they respond to their children. Parents are encouraged to talk about their emotions and to replace negative thoughts with more helpful thoughts. They are also taught that seeing a problem as permanent, pervasive and personal is part of pessimistic thinking. The therapist stresses that the most problems are variable, specific rather than pervasive and not personal.

What about trauma-narration and processing?

This part proceeds the same in the child and the parents. Parents are made aware that children often become more rebellious in attending this part of therapy, but that this will decrease during treatment after which the child experiences less stress. Gradually, children will start reminiscing about the trauma, while writing the trauma story children develop feelings of control with regard to dealing with these memories and emotions. Children learn that the memories of the trauma they go through can do damage. The purpose of the exposure is that children relive and endure the feelings of trauma in a safe place, until the feelings decrease naturally.

Trauma-narration

After the child has shown that they have affective and cognitive skills to express feelings and thoughts, he/she is encouraged to tell in more detail about the abuse. While developing and processing the trauma story, there are two primary goals:

1. That the child feels more at ease and less avoidant with regard to the memories of the abuse.
2. To identify and correct maladaptive thoughts and beliefs of the child. It is important that in this part of the treatment no suggestions are given to the child. However, if the child seems to exaggerate or fantasize, the therapist should become aware of this.

What about cognitive processing?

Children

When children try to understand the abuse, they often do not have enough information or knowledge to contain the abuse. This allows them to develop confusing, wrong and dysfunctional thoughts about the abuse. Challenging these thoughts can help change the child's negative outlook on the world, often increasing anxious and/or depressive symptoms. This part takes place only after sharing the traumatic memories.

What is in-vivo gradual exposure?

Children who have been sexually abused can develop fear of other harmless stimuli (such as a dark room). A combination of in-vivo exposure and behavioural empowerment can help the child to reduce this anxiety. It is often not possible for the therapist to do this himself, so usually the therapist coaches the parents in performing the in-vivo exposure at home or at school.

What are the joint parent-child sessions?

The content and goals of the joint sessions are discussed in general terms early in the treatment, but it is better not to specifically plan that the trauma story will be shared. There are situations where sharing the trauma story is better not to take place, when this will, for example, evoke an unprocessed trauma of the parent(s). In that case, the parent just tells the child how proud he is. Most parents, however, respond well to hearing the trauma story.

Prepare for and run the joint sessions

Parents are encouraged to practice the skills they have learned, such as active listening skills, at home before starting the joint sessions. The first session focuses on practicing skills, such as emotional expression. For example, parents and children can ask each other questions about this. The trauma story is also shared with the parents. Possibly additional sessions may focus on sex education. The communication between parent and child is also observed.

How can we increase safety and what are future developments?

Healthy sexuality – children

Providing accurate information about sexuality in an age-appropriate way can help to correct or prevent maladaptive thoughts about sexuality. It is important to clarify parents' views on sex education.

Healthy sexuality – parents

Parents need to understand why it is important for the child to receive sex education. Parents should be encouraged to share their ideas about sex with the therapist. If parents are more comfortable with the idea of sex education, the therapist can give guidelines on how to proceed. Parents are encouraged to start sex education during everyday activities, adapted to the child's level of development. They are encouraged to do so in a positive way.

Personal safety skills – children

This section educates on personal safety skills. In doing so, children learn what to do to reduce the risk of victimhood and to feel that they can protect themselves. ‘Body ownership' is an important part of this, in which children learn that they are in charge of their body and decide for themselves whether they want to be touched or not. In young children, it can be helpful to identify genitals. It also helps to learn about OK touches and non-OK touches, and to say ‘no’.

Personal safety skills – parents

The therapist involves the parents in this component of the therapy. Together, skills are practiced and the parents are given information about what the child is learning.

Child sexual abuse is often defined as contact or interaction between a child and an adult or an older child, in which the adult engages in sexual behaviour with the child. This includes many types of age-inappropriate sexual interactions (exposure to porn, fondling) and more invasive behaviors such as oral-genital contact and penetration. A study shows that almost 1 in 10 children from childhood up to the age of 17 have experienced sexual abuse with or without oral-genital contact. Another study shows that approximately 7.9% of adult men and 19.7% of women were sexually abused as children.

What is the use of modules for psychotherapy? - Chapter 12

What is this chapter about?

Formal professional ideas about dealing with behavior and emotional problems of children and adolescents are now about a century old. Since then, different treatment models have evolved and have sometimes replaced old theories and exercises. A critical shift began when the development of treatment was accompanied by empirical research. This led to randomized controlled trials, protocols and manuals.

What is Evidence-based psychotherapy (EBP) for children and adolescents?

Most EBPs have a certain design, so that they often focus on a specific problem or a specific disorder or on a homogeneous cluster of disorder (e.g. all depressive disorders). There is often a fixed order of steps and sessions.

EBPs in everyday clinical care

The 'deployment' targeted model of intervention development assumes that in order to develop interventions that work well in the contexts for which they are intended, interventions must be developed in these contexts must and tested and the effects should be compared with other interventions intended for the same context. This makes the results a lot more informative and valid. This does not mean that current EBPs are not revolutionary and remarkable, but that further evolution is needed to increase the initial efficacy of treatments. This can be done by improving strategies in the current form of EBPs, or by an alternative approach: changing the protocol design. These are changes in effort to develop, implement and test EBPs in everyday clinical care contexts.

What are modular treatment designs?

Scope and goals

Modular treatment has a different approach on at least two dimensions: flexibility and changeable content. This adaptability is quite important but not always necessary. Modular treatment creates a framework for:

• Modifying treatment approaches by adding and removing modules,
• Increasing the diagnostic breadth of a treatment protocol by adding content that is relevant to multiple disorders.

These content benefits help reduce the number of interventions clinicians need to learn for various cases.

Elements and structure

Treatment is called modular, or the treatment components are called modules. Importantly, these modules refer to essential, discrete and functional units of a protocol that can be rearranged to form different structures and relationships. Different modules can form a larger therapy together, for example for depression. Combined with other modules, this can be a treatment program for other disorders. Also the 'coordination modules', a kind of small manuals to coordinate the treatment, are discrete and rearrangable.

What is the MATCH-ADTC protocol?

Modular approach to therapy for children with anxiety, depression, trauma, or conduct problems, match-ADTC, is primarily focused on anxiety, depression, traumatic stress and conduct problems.

Structure of the MATCH protocol

The MATCH protocol is a collection of treatment procedures and coordination modules that describe the logical steps of treatment for the four problem areas. The protocol is more like a library of procedures than a traditional book, with a handy online version available. It provides search strategies to make the use of the 400-page protocol a lot easier.

Structure within the modules

A uniform model has been developed for each content module, in order to create familiarity with the elements of the protocol structure for various cases and problems. The structure starts with the purpose or function of the module, for whom the module is intended, what the goals of the module are, what materials are used, which goals are prioritized, a description of the procedure, a script, a list of suggestions for closing a session, explanation of what information may be shared with whom, tips and a reminder for users to keep their own style.

Clinical coverage of the protocol

There is a focus on a protocol that involves a wide variety of juvenile dysfunctions to cope with different clinical cases and a protocol that supports changes in treatment when new problems call attention or environmental factors are an obstacle. When challenges arise, different modules can be selected. Key areas of the protocol can 'borrow or use' procedures from another area to address interference.

Coordinating the content

The classification of procedures in the protocol stems from the logical use of the modules. For each problem area there is a standard road and an alternative road if necessary. The standard path follows a standard order of the content modules for cases where modules from other sections are not required. The alternative road is a guide to a detour that refers to other sections.

Clinical information system for navigating within MATCH

The use of module coordination for treatment planning should be supported by a constant flow of information about the functioning of the juvenile during treatment. For this, a ‘client dashboard’ can be used, on which there are weekly reports of the child’s progress .Here, improvements are tracked and reported based on specific main problems identified at the beginning of treatment. Resources that can be used for this are the Brief Problem Checklist and the CBCL. The dashboard is used to report which young people are improving and which are not. In combination with the MATCH protocol, treatment episodes can be efficiently navigated, which will help in making decisions about how long modules should last, when to change direction and when the end of treatment should be supervised.

Research evaluation of the MATCH protocol

There are three studies in which the MATCH protocol is used. Here, participants are randomized assigned to MATCH or care giving as usual. Results are not yet known.

What are some questions regarding modular methods?

Since modular methods are quite new, there are several questions about it.

1. How is it determined whether a particular module or problem area is followed or another should be followed? In principle, a decision to switch to another module should be based on information about whether the client has understood and mastered the skills of the current module. These decisions are often made on the basis of the aforementioned dashboard.
2. How is it determined when the treatment is complete? Modular treatments use separate criteria for when treatment is complete, as clients are not expected to complete all sections or even all modules and the focus is on common problems.
3. How is it importance attached to the parents or the child's opinion in making decisions in modular treatment? Collecting information is the key to making decisions and it seems to bring information from both parent and child. However, they often differ. When parent and child reporting on progress contradicts each other, the clinician should rely on other available information.
4. How is protocol adherence determined by the therapist? Protocol adherence at the basic level is the implementation of procedures as described in the modules. A modular approach also involves decision-making principles. However, the author believes that clinicians can defend decisions well based on information obtained during the treatment itself.
5. How should empirically-guided decisions go hand in hand with clinical judgment? The adherence to empiricism creates a tendency of unwillingness in abandoning the use of standardized adoption for clinical decisions. However, one should try to find the right balance between the two ingredients.

What can be concluded?

Thanks to the increasing use of research to develop and test treatment and documentation on procedures, the youthful psychotherapy has been transformed from ‘art’ into increasingly rigorous science. An important task of the future is the transition from research on efficacy to implementation in everyday clinical practice. Modular protocols and treatments can help in achieving this.

Formal professional ideas about dealing with behavior and emotional problems of children and adolescents are now about a century old. Since then, different treatment models have evolved and have sometimes replaced old theories and exercises. A critical shift began when the development of treatment was accompanied by empirical research. This led to randomized controlled trials, protocols and manuals.

What is Dialectical Behavioural Therapy (DBT)? - Chapter 13

What is this chapter about?

Dialectical behavioural therapy (DBT) is a perspective within CBT and is applicable to juveniles with multiple problems who experience difficulties in regulating their emotions and behavior.

What are the theoretical foundations of DBT?

DBT is a mixture of CBT change strategies and acceptance. This is mainly based on behaviorism and cognitive theories. In addition to the fact that DBT, as with CBT, directs individuals to change their thoughts and behaviors, it also teaches them to accept their own reality as it is at the moment. This emphasis on acceptance is derived from Zen mindfulness. ''Dialectic'' refers to the multiple stressor that arise from the treatment of multi-problem patients. The main dialect is acceptance and at the same time working towards change. The therapist helps the patient to find his or her own middle ground. The dialectic is located on two levels; the level of change and acceptance and flexibility and stability. Specific dialectical strategies are applied to recognize contradictions in behavior and thinking. The patient should go from thinking 'one thing or the other', to ‘both’ thinking. Linehan's biosocial therapy can help in understanding the aetiology and maintaining emotional dysregulation while at the same time giving direction to how this can be more effective. This theory states that some individuals have biological predispositions that make them vulnerable and cause them to experience more intense emotions and thus react more strongly. At the same time, these individuals are in a debilitating environment. The aetiology of dysfunction lies in the transaction between the biological predispositions and the environment.

How can one use DBT in adolescents with multiple problems?

Who is the target of DBT?

Criteria for participating in DBT are as follows:

1. The patient must be between 12-18 years old;
2. There has been a suicide attempt or non-suicidal self-harm or suicidal idealization.
3. The patient has borderline personality characteristics. If there is psychosis or mental retardation at the moment, DBT is not suitable. Furthermore, patients can vary in terms of ethnicity, SES etc.

Who is providing the treatment?

The treatment team consists of at least three healthcare professionals who have had training in DBT and prefer to have experience with adolescents. We work with a multidisciplinary team.

What is the structure of the treatment?

Treatment begins with an in-depth evaluation on the inclusion criteria. The first phase of treatment, which lasts at least 20 weeks, consists of participation in five methods of treatment. This phase is completed when primary problem behaviours (drug use, suicidal behaviour, etc.) are reduced. Then phase 2 follows, which lasts at least 16 weeks. Phase 2 consists of weekly group therapy. DBT has a presence policy, which means that patients may only miss 4 sessions.

What is comprehensive DBT?

Comprehensive treatment includes five functions:

1. Increasing the patient's capabilities. This refers to learning new skills in a training group with psycho-education and families.
2. Improving motivation to change. This is 1-to-1 work with the therapist and the patient to reduce factors interfering with the use of skills and thus increase motivation.
3. Ensuring that new possibilities generalize from therapy to everyday life. This is done by means of in-vivo interventions.
4. Increasing the therapist's ability and motivation to treat the patient effectively. This is something like ‘therapy for the therapist’ and is meant to reduce burnout and increase fidelity to the DBT model.
5. Structuring the environment so to provide support.

What are different stages in DBT?

DBT is organised on the basis of stages. Pre-treatment and the four stages of treatment in DBT all have specific treatment goals. Pre-treatment focuses on orienting and obtaining commitment to the treatment. Stage 1 focuses on determining safety and behavior dis-control. Stage 2 focuses on reducing post-traumatic stress through emotional processing of the past. Stage 3 strives to increase self-esteem and works on individual goals. Stage 4 increases hedonistic capacity.

What are primary and secondary behavioural goals?

Targets in DBT are sets of behaviors that need to increase or decrease.

Primary behavioural goals

Stage 1 goals

Stage 1 goals are hierarchically organized:

• Reducing life-threatening behaviors: DBT focuses on suicidal behavior as a top priority. Suicidal behavior is seen as a maladaptive problem-solving strategy of which diminishing emotional pain is the central goal. DBT helps to develop a meaningful life and effective problem solving.
• Reducing therapy hindering behaviors: multi-problem adolescents often already have experienced failure in previous therapies. Problems with therapy include motivation difficulties, relational or other behavioural difficulties or patient behavior in which effective therapy behaviors are punished and ineffective behaviors are energized. DBT focuses on behaviors of the patient, family and therapist who oppose the therapy.
• Reducing behaviors that affect quality of life: multi-problem adolescents exhibit behaviors that have a direct impact on the quality of their lives. These include, for example, dysfunctional relationship interactions, school or work-related dysfunctions, impulsive behavior, substance abuse, etc.

Secondary behavioural goals

Secondary behavioural goals are addressed during the whole treatment, not during a specific phase. These goals focus on dialectical dilemmas or behavior patterns. Each pattern represents an aspect of the transaction between biological emotional vulnerability and the debilitating environment. The individual learns to alternate between regulatory and regulatory patterns of behaviour. Fluctuations between different poles (vulnerability – environment) create a lot of tension and discomfort and are thus an obstacle in therapy. The emphasis is therefore on increasing the possibility of walking the middle ground and thus reducing dialectical tension between emotions, thoughts and actions.

What are different types of treatment?

Individual therapy

DBT individual therapy consists of 20 weeks with sessions of 50-60 minutes per week. The primary goal is to change the adolescent's motivation and keep him/her involved in therapy during the duration of treatment. Problem-oriented and acceptance strategies are used to teach new, appropriate behavior. The therapist learns to endorse such behaviors and to ignore ineffective behaviors through the strategic use of the therapeutic alliance. Variables that monitor and maintain problem behavior need to be identified. Validated cognitive and behavioural strategies are often used, such as skills training, exposure, contingency management and cognitive modification.

Multi-family skills training group

The skills training group is a weekly, two-hours training and consists of four teenagers with their parents. A sense of community and learning and the strengthening of the commitment can be obtained. In this group, the focus is primarily on acquiring and strengthening new skills in problems such as emotion dysregulation.

What is intervention consultation?

In between individual sessions, the adolescent is encouraged to have contact with the therapist by in-vivo assistance during crisis, before adolescents engage in maladaptive behaviours. The goal is to generalize skills to situations outside therapy.

What is family therapy?

DBT's family therapy has multiple functions:

• Orienting the parents concerning DBT;
• Providing psycho-education;
• Assisting in modifying environment contingencies that maintain maladaptive behaviors;
• Increasing skills used within the family context;
• Increasing adherence to therapy and reducing behaviors that get in the way of therapy.

What is the DBT consultation team?

The DBT consultation team meets for approximately 90-120 minutes per week to discuss the treatment of the adolescent. The same acceptance and change strategies are used as with the adolescents and their families.

What is phase 2 of DBT?

After the first phase, adolescents and parents receive a certificate and stop individual and multi-family therapy. During phase 2, the adolescent participates in a 'graduate group' aimed at maintaining the positive effects of the treatment.

What can be concluded?

DBT is an evidence-based treatment initially developed for chronic suicidal adolescents diagnosed with bipolar disorder. It has been adapted for use in both suicidal adolescents and multi-problem adolescents with varied diagnoses. It is an extensive treatment consisting of multiple phases and treatment methods.

DBT is a mixture of CBT change strategies and acceptance. This is mainly based on behaviorism and cognitive theories. In addition to the fact that DBT, as with CBT, directs individuals to change their thoughts and behaviors, it also teaches them to accept their own reality as it is at the moment. This emphasis on acceptance is derived from Zen mindfulness. ''Dialectic'' refers to the multiple stressor that arise from the treatment of multi-problem patients. The main dialect is acceptance and at the same time working towards change. The therapist helps the patient to find his or her own middle ground. The dialectic is located on two levels; the level of change and acceptance and flexibility and stability. Specific dialectical strategies are applied to recognize contradictions in behavior and thinking. The patient should go from thinking 'one thing or the other', to ‘both’ thinking. Linehan's biosocial therapy can help in understanding the aetiology and maintaining emotional dysregulation while at the same time giving direction to how this can be more effective. This theory states that some individuals have biological predispositions that make them vulnerable and cause them to experience more intense emotions and thus react more strongly. At the same time, these individuals are in a debilitating environment. The aetiology of dysfunction lies in the transaction between the biological predispositions and the environment.

What is mindfulness-based treatment? - Chapter 14

What is this chapter about?

There is increasing interest in the development and implementation of mindfulness-based psychotherapy for adults with chronic pain, anxiety, depression and other disorders. There is also research about mindfulness in children and adolescents.

What is mindfulness?

Mindfulness is seen as a kind of attention-focused attention, exercising mindfulness is often seen as training attention. It is about being conscious. As a process, mindfulness is the behavior of giving non-judgmental attention to internal and external events at any time. Internal events are thoughts, emotions, perceptions and body sensations. External events are about the environment, situations and interpersonal experiences. Exercising mindfulness is about attention. A mindful state of thought is said to be attentive and receptive of experiences, associated with an attitude of curiosity and non-judgmental acceptance.

What are similarities and differences between mindfulness and cognitive behavioural therapy?

Mindfulness is based on a paradigm that is fundamentally different from CBT. Mindfulness has a different theoretical basis and is probably based on other active mechanisms. However, some elements derive from traditional cognitive and behavioural therapy, for example the use of a problem formation model, identification of goals, repeated observations of thoughts and feelings, homework assignments and evaluation of treatment. These components are integrated into a paradigm of mindfulness and acceptance.

What is restructuring and decentralisation?

CBT focuses on the content of thoughts, mindfulness focuses on the process of thinking. However, the active mechanism in both CBT and mindfulness is the result of change of not the content of the thoughts but the processes of thought. Decentralisation is a central component of the efficacy of mindfulness, defined as metacognitive insight. This is experiencing thoughts as events in the field of consciousness.

What is the difference between situational exposure versus exposure to life?

CBT models use exposure tasks, for example to treat fears. This is called situational exposure. Mindfulness uses exposure to life; it treats avoidable behaviors by encouraging thoughts to focus attention on choices and thus promote psychological resilience. The exercise of attending to thoughts and feelings can be seen as unconditioned exposure with response prevention.

What about change versus acceptance?

CBT has been described as a change-based model, while mindfulness is an acceptance-based model. It is the exercise of observing what occurs at any time with non-judgmental acceptance. It does not attempt to avoid or change thoughts or emotions, even if they are unpleasant. The paradox is that it is precisely from this acceptance that therapeutic changes become possible.

Mindfulness as a therapeutic intervention?

Exploring or defining mindfulness as therapeutic intervention comes with difficulties and paradoxes. First, mindfulness is fundamentally not conceptual and experimental. Therefore, it is extremely difficult or even impossible to accurately describe mindfulness in words. Secondly, mindfulness is not about analysing, archiving or changing things, so exercise is not an 'intervention'. The therapist lets go of the idea of change and maintains an attitude of acceptance.

How can we measure mindfulness?

To study mindfulness, we need to be able to measure mindfulness. There are four measurement instruments available to do so: the Child and Adolescent Mindfulness Measure (CAMM), the Mindful Thinking and Action Scale for Adolescents, the Mindful Attention Awareness Scale (MAAS), and the Avoidance and Fusion Questionnaire for Youth (AFQ-Y0).

How can we integrate mindfulness into therapies?

The three level satisfaction model (Germer, 2005) of mindfulness provides a useful structure for describing ways mindfulness can be integrated into therapy. The first level covers the mindfulness of the therapist himself, which can influence aspects of the therapy. The second level is the theoretical framework of mindfulness for the therapeutic approach. The third level is the level at which mindfulness skills are taught to clients.

Four mindfulness-based therapies

The most prominent mindfulness-based therapy is the previously discussed (chapter 13) dialectical behavioural therapy (DBT). In addition, the following therapies are also based on mindfulness: acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBSR). MBSR and MBCT can be distinguished in sharing an emphasis at:

• Maintaining the therapist's own pursuit of mindfulness.
• Developing a consistent daily exercise of mindfulness in the client.

DBT and ACT are about teaching specific cognitive skills, emotion regulation strategies and behavioural change strategies that are absent in most practice-based therapies (MBSR and MBCT).

What are non-practice-based therapies?

Dialectical behavioural therapy (DBT)

DBT is a treatment for borderline and is an integration for change and acceptance. It helps a client to deal with paradoxical tensions that arise between polarized positions. A balance must be created between unconditional self-acceptance and a recognition that behavioural change is needed.

DBT in adolescents

DBT focuses on the development of adolescents, recognising the important role of parents and family by involving them in treatment.

What is acceptance and commitment therapy (ACT)?

ACT combines elements of behavioural therapy, mindfulness and acceptance. It is based on the relational framework (RFT). RFT is a constructivist theory of human language and cognition. It suggests that all events and actions only have meaning when they take place in the relational context. Key features of ACT are cognitive fusion and experimental avoidance, which lead to psychological inflexibility and suffering.

ACT in adolescents

ACT’s flexible model can be adapted to the therapeutic and development requirements of young people. ACT-A focuses on developing general psychological flexibility and acceptance of all experienced phenomena.

What are practice-based therapies?

Mindfulness-based stress reduction (MBSR)

MBSR has been developed for patients with chronic pain and is also applied to other physical and psychological health conditions. It is presented in an educational way, rather than as a therapeutic approach. Weekly group sessions involve exercises, with dialogue, psycho-education and exercises related to dealing with problems in life.

MBSR in children and adolescents

The adaptation of MBSR programs for juveniles in clinical and non-clinical settings has been accepted. As with all therapies, adaptations are suitable for development. These include shorter exercises and the involvement of sensory learning activities.

Mindfulness-based cognitive therapy (MBCT)

MBCT was originally intended to prevent depressive relapses of previously depressed clients. It looks a lot like MBSR. MBCT integrates cognitive techniques aimed at reducing cognitive vulnerabilities to prevent depressive relapse with mood-related cognitive, affective and psychological patterns.

MBCT in children and adolescents

MBCT must also be made developmentally suited for use in children and adolescents. This works the same way as with MBSR. MBCT-C is based on resilience.

What do the authors think of mindfulness-based interventions in children and adolescents?

Within the paradigm of exposure to life emphasized by mindfulness therapy, it can be difficult to stay in the present with thoughts and feelings. However, no negative outcomes of mindfulness interventions have been reported. However, mindfulness is not recommended when there are traumatic memories.

What can be concluded?

Almost everyone has the opportunity to exercise mindfulness awareness. It's an easy exercise in bringing greater awareness compared to living on autopilot. The difference between mindfulness in youth and adults is not yet clear, but young people seem more responsive to mindfulness. However, in very young clients there may be an involuntary participation, which can make therapy more difficult.

There is increasing interest in the development and implementation of mindfulness-based psychotherapy for adults with chronic pain, anxiety, depression and other disorders. There is also research about mindfulness in children and adolescents.

What are guidelines of developmental psychology for therapy in adolescents? - Chapter 15

The literature on therapeutic interventions in adolescents continues to increase. As new interventions develop, it is argued that the quality of these treatments is likely to increase when important development milestones and changes in development during adolescence are taken into account. Interventions are expected to be in line with the level of development of those for whom treatment is intended. The adolescent's level of development is seen as a time when there is accumulation of predictable, age-related changes in biological, cognitive, emotional and social functioning.

Why focus on adolescents?

Adolescence is a transition period between childhood and adulthood, characterized by more biological, psychological and social role changes than in other periods of life. Here are two moments of transition: from childhood to early adolescence and from early adolescence and from late adolescence to adulthood. Given the amount of changes in adolescence, it is not surprising that there are also significant changes in the frequency and types of psychological disorders that occur during adolescence. It can be a period of adaptation or maladaptation. It is a critical period in development. A focus on this period is effective for demonstrating the importance and usability of the development perspective.

What is an overview of recent research on CBT interventions in adolescents?

44 empirical articles have been reviewed. This shows that depression is most often the focal point of interventions in adolescents. Substance abuse is second. Attention to development problems is still increasing, but this does not necessarily mean that development problems are also taken more seriously. However, there also appears to be increasing attention to development factors as potential moderators. The review shows that many studies are looking at this. So there is increasing awareness of developmental factors in understanding conditions under which treatment is effective or not. However, attention to problems varies widely among the authors of studies. Moreover, there are few concrete examples or methods for including concerns about development in treatment.

What is a framework for understanding development and adaptation in adolescence?

Appreciation for the rapid development changes in adolescence and the context of such developments would contribute to the treatment outcome. The framework for such large constructs emphasizes biological, psychological and social changes in the development period of adolescence. At the most general level, it is indicated that primary developmental changes have an impact on the outcomes of development through the interpersonal context in which adolescents develop. Thus, developmental changes have an impact on behaviors that are significant to others, which in turn affects the way adolescents solve problems (such as problems in autonomy, sexuality, identity). The framework on understanding adolescent development and adaptation is on page 438.

What are primary developmental changes in adolescence?

Three types of primary developmental changes occur during adolescence: biological/puberty, psychological/cognitive and social role definition. These changes are seen primarily because they are universal across different cultures and occur before other developmental outcomes of adolescence.

Biological/puberty changes

Adolescence is a period of physical growth and change. The peak of puberty development occurs in women two years earlier than in men. Also, there is intra-individual variation (not all puberty events begin at the same time). So it is possible that puberty is different for everyone. It is also necessary to distinguish between the status of puberty (individual place in the order of predictable changes) and timing of puberty (the timing of puberty compared to peers). Both affect the mood and affective expression of the adolescent, the quality of family relationships and psychosocial adjustment. Puberty timing (early onset of puberty) can be related to adaptation difficulties and other problems. The status of puberty is associated with other problems, including obesity.

Psychological/cognitive changes

Few researchers have looked at whether treatments are more effective depending on the level of cognition. This must therefore be given extra attention.

What about cognition in theoretical formulas?

All cognitive behavioural approaches emphasize the importance of cognitive processes in the development, maintenance and modification of behavior. For example, behaviour is often viewed as the product of cognitive processes. These processes determine what we do, how we receive things, remember, etc. For this, cognitive processes underlying the problem need to be identified and one should learn how to change the cognitive processes.

The focus on cognition in treatment

In CBT, maladaptive thoughts are identified and false assumptions are challenged. More adaptive thoughts are encouraged. Problem solving is also a strategy for the development of adaptive responses. CBT techniques focus on self-reflection, thinking about consequences and considering future possibilities. This requires a high level of cognitive development.

What about social roles?

During adolescence, many changes take place in social status. Although social redefinition is a universal fact, specific changes can vary. In some communities, for example, there are rituals of changes in puberty. In Western culture, changes in role definition can be inter-personal, political, economic and legal. Research shows that stereotypical role expectations during adolescence are even more intense.

What about the interpersonal context of adolescents?

The interpersonal context of adolescents consists of four components: family context, context of peers, school context, and work.

Family context

During adolescence, transformations take place in the relationships within the family. For example, there is increased emotional distance between the parents and the child during the peak of puberty. There may also be an increase in conflict and negative affectivity. A big task of the parents here is to be responsive to the increased responsibility of the adolescent while monitoring their behavior.

Context of peers

Poor relationships with peers during adolescence are robust predictors of difficulties in adulthood (dropping out of school, crime). Positive relationships with others are necessary and have a positive impact on cognitive, social cognitive, linguistic, gender roles and moral development.

School context

The school environment is important not only for cognition and achievement, but also for the development of personality, values and social relationships. The physical setting, limited sources, philosophy of education, teacher expectations, curriculum characteristics and interactions between the teacher and student are related to different outcomes in adolescence and childhood. CBT therapists can help to determine the nature and quality of the adolescent's school environment. In addition, CBT interventions are also often performed in the school environment.

Work

Although many adolescents have jobs, little research has been done on its effects on development. However, based on the available research, it seems that the working environment can have both a positive and negative impact. Although adolescents who work develop an increased self-reliability they can also:

• Develop cynical attitudes about work;
• Spend less time reducing the emotional distance with their family;
• Be less involved in school and set fewer goals;
• Use drugs or engage in delinquent behavior, and;
• Have less time for self-exploration and identity development.

Exposure to deviant peers at work can also have negative effects.

What are developmental outcomes of adolescents?

Below are the primary developmental outcomes in adolescence.

Performance

Decisions during adolescence can have serious consequences for future education and career. There is often an increase in choices and this creates anxiety about life decisions. The therapist can help the adolescents manage these challenges.

Autonomy

Autonomy is multidimensional and covers three separate constructs: emotional, cognitive and behavioural autonomy. Emotional autonomy has to do with dependence on parents, of which they need less emotional support. Behaviour autonomy has to do with the capacity to make own decisions. The therapist should pay attention to autonomy-related problems during treatment.

Identity formation

The development of identity is a major psychological task for adolescents. This is done through role-exploration and role-commitment. Identity is multidimensional and covers various domains (interpersonal, sexual, political, academic, religious, etc.). There are four identity states with two dimensions: commitment and exploration. Identity moratorium refers to lots of exploration and little commitment, identity foreclosure refers to many commitment without exploration, identity diffusion refers to no commitment and no exploration, and identity performance refers to commitment after a lot of exploration.

Intimacy

It is only in adolescence that friendships become potentially intimate. This is characterized by trust, loyalty and helpfulness. Intimate sharing with friends increases during adolescence and relationships become more emotionally charged. There is also a greater chance of relationships with peers (of the opposite sex).

Psychological adjustment

Knowledge of various psychopathologies in adolescence and how these develop and change from childhood to adolescence is important and helpful in therapy. The therapist can benefit from knowledge about the development variations in the start and course of different psychopathologies ,and the extent to which there is overlap/comorbidity

Sexuality

There are often mixed reactions to the sexual maturity of an adolescent, not only by the adolescent himself but also by the parents. They often want to influence the decisions of the adolescents regarding sexual activity. Despite the high levels of sexual activity, little is known about typical adolescent sexuality. However, it is known that changes affect sexual behaviour both directly (hormonally) and indirectly (socially). Ethnicity and religious differences can also have an impact. It is important to provide sex education.

What are implications from developmental psychology for the use of CBT in adolescents?

The development uniformity myth

The development level uniformity myth is the tendency of clinicians to see children and adolescents of different ages as more the same than different. A consequence of this is that treatments are used without considering the client's level of development. These assumptions of uniformity regarding development may get in the way of treatment.

Developmental standards and norms

Knowledge about development standards and norms are important for making appropriate diagnostic decisions, identifying treatment requirements and selecting appropriate treatment. In the absence of knowledge, over- or underdiagnosis may result. Taking into account the trend towards greater autonomy in adolescents in recent years, certain treatments are more suitable. It is therefore important to take these types of development standards into account in the treatment of these types of development standards.

Development level as a moderator

When examining moderators of treatment efficacy, there is interest in conditions that determine whether a treatment is effective or not. It seems reasonable to suggest that the of development in a child (with associated skills) affects the increase or limitation of the treatment effect. It is therefore recommended that the level of cognitive development be established in advance of treatment. It is necessary to determine whether the adolescent is able to:

• Determine future consequences.
• Generate alternative solutions.
• Think in a metacognitive way, thus to think about one's own thinking.
• Think in an organized way.
• Consider other’s perspectives.

Development level as mediator

Examining the level of development as a mediator focuses on a different set of questions. This relates to the possible mechanisms by which the treatment has the effect obtained. A mediator is seen as a factor responsible for at least and part of the treatment effect. It is an antecedent on the treatment outcome and a change in the mediator is associated with a change in outcomes. When examining mediator models, it must therefore be proven that changes in the mediator involve changes in the treatment outcome. It is important that therapists not only address the symptoms, but also focus on the normative level of development of the adolescent's skills.

Level of development: selecting an intervention approach

The skills available to a child/adolescent, the level of abstract reasoning and perspective-taking skills determine the implementation of a treatment. Consideration of the level of development is therefore crucial in selecting a suitable treatment for children and adolescents.

Developmental psychopathology and CBT in adolescents

Developmental psychopathology is an extension of developmental psychology in the sense that it looks at variations in normal development. Research in this area provides information on precursors of the development and future outcomes of psychopathology. It is important to have knowledge about risk and protective factors, cumulative risk factors, equifinality, multifinality and other factors related to developmental psychopathology. It also involves problems of continuity- discontinuity. Antisocial behaviors have continuity in that adults with certain behaviors, also often exhibit these behaviors in early childhood. Discontinuity, however, applies to children who exhibit certain behaviours early on, but no longer in adulthood. With knowledge about developmental psychopathology, the therapist is better able to answer certain questions and generate hypotheses. Without the answers to these questions, there is a good chance that the therapist will misdiagnose.

What are recommendations for the therapist?

• Stay informed about literature and research into treatment outcomes. Knowledge about treatments is necessary.
• Consider cultural factors. These factors are important for diagnosis and treatment.
• Use developmental strategies. Use strategies that align with the level of development and that rely on relevant development factors.
• Focus on developmental tasks and milestones that the adolescent is trying to master.
• Think multi-systematically; consider relevant contexts and involve those in the treatment.
• Help parents become sensitive to development, since adult responses to development are crucial and should be taken into account.
• Anticipate future development tasks and milestones.
• Consider the concept of equifinality (different developmental pathways can lead to the same disorder).
• Look for alternative models to allow the treatment to take place.

Although so far many treatments are not oriented towards development, there is increasing growth in attention to development factors. It is important to have an understanding of adolescent development and the greatest developmental tasks during this period, the interpersonal contexts associated with this development and factors relevant to interventions.

The literature on therapeutic interventions in adolescents continues to increase. As new interventions develop, it is argued that the quality of these treatments is likely to increase when important development milestones and changes in development during adolescence are taken into account. Interventions are expected to be in line with the level of development of those for whom treatment is intended. The adolescent's level of development is seen as a time when there is accumulation of predictable, age-related changes in biological, cognitive, emotional and social functioning.

What about change processes and active components? - Chapter 16

What is this chapter about?

Evidence for the efficacy of CBT in children and adolescents is growing exponentially. Although much progress has been made in identifying what works in treatment for which children and for what disorder, less is known about how treatment works. This gap between efficacy and the process of understanding how intervention effects are achieved surprise some people. CBT is based on principles of contingency management, skills training, exposure and cognitive restructuring. So, how can there still be ambiguity? The thing is, it is often not clear whether outcomes vary as a function of the different components of the treatment, the way they are implemented or as a function of their order. Such ambiguities have yet to be cleared up. The focus is therefore on identifying the change processes in CBT. In this chapter, several studies will be discussed to identify what it is that makes treatment work.

Do outcomes improve when parents are involved in the CBT?

One of the most prominent problems in literature is about involving parents in CBT. 25 studies have been looked at, and 40% of the studies found better outcomes if a parent component was added to the treatment. In only two studies, significantly worse outcomes were found when parents were involved in the treatment. The shape of the components (parent sessions only, joint sessions) didn't seem to matter much. This means that more research is required into the role of parental involvement in CBT. Probably the role of parental involvement in the treatment has a different influence in different disorders.

Do outcomes improve when young people are involved in treatments that focus on parents in principle?

This question focuses on studying whether adding a youth component to a parental treatment results in better outcomes. The majority of studies show that adding a youth component does not increase the outcomes of treatment. An important caveat is that these studies were mainly aimed at younger children. During adolescence there is an increase in autonomy, self-awareness and social relationships, so it is plausible that older children and adolescents benefit more from direct involvement in therapy than younger children. More research is therefore needed.

What is the impact of treating parents' mental health directly?

A third theme focuses on improving child outcomes by directly addressing the mental health problems of parents. This is based on the idea that psychopathology or maladaptive behavior of parents can interfere with effective parenting or contribute to child problems through modelling. Three of the six studies show success in improving child outcomes by addressing the mental health of parents. However, several other studies do not see any benefits. Here too, more research is needed.

Are more components better than less components?

Another theme concerns the argumentation of adding new components to existing treatments. It turns out that not all components are useful to add. However, no clear theme has emerged to characterize components that do not work. Examples of components that have no added value are increasing social support for single parents, perspective-taking training and treating aggression in treating anxiety. There have been mixed results on the efficacy of adding components with parent training skills. It seems that adding components does not automatically result in better treatment outcomes.

What are process outcomes studies?

More and more studies focus on investigating correlations between process variables and treatment outcomes in CBT. Three areas have attracted particular attention: the contribution of the therapeutic alliance to the treatment outcome, the impact of the client's involvement on the outcome and the influence of processes that facilitate engagement.

Does the therapeutic alliance contribute to CBT outcomes in children and adolescents?

Therapeutic alliance is defined as the reciprocal relationship between the client and therapist and thus concerns a number of facets of the therapeutic relationship. The most prominent is the emotional connection with the therapist and the feeling of cooperation in the treatment. Early findings suggest that the therapeutic alliance is modestly related to treatment outcomes for various disorders. However, much of this research has been done in contexts with usual care and treatments with unfamiliar efficacy. Over the last ten years, this pattern has started to change. More recent research indicates that the alliance does indeed contribute to predicting the outcome of treatment and is responsible for approximately 6-7% of the variance in the treatment outcome. Most studies have examined the role of alliance in isolation from other potential process predictors. The contribution of other therapy variables is not taken into account. The result is that the role of the alliance may be overestimated. For this, it is important not to separate specific alliance effects from specific intervention effects. More research is therefore required on the status of the alliance in the process of change.

How important is the active client's involvement in CBT in young people?

CBT is more than just passive exposure to the treatment protocol. Although it is more structured than traditional child therapy, it cannot be reduced to just treatment manuals. CBT emphasizes the importance of active participation of the child/adolescent. For example, not only are they told about coping skills, these skills are also practiced in the sessions. Moreover, skills and strategies are not presented as abstract concepts but integrated into everyday experiences. Precisely because client involvement is an important assumption of CBT, it has received little empirical attention. Evidence for the association between engagement and treatment outcomes is scarce and consists primarily of verbal indicators of active, positive engagement associated with improvements in behavior in the classroom as the only evidence. More recent research indicates that it is not necessarily involvement, but rather active involvement in active treatment components that contribute to positive treatment outcomes. A study that looked at involvement based on homework done shows that children and adolescents who are actively involved have better treatment outcomes. Especially since the involvement is central to CBT, more research is needed.

What can the therapist do to facilitate engagement?

Although active client involvement is a main treatment principle at CBT, little attention is paid to how the therapist can respond to behaviors or actions that facilitate engagement. Manuals emphasize the importance of the therapeutic relationship but provide little information on how this should be done. Research shows that alliance is positively associated with collaboration strategies, such as presenting therapy as something that needs to be done in a team and building a connection through the use of certain words (such as ‘we’). So there is a connection between the therapist's behaviors and the level of therapeutic alliance. It also appears important to take the child's perspective into account when setting treatment goals. Furthermore, research shows that putting pressure on the child is bad for the therapeutic alliance. It is important that therapists are familiar with treatment components and can apply them flexibly, so that treatment can be adapted to the individual. This is also likely to increase engagement. In general, an interesting pattern of findings on involvement in CGT develops. A lower structure and greater flexibility combined with therapist responsiveness seems to be associated with positive alliance and engagement. These patterns reflect the implementation of components in a manual based protocol. It could also be that engagement is enhanced by explicit instruction of strategies associated with positive alliance and active engagement. More research is needed to determine these findings in young people with different disorders and of different ages.

There are several trends in the literature on CBT in young people. First, studies on research components and therapy processes have increased enormously over the past decade. The review of these authors indicates that it is difficult to demonstrate positive effects of specific components added to main treatments. There are a lot of mixed results. A meta-analysis should provide more clarity. There is also an increasing interest in relational processes in CBT in children and adolescents. Increasing evidence shows that the therapeutic alliance is a predictor of treatment outcome in CBT in adolescents. It also appears that the alliance and client involvement are related to specific behaviors of the therapist in the treatment sessions. This suggests that the alliance is not a vague factor of warmth and trust, but rather a measurable process following specific therapist behaviors. This may be enhanced by training therapists in facilitating alliance. Despite the huge growth in research into CBT components and processes, there are still only a small number of studies available where processes and procedures for maximizing treatment outcome are identified. More research needs to be done to increase outcomes and help children and adolescents to benefit more from CBT.

Evidence for the efficacy of CBT in children and adolescents is growing exponentially. Although much progress has been made in identifying what works in treatment for which children and for what disorder, less is known about how treatment works. This gap between efficacy and the process of understanding how intervention effects are achieved surprise some people. CBT is based on principles of contingency management, skills training, exposure and cognitive restructuring. So, how can there still be ambiguity? The thing is, it is often not clear whether outcomes vary as a function of the different components of the treatment, the way they are implemented or as a function of their order. Such ambiguities have yet to be cleared up. The focus is therefore on identifying the change processes in CBT. In this chapter, several studies will be discussed to identify what it is that makes treatment work.

What about evidence-based treatments for children and adolescents? - Chapter 17

There is strong evidence that child and adolescent psychotherapy works, but some treatments appear to work better than the other. How well a therapy works depends on both the type of therapy and the problems of the individual. Evidence for the action of a therapy is best obtained through randomized controlled trials (RCTs). In an RCT, children with a specific problem are randomly selected for a treatment or control condition and the effects of both conditions are compared. No treatment is ever completely valid. There are always important questions to ask about different types of treatments (e.g. the essential components of the treatment, the characteristic of the client that can predict the outcome, etc.).

What about different effectiveness of treatments?

In 1995, the first formal report on the scientific evidence of the effectiveness of treatments was approved. Three categories were used for ''scientifically valid'' treatments:

1. Well-determined treatments.
2. Likely to be effective treatments.
3. Experimental treatments.

The difference between well-determined and likely effective treatments is that a well-determined treatment must prove superior to a psychological placebo, pill, or other treatment, while a likely effective treatment only needs to be superior to a waiting list or no treatment control condition. In addition, before a treatment can be called a well-determined one, evidence is needed from at least two different research teams, whereas the effects of a likely effective treatment requires only evidence from one research team. For both conditions, the characteristic of the client must be well specified (age, gender, ethnicity, diagnosis etc.) and should be carried out with treatment manuals. It should also be clear that the effects are indeed due to treatment and not to external factors. The third condition, experimental treatments, are treatments that have not yet been proven to be effective. This category includes treatments that are frequently used in practice, but have not yet been evaluated, or new treatments that have not yet been tested.

Ollendick identified three concerns about scientific evidence of the effectiveness of treatments:

1. Some treatments may seem more effective than others, making the 'Dodo bird' effect (that all treatments are equal) less sustainable.
2. The use of treatment manuals can lead to mechanical, inflexible interventions that result in loss of creativity and innovation.
3. Treatments that prove effective in a clinical setting do not have to be effective in real life.

Quite a few of the treatments used in clinical practice today do not appear to have been systematically evaluated and therefore fall into the third category. However, it is important that these treatments are also evaluated, because research shows that these treatments are not always very effective when compared with alternatives that do not contain therapy or with no treatment at all.

It would not be ethically justified to offer children and their families treatments that could be ineffective or even harmful. Identification, publication and the use of scientifically proven treatments are, on the other hand, consistent with the ethical standard. The identification and use of scientifically proven treatments has two sides. On the one hand, it seems unethical to use a treatment that has not been scientifically researched, but on the other hand relatively few scientifically proven effective treatments have been developed, and it seems unethical not to treat problem areas and disorders when a treatment is available for this, even if it is not (yet) scientifically proven effective. What should a practitioner do when a family comes to him with a particular problem for which there is no scientifically proven therapy? Kinscherff suggests that clinicians should select the best approach to help the client from all approaches in which the clinicians are competent. Clinicians should remain informed about the benefits of treatment, including empirically proven treatments, and maintain their skills by learning new procedures and strengthen the skills they already possess. Because there is always a limit in terms of the number of treatments a clinician can master, it is important that he knows when to refer the client to an approach that is more effective. In summary, Kinscherff states that someone knows his limitations and must continue to develop themselves.

What are instructions for treatments?

The use of a manual in a particular treatment provides other professionals with information about the components of the treatment, provides a clear description of the treatment that makes it possible to decide whether the treatment is appropriate, and it helps to choose the right variant of the psychotherapy that has been implemented.

Chorpita, Daleiden and Weisz criticized manuals that focused on the procedure of treatment and proposed an alternative model that places more emphasis on the underlying principles of change compared to the procedures of the change. This is for several reasons. First of all, when a treatment is defined by the procedures in the manual, it indicates that even minor revisions to a manual can already lead to new evidence. The second concern is about the unavailability of manuals for multiple problem areas, and what to do in these cases. Third, they wondered what to do when there is more than one manual available for a particular disorder, and how clinicians select the right ones. The alternative model of Chorpita, Daleiden and Weisz is a methodology for the identification and selection of 'ordinary elements' or underlying principles of scientifically proven protocols. They showed that elements of implementation (e.g. time-out, exposure, cognitive restructuring) could be reliably coded, after which they could be empirically divided into groups that represent specific approaches. This allows the equality between manuals to be empirically investigated, also the inaccessibility of manuals can be addressed because this system can look for manuals of similar problem areas, and can counteract the problem of multiple manuals for a single problem area by creating a main profile that represents the overall frequency of approaches. Although this model provides promising alternatives, more research needs to be done on its use as an intervention strategy.

In its simplest form is a manual of a treatment and set of guidelines that informs the customers how to perform a particular treatment and specifies the principles that lie at the expense of the treatment. They standardize and specify the treatment at the same time. More and more treatments are currently being recorded in manuals. What are the consequences of this? Kendall and colleagues have identified six (mis)perceptions that can arise as a result of the use of manuals, and these are some question-like misperceptions:

1. How flexible are these manuals?
2. Do they replace a clinical judgment?
3. Do they detract from the creative process of therapy?
4. Do they stifle improvement and change?
5. Are they effective for patients with multiple diagnoses or clinical problems?
6. Are they primarily designed for use in research programs with little or no use in clinics?

No clear answers are available to these questions and research is needed to explore these (mis)perceptions. In addition, Kendall and his colleagues come up with evidence of their own work with children with anxiety disorders that at least some of these questions need not be problematic. For example, they investigated the degree at which flexibility influenced the outcome of the treatment. They defined 'flexibility' as a construct that measures the adaptive attitude of the therapist in relation to the specific situation, while he/she adheres to the instruction and suggestions in the manual. Therapists reported being flexible in their implementation of the treatment plan (both in general and specific strategies), while adhering to the treatment procedure. The degree of flexibility did not depend on whether there was comorbid with other disorders or on the outcome of treatment.

In these studies, the treatments with manuals were 'individualized' in a flexible way by linking certain characteristics or profiles of the client to specific elements or components of previously established effective treatments. This is also called 'prescriptive matching'. The assumption of this is that such an approach is more effective and leads to more positive outcomes. There is a lot of evidence that interventions are more effective when they focus on the specific problems of the client. However, there are limitations to the studies demonstrating this effectiveness, as no control group has been used. A different approach to intervention is the 'modular approach'. This approach involves defining each technique used in the treatment as an independent module that could be integrated with other techniques. This is individualized and seems to be effective.

What about efficacy and effectiveness?

Ollendick's concern about the scientifically proven treatments lies in the difference between studies of efficacy and studies of effectiveness. 'Efficacy studies' demonstrate that the benefits of a treatment that is applied in a fairly standardized way (i.e. with a manual) are caused by the treatment and not by the changing factors or other external factors. These studies are carried out under highly controlled conditions, often in laboratories. Many of these studies consist of RCTs and are good experimental setups. However, in recent years questions have arisen about whether treatments that prove effective in the laboratory do also prove effective in reality, so in the ordinary population. This distance between efficacy and effectiveness plays a major role to this day.

Nevertheless, it is clear that 'effectiveness studies' that demonstrate the external validity of a treatment are very important. These studies need to be carried out, as they make it clear that the treatment itself really is the mechanism behind the changes and that the change is not because of external factors. These studies should look at both internal and external validity.

Weisz identified a set of characteristics associated with research into the outcome of child psychotherapy that distinguishes efficacy from effectiveness. He characterized research therapy as therapy for a relatively homogeneous group of children who undergo less severe forms of psychotherapy and where there is a problem in only one domain. Such studies are carried out in laboratories or in school settings with clinicians who are 'real' researchers, who are well trained and monitored. In contrast, clinical therapy (clinic therapy) is characterized by heterogeneous groups of children who are frequently exposed to treatments involving a broad spectrum of clinical problems. The treatment takes place in a clinic, school or hospital where the therapists have a lot of extreme cases, have had little training and are not monitored. There is also little use of manuals.

Boundaries between efficacy and effectiveness are not always clear. Chorpita noted that the demarcation between efficacy and effectiveness can be investigated in four ways. In evaluating actual effectiveness, studies look at therapist practices and the outcomes. This controls for 'upstream' elements, which increase the chances of a positive outcome. The second type of research that proves effective is 'transportability research'. This investigates whether a particular intervention can be promising in an actual clinical setting rather than just in the laboratory. A third approach concerns the use of system employees (such as the school counsellors) as therapists. This is also called 'dissemination research'. This allows one to determine the effectiveness of a treatment. The fourth approach is the 'system evaluation research', in which the system that is evaluated and the research team are completely independent of each other. This allows one to determine whether treatment is effective in itself (i.e. without the influence of the therapists).

There is strong evidence that child and adolescent psychotherapy works, but some treatments appear to work better than the other. How well a therapy works depends on both the type of therapy and the problems of the individual. Evidence for the action of a therapy is best obtained through randomized controlled trials (RCTs). In an RCT, children with a specific problem are randomly selected for a treatment or control condition and the effects of both conditions are compared. No treatment is ever completely valid. There are always important questions to ask about different types of treatments (e.g. the essential components of the treatment, the characteristic of the client that can predict the outcome, etc.).